Art-5-Malamet
PROSTHETIC DENTISTRY www.stomaeduj.com
SELECTING AN APPROPRIATE OCCLUSAL SCHEME WHEN
Review Articles
FABRICATING IMPLANT-SUPPORTED FIXED DENTAL
PROSTHESES: A SYSTEMATIC REVIEW
Mariam Margvelashvili-Malament1a* , Kenneth Albert Malament1b , Steven E. Eckert2c
1Department of Prosthodontics, School of Dental Medicine, Tufts University, Boston, MA, USA
2College of Medicine, Mayo Clinic, Rochester, MN, USA
a
DMD, MSc, PhD, Assistant Professor; e-mail: mariam.malament@tufts.edu; ORCIDiD: https://orcid.org/0000-0002-3751-0675
b
DDS, MScD, Clinical Professor; e-mail: kenneth.malament@tufts.edu; ORCIDiD: https://orcid.org/0000-0002-7144-5643
c
DDS, MS, Professor Emeritus; e-mail: seeckert@me.com; ORCIDiD: https://orcid.org/0000-0001-9382-7135
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(3).art.5
Background Dental implants are ankylosed in the bone without a periodontal ligament resulting in a lack
of micro-mobility during chewing. Consequently, occlusion with dental implants may be at greater risk,
specifically when the teeth come into contact in lateral excursive movements.
Objective A systematic review of the literature was performed to identify occlusal concepts that were most
favorable for implant-retained fixed restorations.
Data Sources A search of the literature was conducted using PubMed and EndNote literature online software
databases. Keywords were used to assist in the identification of the literature.
Study Selection The literature search identified 49 articles using PubMed and 33 articles using the author-
created EndNote database.
Data Extraction Two occlusal concepts were identified, namely mutually protected occlusion and group
function unilateral occlusion. None of the articles demonstrated clear scientific evidence to identify
superiority of one concept over the other.
Data Synthesis Based upon the systematic review of the literature, no scientific evidence was identified
favoring any specific occlusal concept.
KEYWORDS
Occlusion; Dental Implants; Implant Supported Fixed Restoration; Mutually Protected; Group Function.
1. INTRODUCTION or they could support the entire dentition with
fixed dental prostheses. Although natural teeth and
The primary purpose of teeth is to prepare food for dental implants may provide similar support for
ingestion. Processing food demands the actions of dental prostheses, there are substantial differences
trituration, manipulation, and deglutition. When between the two. The implant is an alloplastic device
teeth are lost, the function is compromised [1]. The that replaces the natural tooth root and supports
replacement of missing teeth is accomplished using the prosthesis. Although implants may provide
dental prostheses. These prostheses may be used to aesthetic and comfortable tooth replacement, there
replace all the teeth with complete dental prostheses, are characteristics associated with the use of dental
or some of the teeth with partial dental prostheses. implants that must be considered [5]. Perhaps the
Replacement teeth may gain support using remaining most obvious is the lack of a periodontal ligament
natural teeth, dental implants, residual alveolar around implants and thus a lack of micro-mobility
ridges, or a combination of these structures. Studies during chewing. Consequently, occlusion with dental
clearly indicate that removable prostheses are not as implants may be at greater risk, especially when teeth
effective in restoring function, esthetics, and patient contact in lateral excursions [6].
self-esteem. In fact, multiple nutritional deficiencies, The aim of this review was to identify the most har-
associated comorbidities, and loss of self-confidence monious relationship of prosthetic teeth when sup-
have been reported with removable prostheses [2-4]. ported by dental implants and describe occlusal
Implants may provide single tooth replacement, theories using a systematic review.
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Margvelashvili-Malament M, Malament KA, Eckert SE. Selecting an appropriate occlusal scheme when fabricating implant-supported fixed
dental prostheses: a systematic review. Stoma Edu J. 2021;8(3):189-194.
Received: July 17, 20211; Revised: August 05, 2021; Accepted: September 03, 2021; Published: September 07, 2021
*Corresponding author: Dr. Mariam Margvelashvili-Malament, Assistant Professor
Department of Prosthodontics, School of Dental Medicine, Tufts University, 1 Kneeland Street, Boston MA 02111, USA
Tel: +1 (617) 636-7000; Fax: +1 (617) 636-6583; e-mail: mariam.malamet@tufts.edu
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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Margvelashvili-Malament M, et al.
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2. MATERIALS AND METHODS
Review Articles Database/ Search terms Filters used Results
Software
The research question for this review was formulated PubMed “(dental implants OR Humans, Randomized 49
following the Preferred Reporting Items for Syste- implants) AND Occlusion Controlled Trial, Clinical
AND implant restoration AND Trial, Systematic Review
matic Reviews and Meta-Analyses (PRISMA) guide- "dental implants"[Mesh]”
lines using the Population, Intervention, Comparison
EndNot "Dental Occlusion and 33
and Outcome (PICO) tool. Dental Implant and Fixed
POPULATION: The patient group receiving fixed Prosthesis or Occlusion or
dental prostheses supported by implants. Group Function and Mutually
Protected”
INTERVENTION: The patient group receiving a spe-
Hand search N/A N/A 3
cific form of treatment. Unilateral group function lat-
eral occlusion with multiple posterior teeth guiding Table 1. Search strategy.
lateral movements.
2.1. Screening Process
COMPARISON: The patient group receiving an alter- A total of 49 (PubMed) and 33 (EndNote) articles
native form of treatment. Mutual protection placing were selected by two of the authors (M.M.M. and
lateral contacts on anterior teeth thereby separating S.E) as being of potential interest to the reader on
the posterior teeth during mandibular movements. the topic of dental occlusion. These articles were as-
OUTCOME: The results obtained from the two com- sessed by reviewing the titles and then by reading
pared treatments. the abstracts. Any disagreement regarding the qual-
In partially and/or completely edentulous patients ity of the article was managed through discussion
restored with implant-supported fixed dental and eventually by the inclusion of the third author
prostheses either a mutually protected occlusion, (K.A.M) if necessary.
whereby the anterior teeth separate the posterior The authors, after compilation and assessment of
the articles, extracted the available data from the ar-
teeth in laterotrusion, or a group function occlu-
ticles and compiled the gathered data. The articles
sion, where the anterior and posterior teeth contact
were evaluated relative to the use of natural tooth
simultaneously on the working side result in fewer support or dental implant support of the final pros-
complications? The dental literature was to be evalu- theses.
ated to determine the relative superiority of one
occlusal scheme over the other to answer the PICO 3. RESULTS
question.
An electronic search was conducted utilizing the Using the literature search described, no studies
following database and Software: PubMed and were identified to answer the PICO question. There
EndNote using the search strategy “(dental implants were subjective descriptions of different techniques
OR implants) AND Occlusion AND implant resto- that were used in the management of clinical pa-
ration AND "dental implants"[Mesh]” and "Dental tients relative to the posterior fixed occlusal scheme.
Occlusion and Dental Implant and Fixed Prosthe- The PubMed search was linked with 49 articles. After
screening the titles, 39 were assessed as irrelevant, 7
sis or Occlusion or Group Function and Mutually
as potentially relevant, 2 as hypothetical designs and
Protected” respectively. No language or journal type
1 as relevant. The EndNote search was linked with 33
restrictions were applied to the search. A supple- articles, 23 were reviewed as irrelevant, 7 potentially
mental hand search was also conducted. Search relevant, 3 represented hypothetical designs (Fig. 1).
strategy and outcomes for each source are provided
Identification
in Table 1. Records identified through
To meet the eligibility requirements, the selected database search: PubMed (49),
EndNote (33), Hand Search (3) Records excluded after title
studies had to meet the following inclusion criteria: screening: PubMed (39),
1. Human studies. EndNote (23)
Screening
Records remaining after title
2. Randomized controlled clinical trials (RCT), clinical screening: PubMed (10),
trials, systematic reviews. EndNote (10), Hand Search (3)
3. If multiple publications on the same cohort to be Duplicate records excluded
found, only the publication with the longest follow- Records remaining after abstract Records excluded after abstract
Eligibility
up time was included. level screening: PubMed (3), level screening: PubMed (7),
EndNote (7) EndNote (3), Hand Search (3)
The exclusion criteria included the following:
1. Not meeting inclusion criteria.
Included
Full-text articles assessed for Full-text articles excluded:
2. Duplicate publications. eligibility: PubMed (3), EndNote (7) PubMed (2), EndNote (4)
3. Full-text not available in English.
4. Full-text unavailable. Studies included:
PubMed (1), EndNote (3)
5. No information available about occlusal concepts
applied. Figure 1. Screening process.
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Dental occlusion described as mutually protected occlusal design concept over another. Even from
Review Articles
occlusion was identified as the most common the standpoint of descriptive studies there is no
method of management of lateral articulation of the clear recommendation. The lack of a periodontal
teeth. Group function was identified in three articles, ligament limits the micromotion and proprioceptive
although no scientific studies were performed. Due capability of implant-supported fixed restorations
to an inability to identify a study, or studies, that making them potentially more succeptible
answer the PICO question or provided conceptual to technical complica-tions. Therefore, it is of
homogeneity, no Meta-Analysis or risk of bias paramount importance to provide optimal occlusion
assessment could be conducted. The following to hopefully generate higher survival rates for
opinion-based and clinical articles were identified implant-supported fixed restorations. However, the
and are summarized in Table 2. question remains as to what is the optimal occlusal
Wismeijer et al. [7] described implant reconstruction scheme. Although this systematic review failed to
in the edentulous mandibular arch opposing an identify studies that would answer the question
edentulous maxilla as being treated using bilateral directly, suggestions dervied from the included
balanced occlusion. Mutually protected occlusion or articles as well as the factors that may be considered
group function was suggested when the maxilla was confounding variables are further discussed.
dentate. In an article that was primarily describing Two occlusal concepts that are currently applied to
the use of short implants in the posterior areas, fixed restorations on implants are: group function
Misch et al [8] suggested that cantilevers should occlusion and mutually protected occlusion.
be eliminated, and the patient should be restored Both occlusal approaches share the concept of
with a mutually protected or canine guided occlusal simultaneous, bilateral contact of posterior teeth
concept. when the jaws are in maximum intercuspation.
In 2016, Sheridan et al. [9] performed a systematic The concepts differ in the way that occlusion of
review that failed to identify evidence in favor of any
the anterior teeth is described with group function
specific occlusal management. Once again, these
exhibiting very light contact of the anterior teeth
authors suggested mutually protected occlusion
while mutual protection entails anterior teeth
with anterior guidance with wide freedom in
contact in all excursive movements thereby
centric and avoidance of cantilevers. Considering
separating the posterior teeth.
the descriptors, specifically with “wide freedom in
Mutually protected occlusion is considered by
centric,” the readers may have interpreted the terms
as fulfilling the description of group function. many to be the ideal occlusal scheme for the
Esquivel-Upshaw et al [10] studied the effect of natural dentition. D’Amico described the size and
direction and magnitude of occlusal loading on innervation of the canine tooth as a way to explain
implant supported FDPs. The authors provided group the rationale for embracing the mutual protection
function to the treated patients and identified these concept [11-13]. Conversely, group function exhibits
lateral excursive contacts as not being associated unilateral, simultaneous anterior and posterior tooth
with a higher fracture occurrence. Conversely, the contact as the jaws move laterally from maximum
strong centric contacts resulted in higher porcelain intercuspation. Primary support for the concept of
fracture rate. None of the treated patients received group function is seen when the dentition exhibits
mutually protected occlusion. The authors suggested abrasive wear after years of function [14-18].
that due to the absence of a periodontal ligament, Although without clear scientific or clinical evidence,
implant supported fixed dental prostheses should three of the selected four studies recommended
have lighter maximum intercuspation contacts. mutually protected occlusion for implant-supported
fixed restorations.
4. DISCUSSION Most of the authors highlight the complexity of
biomechanics with implant-supported fixed dental
This systematic review of the literature failed to prostheses. Misch et al. suggested decreasing
identify randomized controlled clinical trials or stress through a biomechanical approach, namely:
cohort studies that would promote one specific splinting implants and avoiding cantilevers, applying
Author/Year Journal Study Sample Size Occlusal Observation Prostheses’ Results
Design (number of FDPs Concept Used Time Survival Rate (%)
Wismeijer, D. et Journal of Review N/A N/A N/A N/A Recommends mutually protected
al 1995 Prosthetic Dentistry occlusion
Misch, C. E. Journal of Retrospective 338 Mutually Up to 6 years N 98.9% Recommends methods to decrease
et al 2006 Periodontology Case Series protected biomechanical stress (including
mutually protected occlusion)
Sheridan, R. A. Implant Dentistry Review N/A N/A N/A N/A Recommends mutually protected
et al 2016 occlusion
Esquivel-Upshaw, Journal of Dentistry RCT 89 Group Function 3 years 85% Recommends light centric contacts
F. H. et al 20146
Table 2. Included studies.
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a mutually protected occlusal concept, and selecting it was made originally will provide a cosmetic
Review Articles an implant design to increase bone-to-implant benefit for the patient but in terms of full functional
contact area. Unfortunately, this study lacked a replacement, the incremental stacking of porcelain
control group utilizing an alternative occlusal will never be so accurate that it could be used
concept. Mutually protected occlusion resulted in without adjustment. In addition to the abrasive
high survival rates, yet the study does not answer nature of metal ceramic restorations there is also a
the PICO question of current systematic review. It tendency for the material to lose surface detail over
shows successful application of this occlusal concept time. The cost of metal ceramic is dependent upon
but fails to demonstrate its superiority [8]. the type of metal alloy that is used. This is a material
Esquivel-Upshaw, et al. showed no risk of higher that was quite popular through the first decades of
fracture of implant-supported fixed dental prosthesis implant dentistry but it appears to have lost much of
in excursive contacts (group function). This was the previous popularity of this material.
true for both metal-ceramic and ceramic-ceramic The use of milled, or pressed, all ceramic materials
restorations. However, similarly to Misch there has demonstrated a number of advantages. Since
was no control group of the alternative occlusal the design of such a prosthesis (milled) can be
concept group. Regardless, the authors recommend saved digitally, any future damage in the form of
hypoocclusion in maximum intercuspation on breakage, could be easily restored as long as the
implant-supported fixed restorations [10]. fixed dental prosthesis is retrievable. Perhaps a more
Another concept that should be mentioned is important advantage is that monolithic all ceramic
bilateral balanced occlusion. Unlike mutually pro- materials exhibit very little, if any, discernible wear
tected occlusion and group function, bilateral over time. With the advent of lithium disilicate
balance provides bilateral contacts in eccentric and zirconia materials the aesthetic replacement
movements. While this occlusal concept is popular of posterior teeth should be easy to achieve and
in complete denture prosthodontics, it should reliable and predictable into the future. Assuming
also be considered when a fixed restoration that the choice of material will be that of a milled
opposes a removable complete denture. When a all ceramic material, it is important to remember
prosthodontist considers the alternative occlusal the unique characteristics of the dental implant
concepts for treating edentulous pateints with fixed that must be duplicated or compensated for in the
prostheses, the decision is often made based upon
final prosthesis. Perhaps the most critical factor as it
clincal experience and personal and laboratory
relates to implants is the relative immobility of the
preferences. However, another important aspect
individual implants. Unlike natural teeth that exhibit
that should be considered is the type of restorative
physiologic mobility, implants are, for all intents and
material being used. Normally the material choices
purposes, rigid within bone. This rigid device must
are acrylic resin, cast metal, metal-ceramic, and
have a carefully controlled occlusal relationship
milled or pressed ceramic materials. Over time,
with the opposing teeth. The patient can advise the
the use of acrylic resin has diminished because of
unfavorable wear characteristics. Although acrylic clinician of the presence of high occlusal contacts
resin prostheses usually have a supporting metal but it is very hard to communicate to the patient the
substructure, the wear characteristics of acrylic more important factor related to lateral motions and
or composite materials as an occlusal material how those must be compensated in the prosthetic
demonstrate moderate to severe wear in a relatively design.
short period of time. The prostheses can be removed
and the surface veneering material replaced, but 5. CONCLUSIONS
this will require a number of appointments that
will incur some cost. In addition, the customization Within the limitations of this systematic review the
of the occlusal surface of the prosthesis may create authors agreed on the following conclusions:
an occlusal awareness for the patient that could be • There is lack of information as to which occlusal
unfavorable. scheme, mutually protected or group function, is
Full cast metal restorations could certainly be more favorable.
considered. The advantage of cast metal is that • Based upon clinical preference and experience,
most cast materials exhibit a hardness and a wear group function or mutually protected occlusion,
pattern similar to that seen with natural dentition. both appear to be acceptable occlusal schemes for
The disadvantage of cast metal is the appearance implant supported fixed dental prostheses.
and the relatively high cost associated with such a • Future clinical studies are needed to assess
prostheses. In today's esthetically conscious society, scientific and clinical evidence of the superiority of
full cast metal restorations are unlikely to prove one occlusal scheme over other.
acceptable. Metal ceramic restorations have been
one of the most popular choices for restorative AUTHOR CONTRIBUTIONS
material for more than 50 years. Metal ceramic is MM-M: was responsible for the conceptualization, design, data
relatively stable over time although it is somewhat analyses and writing the manuscript. SE: was responsible for the
prone to chipping and fracture of the veneering conceptualization, design, and data analyses, and editing the
ceramic material. The restoration, because of the manuscript. KM: was responsible for editing the manuscript. All
fabrication process, is built up incrementally. The the authors gave their final approval and agreed to be accountable
ability to duplicate a prosthesis sometime after for all aspects of the work.
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Mariam MARGVELASHVILI-MALAMENT
DMD, MSc, PhD, Assistant Professor
Department of Prosthodontics
School of Dental Medicine
Tufts University - TUSDM
CV Boston, MA, USA
Dr. Margvelashvili-Malament is an Assistant Professor in the Department of Prosthodontics at Tufts University School of
Dental Medicine (TUSDM). She is a Diplomate of the American Board of Prosthodontics and Fellow of the American College of
Prosthodontics.
She received her DMD from the Tbilisi State University in Georgia, Master of Science and PhD Degrees in Dental Materials from
the University of Siena, Italy. She is a co-author of the national residency program in Prosthodontics in Georgia. She was also the
Founding Chair of the International Dental Program at the University of Georgia.
She is the recipient of an ITI Scholarship. She completed her Advanced Graduate training in Prosthodontics at TUSDM with
high honors. She has lectured internationally and published numerous scientific articles and she also serves as a reviewer for
international journals.
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Questions
Review Article
1. How can mutually protected occlusal concept be described?
qa. An occlusal scheme in which the posterior teeth prevent excessive contact of the anterior teeth in
maximal intercuspal position, and anterior teeth disengage the posterior teeth in all mandibular excursive
movements;
qb. An occlusal scheme in which multiple posterior teeth contact in all mandibular excursive movements
on the working side to distribute occlusal forces;
qc. An occlusal scheme in which the buccal and lingual cusps of the maxillary posterior teeth on working
and balancing side contact buccal and lingual cusps of mandibular posterior teeth in all mandibular
excursive movements;
qd. None of the above.
2. How can group function occlusal concept be described?
qa. An occlusal scheme in which the posterior teeth prevent excessive contact of the anterior teeth in
maximal intercuspal position, and anterior teeth disengage the posterior teeth in all mandibular excursive
movements;
qb. An occlusal scheme in which multiple posterior teeth contact in all mandibular excursive movements
on the working side to distribute occlusal forces;
qc. An occlusal scheme in which the buccal and lingual cusps of the maxillary posterior teeth on working
and balancing side contact buccal and lingual cusps of mandibular posterior teeth in all mandibular
excursive movements;
qd. None of the above.
3. Slightly hypo-occlusion in maximal intercuspal contacts is recommended for
implant-supported fixed restorations because:
qa. The lack of a periodontal ligament limits the micromotion;
qb. The lack of a proprioceptive capability of implant-supported fixed restorations;
qc. Both a. and b. are correct;
qd. None of the above.
4. Based on the findings of this systematic review, the following is correct:
qa. There is a lack of information as to which occlusal scheme, mutually protected or group function, is
more favorable for implant-supported fixed restorations. Group function or mutually protected occlusion,
both appear to be acceptable occlusal schemes;
qb. There is strong scientific evidence that suggests the use of group function occlusal concept for
implant-supported fixed restorations;
qc. There is strong scientific evidence that suggests the use of mutually protected occlusal concept for
implant-supported fixed restorations;
qd. None of the above.
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