2. ized by fixed metal/resin temporaries
placed immediately after implantation
for 40 to 60 days on the implant abutments.11,12 Applying this procedure
shortly after operation, the patient
should adapt easily to group guidance.
Using natural canine guidance in
such cases can cause problems for
long-term success of implants. During
lateral movement of the mandible, a
high compression force is noted in the
area of the artificial canine and, as
well, a significant compression on the
premolar and molar zones of the working side. On the disclusion side, an
important tensile force on the implants
is evident. Compression on the working side and tensile force on the contralateral side of the arch induce a
micromovement of the monoblock
bridgework with the unpleasant results
of bone loss combined with possible
implant loss. Lots of failures are
caused by this phenomenon. (As I
started the rehabilitation of the edentulous maxilla and mandible with
implant-supported fixed bridges in the
early 1990s, I had a lot of problems 3
to 4 years after definitive placement of
the bridgework because I applied a
canine guidance in these cases.)
Using unilateral group guidance,
the compressive force is distributed on
premolars and molars of the working
side. Nevertheless, tensile forces are
noted on the contralateral side. These
forces are less destructive but also
dangerous (Fig. 1A).
Therefore, the author recommends a bilateral balanced occlusion
in such implant cases. This guidance
causes better loading transference to
the jaw. Under this condition, tensile
forces are minimized. The compressive force is distributed over almost
the whole arch. During chewing function, the contralateral side is also supported (Fig. 1B). Furthermore, it is
important to eliminate the palatal contacts of the upper incisors during protrusive movement. Otherwise, significant tensile forces are noted in the
posterior areas on both sides of the
upper bridgework. This lever is especially dangerous for implant patients
with parafunctional habits (Fig. 1C).
Finally, it is recommended to eliminate prematurities on the occlusal table of bridgework during lateral
movements.
50
MONOBLOCK IMPLANT BRIDGES
monoblock bridge, the natural canine
guidance can also be maintained.
There are no destructive forces on
teeth and implants.
CASE PRESENTATIONS
Case No. 1
The edentulous maxilla and mandible are provided with implants. The
implants are immediately loaded with
fixed metal/resin temporaries. Forty to
60 days postoperatively, the definitive
monoblock bridges (metal/porcelain)
are fabricated.
The following aspects are
respected:
• Centric jaw relation (Fig. 2)
• No canine guidance, but a bilateral balanced group guidance
(Fig. 3)
• Prematurities are eliminated during lateral movements (Fig. 4)
• No palatal contacts of the upper
incisors in protrusive movements
(Fig. 5)
Case No. 2
Fig. 1. Effects of compressive and tensile
forces on implants of monoblock bridges. (A)
Lateral movement in unilateral balanced occlusion: Compressive force (white arrow) in
the premolar and molar area causes a tensile
force (red arrow) on the contralateral side. (B)
Lateral movement in bilateral balanced occlusion: Compressive force (white arrow) in the
premolar and molar area causes no tensile
force on the contralateral side. (C) Protrusive
movement: Compressive forces (white arrows) on the upper incisors cause tensile
forces (red arrows) on both sides of the upper
bridgework.
If the edentulous maxilla is supplied with an ordinary removable
prosthesis and the edentulous mandible with an implant-supported monoblock bridge, the canine guidance can
be maintained. If in such cases the
shearing forces are too high, the upper
prosthesis cannot be kept stable on the
maxilla. Therefore, these forces are
not destructive to the implants in the
edentulous mandible.
According to clinical observation
in the last 15 years, in situations in
which implants are tied together with
natural teeth to restore the jaw with a
The maxilla is restored with a
conventional prosthesis. The edentulous mandible is provided with an
implant-supported monoblock bridge.
In this case, the natural canine guidance is maintained (Fig. 6).
Case No. 3
In the upper jaw, implants and
natural teeth are tied together with a
monoblock bridge. The mandible has
conventional bridgework. According
to my clinical observation in the last
15 years, canine guidance has no destructive effects on teeth and implants
(Fig. 7).
RESULTS
The occlusion and articulation of
an implant-supported suprastructure
has to diminish stress on the implants.
For the treatment of the edentulous
maxilla and mandible with fixed implant bridges, the occlusion pattern
has to be changed to a bilateral balanced group guidance. Canine guidance in these cases can cause destructive forces on implants and
bridgework. Loss of implants and failure of the restoration are the consequences. The first adjustment should
be executed with fixed temporaries
3. Fig. 2. Maxillary and mandibular casts
mounted on the articulator.
Fig. 5. No palatal contacts of the upper incisors in protrusive movement.
Fig. 6. Prosthesis and implant-supported
monoblock bridge with natural canine
guidance.
Fig. 3. A bilateral balanced occlusion of the
monoblock bridges is realized.
Fig. 7. Monoblock bridge (teeth and implants
tied together) in the maxilla and classic
bridgework with canine guidance.
Fig. 4. Intraoral view of implant-supported
bridgework during lateral movement.
(metal/resin) on the implants. They are
used for 40 to 60 days after operation.
Applying the results of occlusion, articulation and vertical dimension the
transitional bridges are exchanged for
definitive bridgework (metal/porcelain).
Beside group guidance, it is important for these bridges to eliminate
contacts on the upper incisors during
protrusive movement and prematuri-
ties on the occlusal table of bridgework during lateral movement.13 In the
other implant cases that are presented,
the canine guidance is applied similar
to natural teeth arches.
DISCUSSION
In function, the mandible works
like a hammer and the maxilla represents the anvil. The forces that influence implants and bridgework are
compressive, tensile, and shearing
forces. Overload on fixtures leads to
an osteolysis around the implants.14,15
The fixtures lose their osseointegration. Without correct articulation, a
destructive load transmission is noted
on the fixtures. The consequences
could be implant loosening and implant fracture. Applying screwretained bridgework, loosening and
fracture of the fixation screws are also
possible. Implant loosening is often
noticed in the porous maxillary bone
and fracture in the dense mandibular
bone jaw. These observations appear
to take place especially in the posterior
implant sites of the lower jaw.
Working according to the principles of gnathology in placing the condyles in the most retruded position as
possible (centric bite), and applying a
bilateral balanced occlusion, the mechanical load is transmitted over the
suprastructure on all implants. Stress
reduction is achieved. A main problem
in implantology is bruxism.16 Bruxism
is the vertical and horizontal, nonfunctional grinding of teeth. Bruxism is the
most common oral habit. The maximum biting force of bruxers is greater
than conventional biting forces. The
maximum vertical component of bite
force in occlusion in the molar region
is 6 to 10 times higher than during
natural chewing function. In the natural dentition, the maximum force is
approximately 400 N, patients with
implants approximately 200 N, and
patients with conventional prostheses
approximately 100 N.17
Bruxism imparts overload on implants. Even by adapting correct occlusion and articulation patterns, the
results in these cases are often
unfavorable.
CONCLUSION
A knowledge of forces that affect
implants and suprastructure is important for the restorative dentist to realize. This includes the surface areas
and vertical dimension of occlusion of
fixed restorations. The goal is to prevent destructive forces on implant
bridgework and fixtures. In cases in
which the edentulous maxilla and
mandible are provided with large
monoblock implant bridges, the author
recommends a bilateral balanced
group guidance.
IMPLANT DENTISTRY / VOLUME 13, NUMBER 1 2004
51
4. DISCLOSURE
The author claims to have no financial interest in any company or any
of the products mentioned in this
article.
REFERENCES
1. Misch CE. Clinical biomechanics in
implant dentistry. In: Misch CE, ed. Contemporary Implant Dentistry, 2nd ed. St.
Louis: Mosby; 1999:303–316.
2. Weinberg LA. Reduction of implant
loading with therapeutic biomechanics.
Implant Dentistry. 1998;7:277–285.
3. Adell R, Lekholm B, Rockler B, et al.
A 15-year study of osseointegrated implants in the treatment of the edentulous
jaw. Int J Oral Maxillofac Surg. 1981;10:
387–396.
4. Engleman MJ, Sorensen JA, Moy P.
Optimum placement of osseointegrated
implants. J Prosthet Dent. 1988;59:467–
473.
5. Bahat O. Treatment planning and
placement of implants in the posterior
maxillae: Report of 732 consecutive No-
belpharma implants. Int J Oral Maxillofac
Implants. 1993;8:151–157.
6. Misch CE. Chapter 10. Diagnostic
casts, preimplant prosthodontics, treatment prostheses, and surgical templates
In: Misch CE, ed. Contemporary Implant
Dentistry, 2nd ed. St. Louis: Mosby; 1999:
140–141.
7. Bocklage R. Rehabilitation of the
edentulous maxilla and mandible with fixed
implant-supported restorations applying
immediate functional loading: A treatment
concept. Implant Dentistry. 2002;11:154–
158.
8. Stuart CE. The geometrics of the
gnathic system. J Gnathol. 1982;1:6–13.
9. Kantor M, Silverman S, Garfinkel L.
Centric relation recording techniques: A
comparative investigation. J Prosthet
Dent. 1972;28:593–600.
10. Weinberg LA. Axial inclination and
cuspal articulation in relation to force distribution. J Prosthet Dent. 1957;7:804–813.
11. Bocklage R. Advanced alveolar
crest atrophy: An alternative treatment
technique for maxilla and mandible. Implant Dentistry. 2001;10:30–35.
12. Tarnow DP, Emitiag S, Classi A.
Immediate loading of threaded implants at
one stage surgery in edentulous arches:
Ten consecutive case reports with 1 to 5
year data. Int J Oral Maxillofac Implants.
1997;12:319–324.
13. Stuart CE. Overlap of the upper anterior teeth and its determinants.
J Gnathol. 1983;2:3–10.
14. Misch CE. Bone response to mechanical loads. In: Misch CE, ed. Contemporary Implant Dentistry, 2nd ed. St. Louis:
Mosby; 1999:317–328.
15. De Lange G, De Putter C. Structure
of the bone interface to dental implants in
vivo. J Oral Implantol. 1993;19:123–135.
16. Misch CE. Dental evaluation. In:
Misch CE, ed. Contemporary Implant Dentistry, 2nd ed. St. Louis: Mosby; 1999:
124–127.
17. Braun S, Hnat WP, Freudenthaler
JW, et al. A study of maximum bite force
during growth and development. Angle
Orthodont. 1996;66:261–264.
Reprint requests and correspondence to:
Rainer Bocklage, DrMedDent, DUI
Langemarkstr.11, D-41539
Dormagen, Germany
E-mail: info@drbocklage.de
Abstract Translations [German, Spanish, Portugese, Japanese]
AUTOR: Rainer Bocklage, Dr. med. dent.,
DUI. *Privat praktizierender Arzt. Schriftverkehr: Rainer Bocklage, Dr. med. dent.,
DUI, Langmarkster 11, D-41539 Dormagen.
eMail: info@drbocklage.de
Biomechanische Aspekte von einteiligen Implantatbrücken für den zahnlosen Oberund Unterkiefer: Konzeptionen zu Zahnreihenschluss und Artikulation
ZUSAMMENFASSUNG: Die genaue Kenntnis der auf die Implantate und deren Überbau
einwirkenden Kräfte ist für den behandelnden Zahnarzt bei der Wiederherstellungsbehandlung von größter Bedeutung, da nur so die Oberflächenbereiche und vertikalen Ausdehnungen der festen Wiederherstellungsmedien exakt festgelegt werden können.
Das Okklusionsprinzip zielt darauf ab, gestressten Implantaten den erforderlichen Schutz
zukommen zu lassen und ein Bewusstsein für eventuell vorliegende zerstörerische Kräfte
zu entwickeln. Wird ein zahnloser Ober- oder Unterkiefer mittels einteiliger Implantatbrücke wiederhergestellt, empfiehlt der Autor des Artikels den Einsatz einer bilateral
austarierten Gruppenführung.
Missachtet man bei der Behandlung die normalen biomechanischen Prinzipien, muss als
Ergebnis mit Implantatverlust und Fehlschlagen der gesamten Wiederherstellungsbehandlung gerechnet werden. Für die Erstanpassung des Zahnreihenschlusses und der Artikulation unmittelbar nach erfolgter Implantierung werden feste Provisorien auf den Implantaten befestigt. Nach 40 bis 60 Tagen werden diese Provisorien dann durch die
endgültigen Implantatbrücken ersetzt.
SCHLÜSSELWÖRTER: Biomechanik, Kräfte, Überlastung, Gruppenführung
AUTOR: Rainer Bocklage, Dr. med. dent,
DUI. *Práctica Privada. Correspondencia a:
Rainer Bocklage, Dr. med. dent., DUI, Langemarkster 11, D-41539, Dormagen, Alemania.
Correo electrónico: info@drbocklage.de
Aspectos biomecánicos de los puentes de implante de un solo bloque para el maxilar y
la mandíbula edentulosa: Conceptos de oclusión y articulación
ABSTRACTO: En el conocimiento de las fuerzas que influencian a los implantes y la
supraestructura es importante que el dentista de restauración tenga en cuenta las áreas de
la superficie y la dimensión vertical de las restauraciones fijas.
El propósito de los conceptos de oclusión es respetar la protección de implantes que
52
MONOBLOCK IMPLANT BRIDGES
5. reciben la transmisión de tensión y estar al tanto de sus fuerzas destructivas. En casos
donde el maxilar y la mandíbula edentulosa se incluyen con puentes de implantes de un
solo bloque grande, el autor recomienda una guía grupal equilibrada bilateral.
Si los principios biomecánicos no son respetados, resultará en la pérdida del implante y
la falla de la restauración. Para el primer ajuste de la oclusión y la articulación inmediatamente luego de la colocación, se colocan en los implantes puentes temporarios fijos.
Otros 40 a 60 días después, se cambian los temporarios por el puente definitivo con
implantes.
PALABRAS CLAVES: biomecánica, fuerzas, sobrecarga, guía grupal.
AUTOR: Rainer Bocklage, Doutor em Odontologia, DUI. *Clínica particular. Correspondência para: Rainer Bocklage, Dr. med.
dent,, DGI, Langemarkster. 11, D-41539, Dormagen, Germany. e-mail: info@drbocklage.de
Aspectos biomecânicos das Pontes de Implante Monobloco para as e Mandíbula:
Conceitos de Oclusão e Articulação
RESUMO: O conhecimento de forças que influenciam os implantes e a supra-estrutura é
importante para o dentista restaurador perceber as áreas de superfície e a dimensão vertical
de restaurações fixas.
O objetivo dos conceitos de oclusão é respeitar a proteção de implantes que recebem a
transmissão de tensão e ser consciente das forças destrutivas. Nos casos em que a e a
mandíbula são providas de grandes pontes de implante monobloco, o autor recomenda
direção de grupo bilateral e equilibrada.
Se os princípios biomecânicos não forem respeitados, o resultado será perda de implante
e falhas na restauração. Para o primeiro ajuste de padrões de oclusão e articulação
imediatamente após a implantação, próteses temporárias fixas são colocadas nos implantes. Uns 40 ou 60 dias mais tarde, as próteses temporárias são trocados por próteses de
implante definitivas.
PALAVRAS-CHAVE: biomecânica, forças, sobrecarga, direção de grupo
IMPLANT DENTISTRY / VOLUME 13, NUMBER 1 2004
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