Review Article
*Department of Oral
Function, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam and Department of Oral and Maxillofacial Surgery, Prosthodontics
and Special Dental Care, University Medical Center, Utrecht, The Netherlands
Introduction
SUMMARY
(Over) load
Forces on dental implants are characterized by their
magnitude and direction. An in vivo study by Richter
(17) has demonstrated maximum vertical forces (load
levels) on implants in the premolar region during
habitual mastication to vary from about 60 N for brittle
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Biological complications
The consequences of overload of dental implants can be
divided into two groups: biological and biomechanical
Biomechanical complications
In case of biomechanical complications, one or more
components of an implant system fail, e.g. fracture of
an implant itself, loosening or fracture of connecting
screws or abutment screws, loosening or excessive wear
of mesostructural components in overdentures, and
excessive wear or fracture of suprastructural porcelain
or acrylic teeth (29, 30).
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Especially, the loosening of screwnut attachments in
prosthetic constructions occurs relatively frequent (31).
The preload of the screw (i.e. the tensile force established in the screw after tightening) and the clamping
force between the surfaces of screw and nut stabilize
the attachments. The screw loosens when the occlusal
forces on the prosthetic construction exceed these
stabilizing forces (32). Obviously, the larger the forces
on the construction, the sooner loosening will occur.
Fractures of implants and screws happen only seldom
(29). Pre-disposing factors are thin implants and loss of
bone till a weak part of the implant, which is mostly at
the level where the abutment screw ends. The fracture
of a connecting screw of implant components is usually
preceded by a stage of screw loosening (33). Connecting
screws mostly fracture at the level where the screw
thread part ends.
Causality
To present convincing evidence for the possibility that
bruxism leads to failure of dental implants, a cause-andeffect relationship needs to be established. The criteria
for a valid causal relationship are summarized in
Table 1, following the guidelines proposed by Spilker
(34).
The first criterion in Table 1, viz. the absence of bias
and confounding factors, is not met in articles that deal
with the association between bruxism and failure of
dental implants: none of the below-cited articles is
completely free of bias and confounders. For sake of
conciseness, no details will be presented, but a convincing example of the vast presence of bias is the fact that
a diagnosis of bruxism, being an oral movement
disorder with two faces (dynamic teeth grinding and
static clenching), is difficult to establish (see below).
As a second criterion for a valid cause-and-effect
relationship, the suggested cause (i.e. bruxism) should
precede the effect (i.e. implant failure). To that end, a
Discussion
From the above paragraphs, it can be gathered that the
various biomechanical, epidemiological, and experimental (clinical) studies yield contradictory results in
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relation to the question whether or not bruxism may
lead to the failure of dental implant procedures. Apart
from the fact that the association under study only
partly fulfils the criteria for a valid causal relationship,
there is a large variation between studies in both the
technical aspects (i.e. related to the implants and their
suprastructures) as well as the biological aspects (i.e.
related to the patients) of the material under examination: there are hardly any studies whose materials are
fully comparable. This further complicates the interpretation of the literature about this subject. Moreover,
there is also a lot of variation in the mode, duration,
and frequency of the evaluations as well as in the study
design. For example, a large part of the current
knowledge about loading of dental implants is derived
from studies using finite element models (e.g. 45).
However, because of the assumptions that are part of
such mathematical models, one cannot easily extrapolate the findings to the clinical situation (46). Unfortunately, a clinical verification of the outcomes of finite
element analyses is not easy to perform for ethical and
practical reasons.
Table 2 gives an impression of the many factors that
should be taken into account by researchers, who want
to study the causal relationship between bruxism and
Table 2 Overview of factors that can differ among studies to the
possible causal relationship between bruxism and implant failure
Implant-related factors
Environment: edentulous, partially dentate
Position: upper, lower, anterior, posterior
Number: ranging from 2 per jaw up to 1 per element
Implant: shape, material, length, diameter
Suprastructure: fixed, removable
Attachment: bar (extensions yes/no), ball
Loading: immediate, early, late
Occlusion: area contact, point contact
Articulation: balanced, cuspid guidance
Prevention of failure: stabilization splint yes/no
Patient-related factors
Age
Gender
General health: complication yes/no
Oral health: complications yes/no
Bruxism: present yes/no
Evaluation-related factors
Frequency
Duration: short-term, long-term
Design: retrospective, prospective
Implant failure: criteria yes/no
Bruxism: oral history, inspection, polysomnography
Practical guidelines
Although so far, there is no convincing evidence that
bruxism causes an overload of dental implants and their
suprastructures, practitioners better proceed carefully
when planning implant procedures in bruxists, given
the seriousness of the possible complications. Below,
some practical guidelines are given as to reduce the risk
of complications and, ultimately, implant failure. It
should be stressed that, because of the lack of a solid
scientific foundation, the guidelines are not evidence
based, but rather experience based: they are mainly
extracted from expert papers on this subject. All
guidelines aim to minimize the forces that are applied
to the implants.
A frequent advice is related to the number of
implants. In the presence of bruxism, most authors
recommend to place more implants than would have
been necessary in the absence of this movement
disorder. More specifically, as to avoid free-ending
situations, one implant should be placed for each
missing element (21, 32). This recommendation is
supported by the findings of in vivo studies that
indicate a reduction of the forces that are being
exerted on an individual implant when the number
of implants increases (47). Of course, given the costs
and the irreversible nature of placing more implants,
careful clinical decision-making should be built into
the treatment plan. In addition, mechanically connecting the implants leads to a better distribution of
the forces and a reduction of the stresses in the bone
around the implants (48). Interestingly, the type of
mesostructure (bar with or without extension; ball),
from which the overdenture obtains its retention, is
not a factor that needs to be taken into account in
edentulous bruxists (49). A final recommendation
regarding the implants themselves is related to their
length and diameter: longer implants with a larger
diameter help to keep the stresses in the bone as low
as possible (21, 50).
Conclusion
Bruxism is generally considered a contraindication for
dental implants, although the evidence for this is
usually based on clinical experience only. So far,
studies to the possible cause-and-effect relationship
between bruxism and implant failure do not yield
consistent and specific outcomes. This is partly because
of the large variation in the literature in terms of both
the technical aspects and the biological aspects of the
study material. Nevertheless, given the seriousness of
possible biological and biomechanical complications,
careful pre-surgical planning and (post-) prosthetic
preventive measures should be given consideration in
bruxists.
Acknowledgments
This paper is an adapted and translated version of the
Dutch article Lobbezoo F, Brouwers JEIG, Cune MS,
Naeije M. Tandheelkundige implantaten bij bruxisten.
Ned Tijdschr Tandheelkd 2004;111:85-90, with permission from The Nederlands Tijdschrift voor Tandheelkunde B.V., Nieuwegein, The Netherlands.
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