The Innovative Smile – “Implant Integrated Occlusion (IIO)”
By Sangiv I Patel RDH, DDS, AFAAID (Mastership Dental Biometrics) // July 13, 2014
Dental Implantology and rehabilitation has progressed from a science focused on implant integration to instant gratification procedures such as “all on four” and “teeth in a day” concepts.
The one element that has eluded us is predictable longevity beyond Implant integration. Dr. Tatum’s observation that occlusion is the primary enemy while the TMJ’s are imprecise, acknowledges the challenges that continue to exist for the rehabilitative dentist.
The Key question is, how long does the complete rehabilitation really last?
The 40 year development of “NIRISAB” by Dr. Tatum is a testament to his passion to generate longevity.
This three part series will introduce current concepts and future potential of the dental trinity: occlusion, TMJ’s and neuromuscular components in stomatognathic rehabilitation.
I am honored to have been asked to introduce my “The Innovative Smile” (TIS) to dental implantology with Dr. Tatum’s endorsement.
“The Innovative Smile” (TIS) was founded and has been continually developed by me since 2002. It is with the understanding that the stomatognathic system is designed with a natural resiliency to environmental stressors.
The system is empowered by the trigeminal nerve and is adaptable. Modern dental treatments and materials do not have this capacity.
Among the most rigid restorations are dental Implants restored with crowns, bridges, overdentures, and screw retained prosthetics.
Additional biomechanical complexity is added due to the vast array of occlusal schemes and material selection such as resins, metals and/or zirconia based prosthetics.
These treatments and materials alter the natural resiliency of the masticatory system.
Accepting physiologic evidenced based treatment planning and treatment delivery for these rehabilitative and restorative options is critical to the longevity of proposed treatment and the health and stability of the stomatognathic system.
The current standard of “Implant Protected Occlusion” (IPO) was designed to protect the implant and the restoration from failure secondary to occlusal forces and trauma.
In 2004, Kim Y, Oh T-J, Misch CE, Wang H-L. Published “Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale”.
They state “implant-protected occlusion has been proposed strictly for implant prostheses (Misch & Bidez 1994).
This concept is designed to reduce occlusal force on implant prostheses and thus to protect implants.
For this, several modifications from conventional occlusal concepts have been proposed, which include providing load sharing occlusal contacts, modifications of the occlusal table and anatomy, correction of load direction, increasing of implant surface areas, and elimination or reduction of occlusal contacts in implants with unfavorable biomechanics.
Also, occlusal morphology guiding occlusal force to the apical direction, utilization of cross-bite occlusion, a narrowed occlusal table, reduced cusp inclination, and a reduced length of cantilever in mesio-distal and bucco-lingual dimension have all been suggested as factors to consider when establishing implant occlusion.
Basic principles of implant occlusion may include:
(1) bilateral stability in centric (habitual) occlusion.
(2) evenly distributed occlusal contacts and force.
(3) no interferences between retruded position and centric (habitual) position.
(4) wide freedom in centric (habitual) occlusion.
(5) anterior guidance whenever possible.
(6) smooth, even, lateral excursive movements without working/non-working interferences.
The longevity this paradigm and practice of Implant Protected Occlusion provides, often comes as a result of an under engineered or non-functional occlusion.
In Washington D.C in 2010, I introduced “Implant Integrated Occlusion” (IIO).
It is my paradigm and model within the scope of my “The Innovative Smile” (TIS).
“Implant Integrated Occlusion” (IIO) is the evolution in implant occlusion founded on the principles of “physiologic occlusion” generated in the development of “The Innovative Smile” (TIS).
Even though “Implant Integrated Occlusion” (IIO) is a term formally coined by me just 2 years ago, I have been teaching it in different formats since 2007.
IIO has now developed a merit based following after a period of 5 plus years in development and clinical application.
IIO is designed not to protect the implant and prosthetic, but to leverage the energy transfer during the process of occluding to manage the equilibrium between skeletal (tooth and bone) modeling and remodeling.
Inherent in this energy transfer is the preservation of occlusal materials, abutment screws, all-ceramic abutments, the implant-bone interface and therefore soft tissue levels.
Implant Integrated Occlusion (IIO) increases the longevity of implant and rehabilative dentistry by clinical application of IIO’s 10 tenants.
These critical tenants require significantly more explanation than this brief introductory article will allow.
In approximately 10 short years, Cone Beam CT technology has revolutionized diagnosis and treatment planning. A clear differentiation to accept is that CBCT technology yields a static 3-D snapshot in time.
Our stomatognathic system is dynamic and therefore requires 4-D technologies able to assess function in time and motion.
Remember, it is the fourth dimension of time and motion that determines longevity.
Digital Occlusion (T-Scan® Computerized Analysis system (Tekscan, Inc.) is an essential technology required to practice IIO’s 10 tenants.
This 4-D technology allows analysis in chronology and therefore provides the capacity to gauge adaptation.
Implant Protected Occlusion’s intraoral interpretation is primarily via the utilization of articulating paper marks (Fig.1).
This technique has now been proven inaccurate by several studies. In comparison, Digital Occlusion via the T-scan accelerates with accuracy the diagnosis, treatment and application of “physiologic occlusion” principles.
The T-scan (Fig.2) is an essential technology because it:
1. maps occlusal contact locations.
2. measures intensity of those contacts.
3. tracks center of force trajectory.
4. calculates occlusion time.
5. calculates disclusion time.
6. measures force distribution.
7. demonstrates timing of contacts.
8. monitors the generation of bilateral simultaneity.
It is what I call “digital proprioception”.
The T-scan is the only mechanism available to engineer longevity at the terminal intraoral contact position during occluding.
I realize that this introductory article will generate many questions.
I hope it intrigues you enough to take the journey to understand Dr. Tatum’s enemy of occlusion closely, accurately, in real time and over time on each patient.
“Implant Integrated Occlusion (IIO)” is designed to help you conquer the learning curve of today’s occlusal management with predictability.
This will empower you to increase the longevity of your patient’s oral rehabilitation and therefore the longevity and quality of their lives.