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The Journal of Advanced Prosthodontics logoLink to The Journal of Advanced Prosthodontics
. 2025 Aug 19;17(4):247–258. doi: 10.4047/jap.2025.17.4.247

Digital analysis of occlusion variations in single posterior implant-supported fixed prostheses: a systematic review and meta-analysis of clinical trial studies

Victor Augusto Alves Bento 1,✉, Cleber Davi Del Rei Daltro Rosa 2, Leonardo Ferreira de Toledo Piza Lopes 2, Cleidiel Aparecido de Araújo Lemos 3, Eduardo Miyashita 4, Eduardo Piza Pellizzer 2
PMCID: PMC12411302  PMID: 40919047

Abstract

PURPOSE

This systematic review and meta- analysis aimed to evaluate the occlusion variations in single posterior implant supported fixed prostheses.

MATERIALS AND METHODS

The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed and the study was registered in the international prospective register of systematic reviews (PROSPERO) platform (CRD42024501657). A systematic search of the PubMed/MEDLINE, Embase, Web of Science, and Cochrane Library databases published until December 2024 was done by 2 independent reviewers, without restriction of language or publication date. A meta-analysis was performed using the R version 4.0.2, considering the significance level P < .05. Quality assessments were performed using the ROBINS-I tool.

RESULTS

Five studies were included, totaling 150 participants and 146 posterior single implant-supported fixed prostheses evaluated over time. The meta-analyses were performed with different follow-up months to evaluate the means in percentage the occlusal variations: 0,5 months (5,91%); 3 months (7,70%); 6 months (8,29%); 12 months (13,01%); 24 months (14,31%); 36 months (19,41%). Significant difference (P < .05) was presented from 12 months of follow-up.

CONCLUSION

Implant-supported prostheses present occlusal variations after installation, with a progressive increase over time, being significant after 12 months of installation. Therefore, careful long-term monitoring of occlusion is essential, with occlusal adjustments being considered when necessary.

Keywords: Dental implant, Implant-supported prostheses, Occlusal variations, Single crown

INTRODUTION

Oral rehabilitation for patients with missing teeth using implant-supported fixed prostheses is a highly predictable treatment option known for its excellent longevity.1,2 However, mechanical complications linked to implant prostheses, such as screw loosening, prosthesis and implant fracture, can compromise their longevity.3,4,5 These complications often arise due to occlusal overloads from osseointegrated implants, which exhibit distinct biomechanics compared with natural teeth due to the limited tactile sensitivity and absence of the periodontal ligament.6,7

To mitigate biomechanical stress at the prosthesis-implant interface, an occlusal scheme aimed at protecting the implant has been proposed. This involves establishing light contact during forceful occlusion and ensuring no contact occurs in the maximum intercuspal position; leaving an occlusal gap of 10 – 30 µm between the opposing natural tooth and the occlusal surface of the implant-supported single crown is recommended.8,9,10 This scheme results in a quantifiable time delay in the occlusion of implant-supported prostheses, whereby natural teeth occlude before implant-supported prostheses in fractions of seconds.11 However, studies have shown that implant prostheses do not maintain contact over time.12,13

The natural dentition undergoes continuous eruption and mesial displacement, at a rate of approximately 0.1 to 0.2 mm annually, as a physiological response to the wear generated on the proximal and occlusal surfaces over time.14,15 In contrast, osseointegrated dental implants display vertical displacement of approximately 3 – 5 µm and lateral displacement of 10 – 50 µm, whereas natural teeth exhibit values of 25 – 100 µm vertically and 56 – 108 µm laterally.4,9 Therefore, dental implants are unable to replicate the positional changes of natural teeth due to the absence of the periodontal membrane, resulting in occlusal variations.16 Furthermore, other changes may arise from occlusal abrasion, periodontal disease, temporomandibular diseases, and orthodontic treatment.17,18

Conventional methods, such as the use of articulation paper, shim stock foil, and impression waxes, are commonly used in clinical settings to determine and adjust clinical occlusion. However, their accuracy in quantifying occlusal force depends heavily on the knowledge and experience of the professional.19,20 In contrast, digital methods, such as CT scans, capture instantaneous occlusal contact, including position, intensity, and distribution in the chewing cycle, with a dynamic accuracy of 0.01 seconds. They provide an objective reflection of the distribution and changes in occlusal contact with each tooth in the dental arch.21,22 Additionally, more accessible devices, such as the T-scan, OccluSense, and intraoral scanners, record the trajectory of the center of the occlusal force, aiding in determining dynamic changes in balanced occlusal force. These devices are highly reliable for analyzing and evaluating the distribution of occlusal contact at maximum intercuspation.23,24

The scientific understanding of occlusion in partial posterior implants supported by fixed dental prostheses evolves with time, with associated factors remaining unclear and lacking substantial evidence in the literature. Therefore, this systematic review and meta-analysis aimed to evaluate long-term variations in the occlusion of single posterior implant-supported fixed prostheses using digital methods. The null hypothesis posits that significant differences will not be observed in the occlusion variations of single posterior implant-supported prostheses over time.

MATERIALS AND METHODS

Protocol and registration

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020,25 consistent with previous studies.26,27,28 A protocol was drafted and registered with the International Registry of Systematic Reviews (PROSPERO-42024501657).

PICO question

The PICO question (population, intervention, comparison, outcome) was: “Do fixed implant-supported posterior single prostheses present variations in occlusion over time?”. The population included participants with fixed posterior implant-supported prostheses. The intervention used was the occlusal changes of posterior single implant-supported fixed prostheses with antagonist teeth. The comparison consisted of occlusal register in prosthetic placement appointment. The outcome assessed was the occlusal changes of posterior single implant-supported fixed prostheses over time.

Eligibility criteria

The inclusion criteria: 1) clinical trial studies (retrospective or prospective cohort studies); 2) studies with at least 10 participants; 3) information on the occlusal changes of posterior single implant-supported fixed prostheses with antagonist teeth; 4) long-term follow-up. The exclusion criteria were clinical trial studies less than 10 participants, without follow-up, and without digital methods register for occlusal changes.

Search strategy

Two researchers independently (V.A.A.B., C.D.D.R.D.R.) searched for relevant studies in the PubMed/MEDLINE, Embase, Web of Science, Cochrane Library, and ProQuest (gray literature)databases published until December 2024. The detailed search strategies for each database are provided in Supplementary Table 1 (Supplementary material).

Selection process

A Rayyan QCRI reference manager (https://rayyan.ai/) was utilized for importing search results, removing duplicates, selecting relevant studies, and application of eligibility criteria. When the first 2 researchers disagreed, a third researcher (E.P.P.) was consulted, and agreement was obtained by consensus.

Data extraction

One author (V.A.A.B.) collected data from the included articles, and 2 authors (L.F.T.P.L., E.M.) reviewed all the information collected. The variables registered: information about the author, years of studies, number of participants, age, sex, digital system, follow-up, occlusal changes, and results.

Risk of bias

The quality of the selected studies was assessed using the quality assessment tool, independently analyzed by 2 investigators (V.A.A.B., L.F.T.P.L.), provided by the ROBINS-I tool.29

Meta-analysis

A single-arm meta-analysis of percentage was performed by using R software (version 4.0.2; The R Foundation for Statistical Computing [http://www.r-projetct.org/]) by one researcher (C.A.A.L.) and reviewed by 2 authors (E.P.P., E.M.). The package “meta” was used to perform the statistical calculations and to generate forest plots with a 95% CI, and a P-value < .05 deemed statistically significant. The measurement sequence of the studies was grouped into “MRAW” (untransformed means) and was used to estimate the confidence interval for individual studies to evaluate the means in percentage, considering the significance level P < .05. The I2 data were used to estimate heterogeneity. If I2 was greater than 50%, the random effect model was used; otherwise, the fixed effect model was used.

Additional analysis

An analysis was performed to compare the level of intra-examiner agreement during individual research, utilizing the kappa concordance criteria. Any disagreements were resolved by discussion and consensus among all authors.

RESULTS

Search strategy

The search identified 702 articles, 240 of which were sourced from PubMed/MEDLINE, 194 from the Embase, 190 from the Web of Science, 47 from the Cochrane Library, and 31 from theProQuest. After the exclusion of 207 duplicate entries articles, 495 studies were selected for reading the titles and abstracts. Of these, 14 articles were selected to apply the eligibility and exclusion criteria, of which 9 articles30,31,32,33,34,35,36,37,38 were excluded for the reasons listed in Table 1. Thus, 5 articles were included in the analysis. The search strategy is visualized as a flow diagram in Figure 1. The Kappa indicated a high level of agreement in all databases (PubMed/MEDLINE: 0.75; Embase: 0.78; Web of Science: 0.78; Cochrane Library: 1.0; and ProQuest: 1.0).

Table 1. Excluded studies and reasons for exclusion.

References Reasons for Exclusion
Dario (1995),30 Stevens (2006)31 case reports
Cotruta et al. (2015),32 He et al. (2023)33 in vitro studies
Okada et al. (2015)34 without digital method
Ding et al. (2023)35 without follow-up
Luo et al. (2019)36 less than 10 participants
Pellicer-Chover et al. (2014),37 Saud et al. (2023)38 implant-supported fixed partial prostheses
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Fig. 1. Flow diagram detailing search strategy.

Fig. 1

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*PubMed/MEDLINE, Embase, Web of Science, Cochrane Library, and ProQuest.

Characteristics of included studies

A total of 5 clinical trial studies12,13,39,40,41 (prospective), published between 2017 and 2023 were included, with a total 150 participants (76 women and 74 men) and 146 posterior single implant-supported fixed prostheses evaluated over time. All studies showed significant occlusal changes of implant-supported fixed prostheses over time (Table 2).

Table 2. Characteristics of included studies.

Author / Year Type study Total patients Age mean (year) Total implant-supported prostheses Digital system Evaluation time (months) Occlusal variation (Mean ± SD) Results
Madani et al. (2017)12 P 21 (10W and 11M) 30.81 ± 8.85 21 T-Scan III® (Tekscan, EUA) Post installation, 3 and 6 Post installation: 4.0 ± 0.19%
3: 4.52 ± 0.20%
6: 5.0 ± 0.28%		 Occlusal forces at 6- and 3-month follow-up were significantly greater than those of post-installation prosthesis insertion.
Furthermore, there were significant differences between the 3- and 6-month follow-up.
Luo et al. (2020)13 P 33 (18W and 15M) 42.8 ± 12.9 37 (36 months) T-Scan III® (Tekscan, EUA) 0.5, 3, 6, 12, 24 and 36 0.5: 7.46 ± 4.21%
3: 9.87 ± 6.79%
6: 10.59 ± 6.59%
12: 13.03 ± 10.61%
24: 14.32 ± 10.99%
36: 19.09 ± 11.76%		 Occlusal forces increased significantly from 2 weeks to 3 months, from 6 to 12
months, and from 12 to 24 months.
Ding et al. (2022)39 P 33 (18W and 15M) 42.8 ± 12.9 37 (36 months) T-Scan III® (Tekscan, EUA) 0.5, 3, 6, 12, 24, 36, 48 and 60 0.5: 7.0 ± 4.2%
3: 9.9 ± 6.8%
6: 10.6 ± 6.6%
12: 13.0 ± 10.6%
24: 14.3 ± 11%
36: 20.2 ± 14.8%
48: 16.7 ± 8.6%
60: 23.3 ± 16.8%		 The occlusal forces of the implant-supported single crowns increased from 2 weeks to 3 months and from 6 to 36 months.
Zhou et al. (2022)40 P 30 (18W and 12M) 55.83 ± 9.46 18 T-Scan III® (Tekscan, EUA) 0.5, 3 and 6 0.5: 3.39 ± 2.61%
3: 6.90 ± 4.77%
6: 7.31 ± 4.60%		 The occlusal strength of implant-supported prostheses increased significantly by an average of 2.04 times from 2 weeks to 3 months, while no significant difference was found from 3 months to 6 months.
Zhang et al. (2023)41 P 33 (12W and 21M) 46.8 33 Scanner intraoral (3Shape TRIOS Color, 3Shape) LS: 12 and 36
ZrO: 12 and 36		 LS 12: 0.909 ± 2.842 mm2
LS 36: 1.075 ± 2.575 mm2
ZrO 12: 0.812 ± 1.808 mm2
ZrO 36: 1.676 ± 2.551 mm2 		No significant differences were found between the two groups at the 1- and 3-year follow-up.
Despite this, the occlusal performance of implant prostheses needs to be closely examined during follow-up and appropriate occlusal adjustments need to be considered.
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LS, monolithic lithium disilicate; M, men; P, prospective; W, women; ZrO, zirconia.

Outcomes

Four studies12,13,39,40 evaluated occlusal changes using the T-Scan III® digital system (Tekscan Inc., Boston, MA, USA), presenting measurements as a percentage of variations, while the study by Zhang et al.41 used an intraoral scanner system (3Shape TRIOS Color, 3Shape), presenting the data in mm2 differences.

In general, the study by Madani et al.12 evaluated 21 implant-supported prostheses, 9 located in the maxilla and 12 in the mandible, 13 of which were premolars and 8 molars. The study by Luo et al.13 evaluated 37 prostheses, including 22 metal-ceramic crowns, 12 crowns on metal-resin implants, 2 cast metal crowns and 1 ceramic crown. The study by Ding et al.39 evaluated 37 prostheses, including 19 metal-ceramic crowns, 16 crowns on metal-resin implants, 2 cast metal crowns and 1 ceramic crown. The study by Zhou et al.40 evaluated 18 prostheses, all screw-retained zirconia crowns, 15 premolars and 3 molars, 6 located in the maxilla and 12 in the mandible. Zhang et al.41 evaluated 33 prostheses, 25 molars and 8 premolars, all full ceramic crowns (17 monolithic lithium disilicates and 16 zirconia veneers). The studies did not specify the type of implant (Morse cone or external hexagon). The studies by Luo et al.)13 and Ding et al.39 presented complication rates, such as crown fractures, screw loosening, and loss of retention at 16.2% and 8.1%, respectively.

Risk of bias

The evaluation of results for quality of methodology used in the ROBINS-I tools for non-randomized interventional studies indicated a moderate risk of bias in studies by Madani et al.,12 Luo et al.,13 and Ding et al.,39 identifying deficiencies, mainly, in domain D4 (Bias due to deviations from intended interventions), as they are prospective studies with convenience findings (Fig. 2).

Fig. 2. Results of appraisal of risk of bias in studies based on ROBINS-I.

Fig. 2

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Meta-analysis

Zhang et al.41’s study was not considered for meta-analysis, as it investigated the occlusal change with intraoral scanner presenting results in mm2, making a comparison impossible; thus, 4 studies12,13,39,40 were included for meta-analysis. The percentage of occlusal changes of posterior fixed prostheses supported by single implants over time were extracted from each study for the single-arm meta-analysis. The meta-analysis was performed with different follow-up months to evaluate the means in percentage the occlusal variations: 0.5 months (5.91%; CI: 3.23 – 8.58%; heterogeneity: I2 = 91% t2 = 5.0390; P < .01); 3 months (7.70%; CI: 4.47 – 10.93%; heterogeneity: I2 = 94% t2 = 9.9314; P < .01); 6 months (8.29%; CI: 4.95 – 11.62%; heterogeneity: I2 = 95% t2 = 10.7082; P < .01); 12 months (13.01%; CI: 10.60 – 15.43%; heterogeneity: I2 = 0% t2 = 0; P = .99); 24 months (14.31%; CI: 11.80 – 16.82%; heterogeneity: I2 = 0% t2 = 0; P = .99); 36 months (19.41%; CI: 15.26 – 23.56%; heterogeneity: I2 = 0%; t2 = 0; P = .81). Significant difference was presented in 12, 24, and 36 months of follow-up, based on the confidence interval diamond not overlapping the line of no effect (CI: 7.20 – 8.53%; heterogeneity: I2 = 95%; t2 = 0.83; P < .01; subgroup difference: P < .05) (Fig. 3).

Fig. 3. Forest plots. Percentage of occlusal changes of posterior single implant-supported fixed prostheses over time.

Fig. 3

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DISCUSSION

This systematic review and meta-analysis rejected the null hypothesis, as significant differences in the occlusal variations of implant-supported dentures were observed over time. The meta-analysis revealed that occlusal changes became apparent from 0.5 months following the installation of implant-supported prostheses, progressively increasing over time and reaching significance at 12, 24, and 36 months.

The continuous eruption of natural teeth antagonistic to implant-supported prostheses is considered the primary factor causing occlusal variations in prostheses because osseointegrated dental implants are ankylosed and do not move, so initially, the light contact established at the time of prosthesis installation evolve into early contact over time, resulting in increased occlusal force in this region.13,39 Madani et al.12 associated the light occlusal contact established during installation with inducing the eruption of antagonist tooth. However, this association has been refuted by studies demonstrating similar changes in natural teeth in function, which is a natural compensatory mechanism for occlusal wear of natural enamel.14,15

A systematic review and meta-analysis conducted by Mao et al.42 revealed that ceramic prosthetic materials induce significantly greater wear on antagonistic tooth enamel than on natural teeth. Specifically, metal-ceramic and monolithic zirconia crowns were found to cause the most significant wear. In conjunction with these findings, greater wear of the natural tooth implies increased eruption, resulting in elevated occlusal force in the region. However, the studies included in this systematic review did not evaluate the occlusal wear of the natural tooth opposing the implant-supported prosthesis. Additionally, they did not specify which type of crown material exhibited the greatest increase in occlusal strength over time. Therefore, this systematic review could not determine whether natural tooth wear played a significant role in the observed occlusal variation.

Another factor contributing to changes in the occlusion of implant-supported prostheses is the greater physiological mobility observed in natural teeth compared with implants when subjected to occlusal load. Natural teeth benefit from the cushioning effect of the periodontal ligament, allowing for some degree of intrusion during occlusal load. Studies have reported an average axial displacement of 25 – 100 µm for teeth in the socket, whereas the axial movement of osseointegrated implants is approximately 3 – 5 µm.4,9,16 Therefore, when occlusal loads are applied, implant-supported dentures experience higher occlusal forces and earlier occlusal contact than natural teeth, despite initially establishing lighter contact during installation.13

Inadequate occlusal force is considered one of the primary causes of fracture in veneer implant prostheses, regardless of the type of crown material used.13,39 Among the studies reviewed, Luo et al.13 and Ding et al.39 were the only ones who reported complication rates during the testing period. In these studies, fracture of the veneer material emerged as the most common technical complication. Ding et al.39 observed that before fractures occurred, the prostheses experienced occlusal forces similar to or greater than those experienced by natural teeth, even after adjustments for light contact. However, the study did not specify the type of crown material associated with the fractures.

The study by Ding et al.39 was the sole investigation to explore occlusal changes in relation to peri-implant bone level. Their findings indicated that changes of 1% resulted in a marginal increase in bone loss by only 0.008 mm, suggesting an inability to attribute marginal bone loss solely to excessive occlusal force. Long-term clinical studies focusing on the potential impact of overload on peri-implant bone loss are lacking. Additionally, a systematic review by Bertolini et al.43 concluded that the effect of traumatic occlusal forces on peri-implant bone loss has been inadequately reported, providing insufficient evidence to establish a cause-and-effect relationship in humans.

The study conducted by Zhang et al.41 was the sole investigation that utilized an intraoral scanner to evaluate occlusal changes. Although evidence suggests that this system accurately captures static interocclusal recordings of the quadrants, its accuracy in analyzing occlusal changes has not yet been demonstrated. In contrast, all studies included in the meta-analysis assessed occlusion variations using the T-scan system, which has already been established as a reliable and valid method for measuring the distribution of occlusal contacts, occlusal contact time, and occlusal contact area. Additionally, studies have presented general occlusal strength as a measure of the percentage of variations.12,13,39,40 The meta-analysis conducted in this review revealed a significant increase in occlusal variations from 12 months onwards. However, studies by Luo et al.13 and Ding et al.39 observed a significant increase within the initial 6 months following prosthesis installation. These findings provide clinically relevant data for monitoring of implant-supported prostheses.

The main limitation of this study is that intrinsic factors related to occlusion variations, such as screw loosening, settling effect, prosthetic misfit, or mechanical wear of abutment connections, were not explored by the clinical studies included in this systematic review, and these factors are related to inflammation in occlusal force. Furthermore, no study compared the change in occlusal force involved in implant-to-implant occlusion. Therefore, it is recommended to conduct new randomized clinical studies evaluating all intrinsic factors related to occlusion variations of implant-supported prostheses.

CONCLUSION

Based on the findings of this systematic review and meta-analysis, the following conclusions were drawn:

  • 1. Implant-supported prostheses present occlusal variations after installation, with a progressive increase over time.

    2. Significant changes in the occlusal variations of implant-supported prostheses appear after 12 months of installation.

SUPPLEMENTARY MATERIAL

Supplementary Table 1

Set of terms used in the database searches

jap-17-247-s001.pdf (31.9KB, pdf)

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Associated Data

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Supplementary Materials

Supplementary Table 1

Set of terms used in the database searches

jap-17-247-s001.pdf (31.9KB, pdf)

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