Journal of Oral Rehabilitation 2006 33; 152159
Review Article
Dental implants in patients with bruxing habits
F. LOBBEZOO*, J. E. I. G. BROUWERS*, M.S. CUNE & M. NAEIJE*
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
SUMMARY Bruxism (teeth grinding and clenching) 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. Although there is still no proof
for the suggestion that bruxism causes an overload
of dental implants and of their suprastructures, a
Introduction
Bruxism is a movement disorder of the masticatory
system that is characterized, among others, by teeth
grinding and clenching, during sleep as well as during
wakefulness (1, 2). Several recent review articles
describe the definitions, epidemiology, (differential)
diagnosis, aetiology, and treatment of this disorder (3
5). Bruxism is frequently considered an aetiological
factor for temporomandibular disorders (TMD), tooth
wear (e.g. attrition), loss of periodontal support, and
failure of dental restorations, although conflicting
evidence for many of these purported aetiological
relationships can be found in the literature (611).
Bruxism has also been suggested to cause excessive
(occlusal) load of dental implants and their suprastruc-
tures, ultimately resulting in bone loss around the
implants or even in implant failure. Not surprisingly,
bruxism is, therefore, often considered a cause of concern
or even a contraindication for implant treatment, as
stated in many textbooks and conference proceedings on
oral implantology and prosthetic dentistry (e.g. 12, 13).
In addition, many researchers use bruxism as an exclu-
2006 Blackwell Publishing Ltd
*Department of Oral
careful approach is recommended. There are a few
practical guidelines as to minimize the chance of
implant failure. Besides the recommendation to
reduce or eliminate bruxism itself, these guidelines
concern the number and dimensions of the implants,
the design of the occlusion and articulation patterns,
and the protection of the final result with a hard
occlusal stabilization splint (night guard).
KEYWORDS: bruxism, dental implants, overload, fail-
ure, causality
Accepted for publication 3 May 2005
sion criterion for the selection of their participants in
clinical studies concerning treatment modalities with
dental implants (e.g. 1416). These authors argue that
the overloading influence of bruxism on implants and
their suprastructures yields a higher risk of biological and
biomechanical complications than would be the case
during physiological masticatory activities. However,
sound scientific proof for such an argument is never
mentioned. In this review article, aspects of load and
overload of dental implants are described and the
available evidence for a possible cause-and-effect rela-
tionship between bruxism and implant failure is being
discussed. Finally, a set of practical guidelines is given for
clinicians who have indicated a treatment with dental
implants in a patient with bruxism.
(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
152

foods (crackers) up to 120 N for tough foods (jelly
babies). In the same study, it was shown that maximal
clenching in the intercuspal position, during which not
only the implant but the entire dental arch is loaded,
yields maximum vertical forces of about 50 N on the
implant, while maximal clenching on an occlusal foil,
inserted at the level of the implant, doubles the
maximum load levels on the implant. In another
in vivo study, Richter (18) demonstrated that the hori-
zontal components of forces, applied to suprastructures,
result in bending moments of about 90 Nmm for forces
in the linguo-buccal direction and of about 170 Nmm
for bucco-lingual forces. These latter forces also yield
the highest stress values in the alveolar bone, viz. up to
maximum values of more than 6 MPa at the residual
ridge crest on the buccal side. For comparison reasons,
mesio-distal forces cause a maximum cervical stress of
about 1 MPa only (18).
The values of the forces and moments, as presented by
Richter (17, 18), have been established during the
performance of conscious oral activities. For unconscious
oral motor activities like bruxism, such values are not yet
available. Proprioception around dental implants is
limited because of the absence of a periodontal ligament.
Consequently, the proprioceptive feedback mechanisms
to the jaw closing muscles are limited as well. In addition,
the perception of forces is limited in implant patients
(19). It is, therefore, not unlikely that forces that are
applied to implants during bruxism are even larger than
those exerted during mastication. Engel et al. (20) claim
this to be common knowledge. In other words, chewing
is supposed to be a physiological load for dental implants;
bruxism, an overload.
When the term overload is being used, it is impli-
citly suggested that an implant is either in the process of
ailing or failing, or has already failed (21). According to
El Askary et al. (21), the warning signs of implant
failure are: loosening or fracture of connecting screws
or abutment (screws), swelling or bleeding of peri-
implant soft tissues, purulent exudate from deep
peri-implant pockets, pain (rare), fracture of supra-
structures, angular bone loss as noted on radiographs,
and chronic infection and soft tissue sloughing during
the healing phase following first-stage surgery.
Biological complications
The consequences of overload of dental implants can be
divided into two groups: biological and biomechanical
2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 152159
DENTAL IMPLANTS IN BRUXERS 153
complications. Biological complications can, in turn, be
divided into early failures and late failures (22). In case
of early failures, osseointegration was insufficient: the
implant is lost before the first prosthetic loading. Early
failures, however, may also occur in case of early
loading (68 weeks after surgery) or immediate loading
(within 2 weeks following surgery) of dental implants.
In such cases, the implant fails at an early stage, with a
suprastructure in situ.
Contrary to early failures, late biological failures are
characterized by pathological bone loss after full osseo-
integration was obtained at an earlier stage. Such bone
loss is usually localized around the cervix of the
implant, and is considered excessive when the loss is
more than 02 mm year)1, after the implant has been
functional for 1 year (23). Late biological implant
failures are, among others, associated with overload.
Some insight into bone physiology is needed for a
proper understanding of the mechanisms of excessive
bone loss because of overload. Mechanical load causes
adaptation and remodelling of bone via a process of
resorption and deposition. When similar amounts of
bone are being resorbed and deposited, equilibrium is
present that is characteristic for a physiological loading
of bone (24). In case of overload, equilibrium between
bone resorption and deposition is being disturbed,
thereby causing fatigue-related micro-fractures at, and
around, the boneimplant interface (24). These frac-
tures are being repaired by bone resorption and a
subsequent ingrowth of connective tissue and epithe-
lium instead of new bone. This process was derived
from animal studies (2527). Likewise, animal studies
also demonstrated that dynamic overload, like teeth
grinding, results in excessive angular bone loss (28).
Form the above, the suggestion can be gathered that
bruxism is associated with implant failure. Supposedly,
especially the large, laterally directed forces that go
with teeth grinding are responsible for this clinical
problem.
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).
154 F . L O B B E Z O O et al.
Especially, the loosening of screwnut attachments in
prosthetic constructions occurs relatively frequent (31).
The preload of the screw (i.e. the tensile force estab-
lished 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-and-
effect 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 convin-
cing 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
Table 1 Criteria for establishing causation [after Spilker (34)]
Cause-and-effect criteria
Bias and confounding factors are absent
The cause precedes the effect
The association makes epidemiological sense
A doseresponse gradient is present
The association is specific
The association is consistent
2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 152159
prospective approach of the study sample is required; it
is not possible to establish the order of events retro-
spectively. Moreover, it is essential to include multiple
evaluations over time in the study design. Many studies
to the association between bruxism and implant failure,
however, have a retrospective design (e.g. 33, 35) or
even have the format of a case report (e.g. 36).
Therefore, these studies are difficult to interpret. For-
tunately, several studies do have a prospective design.
Lindquist et al. (37) presented a 15-year prospective
study, during which five evaluations were performed.
They concluded that clenching was not significantly
correlated with marginal bone loss and did not lead to
problems with suprastructures. Given the strong study
design, this conclusion is important for the final
judgement of the purported causal relationship that is
being evaluated in the present article. Contrary to the
conclusion of Lindquist et al. (37), several other
prospective studies, although covering shorter study
periods than in the study by Lindquist et al. do report
significant associations between bruxism and problems
with dental implants or their suprastructures. Wannfors
et al. (38) reported a significant relationship between
bruxism and implant failure after the implants have
been functional for 1 year. Likewise, Glauser et al. (39)
found a higher percentage of implant loss in bruxists
than in non-bruxists (41% versus 12%, after 1 year).
Bragger et al. (40) even reported technical problems
with implants in 60% of their bruxists over 5 years, as
compared with about 20% in their non-bruxists.
Interestingly, in contrast with their later findings in
1996 (37), Lindquist et al. conclude in 1988 (41) that
clenching does contribute significantly to marginal
bone loss over a 6-year period. Taken all evidence
together, the prospective studies do not have unequi-
vocal outcomes. Nevertheless, the available evidence
slightly tends to confirm the presence of a causal
relationship between bruxism and implant failure.
To fulfil the third criterion for a causal relationship,
the association between bruxism and implant failure
needs to be plausible from an epidemiological point of
view. About 620% of the general adult population
reports bruxism (for a review, see 7). Given the high
success rates for most dental implant systems, it is
therefore unlikely that all implants fail in the presence
of bruxism. On the other hand, it is possible that
bruxism is a commonly used contraindication for
implant procedures, so that the presence of bruxism
in populations of implant patients is lower than that in

the general population. Unfortunately, there is no
research available about this subject. The usually high
success rates of implant procedures, which sometimes
reach up to almost 99% (37), indicate that implant
failure is an exception rather than the rule. As a
consequence, studies to factors that contribute to
implant failure, such as bruxism, need to include large
samples as to ascertain large-enough numbers of
failures.
The literature does indicate that in studies, in which
bruxism was used as an exclusion criterion, success
rates of about 95% are found after 1824 months
(1416), while for studies that included bruxism
patients in their study sample, lower success rates are
reported, i.e. about 80% after 12 years (39, 42). On
the other hand, some studies report high success rates
despite the inclusion of bruxists in the study popula-
tion. For example, the cumulative success rate after
6 years varies between 92 and 95% in a study by
Quirynen et al. (43), while Lidquist et al. (37) reported a
success rate of almost 99% after 15 years. In other
words, epidemiological data yield equivocal results with
regard to the purported causal relationship between
bruxism and implant failure. Hence, the third criterion
in Table 1 is not fulfilled unequivocally.
According to the fourth criterion for a valid cause-
and-effect relationship, a doseresponse gradient needs
to be present. Although on the response side, efforts
have been undertaken to collect sufficient evidence (for
example the amount of marginal bone loss is suitable
for quantifying the response), on the side of the dose
only little has been carried out so far to quantify
bruxism. Engel et al. (20) use the amount of tooth wear
as a measure of parafunctional activities. These authors
found no association between tooth wear and marginal
bone loss. In the discussion of their paper, they
elaborate on the disadvantages of their measure for
bruxism, which, among others, can be the result of
teeth grinding, but not of clenching. On top of that, the
clinical distinction between attrition and other types of
tooth wear, like erosion, is sometimes difficult. Further,
the observed tooth wear may have happened in the
past while at the time of the clinical evaluation,
bruxism is no longer present. Finally, it is difficult, if
not impossible, to determine the amount of tooth wear
on restored teeth. In contrast to Engel et al. (20), Tosun
et al. (44) used the current gold-standard technique for
the establishment of a diagnosis of sleep bruxism, viz. a
sleep recording (polysomnography; PSG) (3). PSG is
2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 152159
DENTAL IMPLANTS IN BRUXERS 155
very suitable for the quantification of bruxism. In the
study sample of Tosun et al. (44), implant failure was
found in 5% of the cases. PSG recordings of this 5%-
subsample revealed the presence of sleep bruxism in
about one-third of the cases. Unfortunately, the uncon-
trolled character of this study prevents an unequivocal
interpretation of this outcome. In the other studies, to
which this review refers, bruxism was determined
anamnestically and/or clinically, so that no reliable
diagnosis of bruxism was established in these studies. In
some of the articles, the mode of bruxism determin-
ation is not given at all. From the above, it is clear that
the existence of a causal relationship between bruxism
and implant failure cannot be proven on the basis of the
fourth criterion in Table 1.
The more specific the association is, the likelier the
causal character of the relationship of interest (Table 1,
criterion 5). In other words, when fewer factors are
involved in the failure of dental implants, this criterion
is better fulfilled. Most studies, however, indicate that
multiple factors play a role in implant failure: bruxism,
but also (and may be even more importantly) smoking
(37), a bad oral hygiene (37, 41), post-operative
infections (38), and a poor bone quality (39). Possibly,
the simultaneous presence of multiple factors leads to
multiple implant failures at the same time (35). In
short, the failure of dental implants is not specifically
because of bruxism. The fifth criterion is thus not
fulfilled.
Finally, according to the sixth criterion in Table 1,
the association between bruxism and implant failure
needs to be consistent. From the above description
about the other criteria for valid cause-and-effect
relationships, it can be gathered that bruxism some-
times can, and at other times cannot, be associated with
the failure of dental implants. Hence, the sixth criterion
is not fulfilled either.
Taking all evidence together, it must be concluded
that so far, the proof for a cause-and-effect relationship
between bruxism and implant failure is insufficient:
only the second criterion partly contributes to the
evidence. Future studies need to be designed as to
specifically address this purported causal relationship.
Discussion
From the above paragraphs, it can be gathered that the
various biomechanical, epidemiological, and experi-
mental (clinical) studies yield contradictory results in
156 F . L O B B E Z O O et al.
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 examina-
tion: there are hardly any studies whose materials are
fully comparable. This further complicates the inter-
pretation 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 extrapo-
late the findings to the clinical situation (46). Unfortu-
nately, 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
2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 152159
implant failure and who want to enable a comparison
with other researchers studies to this relationship at
the same time. At least, authors should describe the
factors mentioned in the table, so that the reader can
identify the differences and similarities between studies.
The many possible combinations in Table 2 also dem-
onstrate that the subject of this review still offers a lot of
challenges.
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 con-
necting 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).

According to Esposito et al. (51), the literature does
not yet indicate how predicable early loading or
immediate loading of dental implants is. Caution is,
therefore, recommended when using either of these
techniques, especially in bruxists. Most authors agree
that in occlusion, the prosthetic rehabilitation should
have single point contacts as close to the centre of the
implant as possible. Articulation should be character-
ized by flat incline planes of the cusps as to protect the
implant system against the lateral components of the
forces that are being exerted during, for example, teeth
grinding (5254). Research using finite element models
has indicated that especially non-axial, horizontal
forces result in high tensions around the cervix of an
implant (45).
A hard stabilization splint for nightly use (night
guard) contributes to optimally distributing, and ver-
tically redirecting, the forces that go with nocturnal
teeth grinding and clenching (21, 32, 50, 5355).
Finally, most authors recommend to at least try to
minimize or, even better, eliminate bruxism behaviour
in implant patients. However, such efforts require
difficult, and often multidisciplinary, treatments with
unpredictable outcomes (3, 56).
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 per-
mission from The Nederlands Tijdschrift voor Tandhe-
elkunde B.V., Nieuwegein, The Netherlands.
2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 152159
DENTAL IMPLANTS IN BRUXERS 157
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Correspondence: Dr Frank Lobbezoo, Department of Oral Function,
Academic Centre for Dentistry Amsterdam (ACTA), Louwesweg 1,
1066 EA Amsterdam, The Netherlands.
E-mail: f.lobbezoo@acta.nl