Functional Occlusion

Presented byDr. Ruchi Saxena Dept. of Orthodontics

Contents

Mechanics of Mandibular movement  Types of functional occlusion  Criteria for optimal functional occlusion  Functional occlusion for the Orthodontist


Mechanics of Mandibular Movement



 

Complex series of rotational & translational activities Combined and simultaneous activities of TMJ 2 types of movement :Rotational Translational

Rotation


Dorlands Medical dictionary defines rotation as the process of turning around an axis: movement of body about its axis -Rotational movement around a fixed point in the condyle -Rotational movement occurs in 3 planes of space

Horizontal axis of rotation

Hinge movement  Terminal hinge axis  Pure rotation


Frontal (vertical) Axis of rotation

 

One condyle moves anteriorly Vertical axis of other condyle remains in terminal hinge axis This type of isolated movement does not occur naturally

Sagittal Axis of rotation



One condyle moves inferior while other remains in the terminal hinge position

Ligaments of TMJ prevent inferior movement

Translation Movement


A movement in which every point of the moving object has same velocity

Single plane border movement

Border movements-when the mandible moves through the outer range of motion reproducible limits results. Sagittal plane border and functional movement Frontal plane border and functional movement Horizontal plane border and functional movement

Sagittal plane border and functional movement

   

1.Post. Opening border 2.Ant. Opening border 3.Superior contact border 4.Functional

Posterior opening border movement



2 stage hinging movement -rotational movement of the mandible with the condyles in the terminal hinge position -pure rotation occurs till anterior teeth are 20-25 mm apart

2nd stage

TMJ ligaments tightens anterior &inferior movement of condyle shift in the axis of rotation 2nd stage  Max opening is in the range of 40-60 mm

Anterior opening border movement

 

Contraction of lateral pterygoid Posterior movement of condyle

Superior contact border movements



 

Its precise delineation depends upon five factorsThe amount of variation between CR & CO Steepness of cuspal inclines of posterior teeth

Amount of vertical and horizontal overlap of anterior teeth The lingual morphology of anterior teeth The general inter arch relationships of teeth

Common relationship of the teeth when condyles are in the centric relation (CR)

Force applied to the teeth will create a superioanterior shift of the mandible to ICP

W hile the mandible moves forward, contact of the incisal edges of the mandibular anterior teeth with the lingual surfaces of the maxillary anterior teeth creates an inferior movement

Horizontal movement of the mandible while the incisal edges of maxillary and mandibular teeth pass across each others

Continued forward movement of the mandible results in a superior movement while the anterior teeth pass beyond the end-to-end position resulting in posterior tooth contacts

Continued forward movement is determined by the posterior tooth surfaces untill the maximum protrusive movement is established by the ligaments

Functional movement
Free movements  Postural position


Chewing stroke

Postural effect on functional movement

Horizontal plane border &functional movement

 

Goathic arch tracing Rhomboidal shape pattern

Horizontal components
   

1.Left lateral border movement 2.continued left lateral border with protrusion 3.right lateral border 4.continued right lateral border with protrusion

Left lateral border movement

   

Contraction of right lat pterygoid Relaxation of left lat pterygoid Orbiting condyle- right side Rotating condyle- left

Continued left lateral border movements with protrusion



Contraction of both left and right lateral pterygoid Condyle moves anteriorly to the right

Right lateral border movements



Contraction of left lateral pterygoid while right side muscle relaxes

Continued right lateral border movement with protrusion

Mandibular border movements in the horizontal plane recorded at various degrees of opening. The border comes close together as the mouth is opened

Functional movements
 

Occurs near the ICP Initially it begins at a distance from ICP

Frontal border &functional movement

     

Shield shape pattern 1.Left lateral superior 2.Left lateral opening 3.Right lateral superior 4.Right lateral opening 5.Functional

Left lateral superior

Determined by the morphology & inter arch relationships of maxillary and mandibular teeth  Inferiorly concave path is generated


Left lateral opening border movements



An opening movement of the mandible produces a laterally convex path

Right lateral superior border movements

Right lateral opening border movement

Functional movement


Begins and ends at ICP

Envelope of motion


By combining border movements in all the planes, a three dimensional envelope of motion can be produced that represents the maximum range of movements of the mandible. Shape differs from person to person

Functional occlusion is defined as an arrangement of teeth which will provide the highest efficiency during all excursive movements of the mandible which are necessary during function

Types of functional occlusion



Lateral Protrusive Retrusive

Protrusive: It includes the eccentric contacts that occur when the mandible moves forward. Ideally six mandibular anterior teeth contact along the lingual inclines of maxillary anterior teeth while the posterior disocclude. These are called as a guiding inclines of the anterior teeth

Protrusive movement of the mandible

Disclusion of the posterior teeth must be immediate

It occurs in 3 stages 1. Initial contact 2. Beginning of anterior discluding factor 3. End to end position

For proper disclusion there must be proper horizontal & vertical overlap free mandibular movement

 Vertical overlap of the maxillary anterior teeth-

should be at least 1.5mm of interocclusal space

What if there is too much of 1. horizontal overlap?? (class II div 1) 2. Vertical overlap? (class II div 2 ) 3. Or no overlap? (class III or open bite )

Class II div 1
Patient has to reach out for ant teeth to engage No immediate disclusion Horizontal forces on posterior teeth

Class II div 2


Unwanted occlusal forces on the anterior teeth during disclusion

Class III or open bite



No anterior disclusion

Retrusive movements
It occurs when the mandible moves posteriorly from ICP  It is quite small (1-2mm)  This movement is restricted by ligaments of TMJ


Lateral : It includes tooth contact that occurs on canines and posterior teeth on the side which mandible moves.

The condyle on the side towards which movement occurs is referred as working side

The condyle on the other side is non working or balancing side

During lateral movement the working side condyle may rotate, rotate or move laterally and also upward &downward. This lateral movement is called Bennette movement

This movement necessary to permit rotation of the condyles because 1.Restraining effects of tempromandibular ligament 2.Walls of the glenoid fossa 3.Eccentric shape of the condyle


Bennette movement can be of two types Immediate or early shift  Gradual or progressive shift


During lateral movements the functional occlusion can be of two types: Canine guided Group function

 

Canine guided or cuspid protected occlusion

   

This theory was put forward by Nagao 1919 Shaw 1924 DAmico 1958 It includes disclusion of all the posterior teeth by cuspid in lateral excursions

During lateral mandibular movement the upper and lower canines of working side contact, causing disclusion of all posterior teeth on working and balancing sides. Hence the terms canine protected , canine guided occlusion, canine rise, canine lift.

Canine guided lateral movement of mandible

Lateral excursion may also be guided by the central/ lateral incisors on the working side acting in a group function with canine. The canine must be the major discluding tooth.

Why canine ??
Longest and largest root therefore the best crown root ratio  Dense compact bone  Fewer muscles are active when canine contacts during eccentric movement  Lower muscle activity less force


Concave palatal surface of upper caninesuitable for lateral gliding movement Greater root surface area providing greater proprioception ????

Class II div 1
Canine to lower Incisors contact \

Class II div 2


Lateral excursion may be guided by upper canines and lower incisors /retroclined incisors

Class III or open bite

guidance from posterior teeth on lateral excursion

Group functional occlusion

Group function refers to the distribution of lateral forces to the group of teeth rather than protecting those teeth from contact in function by assigning all the forces to one particular tooth.

Group function

This is advantageous if the PDL support of canine is compromised  It is indicated wherever the arch relationship doesnt allow anterior disclusion


Since the 1st tooth contact is an eccentric position and on the inclines of cusps of posterior teeth the force is torsional.  The force exerted has both vertical and horizontal component


How to reduce horizontal component?



Reduce the magnitude of force striking the inclines -Simultaneously striking many working surfaces

Reduce the angle of inclines -Making vertical component more than horizontal

Similiarities between group function and cuspid protected functional occlusion



Both provide multiple post contact with ICP located coincident with centric relation position Absence of posterior contact on balancing side during lateral excursion

No posterior contact during anterior incision Anterior group functional guidance during protrusion with post disclusion (Mc Adam 1974 JPD)

Mutually protected occlusion



An occlusal scheme in which the posterior teeth prevent excessive contact of anterior teeth in maximum intercuspation and the anterior teeth disengage the posterior teeth in all mandibular excursive movement Canine protected occlusion is a form of mutually protected articulation

Optimum functional occlusion



It describes conditions which appears to be least pathogenic for the greatest number of patient over a longest time

Criteria for the optimal functional occlusion

Optimal orthopedically stable joint position Optimal functional tooth contact

Optimal orthopedically stable joint position

  

Patient is comfortable Position of joint is stable Should be able to accept the load applied across the joint by muscles The mandible should be able to move in any possible direction without teeth getting in its way.

The mandible should close into maximum intercuspation without deflecting the condyle from the ideal relationship in the fossae.

Centric relation- defined by Gnathologists as that position of the condyle which is uppermost, midmost & rearmost in the fossa when the jaws are at closed position

Musculo skeletally stable position



Okeson defined centric relation when the condyles are located in their most superior anterior position in the articular fossa resting against the posterior slope of articular eminence with the articular disc properly interposed

The most superoanterior position of the condyle (solid line ) is MS the most stable position of the joint. However, if the inner horizontal fibres of the TM ligamnet allow for some posterior movement of the condyle, posterior force will displace the mandible from this to a more posterior, less stable position ( dotted line). The two positions are at the same superior level

Management of Tempromandibular Disorders and Occlusion 5th edition JEFFERYP.OKESON

The retrodiscal tissue is vascularized and well supplied with sensory nerves

force pain and breakdown

Post aspect of mandibular fossa is seen to be quite thin and apparently not meant for stress bearing.


  

Positional stability of joint is dictated by the muscles that pull across the TMJ
Masseter- superior &anterior Medial pterygoid- superior & anterior Temporalis- straight superior

However optimal joint relationship is achieved only when the articular discs are properly interposed between condyles and the articular fossa The purpose of the disc is to seprate, protect, and stabilzes the condyle in the mandibular fossa during functional movements,

This MS position is similar to the superior position defined by Dawson as CR

Optimal functional tooth contacts



Musculoskeletal stable position of the joints can be maintained only when it is in harmony with a stable occlusal condition

W hen only right side occlusal contacts are present, activity of the elevator muscles tends to pivot the mandible using the tooth contacts as a fulcrum. The result is an increase in joint force to the left TMJ and a decreased force to the right TMJ

Management of Tempromandibular Disorders and Occlusion 5th edition JEFFERYP.OKESON

with bilateral occlusal contacts & increase in number of the occluding teeth stability is achieved

Management of Tempromandibular Disorders and Occlusion 5th edition JEFFERYP.OKESON

The optimum occlusal conditions during mandibular closure would be provided by even and simultaneous contact of all possible teeth. This furnishes maximum stability for the mandible while minimizing the amount of force placed on each tooth during function.

Therefore the optimal functional occlusal developed to this point can be described as Simultaneous contact of all the possible teeth when the mandibular condyles are in their most superioanterior positions, resting against the posterior slopes of the articular eminence with the disc properly interposed.


Musculoskeletal stable position (CR) coincides with the maximum intercuspal position of the teeth (CO)

It is generally accepted that in most individuals with a natural dentition there is a short path of movement between the retruded contact position and intercuspal in anterior- posterior direction

Hildebrand (1931), Heath (1949), Posselt (1952 ), Shefter&Mcfall (1984) have shown that a discrepancy of 0 .5-1.5 mm exists between CR & CO

William (1971), Aubrey (1978), Park (1978 ),Roth (1981) promotes the concept of an ideal treatment goal being coincidence of the CR and CO

Epidemiological studies fail to find this type of occlusion in natural dentiton Why this should be then the goal following orhtodontic treatment.???

Argument put forward is non coincidence of the two position (CR&CO) is associated with TMD (Solbergetal 1979: Ingerwall et al 1980) However the evidence is inconclusive..

CR does not exactly coincide with CO  There is no disadvantage to the patient of having a CR that coincides with CO  Treatment need not be unduly lengthened to achieve this goal


Direction of force placed on teeth

Role of periodontal ligament  Acts as natural shock absorber controlling force of occlusion  Orientation of PDL fibre helps in dissipation vertically directed force on the long axis


Management of Tempromandibular Disorders and Occlusion 5th edition JEFFERYP.OKESON

To summarize, if a tooth is contacted in such a way that the resultant forces are directed along the long axis of the teeth, the PDL is quite efficient in accepting the forces and breakdown is less likely.

The process of directing the occlusal forces along the long axis of tooth is called axial loading

2 methods of axial loading 1. Development of tooth contacts on either cusp tips or on flat surfaces


Tripodization  Each cusp contact an opposing fossa such that it produces three contacts surrounding the actual cusp tip.


Amount of force placed on the teeth



The TMJ permits various excursive movements of the mandible that allow horizontal forces to be applied on the teeth. Horizontal forces are not accepted well by supporting structure so it is important to identify which teeth can best accept these horizontal forces.

The amount of force that can be generated between the teeth depends on the distance from the TMJ and the muscle force vectors. Much more force can be generated on the posterior teeth (A)than on the anterior teeth (B)

Management of Tempromandibular Disorders and Occlusion 5th edition JEFFERYP.OKESON

The posterior teeth function effectively in accepting forces during closure of the mouth.

Anterior teeth are in proper position to accept the forces of eccentric mandibular movement

Canine guided or group function?? Epidemiological studies have attempted to discover which type of lateral occlusion scheme is found in untreated natural dentition

Contradictory results!!!
May refelct various methodologies .

Besler & Hanman (1985) concluded that canine protected occlusion dont significantly alter muscle activity during mastication, but do significantly reduce muscle activity during para functional clenching.

Physiological studies were designed  Williamson and Lundquist 1983 examined EMG activity of the temporalis and masseter muscles during lat excursion in individual with canine guidance and group function less activity in individual with canine guidance


The evidence in favour of one type of occlusal scheme over another is scarce. Mediotrusive contacts should be avoided in developing an optimal functional occlusion

The laterotrusive contacts need to provide adequate guidance to disocclude the teeth on the opposite side of the arch (mediotrusive or non working side) Mediotrusive contacts can be destructive to masticatory system

Functional occlusion for orthodontist



It is generally assumed that the ideal static occlusal relationship is compatible with an ideal functional occlusion but this is not necessarily so

There are various reasons for orthodontist to seek more knowledge in the area of functional occlusion1. The answer to the stability of the treated orthodontic case would at least partially rest in the functional dynamics of occlusion

2. The treatment rendered orthodontically is of

benefit to the patient or at least no harm to him

3.To refute some of the claims made by nonorthodontists, that a good functional occlusion can not be obtained if bicuspids are removed for orthodontic purposes

Role of equilibration


Unrealistic!!!

Dont grinde your teeth thats my job!!!

For a case to be equilibrate to a stable centric most tooth position should be proper to begin with and should be close to centric

Very time consuming Equilibration should not be performed untill growth has been completed Stability of the jaw is a pre requisite for a stable equilibration

Basic concepts of functional occlusion

Free movementof the mandible  Mandible should be able to close into maximum intercuspation  One must utilize a specific set of criteria for a functional occlusion goal throughout diagnosis, treatment &retention


Treatment objective
Roth 1981  Pleasing facial esthetics  Molar relationship and tooth alignmentAngles norms  Functional occlusion evaluated gnathologically


Stability of post treatment tooth positions and alignment Comfort efficiency and longevity of the dentition, supporting structures & TMJ

Evaluation of occlusal disharmony

  

Occlusal interferences: Centric Excursive Protrusive Lateral working Lateral non working

Centric Interference
Interference between CR& CO Mandible moves forwards, upwards and laterally Directed by the sliding contacts of the inclined planes of occlusal surfaces of the maxillary teeth hence termed centric slide

Protrusive interferences
It occurs during protrusive gliding movements of mandible  Distal surface of maxillary & mesial surface of mandibular post teeth  Lingual incisal surface of maxillary and labial surface of mandibual teeth


Occlusal Correction: principles&practice Solnit&Curnutte

Working interferences
The side towards which jaw moves  Occurs between the buccal cusp of maxillary and mandibular teeth


Non working interferences



It occurs on lingual cusps of maxillary teeth and buccal cusp of mandibular teeth

Sign and symptoms from occlusal interferences

Occlusal wear  Excessive tooth mobility  TMJ sounds  Limitations of opening of movement  Myofacial pain  Contracture of mandibular musculature


Diagonosis and treatment planning

It is necessary to diagnose a case from a mandibular position of centric relation, if we wish to treat to centric occlusion  The neuromuscular positioning of the mandible to accommodate to occlusal discrepancies will hide the true discrepancies


Records should be taken in centric relation to evaluate how much discrepancies lies in which planes of space The cephalometric tomograph of TMJ is a good indicator of state of bony elements of joints.

Use splints before orthodontic treatment

The purpose of repositioning splint1. To enable operator to find true centric

which is stable and comfortable 2. To test patients response to change in occlusion before embarking on complex occlusal therapy

The mandibular postural changes during splint therapy due to1.Relaxation of muscles 2.Disrupt muscle engrams and reduce symptoms

The objective is to Seat the condyles in the most superior position possible and to adjust the occlusal surface of the splint to achieve maximum intercuspation


Finishing to Gnathological principles

Gnathological objectives Stable centric relation and CR and CO coinciding  Simultaneous contact of centric stops  Direction of stress should be directed along the long axis  Mutually protective occlusal scheme


Excursive occlusive scheme

  

Gentle lateral and protrusive lift Necessary in terms of post treatment stability Excessive lateral stress on cuspid lingual movement

lower ant crowding

An improper anterior guidance in protrusive will tend to enhance the chance of relapse in maxillary teeth labially  Very common in post treatment orthodontic cases because of  bracket placement elongation of the maxillary incisors


Insufficient torque of the maxillary incisors

too steep anterior lift insufficient glide

The Ideal and the possible



Ideally centric relation and habitual centric occlusion of the teeth should be coincidental Is it so???

 

Roth 1981- there is some slight repositioning of the mandible in even the best of the cases Shefter& Mcfall 1984 Agergberg & Sandstrom 1988 Discrepancy of 0.5-1.5 mm exists Journal of Orthodontics: March 2000 Functional Occlusion: A review J.R. Clark & R D Evans

What can be really achieved. To treat the orthodontic case close enough to centric so that there isNo discernible discrepancy between CR and CO and if equilibration is necessary the case can be equilibrated

Ideal tooth positioning



 

Andrews once said we (orthodontist) tend to look at teeth collectively rather than individually SIX keys to normal occlusion Further modified by Roth for an ideal occlusion

jco April1981: functional occlusion for orthodontist Ronald.R. Roth

Lower incisors at the cephalometric goal of +1to A- pog line

Tip of the upper incisors 2-2.5mm below the lip embrasure of upper and lower lip

No more than 1 mm of attached gingiva should be visible upon a full smile

2-2.5 mm of overjet and overbite

A level or nearly level occlusal plane at the end of the treatment

Divergence of occlusal plane from angle of eminence for excursive clearance

-Lower incisors point to point contact with the roots in a same plane.  Lower cuspid crowns angulated mesially 5 degree  Incisal tip 1 mm higher than the incisal edges of lateral incisors

Exaggerated mesial rotation on extraction cases  Lower bicuspids upright by 1 degree  distal rotation more in extraction cases  Lower molar should be upright distally by 1 degree


Lower buccal segment should have torque closer to Andrews measurement  Upper 6 yr molar should have -Distal rotation -Mesio axial inclination -Buccal root torque


Upper bicuspid should be uprighted to 0 degree, with no rotation, distal rotation in extraction cases  Upper cuspid  Contact point adjacent to the contact points of bicuspids and lateral incisors  Mesial crown tip of 11-13 degrees


Upper lateral and central incisors should be almost equal in incisal edge length  9 degrees and 5 degrees mesio axial inclination  Sufficient torque


There should be no spaces or rotations in the arch The arch form should be modified catenary curve

Treatment priorities
Correction of crossbites  Reduction of jaw relationship  Elimination of crowding  Establishment of the space for severely malposed teeth  Space consolidation of lower arch


Levelling of the Curve of Spee  Finishing of the lower arch  Establishment of the desired molar relationship  Consolidation of maxillary space and retraction or intrusion of the maxillary anterior teeth


Artistic positioning and torque of maxillary anteriors  Over correction of buccal segment, curve of spee, rotations and root positions at extraction sites  Final detailing of tooth position


It is of utmost importance that lower arch must be finished and in the correct position to act as a template to receive the upper teeth

Detailing of tooth position in the treatment



Bracket placement is of utmost importance in achieving a good occlusal intercuspation Improperly placed bracket should be corrected at earliest As Roth says It is foolhardy to think that one can achieve a consisitently good functional result by never reseating brackets or bands

Prior to over correction  Analyze the tooth fit to see if the upper arch can contain lower arch and still provide an over bite Tip  Torque  Cuspid height


Tipped incisors occupy more space

Torqued incisors occupy the arc of a bigger circle  Cuspids that have their contact gingival to bicuspids and lateral may take1/3rd less space


Rotation of the molar take up too much of space  Insufficient buccal root torque of upper molar makes for balancing and centric interferences  Lack of width in the lower bicuspid area can create a centric slide


It is well to to remember that the better the lower arch is treated the better the case will look after settling

Control of the vertical dimension and the molar fulcrum

Avoid extrusion of the posterior teeth and excess vertical alveolar growth- molar fulcrum  2 things can happen  Appearance of open bite and tongue thrust swallow  No open bite but clicking of the TMJ


Open bite due to interference

Clicking of TMJ/stiffness of mandibular musculature

Anchorage control of vertical direction is of utmost importance to prevent creating a molar fulcrum. TPA or occipital pull head gear can be useful In cases with short ramus height or posterior facial height care should be taken not to drive molars distally

Light flexible wires such as nitinol or D-Rect braided wire should be used No attempts should be made to completely level the curve of spee

If long class II elastics are used there could be extrusion of molars tipping of occlusal plane less clearance of posterior teeth on movement of mandible

Short class II elastic extrude the lower bicuspid thus levelling curve of spee,

Overcorrection of the A-P relation



It is done with headgear and short class II elastics Overcorrection is held upto 3 months The wires can be changed to braided rectangular wires as needed to seat the occlusion

While the occlusion is being brought back from over correction, it is necessary to start checking to see if mandible is in centric Next the patient is asked to execute various mandibulal excursions The glide should be smooth and slow if cuspid guidance is correct and there are no interferences

Finishing in centric relation

Correct A-P jaw relationship( over correct then hold, then settle back)  Eliminate molar fulcrum  Coordinate arch width and arch form with mandible in centric relation  Watch cuspids height and midline


Level curve of spee  Check for centric deflection  Marginal ridge heights  rotations


After centric is obtained

Check tooth detailing by having patient to go through test excursions  Torque of upper incisors  Tip of incisors and cuspids  Overbite and overjet  Flatness of curve of spee


Second molar position  Look for anterior group function, posterior clearance,cuspid guidance,and balancing interferences.


At the end of appliance therapy the occlusion should resemble a bilateral balanced occlusal scheme during the excursions The anterior guidance should not be adequate

One must plan for this occurrence by keeping the anterior guidance a little shallow at the end of mechanotherapy.

Retention phase
Acc to Dawson, failure to properly establish the correct guidance is a major cause of post treatment instability  As long as the ant guidance remains intact capability of discluding the post teeth in eccentric jaw position, the protection of posterior teeth is assured


For this routine bonding of maxillary ant teeth with lingual retainer is advised A functional rationale for bonded retainers: Angle orthodontics 1993

Bibliography
Occlusion: principles &concepts 2nd Edition Jose dos Santos Evaluation, Diagnosis &treatment of Occlusion problemsDawson Occlusal correction : Principles &Practice Solnit & Curnutte Occlusion: 3rd edition Ramfjord& Ash A colour Atlas of occlusion &malocclusion Howatt, Capp, Barrett Functional occlusion for orthodontist- JCO 1981 Ronald.H.Roth Management of tempromandibular disorders &occlusion 5th edition Jeffery P. Okeson