Prosthodontics

The importance of occlusal balance in the control of complete dentures

Anna M. Dubojska, MSc, MCGI*/ Graham E. White, KCOM, PhD, MMedSci, FCGI. CGIA**/Slawomir Pasiek, DDS,
Objeclive: The importance ofocclu.sal balance to the control of complete dentures during function wiis assessed. Method and materials: The complete dentures offive patients who were having difficult) controlling tiicir prostheses were accurately duplicated. The artificial teeth were replaced with occhisally balanced teeth. No other changes were made. Patients were asked to report their experiences with the new dentures afier 1 week. 3 weeks, and 6 weeks. Results: By the end uf weeks, improvements in denture stability and eating comfort were reported by all patients. Conclusion: Improvements occurred when the occlusion was balanced, despite existing jaw relationship errors. fitting inaccuracies, and peripheral e.xtension errors. (Quintessence Int 1998;29:389-394) Key words: complete denture, denture stability, ocelusal balance

Adaptation to dentures Clinical relevance This study suggests that occlusal balance and removal of occlusally induced denture movements is as important to efflcient complete denture control as fitting accuracy to underlying tissues, peripheral extension, or accurate recording of centric relation. Basker et al' described the function of m echan o receptors in the oral mticosa when new dentures are fitted. Impulses arising from these receptors, which record touch and pressure, are transmitted to the sensory cortex, with the result that the patient can "'feel" tbe dentures. However, continuous stimulation of these receptors does not result in a corresponding stream of impulses. The receptors adapt to the new environment, so that the patietit begins to lose conscious awareness of the new dentures in tbe mouth. Furtber stimulation arises when force.s from tooth contacts are transmitted to the underlying tissues. The pattern of the stimulation of the mecbanoreceptors enables the patient to recognize food between the teeth and the presence or absence of occlusal disharmony. Basker et al' reported tbat after new dentures were fitted, 60^ of experienced complete-denture patients were able to speak and eat satisfactorily within a week. A furtber 20% required tip to 1 month to become proficient. Tbese authors also recognized that some patients never become proficient denture wearers. ' Grant et al- concluded that a lack of occlusal balance causes dentures to tilt on their supporting tissues, disrupting the retentive seal. They also thought that many patients could successfully wear dentures without occlusal balance but that as retentive factors decrease (ie, as supporting tissues resorb), displacing forces gen389

t is often assumed that patients provided with complete dentures made without occlusal balance will, after a period of time, become accustomed to their dentures and be able to control tbem during mastication. Some of tbese patients, however, cannot control their prostheses, especially tbe mandibular ones, despite long perseverance.

* Teacher in Dental Sciente, Department of Neurology and Oromandibular Dysfunction. Institute of Denlistry. Medical University. Lodz, Poland. " Senior Lecturer, Department of Restorative Dentistry, Sehool of Clinical Dentistry, Llniverty of Shettkid, Sheffield, Etjgland. Lecturer, Department of Prosthodontics, Itistitute of Dentistry. Medical Universily, Lodz, Poland Reprint requests: Dr Graham E. White, KCOM, Department ot Restorative Dentistry, School of Clinical Dentistry, Claremont Creseent. SliefTield SIO 2TA, England. E-mail: G.E.White@Shefneld.ai.-.uk

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erated by lack of balance assume greater significance. Furthermore, difficult-to-wear dentures made witbout occiusal balance will often bave inaccurate maxillomandibular relationships together with fitfing errors and inadequate peripheral extension. Balanced occlusion and denture stability There are tbose who have questioned the validity of occiusal balance on the grounds that wben food has been introduced between the teeth, occiusal balance is lost at precisely tbe time it is most needed, ie, "enter foodexit balance." Mindful of this problem, Tbompson' recommended that patients divide mouthfuls of food and chew it on both sides of the mouth, simultaneously. In justifying the need for occiusal balance, Hobkirk-' concluded that the artificial teeth come into contact for a total of about 20 minutes a day during swallowing and briefly during mastication. When a bolus of food is placed between the teeth, they will be held apart; as the pafient begins to penetrate the food, the denture will be inclined to move. This will be resisted by the retention of the denture and the pafient's own muscular control. Furtber into the masticatory cycle, however, the teeth come closer to each other or may momentarily touch. Should there be any interfering contacts at tbis stage, instability will result. Because of tbese intermittent tooth contacts, Hobkirk'' believed that complete dentures should have balanced occlu,sion. Hickey et al,-' in contrast, thought that dentures make several thousand contacts a day in both centric and eccentric positions with no food in the mouth and that, even while chewing, the teeth cut through to contact every few fracfions of a second. Because of this, balanced occlusion is desirable to ensure even pressure in all parts of the arch to maintain the stability of the dentures while tbe mandible is in centric and eccentric posifions. In considering denture stability, Gerber* concluded that it is necessary to occlusally balance teeth placed in positions that would avoid instability, ie, to occlusally balance already stable dentures. Denture stability is achieved in this metbod by arranging the posterior teetb on a curve that follows the curve of the residual ridges, Occiusal forces are transmitted at 90 degrees to the underlying bone, promoting a high level of stability even in resorbed residual ridges. This limitation of occlusally induced denture movement prevents the mouth soreness observed by Hickey et al,-^ which is caused by denture movement along the slopes of the residual ridges during deflective tooth contacts. For flat residual ridges, Gerber" recommended restricting the
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po.sterior teeth to the flatter ridge parts and not allowing teetb to be placed over inclined ridge parts. The aim of tbe present investigation was to assess the importance of occiusal balance in the control of complete dentures during function. Method and materials Patients who were having difficulty controlling complete dentures had their prostbeses accurately duplicated and the artiflcial teeth replaced witb occlusally balanced ieetb. No other changes were made. Fitting accuracy, peripheral extension, and possible errors in maxillomandibular relafionsbips, whether apparent or not, were ignored. The patients' reactions to the experimental dentures were then assessed after 1 week, after 3 weeks, and after 6 weeks of use. Test group Pafients attending the Prostbodontic Clinic at the Institute of Dentistry in Lodz, Poland, for new complete dentures formed tbe test group. From this number five patients wbo bad worn complete dentures for at least 2 years without success were selected. From an examination of the dentures of all five pafients, it was evident that occiusal balance had not been provided and that a simple hinge ariiculator had almost ceriainly been used. The mandihular molar teeth were set over a .sloping part of the lower residual ridge and the curve of the occiusal plane of the posterior teeth was not related to the condylar path angles. During protrusive jaw movements and edge-to-edge incisor tooth contacts, these combined factors allowed a space to exist between the posterior teetb; tbis space produced mandibular denture filting (Fig 1). When the pafients were que.stioned ahout their problem dentures, typical complaints were, "The dentures move when I eat," and "I get sore spots under my dentures." Two pafients indicated that they removed their dentures to eat. Fabrication of the experimental prostheses The patients' existing dentures were duplicated by direcfiy investing them in a denture-processing flask. The dentures were then removed, and the resulting mold cavity was packed in heat-cured acrylic resin (Fig 2). The dentures were then polymerized by wet heat followed by slow overnight cooling to room tetnperature. After careful trimming and very light polishing, the resuUing dentures were an accurate copy of the original prostheses, except that the arfificial teeth were reproduced in pink resin (Fig 3).
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Fig 1 Patient making a protrusive aw movement, showing a lack of posterior tooth contact.

Fig 2 Two-part denture mold made by investing and then removing a resin denture.

Fig 3 An ali-pink resin, dupiicated denture seated on a casi made Irom its investment stone.

Fig 4 Gothic Arch tracing plate fixed to the duplicated mandibular denture with impression compound.

TABLE 1

Sagittal condylar path angles for patients in the study (degrees)

Patient 1 2 3 4 5 Left joint 32* 33* 23 37 30 Right joint 4033 32 35 35

Fig 5 Facebow lollowmg the protrusive movement of a patient's left condyle to produce a tracing of its sagittal path angle.

The tracir g was stiort and/or confLsed, so tliat only an incomplete pari f the Irac rg was used.

The stone plaster used as investing material in the processing flask was required to accurately flow into the fitting surface of the original dentures. After it vi-as carefully recovered from the flask and trimmed, this investment material formed the future working casts (Fig 3). Softened impression compound was used to fix maxillary and mandibular Gothic Ari:h tracing plates (Condylator-Service) to the old dentures (Fig 4) and to connect a Condyiator facebow (Condylator-Service) to the mandibular transfer plate. After the height of the upper stylus was adjusted to just separate the artificial teeth and tracing plates during mandihular movements, the patient was asked to make protrusive jaw moveQuintessence Internationai

ments. Writing styli positioned over each joint were used to make left and right tracings of sagittal condylar inclination on a card resting on the side of the patient's face (Fig 5), A protractor was then used to determine the angles of the tracings. Patient I had difflculty producing both the left and right tracings, and patient 2 had difficulty producing the left condylar tracing. These patients could not easily tTiake protrusive jaw movements (Table 1), The composition material joining the transfer plate to the mandibular denture produced accurate imprints of the posterior teeth. These imprints were used as locators to position the duplicated mandibular denture, with hard 391

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Fig 6 Duplicated denlure and cast related to an aaustat:le articuiator by means of a lacebcw.

Fig 7a Masiiiary and mandibular duplicated dentures fixed together in maximai intercuspation, ready to mount tiie maxillary denture and cast pn the articuiator.

Fig 7b Mounted dupiicated dentures. The top line tracing follows ttie ourve of the residuai mandibuiar ridge. The bottom line shows the ocolusal plane pf the ppsteiipr leeth of the original dentures.

wax, on its cast in the transfer plate, Imrnediately after this, the facebow record was used to mount the duplicated mandihular denture atid its cast otito a Condylator Itidividual articuiator (Fig 6), White and Duhojska^ showed that different tnodels of adjustable articiulators, programtned with idetitical condylar path angles and incisai guidaitce settings, produce different paths of mandibular movement. Among the articulators tested, the Condylator articuiator (Condylator-Service) was found to produce correctly formed cusp groove angles, so this instrntnent was chosen to provide balanced occlusion in the pre.sent study. The duplicated dentures were then waxed together in their position of maxirnum intercuspation to mount the maxillary model in the articuiator (Fig 7a), The measured left and right condylar path angles were then transferred to the articuiator. Left and right mandibular residual ridge profile lines were then drawn on the
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sides of the tnandibular cast. For cotnparison, the curve of the occlusal plane of the original dentures was also drawn (Fig 7b). After the duplicated pink resin teeth were ground away, new resin anterior and posterior teeth (Mifatn Super Lux) were set up in occlusal balance according to the methods described by Gerber^ (Fig 8a). Especially important, the posterior teeth were restricted to the flatter parts of the residual mandibular ridge to promote stahility in the dentures when separated hy foodunder loading situations (Fig 8b), In all five patients, this meant that the maxillary and mandibular second molar teeth were not used. In some patients, other tooth substitutions were also necessary (Fig 8c). After the trial experimental dencures were assessed in the mouth for appearance and occlusion, accurate stone overcasts were made to attach the artificial teeth to the duplicated bases with autopolymerizing resin (Vertex Castapress, Dentimex Zeist). The polytnerized dentures were returned to the Condylator articuiator, and occlusal prematurities affecting occlusal balance were removed with stones and ahrasive paste. Placement of the experimental prostheses Immediately after placement, the experimental dentures were assessed for occlusal balance. The patients were instructed to make protrusive jaw movements (Fig 9a), as well as lateral and protrusive jaw movements, while keeping the maxillary and mandibular posterior teeth in contact. The same occlusal contacts observed in the laboratory were found in the mouth (Fig 9b), The lack of posterior tooth contact in protrusion of one patient's original dentures (Fig 9c), for example, was eliminated on the articuiator and in the mouth by the new denture (Figs 9a and 9h).
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Fig 8a New setup, showing protrusive looth contacts. Tiie incisai rod is not contacting the incisai guidance tabie, reprodtjcing the situation in the mouth.

Fig eb Poslerior teeth set up to loilow the curve ol the residuai mandibular ndge, thereby promoting a high degree of stabiiity Note the bottom iine, which shows the aimost tiat occlusal piane of the originai dentures.

Fig Sc Dentures with reduced occiusal table Note the use ot a premolar instead of a mandibuiar second molar and the use ot only one maxiliary molar. The distal mandibular premoiar aids stability when It contacts the maxiiiary moiar during protrusion.

Fig 9a Patient making a protrusive jaw movement with Ihe new dentures. The posterior teeth are still in contact.

Fig 9tj Dentures in Fig 9a, showing Ihe same tooth oontacts in the iaboralory as lound in the mouth.

Fig 9c Original dentures cf the patient in Fig 9a Note the absence ot tooth contacls.

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The two patients who had earlier difficulty in protruding the mandible were not able to make lateral jaw movements, and side-to-side head movements were made instead. It was speculated that the patients bad accomtnodated to tbeir original dentures' incorrect maxillotnandibular relationships to an extent that prevented lateral movements. Functional mandibular denture stability was assessed by the application of alternate finger tip pressure on the most distally placed posterior teeth on each side of the mouth. The dentures were observed not to move utider tbese occlusal loads despite tbeir universally poor adaptation to tbe underlying tissues. The patients were told not to wear their original dentures after they had been provided with their experimental pro.stheses. To ensure compliance, the investigators retained the patients" original dentttres for the duration of the experiment. Resnlts Patients were recalled for a.ssessment after I week. 3 weeks, and 6 weeks of wearing their experimental prostheses. After I week, two patients reported much improved denture stability and chewing comfort, but three patients did not notice much difference. After 3 weeks, four patients reported much improved denture stability and greater comfort during eating. The two patients who previously could not make lateral mandibular movements could now demonstrate this function without difficulty. After 6 weeks, all five patients reported much improved denture stability and greater comfort of their dentures during eating. All patients demonstrated tbat tbey could make lateral and protrusive jaw movements without difficulty. The patients reported that the itiiprovements occurred without them being required to "'do anything different," and they were at a loss to explain bow this had occurred. Tbe increase in stability during eating was particularly commented on. together with what was described as the "better fitting" of tbe mandibular denture. The absence of second molar teeth and/or the existence of tooth substitutions was noted by tbe patients, but they did not adversely comment on tbe unconventional appearance. When the original dentures were returned to tbe mouth, protrtisive jaw movements were observed to produce a space between the maxillary and mandibular occlusal surfaces of tbe posterior teeth. This lack of contact produced mandibular denture tilting when the maxillary and mandibular incisors were in edge-to-edge contact. All five patients reported tbat their original dentures now felt "strange" and that they would not like to return to them.
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Snmmary Wben difficult-to-wear complete dentures without occlusal balance were duplicated and new teeth with occlusal balance were substituted, all five participating patients reponed an improvement in denture stability and chewing comfort. Tbe reduction of the occiusal table, produced by confining tbe posterior teeth to those parts of the residual ridge table to support denture loads without denture movement, bad a strong denture-stabilizing effect. This could be demonstrated by applying occlusal loads witb a finger tip on the distal-most tnandibular molar teetb, a pressure that displaced dentures with these teeth set over sloping residual ridge parts. These improvements were made despite remaining jaw registration errors and poor adaptation of the dentures to their underlying tissues. From tbese results, it may be tbeorized that occlusal balance and the removal of occlusally induced denture movements is as important to efficient denture control as fitting accuracy to underlying tissues, peripheral extension, or accurate recording of centric relation. References
1. Basker RM, Davenport JC. Tomlin HR. Prosthetic Treatment of the Edentulous Patient, ed 3. London: Macmillian, 1992. 2. Grant AA, Heath JR, McCord JF. Complete Prosthodonties, Problems, Diagnosis and Management. London: Wolfe, 1994. 3. Thompson H. Occlusion, ed 2. London: Wright, 1990. 4. Hobkirk JA. Complete Denture.s: Dental Practitioners Handbook 1. Bristol, England: Wright, 1986. 5. Hickey JC, Zarb GA, Bolender CL. Boucher's Prostliodontic Treatment for Edentulous Patients, ed 9. St Louis: Mosby. 1985. 6. Gerber A. Complete dentures. Color atlas. Quintessence Int 1974;5(121:3.1-38. 7. White GE, Dubojska AM. System konstrukeji protez ealkowitych w oparciu o artykiilalor Gerbera-Condylator. Qumtesienee Int (Polish ed) l99;4:219-238.

Volume 29, Number 6, 1998