L.D..Occlusion in FPD

Occlusion in fixed partial denture
OCCLUSION IN FIXED PARTIAL
DENTURE
(library dissertation)
I. Introduction
Establishing or providing occlusion that successfully permits
efficient masticatory function is basic to dentistry and survival.
In health the occlusal anatomy of the teeth functions in
harmony with structures controlling the movements patterns of the
mandible. The structures that determine these patterns of the
mandible are joints and the anterior teeth. During any given
movement the unique anatomic relationships of these structures
continue to dictate a precise and repeatable pathway.
To maintain harmony of the occlusal condition the posterior
teeth must pass close to but not contact their opposing teeth during
mandibular movement. It is important to examine each of these
structures carefully and appreciate how the anatomic form of each
can determine the occlusal morphology necessary to achieve an
optimal occlusal relationship.
II. Fundamentals of occlusion2
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1. Occlusal interferences
Interferences are undesirable occlusal contacts that may
produce mandibular deviation during closure to maximum
intercuspation or may hinder smooth passage to and from the
intercuspal position. There are four types of occlusal interferences :
1. Centric
2. Working
3. Non working
4. Protrusive
The centric interference is a premature contact that occurs
when the mandible closes with the condyles in their optimum
position in the glenoid fossae. It will cause deflection of the mandible
in a posterior, anterior, and / or lateral direction. (Fig. 1).
Fig. 1
A working interference may occur when there is contact
between the maxillary and mandibular posterior teeth on the same
side of the arches as the direction in which the mandible has moved.
If that contact is heavy enough to disocclude anterior teeth, it is an
interference. (Fig. 2).
2
Fig. 2
A non-working interference is an occlusal contact between
maxillary and mandibular teeth on the side of the arches opposite
the direction in which the mandible has moved in a lateral
excursion. The non-working interferences is of a particularly
destructive nature. The potential for damaging the masticatory
apparatus has been attributed to changes in the mandibular
leverage, the placement of forces outside the long axes of the teeth,
and disruption of normal muscle function. (Fig. 3).
Fig. 3
The protrusive interference is a premature contact occurring
between the mesial aspects of mandibular posterior teeth and the
distal aspects of maxillary posterior teeth. The proximity of the teeth
to the muscles and the oblique vector of the forces make contacts
between opposing posterior teeth during protrusion potentially
destructive as well as interfere with the patients ability to incise
properly. (Fig. 4).
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Fig. 4
2. Normal versus pathologic occlusion
In only slightly more than 10% of the population there is
complete harmony between the teeth and the temporomandibular
joints. This finding is based on a concept of centric relation in which
the mandible is in the most retruded position. With the present
concept of the condyles being in the most superoanterior position
with the disc interposed, the results could be different. Nonetheless,
in a majority of the population, the position of maximum
intercuspation causes the mandible to be deflected away from its
optimum position.
In the absence of symptoms, this can be considered
physiologic, or normal. Therefore, in the normal occlusion there will
be a reflex function of the neuromuscular system, producing
mandibular movement that avoids premature contacts. This guides
the mandible into a position of maximum intercuspation with the
condyle in a less than optimal position. The result will be either
some hypertonicity of nearby muscles or trauma to the
temporomandibular joint, but it is usually well within most peoples
physiologic capacity to adapt and will not cause discomfort.
However, the patients ability to adapt may be influenced by
the effects of psychic stress and emotional tensions on the central
nervous system. By lowering the threshold, frequently
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parafunctional jaw activity such as clenching or bruxing occurs, and
a normal occlusion can become a pathologic one. Simple muscle
hypertonicity may give way to muscle fatigue and spasm, with
chronic headaches and localized muscle tenderness, or
temporomandibular joint dysfunction may occur. Pathologic
occlusion can also manifest itself in the physical signs of trauma
and destruction. Heavy facets of wear on occlusal surfaces, fractures
cusps, and tooth mobility often are the result of occlusal
disharmony. There is no evidence that occlusal trauma will produce
a primary periodontal lesion. However, when occlusal trauma is
present, there will be more severe periodontal breakdown in
response to local factors than there would be if only the local factors
were present.
Habit patterns may develop in response to occlusal
disharmony and emotional stress. Bruxism and clenching, the
cycling rubbing together of opposing occlusal surfaces, will produce
even greater tooth destruction and muscle dysfunction.
When the acute discomfort of a patient with a pathologic
occlusion has been relieved, changes that will prevent the recurrence
of symptoms must be effected in the occlusal scheme. Care must
also be taken when providing occlusal restorations for a patient
without symptoms. The dentist must not produce an iatrogenic
pathologic occlusion.
In the placement of restorations, the dentist must strive to
produce for the patient an occlusion that is as nearly optimum as
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his or her skills and the patients oral condition will permit. The
optimum occlusion is one that requires a minimum of adaptation by
the patient. The criteria for such an occlusion have been described
by Okeson.
1. In closure, the condyles are in the most superoanterior
position against the discs on the posterior slopes of the
eminences of the glenoid fossae. The posterior teeth are in
solid and even contact, and the anterior teeth are in slightly
lighter contact.
2. Occlusal forces are in the long axes of the teeth.
3. In lateral excursions of the mandible, working side contacts
(preferably on the canines) disocclude or separate the
nonworking teeth instantly.
4. In protrusive excursions, anterior tooth contacts will
disocclude the posterior teeth.
5. In an upright posture, posterior teeth contact more heavily
than do anterior teeth.
3. Organization of the occlusion
The collective arrangement of the teeth in function is quite
important and has been subjected to a great deal of analysis and
discussion over the years. There are three recognized concepts that
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describe the manner in which teeth should and should not contact
in the various functional and excursive positions of the mandible.
They are bilateral balanced occlusion, unilateral balanced occlusion,
and mutually protected occlusion.
4. Bilateral balanced occlusion
Bilateral balanced occlusion is based in the work of Von Spee
and Monson. It is a concept that is not used as frequently today as it
has been in the past. It is largely a prosthodontic concept which
dictates that a maximum number of teeth should contact in all
excursive positions of the mandible. This is particularly useful in
complete denture construction, in which contact on the nonworking
side is important to prevent tipping of the denture. Subsequently,
the concept was applied to natural teeth in complete occlusal
rehabilitation. An attempt was made to reduce the load on individual
teeth by sharing the stress among as many teeth as possible. It was
soon discovered, however, that this was a very difficult type of
arrangement to achieve. As a result of the multiple tooth contacts
that occurred as the mandible moved through its various
excursions, there was excessive frictional wear on the teeth.
5. Unilateral balanced occlusion
Unilateral balanced occlusion, which is also commonly known
as group function is a widely accepted and used method of tooth
arrangement in restorative dental procedures today. This concept
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had its origin in the work of Schulyer and others who began to
observe the destructive nature of tooth contact on the nonworking
side. They concluded that inasmuch as cross arch balance was not
necessary in natural teeth it would be best to eliminate all tooth
contact on the nonworking side.
Therefore, unilateral balanced occlusion calls for all teeth on
the working side to be in contact during a lateral excursion. On the
other hand teeth on the nonworking side are contoured to be free of
any contact. The group function of the teeth on the working side
distributes the occlusal load. The absence of contact on the
nonworking side prevents those teeth from being subjected to the
destructive, obliquely directed forces found in nonworking
interferences. It also saves the centric holding cusps, i.e. the
mandibular buccal cusps and the maxillary lingual cusps, from
excessive wear. The obvious advantage is the maintenance of the
occlusion.
The functionally generated path technique, originally described
by Meyer, is used for producing restorations in unilateral balanced
occlusion. Mann and Pankey have adapted it for use in complete
mouth occlusal reconstruction.
6. Mutually Protected Occlusion
Mutually Protected Occlusion is also known as canine
protected occlusion or organic occlusion. It had its origin in the work
of DAmico, Stuart, Stallard and Stuart, and Lucia and the members
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of the Gnathological Society. They observed that in many mouths
with a healthy periodontium and minimum wear, the teeth were
arranged so that the overlap of the anterior teeth prevented the
posterior teeth from making any contact on either the working or the
nonworking sides during mandibular excursions. This separation
from occlusion was termed disocclusion. According to this concept of
occlusion, the anterior teeth bear all the load and the posterior teeth
are disoccluded in any excursive position of the mandible. The
desired result is an absence of frictional wear.
The position of maximum intercuspation coincides with the
optimal condylar position of the mandible. All posterior teeth are in
contact with the forces being directed along their long axis. The
anterior teeth either contact lightly or are very slightly out of contact
(appropriately 25 microns), relieving them of the obliquely directed
forces that would be the result of anterior tooth contact. As a result
of the anterior teeth protecting the posterior teeth in all mandibular
excursions and the posterior teeth protecting the anterior teeth at
the intercuspal position, this type of occlusion came to be known as
a mutually protected occlusion. This arrangement of the occlusion is
probably the most widely accepted because of its ease of fabrication
and greater tolerance by patients.
However, to reconstruct a mouth with a mutually protected
occlusion, it is necessary to have anterior teeth that are
periodontally health. In the presence of anterior bone loss or missing
canines, the mouth should probably be restored to group function
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(unilaterally balance). The added support of the posterior teeth on
the working side will distribute the load that the anterior teeth may
not be able to bear. The use of a mutually protected occlusion is also
dependent upon the orthodontic relationship of the opposing arches.
In either a Class II or Class III malocclusion (Angle), the mandible
cannot be guided by the anterior teeth. A mutually protected
occlusion cannot be used in a situation of reverse occlusion or cross
bite, in which the maxillary and mandibular buccal cusps interfere
with each other in a working side excursion.
7. Effects of Anatomic Determinants
The anatomic determinants of mandibular movement, i.e.
condylar and anterior guidance, have a strong influence on the
occlusal surface morphology of the teeth being restored. There is a
relationship between the numerous factors, such as immediate
lateral translation, condylar inclination, and even disc flexibility, and
on the cusp height, cusp location, and groove direction that are
acceptable in the restoration.
a. Molar disocclusion
When subjects with normal occlusions perform repeated
lateral mandibular movements, they will not trace the same path on
electronic recordings, presumably because of the flexible nature of
the articular disc. The measured deviation averages 0.2 mm in
centric relation, 0.3 mm in working, and 0.8 mm in both protrusive
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and non working movements. To avoid occlusal interferences and
nonaxially directed forces on molars during eccentric mandibular
movements, molar disocclusion must equal or surpass these
observed deviations in mandibular movement.
Healthy natural occlusions exhibit clearances that will
accommodate these aberrations. Measurements of disocclusions
from the mesiobuccal cusp tips of mandibular first molars in
asymptomatic test subjects with good occlusions showed
separations averaging 0.5 mm in working. 1.0 mm in nonworking
and 1.1 mm in protrusive movements. Therefore, one of the
treatment goals in placing occlusal restorations should be to
produce a posterior occlusion with buffer space that equals or
surpasses the deviations resulting from natural variations found in
the temporomandibular joint.
b. Condylar guidance
Chief among those aspects of condylar guidance that will have
an impact on the occlusal surface of posterior teeth are the
protrusive condylar path inclination and mandibular lateral
translation.
The inclination of the condylar path during protrusive
movement can vary from steep to shallow in different patients. It
forms an average angle of 30.4 degrees with the horizontal reference
plane (43 mm above the maxillary central incisor edge). If the
protrusive inclination is steep, the cusp height may be longer.
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However, if the inclination is shallow, the cusp height must be
shorter.
Immediate mandibular lateral translation is the lateral shift
during initial lateral movement. If immediate lateral translation is
great, then the cusp height must be shorter. With minimal
immediate translation, the cusp height may be made longer.
(Fig. 5 & Fig. 6).
Fig. 5 Fig. 6
The condylar path, particularly the lateral translation, affects
ridge and groove directions. The effects are observed on the occlusal
surface of a mandibular molar and premolar with the paths traced
by the lingual cusps of the respective opposing maxillary teeth. The
working path is traced on the mandibular tooth in a lingual
direction, and the nonworking path is in a distobuccal direction. The
nearer the tooth is to the working side condyle anterioposteirorly,
the smaller the angel between the working and nonworking paths.
The farther the tooth is placed from the working side condyle, the
greater the angle between the working and nonworking path. When
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immediate lateral translation is increased, the angle also becomes
more oblique.
c. Anterior Guidance
During protrusive movement of the mandible, the incisal edges
of mandibular anterior teeth move forward and downward along the
lingual concavities of the maxillary anterior teeth. The track of the
incisal edges from maximum intercuspation to edge-to-edge
occlusion is termed the protrusive incisal path. The angle formed by
the protrusive incisal path inclination, which ranges from 50-70.
While conventionally regarded as independent factors, there is
evidence to suggest that condylar inclination and anterior guidance
are linked, or dependent factors. In a healthy occlusion, the anterior
guidance is approximately 5 to 10 steeper than the condylar path
in the sagittal plane. Therefore, when the mandible moves
protrusively, the anterior teeth guide the mandible downward to
create disocclusion or separation, between the maxillary and
mandibular posterior teeth. The same phenomenon should occur
during lateral mandibular excursions.
The lingual surface of a maxillary anterior tooth has both a
concave aspect and a convexity, or cingulum. The mandibular
incisal edges should contact the maxillary lingually surfaces at the
transition from the concavity to the convexity in the centric relation
position. The concavity represents a uniform shape in all subjects.
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Anterior guidance, which is linked to the combination of
vertical and horizontal overlap of the anterior teeth, can affect
occlusal surface morphology of the posterior teeth. The greater the
vertical overlap of the anterior teeth, the longer the posterior cusp
height may be. When the vertical overlap is less, the posterior cusp
height must be shorter. The greater the horizontal overlap of the
anterior teeth, the shorter the cusp height must be. With a
decreased horizontal overlap, the posterior cusp height may be
longer.
By increasing anterior guidance to compensate for inadequate
condylar guidance, it is possible to increase the cusp height. If the
protrusive condylar inclination is shallow, requiring short posterior
cusps, the cusps may be lengthened by making the anterior
guidance steeper. In like manner, increasing anterior guidance will
permit the lengthening of cusps that would otherwise have to be
shorter in the presence of a pronounced immediate lateral
translation. (Fig. 7 & Fig. 8).
Fig. 7 Fig. 8
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III. Occlusal assessments1,12
AIMS
1. Establish baseline measurement such as vertical dimension,
over jet and overbite.
2. Detect signs and symptoms of occlusal problems
3. Decide between confirmative or reorganized approach
Significance of occlusal assessment
From a thorough review of literature there is no well controlled
studies that implicates the occlusion as an aetiological factor in
temporomandibular disorders. However the dentist has to pay
attention to the occlusion regarding.
To reduce mobility if caused by the occlusion
Patient comfort, i.e. to check any interferences
Mechanical integrity of restoration, teeth and osseointegrated
fixtures
To maintain control so that treatment can progress in a
predictable manner
1. Methods of checking occlusal contact
a. Occlusal tapes: Before starting, medicate the patient with
antisialogoues and then thoroughly wipe the teeth. A 15 micro
GHM occlusal tape is held with aid of Millers forceps and the
mandible guided to centric relation contact position, or any
excursive position requiring checking.
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It should be noted that density of color of mark is not related
to force of contact and heavier contact tend to spread the mark
peripheral to the actual contacting area, with the later being devoid
of ink. (Fig. 9).
Fig. 9
b. Shim stock: The 12 micron foil is held with mosquito forceps
between the teeth and checked for resistance to the pulling of
foil. However on mobile teeth, it may indicate contacts that are
not necessarily initial contacts. If initial contact are indeed on
the mobile teeth, these teeth will be depressed and the
secondary contacts on other teeth will then appear to be as
primary contacts. (Fig. 10)
Fig. 10
c. Sandblasted surfaces: This can be used for any metal surface.
The occlusal surface is sandblasted with 15-micron aluminum
oxide which produces a matt finish, the restoration is then
placed in patients mouth and movements made. If there are
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any interferences or high points on the restoration, the matt
finish gets polished to a shiny surface in that particular area,
which should then be removed.
d. T-scan: It is an electronic device, which enables tooth contacts
to be observed on a monitor screen, the contacts can be
observed as primary, secondary and tertiary. It also indicates
relative forces on each of these contacts.
Disadvantage: The T-scan identifies the approximate location of
contact, and hence tape markings are necessary for exact location.
T-scan is useful instrument only when used in conjunction with
tapes, shim shocks and sandblasted surfaces. (Fig. 11).
Fig. 11
2. Centric relation contact position (CRCP)
It is the relationship of the mandible to the maxilla in which
initial contact has occurred following closure with condyles in their
most superior position in the fossae with their anterior surfaces
functioning against the posterior facing surface of the ementia.
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Fig.12
3. Movement from centric relation contact position to
intercuspal position
Intercuspal position is an adaptive mandibulomaxillary
relationship, deflective contacts in centric relation may lead to a
path of closure which avoids the single tooth contacts i.e. ICP may
depend upon avoidance of centric relation interferences.
To check for movement observe the incisors to determine
vertical and horizontal dimension of the slide. From CRCP to ICP
It can be subdivided into 2 types
1. Large vertical: Horizontal ratio, where vertical component of
slide is more than the horizontal one. (Fig. 13 and Fig. 14)
Fig. 13 Fig. 14
2. Large horizontal : Vertical ratio, where horizontal component

is more than the vertical one. (Fig. 6 and Fig. 7)
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Fig. 15 Fig. 16
According to Wise when the mandible moves from centric
relation contact position to intercuspal position and vice versa, the
horizontal / vertical movement of the condyle is directly related to
the vertical / horizontal ratio measured at the incisor region of the
mandible.
Patient with large vertical than horizontal component tend to
have little if any horizontal movement of condyles, whereas those
with large horizontal component have a correspondingly larger
horizontal movement of the condyles.
Significance
A slide with large vertical: horizontal ratio is easy to adjust as
condyles move vertically but on average will only move horizontally
by a small amount, conversely a slide with large horizontal : vertical
ratio is difficult to adjust as there is likely to be a large horizontal
shift of condyles.
Following adjustment the former tends to result in CRCP
coinciding with original ICP and requires little adaptation by patient.
The later frequently results in CRCP becoming distal to original ICP
and may result in loss of contact between upper and lower anterior
teeth giving rise to guidance problems.
In patients with history of clicking and large horizontal :
vertical ratio it is prudent to retain deflective contacts, so as to
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prevent the mandible from distally repositioning and possibly
altering condyle / meniscal relationship.
When fabricating a new restoration,
A confirmative approach should be used inc cases of large
horizontal: vertical ratio since removal of deflective contacts
may result in distal movement of the mandible leading to TMJ
clicking and loss of anterior guidance.
A reorganized approach should be used in cases of a large
vertical: horizontal ratio so that CRCP and ICP coincide with
little or no distal movement of condyle
4. Lateral positions and excursions
It is divided into:
b. Working side contact
c. Non - working side contact
b. Working side contact is further divided into
Group function: Contact of two or more opposing pairs of
teeth on working side
Canine guidance: Contact only of opposing canine with other
teeth separated.
Significance: Identification of precise contacts made in lateral
excursion is particularly important in patients with bruxism as
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restoration may alter the direction of mandibular movement, leading
to failures or discomfort to the patients.
Whether the working side contact is group function or canine
guided
The contact should be smooth,
Use similar materials between opposing contacting surfaces to
reduce wear, and as a result changes in guidance.
Ensure there is no excessive mobility of guiding teeth.
Eliminate non-working side interferences, so as to achieve
working side contacts.
If the mandibular movement does not fulfill the above
requirement, then adjustment may be necessary prior to restoration.
5. Straight protrusion
Checked by instructing the patient to close into the ICP and
then slide straight forward until the incisors meet edge to edge.
6. Lateral protrusion
Checked by instructing the patient to close in the ICP then
move forward and to one side.
Marking tapes like GHM and shim stock foil checks both
protrusive contacts.
Significance:
According to the modern theories of occlusion, whether it is a
partial denture or a fixed restoration, in protrusion movement, there
should be contact between opposing, anterior teeth with separation
of posterior teeth. So an occlusion requiring restoration particularly
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of the anterior teeth should be investigated for protrusive contacts
as posterior protrusive interferences often require elimination prior
to restoration of anterior teeth.
IV. SELECTIVE GRINDING3
1. Indications:
A selective-grinding procedure can be used to (1) assist in
managing certain temporomandibular disorders (TMDs) and
(2) complementary treatment associated with major occlusal
changes.
In summary, selective grinding is indicated to improve an
occlusal condition only when sufficient evidence exists that this
alteration will assist in the management of a TMD or in conjunction
with an already established need for major occlusal treatment. At
present no evidence shows that prophylactic selective grinding is of
benefit to the patient.
2. Predicting the outcome of selective grinding
The clinician should remember that even when alteration of
the occlusal condition is indicated, a selective-grinding procedure
may not be the treatment of choice. Selective grinding is appropriate
only when alterations of the tooth surfaces are minimal so that all
corrections can be made within the enamel structure. When the
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malalignment of teeth is great enough that achieving the treatment
goals will penetrate the enamel, selective grinding must be accompa-
nied by proper restorative procedures. Exposure of dentin poses
problems (e.g., increased sensitivity, caries susceptibility, wear) and
therefore should not be left untreated. It is extremely important that
the treatment outcome of selective grinding be accurately predicted
before treatment begins. Both the operator and the patient must
know and be prepared in advance for the results of the selective-
grinding procedure. Patient acceptance and rapport are not
strengthened when, after the procedure is completed, additional
crowns necessary to restore the dentition are added to the treatment
plan.
The success in achieving the treatment goals using a selective-
grinding procedure alone is determined by the degree of
malalignment of the teeth. Because it is necessary to work within
the confines of the enamel only minimal corrections can be made.
The "rule of thirds" is helpful in predicting the success of a selective-
grinding procedure. It deals with the buccolingual arch discrepancy
when the condyles are in the musculoskeletally stable (MS) position.
(Fig. 17).
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Fig. 17
The anteroposterior discrepancy also needs to be considered. It
is best examined by visualizing the centric relation (CR) to
intercuspal position (ICP) slide, which is observed by locating the
mandible in the MS position (i.e. CR) and with a hinge axis
movement bringing the teeth into light contact. Once the buccolin-
gual discrepancy of the posterior teeth is examined (i.e., rule of
thirds), the patient applies force to the teeth. An anterosuperior shift
of the mandible from CR to ICP will be noted. The shorter the slide,
the more likely it is that selective grinding can be accomplished
within the confines of the enamel. Normally an anterior slide of less
than 2 mm can be successfully eliminated by a selective-grinding
procedure.
The direction of the slide in the sagittal plane can also
influence the success or failure of selective grinding. Both the
horizontal and the vertical components of the slide should be
examined. Generally, when the slide has a great horizontal
component, it is more difficult to eliminate within the confines of the
enamel. If it is almost parallel with the arc of closure (i.e, large
vertical component), eliminating it is usually easier. Therefore both
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the distance and the direction of the slide are helpful in predicting
the outcome of selective grinding.
After the CR slide has been examined, the position of the
anterior teeth is evaluated. These teeth are important because they
will be used to disocclude the posterior teeth during eccentric
movements. With the condyles in their treatment position (i.e., CR),
the mandible is once again closed until the first tooth contacts
lightly. An attempt is made to visualize the relationship of the
maxillary and mandibular anterior teeth as if the arc of closure were
continuing until the patient's vertical dimension of occlusion was
achieved. This represents the position of the anterior teeth after the
premature CR contacts have been eliminated. An attempt is made to
predict the type and adequacy of the future anterior guidance.
It is relatively easy to predict the treatment outcome in a
patient with well-aligned teeth and a very short CR slide. It is equally
easy to determine that a patient with a 6-mm horizontal slide and
poorly aligned teeth is not a good candidate for this procedure alone.
The problem with predicting the outcome of selective grinding arises
with the patient who is between these two extremes. Therefore when
it is difficult to determine the outcome of selective grinding, accurate
diagnostic casts are carefully mounted on an articulator so that
further analysis can be made. Tooth alignment and the CR slide are
more easily evaluated on mounted diagnostic casts. When doubt still
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exists, the selective grinding is carefully performed on the diagnostic
casts so that the final results can be visualized. Teeth that are
severely altered should be treatment planned for crowns. Once the
results of the selective grinding are visualized, the potential benefits
of the procedure can be weighed against any additional treatment
needed to restore the dentition. These considerations must be
evaluated before a selective-grinding procedure is suggested to the
patient.
3. Important considerations in selective grinding
The procedure can begin when proper indications for selective
grinding are determined and treatment results have been adequately
predicted. It is advisable, however, not to rush into treatment
without thoroughly explaining the procedure to the patient.
The effectiveness of selective grinding can be greatly influenced
by the operator's ability to manage the patient. Because the
procedure demands precision, careful control of the mandibular
position and tooth contacts is essential. The patient's muscular
activity must be properly restrained during the procedure so that the
treatment goals can be accomplished. Therefore conditions that exist
during the procedure should promote patient relaxation. Selective
grinding is performed in a quiet and peaceful setting. The patient is
reclined in the dental chair and approached in a soft, gentle and
understanding manner. Encouragement is given when success in
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relaxing and aiding the operator is achieved. When it is
advantageous for the operator to guide the mandible to a desired
position, the movement is performed slowly and deliberately so as
not to elicit protective muscle activity. The success of a selective-
grinding procedure is dependent on all these considerations.
4. Treatment goals for selective grinding
Although selective grinding involves the reshaping of teeth, the
mandibular position to which the teeth are altered is also critical.
Selective grinding should begin with locating the MS position (i.e,
CR) of the condyles.
The occlusal treatment goals for selective grinding are as follows:
1. With the condyles in the MS position (i.e., CR) and the
articular discs properly interposed, all possible posterior teeth
contact evenly and simultaneously between centric cusp tips
and opposing flat surfaces.
2. When the mandible is moved laterally, laterotrusive contacts
on the anterior teeth disocclude the posterior teeth.
3. When the mandible is protruded, contacts on the anterior
teeth disocclude the posterior teeth.
4. In the upright-head position (i.e., alert-feeding position), the
posterior teeth contact more heavily than the anterior teeth.
Several methods can be used to achieve these goals. The one
that will be described consists of developing (1) an acceptable
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CR contact position and (2) an acceptable laterotrusive and
protrusive guidance.
a. Developing an acceptable centric relation contact position
The goal of this step is to create desirable tooth contacts when
the condyles are in their MS position (i.e., CR). In many patients an
unstable occlusal condition exists in CR and creates a slide to the
more stable ICP. A major goal of selective grinding is to develop a
stable intercuspal contact position when the condyles are in the CR
position.
Another way of describing this goal is to refer to it as
elimination of the CR slide. A slide of the mandible is created by the
instability of contacts between opposing tooth inclines. When the
cusps tip contacts a flat surface in CR and the elevator muscles
apply force, no shift occurs. Thus the goal in achieving acceptable
contacts in ICP is to alter or reshape all inclines into either cusp tips
or flat surfaces Cusp-tip-to-flat-surface contacts are also desirable
because they effectively direct occlusal forces through the long axes
of the teeth.
The CR slide can be classified as anterosuperior,
anterosuperior and to the right, or anterosuperior and to the left.
Each is created by specific opposing inclines. A basic understanding
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of these classifications makes establishing an acceptable CR position
simpler.
Anterosuperior slide
The slide from CR to maximum intercuspation may follow a
pathway that is straightforward and superior in the sagittal plane. It
is due to contact between the mesial inclines of the maxillary cusps
and the distal inclines of the mandibular cusps. (Fig. 18).
Fig. 18
Anterosuperior and right slide
The CR slide may be anterosuperior with a right lateral
component (i.e., moving to the right). When a lateral component is
present, it is due to the inner and outer inclines of the posterior
teeth.
i. When opposing tooth contacts on the right side of the arch create
a right lateral slide, it is due to the inner inclines of the maxillary
lingual cusps against the inner inclines of the mandibular buccal
cusps. Because these are also the locations for mediotrusive
contacts, they are sometimes called mediotrusive CR
interferences.
29
ii. When a right lateral slide is created by opposing tooth contacts
on the left side of the arch, two contacting surfaces may be
responsible: (1) the inner inclines of the maxillary buccal cusps
against the outer inclines of the mandibular buccal cusps or (2)
the outer inclines of the maxillary lingual cusps against the inner
inclines of the mandibular lingual cusps. Because these inclines
are also the areas for laterotrusive contacts, they are sometimes
called laterotrusive CR interferences. (Fig. 19 & Fig. 20).
Fig. 19 Fig. 20
Anterosuperior and left slide
The CR slide may be anterosuperior with a left lateral
component. When a left lateral shift is present, the opposing inclines
that create it are the same as those that create the right lateral shift
but are present on the opposite teeth.
Understanding the exact location of the contacting inclines can
great assist in the selective-grinding procedure. Of course these
types of incline locations are accurate only if the normal
buccolingual alignment is present. When posterior teeth are in cross
bite, the location of the contacting inclines changes.
30
With an understanding of the previously discussed principles,
the clinician can begin the selective-grinding procedure.
31
Achieving the centric contact position
The patient reclines in the denial chair, and CR is bimanually
located. The teeth are lightly brought together, and the patient
identifies the tooth that is felt to contact first. The mouth is then
opened, and the teeth are thoroughly dried with an air syringe or
cotton roll. Articulating paper (or ribbon) held with forceps is placed
on the side identified as having the first contact. The mandible is
again guided to CR and the teeth contact, lightly tapping on the
paper. The contact areas are located for the maxillary and
mandibular teeth. One or both of the contacts will be on an incline,
either the mesial and distal inclines or the buccal and lingual
inclines. To eliminate the CR slide, these inclines must be reshaped
into cusp tips or flat surfaces.
An acceptable method for reshaping tooth surfaces is the use
of a small green stone in a high-speed handpiece. It is advisable,
however, that beginning students use a green stone in a slow-speed
handpiece to avoid removing too much tooth structure too quickly.
When confidence and expertise are gained, the high-speed handpiece
can be used. It will achieve good results in a reasonable time with
less tooth-to-bone vibration and therefore generally more comfort for
the patient.
When a contact is found on an incline close to a centric cusp
tip, it is eliminated. With this area eliminated, the likelihood is
greater that the next time the posterior teeth come together the
32
contact area will be shifted up closer to the cusp tip. When a contact
area is located on an incline near the central fossa area, the incline
is reshaped into a flat surface. This is often called hollow grinding,
because the fossa area is widened slightly. The clinician should
remember that the buccolingual relationship of the maxillary and
mandibular teeth cannot be altered, because it is determined by the
interarch widths when the condyles are in CR. Therefore the only
way that a cusp tip can contact a flat surface is for the fossa area to
be widened and a new; area created. (Fig. 21 & Fig. 22).
Fig. 21
Fig. 22
Once these incline areas have been adjusted, the teeth are
redried, remarked, and revalidated. If inclines are still present, they
are readjusted in a similar manner until only the cusp tip contacts a
flat surface. Once this has been achieved, the contact relationship
between the two areas is stable. However, these two contacts are not
the only ones necessary to achieve a stable CR position. As
adjustments are made, other teeth will also come into contact and
must be adjusted by the same sequence and technique.
33
The opposing incline contacts in CR are at an increased
vertical dimension of occlusion. As the inclines are eliminated, the
contact position begins to approach the patient's original vertical
dimension of occlusion, which is maintained by the ICP. As closure
occurs, more teeth come into contact. Each pair of contacts is eval-
uated and adjusted to cusp tips and flat surfaces. The clinician
should remember that all contacting incline areas must be
eliminated.
As the CR contacts are developed, sound cusp-tip-to-flat-
surface contacts are established but often at a greater vertical
dimension than the ICP. Therefore it is likely that these new
contacts will not allow the other posterior teeth to contact. When
this occurs, these contacts are reduced slightly so the remaining
teeth can occlude.
Even though cusp tip-to-flat surface contacts are desirable,
these areas must be reduced to permit full contact of the remaining
teeth. It generally is important for function and stability to maintain
prominent cusp tips. Thus the appropriate contact area- to reduce is
the flat surface. However, before this is done, one other factor should
be considered. As a fossa area is reduced, the centric cusp becomes
situated more deeply in the fossa. The deeper a cusp tip is located in
a fossa, the more likely it is to contact an opposing incline during
eccentric movements. Because eliminating posterior tooth contacts
34
is one of the goals of selective grinding, it is most efficient to address
this condition at this time. Therefore the decision to reduce either
the cusp tip or the flat surface is made by visualizing the cusp tip as
it executes the various eccentric movements.
When a cusp tip does not contact an opposing tooth surface
during eccentric movements, the opposing flat surface is reduced.
When a cusp tip does contact an opposing tooth surface, the cusp
tip is reduced. This reduction not only assists in establishing CR
contacts on other posterior teeth but also reduces the likelihood of
undesirable eccentric posterior tooth contacts when the anterior
guidance is developed. When altering either a cusp tip or a flat
surface, the clinician should remember that the same shape must be
maintained so that the desired contact will be reestablished as the
vertical dimension approaches the original values of the patient.
The CR contacts are marked and adjusted until all available
posterior centric cusps are contacting evenly and simultaneously on
flat surfaces. Ideally there should be four CR contacts on each molar
and two on each premolar. Because selective grinding involves only
the removal of tooth structure and cannot control all tooth surfaces
or positions, sometimes less than ideal circumstances result. A
minimum goal that must be achieved is for every opposing tooth to
have at least one CR contact. If this is not done, then drifting of
unopposed teeth can occur; the result may be reestablishment of
undesirable tooth contacts.
35
Anterior teeth that contact heavily during the development of
posterior CR contacts are reduced. It is generally acceptable to
reduce these contacts equally on both the maxillary and the
mandibular anterior teeth until the posterior teeth are reestablished
as the more prominent contacts. When the anterior teeth are being
adjusted, it is vitally important to visualize the future guidance
contacts that will soon be developed. If it is determined that by
grinding more on either a maxillary or a mandibular tooth the
guidance can be improved, this should be done
An acceptable CR position has been developed when equal and
simultaneous contacts occur between cusp tips and flat surfaces on
all posterior teeth. When the mandible is guided to CR and force is
applied, no shift or slide occurs. (There are no inclines to create a
slide.) When the patient closes and taps in CR, all the posterior teeth
are felt evenly. If a tooth contacts more heavily, it is carefully
reduced until it contacts evenly with the other posterior teeth.
2. Developing an acceptable lateral and protrusive guidance
The goal of this step in selective grinding is to establish a
sound and functional complement of tooth contacts that will serve to
guide the mandible through the various eccentric movements.
Posterior teeth are not usually good candidates to accept the
forces of eccentric mandibular movement. The anterior teeth, and
especially the canines, are much better Therefore under optimum
36
conditions the canines should contact during laterotrusive
movements and disocclude all the posterior teeth (bilaterally). When
the canines are in proper alignment, this goal is achieved. Often,
however, they are not properly positioned to contact immediately
during a laterotrusive movement. Because selective grinding deals
only with the removal of tooth structure, this lack of contact cannot
be corrected. When it occurs, the teeth that are best able to accept
the lateral forces should contact and guide the mandible until the
canines can contact and assist in the movement.
Several posterior teeth closest to the anterior portion of the
mouth (e.g., the premolars) best accept laterotrusive contacts. In
other words, when the canines are not positioned so that they can
immediately provide laterotrusive guidance, group function guidance
is established. In this instance the premolars and even the
mesiobuccal cusps of the first molars guide the mandible laterally.
As soon as adequate movement rings the canines into contact, they
are used to assist in the movement.
It is important to remember that this laterotrusive movement
is not static but dynamic. Tooth contacts must be properly
controlled during the entire movement until the canines pass over
each other, allowing the anterior incisors to contact (which is termed
the crossover position). During this dynamic movement all teeth pro-
viding guidance in the group function should contact evenly and
37
smoothly. If it is noticed that the first premolar is responsible for all
guidance during a particular portion of the movement, this tooth
may experience traumatic forces, usually resulting in mobility.
Selective grinding adjusts this tooth until it contacts evenly with the
remaining teeth during the laterotrusive movement.
When developing an acceptable lateral and protrusive
guidance, the clinician should remember the following:
1. Acceptable laterotrusive contacts occur between the buccal cusps
and not the lingual cusps. Lingual laterotrusive contacts and
mediotrusive contacts are always eliminated because they
produce eccentric occlusal instability.
The anterior teeth (not the posterior teeth) best guide
protrusive movements (as they do in lateral movements). During a
straight protrusive movement the mandibular incisors pass down
the lingual surfaces of the maxillary incisors, disoccluding the
posterior teeth. During any lateroprotrusive movement, the lateral
incisors can also be involved in the guidance. As the movement
becomes more lateral, the canines begin to contribute to the
guidance.
38
V. Determining the plane of occlusion4
A correct plane of occlusion allows protrusion without
posterior interference. It allows non-interfering lateral excursions
without loss of function on the working side.
When the mandible is protruded, the anterior guidance and
the downward movement of the condyles should disocclude all
posterior teeth. If the curve of spee is too concave or too high
posteriorly, one or more posterior teeth may interfere in protrusive
movement. Likewise an improper curve can cause interferences on
the nonfunctioning side because of the protrusive movement of the
condyle on that side, or because of an exaggerated curve of Wilson.
(Fig. 23).
Fig. 23
There are other considerations that should not be disregarded,
but they are secondary in importance to the primary requirement of
protrusive and balancing-side disocclusion of the posterior teeth.
These two requirements can be accomplished with an amazingly
wide degree of flexibility as far as the occlusal plane is concerned.
This flexibility makes it possible in many patients to satisfy esthetic
39
requirements without having to drastically alter an entire occlusion.
Teeth should never be restored unnecessarily simply to conform with
an arbitrary predetermined occlusal plane.
It is possible for an occlusal plane to be flat and still fulfill the
basic requirements, but if optimum efficiency in function is the goal,
the occlusal plane will usually have curvatures to it. Better
esthetics is, in most cases, also dependent on the natural curvatures
of the occlusal plane, the perfectly flat plane often being the epitome
of artificiality. A flat occlusal plane can even be harmful, since it
can create stressful crown-root ratios when the curvature of the
supporting alveolar bone is not matched to a reasonable degree with
the curvature of the occlusal plane.
A severely concave plane of occlusion on the lower arch may
function acceptably if it is combined with a steep enough anterior
guidance to disocclude the posterior teeth in excursions.
Appearance is not generally impaired with this combination as long
as the level of the occlusal plane is fairly even on both sides.
The occlusal plane problem that is most detrimental to
esthetics is the slanted plane. Which is high on one side and low on
the other. In fact, there is probably no single factor of occlusion that
is more noticeably unattractive than a slanted plane of occlusion.
Leveling of the occlusal plane always starts with the anterior teeth
for the following two reasons.
40
1. Esthetics:
The location of incisal edge position relates to the smile line
and determines the incisal plane, which is the anterior starting point
for the occlusal plane on each side. For best esthetics, it is an
absolute requirement that the incisal plane be parallel with the
interpupillary line.
2. Function:
Since the functional acceptability of any occlusal plane is
primarily related to letting the anterior guidance do its job, the
anterior segments must be organized before we can know how
effective the anterior guidance can be in disoccluding the posterior
teeth. The importance of the occlusal plane increases as the
steepness of the anterior guidance decreases. The flatter the
anterior guidance, the less capable it is of disoccluding a severely
curved occlusal plane.
3. Examination for occlusal plane problems:
An occlusal examination is not complete unless it includes an
analysis of the occlusal plane. Simply ask the patient to protrude
the mandible. If the posterior teeth separate the anterior teeth,
there is a problem with the occlusal plane. The problem may be the
result of a single misaligned tooth, or it may be cased by improper
curvature of alignment of the entire occlusal plane.
41
Because the condylar path is so important to protrusive
disocclusion of the posterior teeth, condylar paths should be
recorded at least by a clusal plane problem exists. The steeper the
condylar path is in protrusive, the better able it is to help the
anterior guidance disocclude the posterior teeth.
When protrusive separation of the anterior teeth is
accompanied by severe wear of the upper lingual cusps, there is a
probability that condyles and the eminence. The resultant flatter
condylar path is less capable of helping the anterior guidance and
can create critical problems of working out an acceptable occlusal
plane. In such cases, the condylar path should be accurately
recorded so that its effect on the posterior occlusion can be analyzed
along with the anterior guidance. Face bow-mounted diagnostic
casts are essential for this analysis.
4. Correcting occlusal plane problems:
There are two basic approaches to solving occlusal plane
problems. One involves leveling or flattening the occlusal plane so
that it can be disoccluded by the existing anterior guidance, which
remains unchanged. The second approach involves steepening the
anterior guidance so that it can disocclude the existing occlusal
plane, which remains unchanged. There is obviously a compromise
alternative that combines both a steepening of the anterior guidance
with alteration of the occlusal plane. Several considerations need to
be understood before there is a decision on which approach to take
on any given patient.
42
Whether the anterior guidance should be steepened depends
on four factors:
a. Envelope of function
b. Arch-to-arch relationships
c. Esthetic factors
d. Periodontal support
The envelope of function :
It is the principal determinant of the anterior guidance; so any
steepening of the anterior guidance can result in restriction of the
established pattern of function. However, when occlusal-plane
problems separate the anterior teeth in protrusive, it is often
possible to eliminate the posterior interferences by selective grinding
so that anterior contact can be maintained from centric relation.
This is most often possible to accomplish without any major changes
in the anterior guidance.
In some instances, however, changes to the posterior occlusion
may be extensive enough to require posterior restorations in order to
preserve the existing anterior guidance. This is an easier decision to
make if extensive restoration of the posterior segments is needed
anyway for other reasons. In mouths that have no other need for
posterior restorations, orthodontic treatment should be considered
to correct the occlusal plane rather than alter a potentially favorable
anterior relationship.
43
Steepening the anterior guidance does not always restrict the
envelope of function. Posterior tooth alignment can prevent the
mandible from horizontal function and thus be the limiting factor
that dictates verticalized function even though the anterior teeth are
not in contact. In such cases, steeping the anterior guidance may
simply transfer the guiding inclines from the posterior teeth to the
anterior teeth without altering the envelope of function. (Fig. 24 &
Fig. 25).
Fig. 24 Fig. 25
When this procedure is done, even slight modification of the
occlusal plane can result in disocclusion of the posterior teeth in
excursions.
The envelope of function should be evaluated in every case
before extensive changes in the occlusal plane are recommended.
Even though the occlusal plane prevents the anterior guidance from
disoccluding posterior teeth in protrusion, a problem may not exist if
the jaw has no protrusive movement as part of its locked-in
occlusions do not use protrusive movements. If they function solely
in a chop-chop verticalized pattern, there is no need to disocclude
the posterior teeth in jaw relationship that are never used.
44
Analyzing the teeth for signs of instability should make it evident if
there is not horizontal component of function. There is rarely a
functional occlusal plane problem in vertically restricted function if
all the teeth are stable. If there is a need for esthetic improvement
in such patients, the anterior guidance can generally be altered all
the way to verticalized function with no ill effects, and the occlusal
plane can be altered to improve the appearance with almost no
concern that it will interfere with the anterior teeth.
b. Arch-to-arch relationships
Certain arch-to-arch relationships may make restorative
alteration of the anterior guidance contraindicated. If the anterior
teeth are in a stable relationship with strong tongue or lip pressures
related to an anterior open bite or a severe over jet, it may create
instability if the teeth are moved or restored to contact. The occlusal
plane becomes a critical factor in some of those patients because a
disocclusion must be achieved off the flatter surfaces of the farthest
forward teeth that can contact in centric relation. In such
conditions, it is particularly important that the occlusal plane is low
enough in the back to be disoccluded by the relatively flat anterior
guidance.
In the resolution of arch-malrelationship problems the occlusal
plane is always a factor to be considered. The less the anterior
45
guidance is able to disocclude the posterior teeth, the more critical is
the occlusal plane.
c. Esthetic factors
Esthetics is often a key factor in determining what to do with a
slanted or uneven occlusal plane. Very uneven planes can often be
made to function acceptably, but the result is unacceptable
esthetically. When teeth on one side have been unopposed, it is
sometimes very difficult to level both sides because of the severe
elongation on the unopposed side. Unless esthetics is of no concern
whatever, every effort should be made to evenly align the occlusal
plane, including endodontic procedures if needed. Even though
endodontics would have been required, the difference in appearance
would have been worth it. Changes in the anterior segments must
be related to the posterior segments or even the appearance of
correctly aligned anterior teeth will suffer.
d. Periodontal support
Periodontal support around the anterior teeth is critical if the
anterior guidance is steepened to disocclude the posterior teeth. It
is tempting to solve an occlusal plane problem by steepening the
anterior guidance, especially if it takes the place of correcting the
occlusal plane by restoring anterior teeth that need to be restored.
One must remember that if steepening the anterior guidance
restricts habitual patterns of function, there will be a tendency for
46
increased horizontal stress on the anterior teeth. If the supporting
structures are already compromised, this may be a poor decision. It
will be safer to keep the anterior guidance nonrestrictive and make
the changes on the occlusal plane.
If there is no choice, and the steeper anterior guidance must
be used, the teeth should be stabililized to prevent them form being
forced out of alignment. Stabilization can be achieved by splinting,
or by use of a retainer at night when restorations are not needed.
5. Irregular occlusal plane caused by lost but unreplaced
posterior teeth:
When a posterior tooth is lost and the patient is allowed to go
without a replacement, it is almost inevitable that undesirable
changes will take place in the plane of occlusion. Teeth behind the
void have a tendency to lean into the space while unopposed teeth in
the opposite arch supraerupt until they meet opposition. The result
is a collapsed arch that prohibits protrusive or lateral excursions
because of interference form the tilted or elongated teeth. The effect
is the same as a curve of spee that is too high posteriorly. The
protruding mandible directs the stresses onto the teeth least able to
resist it. In addition, these eccentric interferences hyperactivate the
elevator muscles and thus intensify the stress. Tilted lower posterior
teeth, riding against opposing elongated teeth cause the anterior
47
teeth to disocclude, thus preventing the anterior guidance from
doing its job.
Correction of such an interfering occlusal plane is usually
essential if supporting structure problems are to be prevented in all
but the most fastidiously cared for mouth.
When an upper molar has supraerupted into a vacant space
between two lower posterior teeth, the upper tooth should be
shortened to permit protrusion of the mandible without posterior
contact. In some cases this should be done even if it requires
devitalization of the elongated tooth. The same is true if a lower
posterior tooth has elongated into a space above. (Fig. 26).
Fig. 26
If the terminal tooth on the upper has erupted down distal to
the most posterior lower tooth, it does not present a problem, eve
though it fails to conform to the picture of an ideal occlusal plane.
Devitalizing such a tooth just to make the occlusal plane conform
would be wrong, since the upper tooth is behind the lower teeth and
it does not restrict the mandible from moving forward under the
guidance of the anterior teeth. Such a tooth should be prevented
from excessive elongation into soft tissue by splinting or by
48
extension of a lower tooth into contact, but it need not be reduced in
length any more than the position of its pulp permits. (Fig. 27).
Fig. 27
It should be pointed out that when the basic requirements of
an occlusal plane are considered rather than an inflexible demand
for a preconceived contour, it is rarely necessary to devitalize any
tooth to provide an acceptable occlusal plane.
6. Curve of spee too low posteriorly:
Making the distal end of the occlusal plane too low presents no
major problems, since it cannot interfere with the basic
requirements of protrusive and balancing-side disocclusion. If it is
grossly overdone, however, it can create a poor esthetic result, can
cause excessive stress on upper teeth by requiring an unfavorable
crown-root ratio, and could conceivably reduce function in some
mouths by causing too much separation of the posterior teeth in
protrusion.
7. Curve of spee too high or low in front:
If the lower premolars are higher than the cuspids, they can
interfere with the anterior protrusive guidance by bumping into the
49
upper cuspids. If the lower premolars are considerably lower than
the anterior teeth, the result is very poor esthetically. There is rarely
a reason for such a relationship because it requires very simple
clinical judgment to extend the incisal level of the lower anterior into
an esthetically acceptable occlusal plane. The upper teeth may,
however, require some changes to accomplish an ideal plane.
8. Curve of Wilson:
Because the curve of Wilson is always depicted on the lower
arch, we may fail to understand that its real importance is related
more to accommodating the upper lingual cusps into the lower
occlusal scheme. Because of the normal outward tilt of upper
posterior teeth, their lingual cusps are lower than their buccal
cusps. Let us see how this affects the occlusal contours of lower
posterior teeth when the mandible is moved laterally. To emphasize
the influence of condylar pathways, we will imagine that the lateral
anterior guide angle is 0 degrees. In other words, the anterior
guidance is flat.
When the mandible moves toward the working side with such
a flat anterior guidance, the rotating condyle permits the posterior
teeth on that side to move almost horizontally toward the cheek.
The lower lingual cusp must be lowered to prevent it from interfering
with the upper lingual cusp.
On the balancing side, the orbiting condyle moves downward
as it moves forward and permits lateral movement without
interference to the upper lingual cusps. The result in the lower arch
50
is buccal cusps that are higher than lingual cusps and consequently
a concave curve of Wilson. (Fig.28 ).
Fig. 28
There are two ways of effectively changing the curve of Wilson.
The first way is to change the lateral anterior guidance angle. The
steeper the lateral anterior guidance angle, the higher the lower
lingual cusps may be on the same side. Raising the lower lingual
cusps has the effect of flattening the curve of Wilson, and with a step
lateral guidance from the cuspids, there may be a flat curve of
Wilson and still fairly clines direct the teeth on the working side
down as they move laterally.
It rarely serves any purpose, however, to have high lingual
cusps on the lower arch, since the lower lingual cusps are ordinarily
not functioning cusps. At lest they need not contact in any
functional movement. One may wonder why we even worry about
the height of these lower lingual cusps if they serve neither as a
holding contact or as a functioning incline, but they do act as useful
grippers of coarse or fibrous foods and consequently they serve a
51
useful purpose even though they need never be in actual contact (in
normal arch relationship). Furthermore, the lingual cusps should
also be lower than the buccal cusps to make it simpler for the
tongue to get the food on the occlusal surface. If we understand the
reasons for the curve of Wilson, it will become apparent that we have
a fair amount of latitude in establishing an acceptable curve of
Wilson.
The second way we may change the curve of Wilson is by
changing the length of the upper lingual cusps. By shortening the
cusp-fossae angles, we can actually make a flat curve of Wilson.
Such an occlusion can still function without interference and
without losing the upper lingual cusps as centric holding contacts.
All that would be lost is the maximum gripping effect that goes with
closely approximating cusps in excursions. In some mouths the
difference would not even be noticeable, but in others it could give
the patient a feeling of lost efficiency. Since the establishment of an
acceptable curve of Wilson can be accomplished so reason for
denying any patient whatever increased function a proper occlusal
plane can provide.
If the curve of Wilson is made too steep, it may eliminate the
use of upper lingual cusps as holding contacts, since they would
interfere with lateral movements of the mandible. Therefore it
becomes a matter of practicality to establish a curve that serves the
52
functional requirements within fairly broad limits of effectiveness,
while avoiding overly steep inclines that could cause interference.
9. Establishing the plane of occlusion :
There are three practical methods for establishing an
acceptable plane of occlusion. In selecting the method for a
particular patient, remember that the purpose of the procedure is to
cause the posterior teeth to be disoccluded by the anterior guidance.
If there is an esthetic problem, there will be an added purpose of
correcting the plane to a contour and height that is pleasant in
appearance. If there is no esthetic problem, any method that
satisfies the requirements of function and results in a stable
occlusion is acceptable. There is no need to complicate it beyond
these requirements.
53
The three most commonly used methods for establishing an
acceptable occlusal plane are as follows:
1. Analysis on natural teeth through selective grinding.
2. Analysis of facebow-mounted casts with properly set condylar
paths.
3. Use of Pankey. Mann-Schuyler method (PMS) of occlusal plane
analysis using Broadrick occlusal plane analyser. (Fig. 29).
Fig. 29
54
VI. OCCLUSAL SCHEMES1,12
1. Basic principles
Regardless of the type or the number of restorations, the
occlusal scheme to be employed must be decided before restoration.
The different schemes have common aims, which are:
Teeth position should remain stable following restoration.
The restoration must not introduce new deflective contacts.
There should be simultaneous contact between the restoration
and other teeth in the IP with neither high spots nor lack of
occlusion it should be noted that small high spots may remain
undetected by the clinician since the tooth is intruded
following initial contact.
There should be no nonworking side contacts on the
restoration as these produce rotational forces on the tooth and
restoration but their removal is dependent on there being
working side contacts to pick up the guidance.
There should not be working side interference on the
restoration (these often occur on lingual cusps and are difficult
to detect).
The anterior guidance should be in harmony with the
temporomandibular joints and musculature and should not
introduce an occlusal interference.
55
Occlusal forces should be directed through the strongest areas
of the restorative material and tooth.
Occlusal forces should be directed along the long axes of teeth.
2. Confirmative Approach
Restorations are fabricated to the existing jaw relationships.
With this approach the patient will need minimal adaptation, if any.
The restoration should fit into the existing neuromuscular patterns.
Tooth form can be altered, but the following guidelines are observed:
a. The existing intercuspal position is maintained
The objective is to retain the existing intercuspal position
Wherever possible, techniques must be used which facilitate
the fabrication of new restoration witch fit into the existing
intercuspal position
Not only Should the new restorations conform to the existing
intercuspal position, but they should also help retain it that is,
existing deflective contacts (contacts witch alter the closure
from one path to be another) may need to be copied on the new
restorations. Deflective contacts on teeth, which are not to be
re-restored, are left.
If the patient has a large horizontal: vertical ratio, particularly
in conjunction with a previous history of licking of the TMJ
which has now resolved, it is not wise to remove deflective
contacts, since distal repositioning of the condyle could result
in an altered condyle/meniscus relationship, possibly with
56
recurrence of the click. Techniques should be used which
enable the defective contacts to be built back into new
restorations. This requires more laboratory and surgery time
and this must be anticipated.
b. Remove deflective contacts if on one or two teeth are to be
restored
Deflective contacts alter closure from one path to another.
Their removal will frequently result in a new habitual path of closure
terminating in a new intercuspal position. In a patient with a large
horizontal: vertical ratio in with the horizontal component is less
than 1 mm and the patient is not occlusally aware, if one or two
teeth to be re-restored deflective contacts it maybe sensible to
remove these contacts some time before re-restoration, to allow the
mandible to adopt a slightly altered path of closure if the muscles so
desire and then work to the new intercuspal position. If this
procedure is not carried out there is a danger that such change will
take place during the temporary stage, as a result of tooth
preparation leading to inevitable removal of deflective contacts. The
occlusion of this definitive restorations will then differ from that
fabricated in the laboratory. Rarely is it possible to exactly copy the
deflective contacts on the temporary restorations. For a phlegmatic
patient, this may not be of consequence, but for any occlusally
aware patient it may introduce time consuming complications. It
57
must be pointed that this is not occlusal equilibration, merely
adjustment of one or two inclines prior to restoration. It is obviously
a slight modification of the conformative concept, since the
intercuspal position that is being restored to differ slightly from the
original intercuspal position. However, it does avoid clinical
complications and should be seriously considered.
c. Removal of non-working side contacts prior to re-restoration
A non-working side contact tends to guide the mandible
during lateral excursion. Removal of the existing restorations
decreases the vertical component of the movement pathway, since
now the condyle in the fossa will be guiding the movement. The
preparation may contact the opposing tooth. These will be
insufficient space for the restoration in lateral excursion, so that
cementation of the restoration creates a new non-working side
contact. If the patient is occlusally aware, or under stress,
adaptation will almost certainly be slow and discomfort is likely,
since the original contact to which the patient will have gradually
adopted was probably long standing. In response to the patients
complaint of discomfort, frequently the restoration is ground, either
exposing metal beneath porcelain, or perforating the casting. The
technician is often blamed, whereas the fault was the clinicians for
not recognizing the problem originally.
58
Non-working side contacts can only be removed prior to re-
restoration, if there are teeth o the working side available to pick up
the guidance. If no such teeth are present, removal of the non-
working side contacts is impossible and more time should be set
aside to copy the existing non-working side contacts: fabricate
temporary restorations; fabricate the definitive restorations and
check them at the time of fitting.
3. Reorganized Approach
Deflective contacts and occlusal interferences (contacts which
inhibit a smooth movement of the mandible when carrying out
excusive movements with the teeth in contact) are removed allowing
the muscles of mastication to move the mandible free from the
proprioceptive influence of these contacts. The general sequence of
treatment of a reorganized approach.
1. Stabilize the jaw and posterior tooth relationships.
2. Check
3. Determine the anterior guidance
4. Check Restore the anterior teeth
5. Check Restore the posterior teeth
59
In the anterior teeth were restored without stabilization of the
jaw relationships, on removal of the posterior deflective contacts as a
consequence of tooth preparation the jaw relationships would
change, there by altering the anterior guidance relationships. In
consequence, it is far more sensible to first eliminate the deflective
contacts and occlusal interferences, allowing the mandible to find its
own position relative to the maxilla. After provisionally restoring the
posterior teeth the anterior guidance is determined and copied and
then the posterior teeth definitively restored. As removal of the
posterior provisional restorations for their definitive replacement will
not alter jaw relationships, jaw registrations can be made at the
correct vertical dimension, and will be maintained by contact on the
anterior teeth.
This approach implies that any adaptation will have taken
place before re-restoration and that the restoration will fit into the
altered, newly accepted neuromuscular patterns. It also implies that
the existing anterior guidance is acceptable or that it is possible to
re-establish anterior guidance, so that in turn it becomes possible to
provide posterior dissocclusion with its associated mechanical
advantages.
In some instances it is not possible to provide anterior
guidance on anterior teeth, in which case lateral and protrusive
contacts are provided as anteriorly as possible on the posterior
teeth. The techniques for providing a reorganized occlusion are
described.
60
Cases in which a confirmative Approach would usually be
adopted
Singe unit with teeth on either side
Symptom free patient needing re-restoration of several
posterior teeth where the latter are bounded by a tooth
mesially and distally, both with good occlusal stops to
maintain the intercuspal position.
Restoration of a single tooth at the end of the arch although
small adjustments of deflective contacts on the tooth may be
carried out.
Three units at the end of the arch where there is a large
horizontal : vertical ratio, since removal of deflective contacts
may result in a distal movements of the mandible.
Multiple restorations and a large horizontal: vertical ratio and
a previous history of TMJ clicking
Multiple restorations and a large horizontal: vertical ratio in
which dropping back of the mandible following the removal of
deflective contacts would create a large horizontal overjet,
giving rise to either an unrestorable problem or the need to
provide anterior restorations where these were otherwise
unnecessary.
Re-restoration of anterior teeth in a symptom free patient not
requiring restoration of posterior teeth.
61
The advantages of restoring to a confirmative approach
No adaptation, or very little, of the patients neuromusculature
is required.
Treatment is confined solely to the teeth requiring restorations
Index techniques can be used
For a small number of restorations, laboratory procedures are
simplified.
Remember
The greater the number of units to be re-restored, the more
difficult it is to follow a confirmative approach.
The larger the horizontal; vertical ratio, the greater the
indication to work confirmatively, although the procedures
become more complicated, time consuming and less
predictable.
Recognition of the above is essential in treatment planning,
time planning and fee calculation
Cases in which a reorganized approach would usually be
adopted
Extensive re-restoration in the presence of a large vertical :
horizontal ratio. This is a very strong indication for a
reorganized approach.
A three-unit bridge at the end of the arch and a large vertical:
horizontal ratio.
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A sextant or quadrant restoration and large vertical :
horizontal ratio.
Right and left quadrants or posterior sextants and a large
vertical: horizontal ratio.
Extensive re-restoration and the presence of a large horizontal:
vertical ratio where anterior guidance can be provided either
on the anterior teeth, the canines, or the canines and pre-
molars, or on a removable appliance.
The advantages of restoring to a reorganized approach
Proprioceptions from deflective and interfering contacts are
removed.
Preparation of the teeth for crowns, or removal of provisional
restorations does not result in any clinically significant change
in jaw relationships.
The clinician has far greater control and each stage becomes
very predictable
It provides a stable occlusion with simultaneous multiple
occlusal contact
It provides an occlusion that is in harmony with border
movements (the extremes of lateral and protrusive excursions
that could easily be reached if interferences were removed).
It ensures that iatrogenic deflective contacts are not
introduced
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It improves control over interocclusal contacts, thereby
reducing adverse effects from disparate wear between
currently available restorative materials, and the natural teeth
It provides posterior stability which helps prevent anterior
drifting
Remember
A rigid adherence to the reorganized approach can precipitate
extremely difficult restorative problems, particularly in the
presence of a large horizontal vertical ratio.
4. Recommendations for occlusal schemes
1. Posterior occlusal schemes
2. Anterior occlusal schemes
3. Combination of anterior and posterior restorations
1. Posterior occlusal schemes
The type of interocclusal contacts that are provided will vary,
depending on tooth relationships. There is little scientific evidence to
Support the claims for any of the schemes although it should be noted
that Williamson et al (1983) reported that posterior disocclusion
reduces the activity of the elevator muscles and may therefore provide a
mechanical advantage by reducing the forces on teeth and restorations.
a. Cusp tip to fossa without lateral contacts
Here, the opposing cusp tip makes contact with the fossa only
in CRCP IP position and immediately dissoccludes to lose contact
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in all excursions. This is relatively easy to fabricate in the laboratory,
but with the cusp tip fitting to the depth of the fossa, rubbing
contacts occurring during bruxism will often wear away the support
contact on the cusp tip, leading to a loss of stability. It can be
difficult to achieve immediate dissocclusion and possibly, sharp
cutting surfaces are not provided. Adjustment is simplified if there is
a small areas of contact at the very tip of a cusp, rather than a broad
area, which may present some difficulties. Even though the cusp tip
may fit into the fossa, forces may not necessarily be axial and tilting
may occur. This scheme is more applicable to splinted than
unsplinted units because of the possibility of loss of support cusp
contact. The splinting would help maintain tooth stability.
b. Cusp to fossa with working side contacts
This is similar to the first scheme. However, provided there is
not a cross bite relationship, working side contacts are established
between the palatal incline of the maxillary buccal cusp, and the
buccal incline of the mandibular buccal cusp. This is more difficult
to achieve and requires more information for setting the articulator
in lateral excursions.
c. Cusp to fossa contact in CRCP plus anteriorly placed IP
contact (that is, Long Centric, Area of Freedom in Centric).
In this relationship, the tips of the support cusp (that is, that
cups which fits into the opposing fossa and thereby maintains the
65
vertical dimension) contact an opposing flat flossa in both CRCP and
IP and in the intervening areas between the two positions.
It is necessary for the configuration of the latter to be such
that on contact anywhere between the CRCP and IP, there is no
anterior displacement of the mandible.
Disadvantages
Supporting cusp tip may wear, with consequent loss of
occlusal support. This scheme is particularly applicable to a
reorganized restoration in a patient with a large horizontal; vertical
CRCP, IP ratio.
d. Tripod contacts
Support cusps fit into opposing fossae, but the cusp tip, rather
than contacting the base of the fossa is kept just clear of the latter
and instead, three points of contact are established around the
periphery of the cusp tip. The theory is that the tooth position will be
maintained by occlusal contacts, buccally directed forces being
counteracted by lingually facing contacts and vice versa. Provided
there is immediate disocclusion, the absence of cusp tip contacts
should reduce cusp tip wear. Theoretically, the small multiple points
of contact on sharp cusps should improve chewing efficiency.
This scheme is applicable to both splinted and unsplinted
restorations, although it is not possible to use it to provide an area
of freedom relationship.
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e. Cusp to margin ridge contacts
Frequently, there must be contacts between cusps and
opposing marginal ridges. However, this can usually be combined
with a cusp fossa contact for additional stability.
f. Confirmative contacts
An index is used to copy the existing occlusal scheme, which
may then be modified to include any of the schemes above.
There are no controlled studies reporting a greater stability of
one type of occlusal scheme relative to another, or demonstrating
which teeth are likely to be unstable unless corrected by the
provision of different occlusal contacts. There are, however, some
clinical guides
The degree and type of stabilization required from opposing
contacts depends upon whether
The teeth form individual units or are splinted. Theoretically,
splinted units require fewer contacts than the same number of
unsplinted units, as they could be stabilized by contacts only
at each end of the span.
There is increased mobility and / or reduced bony support.
Mobile, poorly supported teeth tend to be more occlusally
unstable than firm, well-supported teeth.
The arch is intact. A proximal contacts assist in stabilization
The teeth are titled
2. Anterior occlusal schemes
67
In CRCP and IP, the anterior contacts should be very slightly
lighter than the posterior contacts. On closure, Shim stock should
be held by the posterior teeth, but just pulled through the anterior.
By this means, the vertical dimension is maintained by posterior
support cusps, thereby preventing anterior teeth assist guiding
excursive movements. Whether or not the anterior teeth are suitably
positioned depends upon both tooth-to-tooth relationships. In the
presence of a large overjet, the guidance should be provided as far
anteirorly as possible, or on a removable appliance fabricated
palatally to the upper anterior teeth. Often with Class III cases
anterior guidance cannot be provided, but this doses not seem
important in these cases.
When provided, it is sensible to establish guidance on the
teeth most able to support it, and not use.
Highly restoratively compromised teeth, such as, a canine with a
poorly constructed post.
Highly mobile teeth, since movement of these would greatly
reduce the angle of guidance. Furthermore, with mobile teeth
guidance on laboratory casts will not match the guidance in vivo.
The shape of the palatal concavity, should fulfill the following
requirements:
Patient comfort
Aesthetic and phonetic acceptability
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Smooth guidance, that is there are no mandibular deflections or
irregularities of movement.
Minimal movement of guidance teeth
No increasing mobility of guidance teeth
Regardless of the cement used, no cementation failure of interim
restorations, assuming the preparation design is adequate.
Currently, there is research into the relationships between
various characteristics of facial morophology, condylar guidance and
anterior guidance. This resultant computerized data should be very
helpful in initially establishing anterior guidance.
Anterior guidance for reorganized large vertical: horizontal ratio
cases
Ramfjord in 1983 describes contacts on the anterior teeth to
match the posterior contacts, a difficult arrangement to produce.
Dawson, in 1974, described a horizontal shelf on the palatal
surfaces of the upper anterior teeth, with immediate posterior
dissocclusion, that is, the area of freedom is only on the anterior
teeth. This is a more practical approach.
3. Combination Of Anterior And Posterior Restorations
a. Gnathalogical Scheme
The movements of the condyles in the fossae determine the
occlusal form. Fully adjustable instrumentation is required. There
should be simultaneous interoclusal contacts of all posterior teeth in
CRCP, with forces directed axially, where CRCP and IP coincide.
Closure in CRCP followed by squeezing of the jaws together, should
not result in any perceptible displacement or slide of the mandible.
69
In any excursive or protrusive movement anterior or canine
guidance separate (dissocclude) the posterior teeth. If anterior
guidance cannot be provided, then guidance should be placed as far
forwards as possible. The anterior teeth contact lightly in CRCP. The
palatal concavities of the anterior teeth are determined by condylar
guidance. The case is waxed on a fully adjustable articulator and
cusp fossae tripod contacts are provided.
Comments
Because of coincide of CRCP and IP, this scheme is more
suitable for large vertical horizontal ratio cases than large horizontal:
vertical ratio cases.
A fully adjustable articulator is required
Reliance on condylar guidance for palatal concavity formation
requires scientific verification. It may provide a good
indication, but clinical determinants are also required.
Tripoid contacts may be unnecessary, particularly for splinted
units.
The technique is demanding
A slide from the CRCP may recur with time. However, in this
study, it is possibly that large horizontal: vertical ratio cases
were
70
Included and these are more likely to be unstable than large
vertical: horizontal ratio cases.
Posterior disocclusion is a good mechanical concept as it
prevents horizontal non-axial forces form being placed upon
posterior restorations. This enhances the resistance form of
preparations and reduces sheer forces on porcelain cusps. It
also reduces elevator muscles activity.
Multiple points of contacts with cusp / fossa relationships may
improve masticatory efficiency.
N.B. Anterior guidance, as used in this text, is the influence on
mandibular movement of contacting surfaces of anterior teeth. It
does not refer to guidance produced by the posterior teeth as
anterior guidance. Posterior guidance is the influence on mandibular
movement of condylar determinants.
b. Area of freedom in centric
As Ramford in 1982 wrote: This advocate a small flat area on a
horizontal plane between the CRCP and IP (Long Centric) and with
occlusal functional guidance leading to the intercuspal position,
rather than the retruded position. The distance between CRCP and
the IP in this scheme is not critical, but usually approximately 0.5
mm 0.3 mm. Dawson, in 1974, advocated that contact anterior to
CRCP occurs only on the anterior teeth, without provision of the
horizontal table on the posterior teeth which become dissoccluded.
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Comments
This scheme is applicable to reorganized large horizontal:
vertical ratio cases
Since lateral excursions can begin from both CRCP and the IP,
disocclusion needs to be provided from both positions,
complicating the restorations.
Cusp tip to fossa occlusion must be provided
Cusp tip to fossa is easier to provide than tripod contact.
Cusp tip to fossa relationship can result in wear
Areas of wear can occur between cusps and fossae leading to a
loss of support cusp contacts and possibly instability
Although advocated as a simple technique careful
determination of mandibular movements is necessary
accuracy.
c. Pankey Mann- Schuyler Concept
The anterior guidance is determined functionally. The upper
and lower anterior teeth and the lower posterior teeth are restored. A
functionally generated path (FGP) technique is used to assist waxing
of the upper posterior restorations. The occlusal plane is determined
from measurements based on the curve of Monson. The aim is to
provide simultaneous interocclusal contact of all posterior teeth in
CRCP with an area of freedom of not more than 0.5 mm anterior to
this resulting in an absence of a non-working side contact and group
function on the working side (although some operators aim for
canine disocclusion).
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Comments
A fully adjustable articulator is not required
Movement of teeth while making an FGP registration leads to
inaccurate registration. It is possible for the guidance teeth to
intrude, bringing the prepared and opposing teeth closer
together than they will be on the casts mounted in the IP.
Flexibility of the mandible under muscle load can lead to
inaccurate registration
Inaccurate registrations reduce the accuracy of the final
restoration.
d. Yuodelis Scheme for advanced periodontitis cases
The foundation of a healthy periodontium is emphasized. The
aim is for simultaneous interocclusal contact of posterior teeth in
CRCP (usually coincident with IP) with forces directed axially.
Anterior disocclusion is provided for protrusive excursions and
canine disocclusion for lateral excursions. Cuspal anatomy is so
arranged that if the canine disocclusion is lost through wear or tooth
movement, the posterior teeth drop into group function. Diagnostic
temporary restorations are important in providing information
essential to this scheme.
Both fully and semi adjustable articulators are used the right
instrument of the case in hand. Emphasis is placed on margin
placement and crown contour.
73
Comments
This is a sensible combination of available techniques
Primary suitable for large vertical horizontal ratio cases
e. Nyman and Lindhe scheme for extremely advanced
periodontitis cases
This applies to bridgework supported by healthy, though
greatly reduced, periodontium. Even contact should be provided in
the IP, although no great emphasis is placed upon the type of
contacts. When distal support is present, anterior dissocclusion
should be provided. When there are long tooth-borne cantilevered
restorations, balanced occlusion is provided, that is, there are
simultaneous working and non-working side contacts on the
cantiliver. All restorations should be fabricated on semi-adjustable
articulators with average settings and there is an emphasis on
supragingival margin placement of restorations.
Comments
Prescription for highly mobile teeth
Mechanical aspects are underplayed, that is, undue
importance is not attributed to them.
Conclusion
74
A decision on the occlusal scheme prescribed should be made
before fabrication of definitive restorations. Commonly, features of
several of the schemes are incorporated in the same cases. The
responsibility for the occlusal prescription is the dentists not the
technicians. To make the prescription, the dentist must be totally
familiar with the various options, the difficulties presented by a
particular case and the realistic possibilities. Someone who has not
waxed cases himself and, as a minimum attended and successfully
participated in a wax additive technique course, is mot unlikely
indeed to be in such a position. Wax additive technique courses are
highly relevant to the dentist and are not just the realm of the
technician. If the dentist is attempting to re-restore the failed
extensively restored dentition, it is a professional obligation to be
competent in at least the fundamentals of occlusal treatment.
The ability to correctly prescribe the occlusal scheme is
fundamental.
75
VII. Determining the type of posterior occlusal

contours4
There are three basic decisions to make regarding the design of
posterior occlusal contours
1. Selection of the type of centric relation contacts
2. Determination of the type and distribution of contact in lateral
excursions
3. Determination of how to provide stability to the occlusal form
For achievements functional efficiency with stability, the
critical objectives of posterior occlusal contours are as follows :
1. Multiple equal intensity contacts on each tooth in centric
relation at the correct vertical.
2. Occlusal forces directed parallel to the long axis of each tooth.
3. Non-interference with any border path of the condyles of the
anterior guidance.
In the design of occlusal contours, the first decision is where
to locate each of the multiple contacts that meet the opposing teeth
when the mandible is in centric relation. These decisions are
determined when each holding contact is related to how it would
direct the occlusal forces. Teeth can withstand tremendous force if
the force is directed up or down the long axis of each tooth because
when force is directed parallel to the long axis it is uniformly resisted
76
by all of the supporting periodontal ligaments except those at the
apex. If forces are misdirected laterally, the tooth loses the support
of about half of the ligaments that are compressed and puts almost
the entire load on the half under tension. So the starting point in
designing occlusal contours is to shape and locate the centric
contacts so that the forces are directed as nearly parallel as possible
to the long axis of both upper and lower teeth.
There are many ways to design occlusal contours if direction of
forces in centric relation were the only surface contacting, another
flat surface could be made to fulfill this first requirement, but it
would not be a very good design for penetrating or grinding fibrous
foods. Proper placement of a sharp cusp against a flat surface could
penetrate foods easily and still direct the forces correctly, but a
single sharp cusp against a flat surface might lack resistance to the
lateral forces that come from the cheeks versus the tongue. The
addition of more contacts seems to be an aid to the requirement of
occlusal stability though it is unlikely that any kind of occlusal
contour is capable of stabilizing posterior teeth if they are not in
horizontal harmony with the neutral zone.
The posterior teeth must do more than penetrate food; they
must also be capable of crushing and grinding it. To fulfill these
roles, they must be able to work one surface against another in
enough proximity to masticate efficiently. To accomplish this, the
sharp cusps are broadened at the base and rounded at the tips. The
77
flat surfaces are changed to fossae, and the walls of the fossae are
curved and angled to relate to the lateral movements of the mandible
as guided by the lower anterior teeth against the lingual surfaces of
the upper anterior teeth. Blades are made to emanate from the lower
buccal cusps to function in reasonable closeness to the upper
inclines.
1. Types of centric holding contacts
There are three basic ways by which centric relation contact is
usually established on restorations.
1. Surface to surface contact
2. Tripod contact
3. Cusp tip to fossa contact
a. Surface to surface contact
Surface to surface contact we refers to this as mashed potato
occlusion. It is the form that results if the articulator is simply
closed together when the wax on the dies is soft. There is never a
valid reason for using this type of contact. It is stressful and it
produces lateral interferences in anything other than near vertical
chop-chop function. (Fig. 30).
Fig. 30
78
b. Tripod contact :
In tripod contact the tip of the cusp never touches the
opposing tooth. Instead, contact is made on the sides of the cusps
that are convexly shaped. Three points are selected from the sides of
the cusps, and each point in turn is made, to contact the side of the
opposing fossa. Contacts or the stamp cusps must be made at the
brim of the fossa wall so that all posterior teeth can disengage from
any contact immediately upon leaving centric relation. Lateral and
protrusive disocclusion of posterior teeth is essential when ever
tripod contact is used because convex lower cusps cannot follow
normally concave border pathways against upper teeth, which are
also convex. This is especially true when the contacts are on the
sides of convex cusps. Consequently, if the lateral anterior guidance
starts with a near horizontal path and if rest closure function
dictates the need for a long centric, it would be necessary to use
flatter occlusal surfaces and wider cusp tips with the contacts
distributed more on the tips than on the sides of the cusps. Fossa
contacts have to be more on ridges and fossa brims than on the
walls of the fossa. Some advocates of tripodism do recommend this.
(Fig. 31).
Fig. 31
79
When the working side condyle translates laterally on a
horizontal plane and the lateral anterior guidance permits the front
end of the mandible to also move laterally on a horizontal plane
before curving down a concave pathway, there is no way to make
tripod contact work if the contacts are on the sides of convex cusps.
Allowing the cusps to move through grooves is not practical because
contacts aligned on the sides of the cusps to facilitate travel through
a straight lateral pathway groove would interfere with a slightly
protrusive lateral pathway. There is no way to align the contacts
around the sides of the cusps to permit the full range of lateral and
protrusive pathways if the anterior guidance starts out with
horizontal paths. This is important to understand because many
periodontally involved mouths are best served by such concave
anterior guidances.
If tripoid contact is to be used with concave anterior
guidances, the contacts must be confined to the tip of broad flat
cusps. A tripodism of sorts can be achieved if you keep the tips of
the cusps wider than the grooves and fossae that they rest against
or pass over. This type of pseudotripodism can even be made to
function in lateral excursions if the upper cusp inclines are matched
to the concave border pathways of the mandible. If there is any
horizontal movement of the mandible in lateral and protrusive
excursions, convex surfaces simply cannot function against the
sides of other convex surfaces without creating stressful
interferences.
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Indication
Tripod contact is difficult to accomplish, but it can be done as
long as the anterior teeth are capable of disocclusion the posterior
teeth in all excursions. For patients whose functional movements,
anterior periodontal supports, arch relation, and tooth position are
best served by posterior disocclusion, tripod contact can be very
comfortable, functional, and beautiful to behold.
Contraindications
Tripod contact should not be used when lateral stress
distribution is best served by including posterior teeth into group
function to help out weak or missing anterior teeth or when the arch
relationship does not permit the anterior guidance to do its job.
Disadvantages
With tripod cannot, any degree of shifting of any tooth produces
an incline interference. Any wear on a centric contact leaves the
remaining centric stops for that cusp to be on inclines. Since
upper and lower arches are usually restored together, even a
minute error in recording of transferring centric relations causes
loss of tripodism on all teeth.
Tripod contact is extremely difficult or impossible to equilibrate
without losing tripodism and ending up with contacts on inclines.
However, this is mostly academic because usually enough
counteracting inclines can be kept in contact to maintain
reasonably good direction of force.
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Advantages
If tripod contact is so difficult to achieve and has so many
limitations, why is it used? Probably the main reason for the
popularity of tripodism is the impression that it is so stable if it is
properly done. This certainly has been one of the main reasons for
advocating it use. However, there is no scientific evidence to show
that tripod contact is more stable than proper tip to fossa contact.
Development of slides is common, even among the most meticulous
operators.
A precisely recorded centric relation will make the majority of
patients very happy even if little else is accomplished, and eccentric
disocclusion of posterior teeth is always better than posterior
interference in excursions. Combined with the clinical observation
that most patients can also function quite well with excursive
disocclusion of the posterior teeth, one can readily see why there are
many patients who are very happy with their tripod contact
occlusions.
Nevertheless, there are no actual indications for tripod contact.
Although it can be used successfully in a large number of patients, it
has definite limitations in many others. It offers no advantages over
proper cusps tip to fossa contact, and since it is more difficult to
achieve, is hard to adjust, and is limited in its use, we would
probably do well to thoughtfully evaluate its practicality.
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c. Cusp tip to fossa contact
If cusp tips are properly located in the most advantageous
fossae, this type of occlusion offers excellent function and stability
with the flexibility to choose any degree of distribution of lateral
forces that is warranted. It is the easiest occlusion to equilibrate.
Resistance to wear is excellent, since the centric stops are on the
cusp tips, whereas in working excursions, contact is on the sides of
the cusp tips as they travel along the inclines of the opposing teeth,
centric excursion, it is accomplished easily by adjustment of the
fossa inclines without disturbing the centric holding contacts.
(Fig. 32).
Fig. 32
With cusp tip to fossa contact, it is not necessary to restore
upper and lower teeth together. In fact, there is no advantage
whatsoever to preparing both arches together. Location of cusp tips
can be determined with extreme accuracy against unprepared teeth,
and cusp height and fossa contours can be established one arch at a
time with complete assurance that the contours will be correct.
Location of cusp tip-to-fossa contacts is decided according to
the best interest of each tooth on the basis of direction of forces as
near parallel to the long axis of each tooth as possible and stability
without interference to eccentric movements.
83
Cusp tip to fossa contact is not a by-product of any specific
technique. It serves the goal of function rather that form. It can be
accomplished with the aid of gnathologic instrumentation, functional
path procedures, or a myriad of other instrumentation techniques.
The one essential for accomplishing it correctly is an understanding
of what we are after. Properly done, it can be beautiful as well as
functional and stable.
d. Posterior contacts in lateral excursions
To make meaningful judgment about the distribution of lateral
stress, we must first distinguish the difference between the rotating
condyle and the orbiting condyle. Each side has physical
characteristics that are important to understand before an occlusal
scheme can be planned with any degree of dependability. In
discussing lateral excursions divide the movements accordingly into
working side occlusion and non-functioning side occlusion (also
referred to as the balancing side)
Working side occlusion refers to the contact relationship of
lower teeth to upper teeth on the side of the rotating condyle. The
side toward which the mandible moves is the working side. The
condyle on the working side can be braced against bone or ligament
throughout the working excursions, and so it is possible and quite
practical to accurately record and restore the posterior teeth to
precise working side border movement contacts.
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Non-functioning side occlusion is the side of the orbiting
condyle. When the condyle leaves its braced position and slides
forward down the slippery incline of the eminentia, it is no longer
solidly fixed against the unyielding bone and ligament. Rather, it can
move up a little, since the mandible bends slightly under firm
muscle pressure. Consequently, tooth contact during non
functioning side excursions should not be allowed. Because of the
flexibility of the mandible, it would not be possible to harmonize
occlusal contours to all the variations resulting from the difference
in muscle force from light to heavy. Hence we have the rule :
whenever lower teeth move toward the tongue, they should not
contact.
The job of disoccluding the non-functioning side is always the
responsibility of the working side. How the working side disoccludes
the non-functioning side is an important decision that must be
made for each individual patient. While the teeth on the working
side are disoccluding the teeth on the non-functioning side, they
must also function as cutters, holders, and grinders.
The dentist must decide how all this is done by selecting one of
the following choices for working side occlusion
1. Group function
2. Partial group function
3. Posterior disocclusion
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None of these choices is optimum for all cases. Selecting the
one that offers the most advantages for each different patient is just
good treatment planning.
Group function refers to the distribution of lateral forces to a
group of teeth rather than protecting those teeth from contact in
function by assigning all the forces to one particular tooth.
To paraphrase a law of physics the more teeth that carry the
load, less load any one tooth must carry. We must decide which
teeth are capable of carrying how much load and assign the load
accordingly. As an example, we would not use a loose cuspid with
little bone support to protect strong posterior teeth from contacting
in a working excursion. Instead, we would allow the posterior teeth
to share the load by bringing them into group function with the
cuspid and the other front teeth on that side.
1. Group function
Group function of the working side is indicated whenever the
arch relationship does not allow the anterior guidance to do its job of
disoccluding the non-functioning side. The anterior guidance cannot
do its job in the following situations.
1. Class II occlusions with extreme over jet
2. Class III occlusions when all lower anterior teeth are outside of
the upper anterior teeth
3. Some end to end bites
4. Anterior open bite cases
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When you are using posterior group function, the following rule
applies; contacting inclines must be perfectly harmonized to border
movements of the condyles and the anterior guidance. Convex to
convex contacts cannot be used to accomplish this.
2. Partial group function
Partial group function refers to allowing some of the posterior
teeth to share the load in excursions whereas other contact only in
centric relation. As an example, a second molar may be very firm
vertically but be hyper mobile buccolingually. Such a tooth should
touch only in centric relation and be disoccluded immediately by the
other teeth in excursions. A very strong first premolar may work
with a moderately strong cuspid and incisors to disocclude a weak
second premolar and molars.
Because of arch relationships, a first and second molar may be
the only sources of disocclusion for balancing side contact. Group
function had better be perfectly harmonized to border movements in
such a case, but it can be done successfully. Anterior teeth with post
orthodontic root resorption or congenitally poor crown root ratios
should sometimes be harmonized to group function with the working
side.
Whether any tooth should share the lateral stresses should be
decided on the basis of each tooths resistance to lateral stress.
There is no good reason why such a decision cannot be made on a
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tooth-by-tooth basis. If a tooth is weak laterally, it should contact in
centric relation only. If a tooth is firm and clinical judgment says
that it would be beneficial to the other teeth to let that tooth share
the lateral stress and wear, that is what should be done.
Some dentists object to ever having posterior teeth contact in
lateral excursions. Strenuous objection to group function usually
comes from having had problems with it. Because of the resultant
problems, objectors may think that group function is actually
harmful. It should be clear that problems with group function result
from improper harmony of the contacting inclines. Attempts at
group function with convex inclines, as an example, are invitations
to hypermobility. Some patients do change their pattern of function
to conform to the restrictive inclines of convex cusps, but it is
unpredictable at best. For group function to be effective in reducing
stress, the cusp inclines must be in perfect harmony with the lateral
border movements of the jaw. Posterior cusp inclines that are not
contoured to match the mandibular border movements are
disoccluded if the inclines are opened out too much, or they interfere
if any part of the incline is steeper than the corresponding part of
the lateral jaw movement. Incline interferences on posterior teeth get
progressively more stressful as they get closer to the condyle
fulcrum, so that a slight interference on a second molar would
probably be more stressful than a more noticeable interference on a
cuspid. If this rule of stress distribution is understood, it is quite
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practical to distribute lateral stress over some or all of the posterior
teeth. It can be done effectively by restorative means and by occlusal
adjustments of the natural teeth.
3. Posterior disocclusion
Posterior disocclusion refers to no contact on any posterior
teeth in any position but centric relations. It can be accomplished
easily with cusp tip to fossa morphology. It must be accomplished
with tripod or surface-to-surface morphology to prevent lateral
interferences in any case with centric contact on inclines that are
steeper than the lateral border movement of the mandible. It occurs
automatically if tripod contacts are distributed on the tips of broad
flat cusps or the lateral guidance angle is steeper than the
contacting posterior surfaces, or both conditions.
In healthy mouths or in mouths with normally strong anterior
teeth, it is an excellent occlusion. Since normal anterior teeth are
quite capable of carrying the whole excursive load, particularly if
they are in harmony with functional border movements.
Posterior disocclusion in all jaw positions except centric
relation is the most desirable occlusion whenever it can be achieved
by an acceptable anterior guidance. Even some weakened anterior
teeth may actually be stressed less by separation of the posterior
teeth from contact in excursions. The reasons for this phenomenon
is the effect that posterior disocclusion has on the contractive force
of the elevator muscles. The moment complete posterior disocclusion
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occurs in protrusive, the masseter muscle stops contracting, the
internal pterygoid muscle stops contacting, and the temporalis
muscle contraction is reduced. In lateral excursions, internal
pterygoid contraction controls the balancing side.
There are two methods of accomplishing posterior disocclusion
1. The anterior guidance is harmonized to functional border
movements first and then the lateral inclines of the posterior
teeth are opened up so that they are disoccluded by a correct
anterior guidance.
2. The posterior teeth are first and then disoccluded by
restriction of the anterior guidance. This method if backward.
Anterior guidance is a proper determinant of posterior
occlusal form and thus should be done first. When posterior
occlusal form determines the anterior guidance, the
correctness of the anterior guidance is a product of chance.
Two different types of anterior guidance can achieve posterior
disocclusion; anterior group function and Cuspid protected
occlusion. Neither is applicable for all cases.
1. Anterior group function: Is the most practical method for
disoccluding the posterior teeth when arch relationships and tooth
alignment permit it. Anterior group function is beneficial in three
ways.
1. It distributes wear over more teeth
2. It distributes the stresses to more teeth
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3. It distributes stress to teeth that are progressively farther from
the condyle fulcrum.
Any one of these considerations would be reason enough to
recommend anterior group function, but in addition to its effect on
stress and wear, anterior group function is extremely comfortable
and efficient. It improves the efficiency of incising movement by
providing lateral as well as protrusive shearing contacts.
Despite its advantages, anterior group function is not
applicable in all cases. Some arch relationships do not permit the
incisors to contact in lateral excursions. Concave anterior guidances
permit group function, whereas convex lateral guidances make it
difficult to accomplish. When it is impractical to distribute the
lateral guidance stress over several teeth, disocclusion of the
posterior teeth can be accomplished by use of the cuspids in one
form or another for cuspid-protected occlusion.
2. Cuspid protected occlusion: It refers to disocclusion by the
cuspids of all other teeth in lateral excursions. It usually serves as
the cornerstone of what is called mutually protected occlusion.
Mutually protected occlusion has been defined in several ways, but
the usual connotation refers to an occlusal arrangement in which
the posterior teeth contact in centric relation only, the incisors are
the only teeth contacting in protrusion, and the cuspids are the only
teeth contacting in lateral excursion. It is an ideal relationship for
some patients, is tolerated by some, and is detrimental to others.
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Clinical judgment should be developed so that cuspid protected
occlusion is used only when it offers advantages over other occlusal
arrangements.
In cuspid-protected occlusion, all lateral stresses must be
resisted solely by the cuspid. Therefore the predominant pre
requisite for its use is the capability of the cuspid to withstand the
entire lateral stress load without any help from other teeth.
It may seem unlikely that any one tooth could have enough
stability to carry such a load over a long period of time without
becoming subjected to excessive wear or hyper mobility. The fact is
that the lateral stresses are minimal if the lingual contours are in
harmony with the functional border movements. In other words,
lateral stress becomes insignificant if the mandible function
normally within the lingual inclines of the upper cuspids.
It is impossible to exert excessive stresses against the cuspids
in centric relation because the posterior teeth also resist the stresses
in that position, if the occlusion is correct.
In natural cuspid protected occlusions, the pattern of function
is rather vertical, and so he mandible does not use lateral
movements that would subject the cuspids to stress in that direction
either.
The cuspids actually assume the role more as a guidance that
actuates vertical function rather than as a resistor to lateral stress.
Any attempt at lateral movement is felt by the presoreceptors around
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the cuspids. Within limits, these exquisitely sensitive nerve endings
protected the cuspids against too much lateral stress by redirecting
the muscles to more vertical function. As long as the pressoreceptors
can keep the muscles programmed to a vertical envelope of function,
there is insufficient lateral stress generated to harm the cuspids.
Some clinicians have reported that the cuspids have the
distinction of being protected by a greater number of presoreceptor
nerve endings than is found around any other tooth. This alleged
density of proprioceptors is supposed to impart a unique capacity to
be cuspid to redirect any functional pattern that would be
destructive. If, for example, a horizontal chewing cycle would exert
too much lateral stress against the cuspids, their special
proprioceptive protectors would simply change the chewing cycle to
a vertical, chop function rather that let harm come to the cuspids or
their supporting structures.
It is easy to see why such a concept would be popular. If the
cuspids really did have the capacity to change functional movements
from horizontal to vertical, it would eliminate much need for concern
with occlusal morphology. Good centric contacts would be all that
would be necessary for posterior teeth, since mandibular movements
could be restricted by changing the cuspids to permit vertical
opening and closing only. Some advocates of cuspid protected
occlusion actually subscribe to such a theory, but further research
has failed to substantiate the report that there are more
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proprioceptors around the cuspids than there are around other
teeth. Furthermore, clinical results over a period of time have shown
that the cuspid, just like other teeth, is also subject to the usual
problems of excessive lateral stress if it interferes with normal
functional movements. Although the cuspids do have the benefit of
normal proprioceptive protection, there does not appear to be any
valid support for the cuspid protection theory on the basis of special
proprioceptive capacity to radically alter habitual patterns of
function.
However, there are other valid reasons why cuspid protected
occlusion works well for many patients. The cuspids have extremely
good crown root ratios, and their long fluted roots are in some of the
densest bone of the alveolar process. Further more their position in
the arch, far from the fulcrum, makes it more difficult to stress
them. In short they are very strong teeth. If their upper lingual
inclines are in harmony with the envelope of function, they are
usually quite capable of withstanding lateral stresses without help
from other teeth. Many patients have natural cuspid protection, and
if the cuspids are firm and the occlusion is comfortable, it should be
maintained, even if the teeth must be restored.
The natural cuspid protected mouth is easily distinguished by
convex or very steep lingual inclines on the upper cuspids. The
patient usually cannot move the jaw laterally, even when asked to do
so. The chewing cycle is a vertical chop. The patient has never
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functioned laterally and has no need for more than minimal lateral
pressure on the closing stroke. If posterior tooth form were brought
into group function with such steep inclines, even the slightest
shifting of a posterior tooth could subject it to extreme lateral stress
because it would be in interference to the powerful closing stroke.
The vector of force against steep incline interference is nearly
horizontal and the stress is further amplified, as it gets closer to the
condyle. In near vertical envelopes of function it is usually better to
let the posterior teeth be disoccluded by the cuspids if the cuspid
protection is natural and if the cuspids are firm. If the mouth
requires extensive restorative treatment and minimal changes to the
cuspids would affect anterior group function without noticeably
altering the chewing cycle, it would be logical to make that change
for the advantages that could be gained. However, changing from
cuspid protection to anterior group function is contra indicated if it
would require a major change in the envelope of function or
extensive reduction of sound lingual enamel.
For simplicity, cuspid protection can be divided into two
categories:
1. Posterior disocclusion by cuspid inclines that are in harmony
with functional border movements.
2. Posterior disocclusion by cuspid inclines that restrict
mandibular movements within habitual functional border
movements.
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Whether a patient functions normally in vertical chop chop
motions or wide horizontal strokes, it will still be possible to
harmonize cuspid inclines. If the harmonized cuspid inclines are the
disoccluding factor for all posterior teeth in lateral excursions, it
may be considered a form of cuspid-protected occlusion. Because of
their arch form or tooth arrangement, many patients will be served
best by this type of occlusion.
Restrictive cuspid protection is usually used as an attempt to
avoid stressful posterior contact in lateral excursion by forcing the
patient into a changed pattern of function. It may result in a
reduction of hypermobility of posterior teeth that have been under
stress. Restrictive cuspid protection falls far short of the immediate
comfort that patients feel with a harmonious anterior guidance. They
must get used to the restrictive guidance. Although some patients
will change their functional patterns when the cuspids get sore
enough to force them into a chop-chop bite, it is an unnecessary
irritation to mouth comfort, and the long term maintainability of
such occlusal relationships is very unpredictable. If the cuspids are
stressed into lateral movement, they are no longer able to protect the
posterior inclines.
It should be reemphasized that from the standpoint of comfort
many patients can tolerate a change to the more vertical function of
a steeper cuspid rise. It is far better, whenever practical, to get
posterior disocclusion from an anterior guidance that is in harmony
with the patients envelope of function.
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e. Selecting occlusal form for stability
Assuming that the cusp fossae relationships are correctly
placed for ideal direction of stress, we still must make decisions
regarding the number of contacting cusps that are needed for
maximum stability under differing conditions. We generally have
four basic types to choose from in normal arch relationships.
Type I: Lower buccal cusps contact upper fossae. There are no other
centric contacts. Working side excursive function is limited to the
lingual inclines of upper buccal cusps. (Fig.33 ).
Fig. 33
If desired, continuous contact can be maintained in working
excursions on the lingual incline of the upper buccal cusps, or if
disocclusion of posterior teeth is desired, it can be easily
accomplished by modification of the upper inclines. Disocclusion of
balancing inclines can be easily accomplished.
This type of occlusal relationship can be very comfortable and
can be made to function in a completely satisfactory manner. It is
the easiest contour to fabricate when one is restoring posterior teeth
because cusp fossae angles on the lower are not critical. If
functionally generated path procedures are used, the upper working
inclines are formed automatically and the upper lingual cusps are
wiped away if lower cusp fossae angles are too steep.
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The only apparent disadvantage to this type of occlusal
relationship is its lack of dependable buccolingual stability. Pressure
from the tongue can tilt the teeth toward the buccal with very little
resistance. Because it lacks the stability that upper lingual cusp
contact would give it, more follow up occlusal adjustment is usually
required than is necessary with more stable occlusal contours.
In periodontal prostheses the splinting itself ensures utilizing
around the arch splinting buccolingual stabilization. It is not
necessary to stabilize the teeth with upper lingual cusp centric
holding contacts. Lower buccal cusp contact is sufficient to satisfy
all the needs of the splinted patient. Working excursion contact is an
elective that can be used when needed for disocclusion of the
nonfunctioning side. From the standpoint of either function or
comfort, patients seem to be just as happy with only contact of the
lower buccal cusp as they are with more elaborate occlusal schemes.
Since it is the easiest occlusal form to accomplish and the easiest to
adjust, it is an acceptable choice of occlusal form whenever
buccolingual stability has been assured by splinting.
Type 2: Centric contact on the tips of lower buccal cusps and upper
lingual cusps. Working side excursive function is limited to the
lingual inclines of the upper buccal cusps. There is no excursive
function on any lower incline. (Fig. 34).
Fig. 34
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The addition of the upper lingual cusps as centric holding
contacts contributes greatly to the stability of the posterior teeth.
Lateral stress toward the buccal is resisted by the contact of the
upper lingual cusps against the lower fossae. Stress toward the
lingual is resisted by the lower buccal cusps against the upper
fossae. Furthermore, the vector of force against the cusp tip to
fossae contacts is directed toward the long axis when the teeth are
stressed laterally, because lateral movements takes place by rotation
of the tooth around a point within the root.
Lateral excursion contact is limited to the lingual incline of
upper buccal cusps, the same as in type I. This presents no problem
of lateral stress as long as the upper inclines are in perfect harmony
with lateral border movements. The return to multiple cusp holding
contacts in each centric closure has sufficient stabilizing effect for
maintenance of the occlusion within practical limits. Working incline
contact can be disoccluded when desired by modification of upper
inclines.
If the upper lingual cusp is to be used as a holding contact in
centric, the inclines of the lower fossae must not be steeper than the
lateral anterior guidance. If the upper lingual cusp is to be
disoccluded in all lateral movements, the lower fossae inclines must
be flatter than the lateral anterior guidance.
Because lower fossae inclines need only be flatter than lateral
anterior guidance inclines, the fabrication of lower occlusal contours
is be precisely identical to border pathways, since they are to be out
of contact in excursions.
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Contact in working excursions can be accomplished by use of
functionally generated path techniques or any other procedure that
accurately records lateral border movements.
From every clinical standpoint, the performance of this type of
occlusal contour is acceptable. It is comfortable and functional and
because it fulfills all the requirements of good occlusal form and can
be accomplished with clinical practicality, it is the type of occlusion
for which we strive in unsplinted restorative cases when posterior
group function is needed.
Type 3 : Centric contact on tips of lower buccal cusps and upper
lingual cusps. Working excursions contact is limited to the lingual
incline of upper buccals cusps and buccal incline of lower lingual
cusps. (Fig. 35).
Fig. 35
This type of occlusal contour is identical to type 2 except that
the buccal incline of the lower lingual cusp becomes a functioning
incline.
The major difference between this type of occlusal form and
type 2 is the difficulty of accomplishing it to bring the upper lingual
cusps into working excursion contact. The buccal inclines of the
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lower lingual cusps must be precisely contoured to the exact lateral
border movement of both the condyle and the anterior guidance. If
the incline is made too flat, it will disocclude. If it is made too steep,
it will interfere.
Certainly there are methods available to use to record these
border movements accurately and to refine the lower inclines to
duplicate than, but unless the additional time, effort, and
instrumentation produce an improvement in the result, it is time
wasted.
Although complexity of fabrication seems to be the only
disadvantage of type 3 occlusal form, it is reason enough not to
advocate it because the result has no clinical advantage over type 2
occlusal form, which can be fabricated with less complicated and
less time consuming procedures without any reduction in the
quality.
Type 4 Tripod contact
There are two types of tripod contact: 1. Contact on the sides
of cusps and the walls of fossae and 2. Contacts on the brims of
fossae and on top of wide cusp tips.
1. Contact on the sides of cusps and the walls of fossae
Contact on the sides of the cusps does not permit any lateral
or protrusive movement on a horizontal plane; so if the anterior
guidance has been flattened even for a short distance from the
centric stops to permit a lateral side shift of the mandible, this type
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of occlusal forms will be contra indicated. It is also contra indicated
for any patients who requires a long centric. (Fig. 36).
Fig. 36
It may be used in vertical or near vertical functional cycles
with either cuspid protected occlusion or anterior protected
occlusion.
In the cases permitting its use, its performance is clinically
indistinguishable from type 2 or type 3 occlusions. Like type 3, it
disadvantage comes from the difficulty in fabricating it. Tripod
contact is the most difficult of all occlusal to fabricate.
3. Centric contact on the brims of fossae and the top of wide
cusp tips: with no contact in eccentric excursions. This type of
tripod contact can be made to function with any type of anterior
guidance because it permits horizontal lateral movement without
interference. It is automatically disoccluded by an anterior
guidance effect other than flat plane; so it cannot be used when
posterior group function is indicated. (Fig. 37).
Fig. 37
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Since it is essentially a flat occlusal contour and cusp tips do
not fit into fossae, it is only necessary to make sure the fossa width
is narrower than the width of the cusp tip. Consequently it is not
extremely difficult to fabricate. Elaborate fossae and groove
contouring can be accomplished as long as the multiple centric
contacts are not disturbed. Even though the contacts may stay the
same, it is possible to develop very sophisticated contours within the
framework of this type of occlusion.
When posterior disocclusion is indicated, this type of occlusal
form may be used with the same clinical success as type 2 occlusal
form that has been modified to disocclude. It is purely a matter of
dentist preference. Patients will not be able to distinguish between
the two forms.
Summary
There are several types of occlusal form that can be used to
restore posterior teeth. What ever contour is selected should be
chosen because it:
1. Directs the forces as near parallel as possible to the long axis
of each tooth
2. Distributes the lateral stress to maximum advantage in
varying situations of periodontal support
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3. Provides maximum stability
4. Provides maximum wearability
5. Provides optimum function for gripping grinding, and crushing
Practicality of fabrication is a factor that should be considered
when the type of occlusal form is being selected. If additional time,
effort, and expense are required to produce the same clinical result
that could be accomplished with greater case of the patients, the
dentist, and the technician, technique orientation has in all
probability taken the place of goal orientation.
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VIII. Disocclusion5
The concept of disocclusion is widely accepted today, most
commonly described as the separation of posterior teeth during
eccentric movement. It is not clear yet how much the cusps of the
posterior teeth should disocclude.
There is minimal literature available regarding the proper
amount of disocclusion. Shooshan (1960) and Scott (1964) stated
that during lateral movement, the molars should disocclude more
than 0.5 mm between maxillary and mandibular posterior teeth on
the nonworking side. Thomas (1967) stated when maxillary and
mandibular cuspid have a tip-to-tip relation during lateral
movement, the molars should disocclude 1.0 mm. The exact amount
of disocclusion has not yet been clarified.
From the above data, Hobo and Takayama derived standard
values for the amount of disocclusion as 1.0 mm during protrusive
movement, 1.0 mm on the nonworking side and 0.5 mm on the
working side during lateral movements. The latter is one-half the
amount that exists in the former two. Solnit has suggested more
disocclusion if possible since the bruxer will wear canines after 10
years and allow working side and nonworking side contacts to recur
(Solnit 1996).
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1. Mechanism of disocclusion
The mechanism of disocclusion during protrusive movement is
illustrated in the following.
a. The mechanism of disocclusion I
This shows the case when the sagittal inclination of the
condylar path is 40 degrees, the condylar and incisal paths are
parallel, and the cusp angle of maxillary and mandibular molars is
also parallel to both the condylar and incisal paths. In this case,
during the protrusive movement the mandible does not rotate
around the intercondylar axis but only translates. Translation as
defined means "parallel displacement of a body" (the mandible).
Since maxillary and mandibular molars slide in contact during
eccentric movement, disocclusion does not occur.
b. The mechanism of disocclusion II
This shows the case when the sagittal condylar path
inclination is 40 degrees, the cusp angle is parallel to the condylar
path but the incisal path is steeper than the condylar path. In this
case, the mandible translates and rotates around the intercondylar
axis; the maxillary and mandibular molars disocclude. The
component of disocclusion occurring when the incisal path is
steeper than the condylar path is referred to as the "anterior guide
component" of the 'mechanism of disocclusion. McHorris (1979)
recommended that the incisal path should be 5 degrees steeper than
106
the condylar path. However, when setting the sagittal incisal path
inclination 5 degrees steeper than the condylar path, the author
computed that the amount of disocclusion during protrusive
movement is only 0.2 mm, about one-fifth the standard value (1.0
mm). If the incisal path is steeper than 5 degrees, the patient will
complain of discomfort.
c. The mechanism of disocclusion III
condylar path is 40 degrees, the condylar and incisal paths are
parallel and however, the cusp angle is shallower than the condylar
path. In this case, the mandible does not rotate around the
intercondylar axis it only translates. However, since the cusp angle
is shallower than the condylar path, the maxillary and mandibular
molars disocclude. Thus, the component influencing the amount of
disocclusion when the cusp angle is shallower than the condylar
path is referred to as the "cusp shape component" as a mechanism
of disocclusion. In this way, the authors found that the cusp angle
was another important factor for disocclusion.
d. The mechanism of disocclusion IV
condylar path is 40 degrees, the incisal path is steeper than the
condylar path and the cusp angle is shallower than the condylar
path. In this case, the mandible translates and rotates
107
simultaneously around the intercondylar axis. By the additive effect
of the anterior guide component caused by the mandibular rotation
and the cusp shape component occurring when the cusp slope is
shallower than the condylar path, the maxillary and mandibular
molars disocclude widely. This condition is seen often in healthy
individuals.
2. Influences on the amount of disocclusion
a. Condylar path
Deviation of the condylar path
Hobo thought the condylar path deviations were due to 'buffer
spacing' which exists in the glenoid fossa (Hobo, Ichida, Garcia
1989). Since the temporomandibular joint is subject to strong
mechanical stress, the 'buffer spacing' allows condylar mobility and
helps prevent transmission of direct stress to the articular eminentia
across the articular disk. If 'buffer spacing' does not exist and the
condyle transmits strong stresses, the disk could not withstand
direct forces and would result in damage such as anterior disk
displacement or a disk perforation.
The difference between eccentric and returning condylar paths :
When Hobo and Takayama (in press) measured mandibular
movement using an electronic computer measuring system with six
degrees of freedom (Hobo, Mochizuki 1983), they allowed the
condylar paths of the subjects to perform back-and-forth movements
108
and found differences between the eccentric and returning condylar
paths. Seventeen healthy subjects, 20 to 24 years of age, were
examined further. As a result, it was found clearly that this
difference showed consistency within each subject and the returning
condylar path always passed above the eccentric condylar path.
Rarely did both paths superimpose. No single case was discovered
where the eccentric condylar path existed above the returning
condylar path.
The authors measured the graphic data output of both
condylar paths. When linking the eccentric and returning condylar
paths, a loop-shaped path was formed. The width between the
eccentric and returning condylar paths measured at 2 mm from the
condylar position in maximum intercuspation, averaged 0.44 mm
during protrusive movement and 0.79 mm during lateral movement,
as shown in Table 1-2.
An arc, drawn with a radius of 2 mm with the center at the
condylar positioning maxium intercuspation, made two intersection
points on the paths. The angles formed by the two lines drawn from
the center of the arc to the two intersection points were measured.
They were approximately 13 degrees average on the protrusive
condyle path and 23 degrees average on the nonworking side lateral
condyle path as shown in Table 1-3 (Hobo, Takayama in press).
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The eccentric condylar path can be measured by use of a
pantograph and occlusal records. Utilizing the above data, the
returning condylar path of an individual patient can be
approximated by subtracting 13 degrees from the measured value of
the eccentric condylar path for protrusive movement and by
subtracting 23 degrees for the lateral movement.
The widths between the eccentric and returning condylar
paths.
Unit : mm Mean SD
Protrusive movement 0.44 0.26
Lateral movement 0.79 0.37
Table 1-3 Comparison between sagittal condylar path
inclinations of eccentric and returning paths.
Eccentric path Returning path Difference

Unit mm
Mean SD Mean SD Mean
Protrusive
40.1 13.8 27.4 7.6 12.7
movement
Lateral
40.5 11.8 17.5 10.9 23.0
movement
During opening and closing movements of the mandible,
various muscles function. The muscles related to a closing
movement are much stronger than the muscles related to an
opening movement. The muscles that influence eccentric movement
may be the muscles related to an opening movement. The muscles
110
that influence the returning movement may be related to the closing
movement. The lateral pterygoid and digastric muscles, which
function during eccentric movement are weak; the masseter,
temporal and medial pterygoid muscles, which function during the
returning movement that are relatively strong. (Fig. 38).
Fig. 38
The soft tissues that connect the condyle and glenoid fossa
may relax during an eccentric movement. They may also contract
unconsciously during the returning movement. Therefore, one can
imagine that the condyle positions in a relaxed manner in the
glenoid fossa during the eccentric movement and is held tightly
during the returning movement. This may be the reason for a
difference as little as 1.0 mm superoinferiorly between the eccentric
movement and returning movement. The difference found between
eccentric and returning condylar paths supports the undeniable fact
that "the condylar path is not fixed but is changeable.
As previously mentioned, the authors observed the deviation of
eccentric condylar paths when they were repeatedly measured.
111
However, the eccentric and returning condylar paths differ from the
above deviation because these paths are created by the physiologic
difference in muscles (opening and closing) utilized.
Controlling the condylar path
In dentistry, the condylar path has been considered the
standard reference for occlusion. However, condylar path was not
fixed but was changeable. Furthermore, when changing the lateral
incisal path, the immediate mandibular translation disappeared
instantaneously, and laterotrusion disappeared simultaneously. This
proved the condylar paths on both working and nonworking sides
were influenced by the anterior guidance.
The anterior guidance influences the condylar path, which
infers the condylar path is influenced by the patient's occlusion.
Therefore, if the patient's occlusion is poor, his condylar path is
affected by malocclusion. If such a condylar path is measured
precisely, reproduced on an articulator, and used as a reference for
the fabrication of a restoration, the occlusion of applying the
measured value of a patient's condylar path as a reference for
occlusion has posed a crucial question.
112
b. Incisal path
The incisal path is that traveled by the incisal point during
eccentric movement. It is the anterior determinant of mandibular
movement. "The influence of the contacting surface of the
mandibular and maxillary anterior teeth on mandibular movements"
is defined as incisal guidance (GPT-6 1994). As previously
mentioned, the incisal path influenced the condylar path. Since the
condylar path is not valid as a reference, it is necessary to
investigate if the incisal path can be used as a new reference of
occlusion instead of the condylar path.
According to the report by Kelly et al (1973), the occurrence
rates of malocclusion included vertical overlap 6.6%, open bite 2.5%,
Angle's Class II 9.4% and Class III 0.8%, totaling 19.3%. These data
showed one out of five patients would not have an incisal path as an
appropriate standard.
The above data indicated that among the patients with normal
occlusion, there were large variations in the incisal path and the
occurrence rate of malocclusion was high. It was concluded that the
incisal path as well as the condylar path would not be valid as
references for occlusion.
Influence of the incisal path on the amount of disocclusion
When the sagittal inclination of the incisal path decreases by
one degree, the amount of disocclusion will decrease by 0.038 mm
113
during protrusive movement. When the frontal inclination of the
incisal path decreases by one degree, the amount of disocclusion will
decrease by 0.042 mm on the nonworking side and 0.039 mm on the
working side during lateral movement.
There exists a variation in the incisal path by approximately
10 degrees both on protrusive and lateral movements from the mean
value. The influence on the amount of disocclusion was calculated
by multiplying the above rate of influence by the amount of variation
(10 degrees). As a result, they were 0.38 mm during protrusive
movement, 0.42 mm on the nonworking side and 0.38 mm on the
The above result was compared with that of the condylar path.
The ratio of the influences of condylar and incisal paths was 1:2
during protrusive movement; 1:3 on the nonworking side and 1:4 on
the working side during lateral movement. On the first molar, the
ratio became 1:3 during protrusive movement and the other ratios
were similar.
These results showed the influence of the incisal path on
disocclusion was much greater than that of the condylar path. The
concept that the incisal path is less important than the condylar
path must be reversed. The incisal path influences disocclusion
more than the condylar path. However, the incisal path cannot be
used as the sole guiding factor for occlusion due to its unreliable
character.
114
c. Cusp angle
Cusp angle is the inclination of the cusp slope from the cusp
tip to the marginal ridge. It is defined as "the angle made by the
average slope of a cusp with the cusp plane measured mesiodistally
or buccolingually" (GPT-6 1994). The cusp plane means the plane
determined by the two buccal cusp tips and the highest lingual cusp
of a molar" (GPT-6 1994), anatomically means a plane comprised of
three cusp tips. The angle formed by the average cusp slope and the
horizontal reference plane is called the effective cusp angle.
The effective cusp angle during protrusive movement is
referred to as the sagittal protrusive effective cusp angle. The
effective cusp angle during lateral movement on the working and
nonworking side is referred to as the frontal lateral effective cusp
angle on the working and nonworking side.
Deviation of the cusp angle
On the contrary, the ratio of variations of condylar and incisal
path inclinations to the mean was 43% and 32%, respectively. The
data of cuspal morphology was, on average, four times more reliable
than that of the condylar path and incisal path. Accordingly, since
the cusp angle is one characteristic of cuspal morphology, it should
have the same reliability.
The above data clarified that the cusp angle does not show the
deviations that appeared in the condylar path nor the variations that
115
appeared in the incisal path among individuals, and the cusp angle
was three to four times more reliable than the other two factors.
The influence of the cusp angle on the amount of
disocclusion
The influence ratio of the condylar path, incisal path and cusp
angle to the amount of disocclusion on the second molar when the
condyle moved 3.0 mm from centric was approximately 1:2:2 during
protrusive movement; 1:3:3 on the nonworking side; 1:4:4 on the
The influence of the cusp angle is 40% to 44% of the total
influence, which is comparable to the incisal path but far larger than
the condylar path. Since the cusp angle is more reliable than other
factors and its influence is large, the authors concluded that the new
reference for occlusion should be the cusp angle of newly erupted
permanent teeth, not the condylar path or the incisal path.
In conclusion, the necessity for disocclusion is explained as follows:
1. "Security insurance" to protect teeth from harmful effects due
to a cuspal interference can be caused by a difference
between the eccentric and returning condylar paths.
2. A redundant need to protect teeth from harmful effects due to
any cuspal interference since anterior guidance varies among
individuals.
This investigation provides the reasons why it is necessary to
create disocclusion. However, in practice, the dentist cannot
measure the returning condylar path of a patient nor alter the
116
incisal path of natural teeth logically. Therefore, it is impossible to
reproduce disocclusion to fulfill the necessary reasons using
prosthetic techniques available today. This suggests the need for
development of new procedures to support this concept.
3. Twin-stage procedure
Until today the condylar path has been regarded as the main
determinant for occlusion in prosthetic treatment. It is measured
and used as a clinical reference. Since the condylar -path has been
shown to have deviation and minimal influence on disocclusion, a
question arises. Is it proper to use the condylar path as the main
determinant?
The deviation of the incisal path in each individual is less than
that of the condylar path. The incisal path influences disocclusion at
the second molar twice as much as that of the condylar path during
protrusive movement, three times on the nonworking side and four
times on the working side during lateral movement. However, when
individual variation and the occurrence rate of malocclusion are
incorporated, the inclination of the incisal path will be distributed
broadly; the incisal path would not be a reliable reference for
occlusion. This infers that the cusp angle, which has not been
studied previously, should be considered as a new reference for
occlusion.
Embryologically, the cusp angle is an independent factor from
both condylar and incisal paths. To obtain good occlusion in
restorative treatment, the critical factor may require reproducing a
117
standard value for the cusp angle. The reproduction of condylar and
incisal paths on an articulator are to be regarded as subordinate
factors. This last statement refutes the long-established theory in
the study of occlusion.
Standard Value of the Cusp Angle
The cusp angle was considered to be the most reliable
reference for occlusion. However, it is common knowledge that
occlusal morphology in adulthood loses its original form due to
caries, abrasion and restorative works. In particular, when the teeth
are lost, no cusps exist for a reference. Accordingly, the cuspal
morphology of an average patient who visits the dental office is not
reliable and cannot be used as a reference for occlusion.
Since there are minimal variations in cusp morphology of
permanent teeth immediately after eruption, and if the value of the
cusp angle at the time of eruption is used as a reference for
occlusion, making a restoration following this guide should be ideal
for the patient.
The authors, however, found no available data on the cusp
angle. To establish a new reference for occlusion, it is necessary to
define a standard value for the cusp angle. To obtain it, the
measured amount of disocclusion was found as the only reliable
relevant data available. The amount of disocclusion is the supero-
inferior distance between maxillary and mandibular opposing cusps
118
in the eccentric position, forming a geometrical triangle between
disocclusion, cusp path and cusp angle.
The cusp path can be determined from the measured values of
the condylar path and incisal path based on the mathematical model
of mandibular movement. When the cusp path is obtained in this
manner, the value of the cusp angle is estimated using trigonometry.
Basic Concept of Twin-Stage Procedure
The basic concept involved in the new procedure requires a
methodical approach. The cast V with a removable anterior segment
is fabricated. First, reproduce the occlusal morphology of posterior
teeth without the anterior segment and produce a cusp angle
coincident with the standard values of effective cusp angle (referred
to as "Condition 1").
Secondly, reproduce anterior morphology with the anterior
segment and provide anterior guidance which produces a standard
amount of disocclusion (referred to as "Condition 2"). The application
of the two conditions described to fabricate the cusp angle and
anterior guidance are innovative clinical procedures. This is named
the "twin-stage procedure."
Outline of the Twin-Stage Procedure
Fabrication of the cusp angle
Fabrication of anterior teeth
1. According to "Condition 2," adjust an articulator to the following
values: sagittal condylar path inclination=40 degrees, Bennett
119
angle=15 degrees, sagittal inclination of the anterior guide
table=45 degrees, and lateral wing angle=20 degrees.
2. Reassemble the anterior segment of the cast. The maxillary and
mandibular casts on the articulator produce the standard
amount of disocclusion.
3. Wax the palatal contours of the maxillary anterior teeth so the
maxillary and mandibular incisors contact during protrusive
movement, and the maxillary and mandibular canines on the
working side contact during lateral movement. Thus, anterior
guidance is established and the standard amount of
disocclusion will be produced.
Presently, the twin-stage procedure is contraindicated in the

following cases
1. Abnormal curve of Spee
2. Abnormal curve of Wilson
3. Abnormally rotated tooth
4. Abnormally inclined tooth
120
OCCLUSAL CONSIDERATION IN IMPLANT SUPPORTED
PROSTHESIS
Contents :
Introduction :
1. Occlusal determinants.
2. Occlusal design and materials.
3. Occlusal forces and transmission.
4. Biomechanics.
5. Weakest component theory.
6. Full arch fixed prosthesis.
7. Types of occlusion implant supported prosthesis.
8. Developing occlusal contact supported prosthesis.
9. Prematurities.
10. Bruxism.
11. Splinting.
12. Complication from over loading implants.
13. Minimizing over loading of implants.
14. Conclusion.
121
INTRODUCTION:
In addressing the subject of oral implantology our must
consider not only the surgical phase of placing the implant but also
the prosthodontic rehabilitative, procedures.
The choice of an occlusal schema for implant-supported
prosthesis is broad and controversial. Whether the selected implant
is endosseous, subperiosteal or transosseous, proper understanding
and application of sound prosthodontic principles in the selection,
placement and restorative phases are prerequisite to successful
implant therapy. Thus long-term success depend on several factors
like proper selection of patient and implant, aseptic and a traumatic
surgical procedures, adequate no load healing period, correct
prosthodentic reconstruction and proper follow up care.
Implant prosthodontics deals not only with the technical
aspects of fabricating an implant supported prosthesis but also with
proper application of occlusal principles for implant selection and
placement and also for prosthetic phase of the treatment.
So accurate occlusion is essential to the long term success of
implant treatment, thus.
Implants cannot bail out our faulty occlusion
Occlusion must be considered in three major areas, it
1. Occlusal determinants
2. Occlusal forces and their transmission to supporting tissues.
3. Occlusal design and materials.
122
1. Occlusal determinants:
Occlusion must be viewed as a dynamic function of the
stomatoguathic system rather than as a static intercuspal position.
- Gradual reduction in face height (WO),
- Changes in the maxillo mandibular relation,
- The presence of temperomandibular dysfunction are important
occlusal deviations seen in implant candidates. There problems
must be properly diagnosed and addressed in the treatment and
laying phase.
The occlusal determinants may be classified as denture
occlusion, TMJs and the neuromuscular mechanism.
Established dental occlusion
Temperomandibular Joints Neuromuscular
mechanism.
In order to provide physiologic occlusion for implant patients,
the dentist should perform occlusal assessment and diagnosis prior
to the restorative phase of treatment, and even prior to implant
selection and placement.
2. Occlusal forces and their transmission to supporting tissues:
Transmission and distribution of stresses to implant
supporting structures depend on the magnitude, direction and
duration of the applied occlusal loads.
123
One of the principle objectives in implant prosthodontics is
reduction of occlusal loads and accordingly reduction of transmitted
stresses to the supporting osseous structure.
The initial reversible signs and symptoms of trauma on
natural teeth do not occur with endosteal implants.
An absence of soft tissue interface between the implant body
and bone results with greatest magnitude of force localized around
the implant bone region, leading to loss of crestal bone around the
implant which results in loss of support to implant increased sulcus
pocket depth.
So unless the density of bone increases or the amount or
duration of force decreases, the condition will progress and even
accelerate until implant less occurs. Thus elements to decreased
crestal bone forces are implemented in occlusal design of the
prosthesis.
The primary forces of occlusion should be directed to the long
axis of the implant body, not the abutment post. Wherever possible
implant bodies should be primarily submitted to the vertical
component of the occlusal load. Horizontal or lateral forces magnify
the amount of compressive and tensile stress at the implant crestal
site and should be reduced or eliminated.
a. Offset load:
Offset usually is facial or lingual occlusal contacts not those in
the long axis of the implant body.
124
In screw-retained restoration, occlusal contact rarely is placed
over an access hole. Therefore offset loads are common when
occlusal screws are used. But when cement refined prosthesis is
used, the occlusal load in directly placed over the long axis of the
implant body.
In case of anterior implants, the screw-retained prosthesis is
placed lingual to the incisal edge of the access hole in the cingulum
region, compared to cement retained prosthesis.
In order to decrease the offset load in screw-retained
prosthesis during lateral excursion, natural truth when present the
greatest load.
A representative blade shaped implant and four root shaped
implants (TPS, core vent, Nobel Pharma and ISIS implant) were
investigated using a loading condition of 5 pounds vertical and 8
pounds lateral.
In summary, the general principles regarding direction of load
to the implant body are.
a. Axial loads to the implant body produce less compressive and
tensile stress.
b. Horizontal loads produce an increase in both compressive and
tensile stress.
c. Screw retained prosthesis often have implant bodies more
lingual compared to cement retained restoration.
125
3. Occlusal design and materials:
A proper occlusal scheme in a primary requisite for long term
survival especially when para function or a marginal foundation are
present.
I. Occlusal design:
The occlusal plan that is unique and specially designed for the
restoration of endosteal implants, providing an environment for
improved clinical longevity of both implant and prosthesis is known
as Implant protective occlusion or medial positioned lingualised
occlusion.
a. Div A bone:
A maxillary implant opposing a natural mandibular molar may
have the lower buccal cusp or primary contact with the central fossa
of the maxillary implant crown. The maxillary posterior implant most
often is positioned under the central fossa of the natural tooth in Div
A bone.
When the mandibular implant opposes a natural maxillary
tooth, the primary contacting cusp becomes the maxillary lingual
cusp.
b. Div B bone:
In div B bone, maxillary and mandibular implants are
positioned under the lingual cusp relative to natural tooth.
126
A mandibular implant opposing a natural maxillary posterior
tooth may have the lingual cusp of maxillary teeth as primary
contact
A maxillary implant opposes the mandibular natural teeth.
The buccal cusp is completely out of occlusion in centric relation
and all mandibular excursion. But the buccal cusp of the opposing
natural tooth is reduced to eliminate any offset load on the maxillary
implant. The primary contact here is the maxillary palatal cusp over
the implant body and the central fossa region of the mandibular
natural tooth.
Certain rules were recommended in the Dentist desk
reference (DDR) to establish proper occlusal design in implant
prosthodontics.
a. Cusp design of crown alignment should be made so that
stresses are directed along the long axis of the implant.
b. Lateral stresses should be avoided or atleast minimized.
c. Width of the occlusal table of implant crown should be
minimized.
d. Cusp height should be minimized to decrease lateral stresses,
providing only centric function.
II. Materials:
The materials on the occlusal aspect of the prosthesis affect
the transmission of force and the maintenance of occlusal schemes.
127
Porcelain occlusal as a hardness of 2.5 times more then
natural teeth, enamel has a 350 kg/mm 2 hardness, composite has
hardness of 85% of enamel, Acrylic resin has a hardness of 17
kg/mm2.
Therefore this shows impact loads are reduced with acrylic
and increases with composite enamel and porcelain.
a. Acrylic:
Acrylic is used in progressive bone loading as a transitional
prosthesis. So in patients with parafunction acrylic transitional
prosthesis used for extended periods to improve the bone-implant
interface during progressive loading period.
Acrylic resin wears 7 to 30 times faster when opposing gold,
resin enamel or polished porcelain. Acrylic fracture is a much more
common complication in fixed restoration than removable
prosthesis. Mechanical retention must be incorporated in metal
superstructure.
b. Metal :
For full arch implant supported prosthesis metal occlusal
surface are used to minimize wear and prolong the accuracy of
occlusal schemes
Metal occlusal surface is also used in posterior restoration in
non-esthetic region and parafunction or marginal interact space
present.
128
c. Porcelain :
Porcelain fracture is the third most common condition
requiring the replacement of fixed prosthesis supported by natural
teeth. The ideal thickness of porcelain to prevent breakage is
approximately 2mm.
Porcelain is used in full arch implant supported prosthesis in
esthetic regions and in bruxism opposing with metal or acrylic.
4. Biomechanics :
Several feature help decrease the effects of horizontal loads
responsible for tension and shear on the crest of the ridge. This
include mainly.
a. Implant diameter and
b. Number of implants supporting prosthesis and distributing load.
Wider implants should be used than narrow diameter implants.
When narrow diameter implants are used in region of greater
forces, additional splinted implants are indicated.
Narrow occlusal tables are recommended in non-esthetic regions
of the mouth, where the occlusal table is reduced from buccal
aspect.
129
In esthetic region, when occlusal table cannot be reduced in
width e.g., in maxillary implant, the buccal cusp of the opposing
natural teeth is reduced.
5. Weakest component theory:
Consideration like:
a. Identifying the weakest like in the overall restoration.
b. Establishing occlusal and prosthetic scheme to protect that
component of structure.
In maxillary denture opposing mandibular implant supported
restoration, the maxillary denture is the weakest link.
So bilateral occlusal scheme, raining of posterior occlusal
plane, implant protective occlusion and elimination of anterior
contacts with mandibular teeth in centric occlusal relation, in
given.
In the case of cantilevers,
Reduced occlusal forces with an absence of lateral contacts in
excursion are recommended on posterior cantilevers or
anterior offset pontics. This decreases the forces and load on
the abutment.
When the cantilever polices on both the arches,
In maxillary posterior implant cantilever anterior teeth, and
mandibular anterior implants cantilever posterior teeth, the
occlusal scheme cannot minimize forces on both. Then it is
better for mandibular cantilever pontics to appose maxilla
implants.
6. Full arch fixed prosthesis :
130
In this case implant restoration should follow mutually
protected occlusal schemes whenever possible. In protrusion there
should be total absence of posterior contacts especially for
cantilevered posterior units.
In mandible the effects of mandibular movement is limited to the
posterior to the mental foramen.
So sufficient number of anterior implants of acceptable length
and anteroposterior distance may often replace the mandibular teeth
with a one-piece rigid bilateral posterior cantilever.
But when implants are used in both mandibular posterior
regions, they s should be independent from the implants placed
in the contralateral region.
As a result instead of cantilever, two to four implants support
an independent prosthesis on at least one side.
In edentulous maxilla flexure of bone is not a concern, so a full
arch prosthesis may be fabricated in one section.
7. Types of occlusion in implant supported prosthesis:
In fixed or removable restoration with opposing fixed or removable
implant supported prosthesis.
Organic occlusion is given:
In fixed or removable implant supported restoration with
opposing removable full denture without implants bilaterally
balanced occlusion is given.
131
In partial prosthesis occlusion is in cases of cantilevers, the
resiliency of the neighboring natural dentition and of the TMJ
in taken.
In single-implant occlusion, implant should be there of any
occlusal overload and function.
8. Developing occlusal contact :
When developing occlusion in a restoration, the anterior guide
must be created; once it is perfectly incorporated, we move to adjust
the occlusion in posterior.
a. Anterior disocclusion guide :
The anterior guide should be as flat as possible allowing for
posterior disocclusion.
As a general rule, a condylar side shift of 3mm should have a
1.5 mm separation in the opposing teeth on the non-working side
and a 1 mm separation on the working side.
b. Posterior occlusal anatomy :
To achieve proper occlusion and efficient masticatory function,
the active cusps must have their corresponding fossae.
The first step will be to relate the cusp within the fossa. This is
done by cusp contacting the fossa inclines and not in the
fossas bottom.
Three contacts per cusp is considered, making sure they are
really contact points and not surface contacts.
132
The next step is, the grooves that will allow the cusps exit from
their fossa during working, non-working and protrusive
movements are designed.
The fossa exit paths are completely opposite in the upper and
lower teeth.
133
a. Upper arch :
Working Groove: Transverse toward buccal.
Non-working Groove: Oblique towards mesial and lingual.
Protective Groove: Towards mesial.
b. Lower arch:
Working Groove: Transverse toward Lingual.
Non-working Groove: Oblique towards distal and buccal.
Protective Groove: Towards distal.
In lateral excursion, this will only allow anterior tooth contact,
while the posterior teeth remain completely free. However in closure,
only the posterior teeth will be in contact.
9. Prematurities :
Prematurities represent any tooth contact during mandibular
closure with the condyles in the centric relation that occurs before
maximum intercuspation.
10. Interferences:
These are non physiological contact that appear is the anterior
and posterior teeth in lateral and protrusive excursion.
a. The non-working interferences are very important because the
mandible pivot to avoid them, which in turn produces.
A compressive component on the working condyle,
predisposing to arthrosis and discal pathology.
134
A Tensional component in the non-working condyle, which
predisposes to hyperlaxitudes and meniscal displacement.
If anterior guidance cannot be accomplished, group function
should be used.
If anterior guidance can be accomplished than posterior
contacts during working movement should be eliminated.
c. Protrusive interferences:
Create a tensional component in both condyles and implant
overloading.
Thus prematurities and interferences will be more or less
pathological depending on whether para functions are present.
10. Bruxism :
Bruxism is a form of eliminating internal tension and is often a
cause of tooth loss.
Bruxism is not a contraindication for implant, but we should
be extremely careful during prosthesis fabrication. Frequent occlusal
follow up are mandatory, eliminating prematurities and interferences
as well as verifying good guidance in the anterior teeth.
11. Splinting:
In the implant tooth fixed prosthesis four important
components may contribute movement to the system, i.e., the
implant, bow, tooth and prosthesis.
There has been controversy regarding whether a rigid fixated
implant may remain successful when splinted to natural teeth.
135
The tooth movement ranger from 8 to 28 in a vertical
direction and that of implant 3 to 5 Because of this
difference in vertical movement the initial occlusal contact
should account for the difference.
Using key ways in fixed bridgework also proves stress relief,
and reduction of occlusal load to the implant.
12. Complication from overloading implants :
a. Crestal bone loss.
b. Screw loosening.
c. Screw fracture.
d. Material fracture.
13. Minimizing overloading of implants :
a. Narrow occlusal table.
b. Splinting.
c. Cantilevers.
d. Proximal contacts.
e. Cement retained restoration.
CONCLUSION
Conclusion has been an important variable in the success of
failure of most prosthodontic reconstruction with natural teeth, a
certain degree of flexibility permits compensation for occlusal
irregularity. Implant dentistry is not as forgiving. The occlusion must
be more rigorously evaluated with implant supported prosthesis.
136
Unfortunately, the occlusion of teeth is frequently overlooked
or taken for granted in providing restorative dental treatment for
patients. This may be due in part to the fact that the symptoms of
occlusal disease are often hidden from the practitioner not trained to
recognize them or to appreciate their significance. The long-term
successful restoration of a mouth with cast metal or ceramic
restorations is dependent upon the maintenance of occlusal
harmony.
While it is not possible to present the philosophies and
techniques required to render extensive occlusal reconstruction in
this limited space, it is essential that the reader develop an
appreciation for the importance of occlusion. The perfection of skills
required to provide sophisticated treatment of complex occlusal
problems may take years to acquire. However, the minimum
expectation of the competent practitioner is the ability to diagnose
and treat simple occlusal disharmonies. He or she also must be able
to produce restorations that will avoid the creation of iatrogenic
occlusal disease.
137
REFERENCES
1. Failure in restored dentition management and treatment
Michael Wise.
2. Fundamentals of fixed prosthodontics Herbert T.
Shillingburg.
3. Management of temperomandibular disorder and occlusion
Jeffrey P. Okeson.
4. Evaluation, Diagnosis, and Treatment of occlusal problems.
Peter E. Dawson,
5. Oral rehabilitation by Sumiya hobo
6. Contemporary implant dentistry. Carl E. Misch
7. Surgical and prosthetic techniques for dental implant Ismail,
Fagan, Meffert.
8. Risk factors in implants Franck Renonard.
9. Implant supported prosthesis, occlusion, clinical cases and
laboratory procedure Vicente Jimenez- Lopez.
10. Journal of California dental association, (2000).
11. Journal of Canadian Dental Association; 2001.
12. Occlusion : Reflection on Science and clinical reality (J.P.D
2003:90:373-84)
13. Occlusal Assessment (JIPS 2004; Vol 4, No.2;39)
138

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L.D..Occlusion in FPD

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Occlusion in fixed partial denture

OCCLUSION IN FIXED PARTIAL

Establishing or providing occlusion that successfully permits

efficient masticatory function is basic to dentistry and survival.

In health the occlusal anatomy of the teeth functions in

harmony with structures controlling the movements patterns of the

mandible. The structures that determine these patterns of the

movement the unique anatomic relationships of these structures

continue to dictate a precise and repeatable pathway.

To maintain harmony of the occlusal condition the posterior

mandibular movement. It is important to examine each of these

structures carefully and appreciate how the anatomic form of each

can determine the occlusal morphology necessary to achieve an

optimal occlusal relationship.

II. Fundamentals of occlusion2

Interferences are undesirable occlusal contacts that may

produce mandibular deviation during closure to maximum

intercuspation or may hinder smooth passage to and from the

intercuspal position. There are four types of occlusal interferences :

The centric interference is a premature contact that occurs

when the mandible closes with the condyles in their optimum

position in the glenoid fossae. It will cause deflection of the mandible

in a posterior, anterior, and / or lateral direction. (Fig. 1).

A working interference may occur when there is contact

between the maxillary and mandibular posterior teeth on the same

If that contact is heavy enough to disocclude anterior teeth, it is an

interference. (Fig. 2).

A non-working interference is an occlusal contact between

maxillary and mandibular teeth on the side of the arches opposite

the direction in which the mandible has moved in a lateral

excursion. The non-working interferences is of a particularly

destructive nature. The potential for damaging the masticatory

apparatus has been attributed to changes in the mandibular

and disruption of normal muscle function. (Fig. 3).

The protrusive interference is a premature contact occurring

between the mesial aspects of mandibular posterior teeth and the

distal aspects of maxillary posterior teeth. The proximity of the teeth

between opposing posterior teeth during protrusion potentially

destructive as well as interfere with the patients ability to incise

properly. (Fig. 4).

2. Normal versus pathologic occlusion

In only slightly more than 10% of the population there is

complete harmony between the teeth and the temporomandibular

joints. This finding is based on a concept of centric relation in which

the mandible is in the most retruded position. With the present

concept of the condyles being in the most superoanterior position

with the disc interposed, the results could be different. Nonetheless,

in a majority of the population, the position of maximum

intercuspation causes the mandible to be deflected away from its

In the absence of symptoms, this can be considered

physiologic, or normal. Therefore, in the normal occlusion there will

be a reflex function of the neuromuscular system, producing

mandibular movement that avoids premature contacts. This guides

the mandible into a position of maximum intercuspation with the

condyle in a less than optimal position. The result will be either

some hypertonicity of nearby muscles or trauma to the

temporomandibular joint, but it is usually well within most peoples

physiologic capacity to adapt and will not cause discomfort.

However, the patients ability to adapt may be influenced by

the effects of psychic stress and emotional tensions on the central

nervous system. By lowering the threshold, frequently

parafunctional jaw activity such as clenching or bruxing occurs, and

a normal occlusion can become a pathologic one. Simple muscle

hypertonicity may give way to muscle fatigue and spasm, with