POSTGRADUATE DEPARTMENT OF CONSERVATIVE

DENTISTRY AND ENDODONTICS

SEMINAR TOPIC:-
RESTORATIVE MANAGEMENT OF WORN
DENTITION - II
(Assesment & role of occlusion in tooth wear)

Presenter- Ashish Choudhary

PG student

UNDER GUIDANCE OF :-
Prof. Dr Riyaz Farooq (HOD)
Dr Aamir Rashid (Asst. Prof.)
Dr Fayaz Ahmed (lecturer)
 RESTORATION OF WORN DENTITION-II
( Assesment & Role of Occlusion in tooth wear)

CONTENTS

 PATIENT’S HISTORY

 EXAMINATION OF WEAR’s PATIENT

 DIAGNOSIS

 MEASUREMENT OF SEVERITY & PROGRESSION OF WEAR

 DILEMA OF OCCLUSION
RESTORATION OF WORN DENTITION-III
( Treatment Planning)

 MOUNTING CAST (Articularors & Facebow transfer)

PROBLEM OF SPACES (increasing Vertical Dimension)

 RESTORATION OF WORN DENTITION

 REHABILIATION OF WORN DENTITION

 MAINTENANCE

 CONCLUSION

REFERENCES
TOOTH WEAR’S MULTI-FACTORIAL
AETIOLOGY

EROSION

ABRASION

ATTRITION

ABFRACTION

BRUXISM
 HISTORY
EXAMINATION
DIAGNOSIS
PATIENT’S HISTORY* ANALYSIS
OCCLUSION

The successful management of any case of

tooth wear is based on deriving an accurate
diagnosis, having a clear understanding of the
basic principles of occlusion, and a good
working knowledge of available materials and
techniques to treat such cases using both
active and passive means

*BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
 The formulation of a comprehensive OCCLUSION
treatment plan relies on an accurate history
and examination of the patient

 The management of tooth wear depends

to an extent on the ability of the patient’s
understanding of the condition in order to
provide information to allow the clinician to
arrive at a differential diagnosis

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
According to Holbrook and Arnadottir, in order to OCCLUSION
prevent or reduce non-carious destruction of tooth
substance it is important to:

• Recognise that the problem is present

• Grade its severity
• Diagnose the likely cause or causes
• Monitor progress of the disease in order to
assess the success, if any, of any preventative
measures

Br Dent J 2003; 195: 75–81

 HISTORY
EXAMINATION
CHIEF COMPLAINT DIAGNOSIS
ANALYSIS
OCCLUSION
 The accuracy and importance of the chief complaint
must be first evaluated
 Common complaints associated with dentitions displaying
tooth wear include concerns relating to:

• Aesthetic impairment (fractured, unattractive

teeth/restorations or tooth discoloration)

• Difficulties with function, such as the efficiency of

mastication or lip/cheek or tongue biting

• Less commonly, comfort (pain and sensitivity)

Dahl B, Carlsson G, Ekfledt A. Occlusal wear of teeth and restorative materials.

Acta Odontol Scand 1993; 51: 299–311
 HISTORY
EXAMINATION
MEDICAL HISTORY DIAGNOSIS
ANALYSIS
may reveal underlying conditions which preclude OCCLUSION
the provision of complex treatment plans, and may
also provide a valuable insight into the aetiology of
the wear pattern observed to be present

1. Medication Br Dent J 1984; 157: 16-19

 asthma inhalers containing steroid or effervescent medication
 aspirin (salicylic acid)
 chewable vitamin C preparations (ascorbic acid)
 various iron preparations
 diuretic agents and antidepressant drugs

2. Presence of a gastro-oesophageal reflux as seen in

patients diagnosed with :
anorexia nervosa, bulimia nervosa or those with hiatus hernia,
sphincter incompetence, oesophagitis, or increased gastric
pressure (and volume) Quintessence Int 1997; 28: 305–313
 HISTORY
EXAMINATION
DIAGNOSIS
3. Female patients are affected by eating disorders ANALYSIS
more frequently than males at a ratio of 10:1.5 OCCLUSION
Cyclical vomiting syndrome and voluntary regurgitation
(rumination) have also been reported as aetiological conditions
respectively
Dent Update 2000; 27: 175–183

4. Pregnancy
 inc. in abdominal pressure
 Morning sickness
Quintessence Int 1996; 27: 123–127

5. A history of heartburn or reflux is a key factor to note

 HISTORY
EXAMINATION
PAST DENTAL HISTORY DIAGNOSIS
ANALYSIS
OCCLUSION
will provide useful information as to the patient’s
previous level and experience of dental care

1. Oral hygiene habits should be ascertained, such as :

 type of toothbrush used,
 the intensity, the frequency and timing of toothbrushing as well as
the abrasivity of the dentifrice being used.

2. A poorly motivated patient or one with negative views

towards dental care or indeed a phobic patient may not be the
best candidate at first instance when considering complex
treatment provision

3. Establish (where relevant) any previous experience of

removable appliance/prosthesis wear experience
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
SOCIAL HISTORY DIAGNOSIS
ANALYSIS
OCCLUSION
 lifestyle stresses
 occupational details which may also have a bearing on
their ability to attend for treatment plans which sometimes take
numerous visits to execute
 Swimmers Br Dent J 1996; 180: 349–352
Copper mine workers

HABITS & DIETARY ANALYSIS

 Smoking, alcohol consumption or dietary trends

 A detailed dietary analysis
Of particular relevance to diet/beverages and tooth surface loss are the
copious consumption of citrus fruits, pickles, vinegar (acetic acid), coarse
food, cola, fruit juices and carbonated drinks
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
 The frequency and quantity of daily intake, the ANALYSIS
duration of consumption and the method of OCCLUSION
eating/drinking should be established

 Patients affected by tooth wear should undertake a

three day consecutive comprehensive diet diary
(Watson and Burke)
Dent Update 2000; 27: 175–183

 The presence of other habits which may be aetiological by

nature such as that of pipe-smoking, pen/pencil biting, and
holding objects between teeth

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
EXAMINATION OF THE WEAR’s ANALYSIS
OCCLUSION
PATIENT

Clinical examination of the dentition has two

primary objectives:

1. To document and record the location, appearance

and degree of toothwear

2. To evaluate the progress of toothwear over time

Dent Update 2002; 29: 162–168

 HISTORY
EXAMINATION
EXAMINATION OF WEAR’s PATIENT* DIAGNOSIS
ANALYSIS
OCCLUSION
Extra-oral examination

Include a meticulous assessment of their

temporomandibular joints and associated musculature

 The presence of any joint or muscle tenderness, clicking, crepitation,

mandibular deviation on opening or closure or any associated aches/
pain
 The maximum jaw opening should be recorded (that less than 40
mm between incisal edges is considered to be restricted)

 Presence of parotid gland enlargement is often seen in bulimic

patients Quintessence Int 1996; 27: 123–127

*BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
The facial vertical proportions should also be DIAGNOSIS
ANALYSIS
carefully examined
OCCLUSION
 include an assessment of the freeway space (FWS),
by determining the patient’s resting vertical
dimension (RVD) and occlusal vertical dimension
(OVD), with the aid of callipers or by the use of a Willis
gauge
 Other techniques that can be used for the evaluation of
vertical dimension include the use of phonetic assessments
(particularly the sibilant sounds), facial soft tissue contour
analysis, jaw tracking and the use of electrical muscle
stimulation techniques Dent Clin North Am 1993; 36: 651–663

 The smile line and lip line should also be noted, as well
as any midline discrepancies
BDJ;2012 ; VOLUME 212 NO. 1
a typical appearance resulting from loss of
occlusal vertical dimension; note the presence of
an ‘inverted lip profile’

BDJ;2012 ; VOLUME 212 NO. 1

 Relationship between lower lip line and incisal
edges of worn anterior teeth

(A) (B)

Elongation of the Elongation of the worn

worn anterior teeth is teeth would lead to an
feasible excessively long clinical
crown

Dent Update 2002; 29: 162–168

 HISTORY
EXAMINATION
DIAGNOSIS
Intra-oral Examination ANALYSIS
OCCLUSION

 Presence of buccal keratoses, scalloping of the

tongue or signs of xerostomia

 The level of oral hygiene should be recorded together

with the undertaking of a Basic Periodontal Assessment
(BPE)

 A dental chart should be completed, detailing the

presence or absence of teeth, dental caries, restorations,
failed restorations, fractures, abrasions and erosive lesions

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

may provide additional clues to the underlying

cause.
For example,
 palatal erosion suggests an intrinsic aetiology
 labial erosion implicates extrinsic factors.
 Lesions involving incisal edges and cusps are generally
associated with attrition,
 Asymmetric lesions may be due to abrasion
 In addition to examining the teeth present, the absence of any
teeth should be noted, given that lack of posterior support can
predispose to anterior tooth wear
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
 Once diagnosed, the location of tooth wear ANALYSIS
(localised, anterior/posterior or generalised) and OCCLUSION

severity of the tooth surface loss should be recorded

(as being restricted to enamel only, into dentine or
severely affecting the teeth or series of teeth)
Tooth Wear Index of Smith and Knight

A comprehensive occlusal assessment is mandatory.

 the presences (or absence) of:
• Crowding
• Rotations
The overbite and overjet
• Tilting
should also be measured
• Drifting
and recorded
• Spacing
• Over-eruption
• Mobility
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
The presence of a stable centric occlusion DIAGNOSIS
(CO) should be determined, and tooth ANALYSIS
OCCLUSION
contacts in the intercuspal position (ICP)
described

 The ease with which the patient can be manipulated

into their retruded arc of closure should also be
established

 Where a patient cannot be readily manipulated into centric relation

(CR), due to protective neuromuscular reflexes, the use of
deprogramming devices should be considered
1. use of cotton wool rolls and wood spatulas
2. anterior bite planes (Lucia jig)
3. full coverage stabilisation splints

BDJ;2004 ; VOLUME 196 NO. 7

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

DEPROGRAMMING
DEVICES

BDJ;2004 ; VOLUME 196 NO. 7

 HISTORY
EXAMINATION
Permissive splints as muscle DIAGNOSIS
ANALYSIS
deprogrammers OCCLUSION

 Are designed to unlock the occlusion to remove deviating tooth inclines from
contact

 When this is accomplished, the neuromuscular reflex that controls closure

into maximum intercuspation is lost

 The condyles are then allowed to return to their correct position in CR if

condition of the articular components permits

 Because all corrective tooth inclines are either separated or covered with
smooth plastic, permisive splints allow the muscles to function according to
their own coordinated interactions, thus eliminating the cause & the effects of
muscle incoordination

PETER E. DAWSON; Evaluation, diagnosis & treatment of

occlusal problems; 2ND EDITION
 HISTORY
EXAMINATION
DIAGNOSIS
CENTRIC RELATION OCCLUSAL SPLINTS ANALYSIS
OCCLUSION

Waxup showing contacts & Lateral view showing

anterior guidance posterior disclusion in
lateral excursions

PETER E. DAWSON; Evaluation, diagnosis & treatment of

occlusal problems; 2ND EDITION
 HISTORY
EXAMINATION
DIAGNOSIS
CENTRIC RELATION OCCLUSAL SPLINTS ANALYSIS
OCCLUSION

Adjusted splint-holding
contacts(black), lateral
canine guidance(red), &
protrusive(green)

Centric relation occlusal splints should be fabricated with

anterior guidance inclines that disclude posterior contact in
all eccentric jaw positions

PETER E. DAWSON; Evaluation, diagnosis & treatment of

occlusal problems; 2ND EDITION
 HISTORY
EXAMINATION
DIAGNOSIS
HAWLEY BITE PLANE ANALYSIS
(ANTERIOR BITE PLANE) OCCLUSION

 Allows the occlusal vertical

dimension to be increased by
only a small amount without
exceeding the VDR

Martin D. Gross; Occlusion in Restorative

Dentistry; 1st edition
 HISTORY
EXAMINATION
DIAGNOSIS
 The first point of tooth contact in CR, hence the ANALYSIS
retruded contact point (RCP) should be identified OCCLUSION
and the presence of any ‘slides’ (and the direction
of the latter) from CR to CO established.

 It is also important to note whether the slide from CR

to CO has a larger vertical or horizontal component

 Tooth contacts during lateral excursive (canine guidance or

group function) and protrusive movements of the mandible
should be determined

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
 If present, any working side/non-working side ANALYSIS
OCCLUSION
occlusal interferences should be described

 Where the patient may be partially dentate, an

evaluation of the denture bearing areas must be
undertaken, as well as the fit of any removable
prostheses

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
ESTHETICAL CONSIDERATIONS WHILE DIAGNOSIS
EXAMINING THE PATIENT……. ANALYSIS
OCCLUSION

EXTRA-ORAL INTRA-ORAL

 Facial Symmetry  Tooth Axis

 Facial-Dental Midline  Balance of Gingival
 Comissural-Bipupillary Levels
line  Zenith positioning
 Smileline  Level of interdental
 Lower teeth-Lip contact
Symmetry  Relative Tooth
 Lower Lip Length Dimension / Tooth Form
 Transitional lines
 Tooth Characterization
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
MIDLINE OCCLUSION

ANALYSIS
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

BALANCE OF
GINGIVAL LEVELS
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

TOOTH DISPLAY
 HISTORY
EXAMINATION
DIAGNOSIS
OCCLUSAL ANALYSIS
OCCLUSION
CONSIDERATIONS

 OVERJET STRUCTURAL
 OVERBITE COSIDERATIONS
 OCCLUSAL
PLANE  LACK OF TOOTH BIOLOGICAL
STRUCTURE IN CONSIDERATIONS
WORN DENTITION
 PUPAL
 PROBLEM OF INVOLEMENT
SPACE FOR  NEED FOR POST &
RESTORATIONS CORE
 NEED FOR CROWN
LENGTHENING
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSAL PLANE OCCLUSION

NORMAL STEP UP / STEP DOWN

(Alternate pattern)
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION
LABIOLINGUAL INCLINATION

Draw a perpendicular
from the central to
occlusal plane
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

Radiographs

 Good quality, accurate long cone periapical

radiographs

 presence of any signs of alveolar bone loss

 Other factors, such as the root surface morphology, anatomy of the pulp
chambers of affected teeth, quality of pre-existing endodontic treatment(s),
presence of dental caries, widening/disturbance of the lamina dura, presence
of retained roots or any signs of periapical pathology (radiolucencies or radio-
opacities) should also be assessed.
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
Articulated study ANALYSIS
OCCLUSION
casts

Good quality study casts poured in vacuum mixed die-

stone should be mounted on at least a semi-
adjustable articulator in centric relation

 Study casts will permit an assessment of the occlusion in the

absence of soft tissue/muscular interferences

The impact of tooth over-eruption can be more readily

assessed together.
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
 Tooth contacts in CR, during lateral excursive ANALYSIS
OCCLUSION
and protrusive movements, and the presence of
occlusal interferences can be more easily
determined

 The space gained by manipulating the mandible into CR

can be noted and the effect of ‘opening the bite’ on the
articulator on the residual dentition also seen, along with
the effect of any trial occlusal adjustments

 The vertical and horizontal components of the slide from

CR to CO can also be examined at this stage

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
Sensibility tests ANALYSIS
OCCLUSION
 Loss of vitality
important to establish the health status of the
dental pulp prior to embarking upon any
complex prosthodontic rehabilitation

 application of ethyl chloride,

 warmed gutta percha or
 electric stimuli to the tooth

However, the ‘true’ vitality status of a tooth can strictly be

only established with the use of Doppler flow techniques

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
Intra-oral photographs ANALYSIS
OCCLUSION

 Including anterior, posterior (left/right) views and

occlusal views of both arches are very important

 Images should be appropriately stored.

Salivary analysis

 can be undertaken for both stimulated and un-stimulated

secretion rates and respective buffering capacities.

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
Diagnostic wax mock-ups DIAGNOSIS
ANALYSIS
OCCLUSION
may be fabricated with the desired final
occlusal scheme and aesthetic requirements
as prescribed by the operator

 They form a useful visual aid and communication tool, to assist in the
evaluation of aesthetics, tooth shape, length, and inclination

 wax up once duplicated by the means of a stone model can be used to

fabricate a vacuum formed PVC matrix that can initially be used to
demonstrate the proposed changes intra-orally by the application of a
provisional crown and bridge material into the vacuum formed matrix

 The matrix helps fabricate definitive restorations using direct resin

composite

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION
 wax mock-up can used as an aid to
help form tooth reduction guides,
assist with the fabrication of
provisional restorations, or used to
form a polyvinylsiloxane (PVS) index,
which helps form direct resin
composite restorations

BDJ;2012 ; VOLUME 212 NO. 1

A) Study casts of a patient displaying B) Diagnostic wax up fabricated in
tooth wear, mounted in centric accordance with an accurate occlusal-
relation on a semi-adjustable aesthetic prescription
articulator

C & D) Information derived from the wax up has been used to guide the
placement of restorative materials
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
DIAGNOSIS OF TOOTH WEAR OCCLUSION

The diagnosis of a patient presenting with

tooth wear should include a description of
the type(s) of lesions observed, together
with an account of their extent/location
and severity.

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
Diagnose the lesion!! DIAGNOSIS
ANALYSIS
OCCLUSION

HISTORY
Chief Complaint
Medical history
Habits
ABRASION ATTRITION Occupation
Lifestyle

EXAMINATION
Extra-oral
Clinical
presentation

ABFRACTION EROSION
 HISTORY
EXAMINATION
DIAGNOSIS
SEVERITY OF TOOTH WEAR ANALYSIS
OCCLUSION

 Tooth Wear Index by Smith & Knight

 BEWE (Basic Erosive Wear Examination)

 THE ACE Classification

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
DIAGNOSIS
LOCATION OF TOOTH SURFACE LOSS ANALYSIS
OCCLUSION

Finally, the pattern of tooth surface loss seen

should be sub-classified into being either
localised or generalised tooth wear

 In the case of localised tooth wear, it is important to

specify the region affected, such as anterior, posterior,
mandibular or maxillary

 Mandibular anterior teeth are relatively less affected by

the process of erosion than the maxillary anterior dentition.

 Posterior teeth are protected by secretions from the

parotid glands
BDJ;2012 ; VOLUME 212 NO. 1
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION
 For cases of localised wear, it is also worth
considering whether there may be space
available for the placement of restorative
materials

 For cases of generalised tooth wear, it is important to

categorise the amount of dento-alveolar compensation
that might have taken place

 The loss of tooth structure may or may not result in an

increase in the Freeway space (FWS)

BDJ;2012 ; VOLUME 212 NO. 1

 HISTORY
EXAMINATION
Following an evaluation of the existing vertical DIAGNOSIS
dimension of occlusion (OVD) patients ANALYSIS
OCCLUSION
presenting with generalised wear may be
assigned to three categories according to
Turner and Missirlian

Category 1 excessive wear with loss of vertical dimension of

occlusion

Category 2 excessive wear without loss of vertical

dimension of occlusion, but with space available

Category 3 excessive wear without loss of vertical

dimension, but with limited space

J Prosthet Dent 1984; 52: 467–474

Dent Update 2002; 29: 162–168
Dent Update 2002; 29: 162–168
Dent Update 2002; 29: 162–168
 HISTORY
EXAMINATION
Measurement of Severity & Progression DIAGNOSIS
of Tooth Wear ANALYSIS
OCCLUSION

 Tooth Wear Index by SMITH & KNIGHT

 Diagnostic Casts / Study Models
 Silicone Impressions
 PROFILOMETRY
 CONTACT STYLUS TECHNIQUE

 “FITTING” the Computer Models together

 OPTICAL TECHNIQUES ( LASER & WHITE LIGHT)

 MICROCOMPUTER TOMOGRAPHY SCANNING

METHOD
J Oral Rehabill. 2012 ;39; 217–225
Silicone Impressions Technique:

A silicone putty The putty (e.g. Rapid) is

impression is taken in an removed from the tray
sectional tray

It is sliced into sections When a section is placed over the

with a scalpel tooth, it is a perfect fit. If wear
progresses, a gap will become
visible at future visits
 HISTORY
EXAMINATION
DIAGNOSIS
 Xhonga et al. (1972) used profile tracings from ANALYSIS
sectioned study models to estimate an avg. daily OCCLUSION
rate of erosion in cervical lesions

 The real problem of measurement of tooth wear by

profilometry is that volumetric loss of tissue has a complex
shape which defies assessment by simple geometric
calibration, such as a ruler might give

Answer to the problem ofcourse lies in the capture of

entire anatomical tooth surfaces of the before and after time
interval

 This requires a digital technique with software facilities

for computer image rendering, fitting & measurement

Toothwear: ABC of the worn dentition; 1st ed

 HISTORY
EXAMINATION
CONTACT STYLUS TECHNIQUE : DIAGNOSIS
ANALYSIS
OCCLUSION

 Null point stylus

fixed in space & the
model of the tooth
which moves
underneath the stylus

 Digital scanning
rendered to the
computer , giving the
appearance of tooth

Toothwear: ABC of the worn dentition; 1st ed

 HISTORY
“FITTING” the Computer Models EXAMINATION
DIAGNOSIS
together : ANALYSIS
OCCLUSION

Wear on the incisal

edge of a canine

 The gray scaling

shows the anatomical
detail before (B), &
wear is superimposed
as a color reference 2
yrs after baseline (2y)

Toothwear: ABC of the worn dentition; 1st ed

OPTICAL TECHNIQUES ( LASER & WHITE LIGHT) :

White light digital

profiler

(B) 3 point triangulation

necessary to determine the
(A) Light being emitted from one port
anatomical location of the
& detected by a CCD in the other
wear area

Toothwear: ABC of the worn dentition; 1st ed

 HISTORY
EXAMINATION
MICROCOMPUTER TOMOGRAPHY SCANNING: DIAGNOSIS
ANALYSIS
OCCLUSION

Micro-Computer Tomography derived model of long term cervical

abrasive wear
Note the inclusion of undercut in the total profile of lesion
Toothwear: ABC of the worn dentition; 1st ed
 HISTORY
EXAMINATION
DIAGNOSIS
REPORTING ANALYSIS
TOOTHWEAR OCCLUSION

 VOLUME REPORTING

DEPTH LOSS

INCREASE IN AREA OF CONTACT

DEPTH × AREA = VOLUME

Toothwear: ABC of the worn dentition; 1st ed

 HISTORY
EXAMINATION
OBJECTIVES of Tooth Wear Measurement by DIAGNOSIS
Profilometry : ANALYSIS
OCCLUSION
Is Occlusal Attrition or Erosion the more rapid
process?

Does the rate of Erosion differ in different molars?

Does the rate of Erosion differ on different

cusps on the same tooth?

Is the rate of erosion affected by preventive therapy?

Is the rate of attrition affected by splint therapy?

Does the rate of cervical tisssue loss relate to occlusal

loss?
Toothwear: ABC of the worn dentition; 1st ed
 HISTORY
EXAMINATION
DIAGNOSIS
Problems with these latest gadgets!!!! ANALYSIS
OCCLUSION
× despite improved accuracy and reliability,
new sophisticated measuring tools are costly
and require specialised hardware and
software, restricting their use in everyday
dental practice

Al-Omiri et al. compared the reliability of three different methods

to detect incisal wear over a 6-month period.
The methods used were a CAD–CAM laser scanning machine, a
tool maker microscope for micromeasurement applications and a
conventional toothwear index (Smith and Knight wear index).
It was found that the tooth wear index was the least sensitive for
tooth wear quantification and was unable to identify wear
progression in most cases
J Dent. 2010;38:560–568
 HISTORY
EXAMINATION
DIAGNOSIS
Problems with these latest gadgets!!!! ANALYSIS
OCCLUSION
× However, the fundamental problem with in
vivo wear studies is the inherent patient
factor J Oral Rehabil. 2001;28:1048–1055

× In addition, the sensitivity of measurement

and replica techniques are an important consideration
J. Engineering Tribology. 2005;219:2–19

 Therefore, appropriate training and calibration are

important to minimise subjective errors and a combination of
methods should be used for a more reliable quantitative
analysis

J Oral Rehabill. 2012 ;39; 217–225

 HISTORY
EXAMINATION
DILEMA OF OCCLUSION DIAGNOSIS
ANALYSIS
OCCLUSION

The three-dimensional relationship of the

mandible to the maxilla, and the clinician's
understanding of it, is fundamental in clinical
dental practice

No matter the degree of restorative dental treatment

provided, be it a small occlusal restoration to a full-
mouth rehabilitation, the occlusion is affected to a
greater or lesser extent

British Dental Journal 2004; 196: 395–40

 HISTORY
EXAMINATION
Occlusion has been defined simply by DIAGNOSIS
ANALYSIS
Davis and Gray as ‘the contacts OCCLUSION
between teeth'
Br Dent J; 2001; 191: 235-245

 These contacts can be considered statically or dynamically,

as teeth slide over each other during mandibular movement

 In addition to the occlusion, the masticatory system is also

composed of the periodontal ligaments, TMJ , the muscles of
mastication and their associated ligaments
Br Dent J 2001; 191: 291-302

 The system is under the control of higher centres in the

central nervous system
 HISTORY
EXAMINATION
Various School of Thoughts for mandibular DIAGNOSIS
positions ANALYSIS
OCCLUSION

 The early Conical and Spherical theories were

superseded by the mechanical models of the
Gnathologists

 These theories were largely driven by developments in

articulator design

 In recent years, the engineering model of occlusion has been

tempered by an increased appreciation of the biological aspects
of the masticatory system.
degree of adaptability

J Prosthodont 1993; 2: 33-43

 HISTORY
EXAMINATION
DIAGNOSIS
 The occlusion achieved during normal ANALYSIS
functional mandibular movements, such as OCCLUSION
swallowing and chewing, occurs within a relatively
small space called the “envelope of motion”

 Abnormal movements are dysfunctional, caused by

derangement of the articular disc and muscle
hypertrophy

 Parafunctional activity is usually habitual, the patient

often being unaware of the movement, and includes
bruxism, clenching, jaw posturing, lip and pencil biting

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
These activities can create excessive forces ANALYSIS
between teeth or produce normal forces at an OCCLUSION
abnormal frequency, producing a risk of:
 fractured cusps or restorations;
 increased tooth mobility;
 muscle fatigue; and
 toothwear

“A harmoniously functioning occlusion allows for smooth

uninterrupted movements over the area of tooth contact”

 Some occlusions may not permit such free movements,

yet the patient does not exhibit the problems described;
his/her neuromuscular system has adapted to the
disharmony
Dent Update 2003; 30: 150-157
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
 However, if a restoration is placed which OCCLUSION
changes the occlusion, the adaptive capacity of
the system may be exceeded, leading to the signs
and symptoms

“ Therefore restorations should be planned so that

they do not cause effects that exceed the adaptive
Tolerance ”

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
Posselt described the extreme or border DIAGNOSIS
ANALYSIS
movements of the mandible as an OCCLUSION
“envelope of motion“
J Prosthet Dent 1957; 7: 787–797

 They represent the movement of the tip of the lower

incisor when viewed in the sagittal or frontal plane

Dent Update 2003; 30: 150-157

Acta Odontol Scand 1952; 10: Suppl 10
 HISTORY
EXAMINATION
DIAGNOSIS
 The mandible initially opens with a hinge ANALYSIS
movement about a horizontal axis known as the OCCLUSION
retruded axis or terminal hinge axis (THA), with the
condyles in the retruded position (RP) (centric
relation)

 This is described as the most superior position of

the condyles in their fossae
 When the mandible rotates around
this axis the first tooth contact occurs
– the retruded contact position (RCP)

 The mandible then slides forwards

bringing the teeth into maximum
intercuspation – the intercuspal position
(ICP) (centric occlusion)

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
The discrepancy between RCP and ICP has both a DIAGNOSIS
ANALYSIS
vertical and horizontal component and may be up OCCLUSION
to 1 mm. Acta Odontol Scand 1952; Suppl 10

However, patients with this slide usually close straight into

ICP from the rest position – the habitual path of closure

 Contact between opposing teeth can occur in the area of

this discrepancy during swallowing, mastication and
parafunctional activity.

 When teeth are in the intercuspal position the occlusal

vertical dimension (OVD) is defined as a measurement of face
height
Dent Update 2003; 30: 150-157
 HISTORY
EXAMINATION
DIAGNOSIS
 When not in contact, teeth are held apart in ANALYSIS
the rest position by the muscles of mastication OCCLUSION
acting on the mandible creating a freeway space
or Interocclusal distance of 2–4 mm

 In practice, this position is variable, being affected by posture

and muscle activity

 When mandibular teeth move from ICP to maximum

protrusion their path is determined by the articulating
surfaces of the anterior teeth, creating anterior guidance

 This does not exist in anterior open bites or edge-to-edge

incisor relationships, where during protrusion the guidance
is obtained from the occlusal surfaces of the posterior teeth
Dent Update 2003; 30: 150-157
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
The angle and length of the movement is OCCLUSION
determined by the incisor relationship

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
ICP is maintained and occlusal forces directed ANALYSIS
axially by two types of Interocclusal contact: OCCLUSION

 The palatal cusps of the maxillary teeth and buccal cusps

of the mandibular teeth (called supporting cusps) contact
the inclined planes of the opposing dentition or the cusp
tips contact the opposing fossae

 The maxillary buccal and mandibular lingual cusps are

therefore the non supporting cusps.

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
 During lateral excursions, the side to which the OCCLUSION
mandible moves is the working side and the
opposite side the non-working side

 On the working side, when only the canines are in contact

during lateral excursions, the occlusion is canine guided; if two
or more pairs of teeth contact in this movement the occlusion is
in group function. This may involve both anterior and posterior
teeth

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
 On opening from RCP the mandible rotates DIAGNOSIS
ANALYSIS
around the THA in an arc of a circle (point Y) OCCLUSION

 This creates an incisal separation of about 2.5 cm.

 On further opening the condyles translate or slide

downwards and forwards along the articular eminencies of
the glenoid fossae to a point of maximum opening

Dent Update 2003; 30: 150-157

 HISTORY
 During lateral movements, the working side or EXAMINATION
DIAGNOSIS
rotating condyle may rotate and move laterally as
ANALYSIS
well as upwards, downwards or backwards. The OCCLUSION
lateral component is termed the Bennett
movement
 The first part is called
immediate sideshift and is
measured on average at 0.5 mm.
The progressive sideshift
describes a more gradual
lateral movement

 The non-working side or

biting condyle moves
downwards, forwards and
inwards, creating the Bennett
angle
Dent Update 2003; 30: 150-157
 HISTORY
EXAMINATION
DIAGNOSIS
 The free-sliding movement of the mandible can ANALYSIS
be disturbed by an occlusal interference occurring OCCLUSION
between opposing teeth

 The interference may arise as a result of tooth movement,

over-eruption or occlusal wear in the unrestored dentition or
of poorly contoured restorations

 To maintain occlusal stability there must be adequate

occlusal contact to prevent such interferences

 This stability can be maintained by assuring occlusal

contacts are not on inclined planes but ideally in a cusp-to-
fossa or cusp to marginal ridge position

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
ASSESSMENT OF THE OCCLUSION ANALYSIS
OCCLUSION

The diagnostic process begins with careful

history taking and clinical examination

The examination should include:

 Extra-oral components – temporomandibular joints,

muscle hypertrophy/spasm

 Mandibular movement – painful, deviated, abnormal

or restricted

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
ASSESSMENT OF THE OCCLUSION ANALYSIS
OCCLUSION

Intra-oral features:
1. Intercuspal position, retruded contact position, lateral &
anterior guidance.

2. Presence, angle & smoothness of any slide from RCP to ICP.

3. Location and extent of occlusal faceting.

4. Ease of movement between mandibular positions as in 1.

5. Extent of posterior support.

6. Over-erupted, tilted or mobile teeth

Dent Update 2003; 30: 150-157
 HISTORY
EXAMINATION
DETECTING OCCLUSAL CONTACTS DIAGNOSIS
ANALYSIS
OCCLUSION
 Articulating paper is used to mark or indicate
the position of occlusal contacts. Thin articulating
paper such as GHM occlusion foil which is 19 microns
thick, marks true contact points; thicker paper (70–200
microns) can produce inaccurate and often larger
points

 To show occlusal contacts the teeth must be dry

 Articulating paper, held in Miller’s forceps , is placed

between the teeth and the mandible guided into whichever
position is being assessed to record the points of tooth
contact

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

Articulating paper
held in Miller’s
forceps
Different occlusal
indicators – wax, paper,
shimstock

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
T-SCAN III SYSTEM DIAGNOSIS
(Computerised occlusal analysis Technology) ANALYSIS
OCCLUSION
 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
OCCLUSION

Occlusal analysis with T-scan III

Contacts with
articulating
paper
 HISTORY
EXAMINATION
DIAGNOSIS
 Articulated study casts, mounted on a semi- ANALYSIS
adjustable articulator using a facebow record, OCCLUSION

provide more detailed information that cannot be

readily assessed in the mouth

 The casts must be articulated in RP so any slide from this

position to ICP is detectable

 The interocclusal records must also include lateral

excursions and protrusion so both the horizontal and vertical
condylar guidance and incisal guidance can be programmed
into the articulator

Dent Update 2003; 30: 150-157

 HISTORY
EXAMINATION
Retruded Contact Position DIAGNOSIS
ANALYSIS
OCCLUSION
“Guided occlusal relationship occurring at
the most retruded postion of the condyles
in the joint cavities”

 A position that may be more retruded than the

centric relation position

The Academy of Prosthodontics

Glossary of prosthodontic terms
J Prosthet Dent 1999; 81: 48-106
 HISTORY
EXAMINATION
CENTRIC RELATION DIAGNOSIS
ANALYSIS
OCCLUSION
“The maxillomandibular relationship in which
the condyles articulate with the thinnest
avascular portion of their respective discs,
with the complex in the anterior-superior
position against the slopes of the articular
eminences”

 This position is independent of tooth contact.

 It is restricted to a purely rotary movement about the
transverse horizontal axis

The Academy of Prosthodontics

Glossary of prosthodontic terms
J Prosthet Dent 1999; 81: 48-106
 HISTORY
EXAMINATION
DIAGNOSIS
Intercuspal position ANALYSIS
OCCLUSION
“The complete intercuspation of the opposing
teeth independent of condylar position.”

 Sometimes referred to as the best fit of the teeth regardless

of the condylar position

Centric occlusion

“The occlusion of opposing teeth when the mandible

is in centric relation”
 This may or may not coincide with the intercuspal
position
The Academy of Prosthodontics
Glossary of prosthodontic terms
J Prosthet Dent 1999; 81: 48-106
 HISTORY
EXAMINATION
IMPORTANCE OF RCP DIAGNOSIS
ANALYSIS
OCCLUSION
RCP is said to be a “relatively reproducible
position” and as such is useful in the restorative
management of dentate and edentulous individuals
and as a reference point for the registration of
transfer records, so that casts can be mounted
on articulators

 Posselt in his classic treatise ‘Studies in the Mobility of the

Human Mandible', found that the retruded position of the
mandible was reproducible to within 0.08 mm and thus
could be termed a border movement

Acta Odontol Scand 1952; 10: Suppl 10.

J Prosthet Dent 1964; 14:,266-278

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
In Dentate subjects…. OCCLUSION

 RCP is an unstrained
position of the mandible
relative to the maxilla
occurring at initial tooth
contact

 This contact follows closure about the terminal hinge axis

where the condylar heads are in their most anterior and
superior position in the glenoid fossae

British Dental Journal 2004; 196: 395–402

 HISTORY
EXAMINATION
Relevant bony anatomy of the skull base DIAGNOSIS
and the right TMJ articulation ANALYSIS
OCCLUSION

A: mastoid process
B: right glenoid (articular)
fossa with the antero-
superior aspect shaded,
C: zygomatic arch

D: posterior hard palate,

E: pterygoid plates, and

F: styloid process

British Dental Journal 2004; 196: 395–402

 HISTORY
EXAMINATION
DIAGNOSIS
 Posselt in 1952 found that in 10% of dentate ANALYSIS
individuals, the RCP coincided with the intercuspal OCCLUSION
position.
Acta Odontol Scand 1952; 10: Suppl 10.

 For the remainder, the RCP is infero-posterior to ICP by

0.5—2 mm

 The movement from the RCP to

the ICP is known as a “slide”

 A slide has the potential for a

combination of horizontal, vertical
and lateral components along its
path
Dent Update 1991; 18: 141-145.
 HISTORY
EXAMINATION
DIAGNOSIS
 Subjects with an easily identifiable, stable and ANALYSIS
OCCLUSION
comfortable ICP may only require a conformative
approach rather than reorganisation at RCP.

 Reorganisation involves altering a patient's existing

ICP to a new ICP.

 This new ICP is made coincident with RCP because

of the reproducibility of the latter.

 This will eliminate the RCP-ICP slide

British Dental Journal 2004; 196: 395–402

 HISTORY
EXAMINATION
In Edentulous subjects… DIAGNOSIS
ANALYSIS
OCCLUSION
 There are no natural tooth contacts to define a
retruded contact

 In this situation, prosthetic tooth

contact (or wax occlusal rim contact) will
be along the retruded arc of closure at
some point

 This is dictated by the occlusal

vertical dimension (OVD) appropriate for
that patient. Therefore, the mandible and
maxilla are in CR at this occlusal vertical
dimension and it is from here that the
prosthetic occlusal scheme is constructed
British Dental Journal 2004; 196: 395–402
 HISTORY
EXAMINATION
DIAGNOSIS
USES OF RCP IN THE DENTATE PATIENT ANALYSIS
OCCLUSION

 Mounting models on an articulator.

Mandibular movement can be simulated
because of pure rotation about the
terminal hinge axis
Helkimo M. Prosthodontic treatment of partially edentulous patients. Various centric
positions and methods of recording them. Zarb G A, Bergman B, Clayton J A, MacKay H F
(eds) pp171-187. St Louis: CV Mosby, 1978

 Reorganising a patient's occlusion at a new occlusal

vertical dimension
 Occlusal analysis in cases of toothwear, tooth
mobility, drifting, pain or repeatedly failing
restorations.
Br Dent J 2001; 191: 291-302
 HISTORY
EXAMINATION
DIAGNOSIS
USES OF RCP IN THE DENTATE PATIENT ANALYSIS
OCCLUSION

 Occlusal splint therapy

J Prosthet Dent 2001; 86: 539-545

 ‘Distalising' the mandible to create palatal

space for anterior restorations
J Oral Rehab 2000; 27: 1013-1023

 Restoring a tooth which is involved in

determining the RCP
Br Dent J ;1982; 152: 160-165
 HISTORY
EXAMINATION
DIAGNOSIS
USES OF RCP IN THE DENTATE PATIENT ANALYSIS
OCCLUSION

 Determining the magnitude and direction

of the RCP to ICP slide in order to assess
the resultant force applied to anterior
restorations
J Oral Rehab;2001; 28: 55-63

 Midline analysis in cases of facial asymmetry,

in order to separate dental and skeletal causes

Ramfjord S P, Ash M M. Occlusion. 4rd edition, p 305.

Philadelphia: WB Saunders Co, 1995
 HISTORY
EXAMINATION
 It has been suggested that RCP is attainable DIAGNOSIS
during mastication and deglutition, and that ANALYSIS
OCCLUSION
restoring a patient to this position may result in
enhanced masticatory efficiency and occlusal
stability
Ramfjord S P, Ash M M. Occlusion. 4rd edition, p 305.
Philadelphia: WB Saunders Co, 1995

J Oral Rehab 2000; 27: 1013-1023

 Furthermore, it has been demonstrated that the

reorganisation of patients to a situation where RCP
coincides with ICP will relapse after a period of time so that
a slide between the two is re-introduced

Prosthet Dent 1973; 30: 591-598

 HISTORY
EXAMINATION
DIAGNOSIS
FACTORS AFFECTING THE RCP RECORDING ANALYSIS
OCCLUSION
 Recording RCP is dependent upon a number of
factors including the patient, operator experience and
training ,the registration material and recording
method employed, the time of the recording, guidance
of the mandible, neuromuscular conditioning and
record handling and storage
Dent Update 2003; 30: 150-157

 The diurnal variance of recording maxillomandibular

relationships has been studied in 13 subjects by Shafagh et al

 Shafagh et al. found that retruded mandibular recordings made

in the evening were more posterosuperior than those made in the
morning
J Prosthet Dent 1975; 34: 574-576
 HISTORY
EXAMINATION
 In the dentate individual the RCP record is taken DIAGNOSIS
at a slightly increased OVD just prior to tooth
ANALYSIS
OCCLUSION
contact (CR) with the mandible rotating about the
terminal hinge axis

 If tooth contact occurs, involuntary programmed

mandibular deviation from the hinge axis will result due to
sensory feedback from periodontal ligament
mechanoreceptors

 Neuromuscular conditioning and the abolition of reflex patterns

of closure can be achieved by the patient biting the teeth together
hard, biting on cotton rolls, holding the mouth open wide, use of
an anterior jig or use of an occlusal splint

Br Dent J 2001; 191: 291-302

 HISTORY
EXAMINATION
 Other influences that affect the RCP recording DIAGNOSIS
include general health, attitude to treatment, co- ANALYSIS
OCCLUSION
operation and comprehension of the procedure, the
patient's body, head and tongue position, state of
relaxation, medication and state of anaesthesia

 The number of teeth, their condition or the ridge form of

edentulous patients will effect the stability of the recording
medium and thus the quality of the recording

 Pain from the operator's guidance technique, the

temporomandibular joints or from muscle tension will
result in reflex mandibular protrusion and hence erroneous
recordings
 HISTORY
MANDIBULAR GUIDANCE & RCP EXAMINATION
DIAGNOSIS
The aim of mandibular guidance is “to help locate ANALYSIS
the condylar heads in the glenoid fossae at the OCCLUSION
terminal hinge axis in a consistent manner, thus
producing mandibular closure about the terminal
hinge axis”
Can be divided into those which are
PATIENT-GUIDED OPERATOR-GUIDED
 Schuyler technique  Chin-point guidance method
 Physiological technique  Three finger chin-point guidance
 Gothic arch (Arrow-point)  Bimanual manipulation method
tracing  Anterior guidance by a Lucia Jig,
Leaf Gauge , tongue blade ,
 Myo-monitor
OSU Woelfel Gauge
 Power-centric registration method
 HISTORY
EXAMINATION
PATIENT-GUIDED… DIAGNOSIS
ANALYSIS
OCCLUSION

Schuyler technique
J Am Dent Assoc 1932; 19: 1012-1021

 uses cones of soft wax

Physiological technique placed posteriorly.
 IN EDENTULOUS
J Prosthet Dent 1955; 5: 319-322
patients
 HISTORY
EXAMINATION
Gothic arch (Arrow-point) tracing DIAGNOSIS
ANALYSIS
OCCLUSION

Maxillary and
mandibular occlusal
rims with a metal plate
on the upper (left) and
stylus on the lower
(right)

Br Dent J 1994; 176: 386-393

Dent Cosmos 1910; 52: 1-19

 HISTORY
EXAMINATION
Gothic arch (Arrow-point) tracing DIAGNOSIS
ANALYSIS
OCCLUSION

The stylus scribes an

arrow-head shaped
tracing on the maxillary
plate outlining the
protrusive and right and
left lateral excursions of
the mandible

Where the lines meet on the plate represents the

retruded mandibular position
Br Dent J 1994; 176: 386-393

Dent Cosmos 1910; 52: 1-19

 HISTORY
EXAMINATION
Gothic arch (Arrow-point) tracing DIAGNOSIS
ANALYSIS
OCCLUSION

 A system of recording a gothic

arch tracing extra-orally

 The stylus plate system is

attached to the rims via forks

Br Dent J 1994; 176: 386-393

Dent Cosmos 1910; 52: 1-19

Myo-monitor
 an electrical jaw muscle stimulating device
which is reputed to achieve muscle
relaxation and produce a neuromuscular
mandibular position J Prosthet Dent 2000; 83: 83-89

 Eg. J-4 Muscle Stimulator which produces pulsed ultra-low

frequency stimulation of facial and masticatory muscles
 Stimulating electrodes are placed over the coronoid notches
& a common electrode is located at the nape of the neck
 Proponents of the myo-monitor suggest that the
‘jaw-closer' muscles act simultaneously, via reflex contraction,
to produce a reproducible retruded mandibular position
Quintessence Int 1972; 12: 57-62

Prosthet Dent 1975; 34: 245-253

 HISTORY
EXAMINATION
OPERATOR-GUIDED… DIAGNOSIS
ANALYSIS
Chin-point guidance method OCCLUSION

Patient's mandible
is guided into a
hinge closure by
the thumb and
index finger of the
operator

Prosthet Dent 1960; 10: 849-855

 HISTORY
EXAMINATION
DIAGNOSIS
Three finger chin-point guidance method ANALYSIS
OCCLUSION

A tripod is created at the

chin-point and lower
border of the mandible
on both sides by the
thumb, index and third
finger

 not recommended for

edentulous subjects

Int J Perio Rest Dent 1984; 4: 62-66

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
Bimanual manipulation method OCCLUSION

Technique is carried out

with the patient supine
and the operator seated
directly behind.

 fifth finger of each hand is placed behind the angle of the

mandible, with the fourth fingers positioned just in front of
the angle

Prosthet Dent 1973; 29: 100-104

 HISTORY
EXAMINATION
DIAGNOSIS
ANALYSIS
Bimanual manipulation method OCCLUSION

 Third fingers are

placed on the inferior
surface of the body of
the mandible, and the
index fingers submentally
in the midline

 Thumbs are positioned laterally to the symphysis

 An alternative method, with the operator in front of the

patient, is to use the index fingers to stabilise the lower
record base and guidance is from the thumbs on the chin
Prosthet Dent 1973; 29: 100-104
 HISTORY
EXAMINATION
DIAGNOSIS
Anterior guidance by a Lucia Jig ANALYSIS
OCCLUSION

The basis of the Lucia jig method and the techniques that
follow, is to provide an anterior reference point
J Pros Dent 1964; 14: 492-505.
 HISTORY
EXAMINATION
DIAGNOSIS
Anterior guidance by a Lucia Jig ANALYSIS
OCCLUSION
 An anterior stop also stabilises the mandible
during recording and permits minimal tooth
separation so that the recording medium is as thin as
possible

 The lingual aspect should slope posteriorly and superiorly

at an angle of between 40–60°

 A selected lower incisor scribes an arrow-head pattern, the

‘wings' and ‘tail' of which can be ground away to leave the apex

J Pros Dent 1964; 14: 492-505.

 HISTORY
EXAMINATION
DIAGNOSIS
Anterior guidance by a Lucia Jig ANALYSIS
OCCLUSION

 This process is repeated until a raised area

of acrylic at the apex remains

 This is the location of the retruded position and the

vertical height is then adjusted until the posterior teeth are
just out of contact

 The record is made at this position with the jig in the mouth

It is important to note that while the jig is being adjusted out
of the mouth, the patient must bite on a cotton wool roll or a
saliva ejector
J Pros Dent 1964; 14: 492-505.
 HISTORY
EXAMINATION
DIAGNOSIS
Anterior guidance by a tongue blade ANALYSIS
OCCLUSION

 The degree of tooth separation

can be altered by the number of
spatulas used

 The patient's teeth must be

discluded for a period of time,
usually between 10–20 minutes
prior to registration

J Prosthet Dent 1970; 23: 11-24

 HISTORY
EXAMINATION
Anterior guidance by a Leaf Gauge DIAGNOSIS
ANALYSIS
OCCLUSION

J Prosthet Dent 1973; 29: 608-610.

 HISTORY
EXAMINATION
Anterior guidance by a OSU Woelfel Gauge DIAGNOSIS
ANALYSIS
OCCLUSION

 was developed by Woelfel at Ohio State University (OSU)

 The specially designed device has a graduated acetate bite
platform, the position of which is adjusted antero-posteriorly
until the teeth are minimally out of contact
J Prosthet Dent 1986; 56: 716-727
 HISTORY
EXAMINATION
DIAGNOSIS
Power-centric registration method ANALYSIS
OCCLUSION

 Operator employs a directed force to achieve

a retruded mandibular position

 With the dentist standing in front and to the right of the

supine patient, the left thumb and forefinger are placed over
the upper teeth

 right thumb is placed on the superior aspect of the chin,

while the second and third fingers take up position along the
inferior border of the mandible

Clin Orth 1981; 15: 32-46

 HISTORY
EXAMINATION
DIAGNOSIS
Power-centric registration method ANALYSIS
OCCLUSION

 Operator's right arm is stiffened and pressure is

applied from the shoulder by leaning

 It has been suggested that reflex muscle shortening acts

to retrude the mandible

Clin Orth 1981; 15: 32-46

 HISTORY
Wise described RCP location techniques for the EXAMINATION
DIAGNOSIS
dentate patient based upon the relative ease of
ANALYSIS
mandibular manipulation OCCLUSION

‘EASY' bimanual manipulation

‘manipulation with slight difficulty'

Anterior guidance from a tongue blade

followed by bimanual manipulation

‘manipulation with more difficulty'

Lucia jig which may need to be left in situ for up to
30 minutes
 For some very difficult patients, an occlusal splint for an
extended period
Br Dent J 1982; 152: 160-165
 HISTORY
EXAMINATION
DIAGNOSIS
Discrepancy Between RCP and ICP ANALYSIS
OCCLUSION

 The mandible is manipulated into RCP and the

patient instructed to slide his or her teeth together
until they meet in ICP or in the position that feels
correct to them

 This is identified using articulating paper

 Lateral excursions are then made to detect the nature of

the guidance and finally protrusive movement is used to
demonstrate the type of anterior guidance

Dent Update 2003; 30: 150-157

THANKYOU………