Occlusal Considerations &

Articulator Selection for

Complete Dentures
Part I & II

Khaled Q Al Hamad BDS Msc MRD RCSEd

Associate Professor Department of Prosthodontics

Dent 445- Lecture 4 & 5

Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Occlusion
Relation of the of the maxillary and mandibular teeth when in functional contact during activity of the mandible.

An integral part within the stemato-gnathic system (SGS) that relates teeth, not only to other teeth, but the other components of the SGS during normal function, Para function and Dysfunction. SGS: Teeth, TMJ, muscles, Periodontium. Terminal Hinge Axis: horizontal axis between the condyles during rotation with a terminal arc of closure at the mandibular incisor of up to 25mm.

RCP & ICP

 Centric Relation: The Maxillomandibular relationship in which the condyles articulate with thinnest avascular portion of their respective disks with the complex in the anterior-superior position against the shapes of the articular eminence Retruded Contact Position (RCP): the initial tooth contact upon closure when the condyles have purely rotated whilst in their most superior unrestrained position in the glenoid fossae. Inter-cuspal Position (ICP): the complete intercuspation of teeth regardless of the condylar position (Centric Occlusion)

 ICP is affected by: mesial drift, tooth wear, tilt and drifting, restoration in supra/infra occlusion, ICP is a habitual position that can change throughout life while RCP is anatomically determined position and thus constant and more reproducible. In 90% of the

Significance Of ICP
Its the position in which vertical occlusal forces are most effectively borne by the periodontium with teeth likely to be loaded axially. Its the end point of the chewing cycle. In every day practice, this is the position in which restorations are made.

Significance of RCP
Most crowns are made usually to conform to ICP and a slide from ICP to RCP is of no importance. Adjusting the contact in RCP is likely important:
When RCP involve a tooth you are about to prepare. When reorganizing at increased VDO. When you need space ( mandibular repositioning

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Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Mandibular Movement
When the mandible moves, teeth slide over each other. This partly determined by:
Shapes of the teeth( anterior guidance) Anatomical constraints of the TMJ (Posterior guidance).

Both should be in harmony.

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 Lateral movements is guided by condyle- fossa relationship and teeth relation ships. Working side: Canine guidance Group function. Combination: initial group function then canine rise towards the end. Non-working side. ( not the balancing side) The side away from which the mandible has moved.

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Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Protrusive Movement
Anterior Guidance (AG): its the effect of the contact between the incisal edges of the lower teeth and that of palatal surfaces of the upper teeth on mandibular movement.
Incisal guidance.
Steep incisal guidance:
increased posterior separation (e.g. class II divII) Possible increase in load on the anterior teeth.

Condylar guidance.(30-60/average:45)

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Requirements for AG
Patient comfort Smooth guidance, that is , there are no mandibular deflection. Acceptable aesthetics & phonetics. Minimal movement of guidance teeth Posterior disocclusion. No cementation failure of fracture of the interim restorations.

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Significance
Guidance teeth are repeatedly loaded non axially.
Manifestations of problems with guidance:
Fracture Wear Tooth migration/mobility TMJ Dysfunction

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Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Video 1

Mandibular rest position

Video 2

Adjusting vertical dimension to obtain the required free way space

Video 3

Registering the maxilo- mandibular relation

Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Posterior teeth-cuspal inclination.

Anatomic teeth: 30. 33 & 45 Semi-anatomic: 20 Flat or monoplane teeth: 0

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 Ideally, teeth should be anatomic effective in chewing food. aesthetically pleasing. designed to be set in balanced articulation. Potential problems denture instability when the articulation is not balanced leading to trauma to the denture bearing area. Non-anatomic teeth designed to be flat and allow even occlusal contact without deflection during excursive movement. can be used with monoplane occlusal schemes set in a simple hinge articulator. useful when the alveolar ridge is markedly resorbed and is difficult to provide a stable mandibular denture. Potential problems chewing efficiency is relatively in effective aesthetic requirements might be jeopardized.
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 advantages to anatomic teeth: -1. Can establish mechanical and physiologic occlusion. -2. Penetrates food more easily. -3. Articulate in harmony with TMJ and masticatory muscles. -4. Resists rotation of denture base through interdigitation with cusps. -5. Better esthetics. -6. Less trauma to underlying tissues. disadvantages to anatomic teeth: -1. Requires and exacting technique. -2. Lateral torque. -3. Relining and rebasing is difficult. advantages to non-anatomic teeth: -1. They dont lock the mandible into one position. -2. They minimize horizontal pressure due to no inclined planes. -3. Closure can occur in more than one position---centric relation can be an area rather than a point. -4. They can easily adapt to Class II & III jaw relationships. -5. They accommodate to changes in vertical and horizontal relations of ridges. -6. Relining and rebasing is easier. 43 -7. They improve denture stability.

Teeth-Materials
The materials from which posterior teeth are constructed are: Acrylic resin. Porcelain. Composite resin. Metal onlays. The acrylic teeth are the most widely used. They are easy to bond to acrylic (chemically)and easy to adjust. Their major disadvantages are their poor resistance to wear. Porcelain has much better resistance to wear but it is difficult to be adjusted and does not bond to the denture base (Mechanical). Patient may complain that the teeth make noise when eating. Composite teeth are increasingly being used for denture opposing natural teeth. Finally, in cases in which the rate of wear of the acrylic teeth has been extremely rapid, metal onlay restorations can be incorporated onto the acrylic teeth.

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Arranging Anatomic Teeth to a Balanced Articulation.

The anterior teeth are set to a low incisal guidance of 0.5 mm vertical and 1-2 mm horizontal overlaps.

Number of Posterior Teeth. The decision on this will depend on the available space. Placing teeth on the residual ridge incline as it ascends to the pad should be avoided. If only three teeth are to be set, the first premolar is dropped.

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 Balanced occlusion (anatomic teeth) advantages:

-1. Esthetics -2. Better food penetration -3. Anatomic occlusion is arranged in harmony with the muscles of mastication

disadvantages:
-1. Precise technique required for set-up -2. Cuspal inclines tend to create greater lateral forces that can harm ridges -3. More time is required to establish a balanced occlusion
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Balanced occlusion with non-anatomic teeth

-although non-anatomic teeth are used here, it should not be considered a monoplane occlusion. -2 advantages to this scheme: -1. Can be used for patients with poor neuromuscular coordination -2. Less time involved with the set-up -2 disadvantages of this scheme: -1. Compensating curve may cause same damaging effects as cuspal inclines -2. Occlusal adjustments are more difficult

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Arranging Non-Anatomic Teeth to Monoplane Articulation.

can have balanced and non-balanced occlusion with non-anatomic teeth. the principles: 0 condylar guidance 0 incisal guidance 0 cusp height flat occlusal plane no vertical overlap

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 A simple hinge articulator. The maxillary posterior teeth are set one at a time with Mandibular wax rim and its references and guides for tooth placement. The maxillary teeth are positioned to occlude with the flat surface of the Mandibular wax rim. There should be 1-2mm of horizontal overlap of the maxillary facial cusps in relation to the Mandibular wax rim. When completed, the occlusal surfaces of the maxillary teeth should be flat against the Mandibular wax rim. The Mandibular teeth are arranged so they will maximally contact the upper teeth. Each tooth is arranged in maximum contact of the flat lingual cusp of the opposing upper tooth contacting the central groove area of the Mandibular tooth. The antero-posterior relation is not critical. Any combination of the premolars and molars can be used to fill the available space. The posterior limit of the extent of these teeth is the point at which the Mandibular ridge begins to curve upward toward the retromolar pad. There is no attempt to eliminate deflective contacts in lateral or protrusive Basically, the patient can clench and grind in and around maximum intercuspation during functional and non functional activities. However some deflective contacts of the posterior will be experienced.
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advantages of monoplane occlusion: -1. More adaptable to unusual jaw relations -2. Can be used in cross-bite cases -3. The mand does not get locked into one position -4. Greater comfort and efficiency -5. Improved denture stability -6. Accommodates to changes in horizontal and vertical relations -7. Relining and rebasing are easier disadvantages to monoplane occlusion: -1. Less efficient mastication -2. Esthetically inferior -3. Clogging of occlusal surfaces -4. Poor food penetration -5. Difficult to establish balanced occlusion indication for monoplane occlusion: -1. Class II or III malocclusion -2. Severe residual ridge resorption -3. Excessive interarch distance -4. Poor neuromuscular skills -5. Poor patient adaptability
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Lingualized Occlusion
Utilizes anatomic teeth for the maxillary denture and modified non anatomic or semi anatomic teeth for the mandibular denture. An attempt to maintain the esthetic & food penetration advantages of the anatomic form while maintaining the mechanical freedom of the non anatomic form. Lingualized occlusion should not be confused with placement of the mandibular teeth lingual to the ridge crest.

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Indications for Lingualized Occlusion.

Can be used in most denture combinations. particularly helpful when the patient places a high priority on aesthetics but a non anatomic occlusal scheme is indicated by the oral conditions such as: Severe resorption. Class II jaw relationship. Displaceable supporting tissue. can be also used effectively when a complete denture opposes a removable partial denture. The goal for bilateral balanced occlusion with lingualized occlusion Usually the desired range of balanced occlusion can be achieved before the anterior teeth make contact. In situations where the anterior teeth would contact before achieving the desired range of bilateral balanced occlusion, the vertical overlap of the anterior teeth can be reduced to approach an incisal guidance of zero. 59 A slight compensating curve will be necessary to achieve continuous posterior contacts anterior to the centric relation.

Principles of Lingualized Occlusion.

Anatomic posterior teeth (33 or 30 degree) are used for the maxillary denture. Tooth forms with prominent lingual cusps are useful. Non-anatomic or semi-anatomic teeth are used for the mandibular denture. A narrow occlusal table is preferred when severe resorption of the residual ridge has occurred. selective grinding is always necessary regardless of specific tooth material. Selective grinding smoothes the fossae of the mandibular teeth, lowers marginal ridges, forms slight buccal and lingual inclines. This create a slight concavity in the occlusal surface. Maxillary lingual cusps should contact mandibular teeth in centric relation. Balancing and working contacts should occur only on the maxillary lingual cusps. This helps to reduce lateral movement of the lower denture placing occlusal forces more lingual to and toward the centre of the mandibular teeth. On the balancing side, the maxillary lingual cusps contact the mandibular buccal cusps as is customary with anatomic tooth arrangement. Protrusive balancing contacts should occur only between the maxillary lingual cusps and the lower teeth. Selective grinding for the protrusive movements should be done on the mandibular teeth only so that the lateral balancing contacts and the vertical dimension of occlusion are not changed. The desired range of balanced occlusion can be achieved before the anterior teeth make contact. In situations where the anterior teeth would contact before achieving the desired range of bilateral balanced occlusion, the vertical overlap of the anterior teeth can be reduced 60 to approach an incisal guidance of zero. A slight compensating curve will be necessary to achieve continuous posterior contacts

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Advantages of Lingualized occlusion.

Cusp form is more natural in appearance compared to non-anatomic tooth form. Good penetration of food bolus is possible. Bilateral balanced occlusion is readily achieved for a region around centric relation. Vertical forces are centralized on the mandibular teeth.

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Introduction to Occlusion
Centric Relation ( RCP) & Centric Occlusion ( ICP) Mandibular Movement Anterior Guidance

Occlusal registrations for CD- clinical steps Occlusal Schemes for CD Articulators

Articulators
An articulator may be defined as "a mechanical device that represents the TMJ & Jaw members to which maxillary and mandibular casts may be attached to simulate jaw movement". Function: to act as the patient in his absence. It can simulate but not duplicate all manidibular movement. However, it can be programmed with certain records to allow fabrication of the restorations.

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Advantages of Articulator over the patient

Better visualization of the patient occlusion, especially lingually. Patient cooperation is not a factor. The refinement of complete denture occlusion is extremely difficult in the mouth because of shifting denture bases and resiliency of the supporting tissues. Considerable more chair side time when utilizing the patient mouth as the articulator. More procedures can be assigned to auxiliary personnel when not using the patient mouth. There is no Tongue, saliva, cheeks with the mechanical articulator

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Classifications
Class I .Simple holding instruments capable of accepting a single static registration. Vertical motion only. Class II. permit horizontal as well as vertical movements but no face bow transfer. can be further subdivided according to mechanism of programming the eccentric motion: average or arbitrary values, based on theories of occlusion. Class III. simulate condylar pathways by using averages or mechanical equivalents for all or part of the motion. allow for a face bow transfer. further subdivided according to the mechanism of programming the eccentric motion :static protrusive or static lateral check records. Class IV. accept three-dimensional dynamic registrations. further subdivided according to the method of programming the articulator: Stereographic recordings, Pantographic recordings, 66 Electronic recordings.

Classifications
According to TMJ Resemblance
ARCON. The element representing the condyle is attached to the lower member of the articulator while the condylar fossae is on the upper member). NON-ARCON. The opposite of the above.

According to adjustability
Non-adjustable (Class I). Semi-adjustable (Class II & III). Fully-adjustable (Class IV).

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 -Bennett angle: angle formed by the sagittal plane and the path of the advancing condyle during lateral mandibular movements as viewed in the horizontal plane. -Fisher angle: angle formed by the inclinations of the protrusive and non-working side condylar paths as viewed in the sagittal plane.

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Simple hinge
A l l o w s r o t a t i o n a l m o v e m e n t o n
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Functionally generated path

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Average Value
Allow limited range of protrusive and lateral movements based on average values through a fixed condylar guidance. Usually set:
30 for condylar guidance. 15 for incisal guidance. 110 for intercondylar distance.

Indication: couple of posterior crowns and short span bridge.

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Semi adjustable/ARCON
These are the workhorses for restorative treatment. Require a facebow. Interocclusal record in protrusive, lateral excursions to program condylar guidance and Bennet angle and shift. Hanaus formula: L=(H/8)+ 12 H:Horizontal condylar inclination L: Lateral condylar inclination

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 Maxillary cast is related to an arbitrary axis of rotation. Condylar guidance is variable but in a straight line. Some adjustment of the incisal table is possible

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Semi adjustable/NON-ARCON

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Fully adjustable
Maxillary is mounted using Kinematic facebow. Mandibular movement is recorded by pantographs, electronic jaw tracking devices (Cardiax), or Sterographic or fossa-moulded
Using intra-oral clutches with studs which mould soft acrylic during border movement. These dynamically carved intra oral 3D records are then transferred to the articultor. Self cure acrylic is then added to fossa insert and the and the articulator excursions are guided by the intra-oral engravings.

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pantographs

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Sterographic or fossa-moulded

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Denar Cadiax Compact System with Gamma Dental Software

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DENAR D5A
Fully adjustable. Arcon construction simulates true anatomical structure. Adjustments: protrusive angle 0-60 degrees; immediate side shift 0-4mm; progressive side shift 0-30 degrees rear wall 30 degrees backward; top wall 30 degrees up, 30 degrees down; intercondylar distance 90-150mm. Medial and Superior wall inserts: removable for custom grinding; choice of curvatures. Adjustable incisal table (T3), custom step incisal table (T2) and long centric incisal pin (P2) are standard. Lingual visibility allows for easy viewing and access to

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