OCCLUSION AND PERIODONTIUM

CONTENT
1. Introduction
2. Stages of development of the occlusion
3. Functional anatomy of masticatory system
4. Physiological occlusion: Types, Contact patterns, bite forces
5. Age changes in Occlusion.
6. Collapse of the occlusion
7. Effect of excessive occlusal force on periodontium
8. Effect of hypo-occlusion on periodontium
9. Effect of non-occlusion on periodontium
10.
Occlusal periodontal consideration during prosthetics
procedures
11.
Occlusal periodontal consideration during restorative
procedures
12.
Occlusal periodontal consideration during orthodontic
procedures
13.
Occlusal periodontal consideration in periodontal
splints
14.
Effect of occlusion on periodontal tissue healing
15.
Occlusal adjustments in periodontal therapy
16.
Conclusion

INTRODUCTION

The term occlusion derived from the latin word occlusio defines the functional
relationship between the components of masticatory system, including the teeth,
supporting tissues,neuromuscular system, temperomandibular joint and craniofacial
skeleton.(McNeill 1997).
Three class of functional occlusion :
1) Physiologic occlusion: it is present when no signs of dysfunction or disease are
present and no treatment is indicated.
2) Non physiologic occlusion or traumatic occlusion is associated with dysfunction or
disease caused by tissue injury and treatment may be indicated.
3) Therapeutic occlusion is the result of specific intervention designed to treat
dysfunction or disease.
A harmonious relationship between occlusion and periodontium is considered mandatory
to maintain a healthy dentition. In a healthy occlusion, there are multiple pin-point
contact between the maxillary and mandibular teeth in maximum intercuspation; and
during protrusive , letroprotrusive and lateral excursive movement there is immediate
disclusion in the form of anterior guidance, canine guided occlusion or a mutually
protected occlusion.(D. Krishna Prasad 2013)
The relationship of occlusion to periodontal health start with the development of the
tooth. As the tooth erupts, pressure from the lips, tongue, cheek, fingers, pacifier and
exposure to food are thrust on the crown. To withstand these forces, custom built
periodontium develops around the root. As the tooth depend on periodontal tissue to keep
it with in the jaw, so the periodontal tissue depend on functional activity of the tooth to
remain healthy. When there is insufficient functional stimulation, the periodontal tissue
atrophies. When the tooth is extracted, the periodontium disappears.
Occlusion is a lifeline of periodontium. In periodontal health, it provides the mechanical
stimulation that marshals the complex biologic mechanism responsible for well being of
the periodontium.
The occlusion is a critical environmental factor in the life of the healthy periodontium
and its influence continues in the periodontal disease. It may be favourable or
unfavourable. If occlusion is favourable, inflammation is a sole destructive factor of
periodontium. If the occlusion is unfavourable it alters the environment and pathway of
the inflammation which produce periodontal injury and become a co-destructive factor.

Terminology and definition

Maximum intercuspation: The position of the mandible when there is maximal

interdigitation and occlusal contacts between maxillary and mandibular teeth; also called
centric occlusion and intercuspal position.( Peter E. Dawson. Evalua)on,Diagnosis, and
Treatment of Occlusal Problems, 2nd ed..Mosby)

Centric relation: The position of the mandible when both condyledisc assemblies are
in their most superior position in their respective glenoid fossa and against the slope of
the articular eminence of each respective temporal bone.

Initial contact in centric relation: The first occlusal contact in the centric relation
closure arc.

Excursive movement: Any movement of the mandible away from maximum

intercuspation.

Lateral excursion: Movement of the mandible laterally to the right or to the left from
maximum intercuspation.

Working side: The side of either dental arch corresponding to the side of mandible
moving away from the midline during a lateral excursion.

Nonworking side: The side of either arch corresponding to the side of the mandible
moving toward the midline during a lateral excursion; also called balancing side.

Protrusion: Movement of the mandible anteriorly from maximum

intercuspation.

Retrusion: Movement of the mandible posteriorly relative to a more

anterior position.

Guidance: The pattern of opposing tooth contact during excursive

movements of the mandible.

Disclusion: The separation of certain teeth caused by guidance

provided by other teeth during an excursion. When anterior guidance
provides for separation of posterior teeth during an excursion,
posterior disclusion is achieved.

Interference: Any occlusal contact in the centric relation closure

arc or in any excursion that prevents the remaining occlusal surfaces
from achieving stable contact or from functioning harmoniously and/or
that encourages masticatory system disharmony; also called an
occlusal discrepancy

Functional Anatomy of Articulatory System

The masticatory system is a complex and highly refined unit. A sound understanding of its
functional anatomy and biomechanics is essential to the study of occlusion.
The masticatory system is generally considered to be made up of three parts: the teeth, the
periodontal tissues and the articulatory system.

TEMPOROMANDIBULAR JOINT
The area where the mandible articulates with the temporal bone of the cranium is called the
temporomandibular joint (TMJ), certainly one of the most complex joints in the body. It provides
for hinging movement in one plane and therefore can be considered a ginglymoid joint. However,
at the same time it also provides for gliding movements, which classifies it as an arthrodial joint.
Thus it has been technically considered a ginglymoarthrodial joint.
The TMJ is formed by the mandibular condyle and the mandibular fossa of the temporal bone,
into which it fits. The articular disc separates these two bones from direct articulation. The TMJ
is classified as a compound joint. By definition, a compound joint requires the presence of at

least three bones, yet the TMJ is made up of only two. Functionally, the articular disc serves as a
nonossified
bone, which permits the complex movements of the joint. Since the articular disc functions as
a third bone, the craniomandibular articulation is considered a compound joint. The function of
the articular disc as a nonossified bone is described in detail later in this chapter under
Biomechanics of the Temporomandibular Joint.
The articular disc is composed of dense fibrous connective tissue for the most part devoid of
any blood vessels or nerve fibers. The extreme periphery of the disc, however, is slightly
innervated.1,2 In the sagittal plane it can be divided into three regions, according to thickness
(Figure 1.1). The central area is the thinnest and is called the intermediate zone. The disc
becomes considerably thicker both anterior and posterior to the intermediate zone. The posterior
border is generally slightly thicker than the anterior border. In the normal joint the articular
surface of the condyle is located on the intermediate zone of the disc, bordered by the thicker
anterior and posterior regions.

Fig 1.1 Articular disc, fossa, and condyle (lateral view). The condyle is normally situated on the thinner
intermediate zone (IZ) of the disc. The anterior border of the disc (AB) is considerably thicker than the intermediate
zone, and the posterior border (PB) is even thicker.

From an anterior view, the disc is usually a little thicker medially than laterally, which
corresponds to the increased space between the condyle and the articular fossa toward the medial
portion of the joint. The precise shape of the disc is determined by the morphology of the
condyle and mandibular fossa (Figure 1-14). During movement, the disc is somewhat flexible
and can adapt to the functional demands of the articular surfaces. However, flexibility and

adaptability do not imply that the morphology of the disc is reversibly altered during function.
The disc maintains its morphology unless destructive forces or structural changes occur in the
joint. If these changes occur, the morphology of the disc can be irreversibly altered, producing
biomechanical changes during function. These changes are discussed in later chapters.

Fig. 1.2 Articular disc, fossa, and condyle (anterior view). The disc adapts to the morphology of the fossa and the
condyle. LP, lateral pole; MP, medial pole

The articular disc is attached posteriorly to a region of loose connective tissue that is highly
vascularized and innervated (Figure 1-15). This tissue is known as the retrodiscal tissue or
posterior attachment. Superiorly, it is bordered by a lamina of connective tissue that contains
many elastic fibers, the superior retrodiscal lamina. The superior retrodiscal lamina attaches the
articular disc posteriorly to the tympanic plate. At the lower border of the retrodiscal tissues is
the inferior retrodiscal lamina, which attaches the inferior border of the posterior edge of the disc
to the posterior margin of the articular surface of the condyle. The inferior retrodiscal lamina is
composed chiefly of collagenous fibers, not elastic fibers like the superior retrodiscal lamina.
The remaining body of the retrodiscal tissue is attached posteriorly to a large venous plexus,
which fills with blood as the condyle moves forward.3,4 The superior and inferior attachments of
the anterior region of the disc are to the capsular ligament, which surrounds most of the joint.
The superior attachment is to the anterior margin of the articular surface of the temporal bone.
The inferior attachment is to the anterior margin of the articular surface of the condyle. Both
these anterior attachments are composed of collagenous fibers. Anteriorly, between the

attachments of the capsular ligament, the disc is also attached by tendinous fibers to the superior
lateral pterygoid muscle.

TMJ. A, Lateral view and (B) diagram showing the anatomic components: RT, retrodiscal tissues; SRL, superior retrodiscal
lamina (elastic); IRL, inferior retrodiscal lamina (collagenous); ACL, anterior capsular ligament (collagenous); SLP and ILP,
superior and inferior lateral pterygoid muscles; AS, articular surface; SC and IC, superior and inferior joint cavity; the discal
(collateral) ligament has not been drawn

The articular disc is attached to the capsular ligament not only anteriorly and posteriorly but
also medially and laterally. This divides the joint into two distinct cavities. The upper or superior
cavity is bordered by the mandibular fossa and the superior surface of the disc. The lower or
inferior cavity is bordered by the mandibular condyle and the inferior surface of the disc. The
internal surfaces of the cavities are surrounded by specialized endothelial cells, which form a
synovial lining. This lining, along with a specialized synovial fringe located at the anterior
border of the retrodiscal tissues, produces synovial fluid, which fills both joint cavities. Thus the
TMJ is referred to as a synovial joint. This synovial fluid serves two purposes. Since the articular
surfaces of the joint are nonvascular, the synovial fluid acts as a medium for providing metabolic
requirements to these tissues. Free and rapid exchange exists between the vessels of the capsule,
the synovial fluid, and the articular tissues. The synovial fluid also serves as a lubricant between
articular surfaces during function. The articular surfaces of the disc, condyle, and fossa are very
smooth, so that friction during movement is minimized. The synovial fluid helps to minimize this
friction further.
Synovial fluid lubricates the articular surfaces by way of two mechanisms. The first is
called boundary lubrication, which occurs when the joint is moved and the synovial fluid is

forced from one area of the cavity into another. The synovial fluid located in the border or recess
areas is forced on the articular surface, thus providing lubrication. Boundary lubrication prevents
friction in the moving joint and is the primary mechanism of joint lubrication.
A second lubricating mechanism is called weeping lubrication. This refers to the ability of the
articular surfaces to absorb a small amount of synovial fluid.5 During function of a joint, forces
are created between the articular surfaces. These forces drive a small amount of synovial fluid in
and out of the articular tissues. This is the mechanism by which metabolic exchange occurs.
Under compressive forces, therefore, a small amount of synovial fluid is released. This synovial
fluid acts as a lubricant between articular tissues to prevent sticking. Weeping lubrication helps
eliminate friction in the compressed but not moving joint. Only a small amount of friction is
eliminated as a result of weeping lubrication; therefore prolonged compressive forces to the
articular surfaces will exhaust this supply. The consequence of prolonged static loading of the
joint structures is discussed in later chapters.

Articular disk: jaw in open position.

Articular disk: jaw in closed position.

Influence of Temporomandibular joint on occlusion

Temporomandibular disorder is comprised of a group of chronic pain conditions that can

involve the temporomandibular joints (TMJs), masticatory muscles and associated
structures and tissues (5).The aetiology of temporomandibular disorder (TMD) is
multifactorial, and numerous studies have addressed that occlusion may be of great
importance.

Animal studies

Creating occlusal alterations

In gereral, the animal models can be grouped into three types: (i) occlusal elevation (bite
raising), that is, a device is placed on the local position to form the interference or raise
the occlusal plane; (ii) occlusal elimination (occlusal loss), that is, exodontias or grinding
is performed until occlusal contact is lost; and (iii) occlusal extrusion, that is, an
orthodontic approach is conducted to disturb the occlusion.

Occlusal alterations and TMJ

Ruben M, Mafla 1971 In a monkey study, the vertical dimension of occlusion (VDO) was

increased by 4 mm through the use of bilateral metal splints at the first molar area over
the course of 15 and 55 days (41). Histological analysis of the TMJ showed evidence of
destructive bony tissue changes in the condyles, glenoid fossa and neck of the condyle in
both the 15- and 55-day specimens. In the 55-day specimens, the condyle was displaced
mesio-inferiorly, and the articular eminence and condylar head were flattened.

Kvinnsland S et al 1993 The effect of occlusal interference on the TMJ was assessed
using a rat model with 1-mm-high EOI unilaterally on the right maxillary first molar (44).
Fluorescent microspheres were injected into the rat to allow the observation of changes in
blood flow in TMJs. After 1520 days, blood flow was increased on the ipsilateral side
relative to the contralateral side. There was also an increase in blood flow in both the

ipsilateral and contralateral TMJs in the experimental animals compared with the controls
(44). These results were interpreted as a demonstration of altered joint loading due to the
interference and a change in blood flow possibly related to tissue damage and
inflammation.

the TMJs are present at birth. MRI results were obtained on 30 infants and young
children from age 2 months to 5 years. None of the 60 joints that were examined had a
displaced TMJ disc.1 Therefore, humans are not usually born with a temporomandibular
disorder (TMD). This means that the TMJs start off as normal with normal ligaments
before the teeth arrive. The teeth arrive at about age 6 months to 1 year old. As the teeth
erupt into the mouth, they stop erupting because they hit an opposing tooth, or they
usually keep erupting .
It is clear that the teeth adapt in position as we age. Hereditary forces cause

teeth to be positioned as our genetics drives

Wiesel and Delahays textbook, Essentials of Orthopedic Surgery,2 states that tendon injuries can
be both acute and chronic processes. tendons can be injured by repetitive microtrauma as
well as a macrotrauma event. In the oral environment, this is seen in the temporalis tendon with
chronic clenching causing a temporal tendonitis. Ligamentous injuries occur as a result of acute
macrotrauma and represent a macrotrauma process. The conclusion can be drawn that
a macrotrauma event is required to tear the ligaments that hold the TMJ disc in place and,
therefore, displace the disc from a normal physiologic position to an abnormal pathologic
position.
When the TMJ ligaments are injured and the disc displaces from normal position to abnormal
position, the system can become unstable. Swelling between the condyle and fossa can cause
occlusal imbalances.
As the degeneration of the TMJ continues, the normal pull of the elevator muscles may cause the
condyle to be displaced to a more position superior in the fossa than normal. As this condylar
displacement superiorly occurs, the teeth then move out of the way so that they are intruded into
the alveolar processes to some degree. Stepping of the occlusion behind the canine teeth usually

on the mandible, but sometimes on the maxilla, is a sequela of this intrusion. When this stepping
is significant, it is an indication of a TMD on the ipsilateral TM.

Influence of tooth loss with temporomandibular disorders

The association between teeth loss and temporomandibular disorders (TMD) is still inconclusive.
A kind of secondary changes of the occlusion after teeth lose called the tightly locked occlusion
(TLO), defined as the occluding contact that delivers angled occlusal force on the drifted
neighbour and/or the tipped antagonists of the lost posterior teeth, was hypothesized to be
association with TMD.
The tightly locked occlusion (TLO), is proved to be difficult to adapt for female in maintenance
of normal masticatory function. The incidence to get TMD for female with the TLO is 45
times high to those without TLO. This association was not found in male. That coincides well
with the fact in clinic that TMD occurring more in female.
The mechanisms of the pathological effect of the TLO on TMD might be that the angled occlusal
force guided by the TLO resulted in a significant difference of local biomechanical environment,
for example, the periodontal- muscle reflex activity, which hence lead to an abnormal joint load.
Functional loading has a great effect on TMJ (2224). The loading on TMJ comes frequently
from the contractions of elevators during occluding. Then occlusion, through the way of
adjusting the elevator contraction by periodontal reflex, modifies the loading on TMJ. The
potentials for remodelling the shape in TMJ responding to occlusal changes are high (25). The
reconstruction procedure. involves extra-cellular matrix synthesis and degradation, and would
result in big changes of joint morphology.

Human studies
Occlusal alteration and jaw movement
Okano N, et al 2002 study the inuence of altered occlusal guidance on condylar displacement
In a 20 healthy human subjects, metallic occlusal overlays were made for the lower canine,
canine to the second molar on the working side and second molar on the balancing side to

simulate a canine protected occlusion (CO), group function occlusion (GO) and bilateral
balanced occlusion (BO), respectively (122). Three-dimensional displacements of the bilateral
condyles were recorded during maximal clenching. Researchers noticed that the simulated CO
and BO caused a statistically signicant decrease in the superior displacements of the balancingside condyle as compared to the simulated GO, implying that TMJ loading of CO and BO may
be reduced
In 2010, Yashiro et al. (125) applied an occlusal interference to 10 healthy adults with good
occlusion. A golden onlay was xed to the upper rst molar contralateral to the side of preferred
chewing in each subject, covering the antagonistic lingual cusp of the lower rst molar by 2.5
mm at full intercuspation. Mandibular incisor-point movement for chewing gum was recorded
with a 3D tracking device before and after insertion of the balancing interference. An obvious
increase was observed in the normalised jerk-cost (NJC), prolonged duration of the decelerative
phase and lowered peak velocity of the jaw-closing movement during chewing induced by the
occlusal disturbance. However, the NJC and velocity prole recovered signicantly after about
90 repetitive chewing cycles. The research group inferred that signicant recovery contributes to
rapid adaptation of the skilfulness of chewing jaw movements to the occlusal interference,
although the adaptation is limited to the degree that impedes normal movement.

MUSCLES OF MASTICATION
The muscles of mastication consist principally of two groups: the elevator muscles and
depressor muscles.
In the stomatognathic system, masticatory muscles, such as the masseter, temporalis and lateral
pterygoid muscle, play a central role in the masticatory mechanism. Spatial orientation and
physiological cross section of masticatory muscle fibres are not the only determining factors for
adjusting masticatory strength; fibre composition is also crucial. In general, the fibres of skeletal
muscles can be classified into two categories: rapidly contracting, phasic, fast-twitch type II

fibres and slowly contracting, tonic, slow-twitch type I fibres.

The muscles responsible for elevating the mandible are the masseter, internal pterygoid, and
much of the temporal muscle. The posteriorly oriented fibers of the temporal muscle also retrude
the mandible. The superficial muscle bundle of the masseter muscle may also assist in protruding
the mandible while the deeper bundle serves to stabilize the condylar head against the articular
eminence. Juxtaposed with the masseter muscle, the medial pterygoid forms a muscular support
for the mandible at its angle. Although the primary function of elevation of the mandible, it is
also active during protrusion.78,131 The lateral pterygoid muscle is now known to function as
two distinct muscles, the inferior and superior lateral pterygoid muscles, with independent and
almost opposite functions.6,14 The inferior lateral pterygoid muscle depresses and protrudes the
mandible. The superior lateral pterygoid muscle does not contract during depression of the
mandible but rather contracts along with the elevator muscles, bracing the condyle
anteromedially.110,119,129,131,151 Motor and sensory innervation of the TMJs and the rest of
the masticatory system are provided by structures of the trigeminal nerve.
The innervation of both the capsular ligaments and the discal ligaments provide essential
proprioceptive input with regard to joint position. Efferent or motor neurons cause muscle
contraction in response to central cortical stimulation and in response to afferent stimuli in reflex
activity.40,131,177
Pain perception causes the nociceptive reflex to open the mouth rapidly through contraction of
depressor muscles and suppression of elevator muscles, consistent with other protective reflexes
within the musculoskeletal system.131 Protective reflexes may be suppressed in individuals
experiencing chronic occlusal parafunction (clenching or grinding of teeth).25,49 Pressure
perception is a function of the numerous mechanoreceptors within the PDL of teeth in contact.
Discrimination within the dentition based on specific teeth in contact, direction of force, and
intensity of force and their influence on muscle activity have been demonstrated in human study
populations and animal studies.22,37,99,109,154 Both research and clinical observations suggest
that elevator muscle contraction is suppressed when anterior teeth promote disclusion or
separation of posterior teeth during excursive mandibular movements.173 Patients with
significant bone loss, significant inflammatory disruption of the integrity of the PDL, or chronic
occlusal parafunction may experience compromised regulation of muscle activity.

Influence of occlusion on masticatory muscles

Animal studys
Yaffe A,1991 In rat experiments to study the effects of occlusal interference on
masticatory muscle activity , electromyography (EMG) has been employed to
record muscle potentials during mandibular movements

using inserted

bilateral bite-raising splints, reduced EMG activity was observed in the deep
masseter of some rats, while others showed increased activity in the anterior
temporalis and superficial masseter muscles during the late phase of
opening (67). After approximately 7 days, all of the rats exhibited decreased
EMG activity (67). This result indicates that splint treatment in rats is
effective at reducing EMG activity and that some animals may have the ability, through
certain biological mechanisms, to adapt to physical disturbance.
Bani D et al. 1999 study in rat model for Morphologic and biochemial changes of the masseter
muscles induced by occlusal wear for this the experimental rat model was set up by amputating
the cusps of the superior and inferior molars of the left side and excising the ipsilateral and
contralateral masseter muscles 26 days later. The occlusal dysfunction resulted in microvessel
constriction, morphological damage of muscular bres and capillary endothelium and elevation
of tissue calcium content in the ipsilateral masseter muscle (38). These changes are probably
related to muscle fatigue and ischaemia, and because tissue areas rich in type I muscle bres are
characterised by a predominantly aerobic metabolism, early signs of injury are readily exhibited.
The ipsilateral muscle damage became more extended and severe with time, while the contralateral muscles showed only slight alterations that were reversible with time, possibly due to
an adaptive response (38). These muscle changes were nearly abrogated by dantrolene, thus
supporting it as a possible new therapeutic tool for the treatment of malocclusion induced muscle
diseases. In the rat study of unilateral molar cusp amputation, occlu- sal alteration resulted in
severe damage to the extrafusal muscle and affected predominantly capsular cells, intrafusal

muscle bres and sensory nerve endings (77). These ndings indicate that occlusal alteration and
related muscle fatigue might be involved in the pathogenesis of human TMD.

Human study
Michelotti A,et al 2005 Effect of occlusal interference on habitual activity of human masseter
in this double-blind randomised cross- over experiment on 11 young, healthy females (126).
One-quarter millimetre golden strips were cemented either to an occlusal contact area (active
interference) of the lower rst molar of the preferred chewing side or to the vestibular surface of
the same tooth (dummy interference) for 8 days each. Electromyography recording of masseter
showed that active interference induced a signicant decrease in the number of activity periods
per hour and their mean amplitude. Dummy interference did not change EMG activity signicantly. None of the subjects developed signs and/ or symptoms of TMD throughout the entire
study, and most adapted to the occlusal disturbance. Pressure pain thresholds of the masseter and
anterior temporalis muscles were assessed using pressure algometry under the same conditions
(127). The results indicated that the application of active interference did not signicantly affect
the pressure pain thresholds of these muscles in healthy individuals.
Huang BY, Whittle T, Murray GM. A working-side change to lateral tooth guidance increases
lateral pterygoid muscle activity. Arch Oral Biol. 2006;51:689696. The inferior head of lateral
pterygoid (IHLP) is thought to play a critical role in the generation and control of lateral jaw
movements. The effect of a working-side occlusal alteration on the activity of the IHLP. A cast
metal overlay was cemented onto the upper right rst molar in 14 subjects to disclude all other
teeth during right laterotrusion, which did not interfere with intercuspal contact. Inferior head of
lateral pterygoid activity was signicantly increased with the occlusal alteration during the
outgoing and return phases of laterotrusion, while bilateral anterior and posterior temporalis,
masseter and submandibular muscles presented no change or a signicant decrease in activity,
which meant that a change to the occlusion on the working side in the form of a steeper guidance
necessitates an increase in IHLP activity to move the mandible down the steeper guidance
In 2008, Li et al. (121) attempted to seek the relationship between an occlusal high spot and orofacial pain symptoms. A 0.5-mm cast onlay was placed on the lower right rst molar of six

volunteers to act as an intercuspal occlusal interference for 6 days. The induced oro-facial
symptoms were collected, and the oro-facial pain was scored on a visual analogue scale (VAS)
by the subjects during the experiment. Mean- while, the surface EMG of the bilateral masseter
and anterior temporalis was recorded before and during the intervention and again after its
removal. The study demonstrated that the unilateral occlusal high spot did induce pain and
various symptoms in the oro-facial and temporomandibular area and lead to subjective
complaints of headache in the right temporal region (VAS 3.7). The EMG of the bilateral anterior temporalis became more unsymmetrical during clenching. The authors speculated that the
changes in muscular activity may have had some relationship with the onset of a tension-type
headache in the temporal region.

Occlusal interference and masticatory muscles

Physiological occlusion: Types, Contact patterns, bite forces

Physiological occlusion:

CONTACT RELATIONS
The contact relations of the teeth tend to vary with the degree of bruxism present in the child. A
number of factors appear to be related to the development of contact relations at the time of
eruption of the teeth, including the position of the tooth germ, presence of permanent teeth,
development of the condyles, cuspal inclines, and neuromuscular influences.
PRIMARY ARCH FORM
The arch form and width for both the primary and perma- nent dentitions has been largely
established by the age of 9 months.13
INTERDENTAL SPACING
The position of the deciduous teeth in the arches generally shows some degree of interdental
spacing, which tends to decrease slightly with age. The size of the primary teeth and the spacing
between them has a relationship to the position of the permanent teeth and the size of the dental
arches (e.g., sufficient interdental space is needed for the perma- nent teeth to erupt into an
uncrowded position). One of the indicators of future sufficiency or insufficiency of space in the
dental arches for the permanent teeth is the presence or absence of spacing between the teeth of
the primary denti- tion14,15 (i.e., spacing between the primary teeth [Figure 16- 4] is necessary
for the proper alignment of the permanent dentition).
The probability of crowding of the permanent dentition based on the amount of interdental
spacing of the primary teeth is given in Table 16-2.
PRIMARY MOLAR RELATIONSHIPS

DETAILS OF THE PRIMARY OCCLUSION

The normal occlusion of the primary teeth at the age of 3 years is as follows:
1. Mesial surfaces of maxillary and mandibular central incisors are in line with each other at the
median line.
2. The maxillary central incisor occludes with the mandibular central incisor and the mesial third
of the mandibular lateral incisor. The mandibular anterior teeth strike the maxillary anterior teeth
lingually above the level of the incisal ridges.
3. The maxillary lateral incisor occludes with the distal two thirds of the mandibular lateral
incisor and that portion of the mandibular canine which is mesial to the point of its cusp.
4. The maxillary canine occludes with that portion of the mandibular canine distal to its cusp tip
and the mesial third of the mandibular first molar (that portion mesial to the tip of the
mesiobuccal cusp).
5. The maxillary first molar occludes with the distal two thirds of the mandibular first molar and
the mesial portion of the mandibular second molar, which portion is represented by the mesial
marginal ridge and the mesial triangular fossa.
6. The maxillary second molar occludes with the remainder of the mandibular second molar, with
the distal surface of the maxillary molar projecting slightly over the distal portion of the
mandibular second molar.

primary /deciduoes dentition

PHYSIOLOGICAL OCCLUSION
The study of occlusion involves not only the static relationship of teeth but also their
functional interrelationships and all components of the masticatory system. Every
restoration, whether a simple amalgam fi lling or complex crown and bridgework,
that involves the occlusal surface will affect the occlusion.[1] Therefore restorations
should be planned so that they do not cause effects that exceed the adaptive
tolerance. Based primarily on laterotrusive movements from centric occlusion
several functional occlusal types are recognized or advocated -- balanced occlusion,
group function, canine protected occlusion, mixed canine-protected occlusion and
group function, fl at plane, and multivareied occlusion.
BALANCED OCCLUSION:

CANINE PROTECTED OCCLUSION: canine-protected function is that on laterotrusive

movements of mandible only the canine contacts and therefore protects remaining
dentition from adverse occlusal torsional forces to and from centric relation and
centric occlusion[2] or as defi ned in GPT-8 the canine-protected occlusion is a form
of mutually protected occlusion in which vertical and horizontal overlap of canines
disengages posterior teeth in excursive movement of mandible. In canine-protected
occlusion is attributed that canines are the most appropriate teeth to guide
mandibular excursion. There are a number of reasons.[3 ]

The canines have a good crown root ratio capable of tolerating high occlusal

forces.
Canines provide high proprioception.
The shape of the palatal surface of canine is concave and is suitable for
guiding lateral movements.

Posterior teeth are better suited to accept vertical versus lateral forces. Lateral
forces placed on posterior teeth can result in a fracture or excessive wear. Lateral
forces should be directed toward the anterior teeth especially canines due to the
root

length

and

position

of

these

teeth

being

at

distance

from

the

temporomandibular joint. Canine-protected occlusion reduces the chances of

temporomandibular dysfunction, since it reduces the lateral tooth contact and
possibility of interfering contacts. Consequently the chance of muscular dysfunction
is reduced.

Various mandibular movement and occlusal contacts during these movements

The tmj and associated musculature permit mandible to move in all three plans i.e. sagittal ,
horizontal and frontal. Any movement of mandible from ICP that result tooth contact is called
eccentric movement.
Three basic eccentric movement are:
1) Protrusive movement
2) Leterotrusive
3) Retrusive
Protrusive mandibular movement : This movement occur when mandible moves forward from
ICP. Any area of tooth that contact opposing tooth during protrusive movement is considered to
be protrusive contact.in normal occlusion relationship the predominant protrusive contact occur
in anterior teeth, between incisal and labial edge of mandibular incisors and against lingual fossa
area and incisal edge of maxillary incisor. on posterior teeth protrusive movement causes
mandibular centric cusps to pass anteriorly acroos occlusal surfaces of maxillary teeth. Posterior
protrusive contact occur between distal inclines of maxillary lingual cusps and mesial induces of
opposing fossae and marginal ridges. Posterior protrusive contact can also occur between mesial
incline of mandibular buccal cusp and distal inclines of opposing fossae and marginal ridge.

2) Leterotrusive mandibular movement

During lateral mandibular movement; right and left mandibular posterior teeth move across their
opposing teeth in different directions. If for example, mandible moves laterally to left, left
mandibular posterior teeth will move laterally across their opposing teeth. However, right
mandibular posteriors will move medially across their opposing teeth. Posterior teeth on left side
during left lateral movement reveals that contacts can occur on 2 incline areas. One contact
between inner inclines of maxillary buccal cusps and outer inclines of mandibular buccal cusps.
Other contact is between outer inclines of maxillary lingual cusps & inner inclines of mandibular
linqual cups. Both these contacts are called LATEROTRUSIVE. The term lingual to lingual
laterotrusive & buccal to buccal laterotrusive issued to differentiate those occuring between
opposing lingual cusp from those occurring between buccal cusps.
Picture
3) Retrusive Mandibular Movement.:- Occurs when mandible moves posteriorly from
1CP.These movements are restricted by ligamentous structures. During retrusive
movement mandibular buccal cusps move distally across occlusal surface of their
opposing maxillary teeth. Areas of potential contact occurs between distal inclines of
mandibular buccal cusps & mesial inclines of opposing fossae & marginal ridges. In
maxillary arch retrusive contacts occurs between mesial inclines of opposing CF's &
marginal ridges.

Bite forces
Bite force is one indicator of the functional state of the masticatory system that results from the
action of jaw elevator muscles modified by the craniomandibular biomechanics.1
The bite force measurements can be made di- rectly by using a suitable transducer that has been
placed between a pair of teeth. This direct method of force assessment appears to be a convenient
way of assessing the submaximal force. An al- ternative method is indirect evaluation of the bite
force by employing the other physiologic variables known to be functionally related to the force
pro- duction.4 Several factors influence the direct measure- ments of the bite force. Thus,
different investiga- tors have found a wide range of maximum bite force values. The great
variation in bite force values depends on many factors related to the anatomical and physiologic
characteristics of the subjects. Apart from these factors, accuracy and precision of the bite force
levels are affected by the mechanical characteristics of the bite force recording system.6

PHYSIOLOGIC AND MORPHOLOGIC VARIABLES

AFFECTING BITE FORCE VALUES
Cranio-facial morphology
Maximum bite force varies with skeletal measures of the cranio-facial morphology that include
the ratio between anterior and posterior facial height, mandibular inclination and gonial angle. It
has been explained that bite force reflects the geometry of lever system of mandible. When the
ramus is more vertical and the gonial angle acute, elevator muscles exhibit greater mechanical
advantage.1,7-10 Pereira et al11 have found a negative correlation between bite force and
mandibular inclination. Braun S, et al 1995have stated that the long-faced type of the craniofacial mor- phology has been associated with smaller values of the bite force.8,10 In this respect,
Farella et al12 have stated that masseter muscles are thicker in short- faced subjects than in
normal or long-faced sub- jects. From the results of these studies, it seems that short-faced
people may exhibit stronger bite force.

Age
The normal aging process may cause the loss of muscle force.13 Indeed, the jaw closing force
in- creases with age and growth, stays fairly constant from about 20 years to 40 or 50 years of
age, and then declines.1 In children with permanent denti- tion between the ages of 6 and 18, bite
force has been significantly correlated with age.14 Bakke et al15 have reported that bite force decreases with age after 25 years in females and af- ter 45 years in males. Bite force decreases
signifi- cantly with age, especially in women.13
Gender
Maximum bite force is higher in males than females. The greater muscular potential of the males
may be attributed to the anatomic differ- ences.13,17-19 The masseter muscles of males have
type 2 fibers with larger diameter and greater sectional area than those of the females.1,20 The
authors have suggested that hormonal differenc- es in males and females might contribute to the
composition of the muscle fibers.20 In addition, the correlation of maximum bite force and
gender is not evident up to age 18. It is apparent that maxi- mum bite force increases throughout
growth and development without gender specificity. During the post-pubertal period, maximum
bite force in- creases at a greater rate in males than in females and thus becomes genderrelated.21 Ferrario et al22 have recorded larger bite force values in males and explained this
result by their larger dental size. Because the larger dental size presents larger periodontal
ligament areas, it can give a greater bite force.
Periodontal support of teeth
The loading forces during mastication induced by the masticatory muscles are controlled by the
mechanoreceptors of the periodontal ligament.24 Therefore, reduced periodontal support may
de- crease the threshold level of the mechanorecep- tors function.25 This condition may cause
changes in the biting.26 Williams et al27 have stated that people with loss of attachment have
shown im- paired sensory function resulting in reduced con- trol of biting force. Alkan et al26
have reported that the biting abili- ties of the subjects with healthy periodontium were
significantly higher than those of people with chronic periodontitis..25 At the same time, Morita
et al28 have demonstrated an interaction of biting ability and periodontal status; however, they

have found little effect of periodon- tal conditions on biting ability. Contrary to these findings,
Kleinfelden and Ludwig24 have stated that the reduced periodontal tissue support did not limit
bite force with maximal strength in natural dentition. In addition, they stated that the diminished number of periodontal neural receptors may be enough for proper feedback mechanism
limit- ing bite force and chewing forces. The discrepancy between these studies could be
attributed to the differences of recording devices and measure- ment areas.
Temporomandibular disorders and pain
Temporomandibular disorders (TMDs) refer to the signs and symptoms associated with pain and
functional-structural disturbances of masti- catory system, especially of temporomandibular and
masticatory muscles, or both.11,30,31 The TMDs are often defined on the basis of signs and
symptoms, the most common of which are temporomandibular joint and muscle pain, limited
mouth opening, clicking, and crepitation.20 Therefore, many clinicians have focused on bite
force to determine whether or not there is an influence of bite force among TMDs
patients.11,14,32 Many authors have found significantly lower bite force for the TMDs patients
than the healthy control subjects. They have considered that pres- ence of masticatory muscle
pain and/or temporo- mandibular joint (TMJ) inflammation could play a role in limitation of
maximum bite force.11,30 Koga- wa et al30 have stated that the most frequent cause for the
limiting bite force was TMJ pain. In accor- dance with these studies, Pizolata et al20 have found
a positive correlation between decreased bite force and muscle tenderness, and TMJ pain.
An important etiological factor causing or contributing to TMDs is bruxism, characterized by
clenching and/or grinding the teeth.33,34 Gibbs et al35 have compared the bite strength in some
bruxists using a gnathodynomometer 12 mm of height in the molar region. They have reported
that bite strength in some bruxists was as much as six times that of non-bruxists.
Dental status
Dental status formed with dental fillings, dentures, position and the number of teeth is an
important factor in the value of the bite force.36 There is a positive correlation between the position and the number of the teeth at both maximal and submaximal bite force.37 The number of
teeth and contact appears to be an important parame- ter affecting the maximum bite force. The
greater bite force in the posterior dental arch may also be dependent on the increased occlusal

contact number of posterior teeth loaded during the bit- ing action. For example, when maximum
bite force level increased from 30% to 100%, occlusal con- tact areas double.38 Bakke et al15
have suggested that the number of occlusal contacts is a stronger determinant of muscle action
and bite force than the number of teeth. Kampe et al39 have analyzed measurements of occlusal
bite force in subjects with and without dental fillings at molar and incisor teeth. The sub- jects
with dental fillings have shown significantly lower bite force in the incisor region. Based on data
obtained in that study, they have proposed that it might be hypothetically due to the adaptive
changes caused by the dental fillings.
Miyaura et al40 have compared maximum bite force values in subjects with complete denture,
fixed partial denture, removable partial denture and full natural dentition groups. Whereas the
individuals with natural dentition have shown the highest bite forces, the biting forces have been
found to be 80, 35, and 11% for fixed partial den- tures, removable partial denture and complete
denture groups, respectively, when expressed as a percentage of the natural dentition group.
THE EFFECT OF THE RECORDING DEVICES AND TECHNIQUES ON BITE FORCE
Recording devices
The concern on the intraoral force has a long history.42 In the related research, a wide range of
methods and devices for the determination of bite forces has been reported. These devices vary
from simple springs to complex electronic devices
1. Gnatodynamometer: The first experimental study defining the intra- oral forces was
performed by Borelli in 1681 who designed a gnatodynamometer.42 He attached different weights to a cord, which passed over the molar teeth of the open mandible, and
with clos- ing of the jaw, up to 200 kg were raised.35
2. strain-gages mounted dynamometer: This appliance uses electronic technol- ogy and
consists of the bite fork and digital body. Its high precision load cell and electronic circuit
for indicating force provide precise measure- ments.20,4
3. piezoelectric film: piezoelectric film generates an electrical signal, which varies with the
force applied to the film. Due to generated electrical signal is a very small electrical
current, an amplifier is designed to amplify the piezoelec- trical signal.46
4. novel min- iature bite force recorder : Its introduced by Floystrand et al47 in 1982. It a
semiconductor in the shape of a silicon beam that served as a sen- sory unit. Loads on the
sensor produce a propor- tional alteration in the two resistors and leads to electric

changes in the circuit. Its calibration test has shown that bite forces in 10 to 1000 N range
good reliability. It had a diameter of 12 mm and the thick- ness of 0.25 mm and consisted
of two conducting interdigitated electrodes on a thermoplastic sheet which faced a second
sheet coated with a semi- conductive polyetherimide ink
5. strain-gage bite force transducer: The strain-gage bite force transducer is available in
different heights and widths. Ferrario et al22 and Kogawa et al30 have measured bite
force with 4 mm height and 5x7 mm wide strain-gaged transducer. Calibration of the
instrument was performed at room temperature between 0 and 350 N, with a 2% error.
A large variability of bite force has been found to be ranked between 446 N and 1221 N.
6. dental prescale system : which consists of a horse-shoe shaped bite foil of a pressuresensitive film and a com- puterized scanning system for analysis of the load. When the
force is applied to occlusal contact, a graded colour is produced by the chemical reaction. The exposed pressure-sensitive foils (PSF) are analyzed in the occlusal scanner. The
scan- ner reads the area and colour intensity of the red dots to assess occlusal contact area
and pressure.
Position of recording device in dental arch
Bite force varies in different regions of the oral cavity.22 The more posteriorly the transducer is
placed in the dental arch, the greater the bite force.63 It has been explained by the mechanical
lever system of the jaw.4,21 In addition, greater bite force can be tolerated better in posterior
teeth, because of the larger area and periodontal liga- ment around posterior teeth roots.63
different positions of the transducer in dental arch may influence the different
muscles that are involved in force production. If the trans- ducer is placed anteriorly between the
incisor teeth, with a resultant mandibular protrusion, the masseter muscle will produce most of
the force together with the medial pterygoid muscle. If the bite force transducer is more
posteriorly placed, then anterior fibres of the temporalis muscle will become more active and
hence make a greater contribution to the effort.63
Unilateral and bilateral measurements
Another factor influencing the value of the bite force is the recording side involved: unilateral or
bilateral application. Shinogaya et al16 have compared bilateral and unilateral bite force
measurements using different transducers. They have employed a pressure-sensitive foil (0.1 mm
thick) for bilateral clenching and a conventional force transducer (6-7 mm thick) for unilateral

clenching. They have concluded that bite force in- creased by about 100% and masseter activity
in- creased by about 50% during bilateral clenching compared to unilateral clenching.

Opening wide of mouth

An increase in the vertical dimension may lead to some changes in the orofacial
structures (i.e., jaw elevator muscles, temporomandibular joints and periodontium). It is
stated that such changes in vertical dimension alter the length of the main jaw elevator
muscles and the position of the mandibular head in the fossa temporalis. Thus, they may
affect the masticatory function, resulting in the bite force values.
Lindauer et al66 evaluated the changes in verti- cal jaw opening affecting the relative
contributions of masticatory muscles for bite force production. When bite force was
consistent, electromyograph- ic activity increased per unit of force production was
relatively high at the smaller degrees of jaw opening, EMG activity has decreased
between 9 and 11 mm of opening, and increased again by 12 mm of opening.

COLLAPSE OF THE OCCLUSION

Pathological changes of the occlusion may occur when posterior tooth support is
reduced or lost . In these case ,the mandible requires a new support which is
usually found in the anterior region of the mouth. Consequently ,an excessive
occlusal load affects the anterior teeth. When posterior tooth support is reduced
or lost pathological changes of the occlusion may occur ,this event is known as
occlusal collapse. The shortened dental arch (SDA) concept, first discussed

internationally by Kyser in 1981, concluded that shortened dental arches

comprising anterior and premolar teeth in general fulfill the requirements of a
functional dentition. Kayser concluded that there was sufficient adaptive
capacity in subjects with SDA when at least four occlusal units are left (one unit
corresponds to a pair of occluding premolars; a pair of occluding molars
corresponds to two units).[2,21]
This concept suggests that the minimum number of occluding pairs of teeth
required to provide satisfactory levels of oral function may vary according to age
and other factors:[9]
Age

Functional level

Occluding pairs

20 50

I optimal

12

40 80

II sub-optimal

10 (SDA)

70 100

III minimal

8 (ESDA)

Kayser and Witter suggested that the anterior and premolar teeth

are the strategic part of the dental arch and are essential for satisfactory oral
function and oral comfort.
Kayser estimated the minimum number of teeth needed to satisfy functional
demands of modern man: biting 12 anteriors + 4 premolars
mastication 8 premolars + 4 molars speech 12 anteriors
esthetics 12 anteriors + 4 premolars in the maxilla mandibular
stability 12 anteriors + 8 premolars + (4 molars in some cases)
when posterior tooth support is reduced or lost pathological changes of the
occlusion may occur ,this event is known as occlusal collapse. It influences the
teeth, the periodontium, intermaxillary relations, the neuromuscular pattern and
the temporomandibular joint (Amsterdam, 1973; Ramfjord and Ash, 1971;
Beaudreau, 1965; Corn and Mrks, 1969).
Due to reduced support, shortened dental arch may be susceptible to occlusal
instability (Kayser 1981)

Schematic representation of the complete and of shortened dental arch

group.the arches consist
Of an intact anterior region and a variation of dental arch length,shown in
shaded teeth and expressed in occlusal units(OU) .i.e. pairs of occluding
premolars.one molar unit is considered to be equivalent to 2 OUs.
Assessment of Occlusal Stability:
'occlusal stability' is defined as the stability of the position of teeth in their
spatial relationship in the occluding dental arches. Based on this definition, the
following 5 parameters were used as indicators for occlusal stability:
1) Interdental spacing: Assessed with metal gauges of 0.1-, 0.5-, and
1.0-mm thickness. Interdental contact was judged to be present when
the 0.1-mm gauge was blocked. used the following scores: 0 = spacing
< 0.1 mm (= interdental contact); 1 = 0.1 < spacing < 0.5 mm; 2 =
0.5 ' spacing < 1.0 mm; 3 = spacing > 1.0 mm. Spacing was measured
between the teeth on the right side of the dentition, starting from the
middle. Mean scores were computed for the upper and lower premolar
regions (starting from the distal side of the canines) and for the upper
and lower anterior regions. Regions were excluded when two or three
interdental sites could not be assessed (bridge or splinted crowns;
Witter et al., 1994a)

2) Occlusal contact: assessed with Artus R occlusal registration strips

(13-jam thickness; Artus, Englewood, NJ, USA; Halperin et al., 1982). In
Intercuspal Position, the presence or absence of contact was recorded
for each maxillary tooth.
3) Vertical and horizontal overbite: measured in millimeters at the right
central incisors, by means of a compass and a ruler.
4) Occlusal tooth wear: assessed for all teeth on the right side of the
dentition. We used the following scores: 0 = no wear facets visible; 1 =
facets in enamel (or in artificial crowns facets < 1 mm); 2 = facets in
dentin (or in artificial crowns, 1 mm < facets < 2 mm); 3 = wear in
secondary dentin (or in artificial crowns facets > 2 mm). Mean scores
were calculated for the combined upper and lower premolar regions
and for the upper and lower anterior regions each.
5) Periodontal support: determined by assessment of the alveolar bone
height at the distal side ofeach premolar, as measured on intra-oral
radiographs (Kodak, 1-1/4 x 1-5/8 in) made by means ofthe bisectingangle technique. Scores were used that expressed the alveolar bone
height (distance between alveolar crest and apex ofthe tooth) as a
fraction of the radiographic tooth length (Eliasson et al., 1986). The
alveolar crest was interpreted as the coronal level where the
periodontal line retained its normal width. The measurements were
made on an x-ray viewer without magnification, with a compass, and
were read to the nearest millimeter on a ruler

AEITOLOGY OF COLLAPSE OCCLUSION

(1) Loss of arch integrity :
Arch integrity is one of the features ofa healthy occlusion. Through the interproximal
contacts the occlusal forces are distributed to all the teeth in the arch. The inter- proximal
contacts also contribute to the mesiodistal stabilization of the teeth. Once the arch
integrity is disturbed, tooth stability is no longer secure. This is due to : early loss of
tooth, congenital spacing between the teeth ,dental caries and faulty restoration.

(2)Tooth attrition
Severe tooth attrition can cause loss of posterior support of the
occlusion and result in the loss of the vertical dimension (Fig. 6). In
very advanced cases of tooth attrition the interproximal contacts will
also be affected which leads to loss of arch integrity.
(3) Malocclusion: In some cases of malocclusion, occlusal contacts may
be missing between groups of teeth. In this case ,the posterior teeth
contact only axially which lead to loss of vertical dimension and supraeruption of teeth in both arches.

Influence of collapse occlusion on:1) Teeth : As a result of a missing tooth and the loss of arch integrity,
migration of the remaining teeth occur.
A typical sequence of events that will follow as a result of loss of a
lower first molar will be
(a) The second premolar will migrate distally.
(b) The second molar will incline mesially.
(c) Following the migration towards the edentulous space of the
neighbouring lower teeth, similar movement will occur in other
segments of the arch.
(d) The tooth opposing the space will over-erupt.
(e) In the upper arch, lack of contact will occur between the teeth
adjacent to the over-erupted upper molar.
(f) Splaying of the anterior teeth (see interarch relations).

Collapse of occlusion( left side)

2) Periodontium :
(a) The opening of interproximal spaces with consequent food
impaction and food retention will predispose to gingivitis and
periodontitis with pocket formation.
(b) The mesial and distal drifting of the teeth creates a favourable
situation for the development of infra-bony pockets
(c) Extrusion of upper molars will lead, together with the
periodontitis, to loss of the buccal plate (which may already be thin)
(d) In cases of malocclusion. Class II Division 1, the palatal tissue
will be traumatized by the lower incisors.

Development of an infra-bony
pocket owing to mesial drift of the second lower molar.

3) Neuromuscular and Intermaxillary relation : As a result of loss of

posterior support and the possible development of a pathological
neuromuscular pattern (Michman, 1974), a forward drift of the
mandible will take place which increase load on upper incisors. As a
result of the forward movement of the mandible, a secondary

tongue thrusting may occur which will lead to a splaying of the

lower incisors and attrition of upper and lower incisors.
4) Temperomandibular joint:- loss of occlusal vertical dimension
occurs.