Customized anterior guidance for

occlusal devices: Classification and

rationale
Roger A. Solow, DDS
The Pankey Institute, Key Biscayne, Fla
Occlusal devices can protect the dentition from attrition and are commonly prescribed for the treatment of myogen-
ous orofacial pain. The occlusal scheme of the device controls the forces on teeth during mandibular closure and ex-
cursions. Smooth anterior guidance from anterior teeth contact and posterior teeth disclusion has been described as
a component of a therapeutic occlusion. Clinical research on the effects of occlusal devices is extensive, but documen-
tation about the actual occlusion studied is lacking. A classification of anterior guidance design for occlusal devices
and the rationale for optimum force distribution is presented. This classification can guide clinicians as to the criteria
for proper occlusal device fabrication and improve dental research. (J Prosthet Dent 2013;110:259-263)

Occlusal devices (ODs) protect the
dentition from attrition due to bruxism
and are commonly prescribed to treat
myogenous orofacial pain.1,2 One cause
of myogenous pain is masticatory
muscle hyperactivity related to occlusal
interferences.3-5 Protrusive muscles are
required to be constantly active when
the mandible avoids an arc of closure
interference. The mandibular condyle
is displaced from its stable bone sup-
port in the glenoid fossa to an unstable
muscle-supported contact on the slope
of the articular eminence.6 Lateral ex-
cursion interferences on posterior teeth
cause periodontal mechanoreceptors
to initiate a neuromuscular response
via direct, afferent impulses into the tri-
geminal ganglion.7,8 Efferent impulses
to the masticatory elevator muscles can
cause prolonged contraction with al-
tered muscle coordination and pain.9-12
The occlusal scheme of the OD controls
the magnitude and direction of force
on the teeth during mandibular closure
and excursions. A therapeutic occlusion
from the OD removes adverse forces by
redistributing contacts with the oppos-
ing dentition. An optimal occlusion
should be provided with the placement
of each OD to discern the effect of oc-
clusal correction on the patients prob-
lem. An OD that does not fulfill the
criteria for a therapeutic occlusion cre-
ates a different malocclusion without
removing the adverse forces that affect
muscle function. The purpose of this
article is to present a clinically relevant
classification of occlusion for ODs.
Clinical criteria for optimum
occlusion on ODs
ODs should have the same occlusal
design for optimal force distribution
as other treatment approaches such
as equilibration, restoration, and or-
thodontics.13-15 Three criteria should
be fulfilled for ODs in all clinical situ-
ations. (1) All teeth should contact
evenly on the OD in the arc of closure
when the mandibular condyles are
physiologically seated in their respec-
tive fossae. (2) Anterior teeth should
not contact more heavily than the pos-
terior teeth. (3) Anterior teeth should
smoothly separate the posterior teeth
during all excursions.
The OD must have a complete
arch design for all the teeth to con-
tact. This prevents the overeruption of
unopposed teeth from the segmental
arch coverage and minimizes the pres-
sure on each contacting tooth. That
pressure is dictated by the equation:
Pressure = Force/Area. Multiple, even,
bilateral posterior teeth contacts are
comfortable for the patient as the
force of closure is distributed through
the maximum number of teeth. An arc
of closure interference, which con-
centrates all force on a single tooth,
is not comfortable for the patient and
stimulates a protective neuromuscular
response.16-18 Even contact of all teeth
in the arc of closure creates mandibu-
lar stability, with the elevator muscles
functioning normally without activa-
tion of the protrusive muscles. These
muscle groups should function re-
ciprocally in a coordinated fashion.19
Even contact shows as dot markings of
all opposing cusp tips against the OD.
Mutually protected articulation
has been defined as posterior teeth
supporting the mandible vertically on
closure and anterior teeth separating
the posterior teeth during excursions.
Anterior teeth are smaller, more sensi-
tive, and more inclined than posterior
teeth.20,21 Patients are not comfortable
if the anterior teeth are traumatized by
excessive contact against the OD.
The separation of the posterior
teeth by the anterior teeth during man-
dibular excursion decreases elevator
muscle hyperactivity.22-25 Artificial ex-
cursive interferences on posterior teeth
decrease muscle coordination and
maximum closure force.26-28 Myofas-
cial pain dysfunction has been attrib-
uted to occlusal trauma on posterior
teeth because of the lack of immediate
anterior tooth guidance.29-32 ODs can
normalize muscle activity and decrease

Visiting Faculty, The Pankey Institue, Key Biscayne, Fla; Private practice, Mill Valley, Calif.
Solow
260 Volume 110 Issue 4

1 Maxillary OD Class I anterior guidance. Black dots are
arc of closure contacts, yellow lines are excursion con-
tacts. Only central incisors contact in protrusion and only
canines contact in lateral excursion.
2 Maxillary OD Class II anterior guidance. Black dots are
arc of closure contacts, yellow lines are excursion contacts.
Only central incisors contact in protrusion. In lateral excur-
sion, initially canines contact, then central incisors. Force is
sequentially distributed between these 2 teeth.

pain by providing a corrected occlu-
sion.33-35 Smooth anterior guidance
shows as a continuous line of the op-
posing incisal edge of a central incisor
or canine against the OD.
Electromyographic studies of splint
design document decreased anterior
temporalis and masseter muscle activity
when clenching on a canine ramp during
laterotrusion compared to group func-
tion or centric occlusion contact.22,25,36
The rationale for canine guidance with
posterior teeth disclusion in OD design
is based on this reduction of elevator
muscle activity, the favorable load distri-
bution of the long canine roots, and the
decreased force on the canine because
of its distance from the TMJ fulcrum in
a Class 3 lever system.
The development of a precise oc-
clusion requires that the OD have a
hard surface and be stable, with no
mobility. A predictable technique for
achieving this is to repetitively rotate
the OD down on one side and reseat it
during an intraoral or diagnostic cast
reline with acrylic resin. This will form
a stable OD that seats with a click and
is resistant to vertical displacement.
Customized anterior guidance for ODs
Not all patients have a full com-
plement of teeth, proper orthodontic
alignment, or ideal periodontal sup-
The Journal of Prosthetic Dentistry
port. Therefore, a single design for
anterior guidance contacts on the OD
is not appropriate for all patients,
and the anterior guidance on the OD
should be customized to optimize
force distribution by contacting the
teeth with the best root length and
periodontal support. Since all pa-
tients should have multiple, even, bi-
lateral posterior teeth contacts on the
OD, the variation in occlusal design
is a result of anterior teeth contact
during lateral, lateral-protrusive, and
protrusive excursions.
Clinical anterior guidance for
ODs can be classified into 4 designs.
Class I where lateral excursion con-
tact is solely on the canines and pro-
trusive excursion contact is solely on
the central incisors (Fig. 1). Class
II where lateral excursion contact is
first on the canines and then on the
central incisors. Protrusive excur-
sion contact is solely on the central
incisors or first on the canines and
then on the central incisors (Fig. 2).
Class III where all excursion contact is
solely on the canines (Fig. 3). Class IV
where there is unacceptable occlusal
design with missing posterior teeth
contacts or posterior teeth contact
in excursions that can prevent proper
anterior teeth contact (Figs. 4, 8).
These designs apply equally to max-
illary and mandibular ODs. The di-
rection of the excursion contact line
from the arc of closure contact to
the end of the border movement is
opposite for each arch. Lateral inci-
sor contact is only in the arc of clo-
sure because of their small roots.
Advantages of customized anterior
guidance on ODs
Class I anterior guidance uses large
root central incisors and canines that
are capable of individually distributing
the forces of excursive contact when
periodontal support is normal. The cli-
nician can choose which portion of the
opposing incisal edge against which to
form a straight-line contact with the
OD in excursion (Fig. 5). For patient
comfort, both central incisors should
bear equal force in protrusive excursion.
Class II anterior guidance shares
the force of lateral excursion contact
between the canine and central inci-
sor when periodontal support of either
is compromised or if the patient no-
tices a sore tooth from severe bruxism.
Since the excursion length is divided
into 2 shorter segments, the horizon-
tal bulk of the OD can be reduced
in these sites. The inclination of the
canine excursion of the OD must be
fairly flat to allow the opposing central
incisor to contact the OD. This tran-
sition from canine to central incisor
Solow
October 2013 261

3 Maxillary OD Class III anterior guidance. Black dots
are arc of closure contacts, yellow lines are excursion
contacts. Only canines contact in lateral and protrusive
excursions. Incisors are limited to arc of closure contact.
4 Maxillary OD Class IV anterior guidance. Black dots
are arc of closure contacts, yellow lines are excursion con-
tacts. Proper occlusion is lacking. Arc of closure contact
is uneven with missing teeth contacts. Lateral excursion
interferences on posterior teeth prevent anterior guidance
by anterior teeth.

5 Maxillary OD with Class I anterior guidance. Note 6 Mandibular OD with Class II anterior guidance. Left
multiple posterior contacts in arc of closure without any canines have moved beyond edge-to-edge relationship.
excursive contact. Central incisors and canines provide all Maxillary left central incisor contacts protrusive track in
anterior guidance contact with only arc of closure contact crossover position.
from lateral incisors.

contact is designed to occur after the
canines are at an edge-to-edge relation-
ship. This crossover contact minimizes
the vertical bulk of the OD in the ante-
rior segment. Lateral and lateral-pro-
trusive guidance occur with the central
incisor contacting the protrusive tract
or the acrylic resin adjacent to that
line (Fig. 6). A mandibular OD for pa-
tients with Angle Class 2, Division 1
can use this sequential contact of the
canines and then central incisors in all
excursions to minimize bulk against
the lower lip.
Class III anterior guidance places
Solow
all force in all excursions on the canine
and has been termed the Michigan
splint (Fig. 7).37 Orthodontic prob-
lems such as anterior open occlusal
relationships can benefit from this
design if space is provided to allow
displaced incisor teeth to erupt to a
more normal relationship. Periodon-
tally compromised incisors oppos-
ing the OD are protected by stronger
canines conducting the excursions.
These incisors should touch in the arc
of closure or at the end of the protru-
sive excursion to prevent extrusion.
Verifying occlusal contacts on the
OD
Clinicians usually use the same pa-
per, silk, or plastic inked ribbon used
to determine contacts in restorative
procedures to adjust the occlusion of
ODs. Research has shown that these
media are inaccurate as the intensity
and size of marking do not correlate
with the actual occlusal contacts.38-42
These media do not show when the
contact is made, only that ink was left
on the OD. Eight-m thick shimstock
(Hanel Foil; Almore Intl, Portland,
262
7 Maxillary OD with Class III guidance also termed
Michigan splint. All excursive contact is solely on ca-
nines. This design protects periodontally compromised
opposing incisors.
Ore) also showed limited accuracy.43
Due to the elasticity of the periodon-
tal ligament, teeth have an inherent
mobility of approximately 100 m,
which can be greater when the tooth
is in traumatic occlusion.44 A mobile
tooth can be a distinct occlusal inter-
ference, but when depressed into its
socket on contact, adjacent teeth can
leave a mark, thereby obscuring the
actual interference.
Computerized occlusal analysis
(Tscan 3; Tekscan, Boston, Mass)
is an objective and accurate means
of discerning the location, inten-
sity, and timing of occlusal con-
tacts.45-47 The 100-m sensor wafer
rests flat against the OD and records
the contacts of the opposing cusp
tips. Digital display documents the
relative force of the occlusal con-
tact in a motion picture-like format.
DISCUSSION
ODs alter the patients existing
occlusion and can be used to pro-
tect against progressive attrition and
preview occlusal correction with or-
thodontics, equilibration, or compre-
hensive restoration. An OD must be
stable, comfortable, and have a prop-
er occlusion so that the patient can use
it consistently to assess the effects of
occlusal change. In this authors expe-
rience it is rare for a patient to pres-
The Journal of Prosthetic Dentistry
8 Maxillary OD with Class IV guidance. Unacceptable
occlusion with lack of even bilateral posterior tooth
contacts. Nonworking interference on right second molar
prevents proper left canine guidance line marks.
ent with an OD that fulfills the criteria
for an acceptable prosthesis. Patients
cannot be expected to use an OD that
rocks, exerts painful pressure on teeth,
or introduces a malocclusion. The fab-
rication of an OD for their own mouth
can teach clinicians the value of a pre-
cise, corrected occlusion.
The lack of smooth anterior guid-
ance can be indicative of posterior
teeth excursive contacts, rough acrylic
resin anterior contacts, or rapid tem-
poromandibular joint disk displace-
ment. Protrusive guidance typically
discludes the posterior teeth rapidly
as both condyles traverse down the ar-
ticular eminence. During lateral excur-
sion, the working-side condyle rotates
and does not function to disclude the
posterior teeth; only the non-working
side condyle traverses down the ar-
ticular eminence. Working-side excur-
sions must be carefully adjusted to
avoid posterior teeth contacts during
strong bruxing pressure. The excur-
sive paths can be flat to minimize the
bulk of the OD, as long as the poste-
rior teeth are immediately discluded.
Extensive literature exists on ODs for
the treatment of temporomandibular
disorders and bruxism. Most research
defines the general type of OD used
without verifying the actual occlusion
studied. The classification system
presented can educate clinicians as to
the criteria for creating proper occlu-
Volume 110 Issue 4
sion on ODs and allow researchers to
better communicate the design of the
OD studied and verify that an optimal
occlusion is the treatment variable.
SUMMARY
Occlusal devices are commonly
used to treat temporomandibular
disorders and progressive attrition.
ODs must fulfill the criteria for proper
occlusion to assess the effect of oc-
clusal correction and to preview de-
finitive treatment with orthodontics,
equilibration, or comprehensive res-
toration. A classification of anterior
guidance variations that illustrates
optimal OD design is presented.
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Corresponding author:
Dr Roger A. Solow
655 Redwood Highway, #251
Mill Valley, CA 94941
Fax: 415-388-3479
E-mail: rasolowdds@aol.com
Copyright 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.