FULL MOUTH OCCLUSAL

REHABILITATION
- U si ng Fix ed P a r ti al D en tu re

LIBRARY DISSERTATION

Dr .I. MAHILAN JEYAVALAN

PG STUDENT
2006-2009

DEPARTMENT OF PROSTHODONTICS
TAMILNADU GOVERMMENT DENTAL
COLLEGE AND HOSPITAL,
CHENNAI

1
 CERTIF ICATE

This is to certify that the Library Dissertation titled

“FULL MOUTH OCCLUSAL REHABILITATION-
USING FIXED PARTIAL DENTURE”
is a bonafide record of work carried out by
Dr. I.MAHILAN JEYAVALAN,
During the period
2006-2009

GUIDE:

Dr. C. THULASINGAM, M.D.S.,

Professor and Head of the Department

Dept. of Prosthodontics,

Tamil Nadu Govt Dental College and Hospital,

Chennai-3

2
 CO NTE NT S
1. Introduction ……………………………………………………..
4
2. Evolution Of Occlusion………………………………………….
6
3. Goals of full mouth rehabilitation……………………………….
21
4. Objectives in doing full mouth rehabilitation…………………….
22
5. Reasons for full mouth rehabilitation…………………………..
23
6. Limitations of full mouth rehabilitation…………………………
25
7. The design of masticatory system……………………………
27
8. Masticatory system disorder…………………………………….
41
9. Occlusion and its determinants……………………………………
47
10. Instruments used for occlusal analysis and treatment…………..
120
11. Diagnostic wax up……………………………………………..
130
12. Occlusal equilibration/ principles of occlusal correction……..
125
13. Role of occlusal splints in FMR………………………………….
143
14. Examination, diagnosis, treatment planning in FMR………….
145
15. Preparing the mouth for FMR ……………………………………
151
16. Treatment Procedures, Philosophies & techniques in FMR……
154
17. Final Restorations for FMR…………………………………
171
18. Common Problems & Difficulties in FMR …………………….
174
19. Post operative care for occlusal therapy patients…………….
178
20. Technological future for occlusal restorations…………………..
179
21. Summary and Conclusion ……………………………………..
182
22. Bibliography …………………………………………………………….
184

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 Intr oduction
Oral rehabilitation is the practice of dentistry that
includes the execution of any phase of our profession. A single amalgam
restoration or a successful periodontal treatment rehabilitates the mouth in
one instance while extensive crowns & bridges do so in another.

When the restorations and treatment include the entire

occlusion the procedure is referred as occlusal rehabilitation.2

Full mouth rehabilitation entails the performance of all

the procedures necessary to produce a healthy, esthetic, well-functioning,
self maintaining masticatory mechanism.-VICTOR .O. LUCIA

Occlusal rehabilitation is the correlation of all indicated

and required dental treatment for a particular patient in order to restore his
occlusion to normal function, to improve esthetics, and to preserve tooth and
their supporting structures. 2

Occlusions are like finger prints; no two are exactly alike. The
occlusions for the teeth are established in functional harmony with the
muscles, nerves, ligaments, and temporomandibular joints. Nature creates a
mouth primarily for function and as long as the occlusion functions
satisfactorily, without pain or discomfort and without damage to supporting
structures, no change in the pattern of occlusion is necessary despite vertical
or horizontal overlaps or different waves or levels of occlusion.

Many theories and philosophies of occlusion have developed. A

single, universally applicable occlusal treatment philosophy, scientifically

4
proved, does not exist. Many of the current rehabilative philosophies have
their roots in empiricism; few are based on scientific fact. So it‟s important
to recognize the limitations in some of these philosophies and to posse‟s
sufficient understanding to separate the fact from wishful thinking.

Full mouth rehabilitation cases are one of the most

difficult cases to manage in dental practice. This is because such cases
involve not only replacement of the lost tooth structure but also restoring the
lost vertical dimensions. Full mouth reconstruction is basically a set of
procedures that are aimed at correcting an improper bite position as well as
restoring chipped or worn out teeth. Improper jaw position is implicated in
various neuro-muscular disorders. Correcting the jaw position not only
restores proper function, but also helps in enhancing the cosmetic
appearance of the patient.
Full mouth fixed rehabilitation is one of the greatest
challenges in prosthodontics. Apprehensions involved in the reconstruction
of debilitated dentitions are heightened by widely divergent views
concerning the appropriate procedures for successful treatment.
In this era, all-ceramic restorations are becoming popular;
however, long-term follow-up of patients with complete rehabilitations using
all-ceramic restorations are not yet available. In patients with parafunctional
habits, metal-ceramic restorations seem to be a predictable treatment. They
provide adequate strength to withstand the parafunctional activity and
improve the longevity of the restorations.

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 E VOL U T IO N O F OCC L U SIO N
For nearly a century, the diversity of concepts about „normal‟
and „ideal‟ dental occlusal relationships has led to confusion in trying to
describe the occlusion of any individual patient8. In addition, a similar
controversy arises when trying to formulate treatment plans for patients who
need extensive dental restorations. And finally, the application of occlusal
concepts to patients with temporomandibular pain and dysfunction has
created a third area of debate8. The need to perform complex restorative
dentistry requires some organizing concepts for delivery of optimal results –
yet, dentists cannot seem to agree on what those concepts should be, nor
even on what constitutes a good outcome8. The past, present and future of
these occlusal concepts and their clinical implications are reviewed

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Early Concepts
 The first mechanical articulator was invented by J.B. Gariot in 1805. It

was a plain line instrument and it is still in use today.

 In 1858 Bonwill described his triangular theory whereby he postulated

that the distance from the incisal edges of the lower incisors to each
condyle is 4 inches, and the distance between the condyles is 4 inches

 Bonwill proposed a concept of bilateral balanced occlusion and

developed an articulator that applied his 4-inch triangular theory.

 In 1866 Balkwill discovered that during lateral jaw movement, the

translating condyle moved medially.

 In 1890 the German anatomist Von Spee observed that the occlusal

plane of the teeth followed a curve in the sagittal plane. Von Spec
attempted to describe the relationship between the condylar path and this
compensating curve, or "curve of Spee," by stating that the steeper the
condylar path (in protrusive), the more pronounced would be the
compensating.

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 From the concepts of these three men, came the age of occlusal theory
and occlusal articulators. Literally hundreds of articulators came and went
in the early 1900.
Age of Occlusal Theories and Occlusal Articulators
 In 1899 Snow devised a method for transferring articulated casts to the

articulator with a face bow.

 In 1901 Christensen observed the opening of the posterior teeth in

mandibular protrusion (Christensen phenomenon). Christensen then

developed a technique for registering the degree of posterior separation
and an articulator with adjustable condyle controls. This was still a two-
dimensional instrument, but an evolutionary improvement over the
Gariot instrument.
 In 1908 Bennett described the immediate side shift (Bennett
movement)."
 The origin for the introduction of the incisal pin to articulators is

unclear; however, the first published article where an incisal pin is

demonstrated was written in 1910 by Gysi.
 Gysi's instrument was one of the first to allow for the Balkwill-Bennett

movements.
Spherical Theory
 In 1916 Monson formulated a three-dimensional occlusal philosophy

by combining the concepts of Bonwill’s 4-inch triangle and bilateral

balanced occlusion, Von Spee's compensating curve, and the observances
of Balkwill and Christensen on condylar movement. This occlusal model
was named the Spherical Theory and was one of the first attempts at
presenting a working theory of three dimensional occlusal concepts.

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 In 1910 Gysi improved on Balkwill’s arrow point tracer to allow visual

registration of centric relation

 In 1918 Hall presented his conical theory, where it was believed that the

condyles were not the guides to mandibular movement. Instead, the

occluding planes of the teeth were the guides for mandibular movement.
Bilateral balance was one of the goals of this theory
 In 1921, Hanau introduced an occlusal instrument that was based on the

scientific writings of Snow and Gysi. Hanau rejected the spherical theory
and proposed the “rocking chair” denture occlusion in 1923.This
rocking chair theory involved heavy contact to the first molar areas to
compensate for the “resiliency and like effect,” which referred to the
resiliency of soft tissue and temporomandibular joint.
 In 1929 Stansberry modified Gysi’s arrow point tracer by adding a

central bearing point that allowed convenience in making the centric

relation record and eccentric jaw position records. These records were
then used to transfer casts of the patient to the articulator, the Stansberry
Tripod.
 In the 1930s Meyer was advocating the use of the functionally

generated path or “chew in” technique for recording bilateral

balancing contacts in eccentric movements

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 The Avery brothers, in 1930, introduced the “anti- Monson Theory,”

which advocated a reverse occlusal curve of Wilson-lateral compensating

curve
 Pleasure, in 1937, introduced his “Pleasure curve” which advocates the

anti-Monson reverse curve except for the second molars. The second
molars are tipped up to allow for bilateral balance of three points (incisal
and both second molars) in eccentric movements.

The occlusal concepts proposed during this period of

dental history from 1800 to approximately 1930, which one could call
the age of occlusal theories, can be summarized as being basically
formulated for complete denture patients in which bilateral balanced
occlusion in eccentric movements was considered essential.

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Modern occlusal concepts
Pankey Mann, Schuler System
 The Pankey-Mann system (1920) was originally an amalgamation of the

Monson theory and the Meyer functionally generated path technique,

where they attempted to gain bilateral balance in eccentric movements (a
holdover from complete denture occlusal theories). The technique
involved restoring the mandibular posterior occlusion to a 4-inch sphere
as described by Monson. The maxillary posterior occlusion was then
fabricated to the mandibular occlusal form by using the maxillary
anterior teeth as guides for the “chew in “registration as advocated by
Meyer. A suspension instrument was used for articulating the casts,
which had no functional movement capability. It was argued that
articulator movement was unnecessary because functional limits were
recorded with the “chew-in” registration.”‟
 A few years later Schuyler joined with Pankey and Mann to evolve what

is now known as the P.M.S. (Pankey, Mann, Schuyler). This occlusal

system retained the Monson spherical theory and the functionally
generated path technique; however, under Schuyler‟s influence.
(1) The balancing side contacts were eliminated;

(2) The importance of incisal guidance was elevated;

(3) The concept of “long centric” or “functional centric occlusion”

was proposed in which centric occlusion is thought of as an area of
contact rather than a point contact; and

(4) The Hanau occlusal instrument with arbitrary face bow and
Broadrick occlusal plane analyzer was adopted.

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 Gnathology
 At approximately the same time that Pankey and Mann were formulating

their concepts of occlusion, another group of researchers headed by

McCollum was studying mandibular movements .The main thrust of their
study was the rotational centers of the condyles in three dimensions:
vertical plane; sagittal plane; and horizontal plane, One assumption was that
the horizontal rotational center passes through both condyles (collinear
hinge axis). These researchers believed that if the rotational centers in the
condyles could be located, and if the border movements of these rotational
centers were recorded and reproduced on a sophisticated three-dimensional
articulator, then all functional motions for the patient could also be
reproduced by that instrument. Once the basic concepts were formulated,
research efforts were centered on methods to locate and record these
rotational centers and their border movements. Many ingenious inventions
were tried and discarded until finally the instrument we know as the
pantograph evolved. With the pantograph one could, for the first time,
record the three-dimensional border movements of the condylar rotational
centers. The concepts taught by McCollum and his associates eventually
became known as Gnathology.
 Gnathological theory at this early time included:

(1) Establishing the rotational centers of the condyles via a hinge axis
location;
(2) Recording the three dimensional envelope of motion of the condyles
via the pantographic tracing;
(3) Maximum intercuspation of the teeth when the condyles are in their
hinge position; and
(4) Bilateral balance with eccentric jaw movements.
12
 Because these, gnathological researchers felt that the condyles were the

determinants of occlusal schemes, they discovered that the side shift of the
condyle would greatly affect cuspal position, especially if bilateral balance
was deemed beneficial.
 Two of the early gnathological researchers, Stallard and Stuart, felt that

the basic theory of mandibular movement was fundamentally correct, but the
application of this knowledge was misdirected. They proposed eliminating
the balancing contacts in eccentric jaw movements by having the canines on
the working side disclude the posterior teeth; they named it the Cuspid
Protection Theory. This also became known as the Mutually & Protected
System.
 A number of other technical developments evolved during the 1940s and

1950s that helped the popularity and accessibility of the gnathologic

concepts.
 Payne and Thomas developed systematic waxing techniques that allowed

for the development of an acceptable occlusal scheme when all the

posterior teeth had been prepared.
 Stuart improved the design of the gnathologic instrument

 Guichet greatly simplified the pantographic recorder and developed his

gnathological instrument, the Denar

 Guichet also advocated overcompensation of the gnathologic instrument

settings to give increased disclusion rather than laboriously making the

instrument follow the lines of the pantograph.
Transographics
 During the 1950s, the engineer Page contended that each mandibular

condyle has its own axis of rotation and that these axes are not
collinear as was postulated by gnathologic theory.
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 Page then developed an occlusal theory, which was called Transograpics

and an occlusal instrument, the Transograph. This was designed to allow

for independent three-dimensional condylar movement.
 Transographic theory questioned the need to record the total envelope

of motion (pantographing) and instead advocated using wax

registrations to record a much smaller functional area within the
envelope of motion, which Page termed the “functional envelope.”
 Page felt that the occlusal form of posterior teeth was determined by the

asymmetrical condylar axis, the functional envelope, and the angle of the
mandible. Transographics lost favor as a widely accepted occlusal theory
after Page died, but his theories did bring renewed interest in research to
prove or disprove the existence of collinear condylar axes.
 Preston, in reviewing this subject, states the following:

Past experiments have been useful, but none have proven or

disproven the presence of collinear or noncollinear condylar arcs.
Only the arc of the rigid clutch and its associated mechanism is
located. Such an apparent arc may result from the resolution of
compound condylar movements
 The value of the Transographic theory lies in the unanswered

questions it raised, such as:

(1) Are condylar axes collinear or asymmetrical?

(2) Is immediate side shift normal function or the result of

pathology?

3) Should occlusal instruments be expected to reproduce jaw

movement?

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Cranial orthopedics
 The most visible proponent of the concept of cranial orthopedics (also

called oral orthopedics) is Gelb.

 The basic concept centers around the belief that the movement of the

mandible is not influenced by the shape of the condyles, but the condyles
may assume a certain shape because the mandible has assumed certain
movements.
 Cranial orthopedics is interested in establishing postural relationships of

the jaws. Occlusion is secondary to obtaining optimal postural relations

of the mandible to the maxilla. The proper relationship of the head on the
spine is essential for proper total body posture and balance.
 Thus, an improper jaw relationship will mean impaired posture and

balance.
 Geometry is the primary basis for achieving postural balance, and like

Hall, in the 1920‟s; geometry is used to justify the theoretical and

therapeutic treatment recommendations.
 Extensive planes of orientation are drawn on unmounted casts of the

maxilla and the mandible. Four classes of malocclusion are possible

based on these planes of orientation?
Class A: correct occlusion;
Class B: structural malocclusion;
Class C: functional malocclusion;
Class D: structuro-functional malocclusion.
The recommended therapy (usually splint therapy, orthodontic
movement, and/or reconstructive dentistry) is based on what is
necessary to realign these planes of orientation into more favorable
relationships. The primary appeal to cranial orthopedics lies in the
15
 realization that the temporomandibular joint has an adaptable
remodeling capacity that has been overlooked by- the static
relationship concepts traditionally espoused by the other modern
schools of occlusion. The apparent universal lack of enthusiasm by the
dental community for the teachings of cranial orthopedists can be traced
to its reliance on unscientific geometrical justification.
Biological Occlusion
 There is ample reason to believe that many successful long-term clinical

treatments have been accomplished using each of the modern schools of

occlusion. Because dentitions can be maintained successfully with
several apparently conflicting occlusal concepts, there is a growing
realization that occlusal concepts are not as “cut and dried” as we once
thought. The flexible concept of occlusion is termed biological
occlusion, and its philosophical goal is to achieve an occlusion that
functions and maintains health.
 This occlusion may include mal- posed teeth, evidence of wear, missing

teeth, and centric occlusion may not always equal centric relation. The
dominant factor is that this occlusion has shown its ability to survive,
thus implying an age factor, i.e., a teenager with temporomandibular joint
symptoms does not fit this occlusal concept, while an asymptomatic 80-
year-old with balancing side contacts does. One who fits this concept
needs no occlusal therapy. However, when occlusal therapy is indicated
(i.e., mutilated dentition, occlusal traumatism, temporomandibular joint
dysfunction), then basic guidelines for occlusal design are needed.
 These goals are compatible with almost all of the occlusal concepts

commonly used today for natural dentitions including P.M.S.,

Gnathology, and Transographics.
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The Neuromuscular,
 Neuromuscular philosophy is based on the understanding that the

temporomandibular joints are in a physiologic resting position based on

the guidance of muscles and stabilized by the occlusion of both the upper
and lower teeth.
 Emphasis is on a physiologic position of the jaw/ mandible position to

the skull (neuromuscular rest position), the physiology of rested muscles

to support a physiologic occlusion for stability of all three entities: the
TM joints, the muscle and the teeth.
 Neuromuscular dentistry (NMD) denies the importance of centric

relation, and advocates jaw relationships.

 NMD uses electromyography to measure the muscle activity using

surface electrodes
 Dickerson stated “the comfortable position of the mandible is
determined by the muscles, not by the joint anatomy”
 This philosophy is widely not accepted because

a. It denies Centric relation

b. Reliance on a rest position, as programmed by electronic
instrumentation, as the starting position for determining maximal
intercuspation.
c. Increasing the vertical dimension based on electronic instrument
determination of a rest position is unscientific at the best.

Okeson
 Noted that the most favorable occlusal concept should „be the least

pathogenic for the greatest number of patients over the longest time‟, but
he did not provide any specific recommendations for achieving that goal.
17
O'leary, Shanley, and Drake

 Found that teeth in a group function occlusion had less mobility than

teeth in cuspid protected occlusion 19.

Siebert

 Found that canine protected occlusion is necessary to limit tooth

mobility.24
Scaife and Holt

 Examined 1200 young people and observed that most North Americans

under the age of 25 had canine guidance either bilaterally or unilaterally.

However, clinical observations suggest that most people over 40 years of
age have group function guidance. Weinberg found only 19 of 100
people had cuspid protected occlusion
McAdam

 Suggest that both occlusions are normal and a dentist restoring only a

portion of an occlusion should not change the occlusal scheme.17

Jemt, Lundquist, and Hedegard

 Looked at group function v. canine guidance in implant restored patients

and found the chewing cycles to be consistent with patients having a

natural dentition.
Williamsom and Lundquist

 Discussed the effects of anterior guidance on the temporal and masseter

muscles and found that posterior disclusion reduced the elevating activity
of the temporal and masseter muscle18

18
Kohno

 States the incisal path should equal the condylar path. When rotation of

the condyle occurs; however, the incisal path may be increased, but not
more than 25 degrees.
Schuyler

 Discussed incisal guidance in oral rehabilitation. He incorporated

freedom of movement in centric occlusion be the addition of a pin in the

anterior guide table. Schuyler lists his objective of an occlusal
rehabilitation.
Dawson

 Discussed anterior guidance and firmly believes anterior guidance should

be related to condylar guidance. Dawson does not believe in allowing the

posterior teeth to share the load in eccentric movement stating
Hobo

 Fabricated two guide tables and use cusp angle instead of condylar path

or incisal path as a basis for the occlusion. This differs from any other
technique we have studied12.
 Hobo And Takyama (1993). Measured the amount of disclusion using

leaf gauge on stone casts mounted on an articulator. They used the

mathematical model for mandibular movement as an analytical tool and
proceeded with the computed analysis.
Heilein

 Discusses how to establish anterior guidance. Incisal edge position is

determined by phonetics and esthetics.14

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Frank .V.Celenza
 Treated 32 full mouth rehabilitation cases using RUM position coincident

with maximum intercuspation. After 12 years observation only 2 cases

showed RUM position coincident with maximum intercuspation
Clements

 Describes an inciso lingual index that will record the information for the

lab tech to adapt wax or porcelain to. This technique was originally
described by Fox
D’Amico –

 States that canine protection favors a vertical chewing pattern and

prevents wear of teeth. 20

Beyron

 States group function, implies contact and stress on several teeth in

lateral occlusion and indicates abrasion as a positive and inevitable

adjustment.20
Kohno and Nakano.

 The inclination of the incisal path should be equal to the inclination of

the condylar path. The incisal path should not be more than 25 o steeper
than the condylar path. A jerky condylar movement will result from an
incisal path that is flatter than the condylar path. If the incisal path is
shallower than the condylar path, the condyle rotates in a reverse
direction during protrusive movements. 21

20
 Goals of complete rehabilitation are44;;
1. Freedom from disease in all masticatory system structures
2. Maintainably healthy periodontium
3. Stable TMJ‟S
4. Stable occlusion
5. Maintainably healthy teeth
6. Comfortable function
7. Optimum esthetics

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 O BJ E C T IVE S OF OCC L U SA L
REHABILITATION66
Some of the most important functional objectives of an occlusal

rehabilitation are:

(1) A static centric occlusion in harmony with the centric

maxillomandibular relation,

(2) An even distribution of stress in centric occlusion over the maximum

number of teeth,

(3) Lateral and anteroposterior freedom of movement in centric occlusion,

(4) Masticating efficiency which involves uniform contact and an even

distribution of stress on eccentric functional tooth inclines which are

coordinated with the incisal guidance and normal functional condylar

movements, and

(5) Reduction of the buccolingual width of the occlusal surfaces of the teeth,

and a reduction of the balancing incline contacts as a means for reducing a

potentially traumatogenic load on the structures supporting the dentition.

22
 Reasons for FMR --VVIICCTTOORR ..OO.. LLUUCCIIAA

a) The most common reason for doing a full mouth rehabilitation is, to
obtain and maintain the health of periodontal tissues
The clinical periodontal findings are correlated with radiographs to
determine the extent and character of any disease ; findings must
then be correlated with the function of mouth
Factors to be examined in functioning of mouth are
Premature contacts and interferences in excursive
movements
Oral habits-bruxism, lip chewing, thread biting, tongue
habits.
b) Tempromandibular joint disturbance
They are difficult to diagnose and great care to be taken to
determine the etiological factors involved
The etiology may be
o Disharmony of function between the movements of joints
and articulation
o Muscular dysfunction – may be due to poor articulations
producing muscle spasms, nervous affliction or some
irritation
Often in joint cases the periodontal condition is usually very
good, which is probably why the joint has been injured instead
of periodontium.
c) Need for extensive dentistry
When multiple teeth are missing,

23
Several worn down teeth
Several old fillings needing replacement.
Usually the patients have little periodontal involvement and no
joint symptoms
These are the easier cases to do full mouth rehabilitation

24
 L im i ta tio n s i n D oi n g FM R

Factors that limit the treatment of occlusions

Limitations have a direct bearing upon any plan of treatment for each patient
requiring restoration in a dysfunctioning occlusion. There are atleast 7
primary factors which limit the plan of treatment in occlusal rehabilitation
no matter what concept is followed

1. Differences in occlusal levels between the anterior and posterior teeth

2. Asymmetries in the body
3. The natural and unnatural wear of tooth
4. The patients individual pattern of chewing
5. The patient‟s intolerance to any change in occlusion by prosthodontic
means
6. The patient wishes
7. The economic factor.
Here are the following precautions or advices or guides before
undertaking any rehabilitation case;-

1. Do not alter the occlusion of the patient unless you are certain that
such change is necessary.
2. Do not rehabilitate the occlusion beyond the limits of the patient‟s
inter-occlusal clearance (free way space).
3. Occlusions are like fingerprints-no two are alike, and therefore, all
cases cannot be treated the same.

25
4. If the existing occlusal curve is not a factor in any temporomandibular
joint disturbance; if it contributes to a healthy periodontium; and if it
participates in a comfortable and functional occlusion, then it is
advisable to duplicate that curve in occlusal rehabilitation.
5. Corrective and restorative dentistry is controlled by many inescapable
limits and the doctor and the patient must take these limitations into
consideration.
6. Do not hesitate to consult with other practitioners in the planning of
your case.
7. Complete the occlusal rehabilitation as quickly as possible.
8. All patients who come to your office do not require occlusal
rehabilitation.
9. It is not necessary to cut and cover every tooth on a patient in order to
rehabilitate his occlusion.
10. Do not resort to a full coverage restoration if one that conserves more
tooth structure is indicated.
11. If the patient‟s occlusion has functioned for many years in a chopping,
up and down motion, do not present him with a so called balanced
occlusion that will skid and slide in lateral and protrusive excursions.
12. Inform the patient that nothing of a material nature lasts indefinitely,
and that restorations may last two years in one patient and perhaps ten
years in another.

26
 T h e De si gn o f M asti ca to r y S yste m
The three most important factors that affect a patient's occlusion are:

1. The first factor is the exact relationship of the components of the

Temporomandibular joint (the TMJ).
2. The second factor is the minute relationship of the upper and lower teeth

when they come together (occlusion). It also includes the specifics of

which cusp on a specific tooth contacts which groove on the opposing
tooth. It is also concerned with how the teeth contact during lateral
excursions
3. The third factor is the Neuromuscular System: This involves the

muscles of mastication which open and close the jaw, as well as the brain

and the cranial nerves which give sensory and motor innervation to the

muscles. The brain is important in the concept of occlusion because it is

the source of both the voluntary muscular activity which operates the

system, as well as unconscious habits such as bruxing (grinding and

clenching) which can lead to some of the most serious disease states of

occlusion.

27
COMPONENTS OF THE MASTICATORY SYSTEM:

The masticatory system is considered to be made up of 3 parts namely:

1. Teeth

2. Periodontal tissues

3. Articulatory system

Articulatory system

All the three should be in harmony. So knowing the structure and function of
this articulatory system is important.

28
Temporomandibular joints
The major components of temporomandibular joints are the cranial base,
the mandible, muscles of mastication with their innervations and vascular
supply. Each joint is described as a Ginglymodiarthrodial, which means that
it‟s capable of both hinging and gliding articulation. An articular disk
separates the mandibular fossa and the articular tubercle of the temporal
bone from the condylar process of the mandible.
The articulating surfaces of the condylar processes and fossae are covered
with avascular fibrous tissue.

The articular disk consists of dense connective tissue; it‟s also avascular
and devoid of nerves in the area where articulation normally occurs.
Posteriorly it‟s attached to a loose highly vascularized and innervated
connective tissue, the retrodiscal pad or the bilaminar zone which
connects to the posterior wall of the articular capsule surrounding the joint.
Medially and laterally, the disk is firmly attached to the poles of the
condylar process. Anteriorly it fuses with the capsule and with the superior
lateral pterygoid muscle. Superior and inferior to the articular disk are two
spaces; the superior and inferior synovial cavities.

29
These are bordered peripherally by the capsule and synovial membranes and
are filled with synovial fluid. Because of the firm attachment to the poles of
each condylar process, the disk follows the condylar movement during both
the hinging and translation, which is made possible by the loose attachment
of posterior connective tissues.
Ligaments
The ligaments of the joints are five.
1. Capsular ligaments
2. Temporomandibular ligaments
3. Sphenomandibular ligaments
4. Articular disk
5. Stylomandibular ligaments
Capsular Ligaments:
It is divided into four parts.

a. Anterior,
b. Posterior,
c. External &
d. Internal segments

30
Anterior & posteriors segments are loose flabby fibers. Anteriorly, these
fibers are inserted into anterior margin of the interarticular fibro cartilage.
Posterior fibers – attached to the margins of glenoid fissure & extend to
neck of condyle.
Upper fibers – attached to the front of articular eminence.
Lower fibers – anterior margin of the condyle
Function: The four portions of capsular ligaments, by the blending of their
fibers, encapsulate the joint.
Other ligaments

31
Muscles
Muscles provide moving forces for all actions in the body. The anatomy &
physiology of the masticatory musculature are therefore important to the
rehabilitation of patients.
The muscles involved in mandibular movements are

I) Muscles Of Mastication: These include

1. Medial pterygoid
2. Masseter
3. Temporalis
4. Lateral pterygoid

Temporalis:

Origin – whole length of temporal fossa, inferior temporal line.

Insertion – Coronoid process & anterior border of ramus of mandible.
Nerve supply – branch from anterior division of mandibular nerve

32
Medial Pterygoid:

Origin – superficial head – maxillary tuberosity Deep head – medial

surface of lateral pterygoid plate
Insertion – medial surface of angle of mandible.
Nerve supply – branch from trunk of mandibular nerve.

Lateral Pterygoid:

Origin – Upper head – infra temporal crest of greater wing of sphenoid

- Lower head – lateral surface of lateral pterygoid plate

Insertion – Upper head – anterior part of intra articular disc & capsule

-Lower head – pterygoid fovea in the neck of condyle.

Nerve supply – branch from anterior division of mandibular nerve.

33
Masseter:

Origin: zygomatic arch

Insertion: outer surface of ramus of the mandible
Nerve supply: branch from anterior division of mandibular nerve

SUMMARY OF MUSCULAR ACTION ON THE MANDIBLE:

1 Depression or opening of the mouth – Suprahyoids, Infrahyoids,

Platysma, Lateral pterygoid
2 Elevation or Closure of mouth - Temporalis Masseter Medial
pterygoid
3 Protrusion, bilateral - external pterygoid, internal pterygoid
masseter– superficial fibers
4 Protrusion, unilateral - medial & lateral pterygoid on protruding
side masseter – superficial fibers
5 Retrusion, bilateral - temporalis – deep fibers.

34
NEUROMUSCULAR CONTROL OF
MANDIBULAR MOVEMENTS:

35
Condylar Movements

1 Rotation.

Rotation is the motion of a body around its axis. Mandibular

rotation occurs in the lower compartment of the TM J, between the
mandibular Condyle and the articular disc. Mandibular rotation occurs
around the rotational centers of the condyles. The Hinge Axis: is the
imaginary line connecting the rotational centers of one condyle with
that of the opposite condyle, and around which the mandible makes
the opening and closing rotational movements.
2 Translation.

36
 Translation is the movement of a body when all its parts move at the
same time. Mandibular translation occurs in the upper compartment of the T
MJ between the disc and the glenoid fossa. In mandibular translation, there
is a change in the relationship of the condyle and its articular disc with the
articular fossa.

Mandibular Movements
With the condylar rotation and translation, the mandible is capable of
performing the following movements:
1-Opening
2-Protrusive
3-Lateral Excursions: right and left
For studying the mandibular movements, we will always start from the
starting point of centric occlusion.
A-Opening Movement
For this movement to occur, the condyle rotates in its place, in
the terminal hinge position. Pure rotation occurs only till the condyles start
to translate moving out of its centricity. Upon rotation of the condyle, the
mandible opens, and teeth are discluded. As soon as the pure rotation ends,
the condyle begins to translate, moving forward and downward on the
superior and anterior walls of the glenoid fossa, with the arc of opening
changing, and the mandible opening further till the maximum opening
position.
B-Protrusive Movement
For this movement to occur Condyles follow the form of the
superior wall of the glenoid fossa, they slide downwards and forwards as the

37
mandible moves in protrusion. This movement causes the separation of the
posterior teeth, a state known as Disclusion.

During this movement, the opposing inclines of the teeth should not touch
each other. The palatal cusp of the upper molar travels distally from its
centric position in the central fossa of the lower opposing tooth, while the
buccal cusp of the lower travels mesially across the central groove of the
upper opposing tooth. The cusp angle should be in harmony with the angle
that the condyle travels during the protrusive movement, or else a protrusive
interference would exist. The steeper this angle, the more allowable cuspal
angle, the longer the cusps and the deeper the fossae.
C-Lateral Excursion Movement

38
 The mandible is capable of moving towards both the right and left
sides. The side to which the mandible moves is called the working side,
while the opposite side is called the non-working side.
The Working Side

This is the side on which we chew. The condyle on the working side is
called the rotating condyle. It rotates in its fossa with a little downward and
backward movement, rotating against the superior and posterior walls of the
glenoid fossa. The buccal cusps of upper and lower molars line up, with the
lower buccal stamp cusp moving from its centric position in the fossa of the
opposing upper tooth towards the buccal along the buccal groove, while the
upper stamp cusp move lingually along the lower lingual groove. During this
movement, any contact that would exist between the lower buccal cusps or
the upper palatal cusps with their opposers would be considered as working
side interferences.
The Non-Working Side
This is the side opposite to where we chew. The condyle on the non-
working side is called the orbiting or translating condyle. The condyle
moves medially till it comes in contact with the medial wall of the glenoid
fossa, then moves downwards, forwards and medially, on the superior and
39
medial walls of the fossa. The palatal cusps of upper molars line up with the
buccal cusps of lower molars. The buccal cusps of the lower teeth moving
lingually from their centric position across the oblique palatal grooves of
their oblique buccal grooves of their lower opponent, during this movement
any contact that would exist between the lower buccal cusps or the upper
palatal cusps with their opposers would be considered as non-working side
interferences.
Bennett Movement (Side Shift)
This is the lateral bodily movement of the rotating (working)
condyle, with medial movement of the orbiting (non-working or translating)
condyle. The medial wall of the glenoid fossa on the non-working side
determines the amount of this movement. The non-working condyle moves
medially till it is in contact with the medial wall. The Initial side shift:
occurs during the initial 2 mm of the anterior movement. The average initial
side shift is 1.7mm medially. There is more medial movement than there is
anterior movement. The Progressive side shift: occurs after the initial side
shift, the curve of the medial wall of the glenoid fossa begins to straighten,
there is more anterior movement with little medial movement Total side shift
= Initial side shift + Progressive side shift The Bennett Angle: angle formed
between the mid-sagittal plane and the medial wall of the glenoid fossa on
the non-working side (7-8 degrees).

40
 M a stic a tor y S y stem D i so r d er
Masticatory system disorder is any disorder of the masticatory system that

is associated with dysfunction, discomfort, or deformation of any or parts

of the total masticatory system, which includes

1) Teeth & their supporting structures- Occlusal diseases

2) Craniomandibular articulations & accessory musculature –
Tempromandibular disorders
OCCLUSAL DISEASES

Occlusal disease is deformation or disturbance of

function of any structures within the masticatory system that are in
disequilibrium with a harmonious interrelationship between TMJ‟s the
masticatory musculature and the occluding surfaces of the teeth

Basic mechanisms of tooth surface deformation are;

1. Stress –results in compression flexure & tension –produce micro fractures &
abfractions
2. Friction –abrasion, & wear of tooth surfaces
3. Corrosion- results of chemical or electrochemical deformation- erosion
Signs & symptoms of various occlusal diseases are

The signs of occlusal disease almost always precede symptoms. The severity
of structural damage is routinely progressive if not treated.

1. Attrition wear

2. Abrasion

41
 3. Erosion of enamel

4. Abfractions

5. Splayed teeth

6. Sensitive teeth

7. Sore teeth

8. Hyper mobility

9. Split teeth & fractured cusps

10. Painful musculature

TEMPRO MANDIBULAR DISORDERS

1) Masticatory muscle disorder
2) Structural intracapsular disorder
3) Conditions that mimic TMDs
Categories of TMD

Category I –Occluso muscular disorders with no intracapsular defects

Category II- Intra capsular disorders that are directly related to occlusal
disharmony and are reversible in re-establishing comfortable function if the
occlusion is corrected

Category III- Intracapsular disorder that are not reversible, but because of
adaptive changes, can function comfortably if occluso muscle harmony is
reestablished.

Category IV- Nonadapted intracapsular disorders that may be either

primary or secondary to occlusal disharmony or may be untreated
42
Pipers classification of TMD

43
44
45
46
O c cl u si o n and I ts D e term i na nts
Ideal occlusion
Classification of occlusion
Centric relation
Vertical dimension
Neutral zone
The envelope of function
Anterior guidance & smile designing
Long centric
The Occlusion Plane
Posterior occlusion
Disocclusion

47
 IDEAL OCCLUSIO N:
Ideal occlusion can be defined as an occlusion compatible with
the stomatognathic system, providing efficient mastication and good
esthetics without creating physiological abnormalities-HOBO 1978.

Guichet 1970 described the standards for ideal occlusion as the following

Criteria-1: Incorporate in the occlusion those factors which have to

do with reduction of vertical stress.
Criteria: 2, Provide for the maximum intercuspation with the
condyles in centric relation
Criteria 3: Provide for horizontal movement of the mandible from the
centric related intercuspal position, until those teeth most capable of
bearing the horizontal load come into function.

He proposed that there is no one ideal occlusal pattern for all individuals
but an appropriate pattern can be found based on the above criteria.
ACCEPTED OCCLUSAL SCHEMES INCLUDE

1. Balanced occlusion
2. Mutually protected occlusion and
3. Group function

Balanced occlusion

Balanced occlusion has all teeth

contact in maximum intercuspation and
during eccentric mandibular movements.

48
It has referred to as a fully balanced or bilateral balanced occlusion and said
to be ideal for restoration with complete dentures.

Balanced occlusion refers to simultaneous tooth contacts during

eccentric movements (Scaife, Holt, 1979); lateral occlusal forces generated
during the movements are shared by all teeth and temporomandibular joints
(Granger, 19541962, Kalpan, 1963). The masticatory movement for
balanced occlusion is based on the theory that forces are generated
horizontally instead of vertically.

Balanced occlusion is based on three classic theories;

1. Bonwill‟s three point occlusal balance –Bonwill’s ,1858

2. Spees‟ curve of Spee – Spee 1890 and
3. Monson spherical theory- Monson -1922, 1932

McCollum & Granger used balanced occlusion as an ideal occlusion for

oral rehabilitation.

Stallard and Stuart (1960) criticized the concept

Cross mouth and cross tooth balance was easy to make chewing less
awkward and balanced occlusion becomes unstable with prematurities
appearing in lateral and centric closures.

49
Lucia used balanced occlusion for oral rehabilitation for 12 years and
observed few patients developed abnormal conditions

Lucia described the failures of balanced occlusion as follows;

1. The cusp –to –fossa occlusion relationship exists only in part of the
molar contacts. The bicuspids cusps function in the opposing
embrasures, making wedging and tooth drifting possible
2. There are large areas of tooth contact and broad occlusal surfaces.
3. In such tight occlusion, slight changes produce readily visible
discrepancy
4. Errors of full-mouth balance are errors of commission, not omission.
5. When a restoration is fully balanced, incision is frequently difficult.
6. In order to produce a full balance, it may be necessary to increase the
vertical dimension to dangerous degree.

A balanced occlusion is appropriate for edentulous patient treatment

because of cross arch balance improves stabilization of complete dentures
but it‟s difficult to make on natural dentition because of its ill effects-
Ramjord, Ash, 1966, Posselt 1962.

50
Balanced Occlusion

Centric position Lateral position

Occlusal Protrusive
Interarch position
contact Working Nonworking
relation
condition

Lingual cusps
Lingual inclines
of maxillary
of anterior teeth
teeth and
One tooth to and buccal and
Point centric buccal cusps of
two-teeth All maxillary and lingual cusps of
mandibular
mandibular teeth posterior teeth teeth make
contact make contact
contact.

Anterior and Cusp to

Cross-tooth Cross –arch
posterior teeth ridge
balance balance
contact relation

51
Mutually protected occlusion

Stallard and Stuart 1960, 1961, 1963... Supported a balanced

occlusion for optimum occlusion for oral rehabilitations, after many
treatments failures they doubted balanced occlusion as an ideal occlusion.

Stuart while studying

the occlusion without attrition on
patients over 60years, He
observed that the molars did not
contact during eccentric
movements but in maximum
intercuspation, they contacted
while the anterior teeth had no contacts. The molars are responsible for
bearing vertical occlusal loads.

Stallard found anterior teeth protect posterior teeth and posterior

teeth protect the anterior teeth. The concept of mutually protected occlusion
is based on this concept (Thomas 1988)

A mutually protected occlusion occurs where the posterior teeth

protect the anterior teeth in centric position. The centric stops on posterior
teeth also help prevent excess loading transferred to the TMJ (Ito et al.,
1986)

The incisors protect the canine and posterior teeth during protrusive
movement and canines protect the incisors and posterior during lateral
movements. Lucia 1961; Thomas 1967; Hobo1978; Williamson,
Lunquist, 1983; Shupe et al 1984.

52
Lucia described the advantages of a mutually protected occlusion as the
following;

1. Minimum amount of tooth contact is involved and this makes for

better penetration of food.
2. A cusp to fossa relationship produces an interlocking of the upper and
lower components, thereby giving maximum support in centric
relation in all directions. The force is closer to the long axis of the
tooth.
3. The arrangement of the marginal, transverse, and oblique ridges so
that they have a shearing action, which makes for a much more
efficient chewing apparatus.

D’Amico found that the canine guidance positioned the mandible into
maximum intercuspation, and no teeth contacted until final position.
Mandibular eccentric movements were guided by the canines except in
protrusive, so the canine is the key element in occlusion.

Lucia 1961- taught that when anterior teeth are strong, a mutually protected
occlusion is used and a balanced occlusion is used when anterior teeth
missing. Interim prosthetic treatment can use a balanced occlusion but the
final treatment should have mutually protected occlusion.

Dawson -1974 - Stated when canines cannot be used, lateral movements

have posterior disclusion guided by anterior teeth on the working side,
instead canines alone he called this the anterior group function.

Schuyler stated when mandibular movement cannot be guided by anterior

teeth, all working side teeth should be used for guidance during lateral

53
movements. The development of osseointergrated prostheses creates
possibilities for canine replacement.

Lucia (1987) stated that with the development of osseointergrated implant

treatment; there are few contraindications to a mutually protected occlusion.

Thomas (1967) stated that when each cusp is waxed using cusp-fossa waxed
using cusp-fossa waxing, a cusp-to-cusp relation during lateral movement
has 1mm posterior disclusion. The amount of disclusion for a ridge-to-ridge
or ridge-to-fossa relation is not precise.

Stuart and Stallard (1960) stated by avoiding cuspal interferences during

eccentric movements, this created a minimum amount of disclusion to
improve masticatory function.

The term mutually protected occlusion was changed to organic occlusion

by Stallard and Stuart (1961), and then described by Thomas (1967).

In organic occlusion, centric relation position and maximum

intercuspation are coincident. The posterior teeth are in cusp-fossa relation,
one –tooth to one-tooth contact. Each functional cusp contacts the occlusal
fossa at three points while the anterior teeth disclude by 25 microns. In
protrusive movement, the maxillary four incisors guide the mandible and
disclude the posterior teeth (Boderson, 1978). In lateral movements, the
lingual surface of the maxillary canine guides along the distal incline of the
mandibular canine and the mesial ridge of the first premolar facial cusp; this
also has been called disclusion.

54
Contra indications for mutually protected occlusion

1. When the masticatory cycle is horizontal

2. The periodontium is compromised.

3. Missing canine or a Prosthetic canine

4. Arbitrary amounts of posterior disclusion

Mutually protected Occlusion

Centric position Lateral position

Occlusal Protrusive
Interarch position
contact Working Nonworking
relation
condition

Maxillary incisors Maxillary

One tooth to
Point centric guide the canines guide
one-tooth
mandible the mandible

It is permissible
Only posterior Cusp to Canines and
to have other
teeth make fossa posterior teeth No tooth
anterior teeth
contact relation disclude contact
contact

Mesial inclines of
Anterior teeth
mandibular first Posterior teeth
have a space of Tripodism
premolar buccal disclude
30µ
cusps may contact

55
GROUP FUNCTION OCCLUSION

Schuyler (1929) introduced the fundamentals of group function occlusion.

He questioned the purpose of the canine and
whether it should receive all occlusal loads
during lateral movements (Schuyler, 1961).

This type of occlusion occurs when all

facial ridges of working side teeth contact
the opposing dentition while the nonworking
side teeth do not contact.

Group function occlusion has had broad support (Mann, Pankey,

Mann,1960; Ramjord, Ash,1966;Posselt,1968;Lauritzen,1974) and has
been observed frequently in natural dentition( McAdam, 1976).

Beyron (1954, 1969) listed characteristics of this type of occlusion;

1. Teeth should receive stress along the tooth long axis.

2. Total stress should be distributed among the tooth segment in lateral
movement.
3. No interferences occur from closure into intercuspal position.
4. Keep proper interocclusal clearance.
5. Teeth contact in lateral movement without interferences. He felt that no
one occlusion could serve as a general basis for every individual.

56
Characteristics of group function occlusion include

1) The theory of long centric,

2) The concept of all working side teeth sharing lateral pressures during
lateral movements, and

3) The concept of nonworking side teeth free from contacts during lateral
movements.

Long centric is a 0.5-0.75mm free space between maximum intercuspation

and centric relation position without changing vertical dimension of
occlusion.

Schuyler (1961) stated that an ideal occlusion has coincident maximum

intercuspation and centric relation position but rarely occurs in clinical
situations. This type of occlusion creates uncertain stability with the
anteroposterior slide.

In group function occlusion, lateral pressure is distributed to all

working side teeth, in contrast to a mutually protected occlusion where
lateral pressures are directed only to the working side canine.

Schuyler felt all working side teeth should bear the lateral pressures during
lateral movement by eliminating nonworking contacts (Schuyler, 1953); he
did not discuss pressure differences on molars compared to anterior teeth.

Guichet (1970) questioned Schuyler‟s theory and stated the lateral pressure
on canines is approximately one-eighth that on second molars. When sharing
the load on the working side, the molar bears a greater burden and not all
teeth share the same amount of load.

57
 In group function occlusion; there are no tooth contacts on the non-working
side. Schuyler observed masticatory movement and found that when the
mandible is closed, the mandibular buccal cusps contact the facial ridges of
maxillary lingual cusps and the cusps are not held in a stable position.

Group function occlusion does not have the harmful effects as seen with a
balanced occlusion and is not as difficult to fabricate as a mutually protected
occlusion. Group function occlusion was felt to be a goal for occlusal
adjustments and has easy application in short-span prostheses.

Dawson (1974) described five concepts important for an ideal occlusion:

1) Stable stops on all teeth when the condyles are in their most superior
posterior position (centric relation).
2) An anterior guidance that is in harmony with the border movements of the
envelope of function.
3) Disclusion of all posterior teeth in protrusive movements.
4) Disclusion of all posterior teeth on the balancing side.
5) Noninterference of all posterior teeth on the working side with either the
lateral anterior guidance or the border movements of the condyles.

These criteria fulfill a mutually protected occlusion not the group function
type of occlusion. Recent group function occlusion supporters are modifying
this concept to include anterior tooth guidance.

58
Group Function Occlusion

Centric position Lateral position

Protrusive
Occlusal
Interarch position
contact Working Nonworking
relation
condition

Maxillary
One tooth to Maxillary
Long centric incisors guide the
two-teeth lingual inclines
mandible
of anterior and No tooth
posterior buccal contact
Anterior teeth Canines and
Cusp to ridge cusps guide the
may or may not posterior teeth
relation mandible
contact disclude

59
OCCLUSION FOR OSSEOINTEGRATED PROSTHESES

Since there is no cushioning effect between fixtures and bone,

occlusal forces are transmitted directly to bone through the osseointergrated
prosthesis. These forces are not limited to masticatory forces but also
include impact forces. The occlusion concept chosen should provide
dynamic elements for each prosthesis. As stated earlier, a balanced occlusion
has been used in fully bone anchored prostheses although use of this concept
in osseointegration prostheses ahs been questioned.

Cusp height can improve masticatory efficiency, but exaggerated

inclinations may cause cuspal interferences (Belser, Hannam, 1985). Since
masticatory movements are usually a vertical movement, the cusp shapes
and inclinations influence the movement. With steep cuspal inclinations,
there is an increase in the vertical element of mastication. With low cuspal
inclinations, there is an increase in the lateral elements of masticatory
movement (Ai, 1962). When comparing the two elements, cuspal
inclinations generate working and nonworking side disclusion twice as much
(Nishio, et., 1986).

Figure shows a
diagrammatic representation
of lateral movement between
maxillary and mandibular
molars. In normal
mastication, the mandibular
molars move in a vertical
direction. When lateral

60
components are added to the masticatory cycle, mandibular molars also have
lateral component during the final stage of the masticatory cycle along the
red line. The inclination of the red line differs form anterior guidance; the
sharper lingual slopes of anterior teeth result in increased angulation of the
red line and more disclusion. Cusp height can be changed following the red
line but when the cusp height exceeds the red line, this results in cuspal
interferences. Therefore, there are limits to increases in cusp heights.

Figure shows
masticatory movements during
normal chewing movements.
When the mandible moves
vertically, occlusal forces are
directed vertically. The force
vectors on mandibular cusps are
shown by arrow F. These forces are divided into vertical and horizontal
components; S. P is the pressure that is equivalent to forces on the opposing
dentition. S is equal to forces applied to opposing maxillary molars when
shearing food. The shear strength acts horizontally on a surface and creates a
cutting action. Increases shear strength occurs between maxillary and
mandibular molars when grinding forces are applied. From the previous
figure, increased shear strength occurs with steeper cusps and vertical
occlusal forces. In contrast, shear strength is not produced with flatter cusps
and a stronger horizontal component is present during mastication.

61
 Since normal mastication occurs vertically, making sharper cusps
in prosthesis can increase the shear strength. Chewing a tenacious food bolus
creates a stronger lateral component, increasing the shear strength between
mandibular and maxillary molars. Balanced occlusion was developed to
increase the shear strength during mastication but has not always been
effective clinically.

If the mandible moved strictly like an articulator, balanced occlusion

would have adequate shear strength and masticatory efficiency. However,
since the condyle-disk assembly contains soft tissue elements, occlusal
forces applied during mastication can cause mandibular deviation. A
balanced occlusion creates cuspal interferences, so to avoid this,
incorporated disclusion into the occlusal scheme. In the mechanical
engineering field, it is better to provide 5-10% free space between edges
for better shear strength, similar to the space between cutting edges of
scissors. If there is no space between the cutting edges, they cannot work
efficiently to cut a thick object. This analogy can be applied to disclusion
in dentition.

Balanced occlusion can function well in complete dentures since the

dentures are supported by movable tissue that has a cushioning effect for
occlusal forces. Denture wearers with 0 to 30 degree cusp inclines show less
disclusion compared to natural dentition (Colaizzi, et al., 1988).

In osseointergrated prostheses, fixtures bear vertical forces better

than horizontal forces so it is preferable to direct forces vertically. A single
fixture can bear occlusal forces equivalent to a single-rooted natural tooth.
Usually there are no fixtures available in the posterior region to support

62
 horizontal loads. For this reason, disclusion is preferred in prosthetic
restoration of posterior osseointergrated implants. Since more horizontal
loads are generated in the anterior region, longer fixtures are used and
restored with attachments to natural teeth.

There is insufficient research to support one occlusion concept for

osseointegration prostheses.

SUMIYA HOBO suggests the following standards for the different types of
osseointegration treatment.

1) When making a fully bone anchored prosthesis, try to use a mutually

protected occlusion to obtain posterior disclusion.

2) When making overdenture prosthesis, use a balanced occlusion. Since the

anterior teeth are supported by overdenture attachments and the posterior
teeth are supported by tissues, some molar disclusion is possible to function
as a modified mutually protected occlusion.

3) When making a freestanding fixed partial denture for the anterior

region including replacement of a canine, use a group function occlusion.
During lateral movements, horizontal loads are shared between the natural
teeth and the prosthesis.

4) When making a freestanding fixed partial denture for the posterior teeth

with natural anterior teeth present use a mutually protected occlusion

with posterior disclusion.

63
 Edentulous classification Type of prosthesis Optimal occlusal scheme

1. Edentulous Fully bone anchored Mutually protected occlusal

fixed partial denture scheme

2. Edentulous Over denture Balanced occlusion

3. Class-III or IV Partially Free standing fixed Group function occlusion

Edentulous partial denture

4. Class I or II Free standing fixed Mutually protected occlusal

partial denture scheme
In posterior region

These guidelines attempt to decrease cuspal interferences and reduce

horizontal or lateral stresses on the fixtures

64
 C la ssifi ca ti on o f oc c lu sio n
To be a valid classification, the classification of occlusion must specify
the relation ship of maximal intercuspation to both the position and
condition of Tempromandibular joints.

Draw Backs Of Angles Classification

1 Angle‟s classification does not consider

TMJ position or condition when relating the
mandibular arch to maxillary arch.

2 Angles classification is not an acceptable

system for evaluating the relationship of
occlusion to Temporomandibular disorders

3 Deflective occlusal contacts can occur in

all of angles classification including angles
class-I occlusions

65
Dawson’s classification
Type I Maximum intercuspation in harmony with centric relation

Implications for type I

Centric relation is verifiable with teeth separated

There is no discomfort in the TMJ region even when firmly loaded
Treatment for TMD is not needed
The jaw can close to maximal intercuspation with premature tooth
contacts or deflections
Occlusal equilibration is not needed except for possible excursive
interferences
The patient can clench with no sign of discomfort
Use of occlusal splint is not indicated
Type I occlusion can occur with any angles classification

66
Type IA Maximum intercuspation occurs in harmony with adapted centric
posture(A-signifies adapted condition)

Implications for Type IA

Intracapsular structures have deformation but have adapted

TMJs can accept loading with no discomfort
Treatment for TMD is not needed
Occlusal correction not needed because there is no TMJ/ occlusion
disharmony

Type II Condyles must displace from a verifiable centric relation from

maximum intercuspation to occur

67
Type IIA Condyles must displace from an adapted centric posture for
maximum intercuspation to occur

Implications for type II & IIA

Centric relation or adapted centric posture can be verified

The source of pain will be in the muscle or interfering teeth
Prognosis is excellent if occlusal interferences are eliminated
TMJ surgery, arthroscopy, joint infections, or lavage are
contraindicated
Treatment reversible with the use of occlusal splint, equilibration the ,
orthodontics or restoration
The occlusal therapy goal to achieve Type I OR IA

68
Type III Centric relation cannot be verified

TMJs cannot accept loading without tenderness or tension, so the

relationship of maximal intercuspation cannot be determined until TMJ
problem resolved

Implications for type III

Indicates the need for pipers classification of TMJ

Should correct TMD before occlusal treatment finalized
Treatment may vary from simple permissible occlusal device to
relieve muscle spasm, to surgical correction for certain type of
muscular disorders
Treatment goal is Type I OR IA
Type II classification applies to conditions that are deemed to be
correctable with a potential for return to normal functional normalcy
but at the time of examination , the TMJs cannot accept load testing
without some degree of discomfort

69
Type IV the occlusal relation ship is in an active stage of progressive
disorder because of pathologically unstable TMJs

Implications for type IV

This indicates an active progressive disorder of the TMJ that make it

impossible to establish a stable TMJ /Occlusion relationship
Typical signs of type IV are
1. Progressive anterior open bite
2. Progressive asymmetry
3. Progressive mandibular retrusion
The goal is to stop the progression of the TMJ deformation until
manageable stability of the TMJ can be confirmed
Irreversible occlusal treatment is contraindicated at this stage

70
 C e n tr ic rel a ti o n
Centric relation is the only condylar position that permits interference free
occlusion
Definition
“Centric relation is defined as the maxillomandibular relationship in
which the head of the condyles articulate with the thinnest avascular
portion of the respective disk, with the complex in the anterosuperior
position against slopes of the articular eminence, this position is
independent of tooth contact, and this position is clinically discernable
when the mandible is directed superiorly and anteriorly. It is restricted to
purely hinge movement about the transverse horizontal axis” –GPT-5
LOCATING CENTRIC RELATION

Locating centric relation may sometimes be difficult. To guide the mandible

into this position, one must first understand that the neuromuscular control
system governs all the movement. The functional concept to consider is that
the neuromuscular system acts in a protective manner when the teeth are
threatened by damaging contacts. Since in some instances, closure of the
mandible in centric relation leads to a single tooth contact on cuspal inclines,
the neuromuscular control system perceives this as potentially damaging to
the tooth Therefore care must be taken in positioning the mandible to assure
the patient‟s neuromuscular system that damage will not occur. Location of
centric relation begins with the anterior teeth no more than 10 mm apart to
ensure that the TM ligaments have not forced translation of the
condyles. The mandible is positioned with a gentle arcing until it freely
rotates around the musculoskeletally stable position. This arcing consists of
71
short movements of 2-4 mm. Once the mandible is rotating around the
centric relation position, force is firmly applied by the fingers to seat the
condyles in their most supero anterior position. In this supero anterior
position the condyle disc complexes are in proper relationship to accept
forces. When such a relationship exists, guiding the mandible to the centric
relation produces no pain.
TECHNIQUES FOR LOCATING CENTRIC RELATION POSITION:
In attempting to locate CR, it is important that the patient be relaxed. This
can be aided by having the patient recline comfortably in the dental chair.
The patient should be approached in a soft, gentle, reassuring, and
understanding manner, and
encouragement should be given when
success is achieved.
1. Chin-point guidance method
The patient is seated upright and relaxed
with the clinician positioned in front. A
softened two-layer wax wafer (1.4 mm
thick) is gently pushed against the cusps
of the maxillary teeth with just enough
force to make slight cuspal indentations. The wafer is removed, chilled and
re-seated in order to check fit and stability. A registration medium is applied
to the mandibular surface of the wax wafer and the patient's mandible is
guided into a hinge closure by the thumb and index finger of the operator.
The mandible is then manually maneuvered a few times about the hinge
axis. After several smooth movements the hinge closure is completed until
the mandibular teeth just indent the registration material. The risk with this
method is the ease with which the condyles can be over-retruded.
72
2. Three finger chin-point guidance method
This method is similar to the chin-point guidance method except for the
hand position of the operator. A tripod is created at the chin-point and lower
border of the mandible on both sides by the
thumb, index and third finger. Gentle
guidance along all three digits is required in
a mid-sagittal plane. This encourages
anterior-superior placement of the condyles
but care is required as it is easy to deflect
the mandible to one side. This technique is
not recommended for edentulous subjects
because the operator‟s hand position can
lead to displacement of the lower denture base. This technique is carried out
with the patient supine and the operator seated directly behind. The fifth
finger of each hand is placed behind the angle of the mandible, with the
fourth fingers positioned just in front of the angle. This permits the condyles
to be directed anterosuperiorly within the glenoid fossae. The third fingers
are placed on the inferior surface of the body of the mandible, and the index
fingers submentally in the midline. The thumbs are positioned laterally to
the symphysis. By opening and closing a few times on the hinge axis the
patient will relax and the registration can be made. This technique can also
be used for the edentulous patient assuming the lower alveolar ridge is
developed enough to allow the provision of a stable and retentive lower
base. An alternative method, with the operator in front of the patient, is to
use the index fingers to stabilize the lower record base and guidance is from
the thumbs on the chin. Smith has described a modification whereby one
73
hand can stabilize both upper and lower record bases.
3. Bimanual manipulation method
This technique is carried out with the patient supine and the operator seated
directly behind. The
fifth finger of each
hand is placed behind
the angle of the
mandible, with the
fourth fingers
positioned just in front
of the angle. This
permits the condyles to
be directed anterosuperiorly within the glenoid fossae. The third fingers are
placed on the inferior surface of the body of the mandible, and the index
fingers submentally in the midline. The thumbs are positioned laterally to
the symphysis by opening and closing a few times on the hinge axis the
patient will relax and the registration can be made. This technique can also
be used for the edentulous patient assuming the lower alveolar ridge is
developed enough to allow the provision of a stable and retentive lower
base. An alternative method, with the operator in front of the patient, is to
use the index fingers to stabilize the lower record base and guidance is from
the thumbs on the chin. Smith has described a modification whereby one
hand can stabilize both upper and lower record bases.

4. Other methods for determining centric relation or anterior centric

posture
A. Anterior bite stops
There are many different versions of anterior stops. They work well if they
permit separation of all the posterior teeth, and if the condyles are
completely free to move horizontally and vertically to their upper most

74
seated positions. Some available methods follow;
Directly fabricated anterior deprogramming device
The Pankey jig
The best bite appliance
The Lucia jig
NTI( Nociceptive trigeminal inhibition)

Leaf gauge

Disadvantages of anterior stops

During equilibrations procedures, you cannot mark the occlusal
interferences with an anterior bite stop in place. Bilateral manipulation
ensures correct condylar position during closure all the way to tooth
contact.
Even with an anterior bite stop place, load testing to verify centric
relation is the only sure way to ensure accuracy.
Load testing can be done in increments starting with gentle loading first
to rule out intracapsular disorders before firm loading by elevator
muscles when an anterior bite stop is in place.
Bilateral manipulation with load testing has proven to be accurate
without the need for added appliances.

75
 B. Techniques for obtaining centric relations advocated
by Victor.O.Lucia
 Two stage registration
 The jig technique
 The Jones bite frame

Criteria for mandible in centric relation

1 The disc is properly aligned on both condyles.

2 The condyle disc assemblies‟ area at the highest point.
3 The medial pole of each condyle-disc assembly is braced by bone.
4 The inferior lateral pterygoid muscles have released contraction and
are passive.
5 The TMJs can accept firm compressive loading with no sign of
tenderness or tension.

Criteria for condyles to be in adapted centric posture.

1 The condyles are comfortable when fully seated at the highest point
against the eminence.
2 The medial poles are braced against bone.(The disc may or may not
be interposed at the medial pole.)
3 The inferior lateral pterygoid muscle has released its contraction and
is passive.
4 The condyle-fossa relationships are at manageable level of stability.

76
 5 Just as in centric relation, the joints must be totally free of any tension
or tenderness when load tested with firm compressive force up
through the TMJs.

The criteria for accuracy in making an interocclusal bite record

1. The bite record must not cause any movement of teeth or

displacement of soft tissue.
2. It must be possible to verify the accuracy of interocclusal record in the
mouth.
3. The bite record must fit the cast as accurately as it fits in the mouth.
4. It must be possible to verify the accuracy of the bite record on the
casts.
5. The bite record must not distort during storage or transportation to the
laboratory.

The tests of accurate interocclusal record Victor.O.Lucia

The are several ways to of determining whether an inter occlusal record is

accurate

1. We should hold the wax wafer up to the light to see whether any
penetration or one / more thin spots the chances are there that it‟s
incorrect, like wise areas of thick and thin spots. Areas of penetration
or thin spots are likely to cause a slight deviation of the mandible
2. If thickness is satisfactory, we place the wafer on the upper teeth and
carefully examine it to determine whether the seat is accurate. their
must not be any „GIVE‟ in any area
3. We have the patient close in to the wafer, first guiding him as we did
during the taking inter occlusal record and then allowing him to close
77
 by his own muscle force. If there is a hesitation in finding
indentations, the inter occlusal record is probably inaccurate.
4. If the foregoing requirements are satisfied, their is only one final test
to make; we have the patient to close into the wafer and hold it firmly;
then we examine the posterior portion for any play between the teeth.
Both sides should be examined carefully.

78
 V e r ti ca l di m e n sio n
Functional and Biologic Considerations for Reconstruction of the
Dental Occlusion

There are 3 critical interfaces between muscle and bone in the masticatory
system:

1. The temporomandibular joint,

2. The periodontium, and
3. The dental occlusion.
According to Moyers and Wainright, the dental occlusion is
the most critical interface and is determined by bone growth, dental
development, and neuromuscular maturation. Structurally, the relationship
of the buccal cusps of the mandibular posterior teeth and the lingual cusps of
the maxillary posterior teeth against the opposing fossa and marginal ridges
maintain the distance between the maxilla and mandible after growth is
complete.

By definition, vertical dimension of occlusion is the distance between the

mandible and maxilla when the opposing teeth are in contact.

Functional occlusion of the dentition occurs within the border movements of

the mandible and, generally, begins with the mandible in a physiologic rest
position. The clinical rest position is highly variable and can be influenced
by a number of factors including cranial-cervical position, the presence or
absence of dentures, speech, and stress. The term rest position is also
somewhat of a misnomer, since the jaw muscles in this position do not

79
necessarily display their least amount of electromyographic (EMG) activity.
This rest, or postural, position is generally in the range of 2 to 4 mm relative
to the intercuspal position. In this position, the mandibular condyles are in
an acquired centric position, anteriorly positioned along the condylar
translation pathway. In this regard, most clinicians agree that the postural
position should not be used as a starting point in the determination of the
vertical dimension of occlusion.

In 1934, Costen described a symptom complex that included loss of dental

occlusal support, ear symptoms (such as pain and tinnitus), and sinus pain.
Since that description, others have demonstrated beneficial effects of
occlusal therapy on auditory symptoms in some patients. However,
Schwartz was unable to confirm the relationships described in Costens
syndrome. On the other hand, Agerberg has reported that the number of
missing teeth was directly correlated with increasing symptoms of
mandibular dysfunction. These findings are consistent with the report of
Pullinger et al12 that occlusal factors do contribute to specific sub
classifications of temporomandibular disorders (TMD). In this regard they
reported 5 occlusal conditions that reached significant levels of association
with TMD: anterior open bite, overjet greater than 6 to 7 mm, occlusal slides
from retruded contact position greater than 2 mm, unilateral maxillary
crossbites, and missing posterior teeth. Mejersjö and Carlsson13 suggested
that the lack of posterior occlusal support is not an etiologic factor and does
not affect treatment outcomes for most patients.

However, they were quick to point out that such an occlusal deficiency may
lead to osteoarthrosis and increased pain due to overload in these joints.

80
Under these circumstances, DeBoever and Carlsson14 considered the lack
of molar support as a perpetuating factor for TMD.

Rivera-Morales and Mohl15 presented a review of the literature regarding

the adaptability of the occlusal vertical dimension. They concluded that
postural rest position has a considerable range of adaptability to increases in
the occlusal vertical dimension. However, the range of comfort varied
considerably among individuals and even within a single individual under
different conditions. The hypothesis that increased vertical dimension will
cause an increase in masticatory muscle hyperactivity is not supported by the
literature. However, the implication that increased EMG activity would be
the natural response to encroachment on the postural position, and that this
would relate to increased muscle pain, may be invalid. Stohler16 has shown
that the injection of saline into the elevator muscles of the jaw, which
resulted in increased pain, caused a decrease in EMG activity and a decrease
in the bite force. Christensen17 noted in all of the masticatory muscles could
explain the decrease in EMG activity in the elevator muscles that were tested
by Carlson et al.18 These findings support the need to determine the
psychobiologic status of each individual patient as accurately as possible
through the history, clinical exam, and appropriate investigations. Such
information will help to establish a working hypothesis with regard to the
adaptive capacity of each patient and the potential impact of altering the
vertical dimension of occlusion on the biologic system.

81
Determinants of vertical dimension of occlusion

Although a static relationship in principle, the vertical dimension of

occlusion is initially determined by

The interaction of the genetic growth potential of the craniofacial

tissues,
Environmental factors, and
The dynamics of neuromuscular function during growth.

Maintenance of the vertical dimension of occlusion is principally related

to the

Interaction of environmental factors and

The dynamics of neuromuscular function throughout the aging
process.

According to Moyers and Wainright craniofacial morphology, growth,

and dental morphology account for much of the variability in dental
occlusion. The correlations among these 3 factors increase up to the age of
12 years.

These concepts are consistent with those of Lavergne and Petrovic, who
emphasize the relationship among 3 tiers of influences on the development
of the occlusion:

(1) The magnitude of tissue and cell growth;

(2) The spatial ordering of the facial skeleton; and

82
 (3) The dental occlusion as it affects the rate, amount, and direction of
mandibular growth.

Environmental factors play a particular role in the development of the

vertical dimension of the facial skeleton and ultimately the vertical
dimension of occlusion. Function of the upper respiratory system has been
shown in a number of studies to play a particular role in this regard. Upper
respiratory obstruction has been shown to cause changes in masticatory
muscle recruitment patterns that correlate with changes in facial soft tissue
that precede facial skeletal adaptations. Linder-Aronson suggests that, for
certain subjects, mandibular retrognathism, increased vertical facial height,
open bite, and crossbite may be due to chronic environmental factors such as
airway obstruction, and that treatment should be directed at eliminating or
reducing the environmental effects on jaw position and dental occlusion.

Biologic Adaptation.

Once growth is complete, maintenance of the vertical dimension

of occlusion is determined by the adaptive capacity of the biologic system
to insult or injury. Adaptive responses can occur within the
temporomandibular joint (TMJ), the periodontium, and the dental
occlusion. In most cases, it is the soft tissues of the TMJ and periodontal
ligament that initially respond to acute micro- and macro trauma. The
fluid compartments that are maintained within the extracellular matrix
rapidly shift in response to variations in strain patterns. The first response
within the TMJ to compressive forces is a shift in the fluids within the
disc and retrodiscal tissues. Once the strain is relieved, the fluid will
return to its original position and the morphology of the tissues is

83
maintained. However, prolonged strain with these tissues will result in an
alteration of the architecture of the collagen and noncollagen proteins and
ultimately a change in tissue morphology.

Strains beyond the levels of adaptation for the soft tissues will then result
in morphologic adaptive changes within the cartilage and bone that may
be apparent radiographicaily. Strains beyond the adaptive capacity of the
tissues will result in degeneration, a loss in vertical support, and
structural changes that have the potential to impact the vertical dimension
of occlusion. Using a 3-dimensional model of the mandible and TMJ
articulation, strain patterns within the TMJ have been shown to increase
23
with an increase in the vertical face height. Ito et al has demonstrated
superior repositioning of the mandibular condyle with anterior splints in
the absence of posterior occlusal contact. In a study reported by Araki et
al,24 the reduction of the crowns of the maxillary molars resulted in
degenerative changes in the mandibular condyles. Vertical adaptive
responses have been outlined by McNamara25 as adaptive changes
within muscle, alterations in the central nervous system, changes at the
muscle-bone interface, and changes within bone and cartilage. Enlow et
26 27
al and Harper et al have previously attributed adaptive changes
within the TMJ to extra capsular forces.

Okeson states that orthopedic stability exists when the stable intercuspal
position of the teeth is in harmony with the musculoskeletally stable
position of the condyles in the fossae. As the discrepancy between an
orthopedically stable TMJ and maximum intercuspation of the teeth
increases, there is an increased risk for intracapsular TMJ disorders to
occur. The concept of orthopedic stability takes into consideration the
84
 temporomandibular joint, the integrity of the masticatory muscles and
ligaments, and the skeletal-dental relationships. Loss of occlusal vertical
dimension may be due to attrition of the dentition, which may be acute
(iatrogenic) or chronic and may involve parafunctional activities. A
decrease in the vertical dimension of occlusion may also be associated
with internal derangement of the TMJ or osteoarthrosis. However, there
is no epidemiologic evidence to suggest that dental attrition is necessarily
associated with signs or symptoms of TMD.

When bone and muscle war, muscle never loses

-Hary Sicher

When teeth and muscle war, muscle never loses

-Peter. E.Dawson

Clinical implications

It is difficult to resolve the opinion of DeBoever and Carlsson14 that

precision-mounted study casts are not necessary as an adjunct to the
diagnosis of TMD or that occlusal reconstruction is not indicated in the
treatment of TMD. Although occlusal reconstruction may not be the
definitive treatment for a particular TMD, it is appropriate to establish a
sound structural and balanced functional base as an adjunct to overall patient
29
management. Rivera-Morales and Mohl outline guidelines for the

85
restoration of vertical dimension that include the careful mounting of study
casts to a semi adjustable articulator using jaw-relation records. This process
is then followed by diagnostic waxup and diagnostic occlusal adjustment on
additional or duplicated mounted casts. In this regard, it is prudent to
accurately assess the status of the structural occlusion in conjunction with
the dynamics of the functional occlusion using sophisticated mounting
procedures.

Such information could contribute to a better understanding of the potential

for addressing structural issues and provide information regarding factors
relating to the adaptive capacity of the patient. The goal of occlusal
reconstruction should be to achieve a structural balance to facilitate
physiologic adaptation and rehabilitation.

Nitzan30 reported that intra-articular pressures in the human TMJ were

significantly reduced after placement of an interocclusal appliance. Although
a reduction in intra-articular pressure may relieve pain resulting from
intracapsular derangement and inflammation of the retrodiscal tissues, it is
not necessarily correlated with a reduction in pain of extra capsular origin.
As Dawson31 points out, condylar access to centric relation is not dependent
on vertical dimension, and increasing the vertical dimension does not unload
the joints if the starting point is a centric relation position. This message is
critical and requires an understanding of the relationship of the dental
occlusion and condylar position within the TMJ.

For any given patient, the mandibular condyle can be in 1 of 3 positions

within the TMJ.

86
 The first position, classically defined as centric relation, implies that
the condyle within the fossa is in its most superior position against the
eminence with the disc properly aligned. This position does not depend on
tooth position or vertical dimension.

The second possible position is an acquired centric position. In this

position the condyle and disc are properly aligned; however, this assembly is
positioned anteriorly along the translation pathway.

Finally, the condyle may be in a deranged reference position within

the fossa. In this position the condyle may be in its most superior position
against the eminence; however, the disc is not properly interposed between
the condyle and fossa.

The latter 2 positions may very well contribute to an alteration of the

normal occlusion, and the vertical dimension of occlusion is affected by
each of these condylar positions. It is important to define the status of this
centric reference position prior to initiation of occlusal therapy.

Clinical Indications for Altering Vertical Dimension of Occlusion 26

In many cases it is possible to increase the vertical dimension of

occlusion if 2 foundational principles are maintained.

1. First, the starting point for reconstruction of the vertical dimension of

occlusion must be with the mandibular condyles in centric relation.
2. Second, reconstruction must be within the range of neuromuscular
adaptation for each individual patient.

87
 The difficulty is determining both of these parameters on an
individual patient basis, accurately recording the centric reference point and
transferring this information to an instrument that simulates the patient‟s
functional occlusion. The prudent course under these circumstances is to
take a diagnostic approach and formulate a hypothesis based on information
from the history, clinical examination, and investigations of condylar
position and status of the neuromuscular envelope. This hypothesis can then
be tested using reversible intervention modalities such as occlusal splints,
removable prostheses, or fixed transitional crowns prior to definitive
alteration of the vertical dimension of occlusion. The need for modification
of the initial hypothesis may become evident, or definitive treatment may be
initiated. The critical message for the clinician who has the ultimate
responsibility for this decision-making process is to establish frequent
outcome assessment protocols and to approach the practice of dentistry as a
clinical scientist.

If the increased vertical dimension is achieved by restorations that

have no other purpose, the procedure is condraindicated
Increasing the vertical dimension on only part of the dentition is
contraindicated because it leads to instability of the entire occlusal
harmony. Segmental bite raising appliances causes intrusion of the
covered teeth and supra eruption of unerupted teeth
The amount of freeway space at rest is not an automatic indication of
whether the vertical dimension can be increased. But if the
musculature is weak and not too resistive to palpation, then there may
be chances of maintaining an increase in v.d if the ample free way
space permits

88
 Closing the vertical dimension-unless it results in labially directed
stress on upper anterior teeth, there do not appear to be any problems
associated with closing the vertical
dimension on natural teeth. It does
not produce stresses since it does
not interfere with muscle lengths.
Closing the vertical dimension to
extreme degree could cause
Coronoid impingement against
zygoma.
Effect of condyle position on
vertical dimension
A safe rule :

For each millimeter of vertical

displacement of condyle [ from centric
relation to maximal intercuspation],the
vertical dimension at the anterior teeth
can be increased by 2mm without
affecting the repetitive contracted length
of elevator muscles

89
Objective vs. Subjective Methods for Determining Vertical Dimension
of Occlusion

Occlusal vertical dimension is defined as the distance measured between

two points when the occluding members are in contact.

In a denture wearer it is initially established with a maxillary and

mandibular base plate and wax rim; in a dentate person it is evaluated prior
to reconstruction and usually maintained.

The determination of occlusal vertical dimension (OVD) is not a precise

process, and many professionals arrive at this dimension through various
means.

Many determine OVD with subjective means, such as the use of resting
interocclusal distance, and speech-based techniques using sibilant sounds.

Niswonger proposed the use of the interocclusal distance (freeway space),

which assumes that the patient relaxes the mandible into the same constant
physiologic rest position. The practitioner then subtracts 3 mm from the
measurement to determine the OVD.

There are 2 aspects that often make this incorrect.

First, the amount of freeway space is highly variable in the same patient,
depending on several factors including head posture, emotional state,
presence or absence of teeth, parafunction, and time of recording.

Second, interocclusal distance at rest varies 3 to 10 mm from one patient to

another. As a result, the distance to subtract from the freeway space is

90
unknown for a specific patient. Therefore, the physiologic rest position
should not be the primary method to evaluate OVD.

Silverman5 stated that approximately 2 mm should exist between the teeth

when the S sound is made. Pound6 further developed this concept for the
establishment of centric and vertical jaw relationship records. While this
standard is accurate, it does not correlate to the original OVD of the patient.
Denture patients often wear the same prosthesis for more than 14 years and
during this time lose 10 mm or more of their original OVD. Yet, all of these
patients are able to say Mississippi with their existing prosthesis. If speech
was related to the original OVD, these patients would not be able to
pronounce the S sounds because their teeth would be more than 12 mm
apart. Patients with temporomandibular joint dysfunction with surgical
increases in OVD and patients with severe atrophy with long-term dentures
demonstrate that OVD may vary more than 20 mm, yet most of them are
able to speak clearly.

Facial measurements to determine OVD can be traced back to antiquity,

where sculptors and mathematicians followed the golden proportion, later
specified as a ratio of 1.618:1. Later, Leonardo da Vinci (1452-1519) in his
book Anatomical Studies contributed several observations and drawings on
facial proportions and the lower one third of the face, which he called divine
proportions. He wrote: The distances between the chin and the nose and
between the hairline and the eyebrows are equal to the height of the ear and
a third of the face. The distance from the outer canthus of one eye to the
inner canthus of the other eye is equal to the height of the ear and to one
third of the face height. In addition, he said facial height (from chin to
hairline) is equal to the height of the hand, and the nose is the same length as
91
the thumb (and also the same length as the distance between the tip of the
thumb and the tip of the index finger). Many professionals, including oral
surgeons, plastic surgeons, artists, orthodontists, and morticians, use facial
or body measurements to determine OVD. A review of the literature
confirms that facial measurements can be compared and help to establish the
original OVD.

The original occlusal vertical dimension is most often similar to the

following dimensions:

1. The horizontal distance between the pupils7

2. The vertical distance from the external corner of the eye (outer canthus) or
the pupil to the corner of the mouth7

3. The vertical distance from the eyebrow to the ala of the nose

4. The vertical length of the nose at the midline (from subnasion to glabella)

5. The distance from one corner of the lips to the other (cheilion to cheilion),
following the curvature of the mouth (more often in Caucasians)7

6. The distance from the eyebrow line to the hair line (in females) (da Vinci)

7. The distance from the outer corner of one eye (outer canthus) to the inner
corner (inner canthus) of the other eye (da Vinci)

8. The vertical height of the ear (da Vinci)

9. The distance between the tip of the thumb and the tip of the index finger
when the fingers are pressed together (da Vinci)

92
10. Twice the length of one eye

11. Twice the distance between the inner canthus of both eyes

12. The distance between the outer canthus and the ear (da Vinci)

Facial measurements, as a start to determine OVD, offer significant

prosthetic advantages.8,9 These are objective measurements rather than
subjective criteria (such as resting jaw position or swallowing). With so
many measurements available, the clinician may take the average of 5 or
more (especially when they are within a 1 to 2 mm range).

Once the initial OVD is determined, the wax rim or acrylic

temporaries may be used to evaluate speech, swallowing, and resting jaw
position. Since there is no absolute method to determine OVD for all
individuals, the facial and finger measurements are attractive because they
require no radiographs or other special measuring devices.

Since OVD is not a specific measurement for the majority of patients, it

may be slightly modified in the transitional stages of treatment and evaluated
relative to patient acceptance and the condylar disc assembly. Esthetic
requirements may mandate a slight decrease in OVD to make the patient
appear more Class III, or a slight increase to make the jaw relationship more
Class II. The latter is often useful in maxillary implant reconstruction cases
because a slightly open OVD usually places a more axial direction of load
on premaxillary implants in centric relation occlusion. Maxillary anterior
implants are often placed more palatally than the roots of the natural teeth. A
decrease in OVD is often used for mandibular anterior implants opposing
natural dentition because a more closed OVD places a more axial force

93
direction on these implants. Crestal stresses on bone are reduced when an
axial load is applied to implants10. In addition; bone is strongest in
compression, 30% weaker in tension, and 65% weaker in shear. A 30-degree
off-axis load reduces the strength of bone by 10% to 20%, and a 60-degree
off-axis load reduces bone strength 30% to 50%.11 Furthermore, an axial
load decreases the stresses to the abutment screw, which decreases the risk
of screw loosening.9

Facial and body parts often have dimensions that are consistently
similar to each other. The original OVD is similar to at least 12 other
dimensions on the face and hands and may be objectively determined in
most patients. The condylar disc assembly position is maintained in a broad
range of OVD. As a result, this dimension may be slightly modified to
improve appearance, help stabilize a denture, or improve the direction of
force on an implant.

94
 N e u tr al z on e
The teeth are the most movable part of masticatory system. If the
outward horizontal forces from the tongue are greater than outward
horizontal forces exerted by buccinators muscle bands and the lips,
teeth will move until the opposing forces are equal. This is the neutral
zone.

It‟s a determinant of occlusion. The neutral zone determines the

position of each tooth and establishes dimensions of entire arch
including the shape and position of alveolar processes.
There is no occlusal scheme that can stabilize teeth if they are in
unbalanced relationship with muscular forces against them.
The teeth and their alveolar process are the most adaptive part of the
masticatory system. They can be moved horizontally or vertically by
light forces.
If irregularity of tooth position, alignment or contour can be corrected
within the neutral zone, the prognosis for long term stability is good.

95
 The problem occurs when the neutral zone is not where we want the
teeth to be.
A treatment decision then must allow determination of if and how we
can change the neutral zone to orient zone where we want the teeth to
be.
Methods of altering neutral zone are

1. Orthodontics
2. Elimination of noxious habits
3. Myofunctional therapy
4. Reduction of tongue size
5. Surgical lengthening of buccinator muscle band
6. Vestibulopalsty

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 T h e e nv e l o pe o f fun c tio n
Every tooth in the mandible has an envelope of motion that
outlines the outer limits to which each lower tooth can be moved. These
limits of movements are imposed on the mandible. These limits are directly
related to the limits imposed by ligaments, bone, and muscles on
temporomandibular joint.
The envelope of function dictates the incisal edge position and
consequentially determines the anterior guidance. Envelop of function is that
functional movement of mandible occurring within the envelope of motion
and can not be determined by recording border movements of condyle.
Pantographic tracing records only the condylar border path but, there is not
enough information to determine the envelope of function that occurs within
the envelope of motion.

Variation
in the envelope
of function
result naturally
from how the
anterior teeth
were guided
during eruption
into their neutral
position by the
tongue and lips.

97
Mechano receptors in and around the teeth program the muscles for
functional jaw movement. The incisal edge position should be in harmony
with the envelope of function. The outer limits of potential jaw pathways are
not a factor in location of the incisal edges or the envelope of function
Te envelope of function is directly related to the neutral positioning of the
anterior teeth
In occlusal rehabilitations the restorations should be in harmony with
envelope of function
In harmony with envelope of function

Stable
Results in best esthetics, comfort and patient
satisfaction

Incisal edges too far back

Unstable
May result in Fremitus, excessive wear, on the labio
incisal contours of lower incisors or the lingual
contours of upper incisors, tooth movement, or fracture
of anterior laminate restorations

Incisal edges too forward

Interferes with the lip closure and neutral zone

Unstable
May result in phonetic problems or feeling that teeth
are too large too forward

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 A n te rio r g uid a n ce & sm il e d e sig n in g
Incisal guidance is the influence on mandibular movements provided by
the contacting surfaces of the maxillary and mandibular anterior teeth.
The steepness of the incisal guidance is influenced by the horizontal and
vertical overlap of the anterior teeth.
In normal occlusion, the lingual inclines (surfaces) of the six upper
anterior teeth may be considered as the incisal guide factor. The muscles
of mastication and the temporomandibular joints control the movements
of the mandible while the teeth are out of functional contact.
From the time the first tooth contact is made until all teeth are in full
functional contact, the teeth play a progressively greater role in directing
the movements of the mandible.
In the study of occlusion, we are more interested in the limited
movements made by the condyles occurring while the teeth are in
functional contact than we are in condylar movements made during the
complete cycle of mastication.

CONTROLLING FACTORS
In the occlusal rehabilitation of a natural dentition, there are three
factors which have an influence upon or establish the occlusal contour of
the posterior teeth.
1. They are the two posterior controls or the temporomandibular joints, and
2. The anterior control or the incisal guidance.

99
 When an articulating instrument is being used, the three controls are
the
1. Two condylar guidances of the articulator, which represent the two
temporomandibular joints, and
2. The incisal guidance formed by the incisal guide pin of the articulator
and the surface upon which it functions. This mechanical incisal
guidance represents the incisal guidance provided in the mouth by the
anterior teeth.
These three controls function, to a degree, separately and
independently, but if there is to be efficiency and harmony of functional
occlusion, all intermediate occlusal contours will be influenced by them and
must function in harmony with them.
IMPORTANCE OF INCISAL GUIDANCE
Much has been written about the importance of the condylar
guidances. Too little attention has been given to the incisal guidance which
equals or surpasses the temporomandibular joints in its influence upon the
functional occlusion of the dentition. It is of primary importance and should
be so recognized in the planning of all restorative dentistry from the single
inlay to complete occlusal rehabilitation.
The paths of movement of the condyle have little or no influence
upon the incisal guidance. Through the years of developmental growth, the
incisal guidance may have a definite influence upon the contours of the
glenoid fossae and the pattern of the movements of the condyles when the
teeth are in function.
Unfavorable incisal guidance may tend to produce abnormal
functional movements of the condyles. It may contribute to abnormal
stresses and movements which are potentially pathologic.
100
 A change or modification of unfavorable incisal guidance will have a
favorable influence upon the pattern of movement of the condyles. There are
right lateral, left lateral, and protrusive guide factors in the incisal guidance
which have their respective influences upon eccentric functional occlusion,
but we must visualize the tripod influence of these three factors (the incisal
guidance and two temporomandibular joints) operating in all eccentric
functional movements of the mandible.
There is a degree of resiliency and flexibility in the functional
movements of the condyles, as evidenced by their vertical translation, but
there is no flexibility or resiliency in the incisal guide factor. The incisal
guidance is controlled by hard tooth surfaces contacting opposing hard tooth
surfaces.
Three different anterior guidance patterns represent variations in the
inclination of the upper anterior teeth. The differences in the incisal edge
position also reflect major differences in the envelopes of function
If the incisal edges on A or B were moved more lingually, there would be
a conflict with
A B C
jaw function
and result
would be
excessive wear
or tooth
mobility
If the incisal
edges on C
moved towards

101
 the labial, their could be no interference to the envelope of function, but
their could be interference with neutral zone, phonetics and lip closure
path.
The process of customizing anterior guidance is designed to locate the
correct incisal edge position.

Determinants of Anterior Guidance As Being:

1. Esthetics

2. Phonetics

3. Condylar border movements

4. Positional relationship of the maxillary and mandibular anterior teeth

Without the boundaries of the anterior teeth and the neuromuscular system
the masticatory apparatus would destroy itself or muscle dysfunction would
occur.

The functions of anterior guidance are:

1. To incise food

2. To aid in speech

3. To aid in esthetics

4. To protect the posterior teeth, by directing the teeth together in centric

occlusion so that the closing forces will be vertically directed onto the
posterior teeth.

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 The anterior teeth must also allow the Bennett movement to occur so
that the final closure forces will be directed along the long axis of the
posterior teeth. This is of particular importance for the restoration of the
canines. As more Bennett movement is introduced and the angle of the
eminence is reduced more lingual concave curvature is needed. In contrast a
steep eminence will be in harmony with a small amount of lingual curvature

DETERMING ANTERIOR TOOTH POSITION AND

CONTOUR
Step1: Refine and verify lower incisal edge position,
shape, and plane. If upper anterior position ahs not been
determined, it must be done in combination with lower
determinations.
Step2: Establish centric holding stops. This is always the
first step. The correct anterior guidance cannot be
determined until all interferences to centric relation have
been eliminated.
Step 3: Lip support in line with alveolar contour. The
upper half of the labial contour can be determined fairly
well on the cast. The upper impression must include the
complete contour of the alveolar process
Step 4: Lip-closure path. This is a critical determinant for
the incisal half of labial contour. It can only be determined
in the mouth.
Step 5: Determine incisal edge length (using the smile
line). This relationship is important for phonetics of the F and V position as
well as for the best esthetics.
103
Step 6: Refine incisal edge position (using F and V
sounds). Determination must be made with gentle,
softly spoken sounds. Make sure incisal plane
contacts inner vermillion border during gentles
speech.
Step 7: Adjust for long centric (if needed). Follow
the rules for anterior guidance after centric relation
and incisal edges have been determined.
Step 8: Establish lingual contours (anterior

guidance) in harmony with the envelope of

function:

a. In straight protrusive
b. In lateral excursions.

Step 9: Evaluate S sounds. The closest speaking

position should produce no whistle or lisp.
Step 10: Evaluate cingulum contours
(using T and D). Round into centric stops.

104
To sum up anterior guidance
For optimum stability, comfort, and function, the anterior teeth must
be:

In harmony with the neutral zone

In harmony with the lips
In harmony with phonetics
In harmony with centric relation
In harmony with the envelope of function

This results in tooth position and contours that are in harmony with a matrix
of functional anatomy that also produces the most natural esthetics.

105
 L o n g c e n tric

“LONG CENTRIC IS RELLY SHORT PROTRUSIVE”-FRANK CELENZA

Long centric is a freedom to close the mandible either into

centric relation or slightly anterior to it without varying
the vertical dimension at the anterior teeth
CONCEPT of LONG CENTRIC is based on these two conflicting beliefs

Horizontal freedom is needed in the entire occlusion to accommodate

a resilient relationship at the articular surfaces
Horizontal freedom was not needed in the occlusal relationship
because there is no resiliency of articulation at the centric relation
position

A flat long centric is not needed in the posterior teeth even if it‟s
incorporated in the anterior guidance

A. The condyles cannot move horizontally

forward because they are up against the
eminentiae at the centric relation
B. They must move downward from the
centric relation to protrude the mandible.
The molars must move down with the
condyles
Long centric involves primarily anterior teeth
Long centric refers to freedom from centric, not freedom in centric

106
 T h e Oc c lu sio n P lan e
The term of plane of occlusion refers to an imaginary surface that
theoretically touches the incisal edges of the incisors and tips of the
occluding surfaces of the posterior teeth.
The plane of occlusion represents the average curvature of the occlusal
surfaces

Curves of occlusion
The composite of curve of Spee, the curve of Wilson and the curve of incisal
edges is referred as curve of occlusion
Curve of Spee
The
curve of Spee
refers to an
anteroposterior
curvature of the occlusal surfaces, beginning at the tip of lower canines and
following the buccal cusp tips of bicuspids and molars and continuing back
, it ideally follow an arc though the condyle.
Curve of Wilson
The curve
of Wilson is the
mediolateral
curve that
contacts the
buccal and lingual cusp tips on each side of the arch. It results from an
inward inclination of lower posterior teeth, making the lingual cusps of

107
lower than the buccal cusps on the mandibular arch.
There are two reasons for inclination of posterior teeth

One has to with resistance loading

Second has to do with masticatory function

Determining acceptable occlusal plane for restorative

cases
Using a simplified occlusal plane analyzer

This simplified method reduces the time required for occlusal plane
analysis because the analysis point for surveying the occlusal plane is
already related to the condylar axis. The pencil point is simply positioned
at the desired height for the lower canine, and the point of the compass is

placed on the center line of the SOPA. The compass pencil is then arced

108
back to show the occlusal plane that correctly relate to condyles. If this
plane would require mutilation of either upper or lower posterior teeth,
the compass point repositioned on the on the front or back line on the
SOPA to compensate. If an acceptable occlusal plane cannot be surveyed,
it is probable that the facebow mounting is incorrect.

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 P o steri or o c cl u si o n
The posterior teeth should have equal intensity contacts that do not interfere
with either the TMJs in the back or the anterior guidance in the front.
The key determinants of posterior occlusion are

1. Plane of occlusion
2. Location of each lower buccal cusp tip
3. Position and contour of each lower fossa

These key determinants are important because once these decisions

are made; all other aspects of posterior occlusion are relative to them

Restorations of posterior teeth should not be considered until the

condyles can be positioned with an acceptable comfort in centric relation

Restorations of posterior teeth should not be completed until the anterior

guidance is correct. The fossa contours are directly related to anterior
guidance and cannot be determined accurately until the anterior guidance
paths have been finalized.

Posterior teeth in the lower arch can be accurately restored with cusp-tip-
to-fossa contact if the following determinations can be made

1. Correct height and placement of buccal cusps

2. Correct height and placement of lingual cusps
3. Correct placement of fossae
4. Correct inclines for fossae walls

110
 Types of posterior occlusal contours

1. Selection of the type of centric relation contacts

2. Determination of the type and distribution of contact in lateral
excursions
3. Determination of how to provide stability to the occlusal form
i. Selection of the Types of centric holding contacts

Centric relation contact is usually established on restorations in one of three

ways

1. Surface-to- surface contact-[ mashed –potato occlusion]

2. Tripod contact
3. Cusp-tip-to-fossa contact

ii. Variations in posterior contact in lateral excursions

As the mandible moves laterally, the lower posterior teeth leave their centric
contact with upper teeth and travel sideways down a path dictated by the

111
condyles in the back and by the lateral anterior guidance in the front. The
movements can be divided into;
Working side occlusion
- contact at the side of rotating condyle
- side towards which the mandible moves
- condyle is braced against the bone / ligament
through out the working excursion
- so it is possible to accurately record and restore the
posterior teeth to precise working side border
movement contacts
Nonworking/non functioning side occlusion
- contact at the side of orbiting condyle
- Condyles leaves its braced position and slides
forward down the slippery inclines of the
eminentiae,
- So it‟s no longer fixed against the underlying bone
or ligament, it can move up.
- So tooth contact during nonfunctioning side
excursions should not be allowed
The job of discluding the nonfunctioning side is always the responsibility
of working side
The dentist must decide the choice of working side occlusion
1. Group function
2. Partial group function
3. Posterior disclusion

Group function refers to the distribution of lateral forces to a group of teeth

rather than protecting those teeth from contact in function by assigning all
forces to one particular tooth.
Group function is indicated wherever the arch relations does not allow the
anterior guidance to do its job of discluding the non functioning side
Eg.
- Class –I occlusion with extreme over jet

112
 - Class –III occlusion with all lower anterior teeth
outside the upper anterior teeth
- Some edge to edge bites
- Anterior open bite

Partial group function refers to allowing some of the posterior teeth to

share the load in excursions, whereas others contact in only in centric
relation

Posterior disclusion refers to no contact on any posterior in any position but

centric relation. It can be accomplished easily by cusp-tip to- fossa
occlusion.
Two Methods of accomplishing posterior disclusion
a) The anterior guidance is harmonized to the functional
border movements first, and then the lateral inclines of the
posterior teeth are opened up so they are discluded by a
correct anterior guidance
b) The posterior teeth are built first and then discluded by
restriction of anterior guidance. This method is backward.
Anterior guidance is a proper determinant of posterior
occlusal form and thus should be done first.
iii. Selecting occlusal form for stability
Assuming the cusp fossa relationships are correctly placed for ideal direction
of stress we must still make decisions regarding the number of contacting
cusps that are needed for maximum stability under differing conditions. We
normally have four basic types to chose from in normal arch relationships

Type-I; Lower buccal cusps contact the

upper fossae. There are no other centric
contacts

Advantages

113
 Very comfortable
Easy to contour and fabricate

Disadvantages

Lack of dependable buccolingual stability

Pressure from tongue can tilt the teeth towards the buccal
Upper lingual cusp contact would give it, more follow up occlusal
adjustment is necessary

Type-2; Centric contacts on the tips of lower buccal cusps and upper
lingual cusps

Advantages

Greater stability of the posterior

teeth
Lateral stresses are restricted
toward the buccal
Stresses towards the lingual is
restricted
Vector of the force against the cusp tip fossa is directed toward the
long axis when the teeth are stressed laterally.

Type- 3; Centric contact on the tips of

lower buccal cusps and upper lingual
cusps

114
 Type-4; Tripod contact. There are two types of tripod contact;

Contacts on the sides of the cusps and walls of the fossae and
Contacts on the brims of the fossae and on the tops of wide cusp
tips

Advantages

May be used with vertical or near vertical

functioning cycles with either canine
protected occlusion or anterior protected
occlusion

Dis advantage

Difficult in fabricating

Several types of occlusal form can be used to restore posterior teeth. What
ever contour is selected should be chosen because it;

1. Direct the forces as near parallel as possible to the long axis of each
tooth.
2. Distribute the lateral stresses to maximum advantage in varying
situations of periodontal support.
3. Provides maximum stability.
4. Provides maximum wearability.
5. Provides maximum function for gripping, grinding and crushing.

115
 D i socc l u sion
Disocclusion is defined as “the separation of opposing teeth during eccentric
movements of the mandible” (GPT-5, 1987)
1. Mechanism of Disocclusion
2. Amount of Disocclusion
3. Influences on the amount of Disocclusion
4. The necessity for Disocclusion
Mechanism of Disocclusion

The mechanism of Disocclusion during protrusive movement is illustrated

The mechanism of Disocclusion I

When the sagittal inclination of the

condylar path is 40o, the condylar and
incisal path are parallel, and the cusp
angle of maxillary and mandibular
molars is also parallel to both
condylar and incisal paths

Here the mandible on protrusive

movement does not rotate around the
intercondylar axis but only translates. Since the maxillary and mandibular
molars slide in contact during eccentric movement, Disocclusion does not
occur

116
The mechanism of Disocclusion II

If the sagittal condylar path inclination is

40o, the cusp angle parallel to condylar
path but the incisal path steeper than the
condylar path
Here the mandible translates and rotates
around the intercondylar axis, the
maxillary and mandibular molars disocclude
The component of Disocclusion occurring when the incisal is steeper
than the condylar path is referred anterior guide component of the
mechanism of Disocclusion
Mc Horris 1979 –recommended that the incisal path that the should be 5
degrees steeper than the condylar path and computed amount of
Disocclusion is only 0.2 mm,
If the incisal path steeper than 5o, the patient will experience discomfort

The mechanism of Disocclusion III

If the sagittal condylar path

inclination is 40o,the condylar
path & incisal path are
parallel; cusp angle shallower
than condylar path.
Here the mandible does not
rotate around inter condylar

117
 axis, it only translates, since cuspal angle is shallower than condylar path,
the maxillary & mandibular molar disocclude thus the component
influencing the amount of disocclusion when the cusp angle is shallower
than the condylar path is referred to as cusp shape component” as a
mechanism of disocclusion

The mechanism of Disocclusion IV

If the sagittal inclination of

the condylar path is 40o, the
incisal path steeper than the
condylar path and the cusp
angle shallower than the
condylar path
Here the mandible
translates and rotates
simultaneously around the
inter condylar axis
By the additive effect of anterior guide component caused by the
mandibular rotation and the cusp shape component occurring when cusp
slope is shallower than the condylar path, the maxillary and mandibular
molars disocclude widely
This condition is often seen in healthy individuals

118
Amount of disocclusion

The concept of disocclusion is widely accepted today, most commonly

described as the separation of posterior teeth during eccentric movement.
But it‟s not clear about the amount of disocclusion

The amount of disocclusion has never defined but was observed subjectively
using the dentist visual judgment. However, visual observation from buccal
approach tend to miss the disocclusion occurring on the lingual side

119
 Instr um ents Used F or Occlusal A nalysi s
a n d T r ea tm e n t
Determine exactly what the requirements for a perfected occlusion; then use
whatever instrumentation is required to fulfill those requirements
By reviewing the requirements for a perfected occlusion we can determine
the most logical instrumentation prerequisites for fulfilling each goal
1. Unrestricted access of the condyles to complete seating in centric
relation
2. Nondeflected closure of anterior contact in centric relation
3. Simultaneous, equal intensity contact of posterior teeth in harmony
with completely seated condyles, and centric relation contact of
anterior teeth.
4. An acceptable plane of occlusion and incisal plane
5. An anterior guidance in harmony with the envelope of function.
Lets relate each of the stated requirements for an ideal occlusion to the
instrument choices in available for satisfying these requirements in the most
efficient and cost effective way.

The instruments used effectively for diagnosis and treatment planning of

occlusal rehabilitations include the following types;

- Fully adjustable articulators

- Semi adjustable articulators
- Set condylar path articulators
- Combinations

120
Any of the above types of instruments can be used with great success if the
operator understands the goals of occlusal diagnosis or therapy.

The major difference in the various types of articulators is related to

variations in how the articulator duplicates the patient‟s condylar paths. In
evaluating an articulator, one should understand that no matter how
sophisticated the instrument is, it still do no more than the following
regarding the condylar movements;

1. Reproduce horizontal axis of condylar rotation

2. Reproduce vertical axis of condylar rotation
3. Reproduce sagittal axis of condylar rotation
4. Permits simultaneous multiple axes of rotation during condylar
translation
5. Permits straight protrusive paths for each condyle
6. Reproduce the paths of each condyle during straight lateral excursions
of the mandible

121
 7. Reproduce multiple paths of each condyle during all possible
excursions of mandible between straight lateral and straight
protrusion.

Only very few instruments are capable of reproducing all the seven condylar
movements without some interpolation. The first six can be reproduced in
most high quality gnathologic instruments

Fully adjustable articulators

The term fully adjustable refers to reproducibility of condylar paths.

Any variation from one type of fully adjustable articulator to another will
be limited to mechanical variations that affect the ease of reproducing
condylar paths

There are two basic methods of recording the condylar paths;

Stereographic and
Pantographic tracings

Stereographic instruments – Simplest fully adjustable articulator. All the

border movements can be recorded accurately in three dimensions by means
of simple intraoral clutches that are stabilized by a central bearing point.

The recordings are made by intending three or four points into doughy self
curing acrylic resin on the surface of the opposite clutch and then moving
the mandible through all border movements.

The condyle paths on the instrument are generated directly into a doughy
mix of resin when the articulator bows are moved through all excursions

122
while the recording studs on the lower clutch track in all the stereographic
paths on the upper clutch

Stereographic techniques have an advantage in the use of the three

dimensional recordings. All the border movements can be programmed into
the condylar guidance, including protrusive and lateral movements

Pantographic recordings-

Pantographs record the mandibular movement in relation to the

established plane in the face in all three planes with the help of graphic
records.

Semi adjustable articulator

 The difference between fully adjustable and semi adjustable

articulator is that the condylar pathways are limited to straight lines
for semi adjustable articulators

 Because of these limitations these instruments are referred to as check

bite articulators.

123
  This means that the horizontal condylar paths are said to align with a
bite record made at centric relation and another bite record made in
protrusive position

 The resultant path is a straight line between the two points

 The advantage offered by straight line pathway in protrusive

movement is that it gives a build in safety factor for necessary
disclusive effect

 Actually the condyles follow convex path which is not copied in the
articulator

 Only the two points of check bite position will be correct

 But the path between the two points will be flatter than the actual
convex path

 This automatically produces a separation from any restorations made

on the straight path when the condyles follow convex path in patient

Requirements-

 Must accept facebow

 Must have positive centric lock
 Must have adjustable incisal guide pin that permits changes in vertical
dimension without moving the position of the pin on the guide table
 Must have provisions for transferable customized anterior guide table
 Must permit the cast to be secured by removable mounting rings
0 0
 Must have condylar paths that are adjustable from 0 to 60
0
 Must have progressive side shift path of atleast 15
 Must have intercondylar width of approximately 110mm(adjustability
of this factor is not a critical factor)

Set path articulators

124
  A 200 horizontal and 150 lateral path works well for achieving
posterior disclusion in majority of the patients

 Articulators based on this setting are set path articulators

 They have features of a acceptable semi adjustable articulator except

condylar paths fixed

 Most set path articulators have set anterior guide angle which is
unaccepted.

 Acceptable for majority of restorative procedures but unacceptable for

patients with occlusal plane problems or inadequate anterior guidance.

Facebow
 A face-bow is a caliper-
like device used to
record the spatial
relationship of the
maxillary arch- it
relates the maxillary
teeth to a horizontal
plane utilizing the
condyles and an
anterior reference point on the face, and then transfers the same
relationship to the condylar elements of an adjustable articulator.
It’s used to mount the maxillary cast to the upper member of the
articulator.

125
Hinge Axis
 Analysis starts not with the teeth but with the jaw. The mandible moves
on hinge axis, through an arc of rotation, the center of which is the
temporomandibular joint.
 The semi-adjustable articulator is
this instrument. The articulator
itself is nothing more than a hinge.
However, to make this instrument
effective, the correct center of
rotation, the condylar hinge axis
must be located on the patient and
then transferred into the articulator.
 This is accomplished with a facebow.

 When the diagnostic casts have been facebow mounted on an articulator

in this manner, the casts can be moved to reproduce the patient's jaw
movements in function, and cusp tips can be placed accurately.
 When the patient receives the restoration, the opposing teeth will meet
the way the restoration was planned, because the mandible will be
moving on this same hinge axis. This is a key step.
 If casts are mounted by hand, on an arbitrary hinge axis, then when the
restoration is tried in, the cusps will strike in different places as the
mandible moves. It's for this reason, that cases fitting well on the model
require time-consuming intraoral adjustments

126
THE FACEBOW --function:
1. The function of the face bow is to record the relationship of the
maxillary arch to the horizontal axis of rotation of the mandible
(sometimes referred to as the terminal hinge axis).
2. Three points of reference are necessary to order to designate a plane.
3. The points needed in order to utilize a face bow are:
4. 1 &2 -- The two skin points that describe the exact or arbitrary points
where the horizontal axis passes through the skin serve to designate
two of the points of the plane of orientation of the facebow
5. When an earpiece facebow is used, the two points where the ear rods
of the facebow enter the external auditory meatus of the ear serve as
the two points of orientation.
6. 3--the third point of reference is located on the face at a point that will
assist the convenient location of the maxillary cast between the upper
and lower members of the articulator.
7. This point of reference may vary depending on which brand of
articulator is used.
8. Having completed the facebow registration, the maxillary cast can be
mounted in the articulator in relationship to the condylar mechanism
and the horizontal plane of reference.

127
TYPES OF FACEBOWS
2 types of face-bows

Kinematic (Hinge -axis) Face-bow

 A face bow that locates the maxillary teeth/cast to the exact hinge
axis/ point of pure rotation of the condyles most accurate, most
complicated- used with fully-adjustable articulator
 A more precise location of the horizontal axis can be made with a
kinematic registration of this axis using a kinematic registration bow.
 The exact location of the points where the axis passes through the skin
is a time consuming clinical endeavor requiring special
instrumentation.
 The precise location of the horizontal axis of rotation is demanded by
the techniques necessary to do extensive restorative procedures.
Arbitrary Face-bow
 A face bow that relates the maxillary teeth/cast to the condylar
elements based upon anatomical estimates reasonably accurate, less
complicated- used with semi-adjustable articulator
 The simple facebow can be utilized to transfer the relationship of the
maxillary arch and an average intercondylar axis.
 The axis can be designated either arbitrarily (average measurement along
the Frankfort Horizontal Plane) or by the position of the ear rod in the ear
canal.
 The difference in the position of the ear bow position is accommodated
for by the design of the articulator and its ear bow receiver points.
 Variations between the point location of the arbitrary and hinge axes
has been demonstrated as sources of error in the fabrication of
extensive dental restorations
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The reality of face bow
The purposes of facebow transfer what to be.
1. The reappearance of The Bonwill's triangle.
2. Reappearance on the Balkwill angle
3. The reappearance of the hinge opening and closing mouth movement axis
4. The reappearance of the opening and closing mouth way of the
mandibular movement
5. The improvement of the reappearance of the mandibular movement
6. The prevention of the premature contact in the prosthesis
7. The establishment standard of the anterior guidance
8. The establishment standard of tooth shaft and overlap
The above thing can be reproduced by doing a facebow transfer.
For clinician, the facebow transfer which can get much information like this
at a time is an absolutely necessary method.

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 E xam i na tion , Diag n o si s, T re atm en t
P la nni ng In FM R
As with any other procedures, the patients with occlusal problems should be
treated as a whole. A through examination of the patient and evaluation of
all the available data are the essential elements necessary for comprehensive
diagnosis and treatment planning.
Diagnosis data are obtained by

1. Visual and digital examination of the oral cavity and associated

structures
2. Medical and dental histories
3. A complete series of roentgenograms
4. Properly oriented cast on an adjustable articulator

Roentgenograms will reveal

1. Extent of carious lesions

2. Type and amount of alveolar bone
3. Presence or absence of any periapical infection
4. Furcation involvements
5. Size, shape and position of roots
6. Condition of supporting structures and teeth
7. Impactions or retained root
8. Status of Endodontically treated teeth
9. Ratio of remaining alveolar bone to the length and width of roots;
stress bearing ability of periodontium
10. Crown –root ratio

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 11. Conditions of coronal portion of the teeth
12. Pulps of the teeth
13. Periodontal ligament space
14. Vertical bone loss
15. Laminadura

Diagnostic casts provides

1. Discrepancies between habitual centric and centric relation, influence

of prematurities
2. Excursive contacts can also studied and if worn facets of occlusion are
evident
3. Relation in size and position of opposing arches
4. Jaw to jaw relations
5. Tooth to tooth positions
6. Overjet and overbite relations
7. Coronal proximal contacts, embrasures and occlusal forms of the teeth
8. Plunger cusps
9. Edentulous areas – form and size of space. Evaluation of its use for
fixed or removable prosthesis
10. Degree of compensating curves- curve of Spee, curve of Wilson
11. Tilted ,rotated or extruded teeth
12. Topography of marginal ridges of teeth
13. Plane of occlusion
14. Vertical dimension – whether to increase or decrease?
15. Attrition and erosion patterns
16. Axial positions of the teeth
17. Cuspid relationships, type of occlusal pattern.

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 BECKER’S Classification & his treatment plan for patients requiring
FMR
Patients in need of occlusal reconstruction may be classified into four main
groups with subordinate classes.

Group I

Class 1 Includes patients in whom there is a collapse in the occlusal

vertical dimension because of the shifting and movement of existing teeth
brought about by failure to replace missing ones, or because of a systemic
disease, or because of a periodontal disease.

Class 2, Includes patients in whom the occlusal vertical dimension is lost

because all the posterior teeth in one or both the casts are absent and those
remaining are in an unsatisfactory occlusal relationship.

Class 3, Includes patients in whom there is a decrease in the occlusal

vertical dimension because of abnormal excessive occlusal and incisal wear.

Group II

Class 1 Includes patients with all or sufficient natural teeth in each jaw and
possessing a satisfactory occlusal relationship.

Class 2 Includes patients possessing a limited amount of occluding teeth in a

satisfactory occlusal relationship but requiring aid in maintaining that
relationship in the form of a preliminary occlusal rim.

Group III

Includes patients who require maxillofacial surgery or orthodontic treatment

as an aid in restoring the occlusal vertical dimension

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Group IV

Includes patients for whom sectional treatment is recommended over

extended periods because of the health of the patient, the age of the patient,
or the economic factor.

There are persons who are included in any combination of these four
groups and classes.

Dawson’s treatment planning for patients with occlusal problems

Dawson’s lists five choices for treatment and three treatment options for
each requirement of occlusal stability. They are

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Five choices of correction are
1. Reductive shaping
2. Repositioning
3. Additive reshaping
4. Surgical repositioning of dentoalveolar process without changing the
skeletal base
5. Surgical repositioning of skeletal segments in relation to cranial base
Three treatment options are
1. Provide the unfulfilled requirement
2. Substitute for the unfulfilled requirement
3. Eliminate the need for unfulfilled requirement.

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 Dia gnostic W ax Up
Process of converting a programmed treatment plan into a three
dimensional visualization.
Programmed treatment planning is utilized step by step to determine the
best choice of treatment.
It is how the sequence that must be followed is planned to achieve a
visualized end result.
Step 1: Mount upper and lower casts with centric relation bite record and
facebow. Duplicate the casts to preserve the
original conditions.

Step 2: Verify the accuracy of the mounting.

Step 3: Examine the occlusal relationship on

the casts. Note the first tooth contact. Note the relationship of all other teeth
when the first tooth contacts at centric relation.

OBJECTIVE- To achieve centric relation contact on all teeth However, one

should start by determining what must be done to achieve contact of the
anterior teeth.

Step 4: Lock the centric latch when observing the casts. Determine what
would be the best choice of treatment to get the back teeth out of the way.
Start with equilibration. Can it achieve front tooth contact without mutilating
the posterior teeth?

Step 5: Determine the correct vertical dimension. Unlock the centric latch
and close the teeth into maximum intercuspation. This is the vertical

135
dimension established by the elevator muscles. Lower the incisal guide pin
so it touches the guide table.

Step 6: Return the Condyles to centric relation and lock the centric lock.
Observe the incisal pin in relation to the guide table. This will show the
amount of closure needed to achieve the same vertical dimension of
occlusion (VDO) in centric relation.

OBJECTIVE- Occlusal interferences should be eliminated by selective

grinding on the casts until the incisal pin
contacts the guide plate. At that point, the
original vertical dimension will have been
reestablished in centric relation. If a
change in VDO is needed to fulfill
requirements for stability, it can be
determined now.

Step 7: Observe the teeth that were reshaped. If reductive reshaping is

mutilative to teeth that do not need restoring, consider one of the other
options for achieving centric relation
contact on all of the teeth.

Note: Also consider the possibility of

the tongue position preventing
complete full arch contact.

Step 8: Remove unsavable teeth from the casts. From the clinical exam, all
teeth that cannot be saved are marked with an X. At this stage of treatment
planning, do not remove any teeth that can be maintained. That decision
should wait.
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Objective: Removing hopeless teeth from the cast often changes the entire
treatment planning process. It permits use of the cut off teeth in
repositioning decisions to achieve holding contacts or improved incisal
plane. It also simplifies decisions regarding treatment choices of fixed versus
removable prostheses or selection of implants.

Step 9: If decisions have been made at the exam to use certain types of
restorations, mark this on the cast.

Step 10: Equilibration is the first treatment option to explore.

Objective: To see if anterior contact in centric relation can be achieved by

equilibration without mutilating teeth that would not otherwise need
restorations.

Step 11: Examine the plane of occlusion. If the casts were mounted with a
facebow that was parallel with
the eyes, the incisal plane and
the occlusal plane will relate to
the bench top. If the occlusal
plane is slanted in the mouth,
it will be slanted on the
articulator.

Objective: With a true

representation of the occlusal
plane on the articulator, a
treatment choice can be
selected that will correct the
problem. It is obvious on these casts that simply reshaping or restoring the
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 teeth will not solve the occlusal plane
problem. Consultation with a surgeon or
orthodontist would be in order.

Decisions regarding the occlusal plane are

often critical to the planning of the entire
restorative process. Occlusal plane analysis
in relation to the Condyles is an important
relationship to consider in order to remove
the protrusive interference to the anterior
guidance

The occlusal plane is established by the

simplified occlusal plane analyzer (SOPA).

The model is trimmed back to the established

new occlusal plane.

The buccal surfaces have to contour

to move the cusp tip more in line with
the upper teeth .The wax up is
completed.

These corrected casts are now used to

form a putty matrix for fabrication of provisional restorations. They are also
the perfect visual aid when presenting the treatment plan to the patient.

Step 12: Establish stable holding contacts on the anterior teeth. This is the
most important step in the diagnostic wax up. It cannot be determined how it

138
can best be accomplished until the decisions have been made to get the back
teeth out of the way of complete closure in centric relation.

Objective: Relating the lower incisal edges to an acceptable alignment and

contour of the upper anterior teeth.

Unmounted casts do not provide the information needed to fulfill this

objective. Anterior contact can only be determined at the correct jaw-to-jaw
relationship. That is why casts must be mounted in centric relation.
Unmounted casts cause missed diagnoses, wasted time and unstable
restorative results due to missed anterior relationships.

Mounted casts permit analysis of the occlusion to determine if contact from

centric relation through the range of anterior guidance can be achieved
without interference from posterior teeth. This analysis is important because
in many cases, anterior contact may be lost when the mandible is permitted
to close back in centric relation. Knowing this before equilibration enables
the dentist to plan the best way to establish holding contacts on the anterior
teeth in centric relation and ensure that the anterior guidance can disclude all
of the posterior teeth in excursions. Often this can be achieved with a simple
buildup restoration on the canines, but in other patients a better solution may
be slight movement of a few teeth.

Step 13: Correct lower incisal edges if needed. This refers to both position
and contour. If the position of the lower incisors does not permit anterior
holding contacts, the correction may involve the contour and position of
both the upper and lower anterior teeth.

Step 14: Start with the lower anterior teeth.

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Objective: To establish correct incisal edge contour. That means a definite
labio-incisal line angle. It also means ideal esthetic contour of the lower
incisal edges.

Anterior incisal edges that have worn the

leading edge to a slanted contour must be
restored to provide a stable holding contact with
the upper anterior teeth. It is during this wax-up
procedure that some important treatment
decisions can be made:

Determine the type of restoration.

Can the incisal edge be restored
with a laminate, or will full
coverage be needed?

Remember that the leading edge of

the lower incisors must have a definite labio-incisal line angle.

Determine the position and contour of the incisal edge. Can the incisal edge
be moved forward or backward if needed to achieve a stable contact? Can it
be done by restoration, or must the tooth be moved?

Determine the type of preparation needed. If the teeth are worn to a thicker
incisal edge, should prep reduction be more on the lingual or on the labial to
facilitate a normal edge contour in best alignment with the upper?

Why start with the lower?

The main reason for starting with the lower anterior teeth first when doing a
diagnostic wax-up is that it simplifies the whole wax-up. The range of

140
change in position of lower anterior teeth is minimal compared with the
upper anterior teeth. The anteroposterior position of lower anterior teeth has
very little flexibility, and their position in the narrow alveolar ridge is quite
limited. The height of lower incisors is also within a limited range that is
consistent with the height and contour of the occlusal plane.I find it a very
useful process to remove the upper cast and just idealize the lower incisal
plane and posterior occlusal plane. This is done by any combination of
reduction and/or addition of tooth material by grinding on the model and/or
waxing contours. When necessary to align contacts, teeth on the model can
be moved, but movement forward of backward by lower anterior teeth is
limited.

Even though the upper cast is removed for the wax-up of the lower arch, it is
nevertheless observed in a centric relation position after the casts are
equilibrated so it will be recognized if lower incisal edges must be moved to
achieve contact with the upper anterior teeth. At this time some tentative
decisions are also made regarding whether the upper anterior teeth will need
to be moved to achieve acceptable contact with the idealized position of the
lower incisal edges.

Step 15: Reevaluate the total occlusion with the upper cast to see how it can
be adapted to occlude with the lower arch. It may require some modification
of the lower wax-up, but it is usually a minimal correction.

Step 16: Establish holding contacts on the upper anterior teeth. The same
five treatment options can be considered to achieve an ideal occlusal
relationship.

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Objective: The wax-up of the upper anterior teeth is designed to develop
your best guess for upper anterior position and contour. If there are to be
changes in the position of the upper incisal edges, the wax-up will be used to
form a matrix for fabrication of provisional restorations. The provisional
restorations can be then modified in the mouth.

Fabrication of the best-guess contour for the upper anteriors is guided by

photographs of the mouth and other clinical observations made at the
examination appointment.

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 R ol e of O cclusal Spl ints i n FM R
Most occlusal splints have one primary function: to alter an occlusion so
it doesn‟t interfere with complete seating of the condyles in centric relation.

Occlusal splints are predictably effective if properly designed and accurately

fabricated for certain specific problems that are related to occlusal factors.

Types of occlusal splints

Every occlusal splint either by accident or design falls into one of two
categories. There are only two types of occlusal splints.

1. Permissive occlusal splints- have a smooth surface on one side that

allows the muscles to move the mandible without interference from
deflective tooth inclines, so the condyles can slide back and up the
eminentiae to complete seating into centric relation. The smooth surface can
face either the lower or the upper arch as long as it frees the mandible to
slide to centric relation.

The primary function of occlusal splints is to alter an occlusion so it does not

interfere with complete seating of the condyles which can be accomplished
by separation of all posterior teeth, allowing only anterior tooth contact
against a smooth flat surface, or by allowing any segment or all of the
occlusal surfaces to freely slide against a smooth surface.

2. Directive occlusal splints- direct the lower arch into a specific

occlusal relationship that in turn directs the condyles to a predetermined
position. Directive splints have very limited use. They should be reserved for
specific conditions involving intracapsular TMDs.

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Upper or Lower Splint?

• The critical factor regarding the effectiveness of any splint, upper or

lower, is whether it completely frees the mandible to move to and from
centric relation. The decision of which type of splint to use should be based
mainly on comfort and unobtrusive esthetics.

• For many patients, a lower splint is preferable because it interferes

less with speech, and flatter anterior ramping is sometimes easier to
accomplish without crowding the tongue.

Principles of Full Occlusal Splint Design

1. The splint should allow uniform, equal-intensity contacts of all teeth

against a smooth splint surface when the joints are completely seated in
centric relation.

2. The splint should have an anterior guidance ramp angled as shallow as

possible for horizontal freedom of mandibular movement.

3. The splint should provide immediate disclusion of all posterior teeth

in all excursive jaw movements from centric relation.

4. The splint should fit the arch comfortably and have good stable
retention.

How Long the Splint must be worn?

The splint should be worn until the following requirements are attained:

1. All related pain is gone.

2. The joint structure is stable.

3. The bite structure is stable.

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 P ri nc ip l e s o f O cc lusa l C or re c ti on / O c cl u sa l
E qu ilib ra ti on
OCCLUSAL THERAPY

Occlusal therapy is any treatment that alters a patient‟s

occlusal condition. It can be used to improve function of the masticatory
system through the influence of the occlusal contact patterns and by altering
the functional jaw position. There are two types: reversible and irreversible.

Reversible Occlusal Therapy

Temporarily alters the occlusal condition or joint position but

when removed returns the patient to the pre existent condition. An example
would be an occlusal appliance. When the occlusal appliance is worn, it
creates favorable alteration in the occlusal contacts and joint position. When
it is removed, the patient‟s original occlusal condition returns.

Irreversible Occlusal Therapy

Permanently alters the occlusal condition so that the original

condition cannot easily if at all return. An example would be selective
grinding of the teeth whereby the occlusal surfaces of the teeth are reshaped
to develop a better contact pattern in a more favorable joint position. Since
this procedure involves the removal of enamel, it becomes irreversible and
therefore permanent. Other forms of irreversible occlusal therapy are fixed
prosthetic procedures and orthodontic therapy.

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PROPER EQUILIBRATION: What does it mean?

Proper equilibration is designed to eliminate all premature or

deflective tooth contacts that prevent the condyles-disk assembly from
completely seating in their respective fossa (centric relation) when the jaw
closes to maximum intercuspation.

For this to be successful, the TMJs must be able to accept firm

loading with no sign of discomfort. If the TMJs are disordered so they
cannot comfortably accept loading, direct irreversible occlusal changes are
contraindicated. But if the TMJs can comfortably accept firm loading, they
will predictably be comfortable with a perfected occlusion that is in perfect
harmony with the comfortably seated TMJs.

DEFINITION: Occlusal adjustment is a procedure whereby selected areas of

tooth surface, in dentate or partially dentate patients, are modified to provide
improved tooth and jaw stability and to direct loading to appropriate teeth
during lateral excursions. Recently, a new definition has been proposed to
replace the previously used term of occlusal adjustment or occlusal
equilibration.' The new term occlusal reshaping is defined as alteration of the
occlusal surfaces of teeth to provide greater functional harmony. Occlusal
reshaping is a common clinical and laboratory procedure used to eliminate
eccentric deflective occlusal contacts and to provide for a stable maximum
intercuspation. It may be carried out to reduce plunger cusps, over-erupted
posterior teeth with unopposed contacts, wedging or locking effects of
restorations or extruded teeth, each of which may prevent freedom of the jaw
to move anteriorly and laterally without tooth contact interferences.
Selective grinding has also been used as an adjunct treatment in different

146
disciplines, including periodontics, orthodontics, general restorative
dentistry and endodontics.

AIMS OF OCCLUSAL ADJUSTMENT

To maintain intra-arch stability by providing an occlusal plane with

minimal curvature anteroposteriorly and minimal lateral curve. This
minimizes the effect of tooth contact interferences.

To maintain interarch stability by providing bilateral synchronous

contacts on posterior teeth in RCP and ICP at the correct occlusal vertical
dimension (OVD). Supporting cusps of posterior teeth are in a stable contact
relationship with opposing fossae or marginal ridges.

To provide guidance for lateral and protrusive jaw movements on

mesially directed inclines of anterior teeth, or as far anteriorly as possible.
Posterior guiding contacts are modified so as not to be a dominant influence
in lateral jaw movements. This is a commonly accepted practice in
developing a therapeutic occlusion as it is clinically convenient. However,
there is inadequate evidence from controlled studies to justify its routine use
in the natural dentition.

To allow optimum disc-condyle function along the posterior slope of

the eminence, by encouraging smooth translation and rotation of the
condyle.

To provide freedom of jaw movement anteriorly and laterally. This

overcomes a restricted functional angle of occlusion (FAO) caused by in-
locked tooth relationships. A restricted FAO arises in the following types of
tooth arrangements: deep anterior overbite, under contoured restorations

147
with loss of OVD, extruded teeth and plunger cusps. This has been a
traditionally accepted practice in restorative dentistry. Although there appear
to be subjective benefits for the patient, these are not verified by controlled
clinical trials.

EQUILIBRATION PROCEDURES Equilibration procedures can be

divided into four parts:

1. Reduction of all contacting tooth surfaces that interfere with the

completely seated condylar position (centric relation).

2. Selective reduction of tooth structure that interferes with lateral

excursions. This will vary as the influence of the anterior guidance varies to
accommodate to individual chewing cycles. It will also vary, as necessary, to
minimize lateral stresses on weak teeth.

3. Elimination of all posterior tooth that interferes with protrusive

excursions. This must be varied in arch-to-arch relationships in which the
anterior teeth are not in a position to disclude the posterior teeth in
protrusion.

4. Harmonization of the anterior guidance. It is most often necessary

to do this in conjunction with the correction of lateral and protrusive
interferences.

These are basic rules to follow for each of these procedures.

148
GRINDING RULES:

Learning where to grind is the key to eliminate mistakes and wasted

time. The process can be made a lot simpler by understanding some basic
rules

. RULE 1: Narrow stamp cusps before reshaping fossae.

RULE 2: Don‟t shorten a stamp cusp

RULE 3: Adjust centric interferences first.

RULE 4: Eliminate all posterior incline contacts. Preserve cusp tips only.

Equilibration procedures in a Nutshell

1. Find and verify centric relation or adapted centric posture (ACP).

Rule out intracapsular disorders

2. Mount casts with a facebow and a centric relation or adapted

centric bite record.

3. Analyze casts to make sure that equilibration is the best choice of

treatment.

4. Eliminate all deflective inclines that interfere with complete closure

in centric relation or ACP.

5. Verify simultaneous contact on both posterior teeth and anterior

teeth if arch alignment permits.

6. Verify that maximum intercuspation occurs in perfect harmony

with centric relation or ACP.

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 7. Eliminate all excursive contact on posterior teeth. The only
posterior tooth contact is in centric relation or ACP.

8. Refine anterior guidance for all excursions (may need to do more

reduction of excursive inclines on posteriors as anterior guidance is altered).

9. Recheck posterior teeth while firmly clenching and grinding. There

should be no contacts on inclines,

10. Verify dots in back… lines in front.

11. Test the results. If an empty mouth clench can cause any sign of
discomfort or pressure in any posterior tooth, the equilibration is not
completed.sss

150
 P re p ar in g th e M ou th for F MR

After completion of necessary diagnostic procedures, having decided

that complete oral rehabilitation is indicated and having made our treatment
plan, we must now prepare the mouth for the restorations. The preparatory
procedures can be basically sorted as procedures for soft tissues and teeth

1. Treatment of the soft tissue

2. Preparation of the teeth
1. Treatment of the soft tissue
Periodontal involvement
The degree of periodontal involvement may be slight to severe.
The time of treatment will depend upon the type and severity of the
condition.
The location of the severely involved tissue is important.
The posterior segments are more difficult to maintain hygiene but
esthetically less important. Removal of all periodontal pockets
posteriorly, even if this entails extensive surgery. This may result in
abnormally long crowns and the restorations for these should be full
coverage to cover all exposed tooth structure to prevent possibility of
secondary decay.
In the anterior region, where esthetics is important, it may be
necessary to accept compromise shallow pockets. But these areas are
easy to maintain hygiene.
2. Preparation of the teeth

151
The type of preparation to be used in the treatment of the function of an
entire dentition is dependant on several conditions. It is our problem to
attach or place restorations that will function properly. How these
restorations are to be placed in or on the teeth will depend primarily upon
the relationship of the teeth to each other and to the opposing members.
Inorder to plan this procedure correctly we need carefully made study casts
properly mounted on an adjustable articulator that duplicates patients jaw
movements. This presupposes that accurate registrations, proper mounting of
casts with facebow transfer, CR record are already taken and we will have to
visualize the finished articulation before we can grind away the tooth
surfaces. Once we have a substantial idea of the articulation to be
established, we are in a position to decide how the teeth are to be prepared.
Certain areas will have to be removed to allow space for an opposing
cusp.
Certain areas will have to be built up to have proper contact.
Certain teeth will have to be warped inorder that they may
interdigitate will the opposing member.
The forces of articulation will have to be visualized and their
dissipation planned.
Method of treatment:

There are a number of factors that will determine whether a case can be
treated by partial or full coverage.

Full Coverage
1. Adverse relationship of long axis of the teeth- When the long axis of
the upper are lower teeth are not ideally related, the use of partial
coverage is precluded in reconstruction procedures.
152
2. Insufficient overjet of posterior teeth- If there is insufficient buccal
overjet then partial coverage are again precluded. To establish proper
buccal over jet and have restorations that blend with tooth restorations,
full coverage is indicated.
3. Cross bite relationship should be treated by full coverage when it is
indicated.
4. Caries susceptible mouth- Teeth with multiple fillings usually requires
full coverage. However, full coverage doesn‟t rule out the possibility of
future decay.
Partial coverage
Are the treatments of choice for the reasons below when indicated?
 There is less destruction of tooth structure
 There are no veneers to construct or maintain
 There are fewer margins in areas susceptible to decay
 There are more guides left for proper contouring

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 T r ea tm en t P ro c ed u r e s, P hi loso p h i es &
T echni que s in FMR

Philosophies & techniques in FMR

I. Gnathological philosophy

a. PMNS Philosophy-L.D Pankey Mann

b. Twin Table technique –Sumiya Hobo

c. Twin Stage procedure -Hobo & Takyama

II. Neuromuscular philosophy

The Gnathological concept/ philosophy

The first and oldest philosophy is that of Gnathology which is
based on a belief that the temporomandibular joints hinge on an axis of
rotation in the glenoid fossa of the skull. All occlusion is guided and brought
together to a finally tuned order, determined by the axis of jaw joint rotation.
The emphasis is on occlusion and joint position, which is fundamentally,
called "centric relation"
Dr Harvey Stallard the founder and father of gnathological
concept stated "Gnathology includes the exact relations existing between the
teeth and the morphological border movements of the condyles: the lateral,
the anterior and the rearmost positions... and most importantly, gnathology
includes knowing how the nine various directions the condyles move
laterally and medially in vertical chewing movements. How the chewing
cycle of cusp points may be related to centricity related cusp-fossa
occlusion, is wanted gnathological knowledge."

154
 The second newer philosophy is Neuromuscular, based on the
understanding that the temporomandibular joints are in a physiologic resting
position based on the guidance of muscles and stabilized by the occlusion of
both the upper and lower teeth. Emphasis is on a physiologic position of the
jaw/ mandible position to the skull (neuromuscular rest position), the
physiology of rested muscles to support a physiologic occlusion for stability
of all three entities: the TM joints, the muscle and the teeth.
Beyron about natural dentitions after studying the occlusion in hundreds of
successful subjects, he was able to characterize the essential features of
those patients‟ occlusions as follows.
1. Maximum number of bilateral centric stops during closing in
maximum intercuspation, regardless of any specific jaw relationship
2. As far as possible, axial loading of posterior teeth for optimal force
distribution within the alveolus.
3. Freedom in the retrusive range of occlusal contact (up to 1 mm),
because this ensures that the mandible is not being forced into a
border position as the teeth are meeting in centric occlusion.
4. Multidimensional freedom of occlusal contact movement, with group
function during laterotrusion, and anterior tooth contacts during
protrusion. This provides the most favorable force distribution for
each type of functional movement.
5. Adequate vertical dimension of occlusion (Note: No clear definitions
for this term have ever been proposed, even by the gnathologists – but
it has been discussed in terms of speaking, chewing, swallowing,
freeway space, etc. As Beyron noted, the so-called „loss of vertical
dimension‟ from occlusal dental wear is usually compensated to some
degree by continuous eruption).
155
 PMNS Phi losophy
One of the most practical philosophies for occlusal
rehabilitation is the rationale of treatment originally organized by
Dr.L.D.Pankey. Utilizing the „principles of occlusion espoused by Dr.
Clyde Schuler, Dr Pankey integrated different aspects of several
treatment approaches into an orderly plan for achieving an optimum
occlusal result with minimum stress on patient and the dentist

Dr Arvin Mann contributed to the concept by developing

Pankey- Mann instrument but it‟s replaced by simpler system, but the
overall concept still referred as PANKEY - MANN-SCHUYLER
PHILOSOPHY (PMNS Philosophy)

PMNS approach is not so much a technique as it is a

philosophy of treatment that organizes the reconstruction of an occlusion
into a sequence of goals that must be fulfilled. The overall concept of
treatment is not limited to any specific instrument or method

The philosophy of goal is to fulfill the following

principles of occlusion as advocated by Schuyler.

1. A static coordinated occlusal contact of the maximum number of

teeth when the mandible is in centric relation
2. An anterior guidance that is in harmony with function in lateral
eccentric position on the working side
3. Disclusion by anterior guidance of all posterior teeth in protrusion
4. Disclusion of all non-working side inclines in lateral excursions

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 5. Group function of the working side inclines in lateral excursions.
Most PMNS advocates now vary with the fifth goal
Sequential steps to accomplish goals in PMNS philosophy
are

PART-I Examination, diagnosis, treatment planning and prognosis

PART-II Harmonization of anterior guidance for the best possible

esthetics, function and comfort

PART-III Selection of an acceptable occlusal plane and restoration of

the lower posterior occlusion in harmony with anterior guidance in a
manner that will not interfere with condylar guidance

PART-IV Restoration of upper posterior occlusion in harmony with

anterior guidance and condylar guidance

The functionally generated path technique is so closely allied with this

part of reconstruction and it‟s almost considered as part of the concept,
though new understanding of the effect of posterior Disclusion has made
this unnecessary for most occlusal restorations.

PMNS Technique

In brief:

The lower is rebuilt to an ideal occlusion using the PM instrument that

allows for Bonwill's triangle and Monson's curve. The incisal guidance is
then rebuilt by grinding or restoring the anterior teeth. The maxillary is
then reconstructed using the FGP technique described by Meyer.25

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 The Procedure;

Examination Diagnosis Treatment Planning and Prognosis:

Full mouth radiographs and study casts are evaluated and the treatment is
tentatively planned, with calculated risks evaluated. When the dentist
have decided on his plan of treatment , an additional set of upper and
lower plaster study casts are made for mounting on the P.M instrument

P.M INSTRUMENT:

The purposes of P.M instrument are:

1. To engineer the entire oral rehabilitation before any single tooth

preparation is made
2. To determine the occlusal plane on the lower cast
3. To study and plan the preparations of lower and upper teeth,
4. To orient the relationship of both the arches in centric position
with maximum esthetics and conservation of tooth structure
5. To allow the preparation plane guides to be made and buccal
contours to be waxed on the teeth of the mounted study casts
exactly as they will be in the finished restoration
6. To establish and carve the occlusal plane and curvature in wax
patterns ,
7. To check the finished restorations.
The design of P.M instrument;

The P.M instrument consists of a main base to which is an attached

vertical rod and a platform base used to hold the lower cast

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 The two assemblies are keyed to slide up and down the upright
rod , with set screws to lock them in position
A horizontal rod has two seats of dividers on the top and a key
way slot on its underside. A face bow frame is keyed to this rod and
can be locked into either an anterior or posterior position to
conform to either anterior or posterior divider seat, depending on
which one is used.
The upper cast mounting assembly consists of a base collar which
is locked into position when the upper collar is mounted. A hinged
mechanism allows the upper cast to be raised or lowered.
The P.M face bow differs from conventional face bow in:

1. Although the P. M face bow rod ends are adjusted to fixed,

arbitrary anatomical landmarks on the face similarly to
conventional face bow, the wax index registration must be made at
terminal hinge position with a good imprint of lower teeth. This is
different from usual, arbitrary face bow. Imprints of upper teeth are
important in conventional face bow usage and the position of the
mandible to the wax indent is not important.
2. The P.M face bow is adjusted to a point 12 mm anterior to the
tragus of the ear on the ala-tragus line [ camper line], whereas
conventional face bows are adjusted to either arbitrary anatomical
landmarks or the points located on the face coinciding with hinge
axis
3. The P.M face bow is used to mount the lower cast whereas
conventional face bow is used to mount the upper cast

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 4. The P.M face bow is adjusted in a different manner from that used
for conventional face bow.

1. Oral rehabilitation using the P.M instrument

i. Mounting the lower plaster study cast
ii. Mounting the upper cast
iii. Cutting the lower cast to the occlusal plane
iv. Cutting the lower cast to preparation plane
v. Constructing the preparation guides
2. Preparation of lower posterior in the mouth
i. Marking the established preparation plane guide on the
teeth
ii. Completing the preparations
iii. Obtaining master cast and wax inter occlusal records
3. P.M face bow registration to mount the lower cast
4. Mounting the master cast
5. Fabrication of wax patterns and finishing the castings
6. Completing rehabilitation of lower teeth
7. Cementation of lower posterior restorations
8. Preparation of upper teeth & upper master cast
9. Mounting the master cast
10. The “functionally generated path” tables
11. Fabricating the bilateral incisal or occlusal guides
12. Functionally generated path technique
13. Correcting the incisal and occlusal guide castings in the mouth
14. Functionally generated path record
15. Transfer the functionally generated path record to the articulator
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 16. Fabricating the wax patterns
17. Final adjustment and cementation of upper castings
a. Corrections in centric occlusion
b. Corrections in the envelope of function on the working side
c. Corrections on the balancing side
Advantages of this technique are

1. It is possible to diagnose and plan treatment for the entire rehabilitation

before a single tooth is prepared
2. It is well organized, logical procedure that progresses smoothly with less
wear and tear on the patient, operator and technician
3. There never a need for preparing or rebuilding more than eight teeth at a
time.
4. It divides rehabilitation into separate series of appointments. It is neither
necessary nor desirable do the entire case at time
5. There is no danger of „getting lost at sea‟ and losing the patients‟ present
vertical dimension. The operator knows exactly where is he at all times.
6. The functionally generated path and centric relation are taken on the
occlusal surface of the teeth to be rebuilt at exact vertical dimension to
which the case will be reconstructed.
7. All posterior occlusal contours are programmed by and are in harmony
with both condylar border movements and perfected anterior guidance
8. There is no need for time consuming techniques and complicated
equipment.
9. Laboratory procedures are simple and controlled to an extremely fine
degree by the dentist

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 The PMNS philosophy of occlusal rehabilitation can fulfill the
most exacting and sophisticated demands, if the operator understands the
goals of optimum occlusion, and it can achieve this with great simplicity and
orderliness of technique. It can be combined with other techniques. And it
can be adapted to any occlusal problem

The four prime objectives of oral rehabilitation are (1) optimum oral
health, (2) functional efficiency, (3) mouth comfort, and (4) esthetics.

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 Twi n Ta bl e technique –Sum iya H obo
This twin table technique has been introduced for developing
molar disclusion by the use of two incisal tables. Molar disclusion is
determined by the cusp shape factor and the angle of hinge rotation. It is
a relatively uncomplicated technique and does not require special
equipment. The final prosthesis by the use of the twin –table technique
results in a restoration with a predictable posterior disclusion and anterior
guidance in harmony with the condylar path.

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 The technique of twin table is as follows;

1. Record the condylar path by using a pantograph or interocclusal records.

Set the working condylar path on the articulator so that the working
condyle moves straight forward along the transverse horizontal axis
2. Make the maxillary cast with a removable anterior segment. Mount the
casts to the articulator. Remove the maxillary anterior segment and move
the articulator through eccentric movements to eliminate interferences
that impede an even, gliding motion. This procedure results in a cusp
shape factor that harmonizes with the condylar path.
3. Insert a flat incisal table and mold chemical cure resin by moving the
incisal pin through eccentric movements. Repeat the procedure on second
table to complete two incisal tables without disclusion.

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4. Use one of the incisal tables without disclusion on the articulator. Place
two 3mm spacers behind the condyle to simulate a protrusive position.
Place a 1.1 mm thick spacer on the mesio buccal cusp tip of the
mandibular first molar, then close the articulator. Make a resin cone
between the incisal pin and the incisal table to establish the angle of
hinge rotation for an average disclusion during protrusive movement.
5. Next place one 3mm spacer behind one condyle in the articulator. Place
1mm spacer on the nonworking side at the mesio buccal cusp tip of the
mandibular first molar to stimulate a lateral movement position. Make a
resin cone between the incisal pin and table. Repeat the procedure for the
other condyle. This creates the angle of hinge rotation for an average
disclusion during lateral movement.
6. Connect the three resins with additional resin to form walls. Add more
resin, and direct the articulator through eccentric movements to complete
the three dimensional incisal tables. This completes the incisal table with
disclusion
7. When making the final restorations, make the maxillary cast with a
removable segment. Remove the anterior segment and use the incisal
table without disclusion to wax the posterior occlusion through eccentric
movements. This establishes the cusp shape factor that forms the molar
cuspal inclination parallel to the condylar path.
8. Use the incisal table with disclusion and reposition the anterior segment
on the maxillary cast. Complete the anterior wax-up by moving
articulator through eccentric movements. This establishes the angle of
hinge rotation and the posterior restorations will ensure a predetermined
amount of disclusion.

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166
 Tw i n S ta ge pr o ce du r e -H o b o & Ta kyam a
This procedure considered cusp angle to be most reliable
reference for occlusion. The other two determinants, incisal guidance and
condylar guidance were not considered as main determinants in this
procedure

Basic concept of twin stage procedure

The basic concepts involved in the new procedure require a methodical

approach. The cast with removable anterior segment is fabricated.

First, reproduce the occlusal morphology of posterior teeth without

anterior segment and produce a cusp angle coincident with standard values
of effective cusp angle (referred to us condition 1).

Secondly, reproduce anterior morphology with the anterior segment and

provide anterior guidance which produces a standard amount of disocclusion
(referred to us condition 2).

The application of these two conditions describes to fabricate cusp angle and
anterior guidance are innovative clinical procedure. This is named as the
twin stage procedure.

Outline of twin stage procedure

Fabrication of the cusp angle

1. According to the condition 1, adjust an articulator to the following

values; sagittal condylar path inclination= 25°, Bennett angle =15°.

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 Sagittal inclination of anterior guide table=25° and lateral wing angle
=10°
2. Make the anterior segment of maxillary or mandibular cast removable
using dowel pins. Remove the anterior segment. Make the maxillary
and mandibular cast on the articulator so that they don no t disocclude
during eccentric movements.
3. Wax the occlusal morphology of the posterior teeth so the maxillary
and mandibular cusp contact during eccentric movements. Thus, a
balanced articulation is obtained and every cusp will have a standard
cusp angle.

Fabrication of anterior teeth

1. According to condition 2, adjust an articulator to the following values;

sagittal condylar path inclination= 40°, Bennett angle =15°, sagittal

inclination of anterior guide table =45°, and lateral wing angle =20°.
2. Reassemble the anterior segment of the cast. The maxillary and
mandibular cast on the articulator produces the standard amount of
disocclusion.

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 3. Wax the palatal contours of the maxillary anterior teeth. So the
maxillary and mandibular incisors contact during protrusive
movements, and the maxillary and mandibular canines on the working
side, contact during lateral movements. Thus, anterior guidance is
established and standard amount of disocclusion is produced.
Contraindication for Twin stage procedure
1. Abnormal curve of Spee.
2. Abnormal curve of Wilson.
3. Abnormally rotated tooth.
4. Abnormally inclined tooth.
In the above contraindicated cases, a vertical axis of the posterior
teeth may have inclined abnormally. As a result, the effective cusp angle
may vary to some extent even though the cusp angle of a natural tooth varies
minimally. In such conditions, the standard effective cusp angle presented in
the twin stage procedure may not be applicable. As a result, the occlusion of
the restoration may be inaccurate.
Test to evaluate Twin Stage procedure
1. The articulator test
2. The intraoral test
In the articulator test, after completion of the posterior occlusal wax
up on the cast mounted on an articulator (condition1), and adjusting the
articulator (condition 2), the specific amount of disocclusion occurring
during various eccentric movements was determined. This is an in vitro test.
In the intraoral test, when the results were completed and
satisfactory, the restoration made on articulator was cemented in the
patient‟s mouth. Then it was tested to determine the amount of occlusion
was reproduced as occurred in test 1. This is an in vivo test.
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 R estora tion s for FM R
The choice of final restorations depends on many factors

1. Fixed dental prosthesis Vs Removable prosthesis

2. Type of restorative material
3. Patient factors

Fixed dental prosthesis Vs Removable prosthesis

Whenever possible fixed dental prosthesis are preferable to removable

dentures because the possibility of maintaining equal distribution of
stress is greater with fixed work than with removable; the distribution
can be maintained longer with less adjustment.

Type of restorative material

The evolution of newer materials has changed the full mouth

rehabilitation procedure into a successful treatment procedure. The many
of the failures of rehabilitation procedures reported in the literature are
mainly due to failure of the materials used in these restorations. The wide
range of materials ranges from the older acrylics to the newer all
ceramics. In this era, all-ceramic restorations are becoming popular;
however, long-term follow-up of patients with complete rehabilitations
using all-ceramic restorations are not yet available.
Patient factors – such as

1. Age, younger patients with larger pulp –metal restorations are ideal if
esthetic permits,

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2. Type of pathology – e.g. in patients with parafunctional habits, metal-
ceramic restorations seem to be a predictable treatment. In patients with
bruxism, metal-ceramic restorations seem to be a predictable treatment.
They provide adequate strength to withstand the parafunctional activity
and improve the longevity of the restorations.

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 C om m o n P ro bl em s & Di ffi c ulti e s in FM R
Ten difficulties in occlusal rehabilitation are27

Before the dentist commits himself to altering an occlusion, he must be

convinced that the conditions present do not prevent or limit the change. The
conditions that make successful treatment difficult are

1. Occlusion with different levels

2. Occlusion with an excessive vertical overlap
3. Occlusion with horizontal overlap
4. Occlusion with a prognathous mandible
5. Occlusion with mobile teeth
6. Occlusion influenced by wear due to bruxism
7. Occlusion with an anterior or posterior cross bite
8. Occlusion with abnormal tongue and swallowing habits
9. Occlusion treated previously
10. Abnormal but functional occlusion of convenience
Occlusion with different levels
An occlusion with different levels may be satisfactory. When these
normal occlusions are altered the result may be disaster because of the
attempt to follow the pattern of uniform occlusal and compensating
curves used in complete denture occlusion
Leveling the occlusal plane of mandibular posterior teeth with that of
mandibular incisors can be accomplished only by increasing the
vertical dimension of occlusion beyond the limits of tolerance when
such occlusions requires restorations, the pattern of different levels
should be duplicated
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 This normal level should not be confused with the abnormal type in
which there are different levels created by extrusion of teeth, due to
failure to replace missing opposing teeth
Occlusion with an excessive vertical overlap
Occlusion with horizontal overlap
Occlusion with a prognathous mandible
Occlusion with mobile teeth
Occlusion influenced by wear due to bruxism
Occlusion with an anterior or posterior cross bite
Occlusion with abnormal tongue and swallowing habits
Occlusion treated previously
Abnormal but functional occlusion of convenience
Common Problems in Full Mouth Rehabilitation

Mathematics, engineering principles, precision, and uniformity

of procedures do not dictate physiology of occlusion. Failures in occlusal
rehabilitation do not result from use of or failure to use, a particular brand of
instrument, a hinge axis recording or any other registrations. Rather, they
result from three basic errors

I. Increasing the vertical dimension of occlusion beyond the limits of

physiologic rest position
II. A disregard for or inability to recognize, the limitations in and around
the mouth and of materials used in reconstruction
III. By rehabilitating every case along the lines and principles
recommended for complete denture construction27

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 F MR fo r O sse o Inte g ra te d Im p l an ts
The role of occlusion in is important to osseointegration prosthesis.
Natural teeth have periodontal ligament receptors which protect the teeth
and periodontium from excessive occlusal forces, but there is no specific
defense against occlusal forces in osseointergrated implants.
Since there is no cushioning effect between fixtures and bone through
osseointergrated prosthesis, these forces are not limited to masticatory
forces but also include impact forces
The occlusion concept chosen should provide dynamic elements for
each prosthesis
In osseointergrated implants, fixtures bear vertical forces better than
horizontal forces.
o A single fixture can bear occlusal forces equivalent to single rooted
natural teeth.
o Usually there are no fixtures available in the posterior regions to
support horizontal loads. For this reason, disclusion is preferred in
prosthetic restoration of posterior osseointergrated implants.
o Since more horizontal loads are generated in the anterior region,
long fixtures are used and restored with attachments to natural
teeth.
Occlusal considerations for implant prosthesis
 No premature contacts or occlusal interferences; timing of occlusal
contacts
The biomechanical mismatch between implant movement and tooth
movement may range from 0µm for an implant opposing implant, 56 µm

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 for a tooth opposing tooth and 28 µm for a tooth opposing an implant,
moreover tooth moves under light forces.

So in developing an occlusal scheme,

Initially only light axial occlusal contacts should be present on the

implant crown under light force.
Later the contacts should remain axial over the implant body and may be
of similar intensity on the implant crown and adjacent teeth when under
greater bite force because all the elements react similar to heavy occlusal
load
Complete arch implant supported prosthesis in one arch opposing natural
teeth does not require light and heavy force occlusal evaluation.
 Influence of surface area- implant protective occlusion should have
adequate surface area to sustain the load transmitted to the prosthesis.
Surface area can be increased by adding more number of implants, they
can be splinted together, by giving removable prosthesis, choosing
wider diameter implants,
 Mutually protected articulation
All the lateral excursions in implant protective occlusion opposing fixed
prosthesis or natural teeth disocclude the posterior components. The
resulting lateral forces are distributed to the anterior segments of the jaws
with overall decrease in force magnitude. This occlusal scheme should be
followed whether or not the anterior implants are in the arch. However if
anterior implants must disclude posterior teeth, two or more implants
splinted together should help dissipate lateral forces.
 Implant body angle to occlusal load- The force of same magnitude
have different effects on bone –implant interface as the direction of

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 applied load is changed. Any load applied at an angle may be normal
force [compressive, tensile] and shear. The results are similar whether an
angled load applied to an implant body perpendicular to occlusal plane or
to an angled implant body. So not only the stress increase under angled
load but it also evolves noxious shear forces damaging to bone growth.
 Cusp angle of crowns[ cuspal inclination]
 Cantilever or offset distance [horizontal offset]
 Crown height / vertical offset
 Occlusal contact positions
 Implant crown contour
 Protect the weakest component
 Occlusal materials
Hobo suggests the following standards for different types of
osseointegration treatment

1. When making fully bone anchored prosthesis , try to use mutually

protected occlusion to obtain posterior disclusion
2. When making overdenture prosthesis, use a balanced occlusion since
anterior teeth are supported by over denture attachments and the posterior
teeth are supported by tissues, some molar disclusion is possible to
function as a modified mutually protected occlusion
3. When making free standing fixed partial denture for the anterior
region including replacement of canine use a group function occlusion
.during lateral movements , horizontal loads are shares between natural
teeth and the prosthesis

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4. When making free standing fixed partial denture for the posterior
teeth with natural teeth present , use mutually protected occlusion with
posterior disclusion
These guide lines attempt to decrease cuspal interferences and reduce
horizontal or lateral forces on the fixtures

Edentulous Type of Optimal occlusal

classification prosthesis scheme
Fully bone
Mutually protected
A. Edentulous anchored fixed
occlusion
partial denture
B. Edentulous Over denture Balanced occlusion
Free standing
Class III or IV Group function
C. fixed partial
partially edentulous occlusion
denture
Class I or II partially Free standing
Mutually protected
D. edentulous (in fixed partial
occlusion
posterior region) denture

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 P o st O p er ati v e Ca re for O c clu sal T h e ra py
P a ti ents
„The goal of complete dentistry is the long-term health of total
masticatory system‟.
When the active treatment phase has been completed for a patient
with occlusally related problem, a program of postoperative care to be
planned that gives patient the best long term prognosis
There are seven major considerations that should influence the program of
post operative care;
1. Condition of the connective tissue of the TMJ
2. Presence or absence of acceptable disk
3. Condition of the supporting structure of the teeth
4. Degree of fulfillments of all requirements for occlusal stability.
5. Presence of habit patterns or nocturnal bruxism
6. Ability or willingness to follow a meticulous oral hygiene program
7. Dietary patterns or general health problems
Abnormalities in any of the above factors may be reason for a special
postoperative counseling
Patient should be told to report any of the following indications for
occlusal disharmony
1. Any discomfort in the teeth when chewing
2. Any indication of high tooth or any sign that one or more teeth contact
before the rest when closing; any tooth that can be made hurt by biting
on it.
3. Any sign of tooth hyper mobility
4. Any pain in the TMJ area.
5. Any limitation of function.
Any one of the signs and symptoms is an indication that the occlusal
relationship is producing excessive stress

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 T ec h no l og ica l Fu tu r e for O c clu sal
Restorations
Traditionally the transfer of occlusal and functional information
from the clinical environment to the laboratory is limited, by providing
opposing models, interocclusal records, shade preferences and written or
verbal communications.
With these limited information the technician would mount and
articulate the cast and restore the case by filling the spaces and trying to
mimic the existing dentition.
The results were often the complete removal of anatomy and
occlusal form and sometimes an esthetic or functional compromise of the
final restorations.
Today with advanced communication tools, increased knowledge
of functional requirements and increased patient expectations, we are
able to give more consistent and effective results with the help of
diagnostic wax-ups [ first three dimensional blue print and map of the
case ], CAD and CAM, computerized occlusal verification.

Computerized Occlusion In The Laboratory

The fundamental principle of this concept was to electronically

capture a preparation‟s image and then use software to interpolate the
information and create a digital preparation. A virtual design could be
suggested and after user defined parameters were set, the restoration
design could be milled from a ceramic block and seated all in one
appointment

Steps involved in the fabrication are

1. File creation
2. Scanning
3. Virtual model
4. Design
5. Database collection
6. Virtual placement
7. Occlusal confirmation

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 8. Anatomic customization
9. Milling
10. Finishing and polishing
Various commercial systems for Computerized Design And
Fabrication are

1. CEREC System-
The first successful chair side CAD
and CAM system is Cerec -1, later Cerec -2,
cerec-3, and Cerec 3D [2004] were
introduced with improvements on user
friendliness, accuracy. Material and milling
options and complex occlusal schemes and
parameters
2. CYNOVAD

This is slight different CAD/CAM], in its approach the primary

focus on the design and fabrication of a customized wax pattern that is then
brought to conventional fabrication process. Here the wax is three
dimensionally sprayed onto a die

The primary advantage of this system is that it is not limited to

single or multiple spans but can take full mouth rehabilitation restoration
through a truly comprehensive system

Using this system the operator can input all variables of anatomic
importance like angles, shifts, curve of Wilson, curve of Spee etc. into a
fully adjustable virtual articulator. They can simulate all functional paths
including protrusive and excursive movements.

3. Digitalized Impressions

ITERO has been developed as an office-based intraoral scanning system,

connected by the internet to a centralized milling center and to the traditional
dental laboratory technician.
The scanner is capable of recording virtually any dental preparation;
therefore, veneers, crowns, bridges, inlays, onlays (essentially any fixed

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prosthesis that can be recorded by conventional impression techniques) can
be recorded electronically.

4.

Computerized Occlusal Verification

T-Scan-II is an electronic occlusal measurement device that can quickly
measure the individual contact intensity and display the results
graphically on a computer screen. Because T-scan-II measures individual
contact intensity and relate it over time, it‟s possible to view the jaw or
model movements in excursive.
In the laboratory T-scan can be used to verify paper and visual
observations to ensure even distribution of occlusal contacts and detect
posterior interferences in protrusive and lateral movements.
Clinically T-scan is used in the same manner as articulating paper,
but can quantify and display much more accurate and relevant data,
providing the clinician with critical information for into integration of
restoration into functioning environment.

While the new technology and computerization can make

procedures more efficient, less labor intensive and more consistent but
they will not replace education, practical experience and clinical and
technical judgment.

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 S U MMA RY & Co n cl u si o n

Success Criteria for Occlusal Treatment

Peter E Dawson states “Without specific treatment goals,

treatment success cannot be measured”
Five requirements for occlusal stability - Peter E Dawson

1. Stable holding contacts on all teeth when the condyles are in

centric relation
2. Anterior guidance in harmony with the envelope of function
3. Immediate disclusion of all posterior teeth the moment the
mandible moves forward of centric relation
4. Immediate disclusion of all posterior teeth on the nonworking
side
5. Non interference of all posterior on the working side with either
the lateral anterior guidance or the border movements of the
condyles

All occlusal treatments should have specific goals. Criteria for success
are an essential requirement for achieving successful complete dentistry.
The following criteria for occlusal treatment have stood test of time in
clinical practice

1. Load test is negative. This means complete absence of any sign of

tension or tenderness in either temporomandibular joint when
joints are firmly loaded.

182
2. Clench test is negative. This means complete absence of any
discomfort in either T.M.J or in any tooth when the patient
clenches with maximal muscle contraction.
3. Grinding test. No posterior interferences. This test is to verify that
all excursive contact is on the anterior guidance only. Posterior
teeth must separate the moment the mandible moves from the
centric relation.
4. Fremitus test negative. This test is to ensure that there is no sign
of Fremitus on any anterior teeth during firm tapping or grinding
excursions.
5. Stability test is positive. This test is to verify that there is no signs
of instability in either T.M.J, any tooth, or with total occlusal
relationship.
6. Comfort test is inclusive. The patient should have a complete
comfort of teeth, lips, face, masticatory musculature, and speech.
7. Esthetic test is inclusive. Both the patient and the dentist should
be completely happy with the appearance of the smile and its
relationship to functional matrix
It is not always a realistic expectation to achieve 100%
success in all these goals. The problems in some patients have
progressed too far to expect complete correction. When this
happens, there should be reasonable explanation for compromised
treatment result.

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 B ibl iog ra phy
1. Modern gnathological concepts – updated - Victor.O Lucia
2. Clinical procedures in occlusal rehabilitation- S. Charles Brecker
3. Functional occlusion from TMJ to SMILE DESIGN-Peter E Dawson
4. Evaluation, Diagnosis & Treatment Planning of Occlusalproblems-2nd
Edition by Peter E Dawson
5. Oral rehabilitation ; clinical determination of occlusion by Sumiya Hobo
& Hisao Takayama
6. Osseo intergration & Oral rehabilitation by HOBO & ECHIDI
7. The Journal Of Prosthetic Dentistry- Volume 86 Number 3 Schuyler
8. Journal of Oral Rehabilitation 16 April 2007
9. The Gnathological vs. The Neuromuscular Approach to Dentistry
Clayton A. Chan, D.D.S., F.I.C.C.M.O.
10. Scaife and Holt. Natural occurrence of cuspid guidance. J Prosthet Dent
22:225-229, 1969.
11. Schuyler, C. H. The function and importance of incisal guidance in oral
rehabilitation. J Prosthet Dent 13:1011-1030, 1963.
12. Hobo, S Twin-tables technique for Occlusal Rehabilitation: Part II -
Clinical Procedures. J Prosthet Dent 66:471-477, 1991
13. Reynolds, J. M. The organization of occlusion for natural teeth. J
Prosthet Dent 26:56, 1971.
14. . Heinlein, W. D. Anterior teeth: Esthetics and function. J Prosthet Dent
44:389-393, 1980.
15. Broderson, S. P.: Anterior Guidance-The Key to Successful Occlusal
Treatment. J Prosthet Dent 39: 396-400, 1978.

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16. DiPietro, G.J. Significance of the Frankfort-mandibular plane angle to
Prosthodontics. J Prosthet Dent 36:624-635, 1976.
17. . McAdam, D. B. Tooth loading and cuspal guidance in canine and group
function occlusions. J Prosthet Dent35:283-290, 1976
18. Williamson and Lundquist, Anterior guidance: Its effect on
electromyographic activity of the temporal and masseter muscles. J
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