L.D..Occlusion in FPD

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Occlusion in fixed partial denture

OCCLUSION IN FIXED PARTIAL

DENTURE

(library dissertation)

I. Introduction

Establishing or providing occlusion that successfully permits

efficient masticatory function is basic to dentistry and survival.

In health the occlusal anatomy of the teeth functions in

harmony with structures controlling the movements patterns of the

mandible. The structures that determine these patterns of the

mandible are joints and the anterior teeth. During any given

movement the unique anatomic relationships of these structures

continue to dictate a precise and repeatable pathway.

To maintain harmony of the occlusal condition the posterior

teeth must pass close to but not contact their opposing teeth during

mandibular movement. It is important to examine each of these

structures carefully and appreciate how the anatomic form of each

can determine the occlusal morphology necessary to achieve an

optimal occlusal relationship.

II. Fundamentals of occlusion2

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Occlusion in fixed partial denture

1. Occlusal interferences

Interferences are undesirable occlusal contacts that may

produce mandibular deviation during closure to maximum

intercuspation or may hinder smooth passage to and from the

intercuspal position. There are four types of occlusal interferences :

1. Centric

2. Working

3. Non working

4. Protrusive

The centric interference is a premature contact that occurs

when the mandible closes with the condyles in their optimum

position in the glenoid fossae. It will cause deflection of the mandible

in a posterior, anterior, and / or lateral direction. (Fig. 1).

Fig. 1

A working interference may occur when there is contact

between the maxillary and mandibular posterior teeth on the same

side of the arches as the direction in which the mandible has moved.

If that contact is heavy enough to disocclude anterior teeth, it is an

interference. (Fig. 2).

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Occlusion in fixed partial denture

Fig. 2

A non-working interference is an occlusal contact between

maxillary and mandibular teeth on the side of the arches opposite

the direction in which the mandible has moved in a lateral

excursion. The non-working interferences is of a particularly

destructive nature. The potential for damaging the masticatory

apparatus has been attributed to changes in the mandibular

leverage, the placement of forces outside the long axes of the teeth,

and disruption of normal muscle function. (Fig. 3).

Fig. 3

The protrusive interference is a premature contact occurring

between the mesial aspects of mandibular posterior teeth and the

distal aspects of maxillary posterior teeth. The proximity of the teeth

to the muscles and the oblique vector of the forces make contacts

between opposing posterior teeth during protrusion potentially

destructive as well as interfere with the patients ability to incise

properly. (Fig. 4).

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Occlusion in fixed partial denture

Fig. 4

2. Normal versus pathologic occlusion

In only slightly more than 10% of the population there is

complete harmony between the teeth and the temporomandibular

joints. This finding is based on a concept of centric relation in which

the mandible is in the most retruded position. With the present

concept of the condyles being in the most superoanterior position

with the disc interposed, the results could be different. Nonetheless,

in a majority of the population, the position of maximum

intercuspation causes the mandible to be deflected away from its

optimum position.

In the absence of symptoms, this can be considered

physiologic, or normal. Therefore, in the normal occlusion there will

be a reflex function of the neuromuscular system, producing

mandibular movement that avoids premature contacts. This guides

the mandible into a position of maximum intercuspation with the

condyle in a less than optimal position. The result will be either

some hypertonicity of nearby muscles or trauma to the

temporomandibular joint, but it is usually well within most peoples

physiologic capacity to adapt and will not cause discomfort.

However, the patients ability to adapt may be influenced by

the effects of psychic stress and emotional tensions on the central

nervous system. By lowering the threshold, frequently

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Occlusion in fixed partial denture

parafunctional jaw activity such as clenching or bruxing occurs, and

a normal occlusion can become a pathologic one. Simple muscle

hypertonicity may give way to muscle fatigue and spasm, with

chronic headaches and localized muscle tenderness, or

temporomandibular joint dysfunction may occur. Pathologic

occlusion can also manifest itself in the physical signs of trauma

and destruction. Heavy facets of wear on occlusal surfaces, fractures

cusps, and tooth mobility often are the result of occlusal

disharmony. There is no evidence that occlusal trauma will produce

a primary periodontal lesion. However, when occlusal trauma is

present, there will be more severe periodontal breakdown in

response to local factors than there would be if only the local factors

were present.

Habit patterns may develop in response to occlusal

disharmony and emotional stress. Bruxism and clenching, the

cycling rubbing together of opposing occlusal surfaces, will produce

even greater tooth destruction and muscle dysfunction.

When the acute discomfort of a patient with a pathologic

occlusion has been relieved, changes that will prevent the recurrence

of symptoms must be effected in the occlusal scheme. Care must

also be taken when providing occlusal restorations for a patient

without symptoms. The dentist must not produce an iatrogenic

pathologic occlusion.

In the placement of restorations, the dentist must strive to

produce for the patient an occlusion that is as nearly optimum as

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Occlusion in fixed partial denture

his or her skills and the patients oral condition will permit. The

optimum occlusion is one that requires a minimum of adaptation by

the patient. The criteria for such an occlusion have been described

by Okeson.

1. In closure, the condyles are in the most superoanterior

position against the discs on the posterior slopes of the

eminences of the glenoid fossae. The posterior teeth are in

solid and even contact, and the anterior teeth are in slightly

lighter contact.

2. Occlusal forces are in the long axes of the teeth.

3. In lateral excursions of the mandible, working side contacts

(preferably on the canines) disocclude or separate the

nonworking teeth instantly.

4. In protrusive excursions, anterior tooth contacts will

disocclude the posterior teeth.

5. In an upright posture, posterior teeth contact more heavily

than do anterior teeth.

3. Organization of the occlusion

The collective arrangement of the teeth in function is quite

important and has been subjected to a great deal of analysis and

discussion over the years. There are three recognized concepts that

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Occlusion in fixed partial denture

describe the manner in which teeth should and should not contact

in the various functional and excursive positions of the mandible.

They are bilateral balanced occlusion, unilateral balanced occlusion,

and mutually protected occlusion.

4. Bilateral balanced occlusion

Bilateral balanced occlusion is based in the work of Von Spee

and Monson. It is a concept that is not used as frequently today as it

has been in the past. It is largely a prosthodontic concept which

dictates that a maximum number of teeth should contact in all

excursive positions of the mandible. This is particularly useful in

complete denture construction, in which contact on the nonworking

side is important to prevent tipping of the denture. Subsequently,

the concept was applied to natural teeth in complete occlusal

rehabilitation. An attempt was made to reduce the load on individual

teeth by sharing the stress among as many teeth as possible. It was

soon discovered, however, that this was a very difficult type of

arrangement to achieve. As a result of the multiple tooth contacts

that occurred as the mandible moved through its various

excursions, there was excessive frictional wear on the teeth.

5. Unilateral balanced occlusion

Unilateral balanced occlusion, which is also commonly known

as group function is a widely accepted and used method of tooth

arrangement in restorative dental procedures today. This concept

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Occlusion in fixed partial denture

had its origin in the work of Schulyer and others who began to

observe the destructive nature of tooth contact on the nonworking

side. They concluded that inasmuch as cross arch balance was not

necessary in natural teeth it would be best to eliminate all tooth

contact on the nonworking side.

Therefore, unilateral balanced occlusion calls for all teeth on

the working side to be in contact during a lateral excursion. On the

other hand teeth on the nonworking side are contoured to be free of

any contact. The group function of the teeth on the working side

distributes the occlusal load. The absence of contact on the

nonworking side prevents those teeth from being subjected to the

destructive, obliquely directed forces found in nonworking

interferences. It also saves the centric holding cusps, i.e. the

mandibular buccal cusps and the maxillary lingual cusps, from

excessive wear. The obvious advantage is the maintenance of the

occlusion.

The functionally generated path technique, originally described

by Meyer, is used for producing restorations in unilateral balanced

occlusion. Mann and Pankey have adapted it for use in complete

mouth occlusal reconstruction.

6. Mutually Protected Occlusion

Mutually Protected Occlusion is also known as canine

protected occlusion or organic occlusion. It had its origin in the work

of DAmico, Stuart, Stallard and Stuart, and Lucia and the members

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Occlusion in fixed partial denture

of the Gnathological Society. They observed that in many mouths

with a healthy periodontium and minimum wear, the teeth were

arranged so that the overlap of the anterior teeth prevented the

posterior teeth from making any contact on either the working or the

nonworking sides during mandibular excursions. This separation

from occlusion was termed disocclusion. According to this concept of

occlusion, the anterior teeth bear all the load and the posterior teeth

are disoccluded in any excursive position of the mandible. The

desired result is an absence of frictional wear.

The position of maximum intercuspation coincides with the

optimal condylar position of the mandible. All posterior teeth are in

contact with the forces being directed along their long axis. The

anterior teeth either contact lightly or are very slightly out of contact

(appropriately 25 microns), relieving them of the obliquely directed

forces that would be the result of anterior tooth contact. As a result

of the anterior teeth protecting the posterior teeth in all mandibular

excursions and the posterior teeth protecting the anterior teeth at

the intercuspal position, this type of occlusion came to be known as

a mutually protected occlusion. This arrangement of the occlusion is

probably the most widely accepted because of its ease of fabrication

and greater tolerance by patients.

However, to reconstruct a mouth with a mutually protected

occlusion, it is necessary to have anterior teeth that are

periodontally health. In the presence of anterior bone loss or missing

canines, the mouth should probably be restored to group function

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Occlusion in fixed partial denture

(unilaterally balance). The added support of the posterior teeth on

the working side will distribute the load that the anterior teeth may

not be able to bear. The use of a mutually protected occlusion is also

dependent upon the orthodontic relationship of the opposing arches.

In either a Class II or Class III malocclusion (Angle), the mandible

cannot be guided by the anterior teeth. A mutually protected

occlusion cannot be used in a situation of reverse occlusion or cross

bite, in which the maxillary and mandibular buccal cusps interfere

with each other in a working side excursion.

7. Effects of Anatomic Determinants

The anatomic determinants of mandibular movement, i.e.

condylar and anterior guidance, have a strong influence on the

occlusal surface morphology of the teeth being restored. There is a

relationship between the numerous factors, such as immediate

lateral translation, condylar inclination, and even disc flexibility, and

on the cusp height, cusp location, and groove direction that are

acceptable in the restoration.

a. Molar disocclusion

When subjects with normal occlusions perform repeated

lateral mandibular movements, they will not trace the same path on

electronic recordings, presumably because of the flexible nature of

the articular disc. The measured deviation averages 0.2 mm in

centric relation, 0.3 mm in working, and 0.8 mm in both protrusive

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Occlusion in fixed partial denture

and non working movements. To avoid occlusal interferences and

nonaxially directed forces on molars during eccentric mandibular

movements, molar disocclusion must equal or surpass these

observed deviations in mandibular movement.

Healthy natural occlusions exhibit clearances that will

accommodate these aberrations. Measurements of disocclusions

from the mesiobuccal cusp tips of mandibular first molars in

asymptomatic test subjects with good occlusions showed

separations averaging 0.5 mm in working. 1.0 mm in nonworking

and 1.1 mm in protrusive movements. Therefore, one of the

treatment goals in placing occlusal restorations should be to

produce a posterior occlusion with buffer space that equals or

surpasses the deviations resulting from natural variations found in

the temporomandibular joint.

b. Condylar guidance

Chief among those aspects of condylar guidance that will have

an impact on the occlusal surface of posterior teeth are the

protrusive condylar path inclination and mandibular lateral

translation.

The inclination of the condylar path during protrusive

movement can vary from steep to shallow in different patients. It

forms an average angle of 30.4 degrees with the horizontal reference

plane (43 mm above the maxillary central incisor edge). If the

protrusive inclination is steep, the cusp height may be longer.

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Occlusion in fixed partial denture

However, if the inclination is shallow, the cusp height must be

shorter.

Immediate mandibular lateral translation is the lateral shift

during initial lateral movement. If immediate lateral translation is

great, then the cusp height must be shorter. With minimal

immediate translation, the cusp height may be made longer.

(Fig. 5 & Fig. 6).

Fig. 5 Fig. 6

The condylar path, particularly the lateral translation, affects

ridge and groove directions. The effects are observed on the occlusal

surface of a mandibular molar and premolar with the paths traced

by the lingual cusps of the respective opposing maxillary teeth. The

working path is traced on the mandibular tooth in a lingual

direction, and the nonworking path is in a distobuccal direction. The

nearer the tooth is to the working side condyle anterioposteirorly,

the smaller the angel between the working and nonworking paths.

The farther the tooth is placed from the working side condyle, the

greater the angle between the working and nonworking path. When

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Occlusion in fixed partial denture

immediate lateral translation is increased, the angle also becomes

more oblique.

c. Anterior Guidance

During protrusive movement of the mandible, the incisal edges

of mandibular anterior teeth move forward and downward along the

lingual concavities of the maxillary anterior teeth. The track of the

incisal edges from maximum intercuspation to edge-to-edge

occlusion is termed the protrusive incisal path. The angle formed by

the protrusive incisal path inclination, which ranges from 50-70.

While conventionally regarded as independent factors, there is

evidence to suggest that condylar inclination and anterior guidance

are linked, or dependent factors. In a healthy occlusion, the anterior

guidance is approximately 5 to 10 steeper than the condylar path

in the sagittal plane. Therefore, when the mandible moves

protrusively, the anterior teeth guide the mandible downward to

create disocclusion or separation, between the maxillary and

mandibular posterior teeth. The same phenomenon should occur

during lateral mandibular excursions.

The lingual surface of a maxillary anterior tooth has both a

concave aspect and a convexity, or cingulum. The mandibular

incisal edges should contact the maxillary lingually surfaces at the

transition from the concavity to the convexity in the centric relation

position. The concavity represents a uniform shape in all subjects.

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Occlusion in fixed partial denture

Anterior guidance, which is linked to the combination of

vertical and horizontal overlap of the anterior teeth, can affect

occlusal surface morphology of the posterior teeth. The greater the

vertical overlap of the anterior teeth, the longer the posterior cusp

height may be. When the vertical overlap is less, the posterior cusp

height must be shorter. The greater the horizontal overlap of the

anterior teeth, the shorter the cusp height must be. With a

decreased horizontal overlap, the posterior cusp height may be

longer.

By increasing anterior guidance to compensate for inadequate

condylar guidance, it is possible to increase the cusp height. If the

protrusive condylar inclination is shallow, requiring short posterior

cusps, the cusps may be lengthened by making the anterior

guidance steeper. In like manner, increasing anterior guidance will

permit the lengthening of cusps that would otherwise have to be

shorter in the presence of a pronounced immediate lateral

translation. (Fig. 7 & Fig. 8).

Fig. 7 Fig. 8

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Occlusion in fixed partial denture

III. Occlusal assessments1,12

AIMS

1. Establish baseline measurement such as vertical dimension,

over jet and overbite.

2. Detect signs and symptoms of occlusal problems

3. Decide between confirmative or reorganized approach

Significance of occlusal assessment

From a thorough review of literature there is no well controlled

studies that implicates the occlusion as an aetiological factor in

temporomandibular disorders. However the dentist has to pay

attention to the occlusion regarding.

To reduce mobility if caused by the occlusion

Patient comfort, i.e. to check any interferences

Mechanical integrity of restoration, teeth and osseointegrated

fixtures

To maintain control so that treatment can progress in a

predictable manner

1. Methods of checking occlusal contact

a. Occlusal tapes: Before starting, medicate the patient with

antisialogoues and then thoroughly wipe the teeth. A 15 micro

GHM occlusal tape is held with aid of Millers forceps and the

mandible guided to centric relation contact position, or any

excursive position requiring checking.

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Occlusion in fixed partial denture

It should be noted that density of color of mark is not related

to force of contact and heavier contact tend to spread the mark

peripheral to the actual contacting area, with the later being devoid

of ink. (Fig. 9).

Fig. 9

b. Shim stock: The 12 micron foil is held with mosquito forceps

between the teeth and checked for resistance to the pulling of

foil. However on mobile teeth, it may indicate contacts that are

not necessarily initial contacts. If initial contact are indeed on

the mobile teeth, these teeth will be depressed and the

secondary contacts on other teeth will then appear to be as

primary contacts. (Fig. 10)

Fig. 10

c. Sandblasted surfaces: This can be used for any metal surface.

The occlusal surface is sandblasted with 15-micron aluminum

oxide which produces a matt finish, the restoration is then

placed in patients mouth and movements made. If there are

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Occlusion in fixed partial denture

any interferences or high points on the restoration, the matt

finish gets polished to a shiny surface in that particular area,

which should then be removed.

d. T-scan: It is an electronic device, which enables tooth contacts

to be observed on a monitor screen, the contacts can be

observed as primary, secondary and tertiary. It also indicates

relative forces on each of these contacts.

Disadvantage: The T-scan identifies the approximate location of

contact, and hence tape markings are necessary for exact location.

T-scan is useful instrument only when used in conjunction with

tapes, shim shocks and sandblasted surfaces. (Fig. 11).

Fig. 11

2. Centric relation contact position (CRCP)

It is the relationship of the mandible to the maxilla in which

initial contact has occurred following closure with condyles in their

most superior position in the fossae with their anterior surfaces

functioning against the posterior facing surface of the ementia.

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Occlusion in fixed partial denture

Fig.12

3. Movement from centric relation contact position to

intercuspal position

Intercuspal position is an adaptive mandibulomaxillary

relationship, deflective contacts in centric relation may lead to a

path of closure which avoids the single tooth contacts i.e. ICP may

depend upon avoidance of centric relation interferences.

To check for movement observe the incisors to determine

vertical and horizontal dimension of the slide. From CRCP to ICP

It can be subdivided into 2 types

1. Large vertical: Horizontal ratio, where vertical component of

slide is more than the horizontal one. (Fig. 13 and Fig. 14)

Fig. 13 Fig. 14

2. Large horizontal : Vertical ratio, where horizontal component


is more than the vertical one. (Fig. 6 and Fig. 7)

18
Occlusion in fixed partial denture

Fig. 15 Fig. 16

According to Wise when the mandible moves from centric

relation contact position to intercuspal position and vice versa, the

horizontal / vertical movement of the condyle is directly related to

the vertical / horizontal ratio measured at the incisor region of the

mandible.

Patient with large vertical than horizontal component tend to

have little if any horizontal movement of condyles, whereas those

with large horizontal component have a correspondingly larger

horizontal movement of the condyles.

Significance

A slide with large vertical: horizontal ratio is easy to adjust as

condyles move vertically but on average will only move horizontally

by a small amount, conversely a slide with large horizontal : vertical

ratio is difficult to adjust as there is likely to be a large horizontal

shift of condyles.

Following adjustment the former tends to result in CRCP

coinciding with original ICP and requires little adaptation by patient.

The later frequently results in CRCP becoming distal to original ICP

and may result in loss of contact between upper and lower anterior

teeth giving rise to guidance problems.

In patients with history of clicking and large horizontal :

vertical ratio it is prudent to retain deflective contacts, so as to

19
Occlusion in fixed partial denture

prevent the mandible from distally repositioning and possibly

altering condyle / meniscal relationship.

When fabricating a new restoration,

A confirmative approach should be used inc cases of large

horizontal: vertical ratio since removal of deflective contacts

may result in distal movement of the mandible leading to TMJ

clicking and loss of anterior guidance.

A reorganized approach should be used in cases of a large

vertical: horizontal ratio so that CRCP and ICP coincide with

little or no distal movement of condyle

4. Lateral positions and excursions

It is divided into:

b. Working side contact

c. Non - working side contact

b. Working side contact is further divided into

Group function: Contact of two or more opposing pairs of

teeth on working side

Canine guidance: Contact only of opposing canine with other

teeth separated.

Significance: Identification of precise contacts made in lateral

excursion is particularly important in patients with bruxism as

20
Occlusion in fixed partial denture

restoration may alter the direction of mandibular movement, leading

to failures or discomfort to the patients.

Whether the working side contact is group function or canine

guided

The contact should be smooth,

Use similar materials between opposing contacting surfaces to

reduce wear, and as a result changes in guidance.

Ensure there is no excessive mobility of guiding teeth.

Eliminate non-working side interferences, so as to achieve

working side contacts.

If the mandibular movement does not fulfill the above

requirement, then adjustment may be necessary prior to restoration.

5. Straight protrusion

Checked by instructing the patient to close into the ICP and

then slide straight forward until the incisors meet edge to edge.

6. Lateral protrusion

Checked by instructing the patient to close in the ICP then

move forward and to one side.

Marking tapes like GHM and shim stock foil checks both

protrusive contacts.

Significance:

According to the modern theories of occlusion, whether it is a

partial denture or a fixed restoration, in protrusion movement, there

should be contact between opposing, anterior teeth with separation

of posterior teeth. So an occlusion requiring restoration particularly

21
Occlusion in fixed partial denture

of the anterior teeth should be investigated for protrusive contacts

as posterior protrusive interferences often require elimination prior

to restoration of anterior teeth.

IV. SELECTIVE GRINDING3

1. Indications:

A selective-grinding procedure can be used to (1) assist in

managing certain temporomandibular disorders (TMDs) and

(2) complementary treatment associated with major occlusal

changes.

In summary, selective grinding is indicated to improve an

occlusal condition only when sufficient evidence exists that this

alteration will assist in the management of a TMD or in conjunction

with an already established need for major occlusal treatment. At

present no evidence shows that prophylactic selective grinding is of

benefit to the patient.

2. Predicting the outcome of selective grinding

The clinician should remember that even when alteration of

the occlusal condition is indicated, a selective-grinding procedure

may not be the treatment of choice. Selective grinding is appropriate

only when alterations of the tooth surfaces are minimal so that all

corrections can be made within the enamel structure. When the

22
Occlusion in fixed partial denture

malalignment of teeth is great enough that achieving the treatment

goals will penetrate the enamel, selective grinding must be accompa-

nied by proper restorative procedures. Exposure of dentin poses

problems (e.g., increased sensitivity, caries susceptibility, wear) and

therefore should not be left untreated. It is extremely important that

the treatment outcome of selective grinding be accurately predicted

before treatment begins. Both the operator and the patient must

know and be prepared in advance for the results of the selective-

grinding procedure. Patient acceptance and rapport are not

strengthened when, after the procedure is completed, additional

crowns necessary to restore the dentition are added to the treatment

plan.

The success in achieving the treatment goals using a selective-

grinding procedure alone is determined by the degree of

malalignment of the teeth. Because it is necessary to work within

the confines of the enamel only minimal corrections can be made.

The "rule of thirds" is helpful in predicting the success of a selective-

grinding procedure. It deals with the buccolingual arch discrepancy

when the condyles are in the musculoskeletally stable (MS) position.

(Fig. 17).

23
Occlusion in fixed partial denture

Fig. 17

The anteroposterior discrepancy also needs to be considered. It

is best examined by visualizing the centric relation (CR) to

intercuspal position (ICP) slide, which is observed by locating the

mandible in the MS position (i.e. CR) and with a hinge axis

movement bringing the teeth into light contact. Once the buccolin-

gual discrepancy of the posterior teeth is examined (i.e., rule of

thirds), the patient applies force to the teeth. An anterosuperior shift

of the mandible from CR to ICP will be noted. The shorter the slide,

the more likely it is that selective grinding can be accomplished

within the confines of the enamel. Normally an anterior slide of less

than 2 mm can be successfully eliminated by a selective-grinding

procedure.

The direction of the slide in the sagittal plane can also

influence the success or failure of selective grinding. Both the

horizontal and the vertical components of the slide should be

examined. Generally, when the slide has a great horizontal

component, it is more difficult to eliminate within the confines of the

enamel. If it is almost parallel with the arc of closure (i.e, large

vertical component), eliminating it is usually easier. Therefore both

24
Occlusion in fixed partial denture

the distance and the direction of the slide are helpful in predicting

the outcome of selective grinding.

After the CR slide has been examined, the position of the

anterior teeth is evaluated. These teeth are important because they

will be used to disocclude the posterior teeth during eccentric

movements. With the condyles in their treatment position (i.e., CR),

the mandible is once again closed until the first tooth contacts

lightly. An attempt is made to visualize the relationship of the

maxillary and mandibular anterior teeth as if the arc of closure were

continuing until the patient's vertical dimension of occlusion was

achieved. This represents the position of the anterior teeth after the

premature CR contacts have been eliminated. An attempt is made to

predict the type and adequacy of the future anterior guidance.

It is relatively easy to predict the treatment outcome in a

patient with well-aligned teeth and a very short CR slide. It is equally

easy to determine that a patient with a 6-mm horizontal slide and

poorly aligned teeth is not a good candidate for this procedure alone.

The problem with predicting the outcome of selective grinding arises

with the patient who is between these two extremes. Therefore when

it is difficult to determine the outcome of selective grinding, accurate

diagnostic casts are carefully mounted on an articulator so that

further analysis can be made. Tooth alignment and the CR slide are

more easily evaluated on mounted diagnostic casts. When doubt still

25
Occlusion in fixed partial denture

exists, the selective grinding is carefully performed on the diagnostic

casts so that the final results can be visualized. Teeth that are

severely altered should be treatment planned for crowns. Once the

results of the selective grinding are visualized, the potential benefits

of the procedure can be weighed against any additional treatment

needed to restore the dentition. These considerations must be

evaluated before a selective-grinding procedure is suggested to the

patient.

3. Important considerations in selective grinding

The procedure can begin when proper indications for selective

grinding are determined and treatment results have been adequately

predicted. It is advisable, however, not to rush into treatment

without thoroughly explaining the procedure to the patient.

The effectiveness of selective grinding can be greatly influenced

by the operator's ability to manage the patient. Because the

procedure demands precision, careful control of the mandibular

position and tooth contacts is essential. The patient's muscular

activity must be properly restrained during the procedure so that the

treatment goals can be accomplished. Therefore conditions that exist

during the procedure should promote patient relaxation. Selective

grinding is performed in a quiet and peaceful setting. The patient is

reclined in the dental chair and approached in a soft, gentle and

understanding manner. Encouragement is given when success in

26
Occlusion in fixed partial denture

relaxing and aiding the operator is achieved. When it is

advantageous for the operator to guide the mandible to a desired

position, the movement is performed slowly and deliberately so as

not to elicit protective muscle activity. The success of a selective-

grinding procedure is dependent on all these considerations.

4. Treatment goals for selective grinding

Although selective grinding involves the reshaping of teeth, the

mandibular position to which the teeth are altered is also critical.

Selective grinding should begin with locating the MS position (i.e,

CR) of the condyles.

The occlusal treatment goals for selective grinding are as follows:

1. With the condyles in the MS position (i.e., CR) and the

articular discs properly interposed, all possible posterior teeth

contact evenly and simultaneously between centric cusp tips

and opposing flat surfaces.

2. When the mandible is moved laterally, laterotrusive contacts

on the anterior teeth disocclude the posterior teeth.

3. When the mandible is protruded, contacts on the anterior

teeth disocclude the posterior teeth.

4. In the upright-head position (i.e., alert-feeding position), the

posterior teeth contact more heavily than the anterior teeth.

Several methods can be used to achieve these goals. The one

that will be described consists of developing (1) an acceptable

27
Occlusion in fixed partial denture

CR contact position and (2) an acceptable laterotrusive and

protrusive guidance.

a. Developing an acceptable centric relation contact position

The goal of this step is to create desirable tooth contacts when

the condyles are in their MS position (i.e., CR). In many patients an

unstable occlusal condition exists in CR and creates a slide to the

more stable ICP. A major goal of selective grinding is to develop a

stable intercuspal contact position when the condyles are in the CR

position.

Another way of describing this goal is to refer to it as

elimination of the CR slide. A slide of the mandible is created by the

instability of contacts between opposing tooth inclines. When the

cusps tip contacts a flat surface in CR and the elevator muscles

apply force, no shift occurs. Thus the goal in achieving acceptable

contacts in ICP is to alter or reshape all inclines into either cusp tips

or flat surfaces Cusp-tip-to-flat-surface contacts are also desirable

because they effectively direct occlusal forces through the long axes

of the teeth.

The CR slide can be classified as anterosuperior,

anterosuperior and to the right, or anterosuperior and to the left.

Each is created by specific opposing inclines. A basic understanding

28
Occlusion in fixed partial denture

of these classifications makes establishing an acceptable CR position

simpler.

Anterosuperior slide

The slide from CR to maximum intercuspation may follow a

pathway that is straightforward and superior in the sagittal plane. It

is due to contact between the mesial inclines of the maxillary cusps

and the distal inclines of the mandibular cusps. (Fig. 18).

Fig. 18

Anterosuperior and right slide

The CR slide may be anterosuperior with a right lateral

component (i.e., moving to the right). When a lateral component is

present, it is due to the inner and outer inclines of the posterior

teeth.

i. When opposing tooth contacts on the right side of the arch create

a right lateral slide, it is due to the inner inclines of the maxillary

lingual cusps against the inner inclines of the mandibular buccal

cusps. Because these are also the locations for mediotrusive

contacts, they are sometimes called mediotrusive CR

interferences.

29
Occlusion in fixed partial denture

ii. When a right lateral slide is created by opposing tooth contacts

on the left side of the arch, two contacting surfaces may be

responsible: (1) the inner inclines of the maxillary buccal cusps

against the outer inclines of the mandibular buccal cusps or (2)

the outer inclines of the maxillary lingual cusps against the inner

inclines of the mandibular lingual cusps. Because these inclines

are also the areas for laterotrusive contacts, they are sometimes

called laterotrusive CR interferences. (Fig. 19 & Fig. 20).

Fig. 19 Fig. 20

Anterosuperior and left slide

The CR slide may be anterosuperior with a left lateral

component. When a left lateral shift is present, the opposing inclines

that create it are the same as those that create the right lateral shift

but are present on the opposite teeth.

Understanding the exact location of the contacting inclines can

great assist in the selective-grinding procedure. Of course these

types of incline locations are accurate only if the normal

buccolingual alignment is present. When posterior teeth are in cross

bite, the location of the contacting inclines changes.

30
Occlusion in fixed partial denture

With an understanding of the previously discussed principles,

the clinician can begin the selective-grinding procedure.

31
Occlusion in fixed partial denture

Achieving the centric contact position

The patient reclines in the denial chair, and CR is bimanually

located. The teeth are lightly brought together, and the patient

identifies the tooth that is felt to contact first. The mouth is then

opened, and the teeth are thoroughly dried with an air syringe or

cotton roll. Articulating paper (or ribbon) held with forceps is placed

on the side identified as having the first contact. The mandible is

again guided to CR and the teeth contact, lightly tapping on the

paper. The contact areas are located for the maxillary and

mandibular teeth. One or both of the contacts will be on an incline,

either the mesial and distal inclines or the buccal and lingual

inclines. To eliminate the CR slide, these inclines must be reshaped

into cusp tips or flat surfaces.

An acceptable method for reshaping tooth surfaces is the use

of a small green stone in a high-speed handpiece. It is advisable,

however, that beginning students use a green stone in a slow-speed

handpiece to avoid removing too much tooth structure too quickly.

When confidence and expertise are gained, the high-speed handpiece

can be used. It will achieve good results in a reasonable time with

less tooth-to-bone vibration and therefore generally more comfort for

the patient.

When a contact is found on an incline close to a centric cusp

tip, it is eliminated. With this area eliminated, the likelihood is

greater that the next time the posterior teeth come together the

32
Occlusion in fixed partial denture

contact area will be shifted up closer to the cusp tip. When a contact

area is located on an incline near the central fossa area, the incline

is reshaped into a flat surface. This is often called hollow grinding,

because the fossa area is widened slightly. The clinician should

remember that the buccolingual relationship of the maxillary and

mandibular teeth cannot be altered, because it is determined by the

interarch widths when the condyles are in CR. Therefore the only

way that a cusp tip can contact a flat surface is for the fossa area to

be widened and a new; area created. (Fig. 21 & Fig. 22).

Fig. 21

Fig. 22

Once these incline areas have been adjusted, the teeth are

redried, remarked, and revalidated. If inclines are still present, they

are readjusted in a similar manner until only the cusp tip contacts a

flat surface. Once this has been achieved, the contact relationship

between the two areas is stable. However, these two contacts are not

the only ones necessary to achieve a stable CR position. As

adjustments are made, other teeth will also come into contact and

must be adjusted by the same sequence and technique.

33
Occlusion in fixed partial denture

The opposing incline contacts in CR are at an increased

vertical dimension of occlusion. As the inclines are eliminated, the

contact position begins to approach the patient's original vertical

dimension of occlusion, which is maintained by the ICP. As closure

occurs, more teeth come into contact. Each pair of contacts is eval-

uated and adjusted to cusp tips and flat surfaces. The clinician

should remember that all contacting incline areas must be

eliminated.

As the CR contacts are developed, sound cusp-tip-to-flat-

surface contacts are established but often at a greater vertical

dimension than the ICP. Therefore it is likely that these new

contacts will not allow the other posterior teeth to contact. When

this occurs, these contacts are reduced slightly so the remaining

teeth can occlude.

Even though cusp tip-to-flat surface contacts are desirable,

these areas must be reduced to permit full contact of the remaining

teeth. It generally is important for function and stability to maintain

prominent cusp tips. Thus the appropriate contact area- to reduce is

the flat surface. However, before this is done, one other factor should

be considered. As a fossa area is reduced, the centric cusp becomes

situated more deeply in the fossa. The deeper a cusp tip is located in

a fossa, the more likely it is to contact an opposing incline during

eccentric movements. Because eliminating posterior tooth contacts

34
Occlusion in fixed partial denture

is one of the goals of selective grinding, it is most efficient to address

this condition at this time. Therefore the decision to reduce either

the cusp tip or the flat surface is made by visualizing the cusp tip as

it executes the various eccentric movements.

When a cusp tip does not contact an opposing tooth surface

during eccentric movements, the opposing flat surface is reduced.

When a cusp tip does contact an opposing tooth surface, the cusp

tip is reduced. This reduction not only assists in establishing CR

contacts on other posterior teeth but also reduces the likelihood of

undesirable eccentric posterior tooth contacts when the anterior

guidance is developed. When altering either a cusp tip or a flat

surface, the clinician should remember that the same shape must be

maintained so that the desired contact will be reestablished as the

vertical dimension approaches the original values of the patient.

The CR contacts are marked and adjusted until all available

posterior centric cusps are contacting evenly and simultaneously on

flat surfaces. Ideally there should be four CR contacts on each molar

and two on each premolar. Because selective grinding involves only

the removal of tooth structure and cannot control all tooth surfaces

or positions, sometimes less than ideal circumstances result. A

minimum goal that must be achieved is for every opposing tooth to

have at least one CR contact. If this is not done, then drifting of

unopposed teeth can occur; the result may be reestablishment of

undesirable tooth contacts.

35
Occlusion in fixed partial denture

Anterior teeth that contact heavily during the development of

posterior CR contacts are reduced. It is generally acceptable to

reduce these contacts equally on both the maxillary and the

mandibular anterior teeth until the posterior teeth are reestablished

as the more prominent contacts. When the anterior teeth are being

adjusted, it is vitally important to visualize the future guidance

contacts that will soon be developed. If it is determined that by

grinding more on either a maxillary or a mandibular tooth the

guidance can be improved, this should be done

An acceptable CR position has been developed when equal and

simultaneous contacts occur between cusp tips and flat surfaces on

all posterior teeth. When the mandible is guided to CR and force is

applied, no shift or slide occurs. (There are no inclines to create a

slide.) When the patient closes and taps in CR, all the posterior teeth

are felt evenly. If a tooth contacts more heavily, it is carefully

reduced until it contacts evenly with the other posterior teeth.

2. Developing an acceptable lateral and protrusive guidance

The goal of this step in selective grinding is to establish a

sound and functional complement of tooth contacts that will serve to

guide the mandible through the various eccentric movements.

Posterior teeth are not usually good candidates to accept the

forces of eccentric mandibular movement. The anterior teeth, and

especially the canines, are much better Therefore under optimum

36
Occlusion in fixed partial denture

conditions the canines should contact during laterotrusive

movements and disocclude all the posterior teeth (bilaterally). When

the canines are in proper alignment, this goal is achieved. Often,

however, they are not properly positioned to contact immediately

during a laterotrusive movement. Because selective grinding deals

only with the removal of tooth structure, this lack of contact cannot

be corrected. When it occurs, the teeth that are best able to accept

the lateral forces should contact and guide the mandible until the

canines can contact and assist in the movement.

Several posterior teeth closest to the anterior portion of the

mouth (e.g., the premolars) best accept laterotrusive contacts. In

other words, when the canines are not positioned so that they can

immediately provide laterotrusive guidance, group function guidance

is established. In this instance the premolars and even the

mesiobuccal cusps of the first molars guide the mandible laterally.

As soon as adequate movement rings the canines into contact, they

are used to assist in the movement.

It is important to remember that this laterotrusive movement

is not static but dynamic. Tooth contacts must be properly

controlled during the entire movement until the canines pass over

each other, allowing the anterior incisors to contact (which is termed

the crossover position). During this dynamic movement all teeth pro-

viding guidance in the group function should contact evenly and

37
Occlusion in fixed partial denture

smoothly. If it is noticed that the first premolar is responsible for all

guidance during a particular portion of the movement, this tooth

may experience traumatic forces, usually resulting in mobility.

Selective grinding adjusts this tooth until it contacts evenly with the

remaining teeth during the laterotrusive movement.

When developing an acceptable lateral and protrusive

guidance, the clinician should remember the following:

1. Acceptable laterotrusive contacts occur between the buccal cusps

and not the lingual cusps. Lingual laterotrusive contacts and

mediotrusive contacts are always eliminated because they

produce eccentric occlusal instability.

The anterior teeth (not the posterior teeth) best guide

protrusive movements (as they do in lateral movements). During a

straight protrusive movement the mandibular incisors pass down

the lingual surfaces of the maxillary incisors, disoccluding the

posterior teeth. During any lateroprotrusive movement, the lateral

incisors can also be involved in the guidance. As the movement

becomes more lateral, the canines begin to contribute to the

guidance.

38
Occlusion in fixed partial denture

V. Determining the plane of occlusion4

A correct plane of occlusion allows protrusion without

posterior interference. It allows non-interfering lateral excursions

without loss of function on the working side.

When the mandible is protruded, the anterior guidance and

the downward movement of the condyles should disocclude all

posterior teeth. If the curve of spee is too concave or too high

posteriorly, one or more posterior teeth may interfere in protrusive

movement. Likewise an improper curve can cause interferences on

the nonfunctioning side because of the protrusive movement of the

condyle on that side, or because of an exaggerated curve of Wilson.

(Fig. 23).

Fig. 23

There are other considerations that should not be disregarded,

but they are secondary in importance to the primary requirement of

protrusive and balancing-side disocclusion of the posterior teeth.

These two requirements can be accomplished with an amazingly

wide degree of flexibility as far as the occlusal plane is concerned.

This flexibility makes it possible in many patients to satisfy esthetic

39
Occlusion in fixed partial denture

requirements without having to drastically alter an entire occlusion.

Teeth should never be restored unnecessarily simply to conform with

an arbitrary predetermined occlusal plane.

It is possible for an occlusal plane to be flat and still fulfill the

basic requirements, but if optimum efficiency in function is the goal,

the occlusal plane will usually have curvatures to it. Better

esthetics is, in most cases, also dependent on the natural curvatures

of the occlusal plane, the perfectly flat plane often being the epitome

of artificiality. A flat occlusal plane can even be harmful, since it

can create stressful crown-root ratios when the curvature of the

supporting alveolar bone is not matched to a reasonable degree with

the curvature of the occlusal plane.

A severely concave plane of occlusion on the lower arch may

function acceptably if it is combined with a steep enough anterior

guidance to disocclude the posterior teeth in excursions.

Appearance is not generally impaired with this combination as long

as the level of the occlusal plane is fairly even on both sides.

The occlusal plane problem that is most detrimental to

esthetics is the slanted plane. Which is high on one side and low on

the other. In fact, there is probably no single factor of occlusion that

is more noticeably unattractive than a slanted plane of occlusion.

Leveling of the occlusal plane always starts with the anterior teeth

for the following two reasons.

40
Occlusion in fixed partial denture

1. Esthetics:

The location of incisal edge position relates to the smile line

and determines the incisal plane, which is the anterior starting point

for the occlusal plane on each side. For best esthetics, it is an

absolute requirement that the incisal plane be parallel with the

interpupillary line.

2. Function:

Since the functional acceptability of any occlusal plane is

primarily related to letting the anterior guidance do its job, the

anterior segments must be organized before we can know how

effective the anterior guidance can be in disoccluding the posterior

teeth. The importance of the occlusal plane increases as the

steepness of the anterior guidance decreases. The flatter the

anterior guidance, the less capable it is of disoccluding a severely

curved occlusal plane.

3. Examination for occlusal plane problems:

An occlusal examination is not complete unless it includes an

analysis of the occlusal plane. Simply ask the patient to protrude

the mandible. If the posterior teeth separate the anterior teeth,

there is a problem with the occlusal plane. The problem may be the

result of a single misaligned tooth, or it may be cased by improper

curvature of alignment of the entire occlusal plane.

41
Occlusion in fixed partial denture

Because the condylar path is so important to protrusive

disocclusion of the posterior teeth, condylar paths should be

recorded at least by a clusal plane problem exists. The steeper the

condylar path is in protrusive, the better able it is to help the

anterior guidance disocclude the posterior teeth.

When protrusive separation of the anterior teeth is

accompanied by severe wear of the upper lingual cusps, there is a

probability that condyles and the eminence. The resultant flatter

condylar path is less capable of helping the anterior guidance and

can create critical problems of working out an acceptable occlusal

plane. In such cases, the condylar path should be accurately

recorded so that its effect on the posterior occlusion can be analyzed

along with the anterior guidance. Face bow-mounted diagnostic

casts are essential for this analysis.

4. Correcting occlusal plane problems:

There are two basic approaches to solving occlusal plane

problems. One involves leveling or flattening the occlusal plane so

that it can be disoccluded by the existing anterior guidance, which

remains unchanged. The second approach involves steepening the

anterior guidance so that it can disocclude the existing occlusal

plane, which remains unchanged. There is obviously a compromise

alternative that combines both a steepening of the anterior guidance

with alteration of the occlusal plane. Several considerations need to

be understood before there is a decision on which approach to take

on any given patient.

42
Occlusion in fixed partial denture

Whether the anterior guidance should be steepened depends

on four factors:

a. Envelope of function

b. Arch-to-arch relationships

c. Esthetic factors

d. Periodontal support

The envelope of function :

It is the principal determinant of the anterior guidance; so any

steepening of the anterior guidance can result in restriction of the

established pattern of function. However, when occlusal-plane

problems separate the anterior teeth in protrusive, it is often

possible to eliminate the posterior interferences by selective grinding

so that anterior contact can be maintained from centric relation.

This is most often possible to accomplish without any major changes

in the anterior guidance.

In some instances, however, changes to the posterior occlusion

may be extensive enough to require posterior restorations in order to

preserve the existing anterior guidance. This is an easier decision to

make if extensive restoration of the posterior segments is needed

anyway for other reasons. In mouths that have no other need for

posterior restorations, orthodontic treatment should be considered

to correct the occlusal plane rather than alter a potentially favorable

anterior relationship.

43
Occlusion in fixed partial denture

Steepening the anterior guidance does not always restrict the

envelope of function. Posterior tooth alignment can prevent the

mandible from horizontal function and thus be the limiting factor

that dictates verticalized function even though the anterior teeth are

not in contact. In such cases, steeping the anterior guidance may

simply transfer the guiding inclines from the posterior teeth to the

anterior teeth without altering the envelope of function. (Fig. 24 &

Fig. 25).

Fig. 24 Fig. 25

When this procedure is done, even slight modification of the

occlusal plane can result in disocclusion of the posterior teeth in

excursions.

The envelope of function should be evaluated in every case

before extensive changes in the occlusal plane are recommended.

Even though the occlusal plane prevents the anterior guidance from

disoccluding posterior teeth in protrusion, a problem may not exist if

the jaw has no protrusive movement as part of its locked-in

occlusions do not use protrusive movements. If they function solely

in a chop-chop verticalized pattern, there is no need to disocclude

the posterior teeth in jaw relationship that are never used.

44
Occlusion in fixed partial denture

Analyzing the teeth for signs of instability should make it evident if

there is not horizontal component of function. There is rarely a

functional occlusal plane problem in vertically restricted function if

all the teeth are stable. If there is a need for esthetic improvement

in such patients, the anterior guidance can generally be altered all

the way to verticalized function with no ill effects, and the occlusal

plane can be altered to improve the appearance with almost no

concern that it will interfere with the anterior teeth.

b. Arch-to-arch relationships

Certain arch-to-arch relationships may make restorative

alteration of the anterior guidance contraindicated. If the anterior

teeth are in a stable relationship with strong tongue or lip pressures

related to an anterior open bite or a severe over jet, it may create

instability if the teeth are moved or restored to contact. The occlusal

plane becomes a critical factor in some of those patients because a

disocclusion must be achieved off the flatter surfaces of the farthest

forward teeth that can contact in centric relation. In such

conditions, it is particularly important that the occlusal plane is low

enough in the back to be disoccluded by the relatively flat anterior

guidance.

In the resolution of arch-malrelationship problems the occlusal

plane is always a factor to be considered. The less the anterior

45
Occlusion in fixed partial denture

guidance is able to disocclude the posterior teeth, the more critical is

the occlusal plane.

c. Esthetic factors

Esthetics is often a key factor in determining what to do with a

slanted or uneven occlusal plane. Very uneven planes can often be

made to function acceptably, but the result is unacceptable

esthetically. When teeth on one side have been unopposed, it is

sometimes very difficult to level both sides because of the severe

elongation on the unopposed side. Unless esthetics is of no concern

whatever, every effort should be made to evenly align the occlusal

plane, including endodontic procedures if needed. Even though

endodontics would have been required, the difference in appearance

would have been worth it. Changes in the anterior segments must

be related to the posterior segments or even the appearance of

correctly aligned anterior teeth will suffer.

d. Periodontal support

Periodontal support around the anterior teeth is critical if the

anterior guidance is steepened to disocclude the posterior teeth. It

is tempting to solve an occlusal plane problem by steepening the

anterior guidance, especially if it takes the place of correcting the

occlusal plane by restoring anterior teeth that need to be restored.

One must remember that if steepening the anterior guidance

restricts habitual patterns of function, there will be a tendency for

46
Occlusion in fixed partial denture

increased horizontal stress on the anterior teeth. If the supporting

structures are already compromised, this may be a poor decision. It

will be safer to keep the anterior guidance nonrestrictive and make

the changes on the occlusal plane.

If there is no choice, and the steeper anterior guidance must

be used, the teeth should be stabililized to prevent them form being

forced out of alignment. Stabilization can be achieved by splinting,

or by use of a retainer at night when restorations are not needed.

5. Irregular occlusal plane caused by lost but unreplaced

posterior teeth:

When a posterior tooth is lost and the patient is allowed to go

without a replacement, it is almost inevitable that undesirable

changes will take place in the plane of occlusion. Teeth behind the

void have a tendency to lean into the space while unopposed teeth in

the opposite arch supraerupt until they meet opposition. The result

is a collapsed arch that prohibits protrusive or lateral excursions

because of interference form the tilted or elongated teeth. The effect

is the same as a curve of spee that is too high posteriorly. The

protruding mandible directs the stresses onto the teeth least able to

resist it. In addition, these eccentric interferences hyperactivate the

elevator muscles and thus intensify the stress. Tilted lower posterior

teeth, riding against opposing elongated teeth cause the anterior

47
Occlusion in fixed partial denture

teeth to disocclude, thus preventing the anterior guidance from

doing its job.

Correction of such an interfering occlusal plane is usually

essential if supporting structure problems are to be prevented in all

but the most fastidiously cared for mouth.

When an upper molar has supraerupted into a vacant space

between two lower posterior teeth, the upper tooth should be

shortened to permit protrusion of the mandible without posterior

contact. In some cases this should be done even if it requires

devitalization of the elongated tooth. The same is true if a lower

posterior tooth has elongated into a space above. (Fig. 26).

Fig. 26

If the terminal tooth on the upper has erupted down distal to

the most posterior lower tooth, it does not present a problem, eve

though it fails to conform to the picture of an ideal occlusal plane.

Devitalizing such a tooth just to make the occlusal plane conform

would be wrong, since the upper tooth is behind the lower teeth and

it does not restrict the mandible from moving forward under the

guidance of the anterior teeth. Such a tooth should be prevented

from excessive elongation into soft tissue by splinting or by

48
Occlusion in fixed partial denture

extension of a lower tooth into contact, but it need not be reduced in

length any more than the position of its pulp permits. (Fig. 27).

Fig. 27

It should be pointed out that when the basic requirements of

an occlusal plane are considered rather than an inflexible demand

for a preconceived contour, it is rarely necessary to devitalize any

tooth to provide an acceptable occlusal plane.

6. Curve of spee too low posteriorly:

Making the distal end of the occlusal plane too low presents no

major problems, since it cannot interfere with the basic

requirements of protrusive and balancing-side disocclusion. If it is

grossly overdone, however, it can create a poor esthetic result, can

cause excessive stress on upper teeth by requiring an unfavorable

crown-root ratio, and could conceivably reduce function in some

mouths by causing too much separation of the posterior teeth in

protrusion.

7. Curve of spee too high or low in front:

If the lower premolars are higher than the cuspids, they can

interfere with the anterior protrusive guidance by bumping into the

49
Occlusion in fixed partial denture

upper cuspids. If the lower premolars are considerably lower than

the anterior teeth, the result is very poor esthetically. There is rarely

a reason for such a relationship because it requires very simple

clinical judgment to extend the incisal level of the lower anterior into

an esthetically acceptable occlusal plane. The upper teeth may,

however, require some changes to accomplish an ideal plane.

8. Curve of Wilson:

Because the curve of Wilson is always depicted on the lower

arch, we may fail to understand that its real importance is related

more to accommodating the upper lingual cusps into the lower

occlusal scheme. Because of the normal outward tilt of upper

posterior teeth, their lingual cusps are lower than their buccal

cusps. Let us see how this affects the occlusal contours of lower

posterior teeth when the mandible is moved laterally. To emphasize

the influence of condylar pathways, we will imagine that the lateral

anterior guide angle is 0 degrees. In other words, the anterior

guidance is flat.

When the mandible moves toward the working side with such

a flat anterior guidance, the rotating condyle permits the posterior

teeth on that side to move almost horizontally toward the cheek.

The lower lingual cusp must be lowered to prevent it from interfering

with the upper lingual cusp.

On the balancing side, the orbiting condyle moves downward

as it moves forward and permits lateral movement without

interference to the upper lingual cusps. The result in the lower arch

50
Occlusion in fixed partial denture

is buccal cusps that are higher than lingual cusps and consequently

a concave curve of Wilson. (Fig.28 ).

Fig. 28

There are two ways of effectively changing the curve of Wilson.

The first way is to change the lateral anterior guidance angle. The

steeper the lateral anterior guidance angle, the higher the lower

lingual cusps may be on the same side. Raising the lower lingual

cusps has the effect of flattening the curve of Wilson, and with a step

lateral guidance from the cuspids, there may be a flat curve of

Wilson and still fairly clines direct the teeth on the working side

down as they move laterally.

It rarely serves any purpose, however, to have high lingual

cusps on the lower arch, since the lower lingual cusps are ordinarily

not functioning cusps. At lest they need not contact in any

functional movement. One may wonder why we even worry about

the height of these lower lingual cusps if they serve neither as a

holding contact or as a functioning incline, but they do act as useful

grippers of coarse or fibrous foods and consequently they serve a

51
Occlusion in fixed partial denture

useful purpose even though they need never be in actual contact (in

normal arch relationship). Furthermore, the lingual cusps should

also be lower than the buccal cusps to make it simpler for the

tongue to get the food on the occlusal surface. If we understand the

reasons for the curve of Wilson, it will become apparent that we have

a fair amount of latitude in establishing an acceptable curve of

Wilson.

The second way we may change the curve of Wilson is by

changing the length of the upper lingual cusps. By shortening the

cusp-fossae angles, we can actually make a flat curve of Wilson.

Such an occlusion can still function without interference and

without losing the upper lingual cusps as centric holding contacts.

All that would be lost is the maximum gripping effect that goes with

closely approximating cusps in excursions. In some mouths the

difference would not even be noticeable, but in others it could give

the patient a feeling of lost efficiency. Since the establishment of an

acceptable curve of Wilson can be accomplished so reason for

denying any patient whatever increased function a proper occlusal

plane can provide.

If the curve of Wilson is made too steep, it may eliminate the

use of upper lingual cusps as holding contacts, since they would

interfere with lateral movements of the mandible. Therefore it

becomes a matter of practicality to establish a curve that serves the

52
Occlusion in fixed partial denture

functional requirements within fairly broad limits of effectiveness,

while avoiding overly steep inclines that could cause interference.

9. Establishing the plane of occlusion :

There are three practical methods for establishing an

acceptable plane of occlusion. In selecting the method for a

particular patient, remember that the purpose of the procedure is to

cause the posterior teeth to be disoccluded by the anterior guidance.

If there is an esthetic problem, there will be an added purpose of

correcting the plane to a contour and height that is pleasant in

appearance. If there is no esthetic problem, any method that

satisfies the requirements of function and results in a stable

occlusion is acceptable. There is no need to complicate it beyond

these requirements.

53
Occlusion in fixed partial denture

The three most commonly used methods for establishing an

acceptable occlusal plane are as follows:

1. Analysis on natural teeth through selective grinding.

2. Analysis of facebow-mounted casts with properly set condylar

paths.

3. Use of Pankey. Mann-Schuyler method (PMS) of occlusal plane

analysis using Broadrick occlusal plane analyser. (Fig. 29).

Fig. 29

54
Occlusion in fixed partial denture

VI. OCCLUSAL SCHEMES1,12

1. Basic principles

Regardless of the type or the number of restorations, the

occlusal scheme to be employed must be decided before restoration.

The different schemes have common aims, which are:

Teeth position should remain stable following restoration.

The restoration must not introduce new deflective contacts.

There should be simultaneous contact between the restoration

and other teeth in the IP with neither high spots nor lack of

occlusion it should be noted that small high spots may remain

undetected by the clinician since the tooth is intruded

following initial contact.

There should be no non- working side contacts on the

restoration as these produce rotational forces on the tooth and

restoration but their removal is dependent on there being

working side contacts to pick up the guidance.

There should not be working side interference on the

restoration (these often occur on lingual cusps and are difficult

to detect).

The anterior guidance should be in harmony with the

temporomandibular joints and musculature and should not

introduce an occlusal interference.

55
Occlusion in fixed partial denture

Occlusal forces should be directed through the strongest areas

of the restorative material and tooth.

Occlusal forces should be directed along the long axes of teeth.

2. Confirmative Approach

Restorations are fabricated to the existing jaw relationships.

With this approach the patient will need minimal adaptation, if any.

The restoration should fit into the existing neuromuscular patterns.

Tooth form can be altered, but the following guidelines are observed:

a. The existing intercuspal position is maintained

The objective is to retain the existing intercuspal position

Wherever possible, techniques must be used which facilitate

the fabrication of new restoration witch fit into the existing

intercuspal position

Not only Should the new restorations conform to the existing

intercuspal position, but they should also help retain it that is,

existing deflective contacts (contacts witch alter the closure

from one path to be another) may need to be copied on the new

restorations. Deflective contacts on teeth, which are not to be

re-restored, are left.

If the patient has a large horizontal: vertical ratio, particularly

in conjunction with a previous history of licking of the TMJ

which has now resolved, it is not wise to remove deflective

contacts, since distal repositioning of the condyle could result

in an altered condyle/meniscus relationship, possibly with

56
Occlusion in fixed partial denture

recurrence of the click. Techniques should be used which

enable the defective contacts to be built back into new

restorations. This requires more laboratory and surgery time

and this must be anticipated.

b. Remove deflective contacts if on one or two teeth are to be

restored

Deflective contacts alter closure from one path to another.

Their removal will frequently result in a new habitual path of closure

terminating in a new intercuspal position. In a patient with a large

horizontal: vertical ratio in with the horizontal component is less

than 1 mm and the patient is not occlusally aware, if one or two

teeth to be re-restored deflective contacts it maybe sensible to

remove these contacts some time before re-restoration, to allow the

mandible to adopt a slightly altered path of closure if the muscles so

desire and then work to the new intercuspal position. If this

procedure is not carried out there is a danger that such change will

take place during the temporary stage, as a result of tooth

preparation leading to inevitable removal of deflective contacts. The

occlusion of this definitive restorations will then differ from that

fabricated in the laboratory. Rarely is it possible to exactly copy the

deflective contacts on the temporary restorations. For a phlegmatic

patient, this may not be of consequence, but for any occlusally

aware patient it may introduce time consuming complications. It

57
Occlusion in fixed partial denture

must be pointed that this is not occlusal equilibration, merely

adjustment of one or two inclines prior to restoration. It is obviously

a slight modification of the conformative concept, since the

intercuspal position that is being restored to differ slightly from the

original intercuspal position. However, it does avoid clinical

complications and should be seriously considered.

c. Removal of non-working side contacts prior to re-restoration

A non-working side contact tends to guide the mandible

during lateral excursion. Removal of the existing restorations

decreases the vertical component of the movement pathway, since

now the condyle in the fossa will be guiding the movement. The

preparation may contact the opposing tooth. These will be

insufficient space for the restoration in lateral excursion, so that

cementation of the restoration creates a new non-working side

contact. If the patient is occlusally aware, or under stress,

adaptation will almost certainly be slow and discomfort is likely,

since the original contact to which the patient will have gradually

adopted was probably long standing. In response to the patients

complaint of discomfort, frequently the restoration is ground, either

exposing metal beneath porcelain, or perforating the casting. The

technician is often blamed, whereas the fault was the clinicians for

not recognizing the problem originally.

58
Occlusion in fixed partial denture

Non-working side contacts can only be removed prior to re-

restoration, if there are teeth o the working side available to pick up

the guidance. If no such teeth are present, removal of the non-

working side contacts is impossible and more time should be set

aside to copy the existing non-working side contacts: fabricate

temporary restorations; fabricate the definitive restorations and

check them at the time of fitting.

3. Reorganized Approach

Deflective contacts and occlusal interferences (contacts which

inhibit a smooth movement of the mandible when carrying out

excusive movements with the teeth in contact) are removed allowing

the muscles of mastication to move the mandible free from the

proprioceptive influence of these contacts. The general sequence of

treatment of a reorganized approach.

1. Stabilize the jaw and posterior tooth relationships.

2. Check

3. Determine the anterior guidance

4. Check Restore the anterior teeth

5. Check Restore the posterior teeth

59
Occlusion in fixed partial denture

In the anterior teeth were restored without stabilization of the

jaw relationships, on removal of the posterior deflective contacts as a

consequence of tooth preparation the jaw relationships would

change, there by altering the anterior guidance relationships. In

consequence, it is far more sensible to first eliminate the deflective

contacts and occlusal interferences, allowing the mandible to find its

own position relative to the maxilla. After provisionally restoring the

posterior teeth the anterior guidance is determined and copied and

then the posterior teeth definitively restored. As removal of the

posterior provisional restorations for their definitive replacement will

not alter jaw relationships, jaw registrations can be made at the

correct vertical dimension, and will be maintained by contact on the

anterior teeth.

This approach implies that any adaptation will have taken

place before re-restoration and that the restoration will fit into the

altered, newly accepted neuromuscular patterns. It also implies that

the existing anterior guidance is acceptable or that it is possible to

re-establish anterior guidance, so that in turn it becomes possible to

provide posterior dissocclusion with its associated mechanical

advantages.

In some instances it is not possible to provide anterior

guidance on anterior teeth, in which case lateral and protrusive

contacts are provided as anteriorly as possible on the posterior

teeth. The techniques for providing a reorganized occlusion are

described.

60
Occlusion in fixed partial denture

Cases in which a confirmative Approach would usually be

adopted

Singe unit with teeth on either side

Symptom free patient needing re-restoration of several

posterior teeth where the latter are bounded by a tooth

mesially and distally, both with good occlusal stops to

maintain the intercuspal position.

Restoration of a single tooth at the end of the arch although

small adjustments of deflective contacts on the tooth may be

carried out.

Three units at the end of the arch where there is a large

horizontal : vertical ratio, since removal of deflective contacts

may result in a distal movements of the mandible.

Multiple restorations and a large horizontal: vertical ratio and

a previous history of TMJ clicking

Multiple restorations and a large horizontal: vertical ratio in

which dropping back of the mandible following the removal of

deflective contacts would create a large horizontal overjet,

giving rise to either an unrestorable problem or the need to

provide anterior restorations where these were otherwise

unnecessary.

Re-restoration of anterior teeth in a symptom free patient not

requiring restoration of posterior teeth.

61
Occlusion in fixed partial denture

The advantages of restoring to a confirmative approach

No adaptation, or very little, of the patients neuromusculature

is required.

Treatment is confined solely to the teeth requiring restorations

Index techniques can be used

For a small number of restorations, laboratory procedures are

simplified.

Remember

The greater the number of units to be re-restored, the more

difficult it is to follow a confirmative approach.

The larger the horizontal; vertical ratio, the greater the

indication to work confirmatively, although the procedures

become more complicated, time consuming and less

predictable.

Recognition of the above is essential in treatment planning,

time planning and fee calculation

Cases in which a reorganized approach would usually be

adopted

Extensive re-restoration in the presence of a large vertical :

horizontal ratio. This is a very strong indication for a

reorganized approach.

A three-unit bridge at the end of the arch and a large vertical:

horizontal ratio.

62
Occlusion in fixed partial denture

A sextant or quadrant restoration and large vertical :

horizontal ratio.

Right and left quadrants or posterior sextants and a large

vertical: horizontal ratio.

Extensive re-restoration and the presence of a large horizontal:

vertical ratio where anterior guidance can be provided either

on the anterior teeth, the canines, or the canines and pre-

molars, or on a removable appliance.

The advantages of restoring to a reorganized approach

Proprioceptions from deflective and interfering contacts are

removed.

Preparation of the teeth for crowns, or removal of provisional

restorations does not result in any clinically significant change

in jaw relationships.

The clinician has far greater control and each stage becomes

very predictable

It provides a stable occlusion with simultaneous multiple

occlusal contact

It provides an occlusion that is in harmony with border

movements (the extremes of lateral and protrusive excursions

that could easily be reached if interferences were removed).

It ensures that iatrogenic deflective contacts are not

introduced

63
Occlusion in fixed partial denture

It improves control over interocclusal contacts, thereby

reducing adverse effects from disparate wear between

currently available restorative materials, and the natural teeth

It provides posterior stability which helps prevent anterior

drifting

Remember

A rigid adherence to the reorganized approach can precipitate

extremely difficult restorative problems, particularly in the

presence of a large horizontal vertical ratio.

4. Recommendations for occlusal schemes

1. Posterior occlusal schemes

2. Anterior occlusal schemes

3. Combination of anterior and posterior restorations

1. Posterior occlusal schemes

The type of interocclusal contacts that are provided will vary,

depending on tooth relationships. There is little scientific evidence to

Support the claims for any of the schemes although it should be noted

that Williamson et al (1983) reported that posterior disocclusion

reduces the activity of the elevator muscles and may therefore provide a

mechanical advantage by reducing the forces on teeth and restorations.

a. Cusp tip to fossa without lateral contacts

Here, the opposing cusp tip makes contact with the fossa only

in CRCP IP position and immediately dissoccludes to lose contact

64
Occlusion in fixed partial denture

in all excursions. This is relatively easy to fabricate in the laboratory,

but with the cusp tip fitting to the depth of the fossa, rubbing

contacts occurring during bruxism will often wear away the support

contact on the cusp tip, leading to a loss of stability. It can be

difficult to achieve immediate dissocclusion and possibly, sharp

cutting surfaces are not provided. Adjustment is simplified if there is

a small areas of contact at the very tip of a cusp, rather than a broad

area, which may present some difficulties. Even though the cusp tip

may fit into the fossa, forces may not necessarily be axial and tilting

may occur. This scheme is more applicable to splinted than

unsplinted units because of the possibility of loss of support cusp

contact. The splinting would help maintain tooth stability.

b. Cusp to fossa with working side contacts

This is similar to the first scheme. However, provided there is

not a cross bite relationship, working side contacts are established

between the palatal incline of the maxillary buccal cusp, and the

buccal incline of the mandibular buccal cusp. This is more difficult

to achieve and requires more information for setting the articulator

in lateral excursions.

c. Cusp to fossa contact in CRCP plus anteriorly placed IP

contact (that is, Long Centric, Area of Freedom in Centric).

In this relationship, the tips of the support cusp (that is, that

cups which fits into the opposing fossa and thereby maintains the

65
Occlusion in fixed partial denture

vertical dimension) contact an opposing flat flossa in both CRCP and

IP and in the intervening areas between the two positions.

It is necessary for the configuration of the latter to be such

that on contact anywhere between the CRCP and IP, there is no

anterior displacement of the mandible.

Disadvantages

Supporting cusp tip may wear, with consequent loss of

occlusal support. This scheme is particularly applicable to a

reorganized restoration in a patient with a large horizontal; vertical

CRCP, IP ratio.

d. Tripod contacts

Support cusps fit into opposing fossae, but the cusp tip, rather

than contacting the base of the fossa is kept just clear of the latter

and instead, three points of contact are established around the

periphery of the cusp tip. The theory is that the tooth position will be

maintained by occlusal contacts, buccally directed forces being

counteracted by lingually facing contacts and vice versa. Provided

there is immediate disocclusion, the absence of cusp tip contacts

should reduce cusp tip wear. Theoretically, the small multiple points

of contact on sharp cusps should improve chewing efficiency.

This scheme is applicable to both splinted and unsplinted

restorations, although it is not possible to use it to provide an area

of freedom relationship.

66
Occlusion in fixed partial denture

e. Cusp to margin ridge contacts

Frequently, there must be contacts between cusps and

opposing marginal ridges. However, this can usually be combined

with a cusp fossa contact for additional stability.

f. Confirmative contacts

An index is used to copy the existing occlusal scheme, which

may then be modified to include any of the schemes above.

There are no controlled studies reporting a greater stability of

one type of occlusal scheme relative to another, or demonstrating

which teeth are likely to be unstable unless corrected by the

provision of different occlusal contacts. There are, however, some

clinical guides

The degree and type of stabilization required from opposing

contacts depends upon whether

The teeth form individual units or are splinted. Theoretically,

splinted units require fewer contacts than the same number of

unsplinted units, as they could be stabilized by contacts only

at each end of the span.

There is increased mobility and / or reduced bony support.

Mobile, poorly supported teeth tend to be more occlusally

unstable than firm, well-supported teeth.

The arch is intact. A proximal contacts assist in stabilization

The teeth are titled

2. Anterior occlusal schemes

67
Occlusion in fixed partial denture

In CRCP and IP, the anterior contacts should be very slightly

lighter than the posterior contacts. On closure, Shim stock should

be held by the posterior teeth, but just pulled through the anterior.

By this means, the vertical dimension is maintained by posterior

support cusps, thereby preventing anterior teeth assist guiding

excursive movements. Whether or not the anterior teeth are suitably

positioned depends upon both tooth-to-tooth relationships. In the

presence of a large overjet, the guidance should be provided as far

anteirorly as possible, or on a removable appliance fabricated

palatally to the upper anterior teeth. Often with Class III cases

anterior guidance cannot be provided, but this doses not seem

important in these cases.

When provided, it is sensible to establish guidance on the

teeth most able to support it, and not use.

Highly restoratively compromised teeth, such as, a canine with a

poorly constructed post.

Highly mobile teeth, since movement of these would greatly

reduce the angle of guidance. Furthermore, with mobile teeth

guidance on laboratory casts will not match the guidance in vivo.

The shape of the palatal concavity, should fulfill the following

requirements:

Patient comfort

Aesthetic and phonetic acceptability

68
Occlusion in fixed partial denture

Smooth guidance, that is there are no mandibular deflections or

irregularities of movement.

Minimal movement of guidance teeth

No increasing mobility of guidance teeth

Regardless of the cement used, no cementation failure of interim

restorations, assuming the preparation design is adequate.

Currently, there is research into the relationships between

various characteristics of facial morophology, condylar guidance and

anterior guidance. This resultant computerized data should be very

helpful in initially establishing anterior guidance.

Anterior guidance for reorganized large vertical: horizontal ratio

cases

Ramfjord in 1983 describes contacts on the anterior teeth to

match the posterior contacts, a difficult arrangement to produce.

Dawson, in 1974, described a horizontal shelf on the palatal

surfaces of the upper anterior teeth, with immediate posterior

dissocclusion, that is, the area of freedom is only on the anterior

teeth. This is a more practical approach.

3. Combination Of Anterior And Posterior Restorations

a. Gnathalogical Scheme

The movements of the condyles in the fossae determine the

occlusal form. Fully adjustable instrumentation is required. There

should be simultaneous interoclusal contacts of all posterior teeth in

CRCP, with forces directed axially, where CRCP and IP coincide.

Closure in CRCP followed by squeezing of the jaws together, should

not result in any perceptible displacement or slide of the mandible.

69
Occlusion in fixed partial denture

In any excursive or protrusive movement anterior or canine

guidance separate (dissocclude) the posterior teeth. If anterior

guidance cannot be provided, then guidance should be placed as far

forwards as possible. The anterior teeth contact lightly in CRCP. The

palatal concavities of the anterior teeth are determined by condylar

guidance. The case is waxed on a fully adjustable articulator and

cusp fossae tripod contacts are provided.

Comments

Because of coincide of CRCP and IP, this scheme is more

suitable for large vertical horizontal ratio cases than large horizontal:

vertical ratio cases.

A fully adjustable articulator is required

Reliance on condylar guidance for palatal concavity formation

requires scientific verification. It may provide a good

indication, but clinical determinants are also required.

Tripoid contacts may be unnecessary, particularly for splinted

units.

The technique is demanding

A slide from the CRCP may recur with time. However, in this

study, it is possibly that large horizontal: vertical ratio cases

were

70
Occlusion in fixed partial denture

Included and these are more likely to be unstable than large

vertical: horizontal ratio cases.

Posterior disocclusion is a good mechanical concept as it

prevents horizontal non-axial forces form being placed upon

posterior restorations. This enhances the resistance form of

preparations and reduces sheer forces on porcelain cusps. It

also reduces elevator muscles activity.

Multiple points of contacts with cusp / fossa relationships may

improve masticatory efficiency.

N.B. Anterior guidance, as used in this text, is the influence on

mandibular movement of contacting surfaces of anterior teeth. It

does not refer to guidance produced by the posterior teeth as

anterior guidance. Posterior guidance is the influence on mandibular

movement of condylar determinants.

b. Area of freedom in centric

As Ramford in 1982 wrote: This advocate a small flat area on a

horizontal plane between the CRCP and IP (Long Centric) and with

occlusal functional guidance leading to the intercuspal position,

rather than the retruded position. The distance between CRCP and

the IP in this scheme is not critical, but usually approximately 0.5

mm 0.3 mm. Dawson, in 1974, advocated that contact anterior to

CRCP occurs only on the anterior teeth, without provision of the

horizontal table on the posterior teeth which become dissoccluded.

71
Occlusion in fixed partial denture

Comments

This scheme is applicable to reorganized large horizontal:

vertical ratio cases

Since lateral excursions can begin from both CRCP and the IP,

disocclusion needs to be provided from both positions,

complicating the restorations.

Cusp tip to fossa occlusion must be provided

Cusp tip to fossa is easier to provide than tripod contact.

Cusp tip to fossa relationship can result in wear

Areas of wear can occur between cusps and fossae leading to a

loss of support cusp contacts and possibly instability

Although advocated as a simple technique careful

determination of mandibular movements is necessary

accuracy.

c. Pankey Mann- Schuyler Concept

The anterior guidance is determined functionally. The upper

and lower anterior teeth and the lower posterior teeth are restored. A

functionally generated path (FGP) technique is used to assist waxing

of the upper posterior restorations. The occlusal plane is determined

from measurements based on the curve of Monson. The aim is to

provide simultaneous interocclusal contact of all posterior teeth in

CRCP with an area of freedom of not more than 0.5 mm anterior to

this resulting in an absence of a non-working side contact and group

function on the working side (although some operators aim for

canine disocclusion).

72
Occlusion in fixed partial denture

Comments

A fully adjustable articulator is not required

Movement of teeth while making an FGP registration leads to

inaccurate registration. It is possible for the guidance teeth to

intrude, bringing the prepared and opposing teeth closer

together than they will be on the casts mounted in the IP.

Flexibility of the mandible under muscle load can lead to

inaccurate registration

Inaccurate registrations reduce the accuracy of the final

restoration.

d. Yuodelis Scheme for advanced periodontitis cases

The foundation of a healthy periodontium is emphasized. The

aim is for simultaneous interocclusal contact of posterior teeth in

CRCP (usually coincident with IP) with forces directed axially.

Anterior disocclusion is provided for protrusive excursions and

canine disocclusion for lateral excursions. Cuspal anatomy is so

arranged that if the canine disocclusion is lost through wear or tooth

movement, the posterior teeth drop into group function. Diagnostic

temporary restorations are important in providing information

essential to this scheme.

Both fully and semi adjustable articulators are used the right

instrument of the case in hand. Emphasis is placed on margin

placement and crown contour.

73
Occlusion in fixed partial denture

Comments

This is a sensible combination of available techniques

Primary suitable for large vertical horizontal ratio cases

e. Nyman and Lindhe scheme for extremely advanced

periodontitis cases

This applies to bridgework supported by healthy, though

greatly reduced, periodontium. Even contact should be provided in

the IP, although no great emphasis is placed upon the type of

contacts. When distal support is present, anterior dissocclusion

should be provided. When there are long tooth-borne cantilevered

restorations, balanced occlusion is provided, that is, there are

simultaneous working and non-working side contacts on the

cantiliver. All restorations should be fabricated on semi-adjustable

articulators with average settings and there is an emphasis on

supragingival margin placement of restorations.

Comments

Prescription for highly mobile teeth

Mechanical aspects are underplayed, that is, undue

importance is not attributed to them.

Conclusion

74
Occlusion in fixed partial denture

A decision on the occlusal scheme prescribed should be made

before fabrication of definitive restorations. Commonly, features of

several of the schemes are incorporated in the same cases. The

responsibility for the occlusal prescription is the dentists not the

technicians. To make the prescription, the dentist must be totally

familiar with the various options, the difficulties presented by a

particular case and the realistic possibilities. Someone who has not

waxed cases himself and, as a minimum attended and successfully

participated in a wax additive technique course, is mot unlikely

indeed to be in such a position. Wax additive technique courses are

highly relevant to the dentist and are not just the realm of the

technician. If the dentist is attempting to re-restore the failed

extensively restored dentition, it is a professional obligation to be

competent in at least the fundamentals of occlusal treatment.

The ability to correctly prescribe the occlusal scheme is

fundamental.

75
Occlusion in fixed partial denture

VII. Determining the type of posterior occlusal


contours4

There are three basic decisions to make regarding the design 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

For achievements functional efficiency with stability, the

critical objectives of posterior occlusal contours are as follows :

1. Multiple equal intensity contacts on each tooth in centric

relation at the correct vertical.

2. Occlusal forces directed parallel to the long axis of each tooth.

3. Non-interference with any border path of the condyles of the

anterior guidance.

In the design of occlusal contours, the first decision is where

to locate each of the multiple contacts that meet the opposing teeth

when the mandible is in centric relation. These decisions are

determined when each holding contact is related to how it would

direct the occlusal forces. Teeth can withstand tremendous force if

the force is directed up or down the long axis of each tooth because

when force is directed parallel to the long axis it is uniformly resisted

76
Occlusion in fixed partial denture

by all of the supporting periodontal ligaments except those at the

apex. If forces are misdirected laterally, the tooth loses the support

of about half of the ligaments that are compressed and puts almost

the entire load on the half under tension. So the starting point in

designing occlusal contours is to shape and locate the centric

contacts so that the forces are directed as nearly parallel as possible

to the long axis of both upper and lower teeth.

There are many ways to design occlusal contours if direction of

forces in centric relation were the only surface contacting, another

flat surface could be made to fulfill this first requirement, but it

would not be a very good design for penetrating or grinding fibrous

foods. Proper placement of a sharp cusp against a flat surface could

penetrate foods easily and still direct the forces correctly, but a

single sharp cusp against a flat surface might lack resistance to the

lateral forces that come from the cheeks versus the tongue. The

addition of more contacts seems to be an aid to the requirement of

occlusal stability though it is unlikely that any kind of occlusal

contour is capable of stabilizing posterior teeth if they are not in

horizontal harmony with the neutral zone.

The posterior teeth must do more than penetrate food; they

must also be capable of crushing and grinding it. To fulfill these

roles, they must be able to work one surface against another in

enough proximity to masticate efficiently. To accomplish this, the

sharp cusps are broadened at the base and rounded at the tips. The

77
Occlusion in fixed partial denture

flat surfaces are changed to fossae, and the walls of the fossae are

curved and angled to relate to the lateral movements of the mandible

as guided by the lower anterior teeth against the lingual surfaces of

the upper anterior teeth. Blades are made to emanate from the lower

buccal cusps to function in reasonable closeness to the upper

inclines.

1. Types of centric holding contacts

There are three basic ways by which centric relation contact is

usually established on restorations.

1. Surface to surface contact

2. Tripod contact

3. Cusp tip to fossa contact

a. Surface to surface contact

Surface to surface contact we refers to this as mashed potato

occlusion. It is the form that results if the articulator is simply

closed together when the wax on the dies is soft. There is never a

valid reason for using this type of contact. It is stressful and it

produces lateral interferences in anything other than near vertical

chop-chop function. (Fig. 30).

Fig. 30

78
Occlusion in fixed partial denture

b. Tripod contact :

In tripod contact the tip of the cusp never touches the

opposing tooth. Instead, contact is made on the sides of the cusps

that are convexly shaped. Three points are selected from the sides of

the cusps, and each point in turn is made, to contact the side of the

opposing fossa. Contacts or the stamp cusps must be made at the

brim of the fossa wall so that all posterior teeth can disengage from

any contact immediately upon leaving centric relation. Lateral and

protrusive disocclusion of posterior teeth is essential when ever

tripod contact is used because convex lower cusps cannot follow

normally concave border pathways against upper teeth, which are

also convex. This is especially true when the contacts are on the

sides of convex cusps. Consequently, if the lateral anterior guidance

starts with a near horizontal path and if rest closure function

dictates the need for a long centric, it would be necessary to use

flatter occlusal surfaces and wider cusp tips with the contacts

distributed more on the tips than on the sides of the cusps. Fossa

contacts have to be more on ridges and fossa brims than on the

walls of the fossa. Some advocates of tripodism do recommend this.

(Fig. 31).

Fig. 31

79
Occlusion in fixed partial denture

When the working side condyle translates laterally on a

horizontal plane and the lateral anterior guidance permits the front

end of the mandible to also move laterally on a horizontal plane

before curving down a concave pathway, there is no way to make

tripod contact work if the contacts are on the sides of convex cusps.

Allowing the cusps to move through grooves is not practical because

contacts aligned on the sides of the cusps to facilitate travel through

a straight lateral pathway groove would interfere with a slightly

protrusive lateral pathway. There is no way to align the contacts

around the sides of the cusps to permit the full range of lateral and

protrusive pathways if the anterior guidance starts out with

horizontal paths. This is important to understand because many

periodontally involved mouths are best served by such concave

anterior guidances.

If tripoid contact is to be used with concave anterior

guidances, the contacts must be confined to the tip of broad flat

cusps. A tripodism of sorts can be achieved if you keep the tips of

the cusps wider than the grooves and fossae that they rest against

or pass over. This type of pseudotripodism can even be made to

function in lateral excursions if the upper cusp inclines are matched

to the concave border pathways of the mandible. If there is any

horizontal movement of the mandible in lateral and protrusive

excursions, convex surfaces simply cannot function against the

sides of other convex surfaces without creating stressful

interferences.

80
Occlusion in fixed partial denture

Indication

Tripod contact is difficult to accomplish, but it can be done as

long as the anterior teeth are capable of disocclusion the posterior

teeth in all excursions. For patients whose functional movements,

anterior periodontal supports, arch relation, and tooth position are

best served by posterior disocclusion, tripod contact can be very

comfortable, functional, and beautiful to behold.

Contraindications

Tripod contact should not be used when lateral stress

distribution is best served by including posterior teeth into group

function to help out weak or missing anterior teeth or when the arch

relationship does not permit the anterior guidance to do its job.

Disadvantages

With tripod cannot, any degree of shifting of any tooth produces

an incline interference. Any wear on a centric contact leaves the

remaining centric stops for that cusp to be on inclines. Since

upper and lower arches are usually restored together, even a

minute error in recording of transferring centric relations causes

loss of tripodism on all teeth.

Tripod contact is extremely difficult or impossible to equilibrate

without losing tripodism and ending up with contacts on inclines.

However, this is mostly academic because usually enough

counteracting inclines can be kept in contact to maintain

reasonably good direction of force.

81
Occlusion in fixed partial denture

Advantages

If tripod contact is so difficult to achieve and has so many

limitations, why is it used? Probably the main reason for the

popularity of tripodism is the impression that it is so stable if it is

properly done. This certainly has been one of the main reasons for

advocating it use. However, there is no scientific evidence to show

that tripod contact is more stable than proper tip to fossa contact.

Development of slides is common, even among the most meticulous

operators.

A precisely recorded centric relation will make the majority of

patients very happy even if little else is accomplished, and eccentric

disocclusion of posterior teeth is always better than posterior

interference in excursions. Combined with the clinical observation

that most patients can also function quite well with excursive

disocclusion of the posterior teeth, one can readily see why there are

many patients who are very happy with their tripod contact

occlusions.

Nevertheless, there are no actual indications for tripod contact.

Although it can be used successfully in a large number of patients, it

has definite limitations in many others. It offers no advantages over

proper cusps tip to fossa contact, and since it is more difficult to

achieve, is hard to adjust, and is limited in its use, we would

probably do well to thoughtfully evaluate its practicality.

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Occlusion in fixed partial denture

c. Cusp tip to fossa contact

If cusp tips are properly located in the most advantageous

fossae, this type of occlusion offers excellent function and stability

with the flexibility to choose any degree of distribution of lateral

forces that is warranted. It is the easiest occlusion to equilibrate.

Resistance to wear is excellent, since the centric stops are on the

cusp tips, whereas in working excursions, contact is on the sides of

the cusp tips as they travel along the inclines of the opposing teeth,

centric excursion, it is accomplished easily by adjustment of the

fossa inclines without disturbing the centric holding contacts.

(Fig. 32).

Fig. 32

With cusp tip to fossa contact, it is not necessary to restore

upper and lower teeth together. In fact, there is no advantage

whatsoever to preparing both arches together. Location of cusp tips

can be determined with extreme accuracy against unprepared teeth,

and cusp height and fossa contours can be established one arch at a

time with complete assurance that the contours will be correct.

Location of cusp tip-to-fossa contacts is decided according to

the best interest of each tooth on the basis of direction of forces as

near parallel to the long axis of each tooth as possible and stability

without interference to eccentric movements.

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Occlusion in fixed partial denture

Cusp tip to fossa contact is not a by-product of any specific

technique. It serves the goal of function rather that form. It can be

accomplished with the aid of gnathologic instrumentation, functional

path procedures, or a myriad of other instrumentation techniques.

The one essential for accomplishing it correctly is an understanding

of what we are after. Properly done, it can be beautiful as well as

functional and stable.

d. Posterior contacts in lateral excursions

To make meaningful judgment about the distribution of lateral

stress, we must first distinguish the difference between the rotating

condyle and the orbiting condyle. Each side has physical

characteristics that are important to understand before an occlusal

scheme can be planned with any degree of dependability. In

discussing lateral excursions divide the movements accordingly into

working side occlusion and non-functioning side occlusion (also

referred to as the balancing side)

Working side occlusion refers to the contact relationship of

lower teeth to upper teeth on the side of the rotating condyle. The

side toward which the mandible moves is the working side. The

condyle on the working side can be braced against bone or ligament

throughout the working excursions, and so it is possible and quite

practical to accurately record and restore the posterior teeth to

precise working side border movement contacts.

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Occlusion in fixed partial denture

Non-functioning side occlusion is the side of the orbiting

condyle. When the condyle leaves its braced position and slides

forward down the slippery incline of the eminentia, it is no longer

solidly fixed against the unyielding bone and ligament. Rather, it can

move up a little, since the mandible bends slightly under firm

muscle pressure. Consequently, tooth contact during non

functioning side excursions should not be allowed. Because of the

flexibility of the mandible, it would not be possible to harmonize

occlusal contours to all the variations resulting from the difference

in muscle force from light to heavy. Hence we have the rule :

whenever lower teeth move toward the tongue, they should not

contact.

The job of disoccluding the non-functioning side is always the

responsibility of the working side. How the working side disoccludes

the non-functioning side is an important decision that must be

made for each individual patient. While the teeth on the working

side are disoccluding the teeth on the non-functioning side, they

must also function as cutters, holders, and grinders.

The dentist must decide how all this is done by selecting one of

the following choices for working side occlusion

1. Group function

2. Partial group function

3. Posterior disocclusion

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Occlusion in fixed partial denture

None of these choices is optimum for all cases. Selecting the

one that offers the most advantages for each different patient is just

good treatment planning.

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 the forces to one particular tooth.

To paraphrase a law of physics the more teeth that carry the

load, less load any one tooth must carry. We must decide which

teeth are capable of carrying how much load and assign the load

accordingly. As an example, we would not use a loose cuspid with

little bone support to protect strong posterior teeth from contacting

in a working excursion. Instead, we would allow the posterior teeth

to share the load by bringing them into group function with the

cuspid and the other front teeth on that side.

1. Group function

Group function of the working side is indicated whenever the

arch relationship does not allow the anterior guidance to do its job of

disoccluding the non-functioning side. The anterior guidance cannot

do its job in the following situations.

1. Class II occlusions with extreme over jet

2. Class III occlusions when all lower anterior teeth are outside of

the upper anterior teeth

3. Some end to end bites

4. Anterior open bite cases

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Occlusion in fixed partial denture

When you are using posterior group function, the following rule

applies; contacting inclines must be perfectly harmonized to border

movements of the condyles and the anterior guidance. Convex to

convex contacts cannot be used to accomplish this.

2. Partial group function

Partial group function refers to allowing some of the posterior

teeth to share the load in excursions whereas other contact only in

centric relation. As an example, a second molar may be very firm

vertically but be hyper mobile buccolingually. Such a tooth should

touch only in centric relation and be disoccluded immediately by the

other teeth in excursions. A very strong first premolar may work

with a moderately strong cuspid and incisors to disocclude a weak

second premolar and molars.

Because of arch relationships, a first and second molar may be

the only sources of disocclusion for balancing side contact. Group

function had better be perfectly harmonized to border movements in

such a case, but it can be done successfully. Anterior teeth with post

orthodontic root resorption or congenitally poor crown root ratios

should sometimes be harmonized to group function with the working

side.

Whether any tooth should share the lateral stresses should be

decided on the basis of each tooths resistance to lateral stress.

There is no good reason why such a decision cannot be made on a

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Occlusion in fixed partial denture

tooth-by-tooth basis. If a tooth is weak laterally, it should contact in

centric relation only. If a tooth is firm and clinical judgment says

that it would be beneficial to the other teeth to let that tooth share

the lateral stress and wear, that is what should be done.

Some dentists object to ever having posterior teeth contact in

lateral excursions. Strenuous objection to group function usually

comes from having had problems with it. Because of the resultant

problems, objectors may think that group function is actually

harmful. It should be clear that problems with group function result

from improper harmony of the contacting inclines. Attempts at

group function with convex inclines, as an example, are invitations

to hypermobility. Some patients do change their pattern of function

to conform to the restrictive inclines of convex cusps, but it is

unpredictable at best. For group function to be effective in reducing

stress, the cusp inclines must be in perfect harmony with the lateral

border movements of the jaw. Posterior cusp inclines that are not

contoured to match the mandibular border movements are

disoccluded if the inclines are opened out too much, or they interfere

if any part of the incline is steeper than the corresponding part of

the lateral jaw movement. Incline interferences on posterior teeth get

progressively more stressful as they get closer to the condyle

fulcrum, so that a slight interference on a second molar would

probably be more stressful than a more noticeable interference on a

cuspid. If this rule of stress distribution is understood, it is quite

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Occlusion in fixed partial denture

practical to distribute lateral stress over some or all of the posterior

teeth. It can be done effectively by restorative means and by occlusal

adjustments of the natural teeth.

3. Posterior disocclusion

Posterior disocclusion refers to no contact on any posterior

teeth in any position but centric relations. It can be accomplished

easily with cusp tip to fossa morphology. It must be accomplished

with tripod or surface-to-surface morphology to prevent lateral

interferences in any case with centric contact on inclines that are

steeper than the lateral border movement of the mandible. It occurs

automatically if tripod contacts are distributed on the tips of broad

flat cusps or the lateral guidance angle is steeper than the

contacting posterior surfaces, or both conditions.

In healthy mouths or in mouths with normally strong anterior

teeth, it is an excellent occlusion. Since normal anterior teeth are

quite capable of carrying the whole excursive load, particularly if

they are in harmony with functional border movements.

Posterior disocclusion in all jaw positions except centric

relation is the most desirable occlusion whenever it can be achieved

by an acceptable anterior guidance. Even some weakened anterior

teeth may actually be stressed less by separation of the posterior

teeth from contact in excursions. The reasons for this phenomenon

is the effect that posterior disocclusion has on the contractive force

of the elevator muscles. The moment complete posterior disocclusion

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Occlusion in fixed partial denture

occurs in protrusive, the masseter muscle stops contracting, the

internal pterygoid muscle stops contacting, and the temporalis

muscle contraction is reduced. In lateral excursions, internal

pterygoid contraction controls the balancing side.

There are two methods of accomplishing posterior disocclusion

1. The anterior guidance is harmonized to functional border

movements first and then the lateral inclines of the posterior

teeth are opened up so that they are disoccluded by a correct

anterior guidance.

2. The posterior teeth are first and then disoccluded by

restriction of the anterior guidance. This method if backward.

Anterior guidance is a proper determinant of posterior

occlusal form and thus should be done first. When posterior

occlusal form determines the anterior guidance, the

correctness of the anterior guidance is a product of chance.

Two different types of anterior guidance can achieve posterior

disocclusion; anterior group function and Cuspid protected

occlusion. Neither is applicable for all cases.

1. Anterior group function: Is the most practical method for

disoccluding the posterior teeth when arch relationships and tooth

alignment permit it. Anterior group function is beneficial in three

ways.

1. It distributes wear over more teeth

2. It distributes the stresses to more teeth

90
Occlusion in fixed partial denture

3. It distributes stress to teeth that are progressively farther from

the condyle fulcrum.

Any one of these considerations would be reason enough to

recommend anterior group function, but in addition to its effect on

stress and wear, anterior group function is extremely comfortable

and efficient. It improves the efficiency of incising movement by

providing lateral as well as protrusive shearing contacts.

Despite its advantages, anterior group function is not

applicable in all cases. Some arch relationships do not permit the

incisors to contact in lateral excursions. Concave anterior guidances

permit group function, whereas convex lateral guidances make it

difficult to accomplish. When it is impractical to distribute the

lateral guidance stress over several teeth, disocclusion of the

posterior teeth can be accomplished by use of the cuspids in one

form or another for cuspid-protected occlusion.

2. Cuspid protected occlusion: It refers to disocclusion by the

cuspids of all other teeth in lateral excursions. It usually serves as

the cornerstone of what is called mutually protected occlusion.

Mutually protected occlusion has been defined in several ways, but

the usual connotation refers to an occlusal arrangement in which

the posterior teeth contact in centric relation only, the incisors are

the only teeth contacting in protrusion, and the cuspids are the only

teeth contacting in lateral excursion. It is an ideal relationship for

some patients, is tolerated by some, and is detrimental to others.

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Occlusion in fixed partial denture

Clinical judgment should be developed so that cuspid protected

occlusion is used only when it offers advantages over other occlusal

arrangements.

In cuspid-protected occlusion, all lateral stresses must be

resisted solely by the cuspid. Therefore the predominant pre

requisite for its use is the capability of the cuspid to withstand the

entire lateral stress load without any help from other teeth.

It may seem unlikely that any one tooth could have enough

stability to carry such a load over a long period of time without

becoming subjected to excessive wear or hyper mobility. The fact is

that the lateral stresses are minimal if the lingual contours are in

harmony with the functional border movements. In other words,

lateral stress becomes insignificant if the mandible function

normally within the lingual inclines of the upper cuspids.

It is impossible to exert excessive stresses against the cuspids

in centric relation because the posterior teeth also resist the stresses

in that position, if the occlusion is correct.

In natural cuspid protected occlusions, the pattern of function

is rather vertical, and so he mandible does not use lateral

movements that would subject the cuspids to stress in that direction

either.

The cuspids actually assume the role more as a guidance that

actuates vertical function rather than as a resistor to lateral stress.

Any attempt at lateral movement is felt by the presoreceptors around

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Occlusion in fixed partial denture

the cuspids. Within limits, these exquisitely sensitive nerve endings

protected the cuspids against too much lateral stress by redirecting

the muscles to more vertical function. As long as the pressoreceptors

can keep the muscles programmed to a vertical envelope of function,

there is insufficient lateral stress generated to harm the cuspids.

Some clinicians have reported that the cuspids have the

distinction of being protected by a greater number of presoreceptor

nerve endings than is found around any other tooth. This alleged

density of proprioceptors is supposed to impart a unique capacity to

be cuspid to redirect any functional pattern that would be

destructive. If, for example, a horizontal chewing cycle would exert

too much lateral stress against the cuspids, their special

proprioceptive protectors would simply change the chewing cycle to

a vertical, chop function rather that let harm come to the cuspids or

their supporting structures.

It is easy to see why such a concept would be popular. If the

cuspids really did have the capacity to change functional movements

from horizontal to vertical, it would eliminate much need for concern

with occlusal morphology. Good centric contacts would be all that

would be necessary for posterior teeth, since mandibular movements

could be restricted by changing the cuspids to permit vertical

opening and closing only. Some advocates of cuspid protected

occlusion actually subscribe to such a theory, but further research

has failed to substantiate the report that there are more

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Occlusion in fixed partial denture

proprioceptors around the cuspids than there are around other

teeth. Furthermore, clinical results over a period of time have shown

that the cuspid, just like other teeth, is also subject to the usual

problems of excessive lateral stress if it interferes with normal

functional movements. Although the cuspids do have the benefit of

normal proprioceptive protection, there does not appear to be any

valid support for the cuspid protection theory on the basis of special

proprioceptive capacity to radically alter habitual patterns of

function.

However, there are other valid reasons why cuspid protected

occlusion works well for many patients. The cuspids have extremely

good crown root ratios, and their long fluted roots are in some of the

densest bone of the alveolar process. Further more their position in

the arch, far from the fulcrum, makes it more difficult to stress

them. In short they are very strong teeth. If their upper lingual

inclines are in harmony with the envelope of function, they are

usually quite capable of withstanding lateral stresses without help

from other teeth. Many patients have natural cuspid protection, and

if the cuspids are firm and the occlusion is comfortable, it should be

maintained, even if the teeth must be restored.

The natural cuspid protected mouth is easily distinguished by

convex or very steep lingual inclines on the upper cuspids. The

patient usually cannot move the jaw laterally, even when asked to do

so. The chewing cycle is a vertical chop. The patient has never

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Occlusion in fixed partial denture

functioned laterally and has no need for more than minimal lateral

pressure on the closing stroke. If posterior tooth form were brought

into group function with such steep inclines, even the slightest

shifting of a posterior tooth could subject it to extreme lateral stress

because it would be in interference to the powerful closing stroke.

The vector of force against steep incline interference is nearly

horizontal and the stress is further amplified, as it gets closer to the

condyle. In near vertical envelopes of function it is usually better to

let the posterior teeth be disoccluded by the cuspids if the cuspid

protection is natural and if the cuspids are firm. If the mouth

requires extensive restorative treatment and minimal changes to the

cuspids would affect anterior group function without noticeably

altering the chewing cycle, it would be logical to make that change

for the advantages that could be gained. However, changing from

cuspid protection to anterior group function is contra indicated if it

would require a major change in the envelope of function or

extensive reduction of sound lingual enamel.

For simplicity, cuspid protection can be divided into two

categories:

1. Posterior disocclusion by cuspid inclines that are in harmony

with functional border movements.

2. Posterior disocclusion by cuspid inclines that restrict

mandibular movements within habitual functional border

movements.

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Occlusion in fixed partial denture

Whether a patient functions normally in vertical chop chop

motions or wide horizontal strokes, it will still be possible to

harmonize cuspid inclines. If the harmonized cuspid inclines are the

disoccluding factor for all posterior teeth in lateral excursions, it

may be considered a form of cuspid-protected occlusion. Because of

their arch form or tooth arrangement, many patients will be served

best by this type of occlusion.

Restrictive cuspid protection is usually used as an attempt to

avoid stressful posterior contact in lateral excursion by forcing the

patient into a changed pattern of function. It may result in a

reduction of hypermobility of posterior teeth that have been under

stress. Restrictive cuspid protection falls far short of the immediate

comfort that patients feel with a harmonious anterior guidance. They

must get used to the restrictive guidance. Although some patients

will change their functional patterns when the cuspids get sore

enough to force them into a chop-chop bite, it is an unnecessary

irritation to mouth comfort, and the long term maintainability of

such occlusal relationships is very unpredictable. If the cuspids are

stressed into lateral movement, they are no longer able to protect the

posterior inclines.

It should be reemphasized that from the standpoint of comfort

many patients can tolerate a change to the more vertical function of

a steeper cuspid rise. It is far better, whenever practical, to get

posterior disocclusion from an anterior guidance that is in harmony

with the patients envelope of function.

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Occlusion in fixed partial denture

e. Selecting occlusal form for stability

Assuming that the cusp fossae relationships are correctly

placed for ideal direction of stress, we still must make decisions

regarding the number of contacting cusps that are needed for

maximum stability under differing conditions. We generally have

four basic types to choose from in normal arch relationships.

Type I: Lower buccal cusps contact upper fossae. There are no other

centric contacts. Working side excursive function is limited to the

lingual inclines of upper buccal cusps. (Fig.33 ).

Fig. 33

If desired, continuous contact can be maintained in working

excursions on the lingual incline of the upper buccal cusps, or if

disocclusion of posterior teeth is desired, it can be easily

accomplished by modification of the upper inclines. Disocclusion of

balancing inclines can be easily accomplished.

This type of occlusal relationship can be very comfortable and

can be made to function in a completely satisfactory manner. It is

the easiest contour to fabricate when one is restoring posterior teeth

because cusp fossae angles on the lower are not critical. If

functionally generated path procedures are used, the upper working

inclines are formed automatically and the upper lingual cusps are

wiped away if lower cusp fossae angles are too steep.

97
Occlusion in fixed partial denture

The only apparent disadvantage to this type of occlusal

relationship is its lack of dependable buccolingual stability. Pressure

from the tongue can tilt the teeth toward the buccal with very little

resistance. Because it lacks the stability that upper lingual cusp

contact would give it, more follow up occlusal adjustment is usually

required than is necessary with more stable occlusal contours.

In periodontal prostheses the splinting itself ensures utilizing

around the arch splinting buccolingual stabilization. It is not

necessary to stabilize the teeth with upper lingual cusp centric

holding contacts. Lower buccal cusp contact is sufficient to satisfy

all the needs of the splinted patient. Working excursion contact is an

elective that can be used when needed for disocclusion of the

nonfunctioning side. From the standpoint of either function or

comfort, patients seem to be just as happy with only contact of the

lower buccal cusp as they are with more elaborate occlusal schemes.

Since it is the easiest occlusal form to accomplish and the easiest to

adjust, it is an acceptable choice of occlusal form whenever

buccolingual stability has been assured by splinting.

Type 2: Centric contact on the tips of lower buccal cusps and upper

lingual cusps. Working side excursive function is limited to the

lingual inclines of the upper buccal cusps. There is no excursive

function on any lower incline. (Fig. 34).

Fig. 34

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Occlusion in fixed partial denture

The addition of the upper lingual cusps as centric holding

contacts contributes greatly to the stability of the posterior teeth.

Lateral stress toward the buccal is resisted by the contact of the

upper lingual cusps against the lower fossae. Stress toward the

lingual is resisted by the lower buccal cusps against the upper

fossae. Furthermore, the vector of force against the cusp tip to

fossae contacts is directed toward the long axis when the teeth are

stressed laterally, because lateral movements takes place by rotation

of the tooth around a point within the root.

Lateral excursion contact is limited to the lingual incline of

upper buccal cusps, the same as in type I. This presents no problem

of lateral stress as long as the upper inclines are in perfect harmony

with lateral border movements. The return to multiple cusp holding

contacts in each centric closure has sufficient stabilizing effect for

maintenance of the occlusion within practical limits. Working incline

contact can be disoccluded when desired by modification of upper

inclines.

If the upper lingual cusp is to be used as a holding contact in

centric, the inclines of the lower fossae must not be steeper than the

lateral anterior guidance. If the upper lingual cusp is to be

disoccluded in all lateral movements, the lower fossae inclines must

be flatter than the lateral anterior guidance.

Because lower fossae inclines need only be flatter than lateral

anterior guidance inclines, the fabrication of lower occlusal contours

is be precisely identical to border pathways, since they are to be out

of contact in excursions.

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Occlusion in fixed partial denture

Contact in working excursions can be accomplished by use of

functionally generated path techniques or any other procedure that

accurately records lateral border movements.

From every clinical standpoint, the performance of this type of

occlusal contour is acceptable. It is comfortable and functional and

because it fulfills all the requirements of good occlusal form and can

be accomplished with clinical practicality, it is the type of occlusion

for which we strive in unsplinted restorative cases when posterior

group function is needed.

Type 3 : Centric contact on tips of lower buccal cusps and upper

lingual cusps. Working excursions contact is limited to the lingual

incline of upper buccals cusps and buccal incline of lower lingual

cusps. (Fig. 35).

Fig. 35

This type of occlusal contour is identical to type 2 except that

the buccal incline of the lower lingual cusp becomes a functioning

incline.

The major difference between this type of occlusal form and

type 2 is the difficulty of accomplishing it to bring the upper lingual

cusps into working excursion contact. The buccal inclines of the

100
Occlusion in fixed partial denture

lower lingual cusps must be precisely contoured to the exact lateral

border movement of both the condyle and the anterior guidance. If

the incline is made too flat, it will disocclude. If it is made too steep,

it will interfere.

Certainly there are methods available to use to record these

border movements accurately and to refine the lower inclines to

duplicate than, but unless the additional time, effort, and

instrumentation produce an improvement in the result, it is time

wasted.

Although complexity of fabrication seems to be the only

disadvantage of type 3 occlusal form, it is reason enough not to

advocate it because the result has no clinical advantage over type 2

occlusal form, which can be fabricated with less complicated and

less time consuming procedures without any reduction in the

quality.

Type 4 Tripod contact

There are two types of tripod contact: 1. Contact on the sides

of cusps and the walls of fossae and 2. Contacts on the brims of

fossae and on top of wide cusp tips.

1. Contact on the sides of cusps and the walls of fossae

Contact on the sides of the cusps does not permit any lateral

or protrusive movement on a horizontal plane; so if the anterior

guidance has been flattened even for a short distance from the

centric stops to permit a lateral side shift of the mandible, this type

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Occlusion in fixed partial denture

of occlusal forms will be contra indicated. It is also contra indicated

for any patients who requires a long centric. (Fig. 36).

Fig. 36

It may be used in vertical or near vertical functional cycles

with either cuspid protected occlusion or anterior protected

occlusion.

In the cases permitting its use, its performance is clinically

indistinguishable from type 2 or type 3 occlusions. Like type 3, it

disadvantage comes from the difficulty in fabricating it. Tripod

contact is the most difficult of all occlusal to fabricate.

3. Centric contact on the brims of fossae and the top of wide

cusp tips: with no contact in eccentric excursions. This type of

tripod contact can be made to function with any type of anterior

guidance because it permits horizontal lateral movement without

interference. It is automatically disoccluded by an anterior

guidance effect other than flat plane; so it cannot be used when

posterior group function is indicated. (Fig. 37).

Fig. 37

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Occlusion in fixed partial denture

Since it is essentially a flat occlusal contour and cusp tips do

not fit into fossae, it is only necessary to make sure the fossa width

is narrower than the width of the cusp tip. Consequently it is not

extremely difficult to fabricate. Elaborate fossae and groove

contouring can be accomplished as long as the multiple centric

contacts are not disturbed. Even though the contacts may stay the

same, it is possible to develop very sophisticated contours within the

framework of this type of occlusion.

When posterior disocclusion is indicated, this type of occlusal

form may be used with the same clinical success as type 2 occlusal

form that has been modified to disocclude. It is purely a matter of

dentist preference. Patients will not be able to distinguish between

the two forms.

Summary

There are several types of occlusal form that can be used to

restore posterior teeth. What ever contour is selected should be

chosen because it:

1. Directs the forces as near parallel as possible to the long axis

of each tooth

2. Distributes the lateral stress to maximum advantage in

varying situations of periodontal support

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Occlusion in fixed partial denture

3. Provides maximum stability

4. Provides maximum wearability

5. Provides optimum function for gripping grinding, and crushing

Practicality of fabrication is a factor that should be considered

when the type of occlusal form is being selected. If additional time,

effort, and expense are required to produce the same clinical result

that could be accomplished with greater case of the patients, the

dentist, and the technician, technique orientation has in all

probability taken the place of goal orientation.

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Occlusion in fixed partial denture

VIII. Disocclusion5

The concept of disocclusion is widely accepted today, most

commonly described as the separation of posterior teeth during

eccentric movement. It is not clear yet how much the cusps of the

posterior teeth should disocclude.

There is minimal literature available regarding the proper

amount of disocclusion. Shooshan (1960) and Scott (1964) stated

that during lateral movement, the molars should disocclude more

than 0.5 mm between maxillary and mandibular posterior teeth on

the nonworking side. Thomas (1967) stated when maxillary and

mandibular cuspid have a tip-to-tip relation during lateral

movement, the molars should disocclude 1.0 mm. The exact amount

of disocclusion has not yet been clarified.

From the above data, Hobo and Takayama derived standard

values for the amount of disocclusion as 1.0 mm during protrusive

movement, 1.0 mm on the nonworking side and 0.5 mm on the

working side during lateral movements. The latter is one-half the

amount that exists in the former two. Solnit has suggested more

disocclusion if possible since the bruxer will wear canines after 10

years and allow working side and nonworking side contacts to recur

(Solnit 1996).

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Occlusion in fixed partial denture

1. Mechanism of disocclusion

The mechanism of disocclusion during protrusive movement is

illustrated in the following.

a. The mechanism of disocclusion I

This shows the case when the sagittal inclination of the

condylar path is 40 degrees, the condylar and incisal paths are

parallel, and the cusp angle of maxillary and mandibular molars is

also parallel to both the condylar and incisal paths. In this case,

during the protrusive movement the mandible does not rotate

around the intercondylar axis but only translates. Translation as

defined means "parallel displacement of a body" (the mandible).

Since maxillary and mandibular molars slide in contact during

eccentric movement, disocclusion does not occur.

b. The mechanism of disocclusion II

This shows the case when the sagittal condylar path

inclination is 40 degrees, the cusp angle is parallel to the condylar

path but the incisal path is steeper than the condylar path. In this

case, the mandible translates and rotates around the intercondylar

axis; the maxillary and mandibular molars disocclude. The

component of disocclusion occurring when the incisal path is

steeper than the condylar path is referred to as the "anterior guide

component" of the 'mechanism of disocclusion. McHorris (1979)

recommended that the incisal path should be 5 degrees steeper than

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Occlusion in fixed partial denture

the condylar path. However, when setting the sagittal incisal path

inclination 5 degrees steeper than the condylar path, the author

computed that the amount of disocclusion during protrusive

movement is only 0.2 mm, about one-fifth the standard value (1.0

mm). If the incisal path is steeper than 5 degrees, the patient will

complain of discomfort.

c. The mechanism of disocclusion III

This shows the case when the sagittal inclination of the

condylar path is 40 degrees, the condylar and incisal paths are

parallel and however, the cusp angle is shallower than the condylar

path. In this case, the mandible does not rotate around the

intercondylar axis it only translates. However, since the cusp angle

is shallower than the condylar path, the maxillary and mandibular

molars disocclude. Thus, the component influencing the amount of

disocclusion when the cusp angle is shallower than the condylar

path is referred to as the "cusp shape component" as a mechanism

of disocclusion. In this way, the authors found that the cusp angle

was another important factor for disocclusion.

d. The mechanism of disocclusion IV

This shows the case when the sagittal inclination of the

condylar path is 40 degrees, the incisal path is steeper than the

condylar path and the cusp angle is shallower than the condylar

path. In this case, the mandible translates and rotates

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Occlusion in fixed partial denture

simultaneously around the intercondylar axis. By the additive effect

of the anterior guide component caused by the mandibular rotation

and the cusp shape component occurring when the cusp slope is

shallower than the condylar path, the maxillary and mandibular

molars disocclude widely. This condition is seen often in healthy

individuals.

2. Influences on the amount of disocclusion

a. Condylar path

Deviation of the condylar path

Hobo thought the condylar path deviations were due to 'buffer

spacing' which exists in the glenoid fossa (Hobo, Ichida, Garcia

1989). Since the temporomandibular joint is subject to strong

mechanical stress, the 'buffer spacing' allows condylar mobility and

helps prevent transmission of direct stress to the articular eminentia

across the articular disk. If 'buffer spacing' does not exist and the

condyle transmits strong stresses, the disk could not withstand

direct forces and would result in damage such as anterior disk

displacement or a disk perforation.

The difference between eccentric and returning condylar paths :

When Hobo and Takayama (in press) measured mandibular

movement using an electronic computer measuring system with six

degrees of freedom (Hobo, Mochizuki 1983), they allowed the

condylar paths of the subjects to perform back-and-forth movements

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Occlusion in fixed partial denture

and found differences between the eccentric and returning condylar

paths. Seventeen healthy subjects, 20 to 24 years of age, were

examined further. As a result, it was found clearly that this

difference showed consistency within each subject and the returning

condylar path always passed above the eccentric condylar path.

Rarely did both paths superimpose. No single case was discovered

where the eccentric condylar path existed above the returning

condylar path.

The authors measured the graphic data output of both

condylar paths. When linking the eccentric and returning condylar

paths, a loop-shaped path was formed. The width between the

eccentric and returning condylar paths measured at 2 mm from the

condylar position in maximum intercuspation, averaged 0.44 mm

during protrusive movement and 0.79 mm during lateral movement,

as shown in Table 1-2.

An arc, drawn with a radius of 2 mm with the center at the

condylar positioning maxium intercuspation, made two intersection

points on the paths. The angles formed by the two lines drawn from

the center of the arc to the two intersection points were measured.

They were approximately 13 degrees average on the protrusive

condyle path and 23 degrees average on the nonworking side lateral

condyle path as shown in Table 1-3 (Hobo, Takayama in press).

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Occlusion in fixed partial denture

The eccentric condylar path can be measured by use of a

pantograph and occlusal records. Utilizing the above data, the

returning condylar path of an individual patient can be

approximated by subtracting 13 degrees from the measured value of

the eccentric condylar path for protrusive movement and by

subtracting 23 degrees for the lateral movement.

The widths between the eccentric and returning condylar

paths.

Unit : mm Mean SD

Protrusive movement 0.44 0.26

Lateral movement 0.79 0.37

Table 1-3 Comparison between sagittal condylar path

inclinations of eccentric and returning paths.

Eccentric path Returning path Difference


Unit mm
Mean SD Mean SD Mean
Protrusive
40.1 13.8 27.4 7.6 12.7
movement
Lateral
40.5 11.8 17.5 10.9 23.0
movement

During opening and closing movements of the mandible,

various muscles function. The muscles related to a closing

movement are much stronger than the muscles related to an

opening movement. The muscles that influence eccentric movement

may be the muscles related to an opening movement. The muscles

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Occlusion in fixed partial denture

that influence the returning movement may be related to the closing

movement. The lateral pterygoid and digastric muscles, which

function during eccentric movement are weak; the masseter,

temporal and medial pterygoid muscles, which function during the

returning movement that are relatively strong. (Fig. 38).

Fig. 38

The soft tissues that connect the condyle and glenoid fossa

may relax during an eccentric movement. They may also contract

unconsciously during the returning movement. Therefore, one can

imagine that the condyle positions in a relaxed manner in the

glenoid fossa during the eccentric movement and is held tightly

during the returning movement. This may be the reason for a

difference as little as 1.0 mm superoinferiorly between the eccentric

movement and returning movement. The difference found between

eccentric and returning condylar paths supports the undeniable fact

that "the condylar path is not fixed but is changeable.

As previously mentioned, the authors observed the deviation of

eccentric condylar paths when they were repeatedly measured.

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Occlusion in fixed partial denture

However, the eccentric and returning condylar paths differ from the

above deviation because these paths are created by the physiologic

difference in muscles (opening and closing) utilized.

Controlling the condylar path

In dentistry, the condylar path has been considered the

standard reference for occlusion. However, condylar path was not

fixed but was changeable. Furthermore, when changing the lateral

incisal path, the immediate mandibular translation disappeared

instantaneously, and laterotrusion disappeared simultaneously. This

proved the condylar paths on both working and nonworking sides

were influenced by the anterior guidance.

The anterior guidance influences the condylar path, which

infers the condylar path is influenced by the patient's occlusion.

Therefore, if the patient's occlusion is poor, his condylar path is

affected by malocclusion. If such a condylar path is measured

precisely, reproduced on an articulator, and used as a reference for

the fabrication of a restoration, the occlusion of applying the

measured value of a patient's condylar path as a reference for

occlusion has posed a crucial question.

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Occlusion in fixed partial denture

b. Incisal path

The incisal path is that traveled by the incisal point during

eccentric movement. It is the anterior determinant of mandibular

movement. "The influence of the contacting surface of the

mandibular and maxillary anterior teeth on mandibular movements"

is defined as incisal guidance (GPT-6 1994). As previously

mentioned, the incisal path influenced the condylar path. Since the

condylar path is not valid as a reference, it is necessary to

investigate if the incisal path can be used as a new reference of

occlusion instead of the condylar path.

According to the report by Kelly et al (1973), the occurrence

rates of malocclusion included vertical overlap 6.6%, open bite 2.5%,

Angle's Class II 9.4% and Class III 0.8%, totaling 19.3%. These data

showed one out of five patients would not have an incisal path as an

appropriate standard.

The above data indicated that among the patients with normal

occlusion, there were large variations in the incisal path and the

occurrence rate of malocclusion was high. It was concluded that the

incisal path as well as the condylar path would not be valid as

references for occlusion.

Influence of the incisal path on the amount of disocclusion

When the sagittal inclination of the incisal path decreases by

one degree, the amount of disocclusion will decrease by 0.038 mm

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Occlusion in fixed partial denture

during protrusive movement. When the frontal inclination of the

incisal path decreases by one degree, the amount of disocclusion will

decrease by 0.042 mm on the nonworking side and 0.039 mm on the

working side during lateral movement.

There exists a variation in the incisal path by approximately

10 degrees both on protrusive and lateral movements from the mean

value. The influence on the amount of disocclusion was calculated

by multiplying the above rate of influence by the amount of variation

(10 degrees). As a result, they were 0.38 mm during protrusive

movement, 0.42 mm on the nonworking side and 0.38 mm on the

working side during lateral movement.

The above result was compared with that of the condylar path.

The ratio of the influences of condylar and incisal paths was 1:2

during protrusive movement; 1:3 on the nonworking side and 1:4 on

the working side during lateral movement. On the first molar, the

ratio became 1:3 during protrusive movement and the other ratios

were similar.

These results showed the influence of the incisal path on

disocclusion was much greater than that of the condylar path. The

concept that the incisal path is less important than the condylar

path must be reversed. The incisal path influences disocclusion

more than the condylar path. However, the incisal path cannot be

used as the sole guiding factor for occlusion due to its unreliable

character.

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Occlusion in fixed partial denture

c. Cusp angle

Cusp angle is the inclination of the cusp slope from the cusp

tip to the marginal ridge. It is defined as "the angle made by the

average slope of a cusp with the cusp plane measured mesiodistally

or buccolingually" (GPT-6 1994). The cusp plane means the plane

determined by the two buccal cusp tips and the highest lingual cusp

of a molar" (GPT-6 1994), anatomically means a plane comprised of

three cusp tips. The angle formed by the average cusp slope and the

horizontal reference plane is called the effective cusp angle.

The effective cusp angle during protrusive movement is

referred to as the sagittal protrusive effective cusp angle. The

effective cusp angle during lateral movement on the working and

nonworking side is referred to as the frontal lateral effective cusp

angle on the working and nonworking side.

Deviation of the cusp angle

On the contrary, the ratio of variations of condylar and incisal

path inclinations to the mean was 43% and 32%, respectively. The

data of cuspal morphology was, on average, four times more reliable

than that of the condylar path and incisal path. Accordingly, since

the cusp angle is one characteristic of cuspal morphology, it should

have the same reliability.

The above data clarified that the cusp angle does not show the

deviations that appeared in the condylar path nor the variations that

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Occlusion in fixed partial denture

appeared in the incisal path among individuals, and the cusp angle

was three to four times more reliable than the other two factors.

The influence of the cusp angle on the amount of

disocclusion

The influence ratio of the condylar path, incisal path and cusp

angle to the amount of disocclusion on the second molar when the

condyle moved 3.0 mm from centric was approximately 1:2:2 during

protrusive movement; 1:3:3 on the nonworking side; 1:4:4 on the

working side during lateral movement.

The influence of the cusp angle is 40% to 44% of the total

influence, which is comparable to the incisal path but far larger than

the condylar path. Since the cusp angle is more reliable than other

factors and its influence is large, the authors concluded that the new

reference for occlusion should be the cusp angle of newly erupted

permanent teeth, not the condylar path or the incisal path.

In conclusion, the necessity for disocclusion is explained as follows:

1. "Security insurance" to protect teeth from harmful effects due

to a cuspal interference can be caused by a difference

between the eccentric and returning condylar paths.

2. A redundant need to protect teeth from harmful effects due to

any cuspal interference since anterior guidance varies among

individuals.

This investigation provides the reasons why it is necessary to

create disocclusion. However, in practice, the dentist cannot

measure the returning condylar path of a patient nor alter the

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Occlusion in fixed partial denture

incisal path of natural teeth logically. Therefore, it is impossible to

reproduce disocclusion to fulfill the necessary reasons using

prosthetic techniques available today. This suggests the need for

development of new procedures to support this concept.

3. Twin-stage procedure

Until today the condylar path has been regarded as the main

determinant for occlusion in prosthetic treatment. It is measured

and used as a clinical reference. Since the condylar -path has been

shown to have deviation and minimal influence on disocclusion, a

question arises. Is it proper to use the condylar path as the main

determinant?

The deviation of the incisal path in each individual is less than

that of the condylar path. The incisal path influences disocclusion at

the second molar twice as much as that of the condylar path during

protrusive movement, three times on the nonworking side and four

times on the working side during lateral movement. However, when

individual variation and the occurrence rate of malocclusion are

incorporated, the inclination of the incisal path will be distributed

broadly; the incisal path would not be a reliable reference for

occlusion. This infers that the cusp angle, which has not been

studied previously, should be considered as a new reference for

occlusion.

Embryologically, the cusp angle is an independent factor from

both condylar and incisal paths. To obtain good occlusion in

restorative treatment, the critical factor may require reproducing a

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Occlusion in fixed partial denture

standard value for the cusp angle. The reproduction of condylar and

incisal paths on an articulator are to be regarded as subordinate

factors. This last statement refutes the long-established theory in

the study of occlusion.

Standard Value of the Cusp Angle

The cusp angle was considered to be the most reliable

reference for occlusion. However, it is common knowledge that

occlusal morphology in adulthood loses its original form due to

caries, abrasion and restorative works. In particular, when the teeth

are lost, no cusps exist for a reference. Accordingly, the cuspal

morphology of an average patient who visits the dental office is not

reliable and cannot be used as a reference for occlusion.

Since there are minimal variations in cusp morphology of

permanent teeth immediately after eruption, and if the value of the

cusp angle at the time of eruption is used as a reference for

occlusion, making a restoration following this guide should be ideal

for the patient.

The authors, however, found no available data on the cusp

angle. To establish a new reference for occlusion, it is necessary to

define a standard value for the cusp angle. To obtain it, the

measured amount of disocclusion was found as the only reliable

relevant data available. The amount of disocclusion is the supero-

inferior distance between maxillary and mandibular opposing cusps

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Occlusion in fixed partial denture

in the eccentric position, forming a geometrical triangle between

disocclusion, cusp path and cusp angle.

The cusp path can be determined from the measured values of

the condylar path and incisal path based on the mathematical model

of mandibular movement. When the cusp path is obtained in this

manner, the value of the cusp angle is estimated using trigonometry.

Basic Concept of Twin-Stage Procedure

The basic concept involved in the new procedure requires a

methodical approach. The cast V with a removable anterior segment

is fabricated. First, reproduce the occlusal morphology of posterior

teeth without the anterior segment and produce a cusp angle

coincident with the standard values of effective cusp angle (referred

to as "Condition 1").

Secondly, reproduce anterior morphology with the anterior

segment and provide anterior guidance which produces a standard

amount of disocclusion (referred to as "Condition 2"). The application

of the two conditions described to fabricate the cusp angle and

anterior guidance are innovative clinical procedures. This is named

the "twin-stage procedure."

Outline of the Twin-Stage Procedure

Fabrication of the cusp angle

Fabrication of anterior teeth

1. According to "Condition 2," adjust an articulator to the following

values: sagittal condylar path inclination=40 degrees, Bennett

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Occlusion in fixed partial denture

angle=15 degrees, sagittal inclination of the anterior guide

table=45 degrees, and lateral wing angle=20 degrees.

2. Reassemble the anterior segment of the cast. The maxillary and

mandibular casts on the articulator produce the standard

amount of disocclusion.

3. Wax the palatal contours of the maxillary anterior teeth so the

maxillary and mandibular incisors contact during protrusive

movement, and the maxillary and mandibular canines on the

working side contact during lateral movement. Thus, anterior

guidance is established and the standard amount of

disocclusion will be produced.

Presently, the twin-stage procedure is contraindicated in the


following cases

1. Abnormal curve of Spee

2. Abnormal curve of Wilson

3. Abnormally rotated tooth

4. Abnormally inclined tooth

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Occlusion in fixed partial denture

OCCLUSAL CONSIDERATION IN IMPLANT SUPPORTED

PROSTHESIS

Contents :

Introduction :

1. Occlusal determinants.

2. Occlusal design and materials.

3. Occlusal forces and transmission.

4. Biomechanics.

5. Weakest component theory.

6. Full arch fixed prosthesis.

7. Types of occlusion implant supported prosthesis.

8. Developing occlusal contact supported prosthesis.

9. Prematurities.

10. Bruxism.

11. Splinting.

12. Complication from over loading implants.

13. Minimizing over loading of implants.

14. Conclusion.

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Occlusion in fixed partial denture

INTRODUCTION:

In addressing the subject of oral implantology our must

consider not only the surgical phase of placing the implant but also

the prosthodontic rehabilitative, procedures.

The choice of an occlusal schema for implant-supported

prosthesis is broad and controversial. Whether the selected implant

is endosseous, subperiosteal or transosseous, proper understanding

and application of sound prosthodontic principles in the selection,

placement and restorative phases are prerequisite to successful

implant therapy. Thus long-term success depend on several factors

like proper selection of patient and implant, aseptic and a traumatic

surgical procedures, adequate no load healing period, correct

prosthodentic reconstruction and proper follow up care.

Implant prosthodontics deals not only with the technical

aspects of fabricating an implant supported prosthesis but also with

proper application of occlusal principles for implant selection and

placement and also for prosthetic phase of the treatment.

So accurate occlusion is essential to the long term success of

implant treatment, thus.

Implants cannot bail out our faulty occlusion

Occlusion must be considered in three major areas, it

1. Occlusal determinants

2. Occlusal forces and their transmission to supporting tissues.

3. Occlusal design and materials.

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Occlusion in fixed partial denture

1. Occlusal determinants:

Occlusion must be viewed as a dynamic function of the

stomatoguathic system rather than as a static intercuspal position.

- Gradual reduction in face height (WO),

- Changes in the maxillo mandibular relation,

- The presence of temperomandibular dysfunction are important

occlusal deviations seen in implant candidates. There problems

must be properly diagnosed and addressed in the treatment and

laying phase.

The occlusal determinants may be classified as denture

occlusion, TMJs and the neuromuscular mechanism.

Established dental occlusion

Temperomandibular Joints Neuromuscular

mechanism.

In order to provide physiologic occlusion for implant patients,

the dentist should perform occlusal assessment and diagnosis prior

to the restorative phase of treatment, and even prior to implant

selection and placement.

2. Occlusal forces and their transmission to supporting tissues:

Transmission and distribution of stresses to implant

supporting structures depend on the magnitude, direction and

duration of the applied occlusal loads.

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Occlusion in fixed partial denture

One of the principle objectives in implant prosthodontics is

reduction of occlusal loads and accordingly reduction of transmitted

stresses to the supporting osseous structure.

The initial reversible signs and symptoms of trauma on

natural teeth do not occur with endosteal implants.

An absence of soft tissue interface between the implant body

and bone results with greatest magnitude of force localized around

the implant bone region, leading to loss of crestal bone around the

implant which results in loss of support to implant increased sulcus

pocket depth.

So unless the density of bone increases or the amount or

duration of force decreases, the condition will progress and even

accelerate until implant less occurs. Thus elements to decreased

crestal bone forces are implemented in occlusal design of the

prosthesis.

The primary forces of occlusion should be directed to the long

axis of the implant body, not the abutment post. Wherever possible

implant bodies should be primarily submitted to the vertical

component of the occlusal load. Horizontal or lateral forces magnify

the amount of compressive and tensile stress at the implant crestal

site and should be reduced or eliminated.

a. Offset load:

Offset usually is facial or lingual occlusal contacts not those in

the long axis of the implant body.

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Occlusion in fixed partial denture

In screw-retained restoration, occlusal contact rarely is placed

over an access hole. Therefore offset loads are common when

occlusal screws are used. But when cement refined prosthesis is

used, the occlusal load in directly placed over the long axis of the

implant body.

In case of anterior implants, the screw-retained prosthesis is

placed lingual to the incisal edge of the access hole in the cingulum

region, compared to cement retained prosthesis.

In order to decrease the offset load in screw-retained

prosthesis during lateral excursion, natural truth when present the

greatest load.

A representative blade shaped implant and four root shaped

implants (TPS, core vent, Nobel Pharma and ISIS implant) were

investigated using a loading condition of 5 pounds vertical and 8

pounds lateral.

In summary, the general principles regarding direction of load

to the implant body are.

a. Axial loads to the implant body produce less compressive and

tensile stress.

b. Horizontal loads produce an increase in both compressive and

tensile stress.

c. Screw retained prosthesis often have implant bodies more

lingual compared to cement retained restoration.

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Occlusion in fixed partial denture

3. Occlusal design and materials:

A proper occlusal scheme in a primary requisite for long term

survival especially when para function or a marginal foundation are

present.

I. Occlusal design:

The occlusal plan that is unique and specially designed for the

restoration of endosteal implants, providing an environment for

improved clinical longevity of both implant and prosthesis is known

as Implant protective occlusion or medial positioned lingualised

occlusion.

a. Div A bone:

A maxillary implant opposing a natural mandibular molar may

have the lower buccal cusp or primary contact with the central fossa

of the maxillary implant crown. The maxillary posterior implant most

often is positioned under the central fossa of the natural tooth in Div

A bone.

When the mandibular implant opposes a natural maxillary

tooth, the primary contacting cusp becomes the maxillary lingual

cusp.

b. Div B bone:

In div B bone, maxillary and mandibular implants are

positioned under the lingual cusp relative to natural tooth.

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Occlusion in fixed partial denture

A mandibular implant opposing a natural maxillary posterior

tooth may have the lingual cusp of maxillary teeth as primary

contact

A maxillary implant opposes the mandibular natural teeth.

The buccal cusp is completely out of occlusion in centric relation

and all mandibular excursion. But the buccal cusp of the opposing

natural tooth is reduced to eliminate any offset load on the maxillary

implant. The primary contact here is the maxillary palatal cusp over

the implant body and the central fossa region of the mandibular

natural tooth.

Certain rules were recommended in the Dentist desk

reference (DDR) to establish proper occlusal design in implant

prosthodontics.

a. Cusp design of crown alignment should be made so that

stresses are directed along the long axis of the implant.

b. Lateral stresses should be avoided or atleast minimized.

c. Width of the occlusal table of implant crown should be

minimized.

d. Cusp height should be minimized to decrease lateral stresses,

providing only centric function.

II. Materials:

The materials on the occlusal aspect of the prosthesis affect

the transmission of force and the maintenance of occlusal schemes.

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Occlusion in fixed partial denture

Porcelain occlusal as a hardness of 2.5 times more then

natural teeth, enamel has a 350 kg/mm 2 hardness, composite has

hardness of 85% of enamel, Acrylic resin has a hardness of 17

kg/mm2.

Therefore this shows impact loads are reduced with acrylic

and increases with composite enamel and porcelain.

a. Acrylic:

Acrylic is used in progressive bone loading as a transitional

prosthesis. So in patients with parafunction acrylic transitional

prosthesis used for extended periods to improve the bone-implant

interface during progressive loading period.

Acrylic resin wears 7 to 30 times faster when opposing gold,

resin enamel or polished porcelain. Acrylic fracture is a much more

common complication in fixed restoration than removable

prosthesis. Mechanical retention must be incorporated in metal

superstructure.

b. Metal :

For full arch implant supported prosthesis metal occlusal

surface are used to minimize wear and prolong the accuracy of

occlusal schemes

Metal occlusal surface is also used in posterior restoration in

non-esthetic region and parafunction or marginal interact space

present.

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Occlusion in fixed partial denture

c. Porcelain :

Porcelain fracture is the third most common condition

requiring the replacement of fixed prosthesis supported by natural

teeth. The ideal thickness of porcelain to prevent breakage is

approximately 2mm.

Porcelain is used in full arch implant supported prosthesis in

esthetic regions and in bruxism opposing with metal or acrylic.

4. Biomechanics :

Several feature help decrease the effects of horizontal loads

responsible for tension and shear on the crest of the ridge. This

include mainly.

a. Implant diameter and

b. Number of implants supporting prosthesis and distributing load.

Wider implants should be used than narrow diameter implants.

When narrow diameter implants are used in region of greater

forces, additional splinted implants are indicated.

Narrow occlusal tables are recommended in non-esthetic regions

of the mouth, where the occlusal table is reduced from buccal

aspect.

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Occlusion in fixed partial denture

In esthetic region, when occlusal table cannot be reduced in

width e.g., in maxillary implant, the buccal cusp of the opposing

natural teeth is reduced.

5. Weakest component theory:

Consideration like:

a. Identifying the weakest like in the overall restoration.

b. Establishing occlusal and prosthetic scheme to protect that

component of structure.

In maxillary denture opposing mandibular implant supported

restoration, the maxillary denture is the weakest link.

So bilateral occlusal scheme, raining of posterior occlusal

plane, implant protective occlusion and elimination of anterior

contacts with mandibular teeth in centric occlusal relation, in

given.

In the case of cantilevers,

Reduced occlusal forces with an absence of lateral contacts in

excursion are recommended on posterior cantilevers or

anterior offset pontics. This decreases the forces and load on

the abutment.

When the cantilever polices on both the arches,

In maxillary posterior implant cantilever anterior teeth, and

mandibular anterior implants cantilever posterior teeth, the

occlusal scheme cannot minimize forces on both. Then it is

better for mandibular cantilever pontics to appose maxilla

implants.

6. Full arch fixed prosthesis :

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Occlusion in fixed partial denture

In this case implant restoration should follow mutually

protected occlusal schemes whenever possible. In protrusion there

should be total absence of posterior contacts especially for

cantilevered posterior units.

In mandible the effects of mandibular movement is limited to the

posterior to the mental foramen.

So sufficient number of anterior implants of acceptable length

and anteroposterior distance may often replace the mandibular teeth

with a one-piece rigid bilateral posterior cantilever.

But when implants are used in both mandibular posterior

regions, they s should be independent from the implants placed

in the contralateral region.

As a result instead of cantilever, two to four implants support

an independent prosthesis on at least one side.

In edentulous maxilla flexure of bone is not a concern, so a full

arch prosthesis may be fabricated in one section.

7. Types of occlusion in implant supported prosthesis:

In fixed or removable restoration with opposing fixed or removable

implant supported prosthesis.

Organic occlusion is given:

In fixed or removable implant supported restoration with

opposing removable full denture without implants bilaterally

balanced occlusion is given.

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Occlusion in fixed partial denture

In partial prosthesis occlusion is in cases of cantilevers, the

resiliency of the neighboring natural dentition and of the TMJ

in taken.

In single-implant occlusion, implant should be there of any

occlusal overload and function.

8. Developing occlusal contact :

When developing occlusion in a restoration, the anterior guide

must be created; once it is perfectly incorporated, we move to adjust

the occlusion in posterior.

a. Anterior disocclusion guide :

The anterior guide should be as flat as possible allowing for

posterior disocclusion.

As a general rule, a condylar side shift of 3mm should have a

1.5 mm separation in the opposing teeth on the non-working side

and a 1 mm separation on the working side.

b. Posterior occlusal anatomy :

To achieve proper occlusion and efficient masticatory function,

the active cusps must have their corresponding fossae.

The first step will be to relate the cusp within the fossa. This is

done by cusp contacting the fossa inclines and not in the

fossas bottom.

Three contacts per cusp is considered, making sure they are

really contact points and not surface contacts.

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Occlusion in fixed partial denture

The next step is, the grooves that will allow the cusps exit from

their fossa during working, non-working and protrusive

movements are designed.

The fossa exit paths are completely opposite in the upper and

lower teeth.

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Occlusion in fixed partial denture

a. Upper arch :

Working Groove: Transverse toward buccal.

Non-working Groove: Oblique towards mesial and lingual.

Protective Groove: Towards mesial.

b. Lower arch:

Working Groove: Transverse toward Lingual.

Non-working Groove: Oblique towards distal and buccal.

Protective Groove: Towards distal.

In lateral excursion, this will only allow anterior tooth contact,

while the posterior teeth remain completely free. However in closure,

only the posterior teeth will be in contact.

9. Prematurities :

Prematurities represent any tooth contact during mandibular

closure with the condyles in the centric relation that occurs before

maximum intercuspation.

10. Interferences:

These are non physiological contact that appear is the anterior

and posterior teeth in lateral and protrusive excursion.

a. The non-working interferences are very important because the

mandible pivot to avoid them, which in turn produces.

A compressive component on the working condyle,

predisposing to arthrosis and discal pathology.

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Occlusion in fixed partial denture

A Tensional component in the non-working condyle, which

predisposes to hyperlaxitudes and meniscal displacement.

If anterior guidance cannot be accomplished, group function

should be used.

If anterior guidance can be accomplished than posterior

contacts during working movement should be eliminated.

c. Protrusive interferences:

Create a tensional component in both condyles and implant

overloading.

Thus prematurities and interferences will be more or less

pathological depending on whether para functions are present.

10. Bruxism :

Bruxism is a form of eliminating internal tension and is often a

cause of tooth loss.

Bruxism is not a contraindication for implant, but we should

be extremely careful during prosthesis fabrication. Frequent occlusal

follow up are mandatory, eliminating prematurities and interferences

as well as verifying good guidance in the anterior teeth.

11. Splinting:

In the implant tooth fixed prosthesis four important

components may contribute movement to the system, i.e., the

implant, bow, tooth and prosthesis.

There has been controversy regarding whether a rigid fixated

implant may remain successful when splinted to natural teeth.

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Occlusion in fixed partial denture

The tooth movement ranger from 8 to 28 in a vertical

direction and that of implant 3 to 5 Because of this

difference in vertical movement the initial occlusal contact

should account for the difference.

Using key ways in fixed bridgework also proves stress relief,

and reduction of occlusal load to the implant.

12. Complication from overloading implants :

a. Crestal bone loss.

b. Screw loosening.

c. Screw fracture.

d. Material fracture.

13. Minimizing overloading of implants :

a. Narrow occlusal table.

b. Splinting.

c. Cantilevers.

d. Proximal contacts.

e. Cement retained restoration.

CONCLUSION

Conclusion has been an important variable in the success of

failure of most prosthodontic reconstruction with natural teeth, a

certain degree of flexibility permits compensation for occlusal

irregularity. Implant dentistry is not as forgiving. The occlusion must

be more rigorously evaluated with implant supported prosthesis.

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Occlusion in fixed partial denture

Unfortunately, the occlusion of teeth is frequently overlooked

or taken for granted in providing restorative dental treatment for

patients. This may be due in part to the fact that the symptoms of

occlusal disease are often hidden from the practitioner not trained to

recognize them or to appreciate their significance. The long-term

successful restoration of a mouth with cast metal or ceramic

restorations is dependent upon the maintenance of occlusal

harmony.

While it is not possible to present the philosophies and

techniques required to render extensive occlusal reconstruction in

this limited space, it is essential that the reader develop an

appreciation for the importance of occlusion. The perfection of skills

required to provide sophisticated treatment of complex occlusal

problems may take years to acquire. However, the minimum

expectation of the competent practitioner is the ability to diagnose

and treat simple occlusal disharmonies. He or she also must be able

to produce restorations that will avoid the creation of iatrogenic

occlusal disease.

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Occlusion in fixed partial denture

REFERENCES

1. Failure in restored dentition management and treatment

Michael Wise.

2. Fundamentals of fixed prosthodontics Herbert T.

Shillingburg.

3. Management of temperomandibular disorder and occlusion

Jeffrey P. Okeson.

4. Evaluation, Diagnosis, and Treatment of occlusal problems.

Peter E. Dawson,

5. Oral rehabilitation by Sumiya hobo

6. Contemporary implant dentistry. Carl E. Misch

7. Surgical and prosthetic techniques for dental implant Ismail,

Fagan, Meffert.

8. Risk factors in implants Franck Renonard.

9. Implant supported prosthesis, occlusion, clinical cases and

laboratory procedure Vicente Jimenez- Lopez.

10. Journal of California dental association, (2000).

11. Journal of Canadian Dental Association; 2001.

12. Occlusion : Reflection on Science and clinical reality (J.P.D

2003:90:373-84)

13. Occlusal Assessment (JIPS 2004; Vol 4, No.2;39)

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