Complete dentures

The role of occlusion in preservation and prevention

in complete denture prosthodontics

Harold R. Ortman, D.D.S.*

State University of New York at Buffalo, School of Dentistry, Buflalo, N. Y.

C omplete denture occlusion, in its broadest concept, is the closure of the maxillary
and mandibular teeth in centric relation and throughout the range of functional and
nonfunctional movements of the mandible. Occlusion must be developed to function
efficiently and with the least amount of trauma to the supporting tissues. The pur-
pose of this article is to review the various concepts of occlusion relating to complete
denture prosthodontics.

THE NATURE OF THE SUPPORTING STRUCTURES

The supporting structures are comprised of hard and soft tissues. The soft tissues
vary in thickness and resiliency and are in a constant state of change. They respond
rapidly to external stimuli, such as pressure, scuffing, heat, and cold, and to internal
factors, such as amount of contained fluid, nutrients, salts, and blood pressure.
Traumatic insults to this tender tissue covering result in hypertrophy and sensitivity.
The change is temporary and reversible if the insult lasts for a short period of time,
but permanent changes take place when tissue tolerance is constantly exceeded.
The hard tissue (bone) is the primary support for the denture base. The nature of
this structure must be understood if it is to be preserved.

REACTION OF BONE TO PRESSURE AND TENSION

The reaction of bone to pressure is paradoxical since it can cause both apposition
and resorpti0n.l If pressure on a tooth is principally in line with its long axis, there
is stimulation for apposition of bone. Pressure perpendicular or tangential to the
long axis of a tooth creates bone resorption, tooth migration, and looseness as bone
resorption occurs.
Normally, the stresses of pressure and tension on bone are transmitted through
avascular tissues such as the teeth, the condylar articulation, and the intervertebral
disc. Such structures are under pressure and are covered by specialized fibrous tissue,
fibrocartilage, or hyaline cartilage. If the pressure is against a vascular tissue covering

*Professor and Chairman of Removable Prosthodontics.

121
122 Ortman J. Pro&h. Dent.
February, 1971

of bone, such as the periosteum, the blood supply to the bone is disturbed and re-
sorption may occur.
The denture-bearing bone has a complex blood supply from two sources: from
the periosteum and from its internal system of arteries. Arteries from the periosteal
network enter the bone, and interference with this supply may lead to bone necrosis
and resorption. The interference may be due to pressure directly on the bone, or it
may be inflammatory in origin. If inflammation is present in bone or in adjacent soft
tissues, a constant internal capillary pressure develops which will set up resorptive
changes.
Pressure of a denture base on the bone of the residual ridge may cause circulatory
insufficiency with a risk of resorption deve1oping.l

DIFFERENCES BETWEEN NATURAL OCCLUSION AND ARTIFICIAL OCCLUSION

1. The teeth in dentitions are retained by periodontal tissues which are uniquely
innervated and structured. When the natural teeth are lost, not only the occlusion is
lost but also the attachments. In complete artificial occlusion, all the teeth are on two
bases seated on slippery tissues.
2. In dentitions, the teeth move independently and can migrate slowly to favor-
able occluding positions. The artificial teeth move as a unit and are instantly dis-
placed by dislodging forces.
3. A malocclusion of natural teeth may be uneventful for several years, and if
symptoms do occur, they are usually localized to the involved tooth or teeth. A mal-
occlusion of artificial teeth creates an immediate response and usually involves a large
area of the supporting tissues.
4. Horizontal thrusts on one side of the natural teeth during mastication affect
only the side involved and are well tolerated ; whereas, in artificial teeth, the effect
is bilateral and usually traumatic in nature.
5. Incising in the anterior region of natural teeth does not affect the posterior
teeth, but it does so in artificial dentitions.
6, Mastication in the second molar region in the artificial occlusion shifts the
base if it is on an inclined foundation; whereas, in natural teeth, it is one of the
power points of mastication.
7. In natural teeth, there rarely is bilateral balance during nonfunctional ex-
cursions; whereas, in artificial teeth, it is necessary to stabilize the bases,
8. In the natural teeth, proprioception gives guidance to the neuromuscular con-
trol during function. This makes it possible for the individual to avoid clashing tooth
contacts and to establish a habitual centric occlusion away from centric relation.
With artificial occlusion, no such signal system is present, and the mandible returns
at the end of the chewing stroke to its optimum power position which is centric rela-
tion. If cusps interfere or if there are premature occlusal contacts, the bases shift to
accommodate them.
Dentists can restore the natural tooth form artificially but not its attachments.
This presents the dentist with a new problem, and it seems logical that some changes
must be made. The above differences make it necessary to consider artificial occlu-
sion as a different problem with different requirements if it is to serve efficiently with
the least amount of trauma.
X”%&f Role of occlusion in complete denture prosthodontics 123

REQUIREMENTS OF ARTIFICIAL OCCLUSION FOR TISSUE PRESERVATION

These requirements are as follows: ( 1) stability of occlusion in centric relation;
(2) balanced occlusion for eccentric contacts; (3) unlocking of the cusps mesiodis-
tally to accommodate the inevitable settling of the denture bases; (4) control of
horizontal force by buccolingual cusp height reduction according to the residual ridge
shape and interarch space; (5) functional balance by favorable tooth-to-ridge crest
position; (6) cutting and shearing efficiency; (7) anterior clearance of teeth during
masticator-y function; and (8) minimum occlusal stop areas for reduced pressure
during function.
The differences between natural and artificial teeth and the requirements for
artificial occlusion make it necessary to consider the dentist-created occlusion as a
unique problem. An occlusion now has to be designed to fit the compromise situation
presented by the edentulous mouth. This pattern must be designed to redress the
unequal stability of the upper and lower denture bases. The lower base is inherently
less stable in most cases, so the occlusal design and placement of the lower occlusal
units are the first considerations in approaching a solution to the problem. A division
of the occlusion into three distinct units, namely ( 1) the incising, (2) the working,
and (3) the balancing, can be made. 2 It is possible to establish requirements for these
units that will favor function and prevent trauma to the ridges.

REQUIREMENTS OF THE INCISING UNITS

1. These units should be sharp to cut efficiently.
2. They should be out of contact during masticating function.
3. They should have as flat an incisal guidance as is possible.
4. They should have horizontal overlap to allow for settling of the bases.
5. They should engage only during protrusive incising jaw movements.

REQUIREMENTS OF THE WORKING OCCLUSAL UNITS

1. They should be efficient in cutting and grinding.
2. They should be narrow to minimize the work force directed to the denture
foundation.
3. They should be over the ridge crest or slightly lingual to it for lever balance
on the lower base.
4. They should receive the occluding force essentially vertically.
5. They should center the working load near the anteroposterior center of the
denture foundation.
7. They should present a plane of occlusion as nearly parallel to the mean foun-
dation plane as is possible.

REQUIREMENTS FOR THE BALANCING OCCLUSAL UNITS

1. They should contact in the second molar region when the incising units con-
tact during function.
2. They should contact at the end of the masticatory stroke when the working
units contact.
3. They should have smooth gliding contact for lateral and protrusive sliding
ex-
cursions.
 J. Prostb. Dent.
124 Ortman Februaw, 1971

Axioms for artificial occlusion based on physical laws were published by Sears3
They are:
1. The smaller the area of the occlusal surface acting on food, the smaller will
be the force necessary to crush food and the pressure transferred to the supporting
structures.
2. Vertical force applied to an inclined plane of an occlusal surface causes non-
vertical force on the denture base.
3. Vertical force applied to an inclined supporting tissue causes nonvertical force
on the denture base.
4. Vertical force applied to a denture base supported by yielding tissue results in
teetering of the base when the force is not contoured.
5. Vertical force applied outside (lateral) to the ridge crest tends to teeter the
denture base.
Dentures are mechanical devices and are subject to the principles of mechanics,
i.e., the lever, the inclined plane, and other mechanical factors. Rather than let them
operate uncontrolled, it is possible to control these forces and to enhance stability.
Many types of posterior teeth are available for the dentist to use in establishing
an occlusion. They can be divided into two main groups: the anatomic and the non-
anatomic.
An anatomic tooth is one which is designed to simulate the natural tooth form.
It has cusp heights of varying degrees of inclination that will facilitate intercuspation
with its opposing member. The anatomic tooth can be modified by grinding, but as
long as it exhibits cusp height, it is anatomic in form.
A nonanatomic tooth is one which has an essentially flat occlusal surface with no
cusp heights to interdigitate (intercuspate) with the opposing member.
The effect of various tooth forms on residual ridges has been the subject of re-
search, but no conclusive evidence establishes one as the best for all situations. All
that can be done, at the present time, to make a selection of the posterior type is to
use clinical observation, experience, and the application of logic. This seems to con-
traindicate the locked cusps of the unmodified anatomic tooth so that the occlusion
clashes on inclines and “humps and bumps” during centric closure after settling.
This inclined plane activity is converted into horizontal stress on the supporting tissue
(Fig. 1).

THE PROBLEM OF USING ANATOMIC TOOTH FORMS

The natural tooth form with its cuspal inclines usually functions in the dentulous
mouth in harmony with its opposing member giving efficient and comfortable masti-
cation. It provides stability to the mandible when bracing for swallowing and in
periods of clamping due to stress.
In the edentulous environment, these same cusps can cause trauma, discomfort,
and instability of the bases due to horizontal components with destruction to the
ridges. The basic problem initially is the coordination of these cuspal inclines to bar-
monize with one another and with the mandibular movements. Even if this is ac-
complished by meticulous records on an adjustable articulator, it cannot exist for
long when transferred to the mouth. The problem of unmodified cusped teeth for
complete artificial denture occlusion may be summed up as follows:
1. It is mandatory to use an adjustable articulator.
Kz:P Role of occlusion in complete denture prosthodontics 125

Fig, 1. (A) Natural occlusion with typical intercuspation. (B) Duplicated artificial occlusion
on bases that “settle” as indicated by the broken lines. The direction of closure moves the lower
denture forward in centric relation as settling occurs. (C) The mesial inclines of the lower teeth
close on the distal inclines of the upper teeth during centric closure resulting in an anterior
thrust to the upper base and a distal thrust on the lower base to satisfy the inclined planes.

2. Eccentric records must be made for articulator adjustments.

3. Mesiodistal interlocking cannot provide for “settling” (Fig. 1, c) .
4. Carefully balanced lateral positions become unbalanced with settling.
5. The bases need prompt and frequent refittings to keep the occlusion harmoni-
ous.
6. The presence of cusps generates more horizontal force during mastication.
The proponents of anatomic teeth seem dedicated to the precision of the articula-
tor and the infallibility of meticulous maxillomandibular relation records. Many
claim that it is not the presence of cusps that is the problem but the mismanagement
of cusps. However the proponents of cusp teeth usually end up with some modifica-
tions by grinding.
Unless the denture foundation is firm and well formed so that accurate centric
and eccentric relation records can be made, unless the ridge relationship is ana-
tomically normal, and unless an adjustable articulator is used, it is dangerous and
damaging to place unmodified cusps on complete dentures. Traumatic occlusion oc-
curs when cusps are not coordinated with jaw movement and with one another. This
harmony of cusps becomes discordant when the dentures “settle.”
It seems to be an indisputable and logical conclusion that all anatomic posterior
teeth need some modification to meet the altered condition under which they func-
tion.

THE PROBLEM OF NONANATOMIC TOOTH FORMS

The major objective of special occlusal forms is to prevent the destruction of
tissue and to preserve the integrity of the supporting ridge.’
126 Ortman J. Prosth. Dent.
February, 1971

Fig. 2. (A) Nonanatomic (flat) teeth set to a flat occlusal scheme. (B) Diagram of a flat
occlusal scheme with a broken line to show the inclination of the occlusal plane to compensate
for the condylar inclination. (C) Diagram of the protrusive position showing the absence of
protrusive balance with a flat plane due to the downward movement of the back part of the
mandible. Balance is possible by a balancing ramp or compensating curve.

While the elimination of cusps on the occlusal surfaces simplifies tooth contact by
avoiding inclined plane forces due to cusps, other problems arise. Flat nonanatomic
teeth occlude in two dimensions (length and width), but the mandible, due to the
incline of the condylar path, moves in a three-dimensional arcuate path. The vertical
component present in mastication and nonfunctional movements is not provided for
so that this form loses shearing efficiency and protrusive and bilateral balance (Fig.
2).
This can be compensated for by setting a curved occlusal plane mesiodistally for
protrusive balance and a lateral balancing ramp for bilateral balance. The design of
the occlusal surface should provide cutting ridges and spillways to provide for ade-
quate function.

EVALUATION OF THE OCCLUSAL FORMS

In evaluating the effectiveness of the occlusal forms of artificial teeth, two factors
must be of paramount consideration; namely, the comminuting efficiency and the
horizontal force distributed to the ridge.
Tests for efficiency of the various tooth forms have been conducted by many in-
vestigators. 5-Q Several authors have shown that comminuting efficiency was at its
highest point with cusp teeth. They did not agree on any one cusp angulation as the
most efficient. Modified 20 degree teeth seemed to be best in the tests conducted by
Payne5 and Trapozzano and Lazzari.8
Volume 25 Role of occlusion in complete denture prosthodontics 127
Number 2

KyddlO tested the horizontal component of forces delivered to the ridge and found
that it varied with the cusp inclination; the greatest force with 33 degree teeth and
the least with 0 degree teeth.
Sauser and Yurkstas,ll in their tests of geometric occlusal patterns, found that
cornminuting efficiency was best when occlusal surfaces provided cutting edges, with
the upper edge running mesiodistally.
Brewer and co-workers? made a study of duplicate dentures with anatomic and
nonanatomic teeth for a series of patients and found that the majority of patients
could not tell the difference between the two types of teeth and that, when informed,
the majority preferred the nonanatomic form.
As a result of testing, it seems that anatomic teeth perform best, but they do at
the expense of increased horizontal pressure, and it is this pressure that is most likely
to damage the ridge tissues. The efficiency of nonanatomic teeth can be increased by
proper design. Wearers of artificial teeth do not have a scientific approach to the
selection of occlusal tooth form, so their subjective judgment cannot always be
valid.

IMPORTANCE OF THE CONDYLAR PATH TO OCCLUSION

Many dentists believe any tooth form for dentures is satisfactory, because the con-
dyle does not follow a precise path but acts more like a universal joint and can follow
any path the occlusion dictates. Craddockl” said, “For some years the indiscriminate
use of mathematics and geometric symbols, coupled with an admiration for, and a
preoccupation with, the undoubted precision of the many articulators, has injected
into the professional thinking on condylar guidance a degree of precision which
fortunately perhaps does not exist in fact. It cannot be disputed that denture oc-
clusion of great accuracy can be produced by using these complex measurements and
records. The question is, how much a part of these procedures is really necessary to
the excellence of the results?”
Other dentists believe the path is precise and constant and that it guides the
movements of the mandible so exactly that it dictates the occlusion.
What is the truth? So far, it has not been resolved by exact scientific studies to
everyone’s satisfaction. There does seem to be some truth in each position. Tracings
made on the hinge axis with a common starting point showed the condylar path to
be the same for varying incisal guidancesI KurthI claims the condylar path is not
the same for varying incisal guidances. Payne” has shown that the mandible can move
to follow high cusps, low cusps, or no cusps. From this, we could conclude that the
teeth constitute the primary guiding factor of the mandible once they occlude.
The latitude of mandibular guidance by the teeth is shown by the change that
takes place on natural teeth during progressive wear. When continued to an extreme,
the teeth are no longer spheroid as in unabraded natural teeth but exhibit a reverse
curve. Many dentures with acrylic resin teeth are worn to a reverse curve but still
function. KellyI studied the occlusal wear of 150 denture-wearing subjects with resin
teeth set to a spherical occlusion and found that the dentures wore into a reverse oc-
clusal curve. Condylar guidance seems, in most patients, to allow for variations in
the occlusal scheme rather than to direct it. Mandibular action and guidance seem
to be primarily neuromuscular and not so strictly controlled by the temporomandib-
128 Ortman J. R&h. Dent.
February. 1971

Table I. Type of tooth form related to.type~of residual ridge

Ridge type Interridge distance Ridge relation Posterior type

Prominent-firm Close-ideal Normal cusp 1*
Prominent-firm Average Prognathus cusp 1*
Average Average Orthognathus cusp 2t
Average Close Orthognathus cusp 3$
Average Large Normal Cusp 2t or flat
Flat-firm Large Normal Flat
Flat-firm Excessive Prognathus Cusp 2t or flat
Flat-flabby Excessive Orthognathus Flat reverse curve
“Mesiodistal unlocked, slight incline modification (Fig. 4, B).
tMesiodista1 unlocked, moderate incline modification (Fig. 4, C),
SMesiodistal unlocked, gross modification for reverse curve in bicuspids.

ular joints as the complex articulators and their adjustments presuppose. In patients
with loss of condyles, function was still possible.
The mandible is a tripod with each condyle and the teeth as the base. No one or
two combinations of this base completely fix or control the other. The guidance of
the two condyles can be nearly constant, and the tooth guidance can be altered
within limits. However, once the vertical and horizontal overlaps of the teeth have
been established, then the plane of occlusion, the compensating curve, and the tooth
form must harmonize with the three guiding elements of this tripod if balanced OC-
elusion is to be achieved.
Dentists use high cusps and steep incisal guidances and balance the occlusion of
the teeth on a fully adjustable articulator. Other dentists modify anatomic tooth
forms to conform to shallower guidances, while still others will set flat teeth to varying
occlusal planes. Some dentists set teeth to a reverse curve in the belief that this is
the best way to increase the stability of lower dentures and to reduce trauma to the
ridge. The reverse curve is used in occlusal planes which provide for no balance and
in modified planes which provide for some balance.

THE NEED FOR AN EFFICIENT AND SAFE DENTURE PROCEDURE

Many people wear complete dentures with varying degrees of success. The ever-
growing population and the increased life expectancy suggest that the demand for
complete denture service will escalate in spite of the heroic efforts of preventive
dentistry.
Many varied concepts exist regarding the best way to establish the occlusion for
complete dentures. The increasing demand for denture service compels the dentist
to seek an effective and uncomplicated procedure based on functional efficiency and
preservation of supporting tissue. Neither uniformity nor rigid standardization of
technique is advocated. The basic concern is the application of sound basic concepts
of occlusion which will perform as effectively as possible in the edentulous environ-
ment.
Payne,17 discussed the selection of artificial posterior tooth forms and devised a
table for a guide. This table with some modifications appears as Table I.
pu&cle~ $5 Role of occlusion in complete denture prosthodontics 129
u

A B C D
Fig. 3. (A) The spherical scheme with cusp teeth is characterized by a buccal cusp rise for a
balancing contact. The radius for the curvature is above the occlusal plane as shown by the
broken horizontal line. The direction of the resultant force of mastication with this occlusal
scheme is shown in the other broken line. (B) The flat occlusal scheme with the broken line
representing the result of the occluding forces. (C) The reverse occlusal curve with the
radius of the occlusal curve below the occlusal plane. The broken line is the result of forces
which provide lever balance for stability of the lower denture due to lingual incline. (D)
The Pleasure curve, which is a reverse occlusal curve in the bicuspid region for lever bal-
ance, a flat occlusal contact at the first molar, and a buccal rise (spherical) for balance
in the second molar region.

The dentist must be versatile and capable of making intelligent compromisrs.

There are three basic schemes of posterior occlusion called for in Table I.
The spherical scheme. Anatomic teeth are used, and they may be altered. ThiT
scheme appears in natural dentitions unless severe abrasion is present. Balanced
occlusion rarely exists in the natural teeth, but balance is desirable for complete
dentures.
The flat scheme. Nonanatomic teeth are used. Balanced occlusion does not exist.
unless compensating curve balancing inclines are used.
The reverse cuwe. Modified anatomic teeth may be used, but usually nonana-
tomic teeth without balancing contacts are employed. Balance is possible by intro-
ducing a spherical buccal incline in the posterior region of the occlusion. This is
called a “Pleasure curve” after Dr. Max Pleasure who suggested it (Fig. 3, D) .

MODIFICATION OF THE OCCLUSAL SURFACE OF THE ANATOMIC FORM

The mesiodistal unlocking of cusp teeth by grinding is necessary to eliminate
anterior thrust on the upper base and posterior thrust on the lower base as the
dentures settle (Fig. 1). The modification of the buccolingual inclines to control
lateral thrusts during functional and nonfunctional mandibular movements can be
based upon the shape and prominence of the ridge and its ability to resist lateral
130 Ortman

A C
Fig. 4. (A) A natural tooth with bony support to resist horizontal forces that might be due
to steep cusp inclines. (B) Moderate buccolingual cusp modification to retain the spherical
scheme and to cut down lateral forces due to cusp inclination. (C) Further reduction of CUSP
to compensate for less foundation-resistant form. (0) A flat occlusal form for advanced
resorption. Note that the ridge form can be used as an index for the amount of modifica-
tion.

forces (Fig. 4). When the ridge is very flat, the grinding modification ends, and a
flat nonanatomic form is used (Fig. 4, C) .
During years of wearing dentures, it is probable that a patient would start out
with slightly modified posterior cusped teeth and that, in successive sets of dentures,
the occlusal surfaces of the teeth would be modified to become increasingly flatter
until a flat form is worn. Throughout the denture-wearing period of most normal
patients, it should be possible to control the lateral forces on the denture base by
selectively compromising between the efficiency of cusps and the stability of flat
teeth so that the force is within the tissue tolerance of the patient.

SETTING OF THE LOWER POSTERIOR TEETH-

ANATOMIC AND NONANATOMIC
It makes little difference whether the upper or lower teeth are set first so long
as their positions provide the proper arch form in relation to the denture foundation.
Since the lower denture generally is more likely to be unstable, it is easier and more
direct to set the lower teeth first. The position of the lower teeth should be guided
by the following factors:
Anteriorly. The position and height of the first bicuspid is determined by the
setting of the anterior teeth to the proper phonetic and incisal guidance position.
Posteriorly. The last tooth should not be set on a steep lower molar slope. It
should stop where the ridge is firm and never extend distally to the apex of the
retromolar pad.
Buccally. The tooth should be out of occlusion and lateral to the ridge crest.
Lingually. The tooth should not crowd the tongue or project lingually inside the
mylohyoid ridge.
 Role of occlusion in complete denture prosthodontics 131

Fig. 5. The height of the lateral borders of the tongue at rest is on the level, or slightly
above (hypertrophied tongue due to extended edentulous period), the occlusal plane.

Fig. 6. (A) Anterior teeth are set with a flat incidal guidance, and a compensating curve
is set to compensate for the inclination of the condyle path. (B) Diagram of the relation
of the incisal guidance, compensating curve, and the condylar inclination. (C) The balance
of the factors for protrusive occlusal balance. Example: If the incisal guidance is increased,
either the plane of occlusion or the compensating curve must be increased to develop balance.

Occlusal plane. The height of the occlusal plane is governed (a) anteriorly by
the esthetics and function of the anterior teeth, (b) by the lateral borders of the
tongue at rest (Fig. 5)) and (c) posteriorly by a height projected from the occlusal
surface to the middle third of the retromolar pad.
Compensating curve. The compensating curve is set to provide harmony between
the incisal guidance and the inclination of the condylar path (Fig. 6).
Horizontal plane. The cusp teeth are set with the lower buccal and lingual cusps
on the same horizontal plane (Fig. 7).
 132 Ortman J. Pro&h. Dent.
February, 1971

Fig. Fig. 8

Fig. 7. Centric occlusion (CO) with the mandible in centric relation (CR). The buccal cusp
clearance gradually increased by raising the buccal cusp height, as shown by the differences
between the right and left sides.
Fig. 8. Relation of the arch form to the form of the residual ridge. The crosshatch line
represents the residual ridge, the heavy line shows the curvature of the ridge, and the
straight line is the line of the central fossae of the posterior teeth.

If the lower posterior teeth are set so that the central fossae of all of the teeth
make a straight line from the tip of the cuspid to the apex of the retromolar pad,
then the buccolingual position is satisfied, and it will give good lever balance in the
first molar area (Fig. 8).
The modification by grinding of the lower posterior cusp teeth is most effectively
accomplished after they have been set (Fig. 4).

SETTING THE UPPER POSTERIOR TEETH

The upper posterior teeth are set to the lower teeth so that, in centric occlusion
only, the lingual cusp or part of each upper tooth occludes with the central fossa
or center of the lower tooth (Fig. 7). A n increasing clearance of the buccal cusps
from the first bicuspid to the second molar by progressively raising the upper buccal
cusps will provide the following benefits.
1. It centers the occlusal forces over the ridge crest except in the first molar
area where it is slightly lingual providing for lever balance in function (Fig. 8).
2. It provides a mortar and pestle type of occlusion with cusp teeth to provide
smaller occlusal contact for more efficiency and control of resultant forces (Fig. 9).
3. It changes the working cusp contact from the buccal to the lingual area of
the upper and lower teeth, thus, having the effect of moving the tooth lingually for
better lever control (Fig. 10).
4. It simplifies balancing and working contacts (Fig. 11) .
5. It prevents biting of the cheek by holding the buccal mucosa off the food
table.
In prognathic relationships and in some patients with advanced alveolar ridge
resorption, the lower arch form is located too far buccally from the upper teeth
Volume 25 Role of occlusion in complete denture prosthodontics 133
Number 2

Fig. 9. (A) Natural anatomically related cusp teeth have the pressures directed primarily
against the lower buccal cusp tooth due to the direction of the closing force of the chewing
cycle. The upper and lower buccal cusp teeth are the primary working contacts. The resultant
of force is shown by R. (B) The mortar and pestle action of the upper lingual cusp working
only against the lower lingual incline. The lack of contact of the buccal cusp teeth changes the
resultant force to a more favorable direction. Less pressure is needed to penetrate the bolus
of food as a smaller area of contact exists with adequate escapeways.

C
Fig. 10. (A) The resultant direction of forces due to contacts in centric occlusion with un-
modified anatomic teeth (line R). (B) The resultant direction of forces due to cusp con-
tacts in the working position. (C) The resultant direction of force due to modified mortar
and pestle occlusion in centric occlusal contact is made more favorable by moving the force
slightly lingual to the residual ridge. (0) During working contact, the resultant force is
inside the ridge crest providing lever stability for the lower denture.
134 Ortman .1. Prosth. Dent.
February. 1971

Fig. 11. Working and balancing positions are simplified since only the upper lingual cusp con-
tacts the lower tooth. A simple formula for working (W) contacts is with upper lingual cusps
and lower lingual cusps in contact and for the balancing side (B) contacts is with upper lingual
cusps against lower buccal cusps. The contacts are easily obtained by selective grinding as only
the upper buccal cusp has to be ground to remove interferences. The lower buccal and lingual
inclines are ground to provide smooth gliding, simultaneous contacts on both working (W) and
balancing (B) sides monitored by the articulator settings.

for a normal set-up. This may be unilateral or bilateral. To control the upper arch
form and the tipping force of leverage on the upper denture base, the teeth are set
in a cross-bite relationship. To set this relationship, one tooth is the transitional
cross-over tooth, with the cusps “buccal-to-buccal” and “lingual-to-lingual.” The
upper buccal cusps are set posterior from this tooth and in the center of the lower
tooth in a cross-bite relationship (Fig. 12) .
In the orthognathic relationship, the lower denture foundation (basal seat) is
small and weak in relation to the upper, especially in the anterior and bicuspid
areas. A reverse occlusal curve is set in the bicuspid region to favor the stability of
the lower base. The first molar is set to a flat scheme of occlusion, and the second
molar is set to the spherical scheme (Fig. 3, D) . This provides for balancing inclines
for lateral excursions that are not possible when a flat or reverse curve is set for all
the posterior teeth. This change of occlusal schemes from reverse to the spherical is
called the “Pleasure curve.”

BALANCED OCCLUSION
Balanced occlusion is simultaneous contact of the teeth on the right and left
sides and at the front and back from centric occlusal to eccentric occlusal positions
without interferences. Furthermore, this balance must be in harmony with the
temporomandibular joints and with the neuromuscular activity.
Dentures can have balanced occlusion yet fail to have denture balance in func-
tion. Also, it is possible to have dentures balance in function .without having bal-
anced occlusion. Both conditions are necessary to provide stability for functional
and nonfunctional mandibular movements.
Volume 25 Role of occlusion in complete denture prosthodontics 135
Number 2

C
Fig. 12. (A) The cuspal relationship to be used where the upper and lower residual ridges are
in a normal relationship to each other. (B) The transitional crossing spot with the upper and
lower buccal and lingual cusps is flattened by grinding for making static contact in centric
occlusion. (C) A cross-bite relationship with the upper buccal cusp in the lower central fossa.
This is used where the upper ridge is inside (lingual to) the lower residual ridge, and so the
upper tooth is in a favorable position in relation to its ridge. The upper buccal cusp tip is
rounded by grinding to develop a mortar and pestle type of contact.

BALANCING THE OCCLUSION

The factors that guide and affect lateral and protrusive balance are: (a) the
inclination of the condyle paths for protrusive excursions and the inclination of the
balancing side condyle path and the Bennett movement (direct lateral shift) of the
working side for lateral excursions; and (b) the inclination of the occlusal plane,
the cusps of the teeth, the compensating curve, and the incisal guidance.
The first of the listed factors are presented by each patient and are not under
the dentist’s control. They can be recorded and used to adjust the articulator. The
other factors must be manipulated for balanced occlusion on the articulator (Fig. 6) _
It is conceded that the balancing activity on the articulator does not represent func-
tional activity, but the merits of stabilizing the bases by balancing the occlusion for
nonfunctional activity have now become academic. The mortar and pestle type of
occlusal contacts for cusp teeth makes it easy to grind selectively for lateral working
and balancing contacts (Fig. 11) .
Protrusive balancing contacts involve the upper and lower incisors and the upper
and lower second molars. These contacts are important to stabilize the bases during
incising and nonfunctional activities. The path between centric occlusion and the
protrusive balancing position should be smooth and free of mesiodistal cusp inter-
ferences. With the incisal guidance kept as flat as esthetic and phonetic requirements
permit, it is a simple matter to adjust the compensating curve in relation to the
incisal guidance and the condylar inclinations. It is expedient to set the teeth in
a slightly steeper compensating curve than appears to be necessary and then to
136 Ortman J. Prosth. Dent.
February, 1971

adjust it by selective grinding on the lower second molar when the dentures are
finished and inserted.

IMPORTANCE OF REMOUNTING THE DENTURES

No matter how carefully the concepts of occlusion are practiced and perfected
on the articulator, there are errors in the occlusion of the finished dentures which
could be due to the use of trial bases, the behavior of the materials used, and
processing procedures. If not corrected, prematurities (deflective occlusal contacts),
instability of occlusion, and unbalanced inclines will operate to create trauma on
the tissues of the basal seat.
Remounting after processing and again after settling of the dentures is a step
which is frequently overlooked by busy dentists. The check of the occlusion usually
ends with the use of articulating paper on the teeth in the mouth. However, some
marks on the teeth made in this way are deceiving. In the haste of delivery, it is
easy to be satisfied, because the tissue resiliency masks the deflective and interceptive
occlusal contacts. To draw the conclusion that, without critical checking and cor-
rection, centric relation and centric occlusion coincide with static and equal pressure
on the teeth, the supporting tissue, and the temporomandibular joints is to abandon
the dentures to factors that destroy the supporting tissues.
The position of the denture bases on their supporting structures is critical. The
bases must be checked and corrected for overextension, tissue surface artifacts, and
pressure points. The tissues should be in a static, unpressurized, and undisplaced
position when the remount occlusal records are made. Therefore, it is necessary to
make this recording index without pressure or inclined plane activity. A soft non-
pressurizing recording medium used with the closure in centric relation stopping
just short of tooth contact is ideal. A quick-setting plastic or zinc oxide and eugenol
paste gives excellent results in remounting procedures.
After an accurate interocclusal record has been made, the dentures are remounted
on the articulator in the correct centric relationship. This will disclose the occlusal
discrepancies so that they can be eliminated. The occlusal errors will be exposed
on the rigid articulator so they can be observed, located, and removed.

OCCLUSAL CORRECTIONS
The steps involved in the final occlusal correction are listed here:
1. Re-establishment by spot grinding of a static centric occlusion coincident
with centric relation at the proper vertical dimension.
2. Re-establishment of balanced occlusion for a smooth gliding contact by se-
lective grinding.
3. Milling of the occlusion with an abrasive paste made of No. 100 Carborundum
powder and glycerin. The milling is done with the condylar inclination increased
5 degrees and decreased 5 degrees from the recorded inclination. This procedure
mills the occlusion alternately more on the anterior and then on the posterior region
of the occlusion so that the heaviest occlusal contact is in the second bicuspid and
first molar region. This centers the pressure of centric occlusion for bracing and
swallowing contacts at the anteroposterior center of the denture bases for greatest
stability.
 Role of occlusion in complete denture flrosthodontics 137

4. Polishing of all ground surfaces to reduce lateral drag due to friction as the
surfaces articulate.
The occlusion developed in this manner is based on concepts and principles that
have been tested, studied, selected, and refined. Only after this has been skillfully
accomplished has the dentist made the occlusion of dentures functional and safe
within the limits imposed by the conditions of the edentulous mouth.

DIRECTIONS TO THE PATIENT

Unless the patient is experienced, directions and coaching are necessary to pre-
vent the new “denture wearer” from traumatizing the supporting tissues. The com-
posure and good sense which some patients exhibit are reflected in the normal
healthy tissue they are able to preserve for years. Stress directed through the occlu-
sion is the enemy of tissue. A few basic directions to patients will give them a better
understanding of how they can help themselves wear dentures more safely. The
basic points to cover are as follows: ( 1) check the irresponsible drive of most
patients to eat foods beyond the capacities of their ridges; (2) tell the patient to
rest the tissues after periods of overuse or abuse due to stress; (3) bilateral chewing
habits should be developed to stabilize the bases in function and to distribute these
forces to both sides simultaneously-this also prevents tipping of the bases which
results in a clicking impact of the occlusion on the nonfunctioning side; and (4)
protect the supporting structure by a high protein and low carbohydrate diet.

CONCLUSIONS
The preservation of the supporting tissues is a sacred trust that cannot be ignored.
The application of the basic concepts discussed will help to keep this trust in the
hands of the dental profession.

References
1. Ortman, H. R.: Factors of Bone Resorption of the Residual Ridge, J. Paosrn. DENT. 12:
429-440, 1962.
2. Nagle, R. J., and Sears, V. H.: Denture Prosthetics, ed. 2, St. Louis, 1962, The Cl. V.
Moshy Company, pp. 360-366.
3. Sears, V. H.: Experiments in Occlusion, J. PROSTH. DENT. 2: 22-25, 1952.
4. Sears, V. H.: Factors in Designing of Special Occlusal Forms for Artificial Posterior Teeth.
Part I, J. Amer. Dent. Ass. 24: 626-631, 1937.
5. Payne, S. H.: Study of Posterior Occlusion in Duplicate Dentures, J. PROSTH. DENT. 1:
322-326, 1951.
6. Thompson, M. L.: Masticatory Efficiency as Related to Cusp Form in Denture Prosthesis.
Part I, J. Amer. Dent. Ass. 24: 207-219, 1937.
7, Schultz, A. W.: Comfort and Chewing Efficiency in Dentures, J. PROSTH. DENT. 1: 38-48,
1951.
8. Trapozzano, V. R., and Lazzari, J. B.: An Experimental Study of the Testing of Occlusal
Patterns on the Same Denture Bases, J. PROSTH. DENT. 2: 440-457, 1952.
9. Schuyler, C. H.: Full Denture Service as Influenced by Tooth Forms and Materials, J.
PROSTH. DENT. 1: 33-37, 1951.
10. Kydd, W. L.: Complete Denture Base Deformation, J. PROSTH. DENT. 6: 714-718, 1956.
11. Sauser, C. W., and Yurkstas, A. A.: The Effect of Various Geometric Patterns on the
Same Denture Bases, J. PROSTH. DENT. 7: 634-638, 1957.
12. Brewer, A. A., Reibel, P. R., and Nassif, N. J. Comparison of Zero Degree Teeth and
Anatomic Teeth on Complete Dentures, J. PROSTH. DENT. 17: 28-35, 1967.
138 Ortman J. Prosth. Dent.
February. 1971

13. Craddock, F. W.: The Accuracy and Practical Value of Records of Condylar Path Inclina-
tion, J. Amer. Dent. Ass. 38: 697, 1949.
14. Cohen, R.: The Relation of Anterior Guidance to Condylar Guidance in Mandibular
Movements, J. PROSTH. DENT. 6: 758-767, 1956.
15. Kurth, L. E.: Balanced Occlusion, J. PROSTH. DENT. 4: 150-167, 1954.
16. Kelly, E. B.: Has the Advent of Plastics in Dentistry Proved of Great Scientific Value?
J. PROSTK. DENT. 1: 168176, 1951.
17. Payne, S. H.: A Posterior Set-Up to Meet Individual Requirements, Dent. Dig. 47: 20-22,
1941.

STATE UNIVERSITY OF NEW YORK AT BUFFALO

SCHOOL OF DENTISTRY
REMOVABLE PROSTHODONTIC DEPARTMENT
BUFFALO, N. Y. 14214