Introduction

The reason for replacement of natural teeth is not only to aid in

mastication, but for various functions like the maintenance of proper

support for the orofacial musculature, esthetic appearance, proper

speech production, prevention of teeth migration, maintenance of the

morphologic facial height and prevention of TMJ dysfunction

syndromes.

Requirements of occlusal contact relationships

It should be within the adaptive capacity of the patient.

To restore and maintain the health & function of the

stomatognathic system

Simultaneous bilateral contact of opposing posterior teeth must

occur in centric occlusion.

Some criteria established by OKESON for optimum occlusion are:

In closure, the condyles are in the most superoanterior position

against the discs of the posterior slopes of the eminences of the

glenoid fossae.

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 The posterior teeth are in solid and even contact and the anterior

teeth are in slightly lighter contact.

Occlusal forces are in the long axes of the teeth

In lateral excursions, working side contacts (preferably on

canines) disocclude (or) separate the non-working teeth instantly

In protrusive excursions, anterior tooth contacts will disocclude

the posterior teeth

In an upright posture, posterior teeth contact more heavily than

do anterior teeth.

Diagnosis

This is necessary to determine the basis for patients treatment.

Information about the existing occlusal scheme can be derived from 3

sources:

Intra-oral examination

Radiographic survey

Evaluation of mounted diagnostic casts

1. Intra oral examination

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 This examination is done to reveal signs and symptoms of

occlusal pathosis, if present

In case occlusal pathosis is present, they will be found during:

Testing the teeth for the presence or absence of mobility

Severe dental attrition

Charting of periodontal pockets

Determination of defective occlusal contacts from CR to CO

In the absence of any signs and symptoms, these occlusal

contacts may be functional and physiologic.

2. Radiographic Survey

A radiograph is a 2 dimensional representation of a 3

dimensional object. Therefore, a complete radiographic survey cant

be used exclusively to arrive upon a diagnosis. Yet, there are certain

radiographic signs that are indicative of pathologic changes that may

have been caused by the occlusion.

Radiographic signs of occlusal pathosis are:

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 Widening of the PDL space
Thickening
Angular bony defects

Changes in lamina dura

Thinning

These radiographic findings have to be correlated with clinical

evidence found during the time of patient examination.

3. Examination of the mounted diagnostic casts

The relationships between the jaws and teeth that can be

visualized from the mounted diagnostic casts must be identified before

treatment planning. This knowledge is necessary for 3 reasons:

Identification of existing initial tooth contacts and the analysis

of factors that may contribute to any existing pathosis or may

potentiate damage to a future planned occlusion.

Occlusal plane and occlusal contacts study to facilitate and aid in

designing the occlusal scheme of the FPD.

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 In order to plan for an occlusal scheme, the dentist has to first

decide whether changes have to be made in respect to:

a. Character of the opposing dentition

b. Location and amount of tooth contact

c. Plane of occlusion

d. The position in which the occlusion must be established

(CR or CO)

e. Type and number of lateral tooth contacts that occur during

eccentric mandibular movements.

Factors to be studied on the mounted diagnostic casts

A. Centric relation, centric occlusion and initial tooth contacts

CR is an anatomic position i.e. more specifically a

neuromuscular position. It is a position dictated by the muscles

attached to the mandible and articular disc and ligaments and not

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dictated by tooth position. Since it is a position controlled by the NM

system, it can vary slightly from day to day and different times of the

day.

CO is a tooth position. It is the position of the maxilla in relation

to the mandible when the teeth are in maximum inter-cuspation. CO

changes through attrition, tooth migration, tooth loss though it does so

very slowly.

Only when casts are mounted in CR, can the occlusal information

of the patient be portrayed in three dimensions. The information is in

regard to

Initial tooth contact

Subsequent tooth position

This must then be correlated with that from radiographic and

intra-oral examination so that the patients adaptive ability can be

assessed.

The areas to be observed specifically are

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 Interference from CR to CO caused by deflective tooth contacts.

Magnitude and direction of the interference from CR to CO.

Knowing the difference that exits between CR and CO will help

future planning for any occlusal adjustment necessary to achieve

harmonious and simultaneous contact during function.

B. Plane of occlusion

The plane of occlusion of the natural dentition can be visualized

as an imaginary curved plane that connects the incisal edges of the

anterior teeth with cusp tips of the posterior teeth. This antero-

posterior and mesio-distal curved plane is important functionally as it

allows the mandibular teeth to be cradled within the confines of the

maxillary dental arch. It aids in protecting the soft tissues from injury

and in stabilizing the mandible during final closure to CO.

Disruption of this can occur due to supraeruption of tooth due to

the missing antagonist tooth. This results in an indentation of the

occlusal plane, such that during protrusion movement of the mandible

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this extruded tooth will contact the proximal surface of the tooth

bonding the indentation resulting in a deflection downwards. This

leads to increase stresses to tooth, bone and musculature.

When this exceeds the patients adaptive capacity, it leads to:

Increase tooth wear

Changes of lamina dura

Increase tooth mobility

TMJ dysfunction

This problem can be due to one single tooth extrusion or the entire

segment of an arch.

C. Anterior and posterior determinants of occlusion

The anatomic determinants of mandibular movements i.e.

anterior guidance and condylar guidance have a strong influence on

the occlusal surface morphology of the teeth being restored.

(i) Condylar Guidance/ Posterior determinant

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 Condylar guidance that has an impact on the occlusal surface of

posterior teeth is 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. If the protrusive

inclination is steep, the cusp height may be longer. However, if the

inclination is shallow, the cusp height must be shorter.

Immediate mandibular lateral translation is the lateral shift

during 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.

(ii) Anterior Guidance/ Anterior Determinant

The track of the incisal edges from maximum intercuspation to

edge-edge occlusion is termed as the protrusive incisal path. The angle

formed by the protrusive incisal path and the horizontal reference

plane is the protrusive incisal path inclination (Ranges 5070). In

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healthy dentition, the anterior guidance is approximately 510

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. This

should also occur during lateral mandibular excursions.

The mandibular incisal edges should contact the maxillary

lingual surface at the transition from the concavity to the convexity in

CR position. Anterior guidance which is the combination of the

vertical and horizontal overlap of anterior teeth also governs the

occlusal surface morphology of the posterior teeth.

Greater the vertical overlap, longer the posterior cuspal height

and vice versa. Greater the horizontal overlap, less cuspal height

needed and vice versa.

D. Compensating curves in prosthesis Vs the curve of Spee and

Wilson in natural teeth

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 The antero-posterior and mediolateral compensating curves

generated in prosthesis has to follow the already existing curve of spee

and curve of Wilson present in the natural dentition. If the curves are

shallow, then a shallow curve should be generated.

But it should be kept in mind that the anterior guidance and

posterior guidance are the physiologic limits or border movements of

mandibular function. Any factors that will create a steeper guidance

than those dictated by border movements should be considered

pathologic interferences. The dentist must work within these limits to

develop an individual occlusal scheme for each patients particular

needs that will preserve the remaining dentition.

E. Inter-Ridge Space

Often the maxillo-mandibular space is very greatly reduced, due

to natural teeth opposing residual ridges extrude along with the teeth.

Clinically segmental extrusion and its consequences are more likely to

occur with early tooth loss.

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 The extruded teeth needs to be evaluated, if minimal

odontoplasty will bring back the tooth into plane of occlusion or

will it require endodontic therapy followed by the restoration of a

FPD.

Planning the occlusion

Whether to take CR records (or) centric occlusion (or) freedom

in centric

Organization of the occlusal scheme

CR (or) CO (or) Freedom in centric relation

Centric relation is the position of choice:

When there are insufficient occlusal contacts to relate the

mandible to maxilla (to relate the diagnostic casts) in a stable

consistent relationship

When eccentric contacts are to be made.

Centric Occlusion is the position of choice:

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 When stable, maximal occlusal contacts exist with no evidence of

pathosis.

After any anterior or mediolateral deflection from centric

relation have been adjusted.

Freedom in centric relation

A more rational approach to patient treatment is to develop an

occlusion in such a way that there will be no interferences from

centric relation to centric occlusion and no interfering contacts in

lateral eccentric movements throughout the functional occlusal range.

Adjustment of this nature will frequently produce what has been

described as a long centric or freedom in centric relation.

Organization of the occlusion

3 recognized concepts.

Bilateral Balanced Occlusion

Unilateral Balanced Occlusion

Mutually Protected Occlusion

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Bilateral Balanced Occlusion

Based on the work of Von and Spee and Monson

Used only in complete denture construction in which contact on

the non-working side is important to prevent tipping of the

denture.

Also applied in natural teeth during complete occlusal

rehabilitation i.e. attempt made to distribute the stress among as

many teeth as possible.

Disadvantages

As a result of multiple tooth contacts that occurred as the

mandible moved through various excursions produced

excessive frictional wear on the teeth.

Unilateral balanced occlusion/ group function

Based on the concept of Scheyder

Widely accepted during restorative dental procedures

Eliminates tooth contact on the balancing side which would be

destructive.

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 Group function on the working side distributes occlusal load.

Advantages

Maintenance of occlusion i.e. saves the centric holding cusps

from excessive wear

Used in complete mouth occlusal rehabilitation

Functionally generated path described by Meyer is used for

producing restorations in unilateral balanced occlusion.

Mutually protected occlusion/ organic/ canine guided occlusion

Proposed by DAmico, Stuart, Stallard and Lucia.

In this type of occlusion, anterior teeth protect the posterior teeth

in all mandibular excursions and posterior teeth protect the

anterior teeth in the IC position. This type of occlusion is called

mutually protected occlusion.

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Advantages

Patient tolerance

Ease of construction

Disadvantages

Cannot be given when anterior teeth are periodontally weak.

Class II and Class III situations, where the mandible is not

guided by anterior teeth.

In cross bite situations cannot be used.

Features of a mutually protected occlusion are

Uniform contact of all teeth around the arch when the mandibular

condylar processes are in their most superior position.

Stable posterior tooth contacts with vertically directed resultant

forces.

CR = IP

No contact of posterior teeth in lateral or protrusive movements

Anterior tooth contacts harmonizing with functional jaw

movements.

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Interferences

When the teeth are not in harmony with the joints and the

mandibular movements, interference is said to exist.

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.

4 types of interferences

(i) Centric interference

Premature contact that occurs when the mandible closes with

the condyles in their optimum position in the glenoid fossae.

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 Causes deflection of the mandible in a posterior, anterior and/

or lateral direction.

Interference occurs between the mesial inclines of maxillary

teeth and distal inclines of mandibular teeth.

(ii) Working interference

Occurs when there is contact between the maxillary and

mandibular posterior teeth on the same side as the direction in

which the mandible has moved and should be heavy enough to

disocclude anterior teeth.

(iii) Non-working interference

Is an occlusal contact between maxillary and mandibular teeth

on the side of the arches opposite to the direction in which the

mandible moves in a lateral excursion.

It is destructive in nature

(iv) Protrusive interference

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 Occurs when distal facing inclines of maxillary posterior teeth

contacts the mesial facing inclines of mandibular posterior

teeth during a protrusive movement.

Causes destruction forces

These interferences may lead to pathologic occlusion

Pathologic Occlusion

A pathologic occlusion is defined as the one in which sufficient

disharmony exists between teeth and the TMJs to result in symptoms

that requires intervention

Signs and Symptoms

(i) Teeth

May exhibit hyper mobility, open contacts or abnormal wear like

fracture or chipping of incisal edges.

(ii) Periodontium

Chronic periodontal disease.

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 Widened PDL space (radiographically).

Tooth movement.

(iii) Musculature

Chronic muscle fatigue leading to muscle spasm and pain

Restricted opening or trismus

Myositis

(iv) TMJs

Pain, clicking or popping in the TMJs

Treatment

Includes certain objectives. They are:

To direct the occlusal forces along the long axes of the teeth.

To attain simultaneous contact of all teeth in CR

To eliminate any occlusal contact on inclined planes to enhance

the positional stability of the teeth

To have CR coincident with the intercuspal position.

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 To arrive at the occlusal scheme selected for the patient (ex.

Group function or mutually protected occlusion)

Attained by either occlusal equalization procedures or appliances

like occlusal splint.

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References

1. Fundamentals of Fixed Prosthodontics, Herbert T. Schillingburg ,

third edition.

2. Contemporary Fixed Prosthodontics, Stephen F.Rosensteil, third

edition.

3. William FP Malone, David L Koth: Tylmans Theory and Practice

of Fixed Prosthodontics; 8 t h Edition.

4. Hobo S, Shillingburg HT, Whitsett LD. Articulator selection for

restorative dentistry. The Journal of prosthetic dentistry. 1976 Jul

1;36(1):35-43.

5. Steele JG, Nohl FS, Wassell RW. Crowns and other extra-coronal

restorations: occlusal considerations and articulator selection.

British dental journal. 2002 Apr 13;192(7):377.

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