Selection of Posterior Tooth Schemes for Dentures

Robert D. Grady DDS, FACP Associate Professor Division of Restorative Sciences University of Minnesota School of Dentistry

Occlusal Scheme: Systematic arrangement of artificial denture teeth for function and comfort.

Different schools of thought + Inconclusive research = Operators choice

Adaptability

The golden rule is that there are no golden rules. George Bernard Shaw, 1903

Patient adaptability, physically and psychologically, trumps all other factors. Bob Grady, 2007

Denture Success
! Adaptability ! Operator ! Vertical

Occlusal Scheme Selection

Skill (verbal and technical) Dimension of Occlusion ! Centric Relation ! Esthetics ! Accurate impressions ! Occlusal Scheme

Investigators have not shown one type of denture occlusion to be :

superior in function safer to oral structures more acceptable to patients

Goals of Complete Denture Occlusion

! Minimize

General Concepts of Denture Occlusion

!

trauma to the supporting structures ! Preserve remaining structures ! Enhance stability ! Enhance mastication ! Esthetics
In addition we would like to decrease lateral forces to the residual ridges.

Common Features
Simultaneous, bilateral posterior contact in centric relation (centric occlusion) Centralization of centric occlusal forces over the mandibular residual ridges " Buccal-Lingually " Anterior-Posteriorly Functional anatomy is the main determinant of denture tooth position

Types of Patients
! Age ! Physical

Youthful
!

Good
Coordination Musculature Adaptibiliy

ability and anatomy ! Coordination/adaptability ! Jaw relationship ! House classification ! Previous denture experience ! Parafunctional habits

Challenge
Esthetics Demanding

Select anatomic (cusped) posterior teeth

Aged
!

Helpful
Experience Possible low expectation Esthetics

Physical condition of the patient

Patients with poor neuromuscular control have difficulty accommodating to anatomic occlusions. They are best served with monoplane occlusal schemes.

Challenge
Physical limitations Poor adaptability

Select shallow cusps or none at all unless previous denture is cusped

Complete Denture Occlusion

! Neuromuscular

Jaw Relationship
!A

control and adaptability may be the most significant factors in the successful manipulation of complete dentures under function function and denture wearing experience

! Tongue

skeletal class II jaw relationship requires a non-anatomic scheme due to the large envelope of motion. ! Skeletal class III patients chew vertically with little anterior-posterior movement. Most schemes can be used. ! Crossbites generally require non-anatomic schemes.

Previous denture occlusion

If the present dentures have anatomic teeth which have not been severely ground or worn and the alveolar ridges are not severely resorbed, anatomic teeth can be used. If the existing denture teeth have been worn flat, nonanatomic teeth may be a better choice.

Chronic bruxism
Anxious, nervous individuals are more apt to grind, which can be especially traumatic to the supporting structures when anatomic posterior denture teeth are used. They are best served with monoplane occlusal schemes.

Mandibular Ridge Types

Resorbed and/or movable ridges

Such conditions, as demonstrated in these two patients, make it difficult to obtain accurate intraoral records and permit movement of the denture bases during function. The poorer the record base stability, the less cusp height is indicated. Exception: Some patients with highly resorbed ridges retain superb tongue control and a reasonably stable denture base. If they are vertical chewers, rather than wide envelope grinders, they will prefer and be able to handle cusp fossa teeth. Such patients are ideal candidates for lingualized occlusal schemes.

Posterior Tooth Forms Immediate dentures

Many dentulous patients, especially those with severely worn dentitions, have a discrepancy between ICP (intercuspal position) and RCP (retruded cuspal position). Removal of the natural teeth will permit and encourage a retrusive shift in mandibular posture. A non-intercuspated denture tooth form like lingualized or monoplane would give the freedom for the patient to reestablish the correct maxillomandibular relationship.

Anatomic Tooth Forms

Nonanatomic Tooth Forms

Semi-anatomic Tooth Forms

Denture Occlusion Options

Lingualized (lingual contact)

Semi-anatomic

non-anatomic (balancing ramp)

anatomic

nonanatomic

Non-anatomic

10 degree

20 degree

22 degree

33 degree

40 degree

Specifically designed teeth for lingualized occlusion

Lingual Bladed Teeth or Levin Blades

Non-anatomic variations

Anatomic teeth should be -

Exception: European concept of physiologic centric (Vident)

Balanced articulation is the bilateral, simultaneous, anterior and posterior occlusal contact of teeth in centric and eccentric positions.

Is Balance Necessary?

Bolus in Balance out

Is Balance Necessary?
Tests of Balanced and Non-balanced Occlusions
Trapozzano, V. R.: JPD 10: 476-487, 1960.

Is Balance Necessary?
Simplification of Occlusion in Complete Denture Practice: Posterior Tooth Form and Clinical Procedures
Dale Smith: DCNA 14: No. 3; July, 1970.

1) No patient preference 2) Balanced slightly more efficient 3) Percentage of patients using eccentric movements during mastication is small

1) Advocates cuspless teeth primarily for ease of use 2) May use balanced occlusion but cant prove that it is necessary

Balance and the Monoplane Occlusion

Balance and Monoplane Occlusion

Minimize vertical overlap within the dictates of esthetics and phonetics

Minimize vertical overlap within the dictates of esthetics and phonetics

Lingualized Occlusion
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Lingualized Occlusion
The lingual cusp tips should be in contact with the central fossae of the opposing mandibular teeth. The cuspal inclines of the mandibular teeth are relatively flat, resulting in potentially less lateral forces and displacement during function.

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Theoretically, there should be less lateral displacement of the denture and less lateral forces during function when using lingualized posterior denture teeth.

Lingualized Occlusion Lingualized Occlusion

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Lingualized Occlusion
Indications for use
High esthetic demands ! Displaceable supporting tissues ! Weak muscles of mastication ! Previous successful denture with Lingualized Occlusion
! !

Indications
Non-anatomic

Anatomic
Good residual ridges Well coordinated patient Previously successful with anatomic dentures Denture opposes natural dentition When cusp penetration of bolus is desired

Advantages
Good esthetics ! Freedom of non-anatomic teeth ! Potential for bilateral balance Centralizes vertical forces ! Minimizes tipping forces ! Facilitates bolus penetration (mortar and pestle effect)
!

Poor residual ridges Poor neuromuscular control (bruxers, CP etc.) Previously successful with monoplane dentures or Severely worn occlusion on previous denture Arch discrepancies class II or III or crossbite Immediate dentures except when opposing natural dentition Potential poor follow-up

Non-anatomic (monoplane occlusion)

Advantages

Anatomic/semi-anatomic

Disadvantages
No vertical component to aid in shearing during mastication Patients may complain of lack of positive intercuspation position? Somewhat esthetically limited (dont look like natural teeth)

Reduction of horizontal forces CR can be developed as an area instead of a point Freedom of movement Can develop solid occlusion despite arch alignment discrepancies Easily adapted to situations prone to denture base shifting Easy to set and adjust teeth

Advantages Intercuspation may be developed Esthetically similar to natural dentition Balanced occlusion can be achieved Maintains some shearing ability after moderate wear

Disadvantages

Difficult to set Less adaptable to arch relation discrepancies Horizontal force development due to cusp inclinations Harmonious balanced occlusion is lost with denture base settling Requires frequent followup and may require more frequent relines to maintain proper occlusion

Credits: UCLA School of Dentistry American College of Prosthodontists Dr. Gary Cook