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This lecture is about Occlusion. The reference for this script was the record of the lecture.

Occlusion
Occlusion is a force transmitted to the oral structures via muscles to the teeth, this force is in the form of load functional load because its associated with direction which is not always axial. ( axial direction of load is the most preferable type of force application). Factors affecting occlusion: -Structures in the oral cavity resist these forces to prevent their damage, so the healthier the teeth and periodontium were the better the resistance is. -The direction, frequency and magnitude of the applied force -The number of contacts: the number of teeth available in the oral cavity that make contact with an opposing tooth. *The dentist needs a balanced view on occlusion so that the patient can have a balanced occlusion. *Physiological occlusion doesnt necessarily mean ideal occlusion, it depends on the adaptive capacity of the patient himself. there may be one or two criteria deviated from ideal but the patient still can function and be happy with the esthetics of his teeth. If these non-ideal things are beyond the adaptive capacity of the patient then problems start to appear. The masticatory system is composed of: 1- teeth
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2- the articulatory system ( TMJ, muscles and occlusion) 3- the periodontium ( gingiva, bone, periodontal membrane) . * all elements of this system are related to each other and controlled by nerves through neuromuscular control or neural pathway feedback.

This is the articulatory system :-

TMJ Occlusion

Muscles

1)TMJ represents the hinge. 2) Muscles of Mastication are the motors, they are the parts responsible for the motility ( the ability to move) of the other two parts. 3)Occlusion represented by the contact between teeth. Its a system as well because all the elements are interrelated.

Temporomandibular Joint:
Mandibular Fossa Articular eminence

Disk Attachments

Articular Disk

Lateral Pterygoid

Mandibular Condyle

 Muscles of mastication:

Muscle Masseter

Origin Zygomatic arch

Insertion Lateral surface of the ramus Coronoid process

Temporalis

Floor of temporal foosa

Nerve Supply Mandibular division of Trigeminal nerve Mandibular Division of Trigeminal nerve

Action Elevates mandible to occlude teeth *Ant.+sup. Fibers elevate the mandible. *Pos. fibers retract the mandible Elevates the mandible

Medial Pterygoid (two heads)

Lateral Pterygoid (two heads)

Maxillary tuberosity and lateral pterygoid palte Greater wing of sphenoid and lateral pterygoid plate

Medial surface of the angle of mandible Neck of mandible and articular disk

Mandibular Division of Trigeminal nerve Mandibular Division of Trigeminal nerve

Pulls the neck of condyle forward to protrude the mandible.

 Occlusion:

Static

Dynamic

Static occlusion: when the mandible is contacting the maxilla and they are stationary ( not moving). Dynamic occlusion: when the mandible and maxilla are moving together against the surfaces of teeth.

 Static Occlusion :
- Centric occlusion - Centric relation - Freedom in centric - Overbite - Overjet - Cusp to fossa contact - Cusp to marginal ridge contact

Dynamic Occlusion:
-Protrusive and Retrusive movements -Lateral or excursive movements - Envelope of motion
Static Occlusion Centric occlusion: maximum intercuspation of teeth, contact between upper and lower jaws when teeth are maximally intercuspating, irrespective of the position of the condyle.

* Other terms for it: intercuspal position, bite of convenience, habitual bite ( because the patient is habituated to bite in this position, and it is a functional (convenient) position because most of the teeth are intercuspating together). * It is the most easily recorded bite. * Functional forces are applied axially not obliquely. * Contact on posterior teeth is usually heavier than on anterior teeth. * to know that you have stable occlusion, you should see a tripod: two contacts posteriorly and one contact anteriorly.

Centric Relation : The position of the condyle in relation to the maxilla in which its in the uppermost anterior position, the muscles are least restrained and the disc is relaxed in its place. *So, it doesnt depend on teeth but on the position of the condyle and status of muscles, its a bone to bone contact. *Its the most reproducible position thats why its used for edentulous patients. * when you try to manipulate the jaw of a dentate patient to achieve centric relation, after the first tooth contact happens ( which is not necessarily the same as centric occlusion) , the patient shifts to centric occlusion because he cant function on one or two teeth only and needs maximum intercuspation for function to happen.

Sometimes when you are dealing with a partially edentulous patient with no posterior support, you need to do deprogramming for the muscles which will keep resisting you every time you try to manipulate the jaw to record the centric relation, this is done by letting the patient bite on a piece of cotton roll or green stick for a few minutes until the muscles become strained and relaxed then you manipulate the jaw easily to centric relation position.

Freedom in Centric (long centric) : *does centric relation equal centric occlusion? Only 10% of people have them coinciding together , 90% of people have a difference of 1-2 mm between them. In figure (a) the cusp tip is interlocked between the two fossae , and there is a deep bite in the anterior region. So, here there is no freedom in occlusion. In figure (b) the cusp is not interlocked and the anterior teeth have a space between them which allows some sort of movement . So ,here there is freedom in occlusion.
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*Freedom in centric occlusion occurs when the mandible is able to move anteriorly for a short distance in the same horizontal and sagittal plane while maintaining tooth contact.

** Mandibular Movements** 1- Centric relation: occurs in static occlusion. 2- Eccentric relation ( excursive movements): occurs in dynamic occlusion.

Overbite : vertical overlap between upper and lower anterior teeth. Overjet: horizontal overlap between upper and lower anterior teeth. Cusp to fossa contact: when the cusp tip contacts the fossa . Its one tooth to one tooth contact. ( figure B) Cusp to marginal ridge contact: when the cusp tip contacts the marginal ridge. Its one tooth to two teeth contact. (figure A) ** the functional cusp for upper teeth is the palatal and for lower teeth is the buccal.

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Dynamic Occlusion Protrusive , Retrusive , Lateral Movements. -Protrusive movement: the buccal surface of the lower sliding against the palatal surface of the upper in an anterior direction. When this happens, teeth are in centric occlusion, sliding ,and theres a space in posterior teeth. ( christensens phenomenon)

-Lateral (excursive) movements: moving the mandible to one side ( right or left). ** The side that the mandible moves to is called the working side , the other side is the non- working side ( balancing side). ** Canine guidance: dynamic occlusion that occurs on the canines during lateral excursion of the mandible. [When we are moving towards the working side if the canine contacts only, this is called canine guidance]

Canine Guidance.

**Group Function: the contacts are shared between several teeth on the working side during a lateral excursion. [the patient moves the mandible to one side and more than one tooth ( for example: canine, premolar, mesiobuccal cusp of molar) are contacting.

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Group Function

**In the lever system, when the distance from the center increases, the force decreases. The center of our lever is the TMJ, so when I put the oblique forces on an anterior tooth I wont cause damage as if Im applying this force on the posterior teeth. This explains why canine guidance is more preferred than group function. But if the patient has group function and hes satisfied with it, we dont change it for canine guidance, because it all depends on the adaptive capacity of the patient.

Question: if you want to do a class 4 on a central incisor , what are the things that you need to assess to decide if you can do it or not? if I have enough space to put a composite restoration, because if the tooth is broken since a long time ago there may be supra eruption of the opposing tooth.

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Envelope of motion *Movements done to open and close the mandible. The first act of movement is rotation along an imaginary axis ( terminal hinge axis, or transverse horizontal axis) Its called transverse because it passes through the center of both condyles in the horizontal plane an its the axis where rotation happens.

*After rotation, translation happens and the condyle is going against the surface of the glenoid fossa along with the disc.

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Look at the figure below:**From CR downward to HAT this is rotation ( and here this is not the maximum opening, only a few mm) from that point to MO , the condyle slides over the glenoid fossa to reach MO (translation) **from CRMI ( centric occlusion) theres 2 mm between them in 90% of people (the space between them in the figure) then I do protrusion ( sliding) to maximum protrusion MP then maximum opening MO then closure happens on two stages: 1- translation (from MO to HAT) 2- rotation ( from HAT to CO)

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These are the same movements:

CR

CO

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Rotation

Translation MO

Edge to edge

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Maximum Protrusion

Mandibular opening from MP MO

How do we assess the occlusion? 1- Articulating paper , comes in different thicknesses (20,40,60 microns) , we hold the articulating paper with millers forceps, and there should be a dry field, to obtain good results. (ps. Dont fold the articulating paper when you are checking occlusion)

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Millers forceps with articulating paper.

2- Shim Stock: its like foil paper ,very thin ( 8 microns thickness) .it doesnt give you the actual contact points. It shows the contact itself, whether its there or not ( for example you use it when you are doing a crown, you check occlusion with it before and after putting the crown to make sure the occlusion didnt change)

** Balanced Occlusion: balanced equal contacts on entire arch in centric and eccentric movements, we use it in complete denture fabrication.

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 Occlusal Interferences: Causes: 1-high restoration ( premature contact): it hinders smooth guidance in excursion or closure into centric occlusion. 2-Extraction and migration of teeth. 3-Tooth movement due to migration or periodontal problems. 4-Teeth wear, we dont have interlocked cusp contact anymore. 5-Overeruption as a consequence and as a cause.

Consequences: 1- Damage to the teeth 2- Fracture of the restoration or the tooth 3- Migration of teeth and mobility 4- De-cementation of extracoronal restoration 5- MIGHT cause TMJ disorders. 6- Increased muscle fatigue. 7- Tooth Wear. *** If you are doing a simple restoration (class 1,2..) its easier to use centric occlusion not centric relation because its the easiest way to record the occlusion( provided that its stable) , its the most predictable, and the patient has got used to it. In case of an extensive restoration or where the vertical dimension is changed, thats a different story. In the clinic you should follow the IDIC principle , which is: 1-examine: examine the patient, check the Occlusal contact before you start.

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2-Design: design the restoration, the cavity, the restorative material you are going to use. 3-execute 4-Check *Neither infraoccluded Nor supraoccluded restoration is good, they will both cause problems to occlusion. You should have a balanced restoration. **After you are done with a class 4 restoration, what are the movements you ask the patient to do to check occlusion? 1- Lateral excursive 2- protrusive 3- Centric ** If you have a heavily restored canine with canine guidance occlusion and you can change it to group function, then its preferable to change it.

This is the end of the script GOOD LUCK Nagham Ayman Rabi

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