Concepts of Occlusion

Vicki C Petropoulos DMD, MS Associate Professor of Preventive and Restorative Sciences University of Pennsylvania School of Dental Medicine

Acknowlegements
Many of these images are courtesy of the American College of Prosthodontists, UCLA Complete Dentures Educational Curriculum CD, 2004.

Learning Goals
To understand differences between natural dentition and complete denture occlusion To understand the goals of complete denture occlusion and why balance is needed To understand the four types of denture occlusion To understand Hanaus Quint

Learning Goals
To understand the different types of posterior tooth forms, adv. and disadv.

Natural Occlusion (organic) Natural dentition presents

in a variety of individual tooth size, shape, form and alignment, but ideally exhibit certain characteristic occlusion features.

Natural Occlusion (organic)

Bilateral Posterior Centric Contact Anterior Guidance Mutually Protective Scheme of Occlusion

Complete Denture Occlusion

Complete denture dentition also presents in a variety of forms, but also exhibit certain common characteristics

Complete Denture Occlusion

Bilateral centric contacts Bilateral eccentric contacts (balance) to provide stability of the denture bases during function

Complete Denture Occlusion

Because of compromises inherent in restoring the edentulous arch, complete denture tooth forms and arrangements (i.e. occlusion), should be designed to provide function and esthetics while minimizing denture base tipping (lateral) forces

Fundamental differences of natural and complete denture occlusion

1. 2.

3.

Sensory feedback mechanism Derivation of : retention stability support Reaction of supporting structures to masticatory forces

1. Sensory Feedback

Precision of feedback is significantly compromised following loss of teeth and associated structures (periodontal ligament)

2. Derivation of retention, stability and support for natural occlusion

For natural dentition, retention, stability, and support are derived through the periodontium which provides;
Sensory feedback mechanism Difference in reaction of supporting structures to masticatory forces Differences in load transfer mechanism and physiology

2. Derivation of retention, stability and support for complete denture occlusion

Complete dentures receive their retention, stability, and support from the soft tissues overlying residual bone (ridges, buccal shelf, palate, etc.).

Denture Bearing Surface

Retention
Resistance to dislodgment forces in a vertical direction away from the bearing surface

Denture Bearing Surface

Stability
Resistance to laterally oriented dislodgment forces

Denture Bearing Surface

Support
Factors of the Bearing Surface which resist forces in a vertical direction towards the bearing surface

3. Reaction of supporting structures

Natural occlusion Physiologic levels of tension results in alveolar bone apposition (such as that transmitted by loading the periodontal ligament through natural dentition) Complete denture occlusion Non-physiologic compression as may occur under denture bases results in further residual ridge resorption (RRR)

Summary
Natural Dentition

Denture Dentition

Retained in PDL Units move independently Malocclusion effects not immediate Non-vertical forces affect only teeth involved and usually well tolerated Incising doesnt affect posteriors Bilateral balance is rare Tactile sensitivity

Mobile bases on mucosa Teeth move as an unit Malocclusion affects entire base immediately Non-vertical forces affect all teeth and are traumatic Incising affects all teeth attached to base Bilateral balance is often desired for base stability Decreased tactile sense

Summary

Goal of complete denture occlusion is preservation of structure and restoration of function and esthetics Consequences of tooth loss create anatomic changes which result in differences in derivation of retention, stability and support between natural and complete denture teeth The differences in the design of natural and complete denture occlusion are the consequence of differences in the derivation of retention, stability and support. Complete denture form and tooth placement is biomechanical in nature

The Edentulous State

Residual ridge reduction Compromised reflex adaptability Possible increase in parafunctional movements Increased risk of maladaptive denturewearing experience

Occlusion
Denture occlusion is not just about the occlusal plane. The setting of teeth includes orientation of the plane, shaping and positioning of the arch, inclinations and rotations for esthetics, and the mechanics for obtaining proper tooth inclination.

Occlusion
The dentist has the power to establish all factors of occlusion in a complete denture except the condylar path.

Chewing with Dentures

During mastication the teeth make contact on the chewing side and the non-chewing side. Tissue resiliency and denture movement during function account for the higher frequency of non-chewing contacts

Types of Denture Occlusion

Balanced
The preferred occlusal scheme

Monoplane (Neutrocentric) Monoplane with balance Lingualized occlusion

Is Balance necessary?
Protrusive position Protrusive position

Balanced occlusion

vs

Non-balanced occlusion

Is Balance Necessary?

Bolus in Balance out

To Balance or Not to Balance

But do we need balanced occlusion?

Brien Lang
There is little scientific support to select an occlusal concept, however a report by Brewer (1963) found in a 24 hour test period that teeth contact during chewing (10 mins) were much less than tooth contacts during non chewing (2-4 hours). This suggests a need for balanced articulation especially during parafunction

Balanced denture teeth provide denture stabilization during parafunctional jaw movements by ensuring even pressure in all parts of the arch.

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
We spend 2-4 hours/day in parafunction and only 10 minutes/day in function

Objective of Balanced Occlusion

To create stability of the denture bases during eccentric movement Instability of the bases leads to:
Irritation of the hard and soft tissues Excessive denture movement Unequal distribution of forces Potential for more rapid loss of osseous support

When do we Achieve Balanced Occlusion?

At the final try in, we will verify the Jaw Relationship Record At that point we will do a protrusive record to set the condylar inclination Balance will be achieved in the lab

Types of Denture Teeth

Artificial teeth can be
Anatomic (30 degrees or greater) Semi-anatomic (30 to 0 degrees) Nonanatomic (0 degrees)

Advantages
Anatomic
More esthetic Supposed higher chewing efficiency Ease in achieving balanced occlusion

Nonanatomic
Easier to set Kinder to edentulous ridges

Disadvantages
Anatomic
More time consuming to set May cause more/faster bone resorption

Nonanatomic
Unaesthetic Supposed to decrease chewing efficiency

Balance
Balance can be achieved with anatomic OR monoplane teeth. With anatomic teeth it is generated by the tooth arrangement With monoplane teeth it is generated by a balancing ramp

Verify contacts in working excursions

Lack of working side contacts may be the result of:

Poor buccal centric Insufficient curve of Wilson Working interferences in the 2nd molar region Balancing interferences on the opposite side *Check these in the order cited.

Verify contacts during balancing excursion

Lack of balancing side contacts may be the result of:

Poor lingual centric

Working interferences on the opposite side, particularly in the 2nd molar region

Working

Balancing

Protrusive

All things being considered, the most successful denture wearers are usually those who have a good patient/provider relationship and a good, positive outlook and good neuro-musculature control.

Always Remember

Dentures are not a replacement for teeth

Dentures are a replacement for no teeth.

Occlusion
The static relationship between the incising or masticating surfaces of the maxillary and mandibular teeth or tooth analogs

Five Determinants of Mandibular Movements

Right TMJ Left TMJ Teeth Tissues/nerve impulses (proprioception) CNS

Planes of Reference

Mandibular Movement
Rotation
Around the terminal hinge axis

Translation
Condyle glides along the posterior incline of the tubercle

Mandibular Opening

Types of Movement
Border Functional
Speaking (phonetics) Chewing (mastication) Swallowing (deglutition)

Parafunctional
Bruxing clenching

Denture Forces
The amount of force generated with a denture vs. natural occlusion is approximately only 16 %!!!!!

Posterior Determinants of Occlusion

Shape of articular eminence Medial walls of glenoid fossa Shape of condyles

Anterior Determinants of Occlusion

Vertical overlap of anterior teeth Horizontal overlap of anterior teeth Lingual concavities of maxillary anterior teeth

Anterior Determinants of Occlusion

Role of Anterior Teeth

In a normal occlusal relationship the maxillary and mandibular canines contact during lateral movements.

Dynamic Occlusal Contacts

Any movement of the mandible from the centric occlusion position that results in tooth contact is termed eccentric. There are three basic eccentric movements
Protrusive Laterotrusive Retrusive

Protrusive
The mandible moves forward from the centric occlusion position The predominant protrusive contact occurs between the maxillary and mandibular anterior teeth.

Protrusive

Laterotrusive (Working)
Most function occurs on the working side (lateral movement) the side to which the mandible is shifted. Working contacts and cross-tooth contacts occur on the working side. Working contacts occur between the inner inclines of max buccal and outer inclines of mand buccal.

Mediotrusive (Non-working)
Formerly balancing contacts, but now the teeth disclude. Potential sites of contact on the inner inclines of maxillary lingual and mandibular buccal cusps. Mediotrusive contacts are interferences.

Laterotrusive

Retrusive

History
Bilateral Balanced Occlusion
Based on theories related to dentures Became apparent these principles did not apply to fixed prosthodontics Resulted in premature wear, mobile teeth and gingival clefting The preferred occlusal scheme for dentures

Unilateral Balanced Occlusion

Group Function
Earlier rehabs were modified by eliminating balancing contacts Led to the functionally generated path or wax chew-in technique Importance of incisal guidance discovered and incorporated into the occlusal scheme Results in tipping forces on a denture

Group Function
Based on the philosophy that the more teeth to share the load the better
Incisal guidance established first Spreads working side contact over 3 or more teeth in each arch These teeth should be adjacent to each other Involves buccal cusps only

Group Function

Centric Relation
The maxillomandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anterior superior position against the shapes of the articular eminence. This position is independent of tooth contact

Centric Relation
The most important factor to remember is that it is REPEATABLE!!!

Optimum Functional Occlusion

CR---for purposes of this lecture it is the most superoanterior position. CR=CO with even and simultaneous contact of all posterior teeth

REVIEW

Differences between Natural and Complete Denture Occlusion Natural Dentition

Retained in PDL Units move independently Malocclusion effects not immediate Non-vertical forces affect only teeth involved and usually well tolerated Incising doesnt affect posteriors Bilateral balance is rare Tactile sensitivity

Denture Dentition
Mobile bases on mucosa Teeth move as an unit Malocclusion affects entire base immediately Non-vertical forces affect all teeth and is traumatic Incising affects all teeth attached to base Bilateral balance is often desired for base stability Decreased tactile sense

Goals of Complete Denture Occlusion

Minimize trauma to the supporting structures Preserve remaining structures Enhance stability of the dentures Facilitate esthetics and speech Restore mastication efficiency to a reasonable level

Types of Complete Denture Occlusion

Bilateral balance Neutrocentric

We prefer bilateral balance because this type of occlusal arrangement limits tipping of the dentures during parafunctional movements,

Bilateral Balanced Denture Occlusion

The stable simultaneous contact of opposing upper and lower teeth in centric relation position with a smooth bilateral gliding contact to any eccentric position within the normal range of mandibular function, developed to lessen or limit tipping or rotation of the denture bases in relation to the supporting structures.

Bilateral Balanced Denture Occlusion Traditionally bilateral balance was achieved with anatomic posterior denture teeth. However, it can be achieved with nonanatomic teeth using balancing ramps or by manipulating the compensating curve.

Bilateral Balanced Denture Occlusion with Anatomic Posterior Denture Teeth

Protrusive

Balancing

Working

Bilateral Posterior Centric Contact Centralized Forces Balanced Occlusion to minimize tipping
Centric

Monoplane with Balancing Ramps

Working Balancing

Bilateral balanced occlusion can also be obtained with nonanatomic posterior teeth if balancing ramps are employed. In all lateral excursions you should observe at least three points of contact bilaterally if bilateral balance is to be achieved.

Protrusive

Lingualized Opposing Monoplane with Balancing Ramps Working Balancing

A similar concept is used when lingualized maxillary teeth oppose nonanatomic teeth in the mandible. In all lateral excursions you should observe at least three points of contact bilaterally to maintain bilateral balance.

Monoplane Occlusion (Neutrocentric Concept)

This concept of occlusion assumes that the anterior-posterior plane of occlusion should be parallel to the denture foundation area and not dictated by condylar inclination. The plane of occlusion is completely flat and level. There is no curve of Wilson or Curve of Spee (compensating curve) incorporated into the set up. There is no vertical overlap of the anterior teeth. When using this concept of occlusion the patient is instructed not to incise the bolus. With this tooth arrangement DeVan noted that the patient will become a chopper, not a chewer or a grinder.

Monoplane Occlusion (Neutrocentric Concept)

Centric

Balancing

At balancing and protrusive positions there is separation of the denture teeth in the posterior regions leading to tipping of the dentures. This may be disadvantageous in the patients exhibiting parafunctional grinding habits

Hanaus Quint
Five Factors Affecting Occlusal Balance
Condylar Inclination Incisal Guidance Occlusal Plane Inclination Compensating Curve Cuspal Inclination

Hanaus Quint
Inter-relationship of these five factors may be described by Theilmans Formula In order to maintain a balanced occlusion:

C=

Condylar Inclination x Incisal Guidance OccPlane x Cuspal Inclination x CompCurve

Hanaus Quint
Factors controlled by the dentist
Of these five factors, the patient presents you with Condylar Inclination Occlusal Plane cannot be altered substantially since functional requirements dictate its position and orientation The remaining three factors can be controlled by the dentist

C=

Condylar Inclination x Incisal Guidance OccPlane x Cuspal Inclination x CompCurve

Hanaus Quint
Factors controlled by the dentist
Of these five factors, the patient presents you with Condylar Inclination Occlusal Plane cannot be altered substantially since functional requirements dictate its position and orientation The remaining three factors can be controlled by the dentist

C=

Condylar Inclination x Incisal Guidance OccPlane x Cuspal Inclinationx CompCurve Inclination

Hanaus Quint
Within the confines of esthetics and phonetics, minimize Incisal Guidance in Complete Dentures to minimize inclined tipping forces Adjust remaining factors to maintain balance

C=

Condylar Inclination x Incisal Guidance OccPlane x Cuspal Inclination x CompCurve

Posterior Tooth Forms

Lingualized Monoplane neutrocentric Monoplane with balancing ramps Lingualized opposing monoplane Semi-anatomic Anatomic (30 degree)

Posterior Tooth Forms

Anatomic Tooth Forms

Semi-anatomic Tooth Forms

Nonanatomic Tooth Forms

General Concepts of Denture Occlusion Common Features

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

Balance and the Monoplane Occlusion

Minimize vertical overlap within the dictates of esthetics and phonetics

Balance and Monoplane Occlusion

Minimize vertical overlap within the dictates of esthetics and phonetics

Bilateral Balance
Anatomic posterior teeth vs Lingualized

Bilateral balance with anatomic denture teeth

Balancing side

Lingualized Occlusion
Centric Occlusion

Conventional

Lingualized

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

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.

Lingualized Occlusion

Working Side

Centric Occlusion

Balancing Side

Lingualized Occlusion

Lingualized Occlusion
Indications for use
High esthetic demands Severe mandibular ridge atrophy Displaceable supporting tissues Malocclusion Previous successful denture with Lingualized Occlusion

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)

Complete Denture Occlusion

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

superior in function safer to oral structures more acceptable to patients

IN SUMMARY: Complete Denture Occlusion

Neuromuscular control may be the single most significant factor in the successful manipulation of complete dentures under function Tongue function and denture wearing experience