Lingualized occlusion revisited

Rodney D. Phoenix, DDS, MS,a and Robert L. Engelmeier, DMD, MSb US Air Force Dental Clinic, Ramstein Air Base, Germany; University of Pittsburgh School of Dental Medicine, Pittsburgh, Pa
Lingualized occlusion represents an established method for the development of functional and esthetic complete denture articulation. Since its introduction, the lingualized technique has undergone many changes. This article provides an overview of the history and development of lingualized occlusion, and addresses common misconceptions associated with the lingualized technique. In addition, a practical method for the development of lingualized denture occlusion is presented. (J Prosthet Dent 2010;104:342-346) During the past 25 years, lingualized occlusion has gained popularity for complete denture applications.1-4 Along with increased popularity, this occlusal concept has undergone significant changes. Manufacturers have created specialized tooth forms in attempts to optimize esthetics, function, and ease of use. At the same time, clinicians and dental laboratory technicians have modified traditional lingualized procedures. As might be expected, the basic tenets of lingualized occlusion have become blurred during this metamorphosis. This has resulted in misconceptions regarding lingualized occlusion. Gysi5 was first to report the biomechanical advantages of lingualized tooth forms. In the early 1900s, Gysi noted that 60% of his denture patients had developed reverse articulations due to common resorptive patterns. He also recognized the advantages associated with balanced occlusions, but encountered difficulties while attempting to create such occlusions with the prosthetic teeth of the era. In response to these difficulties, Gysi designed and patented Cross-Bite Posterior Teeth in 1927 (Fig. 1). Each maxillary tooth featured a single, linear cusp that fit into a shallow mandibular depression. These teeth were reasonably esthetic, easy to arrange, and encouraged vertical force transmission via their mortar-and-pestle anatomy. During the same period, French was exploring denture occlusion and denture tooth design. Like many prosthetic tooth designers, French appreciated the advantages afforded by balanced denture occlusions.6 By 1935, French had patented his Modified Posterior Teeth (Fig. 2). The maxillary teeth featured shallow fossae, while the mandibular teeth displayed narrow, planar occlusal surfaces. The shallow mortar-and-pestle anatomy encouraged vertical force transmission. The facial contours of the maxillary teeth yielded desirable facial support and esthetics. Despite the designs of Gysi and French, early embodiments of lingualized occlusion failed to gain a significant following. This changed in 1941, when Payne introduced a more cogent form of lingualized occlusion.7 Payne credited Farmer with development of this technique, and provided a brief description of the required laboratory procedures. According to Paynes article, a mortar-and-pestle arrangement was created via judicious recontouring of 30-degree teeth (Fig. 3). The

1 Gysis Cross-Bite Posterior Teeth were introduced in 1927.5 Maxillary posterior teeth featured single, linear cusps that fit into shallow mandibular depressions.

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the United States Government.
a b

Colonel, US Air Force; Director, Department of Prosthodontics, US Air Force Dental Clinic Ramstein. Chair, Department of Prosthodontics, University of Pittsburgh School of Dental Medicine.

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widely used. During the ensuing years, Pound8,9 also championed lingualized occlusion in his articles and presentations. Pound used maxillary teeth having cusp angles greater than 30 degrees in conjunction with mandibular teeth having cusp angles of 20 degrees or less. He carefully reshaped mandibular fossae to produce cross-arch balance. Like his predecessors, Pound ensured that maxillary buccal cusps did not contact mandibular teeth during eccentric mandibular movements. He accomplished this by reducing the facial surfaces of the mandibular posterior teeth rather than elevating the buccal cusps of the maxillary teeth (Fig. 5). Though the method for eliminating maxillary buccal contact was dissimilar, the mechanical results were nearly identical to those described by Payne (Fig. 6). As time passed, additional embodiments of lingualized occlusion were introduced. New tooth forms, tooth combinations, arrangement protocols, and occlusal correction procedures were put forth. Authors such as Ortman,10 Murrell,11 Becker,12 and Kelly13 provided additional support for this occlusal concept. Proponents of lingualized occlusion reported additional advantages including simplified tooth arrangement, simplified occlusal adjustment, reduced lateral forces, efficient bolus penetration, and good esthetics. Throughout this process, the basic tenets of lingualized occlusion remained the same. Tooth arrangement was characterized by articulation of the maxillary lingual cusps with the opposing mandibular occlusal surfaces in centric and eccentric positions. Maxillary buccal cusps were not permitted to contact the mandibular teeth in centric or eccentric positions. Within the past few years, some clinicians have deviated from the established principles of lingualized occlusion.3 They have promoted light contact of the maxillary and mandibular buccal cusps in working and protrusive excursions. This represents

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2 Frenchs Modified Posterior Teeth were introduced during the 1930s.6 Mandibular posterior teeth displayed relatively flat, narrow occlusal surfaces that fit into shallow maxillary fossae.

3 Payne recontoured existing 30-degree tooth forms to produce readily attainable form of lingualized occlusion.7

4 According to Payne, maxillary lingual cusps were to maintain contact with mandibular teeth in centric and eccentric positions, while maxillary buccal cusps were never to contact opposing surfaces in any maxillomandibular relationship.7 maxillary lingual cusps maintained contact with the mandibular teeth in eccentric movements (Fig. 4). In contrast, the maxillary buccal cusps did not contact the opposing teeth during mandibular movements. According to Payne,7 this arrangement provided distinct advantages. Three of these were particularly noteworthy. First, lingualized occlusion yielded cross-arch balance. This resulted in improved denture stability and enhanced patient comfort. Second, lateral forces were reduced because maxillary lingual cusps provided the sole contact with mandibular posterior teeth. As a result, potentially damaging lateral forces were minimized. And third, vertical forces could be centered upon the mandibular residual ridges. The application of vertical forces was considered advantageous for denture stability and maintenance of the supporting hard and soft tissues. Despite the purported advantages, the technique was not

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5 Pound created lingualized arrangements using combination of steep maxillary cusp angles (>30 degrees) and moderate-to-shallow mandibular cusp angles (<20 degrees).8,9 a distinct conceptual and mechanical departure from traditional lingualized principles. Wear of maxillary lingual cusps and/or mandibular fossae rapidly results in buccal and lingual contacts of equal intensity. Crosstooth contact negates centralization of forces on the mandibular posterior teeth, and increases the likelihood of lateral displacement. As a result, the arrangement does not satisfy the objectives of a lingualized occlusion. While variants which display light contact of the maxillary and mandibular cusps may be useful, these arrangements should not be termed lingualized occlusions. By definition, the resultant arrangements are cross-tooth, crossarch, balanced occlusions, and should be classified as such. A wide variety of cusped and noncusped tooth forms may be used to create arrangements that may be considered to be lingualized occlusion. Generally, maxillary teeth with cusp angles of 30 degrees are opposed by mandibular teeth displaying cusp angles of 20 degrees. Some of the most popular combinations include 30- to 33-degree cusp designs for maxillary teeth and 0-degree cusp designs for mandibular teeth. As a result, these cusp forms have been chosen for purposes of demonstration. Success in complete denture fabrication is predicated upon accuracy in all procedures. Clinicians must make accurate impressions and generate accurate casts. Record bases and occlusion rims must be carefully

6 Pounds lingualized occlusal scheme was mechanically similar to that described by Payne. Maxillary buccal cusps did not contact opposing surfaces in any maxillomandibular relationship.8,9 es in eccentric positions. 4. Clearly identify the positions of the retromolar pads. Identify the medial and lateral extensions of the pads with distinct lines on the posterior land area of the mandibular cast. Identify one half the height of each retromolar pad with a distinct line on the land area of the mandibular cast. 5. Position a gently curved template (for example, 20-degree template; Dentsply Trubyte, York, Pa) so that it rests on the mandibular canines anteriorly and bisects the height of the retromolar pad posteriorly. Use identifying lines described in step 4 above. 6. Arrange the mandibular posterior teeth, allowing the metal template to guide the vertical placement and compensating curve (Fig. 7). Determine the mediolateral placement of the mandibular posterior teeth by ensuring that mandibular lingual cusps fall within Pounds triangle.9 7. Modify the vertical dimension of the articulator to accommodate corrective adjustment procedures. To accomplish this, create a 0.5-mm increase in occlusal vertical dimension at the incisal pin. 8. Arrange the maxillary posterior teeth, ensuring that the maxillary lingual cusps are placed in the opposing central grooves. Position the maxillary buccal cusps 1 mm superior to the maxillary lingual cusps (Fig. 8). 9. Return the incisal pin to its neutral (zero) position. 10. Using articulating film and ro-

fabricated and properly adjusted. Determinations of occlusal vertical dimension and anterior tooth position must be accomplished with care. Accurate maxillomandibular records are essential. In addition, articulator mountings must be accomplished and arch relationships must be verified. The purpose of this article was to describe the evolution of lingualized occlusion, common misunderstandings, and a technique for the arrangement of prosthetic teeth in lingualized occlusion. DENTAL TECHNIQUE 1. Program the articulator. Determine and set horizontal condylar guidance elements using a protrusive jaw relation record. Horizontal condylar guidance settings should not differ by more than 5 degrees. Establish and set lateral condylar guidance values using Hanaus formula (L = H/8 + 12).14,15 Determine the incisal guidance by subtracting 20 degrees from the average horizontal condylar guidance value. Set lateral components of incisal guidance at 5 degrees on each side. Establish appropriate soft tissue support, as well as acceptable esthetics and phonetics. 2. Arrange the maxillary anterior teeth in accordance with rim contours. 3. Arrange mandibular anterior teeth to harmonize with maxillary anterior teeth. Ensure appropriate contact of maxillary and mandibular incisal edg-

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7 Curved metal template is used to guide vertical placement of mandibular posterior teeth and to establish suitable compensating curve. Curved template rests on mandibular canine teeth anteriorly and bisects the height of each retromolar pad posteriorly.

8 Curved metal template also guides development of mediolateral curvature (curve of Wilson). Maxillary lingual cusps are placed in the opposing fossae. Maxillary buccal cusps are positioned 1 mm superior to the maxillary lingual cusps, simplifying tooth arrangement and occlusal correction procedures.

A
9 A, Nonworking side contact is limited to maxillary lingual cusps. B, Working side contact is limited to maxillary lingual cusps. Maxillary buccal cusps do not contact mandibular teeth in centric or eccentric positions. tary instrumentation, perform corrective adjustment procedures. Restrict adjustment to the mandibular teeth. Stop the procedure when the incisal pin is in contact with the incisal table. Do not perform corrective adjustment procedures in eccentric positions at this time. 11. Accomplish a clinical evaluation of the tooth arrangement at the trial insertion appointment. Modify the anterior tooth arrangement as necessary. 12. Make centric relation records. Verify the accuracy of the articulator mounting. Remount if necessary. 13. Make required changes in proposed tooth positions. 14. Perform corrective adjustment procedures to ensure appropriate contact in centric relation position. Be certain to reestablish contact between the incisal pin and the incisal table at the proposed occlusal vertical dimension. 15. Perform corrective adjustment to ensure appropriate contact in eccentric positions. Be certain that bilateral posterior contact is present when anterior teeth are in an edge-toedge relationship. 16. Accomplish corrective adjustment procedures for right lateral and left lateral excursions. Ensure sustained, bilateral contact of the teeth as the articulator is moved into right lateral and left lateral positions. Bilateral balance should be evident for

3 mm in each direction as measured at the incisal pin (approximately one half the width of the incisal pin for many articulators). 17. Finalize the proposed denture base contours in wax. 18. Perform investment, wax elimination, packing, and processing procedures. 19. Recover the processed dentures on their respective definitive casts. Return the denture/cast assemblies to the articulator. 20. Perform corrective adjustment procedures. Reestablish the desired occlusal vertical dimension by carefully adjusting the mandibular occlusal surfaces. Carefully recontour the mandibular occlusal and incisal

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surfaces to achieve the desired centric and eccentric contacts (Fig. 9). Refine the occlusal anatomy. 21. Perform a verified clinical remount and repeat the process outlined in step 20 above.
3. Lang BR, Razzoog ME. Lingualized integration: Tooth molds and an occlusal scheme for edentulous implant patients. Implant Dent 1992;1:204-11. 4. Ortman HR. Complete denture occlusion. In: Winkler S, editor. Essentials of complete denture prosthodontics, vol 1. 2nd ed. St. Louis: Ishiyaku EuroAmerica; 1994. p. 217-29. 5. Gysi A. Special teeth for cross-bite cases. Dent Digest 1927;33:167-71. 6. French FA. The problem of building satisfactory dentures. J Prosthet Dent 1954;4:769-81. 7. Payne SH. A posterior set-up to meet individual requirements. Dent Digest 1941;47:20-2. 8. Pound E. Personalized denture procedures. Anaheim: Denar Corp; 1973. p. 4. 9. Pound E. Utilizing speech to simplify a personalized denture service. J Prosthet Dent 1970;24:586-600. 10.Ortman HR. The role of occlusion in preservation and prevention in completed denture prosthodontics. J Prosthet Dent 1971;25:121-38. 11.Murrell GA. The management of difficult lower dentures. J Prosthet Dent 1974;32:243-50.

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12.Becker CM, Swoope CC, Guckes AD. Lingualized occlusion for removable prosthodontics. J Prosthet Dent 1977;38:601-8. 13.Kelly E. Centric relation, centric occlusion and posterior tooth forms and arrangement. J Prosthet Dent 1977; 37:5-11. 14.Javid NS, Porter MR. The importance of the Hanau formula in construction of complete dentures. J Prosthet Dent 1975;34:397404. 15.Hanau RL. Full denture technique for Hanau Articulator Model H. 4 th ed. Buffalo: Hanau Engineering; 1930. Corresponding author: Dr Robert Engelmeier University of Pittsburgh School of Dental Medicine Salk Hall, Room 2025 3501 Terrace St Pittsburgh, PA 15261 Fax: 412-648-8850 E-mail: rle14@pitt.edu Copyright 2010 by the Editorial Council for The Journal of Prosthetic Dentistry.

SUMMARY
This article provides a brief overview of the development of lingualized occlusion and a technique that results in an occlusal scheme as intended by the originators of this approach.

REFERENCES
1. Parr GR, Loft GH. The occlusal spectrum and complete dentures. Compend Contin Educ Dent 1982; 3:241-50. 2. Parr GR, Ivanhoe JR. Lingualized occlusion: an occlusion for all reasons. Dent Clin North Am 1996;40:103-12.

Noteworthy Abstracts of the Current Literature Finite element stress analysis of dental prostheses supported by straight and angled implants
Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S. Int J Oral Maxillofac Implants 2009;24:391-403.
Purpose: A three-dimensional finite element analysis was conducted to evaluate and compare the stress distribution around two prosthesis-implant systems, in which implants were arranged in either a straight-line or an intrabone offset configuration. Materials and Methods: The systems were modeled with three titanium implants placed in the posterior mandible following a straight line along the bone. The straight system was built with three straight implants (no offset). The angled system was built as follows: the first implant (mesial) was an angled implant inclined lingually, the second (median) was straight, and the third (distal) was another angled implant inclined buccally. This buccal incline created an intrabone implant offset owing to the inclination of the angled implants bodies. Each system received a metal-ceramic prosthesis with crowns that mimicked premolar anatomy. In both systems, an axial load of 100 N and a horizontal load of 20 N were applied on the center of the crown of the middle implant. Results: In both systems, the major von Mises stresses occurred with vertical loading on the mesial and the distal neck area of the first and third implants, respectively: 6.304 MPa on the first implant of the straight system and 6.173 MPa on the third implant in the angled system. The peak stress occurred for the minimum principal stress (S3) on the neck of the first implant for both systems at the level of -8.835 MPa for the straight system and -8.511 MPa for the angled system. There was no stress concentration on the inner or outer angles of the angled implants, on the notches along the implant body, or on any apex. Conclusions: In this analysis, the angled system did not induce a stress concentration in any point around the implants that was different from that of the straight system. The stress distribution was very similar in both systems. Reprinted with permission of Quintessence Publishing.

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