A discussion of some factors of relevance to the occlusion of complete dentures

Peter J. Mack, MDS, FDSRCS, DRDRCS*

Key words: Complete dentures, occlusion, prosthodont ics. Abstract

There exists general agreement that in the construction of complete dentures the accurate positioning of the plane of occlusion is essential for correct denture function. Yet rarely does a prosthodontist give detailed instructions concerning the positioning of this plane to the technician who is to set the teeth. In this paper the three-dimensional location and form of the occlusal plane is discussed. For both anatomical and mechanical reasons the author favours the use of the mandibular rather than the maxillary record rim as the clinical determinant of the level of the artificial occlusion. A change in the method of setting the facebow is recommended to allow for the difference between the cranial Frankfort plane and the axis-orbital plane of the articulator. Arguments are advanced to support the proposal that artificial teeth should be set to an intercuspal location forward of centric relation; and that the form of the antero-posterior compensating curve of the artificial dentition should be determined by the clinician before the teeth are set to the registration rims. (Received for publication May 1987. Revised May 1988. Accepted August 1988.)

dimensions by a clinician who often has little accurate information concerning the spatial position of the lost natural teeth. The intention of this paper is to re-appraise some of the clinical techniques employed to determine the ideal form, positioning and transference to an articulator of the occlusal plane of a dental arcade intended to suit a complete denture patient. Four aspects will be discussed: 1. The clinical orientation of the occlusal plane. 2. Transference of the maxillary cast to an articulator. 3. Denture intercuspation. 4. The compensating curve.
1. The clinical orientation of the occlusal plane for complete dentures The registration of the maxillo-mandibular jaw relationship is commonly achieved by use of two registration or bite blocks: close-fitting dental bases on which are set rims made up from either a stable wax or impression compound.
Initial adjustments to the registration blocks Time and effort may be reduced if the registration rims approximate the required dimensions before the patient attends. Over a period of years it has been found that when measured close to the midline, an upper sulcus to rim depth of 18 mm approximates in many to the required final dimension. Others have found that in the anterior region a registration rim formed 12 mm above the tissue surface of the edentulous ridge to be an equally acceptable depth. At the posterior border, a rim built up 5.0 mm from the tissue covering the pterygo-palatine notch would appear to be a useful height from which to commence adjustments (Fig. 1). Most prosthodontists recommend that the support to the maxillary lip be determined at an
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(4

Introduction In the intact dentition the natural plane of occlusion of the teeth may be described and defined, assessed and analysed. For the edentulous patient the same plane must be accurately located in three
~

Senior Lecturer in Restorative Dentistry, The University of Western Australia.

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Fig. 1 .-Registration rim: recommended vertical dimension.

Fig. 2.-Fox

occlusal plane guide.

early stage. Later redefinition may be required, but an approximate contour will aid the sequence of registration rim adjustments that are to follow. Gross alterations to upper rim length should also be made at this time.

(ii) The alignment in the incisal or transverse plane In the clinical situation it is perhaps easiest first to adjust the incisal plane on the maxillary registration rim. Once established, the level will indicate the required alignment of the incisal edges of the upper teeth and also the visible horizontal junction between the occluding dentures. The coronal aspect of the plane is commonly set to lie parallel to an imagined interpupillary line. For most this will prove to be in harmony with the aesthetics of the face. Because people are rarely bilaterally symmetrical, it is important that the clinician should finalize the transverse registration from a distance. Features such as sloping eyebrows or spectacles which attract attention at 300 mm are lost in the more general appraisal of a more distant view. The tendency for both the transverse plane to be raised and the centre line offset to the side
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from which the clinician operates must also be counteracted. One useful technique is to employ an occlusal plane guide (Fig: 2) which may be held against the surface of the maxillary registration rim. An assistant can be asked to confirm the angulation of the plane from a distance of at least two metres, directly in front of the patient. The centre line may be determined at the same time and inscribed on to the registration rim. (iii) The alignment in the sagittal plane The sagittal (antero-posterior) aspect of the artificial occlusion has in the past been the subject of considerable discussion. It is the single axis most often referred to as the occlusal plane (OP). Although there exists considerable variation in the description of this plane, most recently summarized by Williams, one generally accepted definition is that in the natural dentition this plane contacts (a) anteriorly the midpoint of lines bisecting the overbite of the central incisor teeth, and (b) posteriorally the midpoint of lines bisecting the overbite of the occluding buccal cusps of the first molar teeth of each side.
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For complete dentures it has been common practice to set this sagittal plane parallel to the alatragus line. Manyt have questioned the accuracy of this extra-oral guide; and the angular divergence of the ala-tragus line and occlusal plane has been determined by several workers (Table 1). Lundquist and Luther3 in a survey of over 3000 dental patients, found that a forward projection of the occlusal plane in the fully dentate would pass through the lateral commissures of the lips. This anterior guide to the positioning of the plane would appear to be logical - the teeth opening at the same level as the external entry to the mouth.

Table 1. Deviation between ala-tragal line and the occlusal plane

Reference Gysi 1929* Gysi 1958* Nevakari 1958* Isaacson 1959* Lindblom 1960* Posselt, Nevstedt 1961 Olsson 1961 Chick, Payne 1962 Gonzales, Kingery 1968 Divergence *In Olsson A, Posselt U.6 Angular deviation in degrees -7 -7 -6 -4 -7 -6 -7 -2 -4 -5.55

Fig. 3.-Occlusal

plane aligned to the retromolar pad.

Pound4 stated that a posterior extension of the occlusal plane would pass through the centres of the retro-molar pads. In a series of long term analyses of the origin of the retro-molar tissues in the edentate, McCrorie5 was able to confirm that the retromolar pads were derived directly from the gingival mucoperiosteum surrounding the crown of the last molar tooth. It would therefore appear sensible to use the retro-molar pad as an indicator

T h e multiple publications on this topic are not individually referenced in this paper.

of posterior tooth height: an intra-oral guide to reference and intra-oral plane (Fig. 3). To utilize this posterior intra-oral indicator the occlusal plane must be determined on the mandibular record rim. A plane so located tends to be lower in the molar region than that formed by reference to the extra-oral ala-tragus line. Should any divergence occur between the new artificial plane and that of the lost natural line of occlusion, it would seem preferable for denture stability that the posterior border should be lower rather than higher. On firm occlusal pressures the effect of a plane inclined slightly down at the posterior border
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OCCLUSAL PRESSURE

ANTERIOR

I-\
Fig. 4.-Effect of an inclined occlusal plane.

POSTERIOR

+- --

would be to drive the upper prosthesis backwards, the lower forwards. This is the preferred option for complete dentures (Fig. 4). (iv) The vertical location Positioning the now angled occlusal plane in the correct vertical location seems perhaps a simple procedure, but denture problems originating from an incorrect occlusal face height are common. With age, those who retain their natural dentition tend to exhibit considerably less maxillary and more mandibular tooth during speaking and at rest. This changing display is in part a consequence of increased alveolar eruption (as documented by Tallgred), and in part due to natural age changes which result in a reduced muscle tone in the soft tissues of the lips and lower face. The action of gravity further aids this relentless process of covering more upper tooth and allowing the lower lip to fall away from its higher and more youthful position against the mandibular teeth. Robert and Brunde record an almost equal increase in lower and decrease in upper tooth display of about 1 mm for every 10 years of adult life. It seems possible that an over-low mandibular incisor position set by a clinician who has compensated for a lack of forward lip contour by lowering the level of the maxillary incisors may be aggravated by too closely following the oft-advocated routine of setting the mandibular incisal edges to the plane of the mandibular registration rim. This is sometimes justified as a routine technique by arguing that minimal incisor overbite and overjet reduces prosthesis-displacing anterior leverages. Be that as it may, such an artificial setting is often incorrect, for in the anterior part of the mouth the
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level of the occlusal plane is set as a reference for the correctly placed artificial maxillary teeth. In the natural dentition the normal vertical overbite of the incisor teeth permits the mandibular incisal edges to lie naturally superior (and palatal) to the tips of the maxillary teeth - and hence superior to the level of the correctly adjusted registration rims. Patients requesting a natural appearance to unaesthetic complete dentures often ask for their lower teeth to be raised and made more visible. My lowers dont show enough is a common complaint. The length of the lower incisal teeth should be set to harmonize with the soft tissue aesthetics of the lower face, and only be indirectly dependent upon the position of the maxillary teeth and the separately considered vertical height of the mandibular premolar and molar occlusion. Inevitably this means lifting the incisal edges of the lower anterior teeth above the level of the mandibular rim. The angle of the incisal guidance can therefore only be established at a late stage in the registration procedure. In summary, for ideal denture aesthetics the clinician should initially trim the maxillary record block anteriorally for aesthetics against the upper lip, refining any gross adjustments carried out at the first stage of registration block modification. The upper rim should be correctly extended forwards, and then set to lie just below the level of the resting lip in the young, perhaps slightly above that level in the elderly. The mandibular record block should be trimmed posteriorally to match the intra-oral landmarks. These adjustments should be confirmed by other methods, including phonetic tests. The molar region of the upper block should finally be trimmed to give light contact on
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to the lower rim at the now confirmed correct occlusal face height. Thus the height of the posterior maxillary molar teeth should be determined secondarily to that of the occlusal plane and after that of the occlusal face height. The vertical overlap (overbite) of the anterior teeth is determined independently of either.
2. Transference of the maxillary cast to the articulator Transference of this clinically determined plane of occlusion to an articulator may be accomplished rapidly and accurately by the use of a dental facebow. Somet consider that the use of an arbitaryaxis facebow introduces inconsistent variations which detract from its value as an instrument for cast transference, whilst others are of the opinion that facebow transfers are acceptable if the reference points are determined with accuracy. All agree that the kinematic bow is the instrument of choice for hinge-axis location. Many articulators use the Frankfort plane (Porion-Infra-orbitale) as a reference. Though convenient, this anatomical plane differs by approximately 5.5 degrees from that of the axis-orbital plane determined by a kinematic facebow (Table If an articulator is constructed to the Frankfort plane, a correcting adjustment to the angulation of the facebow registration is required. This should be achieved by the addition of a spacer to the orbital plane guide of the upper arm of the articulator as has been proposed by Gonzales and Kingery.8

It is this degree of certainty, reproducibility and convenience12 that has resulted in the position of centric relation being advocated as the ideal intercuspal location for complete dentures even though there is now little doubt that such mandibular positioning is an entirely artificial concept.13 T o develop optimal mechanical and biological efficiency in an artificial dentition for a completely edentulous patient, it would seem to the author that centric occlusion and centric relation should not coincide, but be separated in both the horizontal and vertical plane. The arguments advanced to support this proposal are:
(a) In the natural dentition of man the intercuspal and ligamentous occlusal positions rarely coincide. It is usually possible to record a definite jaw movement or occlusal slide between the (b) Retrusive facets have a protective function in accidental or forced ligamentous closure.16Due to the angulation of retrusive inclines, any potential movement of the jaw resultant from a sudden rearward displacing force will be dissipated through the interlocked cusps of the teeth to the supporting bone, and will not be transferred directly to the condyle heads. (c) All complete dentures exhibit slight vertical and horizontal movements due to tissue compression. Even an extremely well-fitting complete denture is able to move in an anterior or posterior direction a minimum of 0.5 mm before tissue compression resists the movement. If the intercuspal position is registered at a retruded jaw location, posteriorally directed pressures on to the mandible (be they external or self-generated) will not be resisted by alveolar bone via rigid natural cuspal contacts, but by compression of the condyles on to the posterior tissues of the glenoid fossae. (d) If the occlusion of complete dentures is set so that full intercuspation can only occur on a retruded arc of closure, wear of the dentures andor slight forward posturing of the mandible must result in initial cuspal contacts being established between protrusive facets. The resultant horizontal component has the potential to unseat the dentures by movement of the upper denture in an anterior and the lower in a posterior direction. (e) Should the jaw be deliberately retruded to centric relation, complete dentures set to give full intercuspation at a slightly forward centric occlusion will provide initial intermaxillary contacts on retrusive facets. The horizontal component of the forces developed between these facets will potenAustralian Dental Journal 1989;34:2.

3. Denture intercuspation at centric relation or centric occlusion There is general agreement that in the natural dentition the path traced by the mandible on closing from the postural to the intercuspal position is the result of reflex activity in the attached musculature. Centric occlusion is the location to which the closing mandible expects to return. As such it would also appear to be the natural location for the edentulous intercuspal position. There is, however, also general agreement that in determining jaw relations in the edentulous subject there is only one jaw position that is consistently reproducible and that is to be found on the retruded arc of closure. Reproducibility of closing translation is the goal of many advocated clinical techniques of jaw registration. If teeth on complete dentures are made to occlude at centric relation they will do so each time the mandible closes on the (reproducible) retruded arc.
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A -TANGENT

B - CHOR
Fig. 5.--Tangential and chorded occlusal planes.

The result from combining Posselts values with those of angulation determined by Arstad20 gives a value for the horizontal translation of 1.08 k 0.9 mm, and for the vertical displacement of 0.64 -r- 0.5 mm. The author suggests that these figures might form the basis for convenient and clinically acceptable values: that the translation between centric relation and centric occlusion in the artificial occlusion should be represented by a mandibular movement of 0.5 mm in both the vertical and horizontal plane. It is therefore proposed that for all patients the intercuspal position of the ideal artificial occlusion should be established 0.5 mm anterior to and at 0.5 mm reduced occlusal face height from the position registered as centric relation.
4. The compensating curve In the fully dentate, the occlusal surfaces of the natural teeth are aligned to a helicoid curve which has been well described by many authors, possibly in the greatest detail by Brown and co-workers.21 This natural three dimensional curve has historically been dignified by the names of those who first described each separate part of the overall form: Spee, Monson, Wilson, and so on. In the edentulous patient these natural forms do not exist. The compensating curves set to the teeth of a complete denture prosthesis serve but one hnction, that being to permit by artificially balancing the articulation a reasonable degree of denture stability during excursive chewing actions. Two techniques have been proposed to achieve in the complete denture patient the accurate formation of these essential but artificial anteroposterior and lateral compensating curves. The curves may be derived from the clinically adjusted flat occlusal registration rims (plane) (Fig. 5) so that: (a) The flat mandibular rim is considered to form a tangent to the required curvature, or (b) The flat mandibular rim may be considered to form a chord of the required curvature. These techniques will be considered to turn.

tially move the upper denture backwards, the lower denture forwards. Such movements would enhance the correct seating of the dentures upon the alveolar ridges as the teeth slide into full intercuspation.
( f ) The reduced area of tooth contact that occurs when the mandible adopts a ligamentous position permits greater intercuspal point loadings to develop, hence possibly facilitating the comminution of harder foods.

(g) During mastication a shearing comminution of food takes place between working side cusp facets during the closing phase of the chewing cycle, in which action laterotrusive facets may be utilized as shearing surfaces. To reproduce this particular action in an artificial dentition, the mandible must be capable of a slight rearward movement on the working side, from the intercuspal position to a more retruded ligamentous position. Such movement is only possible if there exists a spatial separation of centric occlusion and centric relation. Theoretical discussions concerning jaw relationships can only be of clinical utility if values can be assigned to the concepts discussed. The length of the occlusal slide in adults with full natural dentition is stated by P ~ s s e l t ~ to. ~ be ~ 1.25 k 1 mm. Jacksonlg suggested that the movement path traced between the intercuspal and a retruded occlusal position generated by a patients own musculature is often greater than had previously been considered normal. He recorded horizontal retrusive movements averaging 2.5 mm (range 0.5 to 5.0 mm), with a simultaneous vertical shift averaging 3 mm; and lateral shifts of 2 mm. The average inclination of retrusive facets in respect to the occlusal plane has been determined as 30.6 with a standard deviation of 12.6.20
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(a) The tangential concept A compensating curve set to contact the clinically orientated mandibular occlusal rim at a tangent may be orientated upon a single contact on each side of the arch. The cusp tips of the second premolar teeth are most commonly employed as this point of contact. Posterior to these contacting teeth the compensating curve is conventionally set to rise above the
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Fig. 6.-Effect of a posteriorally raised occlusal plane.

level of the trimmed record block. The degree of rise is ideally arranged to establish a balanced antero-posterior articulation in harmony with the clinically established incisal and condylar guidance angles, but all too often it is set by a dental technician with no further consideration than to suit the exigencies of the occlusion during the wax-up of the denture. Because of the mechanics of any tangent-type articulation it is not possible to determine the level of the posterior denture teeth until the construction of the trial denture is well established. Should the ala-tragus line be used as the reference to set the occlusal plane (as discussed at l.iz), it is possible for the posterior teeth of the artificial occlusion to rise well above the correct natural level. This effect of raised maxillary molar teeth will be particularly noticeable for those patients who demonstrate a steep condylar guidance angle. The consequences are that the upper denture becomes too thin for the simple placement of normal sized molar teeth, the lower denture comes posteriorally too high for patient comfort, and the resultant inclined plane effect tends to unseat both prostheses (Fig. 6). (b) The chorded concept If, however, the occlusal rim is taken to be a chord of the eventual occlusal curve, a four-point contact may be clinically established by the clinician at the registration stage, and transferred as fixed points for the attention of the technician. The points to be indicated on the registration rims are (as previously recommended at l.iv) bilaterally the commissures of the lips and the retromolar pads. The level and inclination of the occlusal plane is
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thus fixed by the clinician and need not thereafter be changed. The radius of the compensating curve may now be planned by the technician to lie between fixed points and to harmonize with the clinically determined incisal and condylar guidance angles. The practical effect is to lower the midpoint of the compensating curve (that is, in the premolar and first molar region) below the plane of the registration rims. The resultant form simulates closely the curvature of the natural dentition in which the plane of occlusion passes from incisal tip to the molar teeth, but does not necessarily contact lower level intermediate cusps. Further advantages are apparent in this chorded arrangement. The occlusal plane curves to follow more closely the contour of the edentulous mandibular ridge, and therefore loadings tend to be directed normally to the underlying supporting tissues and bone. The most dependent point of the curve is at the site of denture balance - in the premolarlfirst molar region where the greatest occlusal forces are commonly concentrated. The advantages of a chorded dental arrangement may be summarized as those of accuracy in determining the position of the teeth and in establishing the plane of occlusion. The technician has both anterior and posterior guides for setting procedures: teeth may be set more quickly and correctly in the intervening interalveolar space. Conclusion When taking the bite for an edentulous patient it is perhaps salutary for clinicians to consider this
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time-honoured yet often ill-understood term as an acronym for the clinical procedures undertaken. For the edentulous patient the clinician registers a bilateral inter-alveolar transferable evaluation. Possibly the greatest emphasis should be placed on the last word, for in the edentulous it is indeed the clinicians evaluation of a patients occlusal needs and jaw relations that determines the ultimate success or failure of the complete denture prosthesis.
References
1. Mack 0. Full dentures. Dental Practitioner Handbook No. 13. Revised reprint. Bristol: John Wright, 1978. 2. Williams DR. Occlusal plane orientation in complete dentures. j Dent 1982;10:311-6. 3. Lundquist DO, Luther WW. Occlusal plane determination. J Prosthet Dent 1970;23:489-98. 4. Pound E. Conditioning of denture patients. J Am Dent Assoc 1962;64:46 1-8. 5. McCrorie JW. Origin of the pear-shaped pad. Dent Pract Dent Rec 1963;13:517-9. 6. Tallgren A. Changes in adult face height due to ageing, wear and loss of teeth and prosthetic treatment. A Roentgen cephalometric study mainly on Finnish women. Acta Odontol Scand 1957;15:Suppl 24:l-122. 7. Robert G, Brunde GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39:502-4. 8. Gonzalez JB, Kingery RH. Evaluation of planes of reference for orientating maxillary casts on articulators. J Am Dent ASWC 1968;76:329-37. 9. Olsson A, Posselt U. Relationshipof various skull reference lines. j Prosthet Dent 1961;11:1045-9.

10. Chick AO, Payne AGL. A note on the occlusal plane and the inclination of anterior teeth. Br Dent J 1962;112:159-60. 11. Winstanley RB. The hinge-axis: A review of the literature. J Oral Rehabil 1985;12:135-59. 12. Lucia VO. Gnathological concept of articulation. Dent Clin North Am 1962;6:183-97. 13. Moss ML. A functional cranial analysis of centric relation. Dent Clin North Am 1975;19:431-42. 14. Posselt U. Studies in the mobility of the human. Acta Odontol Scand 1952;lO:Suppl 10:19-160. 15. Gibbs CH, Lundeen HC. Advances in occlusion. Section 1. Postgraduate Dental Handbook Series No. 14. Massachusetts: John Wright, 1982:2-32. 16. Anderson JN, Storer R. Immediate and replacement dentures. Oxford: Blackwell Scientific, 1973:295-319. 17. Devlin H, Wastell DG. The mechanical advantage of biting with the posterior teeth. J Oral Rehabil 1986;13:607-10. 18. Posselt U. Physiology of occlusion and rehabilitation. oxford Blackwell Scientific, 1969:Ch5: 107-73. 19. Jankelson B. Neuromuscular aspects of occlusion: occlusal articulation. Dent Clin North Am 1979;23:57-168. 20. Arstad T . The capsular ligaments of the temporomandibular joint and retrusion facets of the dentition in relationship to mandibular movement. Oslo: Akademisk Forlag, 1954:l-95. 21. Brown WAB, Whittaker DK, Fenwick J, Jones DS. Quantitative evidence for the helicoid relationship between the maxillary and mandibular occlusal surfaces. J Oral Rehabil 1977;4:91-6.

Address for correspondenceheprints: Division of Restorative Dentistry, The University of Western Australia, Dental School, 179 Wellington Street, Perth, Western Australia, 6000.

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