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5
IN BRIEF
● Clarification of some of the terminology and concepts relating to occlusion as it is used in
everyday practice, making clear why these concepts matter
● Undertaking a simple pre-operative examination of the occlusion as a matter of routine
● Helping clinicians identify cases where articulated study casts will help plan treatment and
design restorations
● Advice is provided about selecting an appropriate articulator and taking appropriate records
at the treatment stage.
For many dentists, occlusion carries an air of mystique. It even seems sometimes that a perverse pleasure is derived in making
the whole subject more complicated than it really is. As a clinician, you need to be able to decide what you expect from your
proposed restoration, and to identify situations where you may need to alter the existing occlusal scheme. At a fundamental
level, you also need to provide the laboratory with appropriate clinical records to ensure that when you fit them, adjustments
to the expensively prepared restorations are minimal. This requires a sound understanding of the basics.
CROWNS AND EXTRA-CORONAL This fifth article in the series will try to present (ICP). Travel into this position is partly guided by
RESTORATIONS: important occlusal concepts in a way which the shape of teeth and partly by conditioned
1. Changing patterns and relates directly to the provision of successful neuromuscular co-ordination.1 ICP is the most
the need for quality crowns. It is not a comprehensive guide to occlu- ‘closed’ position of the jaws.
2. Materials considerations sion, or a manual of techniques for extensive
3. Pre-operative fixed prosthodontics. There are several useful Why does this matter?
assessment books and articles dedicated to the subject and ICP is usually the position in which vertical
some of these are specifically referenced (if a occlusal forces are most effectively borne by the
4. Endodontic
considerations technique is particularly well described) or are periodontium with teeth likely to be loaded axi-
listed in the further reading section. However, we ally, which helps to stabilise their position.
5. Jaw registration and
hope that this article should allow you to avoid Indeed it is the end point of the chewing cycle
articulator selection
most of the problems associated with the provi- where maximum force is exerted. In everyday
6. Aesthetic control sion of crowns. Occasionally some pre-operative practice this is the position of the jaws in which
7. Cores for teeth with occlusal adjustment is needed. Our experience is restorations are made.
vital pulps that this is best taught ‘hands on’ and we would
8. Preparations for full recommend attending an appropriate course Guidance (from the teeth)
veneer crowns before attempting more complex adjustments. What is it?
9. Provisional restorations When a patient moves their mandible from side
10. Impression materials and BASIC CONSIDERATIONS — WHAT MATTERS? to side so that the teeth in opposing jaws slide
technique One of the essential starting points with occlu- over each other, the path taken is determined
11. Try-in and cementation sion is to make sure that the terminology is clear. partly by the shapes of the teeth which make
of crowns There are any number of occlusal terms, many of contact, as well as by the anatomical constraints
12. Porcelain veneers which overlap. There are only a few that really of the temporomandibular joints (TMJs) and
13. Resin bonded metal matter and these need to be understood if what is masticatory neuromuscular function. Each has a
restorations to follow is to make any sense. bearing on the other, and, for want of a better
term, they should work in harmony. In these cir-
1*,3Senior Lecturer in Restorative Dentistry,
The intercuspal position (ICP or IP) cumstances the teeth provide guidance for the
Department of Restorative Dentistry,
The Dental School, Framlington Place, Synonyms: centric occlusion (CO), maximum movement of the mandible. The shape and form
Newcastle upon Tyne NE2 4BW intercuspation of the temporomandibular joints also guide the
2Consultant in Restorative Dentistry, The
movement of the mandible (sometimes called
Dental Hospital, Framlington Place,
Newcastle upon Tyne NE2 4AZ
What is it? posterior guidance). Guidance teeth can be any
*Correspondence to: J. G. Steele Most dentate patients, when asked simply to teeth, anterior or posterior.
E-mail: jimmy.steele@ncl.ac.uk ‘bite together on your back teeth’, close immedi- When the patient slides the mandible out to
ately into a comfortable, reproducible “closed” one side, the side they move the mandible
Refereed Paper
© British Dental Journal 2002; 192: position where the maximum number of tooth towards is called the working side (because it is
377–387 contacts occur. This is the intercuspal position usually the side on which they are about to
need to be made from good quality impres- Records for planning crowns: Articulated study
sions, which have been handled and poured casts
correctly. We will return to this important but Accurate casts of the dental arches mounted in a
underrated subject later (see below: ‘Opposing semi adjustable articulator are the most impor-
Casts’). tant tools of the trade when constructing artifi-
Hand-held study casts enable: cial crowns. The need for an articulator and the
• A judgement to be made regarding the ease of positions in which you mount the casts depend
obtaining a stable ICP. This helps to determine on what you need to do (see Box 3). Articulators
whether or not an interocclusal record is are surrounded by an aura of mystery, but at the
required for the working casts upon which the end of the day they are a tool to help give your
restoration(s) will be made. patient a successful restoration and to help you
• An unimpeded view of ICP. It is possible to to save time, money and hassle. The quality of
view aspects such as the lingual, which the final result is much less dependent on the
it would not be possible to see at the chair- articulator you use than it is on the care you
side. exercise to make and mount the casts that you
• Careful evaluation of clinical crown height put in it.
and the availability of inter-occlusal space for There is little merit in examining study casts
restorative material. These two factors can for planning purposes on a simple hinge or other
help make the decision on how to facilitate the ‘non-anatomical’ articulator because the ability
restoration of short teeth (see Part 3 ‘Pre-oper- to replicate physiological movements will be, at
ative assessment’ in this series). best, crude, and at worst, wholly misleading. A
non-anatomical articulator will allow casts to be
However tempting it may be to assume other- put into a reproducible ICP, which may be helpful
wise, hand-held casts provide no information if there are insufficient contacts to make hand-
about excursive tooth contacts or RCP, beyond held casts stable, but that is the limit of what a
the distribution of wear facets. simple hinge articulator can do.
The combination of a facebow record (which Records for planning crowns: the diagnostic
locates the approximate position of the condylar wax-up
hinge axis in relation to the upper arch) and a jaw In addition to its uses in planning changes in
relation record (which then locates the lower cast appearance (see Aesthetic Control — the sixth
to the upper), enables movements of casts articu- article in this series), a diagnostic wax-up can be
lated on a semi-adjustable articulator to be rea- an absolutely invaluable technique where you
sonably anatomical. You can simulate the move- are changing the occluding surfaces of several
ments of the teeth in lateral and protrusive teeth with crowns or resin bonded restorations
excursions, and around the hinge axis and be con- and allows you to plan the following:
fident that what you see is close to what is really • The new static occlusal contacts (in ICP) and
happening in the mouth. However, whilst the the shape of the guidance teeth
instrument is key, the quality of the casts and • The impact that the modified occlusion has on
the care with which they are mounted are just as appearance
critical. There is no room for carelessness at this • The best options for creating interocclusal
stage, wrongly articulated casts are probably space for restoration(s) or optimising crown
worse than no casts at all as they may result in height by periodontal surgery (see Part 3:
false assumptions about treatment. Similarly, inac- ‘Pre–operative Assessment’ in this series).
curacies with the original impressions can result in
profound errors and the use of an accurate and You can also use the completed wax-up as a
stable impression material (such as addition cured template to determine the form of temporary
silicone) may be appropriate in cases where a and final restorations.
detailed occlusal analysis is necessary. Details of
how to record a facebow record and a retruded PRACTICAL ASPECTS OF OCCLUSION:
hinge axis inter-occlusal record can be found in RECORDS FOR MAKING CROWNS
References 3 and 4. Some simple tips on accurate When the diagnosis stage has been completed,
impression recording can be found in Box 4. the crowns or restorations still need to be made,
Although you can see and reproduce move- and various records are essential at this stage
ments with carefully articulated casts, you may too. This section discusses the choice of articula-
often want to go on to the next stage and prepare tor and the need to obtain accurate occlusal
a diagnostic wax up. records, including the simplest things such as
opposing impressions, which are a frequent this is probably not economically realistic. Box 4
source of error. Finally, it introduces ways of describes the use of alginate for an opposing
controlling guidance on front teeth. impression. In cases involving multiple restora-
tions though, a very stable and accurate material
The articulator may be cost effective in the long term.
When manufacturing the final crowns, in the
interests of simplicity and cost it would seem Interocclusal records (IOR)
sensible to use the simplest cast relating device Once you have your working impression and
that will not compromise the final restoration.5 opposing impression you then need to decide
Small numbers of restorations, which are not whether you need to provide additional informa-
involved in excursive contacts, can very reason- tion to the lab to allow them to mount the casts;
ably be made on a non-adjustable articulator an inter-occlusal record (IOR). There is a common
and then any adjustments made in the mouth perception that providing an intercuspal record
before final cementation. However, crowns (such as a wax or silicone ‘bite’) will improve the
involved in excursions benefit from the use of accuracy of mounted casts. The truth is that in
an articulator with anatomical dimensions so many cases it does precisely the opposite.6
that the excursive movements can be made and For a patient with a stable intercuspal posi-
the shape of the crown adjusted in the lab with tion, the loss of interocclusal contact created by
reasonable accuracy, saving chairside time. This preparation of a tooth for a single unit restora-
becomes particularly important, and cost effec- tion, is unlikely to detract from the ease with
tive, when several restorations are being created which working and opposing casts can be locat-
at the same time. Highly sophisticated semi- ed in ICP. In this circumstance, placing a layer of
adjustable and fully adjustable articulators are wax or silicone between the casts to help to
available for this purpose, but the majority of locate them can often result in them failing to
cases can be managed quite satisfactorily using seat into ICP at all, and there is a very serious
a less sophisticated, fixed average value articu- risk of the record introducing inaccuracies,
lator in combination with a facebow. rather than acting as the ‘insurance policy’ you
It may not be possible to check occlusion on intended. It is worth taking the opportunity of
adhesive restorations prior to cementation, either examining the ease with which any study casts
because the act of checking may damage porce- can be located by hand before deciding whether
lain, which is delicate until cemented, or because an IOR is needed. Often (perhaps even usually)
they will not stay in place during excursions. In you are better with nothing at all.
these cases, controlling the role of the restorations Sometimes an IOR is required to stabilise
in guidance can be critical to their long-term sur- casts, particularly where the teeth that are pre-
vival. A semi-adjustable articulator can be pared are key support teeth in an arch. The
invaluable in situations such as these because it choice of materials is generally between hard
allows the technician to secure restorations onto wax alone, hard wax (as a carrier) used with zinc
the working cast and do the critical adjustments oxide/eugenol, silicone elastomers and acrylic
in the lab so that all you need to do is cement resins. The fundamental requirement is to obtain
them with little or no adjustment afterwards. enough detail in a dimensionally stable record-
ing material to enable casts to be confidently
Opposing casts located in the laboratory whilst not recording so
In any discussion about articulators, it is much detail that it stops the casts seating.
disturbingly easy to forget the importance of an Occlusal fissure patterns reproduced accurately
accurate cast to oppose the working cast. The in the IOR may well not be reproduced to the
opposing impression is often the last thing we do same extent in the cast, preventing full seating
and, after a long session preparing teeth, making of the casts in the record. Furthermore, an IOR
temporaries and taking impressions it tends to be which contacts soft tissues in the mouth and
a bit of an afterthought. However, a poor oppos- causes their displacement (which is obviously
ing impression is very easy indeed to achieve and not reproduced in the stone cast) will result in an
yet can cost a great deal of precious time subse- IOR which will not seat accurately (Figs 11 and
quently. A cast made with a distorted impression 12). In order to meet the requirements for suc-
or a porous impression resulting in plaster blebs cess, an IOR should:
on occlusal surfaces will not fit comfortably into
1. Record the tips of cusps or preparations
ICP. If such a cast is used in the lab it can result in
BUT
a crown which looks perfectly good on the cast
2. Avoid capturing fissure patterns as much as
but which may be very high in the ICP and which
possible
can take a great deal of time to get right prior to
AND
fit. It is easy to record bad opposing impressions,
3. Avoid any soft tissue contact
but good ones are just as easy. Attention to the
few steps listed in Box 4 takes, literally, no extra The key to a successful record is not so much
time but can save a lot of heartache. In an ideal the type of material used, but how it is used. The
world every opposing impression would be smaller the amount you use, the less it is likely to
recorded in a dimensionally accurate and stable cause a problem. A small, trimmed record,
material such as an addition cured silicone, but restricted to the area of the preps themselves,