FIXED PROSTHODONTICS

OPERATIVE DENTISTRY

DAVID E. BEAUDREAU, SAMUEL E. GUYER,

WILLIAM LEFKOWITZ, Section editors

The importance of canine and anterior tooth positions

in occlusion

Arthur Edward Kahn, D.D.S.*

New York, N. Y.

lh e spatial positions of the upper canines and incisor teeth in relation to each other
and to the lower anterior teeth must be in harmony with the temporomandibular
joints and mandibular musculature in order for the physiology of the masticatory
mechanism to be normal.
The contacts of anterior teeth should function in a protective manner in the ex-
cursive movements of the mandible by discluding the posterior teeth. The posterior
teeth prevent the overloading of the anterior teeth. Thus, the relationship between
the anterior and posterior teeth is one of mutual protecti0n.l
The anterior teeth should also work in harmony with the temporomandibular
joint during lateroprotrusive movement to increase the lateral reach of the posterior
teeth as the mandible moves forward and to the side.2 The mandibular teeth are thus
able to balance a large bolus against the maxillary teeth and, through the ancillary
use of the tongue, lips, and cheeks, prepare the bolus for the digestive tract.
Because of this, the lateroprotrusive movement is important in each of the three
basic kinds of chewing: ( 1) incising food with the anterior teeth, (2) examining food
between the tongue and the front teeth, and (3) chopping food with posterior teethe3

ANTERIOR TOOTH FUNCTION

The arrangement of the upper and lower anterior teeth to each other is critical to
the efficiency and harmony of the incisive stroke. If a horizontal overlap of the upper

Presented before the Sixth Congress of the International Academy of Gnathology, Mexico
City, Mexico.
*Formerly, Associate Professor of Prosthetic Dentistry, Boston University, Graduate
School of Dentistry, and Instructor in Occlusion, Department of Periodontology, University of
Pennsylvania, Graduate School of Medicine.

397
398 Kahn .I. Prosthet. Dent.
April, f977

Fig. 1. (A) The occlusion of the teeth when the mandible is in centric relation. Note the
penciled outline on the upper anterior teeth. (B) Centric occlusion. (C) Marked wear facets
on the anterior teeth. (D) Penciled outline reveals the extent of wear. Breakthrough of enamel
cap is already visible on the second premolar. Note the wear on the canines. (E) Break-
through of enamel cap extends from premolar to premolar. (F) The wear patterns are extensive.

incisors to the lower incisors is present and a space exists, there is no possibility of
utilizing the tooth-condyle relations to create an immediate disclusion of the posterior
teeth. When the anterior teeth do not disclude the posterior teeth in the functional
stroke, some degree of distortion of the laterotrusive stroke is required. Such distor-
tion becomes necessary due to the inability to disclude the posterior teeth. Collision
of the teeth thus occurs with the possibility of trauma from occlusion, which may
affect either the attachment apparatus of the teeth, the mandibular musculature, or
the temporomandibular joints or cause excessive tooth wear.4’ 5
Wear of the anterior teeth can also occur when a discrepancy exists between
centric relation and the intercuspal position (centric occlusion). The degree of an-
$Alml&~
“4’ Canine and anterior tooth positions in occlusion 399
”

Fig. 2. (A) The patient had a history of temporomandibular joint pain with inability to chew
without marked discomfort. Note, in addition to the lack of vertical overlap of the incisors,
the horizontal overlap of both upper canines. (B) Note the manner in which the myofunctional
problem is related to the open bite from canine to canine. Each time the patient swallows, the
tongue projects into the spaces between the upper and lower anterior teeth.

terior movement of the mandible in closure from centric relation to centric occlusion
is indicated by the penciled outline on the lingual surfaces of the upper anterior teeth
(Fig. 1, A). As the mandibular anterior teeth glide forward and horizontally from
the retruded contact position in closure to the centric occlusion, wear of the mal-
related teeth can occur (Fig. 1, B to D) . The progressive wear of the anterior teeth
reduces the capacity of the incisors and canines to function as discluders, allowing
collision of the posterior teeth .s As the vertical overlap of the anterior teeth is re-
duced by continuous wear, the enamel wears on the posterior as well as the anterior
teeth (Fig. 1, E and F) . This condition is frequently accompanied by temporoman-
dibular joint dysfunction. In general, the mechanism is a relationship between para-
functions and tooth attrition.’
If the mandible demonstrates a shift laterally from the retruded contact position
as well as anteriorly to centric occlusion, joint or muscle strain and muscle spasm
may result.*-lo
If, in addition to a horizontal overlap of the upper incisors to the lower anterior
teeth, there is a horizontal overlap of the upper canines, the tooth-condyle relations
cannot effect the disclusion which the canines normally are able to pr0vide.l’ The
posterior teeth on both the working and nonworking (balancing) sides are unable to
avoid collision with each other.
The relationship of such an arrangement to the frequency of joint or muscle
strain and muscle spasm is alarming. I2 The syndrome of painful chewing, crepitation,
and occasional trismus is common.
Much can be learned from the foregoing analysis. A patient’s inability to provide
an organized disclusion through the combined tooth-condyle relations of both the
canine and the upper anterior teeth dictates definite criteria to be followed in diag-
nosis and treatment.
When the anterior teeth, particularly the canines, do not properly relate to dis-
elude the posterior teeth, occlusal adjustment of a natural dentition is contraindicated
(Fig. 2, A and B) . Likewise, extensive rehabilitative procedures (posterior or com-
plete) are contraindicated.
 .I. I’rosthet. Dent.
April, 1977

Fig. 3. Pretreatment radiographs. Periodontally involved teeth with a hopeless prognosis may be
strategically retained during orthodontic correction.

THE PROBLEM OF THE HORIZONTAL OVERLAP

Orthodontic procedures should be instituted prior to other rehabilitative measures
to correct the horizontal overlap and thus provide a vertical overlap of the canines
and incisors so they may provide posterior disclusion. Excessive horizontal overlap
is frequently associated with the classic clinical picture of advanced migratory peri-
odontal disease which may also include a reduced vertical dimension of occlusion and
diastemata.
Such a vertical dimension of occlusion can be restored without increasing the
crown-root ratio. As the migrated dentition is brought back together, the vertical
and horizontal overlaps are dramatically reduced. Simultaneous lingual movement
of the upper and lower anterior teeth restores the reduced vertical dimension and
provides a favorable overlap of the anterior teeth.‘” A remodeling of the deformed
labial plate of bone occurs, eliminating the need for corrective alveolar surgery when
involved anterior teeth must be extracted. Hopeless anterior teeth may be strategi-
cally retained during the orthodontic phase of treatment to effect a remodeling of the
labial plate of bone (Figs. 3 and 4).
The advantage of such a sequence of treatment is demonstrated when the original
Volume 37 Canine and anterior tooth positions in occlusion 401
Number 4

Fig. 4. (A) The anterior teeth have migrated to a marked horizontal overlap. The labial plate
of bone is deformed. (B) The vertical and horizontal overlaps are reduced. Anterior disclusion
is now possible. The labial plate of bone is remodeled. (C) The anterior view of appliances dur-
ing the orthodontic phase of treatment. (D and E) Pre- and posttreatment documentation.

diagnostic casts are compared with the casts of the repositioned teeth upon which
processed temporary restorations have been constructed (Fig. 5).
With the combined procedures of orthodontics, periodontics, and occlusal re-
construction, a debilitated dentition usually can be restored. Disclusion can be re-
organized through the combined relationship of the canines, the anterior teeth, and
the temporomandibular joints (Figs. 6 and 7).

THE MYOFUNCTIONAL PROBLEM

Uncontrolled myofunctional problems are a frequent etiologic factor in patients
with an anterior open bite (Fig. 8). Temporomandibular joint dysfunction, speech
 J. Prosthet. Dent.
402 Kahn April. 1977

Fig. 5. (A and C) Pretreatment diagnostic casts. (B and D) Teeth have been repositioned
orthodontically. Processed temporary restorations are in place. Note the improved vertical
dimension and new relationship of the anterior teeth. (E and F) An organized disclusion is now
possible through the combined tooth-condyle relations both canines and the rest of the anterior
teeth.

problems, and periodontal disease are common findings in these patients.l” This is not
surprising, since the posterior teeth cannot be separated except by voluntary exag-
gerated mandibular motions. The chewing mechanism lacks the ability to rest nor-
mally.
Thus, myofunctional therapy frequently needs to be combined with other ther-
apeutic techniques to restore function (Fig. 9). Orthodontic intervention in the pres-
ence of an uncontrolled myofunctional problem usually leads to failure of treatment
(Fig. 10).
Research has indicated that orthodontic intervention is inappropriate if after
treatment is completed, disturbances left uncorrected cause disorders of the stomatog-
Volume 37 Canine and anterzor tooth positions in occlusion 403
Number 4

Fig. 6. (A to F) Pre- and posttreatment documentation. The combined procedures of orthodon-

tics, periodontics, and occlusal reconstruction have been utilized to restore a debilitated
dentition.

nathic system. An orthodontic abnormality of the teeth may be exchanged for a

functional abnormality during mastication and swallowing. This condition could be
considered worse than the original one.1”-20

CANINE DISCLUSION
The random buildup of the lingual concavity of upper canines to provide dis-
elusion should be discouraged. Canine protection means freedom of movement in
lateral and laterotrusive movements, with the occlusion of the opposing canines free-
ing the posterior and anterior teeth. It incorporates in its vertical overlap and lingual
concavity the laterotrusive variants of the rotating condyle, as well as the variations
in mediotrusion which are influenced by the total transtrusive movement. Canine
locking is likely to induce rocking and clenching habits with ultimate destruction of
the supporting periodontal structures.*l
404 Kahn .I. I’mrthet. Dent.
April. 1977

Fig. 7. Posttreatment radiographs.

In organizing the disclusion capacity of the canines, these teeth should be paired
in proper rotated stances so that the tip of the lower canine follows the mesial groove
of the upper canine as though it were following an arc drawn by the near condyle.
The vertical overlap of the upper canine should work with the slope of the eminence
of the orbiting condyle. The degree of disclusion should be sufficient to provide clear-
ances for the teeth on the working and nonworking sides.‘”
Immediate sideshift (Bennett movement \ . without downward, forward. and in-
ward movement of the far condyle (balancing condyle) . must be incorporated in the
lingual concavity of the canine on the side of the vertical axis (working condyle 1,
since there Lvill be no aid from the Lvorking condyle to separate the nomvorking teeth.
The interplay of the determinants of occlusion is intriguing in this respect, since an
immediate sideshift, unless incorporated tllroughout, will cause a collision of tile
posterior teeth.
Such collision of posterior parts deprives the mouth of freedom of movement.
These interferences prevent biting off of thm, tough foods with the incisors or canines
without interferences from the molars.
The angle traversed by the balancing condyle is a discluder of the teeth on the
nonworking (balancing) side. On the rotating (working) side, the vertical overlap
of the canines is the chief discluder. In other words, the posterior teeth on the work-
ing side are canine discluded. The posterior teeth on the balancing side and the
y~wne;
”
“4’ Canine and anterior tooth positions in occlusion 405

Fig. 8. (A to E) The open bite must be reduced prior to restorative measures. The combined
procedures of myofunctional therapy, orthodontics, endodontics, periodontics, and occlusal
reconstructive therapy restore a nonfunctioning mouth to a functioning entity. The mandibular
teeth can now balance the bolus of food against the maxillary teeth and, through the ancilliary
use of the tongue, lips, and cheeks, prepare the bolus for the digestive tract. Restored incisal con-
tacts permit proper enunciation of consonants, which results in a dramatic improvement of
the patient’s speech. Elimination of collisions of posterior teeth through disclusions of posterior
teeth serves to eliminate temporomandibular joint pain and helps immeasurably in the treat-
ment of the periodontal problem.

incisors are canine and condyle discluded. Then, the advancing condyle is a rare
discluder of both the balancing teeth and the incisors. There is, nevertheless, a rela-
tion between the vertical overlap of the canines on the working side and the disclu-
sion of the balancing teeth of the opposite side, since an incorrect angle may cause
collision of the teeth.
 J. Prosthet. Dent.
406 Kuhn April, 1977

Fig. 9. (A and B) Bilateral myofunctional problem. The canines are prevented from eruptmg
to their normal functional relationship by the lateral thrust and continuous pressure of the
tongue. Myofunctional therapy must be instituted prior to orthodontic intervention. Note the
degree of incomplete eruption of the cuspids. (C to J) Pre- and posttreatment documentation.
Note the change in canine length effected through combined use of myofunctional and ortho-
dontic therapy. Note too the improved health of the tissues evident before and after treatment.
pluTle~ “4’ Canine and anterior tooth positions in occlusion 407

Fig. 10. (A) The anterior teeth are protruded. The upper arch has collapsed. As the arch nar-
rows, posterior teeth migrate into a cross-bite relation. (B) The lower arch is completely out of
harmony with the upper arch. (C and D) The open bite extends from the right second premolar
to the left first molar. The collision of the contacting posterior teeth is inevitable, since there is
no vertical overlap of the anterior teeth. (E) The upper first permanent molar has been lost.
The combined etiology of severe periodontal involvement and root resorption affected the loss
of this important tooth. (F and G) Despite an acceptable orthodontic result and the customary
period of retention, the anterior teeth regressed to an open bite relation. Replacement bands
and wires on the four incisors fail to prevent this collapse to the original condition. The
uncontrolled myofunctional problem is the etiologic factor.
 J. Prosthet. Dem.
408 &dm April. 1977

Fig. 11. The tripodal contacts of occlusion.

SELECTIVE ELIMINATION
The selective elimination of food is another function that is made possible through
the laterotrusive movements. If the laterotrusive movements meet the exactness of
the demands upon them in the occlusal organization of the canines and incisors, the
tongue and teeth are able to act harmoniously and without conscious effort to test
the food for foreign or undesirable substances unfit for the digestive tract. The actions
of the tongue and teeth then expel the unwanted portions of the bolus.

DIGESTIVE ACTION BY THE TEETH OF THE WORKING SIDE

With incising and selective elimination of unwanted particles of food completed,
the bolus is shifted to the action of the blades of the posterior teeth of the working
side.
The degree of efficiency of the blades of the chewing mechanism in chopping
up the bolus and thus preparing it for the digestive tract is contingent upon the exact-
ness of organization followed in relating odontocondylar relations to the morphology
of teeth.
In this regard, it is fascinating to note that although the odontocondylar relations
in the organized canine disclusion are developed with centric relation as the end
point, the chewing mechanism functions anterior to this position. Yet, when the
mouth is relaxed and the teeth come together in the closure of swallowing, the man-
dibular buccal cusps seek their respective maxillary fossae, while the ma.xillary lin-
gual cusps are directed to their respective mandibular fossae (Fig. 11) . Tripodal con-
Volume 37 Canine and anterior tooth positions in occlusion 409
Number 4

tact of these elements is achieved, and the exquisite fit of the parts of the teeth occurs.
Therefore, the key to occlusion is disclusion, for without the latter, the parts of
teeth will wear and the resultant change ir+ morphology will be observed on the an-
terior as well as the posterior teeth.

CONCLUSIONS
Organized disclusion by the canines should find the canines paired in proper
rotated stances so that in any of the possible movements of laterotrusion, the tip of
the lower canine engages the mesial groove of the upper canine. In effect, this means
that a Class I centric relation occlusion is requisite to such a rotated stance of the
canines; otherwise, wear of the teeth may occur. Thus, the importance of properly
executed orthodontics in the preservation of the stomatognathic system becomes
critically apparent.

References
1. Stuart, C. E.: Why Dental Restorations Should Have Cusps, J. South. Calif. State Dent.
Assoc. 21: 198-200, 1959.
2. Stallard, H.: Personal Communication, Sept. 14, 1973.
3. Stallard, H.: Personal Communication, Aug. 8, 1973.
4. Beyron, H. L.: Occlusal Changes in Adult Dentition, J. Am. Dent. Assoc. 48: 674-686,
1954.
5. Posselt, U., and Nilson, E.: Occlusal Rehabilitation in Periodontal Therapy, Dent. Clin.
North Am., March, 1964.
6. Shaw, D. M.: Form and Function in Teeth, and a Rational Unifying Principle Applied
to Interpretation, J. Orthod. 10: 703-718, 1924.
7. Lipke, D., and Posselt, U.: Parafunctions mf the Masticatory Mechanism (Bruxism), Re-
port of a Panel Discussion, J. West. Sot. Periodontol. 8: 133-148, 1960.
8. Ahlgren, A., and Posselt, U.: Need of Functional Analysis and Selective Grinding in
Orthodontics, Acta Odontol. Stand. 21: 187-226, 1963.
9. Perry, H. T.: Muscular Changes Associated With Temporomandibular Joint Dysfunction,
J. Am. Dent. Assoc. 54: 644-653, 1957.
10. Grewcock, R. J. G., and Ballard, C. F.: Clinical Aspects and Physiological Mechanism of
Abnormal Paths of Closure, Dent. Pratt. Dent. Rec. 6: 259-267, 291-296, 1956.
11. D’Amico, A.: Canine Teeth-Normal Functional Relation of the Natural Teeth of Man,
J. South. Calif. Dent. Assoc. 26: 6-23, 49-60, 127-142, 175-182, 194-208, 239-241, 1958.
12. Ramfjord, S. C., and Ash, M. M.: Occlusion, ed. 2, Philadelphia, 1971, W. B. Saunders
Company.
13. Wiebrecht, A. T.: Crozat Appliances in Maxillofacial Orthopedics, Milwaukee, 1966,
Crown Ltd.
14. Garliner, D.: Myofunctional Therapy in Dental Practice, ed. 2, Brooklyn, 1973, Bartel
Dental Book Company.
15. Posselt, U., and Nohrstrom, P.: Orthodontic Treatment of Functional Disturbances in
the Adult Dentition, Odontol. Tidskr. 68: 450-462, 1960.
16. Ramfjord, S. P.: Bruxism, a Clinical and Electromyographic Study, J. Am. Dent. Assoc.
62: 21-44, 1961.
17. Ward, M. M., et al.: Visceral Swallowing’and Malocclusion, Dent. Abst. 7: 301, 1962.
18. Rogers, J. H.: Swallowing Patterns of a ormal Population Sample Compared to Those
Patients From an Orthodontic Practice, ,” m. J. Orthod. 47: 674-689, 1961.
19. Moyers, R. E.: An Electromyographic Analysis of Certain Muscles Involved in Temporo-
mandibular Movement, Am. J. Orthod. 36: 481-515, 1950.
20. Hickey, J. C., Woelfel. J. B., Stacy, R. W., and Rinear, L.: Elertromyography in D~nt.11
Research. Part I. Geometric Placement of Reference Electrodes? J. P~OSTHE.I. 1)~s~. 8:
351-361, 1958.
?I. Kahn, A. E.: I’nl)alanced Occlusion in Occlusal Rehabilitation, J. PHO~TIII:I. LIEAT. 14:
X5-738, 1964.
“”--. Stallard. fI.: Personal (:c)lllrnlllri~.ati(lI~, Scl,t. 1-l. I97 ;.

654 M~nrsos AvI:.

NEW YORK, N. Y. 10021

I
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