Arrangement of artificial teeth in abnormal iaw

relations: Maxillary protrusion and wider

upper arch

B. K. Goyal, B.D.S., M.D.S.,* and K. Bhargava, B.D.S., MS.**

Government Dental College and Hospital, Ahmedabad, Gujarat, India

M ost tooth setups are taught and done on casts with normal ridge relationships.
There are times when the dentist is called upon to arrange teeth for abnormal
ridge relationships. He then finds himself at a loss to cope. He fails to understand
how he can change the normal guidelines (such as individual positions and in-
clinations of teeth, their rotational positions, horizontal and vertical overlap, and
the like) to suit the demands of the new ridge relations. An effort is made in this
article to offer guidance in the management of tooth arrangement in abnormal
jaw relations.

RIDGE RELATIONSHIPS
Definition of normal ridge relationship
The maxillary and mandibular ridges are considered to be in normal relation
when, in centric relation, the upper ridge in the anterior region is slightly labial
to the lower ridge (Fig. 1, A) and when, in the posterior region, the interalveolar
crest line between two ridges forms an 80 degree angle to a horizontal plane, i.e.,
the crest of the lower ridge is slightly buccal to that of the upper ridge1 (Fig.
1, B).

Definition of abnormal ridge relationship

Any deviation in the anterior and/or posterior region from the normal ridge
relationship is considered abnormal.
In the anterior region. The ridge relationship is abnormal: (a) when the upper
ridge is located much further anteriorly than the lower ridge, i.e., maxillary pro-
trusion; and (b) when the upper ridge is located in the same line as or lingual
to the lower ridge, i.e., mandibular protrusion or prognathism (Fig. 2, A).

*Lecturer, Department of Prosthetics.

**Senior Professor in charge of the Department of Prosthetics.
107
 108 Goyal and Bhargava .J. t’t o\thet. Dent.
.Iuly, 1974

A
Fig. 1. Normal ridge relation: A, anterior region: B, Posterior region.

In the posterior region. Abnormality is considered to exist: (a) when the crest
of the lower ridge is placed lingual to that of the upper ridge, i.e., a wider upper
arch; and (b) when the crest of the lower ridge is placed much further buccall!
than normal in relation to that of the upper arch, i.e., a wider lower than upper
arch (Fig. 2, B) .
All of these variations may range from a slight to a marked degree. Though
all four situations can exist independently of the others, or sometimes even uni-
laterally, usually a wider upper arch is associated with maxillary protrusion and a
wider mandibular arch with mandibular protrusion. Therefore, for the sake of
clarity, it is well to discuss the management of the abnormalities in the anterior
and posterior regions together, in each of these two categories.

Arrangement of teeth in abnormal ridge relations

Arrangement of anterior teeth in maxillary protrusion.
PROBLEM 1. As the upper arch in these situations is further forward in the
anterior region, the first problem is that of an excessive amount of overjet (horizontal
overlap) which results in an abnormal upper and lower canine tooth relationship.
No attempt should be made to reduce this horizontal overlap by moving the upper
anterior teeth palatally or the lower anterior teeth labially.
PROBLEM 2. In situations where there is a normal upper and lower canine re-
lationship mesiodistally, the distal surface of the lower canine tooth is located at
the tip of the cusp of the upper canine (Fig, 3, A). However, when the upper
anterior teeth have been arranged, it may be that this relation will not be obtained
when the lower anterior teeth are arranged. This discrepancy in canine relationship
is the result of the upper arch being forward in relation to the lower arch so the
lower anterior teeth have to be set further lingually in relation to the upper anterior
teeth. This results in the lower canine tooth finishing anywhere from the tip to the
distal surface of the upper canine tooth (Fig. 3, A). When the maxillary protrusion
is excessive, the distal incline of the cusp of the lower canine will sometimes be
posterior to the distal surface of the upper canine tooth (Fig. 3, C and D) . This
canine relationship also influences the subsequent posterior arrangement of teeth.
MANAGE~IENT. The management of such situations can be attempted in any of
the following ways, depending upon the severity of the maxillary protrusion.
( 1) If the protrusion is not too extreme, the simplest way is to select the lower
anterior teeth of a narrower mesiodistal width and try to achieve the normal canine
relationship.’
 Artificial teeth in abnormal jaw relations 109

b a c

A 6
Fig. 2. Abnormal ridge relations. (A) Anterior region: Q, normal; b, mandibular protrusion;
G, maxillary protrusion. (I?) Posterior region: n, normal; 6, wider mandibular arch; C, wider
maxillary arch.

(2) If esthetics permit, a little crowding of the lower anterior teeth by over-
lapping may solve the problem well.’
(3) Another solution which is effective at times is leave slight spaces between
the upper anterior teeth to attain normal canine relations: However, such a pro-
cedure is esthetically limited.
(4) In situations where the discrepancy is not too great, grinding of the distal
surface of lower canine is sufficient to restore the normal canine relationship. This
procedure can, however, be extended to all of the lower anterior teeth by grinding
their mesial and distal surfaces to narrow their total mesiodistal width. But, this
grinding should be done very judiciously so as not to mar the esthetics or the
anatomic forms of the teeth.
(5) In situations where the discrepancy is excessive and cannot be managed by
the manipulation and modification of the lower anterior teeth, the lower anterior
teeth must be left as they are, and the lower first premolars must be eliminated from
the dental arch.” If the distal incline of the lower canine is entirely posterior to the
distal surface of the upper canine tooth, the situation is ideally suited for such a
procedure, and a satisfactory posterior setup can be developed (Fig. 4).
If, however, the entire distal incline of the cusp of the lower canine tooth is not
free for articulation with the mesial incline of the buccal cusp of the upper first
premolar (Fig. 3, C) , it is well to move the lower canine slightly to achieve the
proper relation with the upper premolar. The slight space thus created in the lower
anterior arch is taken up by the other anterior teeth without affecting the esthetics.
Sometimes slight grinding of the mesial surface of the upper first premolar will
bring it into the correct relation with the lower canine.
It is sometimes recommended that one of the four lower incisors be eliminated.”
The validity of such a procedure is obviously open to question from the esthetic point
of view, especially when a better alternative is to eliminate one of the least impor-
tant teeth, such as the lower first premolar from the lower arch.
Once the anterior teeth are satisfactorily arranged, the posterior teeth are
arranged. If the posterior ridge relation is normal, a normal arrangement of teeth
is used after the lower first premolars have been removed from the dental arch. In
these situations, if the palatal cusp of the upper first premolar interferes with the
lower canine, it is ground off to remove this interference. The other posterior teeth
do not pose much of a problem in arrangement.
Arrangement of posterior teeth when the upper arch is wider.
 110 Goyal and Bhargava .J. Plosthet. Delit.
July, 1974

Fig. 3. Upper and lower canine relationship: A, Normal; B, C, and D, in maxillary protrusion.

Fig. 4. Mesiodistal relationship of upper and lower posterior teeth after removing lower first
premolar tooth.
Fig. 5. Buccolingual relationship of upper and lower posterior teeth in a wider upper arch.
The shaded portion shows where the wax is added.

THE PROBLEM. In this situation, the lower crest of the ridge in the posterior
region is lingual to the upper residual ridge. This relationship is not very common,
but when present, it may give rise to considerable difficulty in the placement of
upper and lower teeth in their correct occlusal relationship. In such instances, the
upper arch is wider than the lower, and if the upper teeth are placed on the crest
of the ridge, they will make inadequate occlusal contact with the correctly placed
lower teeth. At the same time, if an attempt is made to occlude the lower teeth
with the correctly placed upper teeth, the lower teeth will place too far buccally.
leading to an instability of the lower denture. This is much more detrimental as
the lower denture-bearing area is already very small.
MANAGEMENT. The following methods of correction may be employed.
(1) If the discrepancy is very slight, the upper teeth are moved slightly in a
palatal direction to provide a working occlusal contact with the lower teeth.’ How-
ever, such a procedure has a very limited application as the upper posterior teeth
cannot be moved inside (palatally) to any great extent without affecting phonetics
and cheek support.
(2) If the upper arch is much wider than the lower one, any of the following
methods can be used successfully.
(a) The lower posterior teeth are correctly placed on the crest of the ridge. The
Volume 32 Artificial teeth in abnormal jaw relations 111
Numbrr 1

upper teeth are then set so that they occlude well with the lower teeth. Then the
buccal contours are built on the upper teeth in wax which is later replaced by
tooth-colored acrylic resin to fulfill esthetic requirements and to provide support
for the cheek9 (Fig. 5, A).
(b) Another method can be used alternatively for the same problem. The upper
posterior teeth are arranged first to meet the requirements of esthetics. The lower
teeth are kept on the crest of the ridge. This will result in an unfavorable occlusal
relationship of the upper and lower posterior teeth. In order to establish a functional
occlusal contact between the upper and lower posterior teeth, wax is added on the
palatal aspect of the upper posterior teeth. This wax is later replaced by tooth-
colored acrylic resin. This gives a functionally effective occlusal contact as well as
an esthetically acceptable buccal surface contour of the upper posterior teeth4 (Fig.
5, B). Nonanatomic posterior teeth are best for these procedures as they allow more
latitude in their buccolingual placement.

SUMMARY

The upper-lower ridge relationship is an individual problem for each complete

denture patient. When it is normal, not much effort is needed to obtain a suitable
arrangement of artificial teeth. However, when these relations are abnormal, one
has to deviate from the usual procedures to achieve successful results.
One aspect of the problem of abnormal ridge relations was discussed (i.e., maxil-
lary protrusion and wider maxillary arch and its management during arrangement
of artificial teeth). The two conditions are dealt with separately for the sake of
clarity and better understanding of the problem.

References

1. Nichols, I. G.: Prosthetic Dentistry, St. Louis, 1930, The C. V. Mosby Company, p. 337.
2. Fenn, H. R. B., Liddelow, K. P., and Gimson, A. P.: Clinical Dental Prosthetics,
ed. 2, London, 1961, Staples Press, p.259.
3. Craddock, F. W.: Prosthetic Dentistry. A Clinical Outline, ed. 3, London, 1956, Henry
Kimpton, p. 186.
4. Hardy, I. R., and Passamonti, G.: A Method of Arranging Artificial Teeth for Class II
Jaw Relations, J. PROSTHET. DENT. 13: 606-610, 1963.

GOVERNMENT DENTAL COLLEGE

NEW CIVIL HOSPITAL COMPOUND
AHMEDABAD 380016
GU JARAT, INDIA