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R E S T O R A T I V ER EDS ETNO TR IASTTI RV YE D E N T I S T RY

Making Occlusion Work: 2.


Practical Considerations
A.J. MCCULLOCK

stable maxillomandibular relationship


Abstract: In the first of these two articles, occlusal terminology, techniques for should be developed to allow
examining the occlusion, articulators and interocclusal records were discussed. Here
the authors consider some of the practical applications.
reproducibility of the jaw registration and
stability of restorations and teeth. The
Dent Update 2003; 30: 211–219 retruded position is the only relatively
reproducible position of the mandible
Clinical Relevance: A practical knowledge of occlusion is required for successful that is physiologically acceptable.
placement of the smallest and largest restorations.
When the reorganized approach is
indicated, and this is in a small number of
patients, the new ICP is established by:

l occlusal splint therapy to achieve

R estorations must be planned and


designed to fit harmoniously with
the complexities of the neuromuscular
occlusal scheme is to be reorganized to
create a new and stable position, the final
restorations are made to the new ICP that
muscle relaxation,1 allowing the
condyles to move into the retruded
position;
control system, the temporomandibular coincides with RCP and may involve a l elimination of RCP–ICP discrepancy
joints (TMJs) and supporting structures change to the occlusal vertical dimension using provisional restorations,
of the teeth without introducing occlusal (see previous article for abbreviations). occlusal equilibration, additions to
interferences. A stable posterior The factors to be considered are given existing partial dentures to restore
occlusion with smooth uninterrupted in Table 1. the OVD, and orthodontics;
protrusive and lateral movement of the A functional stable posterior occlusion l final restorations when
mandible is necessary. Once the exists when enough teeth are in maxillomandibular relationships are
occlusion has been assessed, which may simultaneous even contact to direct stable.
require articulated study casts, the occlusal forces axially, stabilizing the
decision must be made as to which type positions of both the teeth and the TMJs. In the previous article two theories were
of occlusal scheme should be used for Appropriate posterior stability distributes mentioned describing idealized occlusions
the restorations. occlusal forces over a wide area, – gnathology and Pankey-Mann-Schulyer.
preventing damage to the individual A third concept, of a dynamic individual
components of the masticatory system. occlusion, has developed, based on the
TO CONFORM OR Loss of posterior stability may result fact that not all dentitions fit into a
REORGANIZE? in: prescribed concept and so a more
Before embarking on treatment the functional approach should be adopted.
practitioner must decide whether to l increased toothwear; However, one fact is clear: that an
provide restorations within the existing l mechanical failure of teeth or occlusion should be stable and thus
occlusal scheme (the conformative restorations; ideally ICP and RCP should coincide when
approach) or to change it deliberately l hypermobility, drifting, rotation and an occlusion is reorganized.
(the reorganized approach). If the entire tilting;
l mandibular dysfunction.
STABLE TOOTH CONTACTS
A.J. McCullock, BDS, MSc, FDS RCS, MRD, MRD RCS In the presence of mandibular The morphology of the occlusal
(Edin.), Consultant in Restorative Dentistry, Lister
Hospital, Stevenage, Hertfordshire.
dysfunction, which is not always the surfaces of restored posterior teeth is
case in unstable ICP relationships, a influenced by anterior guidance and

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Posterior occlusion Stable Unstable indicated before restoration when:


No. of teeth for restoration Small (>6) Large
Slide from RCP to ICP Large/small Large/small l the opposing tooth has over-
Drifting of anterior teeth No Yes erupted into an existing under-
Mandibular dysfunction No Possibly contoured or scooped out
restoration, producing a ‘plunger’
= Stable ICP = Unstable ICP cusp;
Conformative approach Reorganized approach l tilted or over-erupted teeth have
Table 1. Factors to be considered when considering provision of restorations. produced an uneven occlusal
plane;
l the tooth to be restored has a
the angulation of the condylar paths. the occlusion has been assessed and non-working side interference;
Stable occlusal contacts in ICP are unwanted contacts identified, l the tooth to be restored creates an
generated using a tripodized, cusp to adjustments can be made in the mouth, occlusal interference in the
fossa or cusp to marginal ridge contact if uncomplicated, or through trial retruded path of closure.
relationship according to preference, adjustments on articulated casts
restoring the intercuspal relation of (Figure 2) to establish their effect. Contacts in RCP should be adjusted
the posterior teeth in the retruded Such mock equilibrations allow an first, then the lateral and, finally, the
position (Figure 1). In many natural accurate assessment of the effects of protrusive interferences. Before the
dentitions supporting cusps contact tooth adjustment and correct planning teeth are touched with a bur the effect
opposing marginal ridges in ICP, of the stages of the adjustment of each adjustment must be
directing occlusal forces along the without damaging the teeth. anticipated. Adjustments to contacts
long axis of the tooth. The cusp to Selective occlusal adjustment is on maxillary teeth will move the point
fossa theory suggests that restored
cusps should contact triangular fossae
developed on the mesial or distal
aspects of posterior teeth. This
pattern is suited to producing
restorations against an existing
occlusion. A tripodized occlusion has
each of the supporting cusps
contacting the opposing teeth at three
points, suspending the cusp tips B L
above the opposing fossa and
preventing them making contact.
Protrusive guidance should
immediately separate posterior teeth
and in lateral movement the working
guidance should immediately disclude
teeth on the non-working side. The
steepness of anterior guidance directly
influences the angle of the cuspal
inclines. To achieve immediate Figure 1. (a) Cusp tip to fossa contact. (b) Tripodized relationship: each cusp tip contacts the
opposing tooth at three points.
posterior disclusion in canine
guidance, mandibular cusps must be
able to glide between maxillary cusps a b
without interference. When anterior
guidance is steep cusps can be made
steep and the fossae deeper.

OCCLUSAL ADJUSTMENT
Occlusal interferences occurring
during mandibular movement may Figure 2. (a) Articulated casts covered in indicator varnish. (b) Trial adjustments to show the
require adjustment before restorative effect of the procedure on the next point of contact.
procedures are contemplated. Once

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objectives for various clinical


a b
situations of increasing complexity is
discussed in the following paragraphs.

Small Number of Units to be


Restored
A single unit or a couple of units must
fit into the existing occlusal scheme
Figure 3. (a) Checking tooth contacts with Shimstock before cementing a bridge. (b) Same (conformative approach) and provide
contacts verified after cementation. the correct supporting cusp contacts.
Before tooth preparation the occlusal
contacts must be checked with
articulating paper and Shimstock, not
of contact buccally and mesially; by ensuring: tooth-to-tooth only on the tooth to be prepared but
those on mandibular teeth will be contact in ICP; no slide from RCP also on the adjacent teeth. The same
moved lingually and distally. This will to ICP if reorganizing the contacts can be verified on the
help in deciding which points to adjust occlusion; no occlusal articulated working casts. At the try-in
when opposing teeth have been marked interferences; correct guidance in stage, ICP and lateral contacts should
by articulating paper, remembering that lateral excursions. be checked with articulating paper on
cusp tips are sacrosanct. If, for l There should be no mandibular the restoration and Shimstock on the
example, the marked contact falls on the dysfunction. adjacent teeth (Figure 3).
lingual facing incline of a maxillary l Thickness of restorative materials When the distal tooth in an arch is
buccal cusp and the buccal facing must be adequate. prepared it is especially necessary to
incline of the opposing mandibular l Occlusal contour of restorations ensure the occlusal record is accurate,
cusp, the latter contact should be must be correct. as errors can readily be introduced
adjusted as the contact will then move l Occlusal vertical dimension must with the vertical dimension if the casts
towards the centre of the tooth. be correct. are tipped or rotated. One way to
For more detailed information readers guarantee accuracy is to try-in self-
are referred to expanded texts on the The practical application of these curing acrylic resin copings, ensuring
mechanisms of occlusal adjustment.2

a b
RESTORATION OF
POSTERIOR TEETH
The posterior teeth provide stable
vertical and horizontal relationships
between the mandible and maxilla.
When planning any posterior
restoration, the practitioner must
consider the following questions:
Figure 4. (a) Self-curing acrylic copings on distal abutments to verify occlusal contacts on the
cast. (b) Ensuring contact and assessing available space for correct thickness of material for
l Is ICP stable?
crown.
l What are the anterior tooth
contacts?
l What design of tooth preparation? a b
l How even is the occlusal plane?
l Occlusal vertical dimension –
adequate or reduced?
l What type of occlusal scheme is
desirable – conformative or
reorganized?

The objectives are: Figure 5. (a) Single-quadrant interocclusal record and (b) self-curing acrylic copings. The over-
erupted first molar has been prepared and waxed-up to produce an even occlusal plane.
l To leave stable occlusal contacts

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Reduced Vertical Dimension


a b Associated with Short Clinical
Crown Height
Both the OVD and ICP may be altered
in this situation (Figure 6). Such cases
usually require restoration in RCP and
the production of a stable and
coincident ICP using the reorganized
approach. Occasionally, the anterior
tooth contact and condylar position are
c d stable, allowing the existing ICP to be
used. The details of recording the OVD
were discussed in the previous article.
On articulated study casts mounted
in RCP at the correct OVD, occlusal
adjustments are carried out to eliminate
any discrepancy between RCP and ICP.
These are then carried out on the
patient’s teeth as an occlusal
e Figure 6. (a) Occlusion in ICP at a reduced equilibration. On the casts, the teeth to
vertical dimension. (b) Teeth in RCP showing be restored are next prepared and
restored vertical dimension and creation of waxed up to full contour, bringing them
space anteriorly. (c) Diagnostic wax-up in into occlusal contact with the opposing
RCP. (d) Composite resin build-ups on
anterior teeth in RCP at the new vertical arch. The new ICP and OVD are
dimension. (e) Metal ceramic crowns maintained by developing the cusp
duplicating the occlusal scheme developed height and fossa depth. Temporary
using the composite restorations. restorations are constructed from this
wax-up and cemented onto the
prepared teeth; minor occlusal
adjustments may be necessary to
develop coincident ICP and RCP.
the occlusal contacts on the teeth are unchanged the approach is The patient is reviewed over several
the same as on the casts (Figure 4). The conformative. weeks to check his/her adaptation to
thickness of the copings can also be The inter-occlusal record (Figure 5) is the new occlusal scheme. This is
measured to see how much available taken following adjustment and tooth determined by a lack of symptoms from
space has been created. preparation. This only needs a record the TMJs, a feeling of comfort and
of the relationship on the prepared side, stability of the restorations. Definitive
providing a full arch impression has restorations are then made duplicating
Single Quadrant been taken and there are adequate the newly established occlusion.
Following loss of posterior teeth in a occlusal contacts on the contralateral
quadrant the antagonistic teeth may side to maintain stability.
over-erupt or tilt, producing an uneven Multiple Units in One Arch
occlusal plane. Unless the over- If most occlusal contacts will be lost in
erupted teeth are recontoured by Opposing Quadrants the preparation of teeth, then a
selective occlusal adjustment or In this situation the occlusal plane and reorganized approach should be used.
restoration, any replacement of the curves of Spee and Monson can be A diagnostic wax-up on articulated
missing teeth will have contact in ICP restored to produce the most casts in RCP will determine the new
and an irregular occlusal form that is favourable occlusal contacts. The OVD position of ICP and temporary
determined by the shape of the is maintained by tooth contact restorations will be constructed
opposing teeth. By eliminating the anteriorly and on the contralateral side, maintaining the occlusal vertical
irregularities, a harmonious occlusal posteriorly by the condylar position in dimension (Figure 7).
contour will be created that ensures ICP using the conformative approach.
stable ICP contacts and avoids lateral When the abutment teeth form
interferences. The replacement has interferences and ICP is unstable it is Full Mouth Rehabilitation
been developed to a modified advisable to reorganize the entire The restoration of all four quadrants
occlusion, but as ICP remains occlusion. together requires that all the

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with articulating paper. Matt gold


a b surfaces more easily show such marks
and should be used at the try-in stage
to verify occlusal contacts before
polishing and cementation.
Gold occlusals would be preferred
where:

l there is a history of parafunctional


activity;
c d l clinical crown height is reduced;
l optimal occlusal control is
necessary in the reorganized
approach.

RESTORATION OF
ANTERIOR TEETH
Figure 7. The replacement of a maxillary denture and crowns. (a) The displaced maxillary Preoperative considerations:
denture. (b) Palatal view of the restorations and edentulous space. (c) Complete arch diagnostic
wax-up in RCP. (d) Temporary bridge replacing all the maxillary restorations. The missing teeth l stability of ICP;
were replaced by single tooth implants and the remaining teeth crowned. l reproduction of correct palatal
contours;
l tooth preparation;
determinants of occlusion be developed stable ICP contacts. The wear l metal coping design;
in unison. It is advisable to provide characteristics of direct composite l protrusive and working guidance;
long-term temporary restorations in resins are less favourable and more l incisor relationship;
such cases as the patient’s tolerance abrasive to the opposing dentition: l phonetics and appearance.
to changes in ICP, RCP, excursive this material should not be used when
movements and possibly the OVD restoring large cavities where tooth Objectives (in addition to the
must be monitored over a long time. contact is solely on the material. Small posterior objectives):
The proposed changes can be Class II restorations can be restored
gradually introduced on the temporary with composite, providing that the l even distribution of forces in
restorations, which are easier to adjust occlusal contacts are primarily on the incisal guidance;
or add to. Such restorations should tooth and not the material. l immediate posterior disclusion
have a metal substructure overlaid with (except in Class III occlusions).
acrylic or composite resin. The Porcelain versus Gold
principles of a reconstruction are no Porcelain occlusal surfaces offer
different from those already described. improved posterior aesthetics but the Anterior Guidance
The treatment plan is divided into technique for developing them is more The anterior teeth are in a balanced
four stages: difficult than in gold and the highly position determined by the lips,
polished surface does not readily mark tongue, occlusal relationship and
1. Occlusal splint therapy.
2. Occlusal equilibration so that ICP
= RCP.
3. Restoration of the anterior teeth. a b
4. Restoration of the posterior teeth,
either by opposing quadrants or
all at one time.

Materials for Restoring


Occlusal Surfaces
Amalgam is an excellent material for Figure 8. (a) A Class II division II incisor relationship with a complete overbite. (b) Shortening the
restoring posterior teeth as it has a lower incisors and building out the palatal surfaces creates stable occlusal contacts.
high resistance to wear, producing

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into protrusion and lateral excursions.


a b Anterior guidance can be duplicated
on an articulator with a customized
incisal guidance table. Self-cure acrylic
resin is shaped by moving the upper
member of the articulator while
maintaining contact with the incisors
and canine tooth on the study casts.
The incisal pin carves out a path in the
setting resin resembling a Gothic arch
c d tracing (Figure 9). This technique is
used when a new reorganized guidance
to which a patient has adapted has been
established on multiple temporary
crowns or when the existing guidance
must be copied.
The canine tooth has a favourable
crown/root ratio for absorbing occlusal
forces as well as a root configuration
e Figure 9. (a) Failing bridgework. (b) Short providing greater surface area, more
clinical tapering crown preparations. (c) periodontal ligament and proprioception
Immediate temporary bridge. Anterior than adjacent teeth.3 It is eminently
guidance was established on the bridge in the suited to guide lateral excursive
mouth, allowing the retention of the re-
prepared teeth to be checked as well as the
mandibular movements and produce
stability of the occlusal contacts. (d) A immediate disclusion of the posterior
customized incisal guidance was produced on teeth. Scaife and Holt4 reported an
the articulator to copy the anterior guidance incidence of 57% bilateral canine
developed in the mouth. (e) The definitive guidance in 1200 individuals. There is
crowns and bridge restoring the upper arch
using a customized incisal guidance table,
little scientific evidence to assist in
ensuring duplication of the palatal surfaces of identifying exactly what canine
the temporary restorations. guidance should be. McHorris5
suggested that the disclusive angle
(which governs the palatal contour of
the working canine) should be 5o greater
alveolar bone support. Changes to the In Class II division I incisor than the condylar guidance angle.
shape of the teeth can produce relationships the overbite and overjet There are several mechanical
unwanted movement if these factors will be increased, leading to the advantages in providing canine
are disrupted, leading to migration, mandibular incisors occluding to the guidance:
rotation over-eruption or formation of palatal aspect of the cingulum close to
diastema. Restorations must be placed the dentogingival junction. If this l easier access in the front of the
in this balanced envelope to achieve relationship is copied in maxillary mouth for adjustments;
stability and longevity. Anterior restorations, ICP contacts may become l smooth mandibular movements can
guidance should provide smooth even unstable, leading to an increase in be produced with immediate
contact on as many anterior teeth as tooth mobility, migration and splaying. disclusion posteriorly;
possible from ICP through the The incisal guidance can be altered by l recording and producing canine
excursions discluding the posterior building out the palatal surfaces of the guidance is less complicated, both
teeth immediately. It should be shallow, restorations to provide occlusal rests in clinically and technically.
work harmoniously with condylar the area of contact of the lower teeth; it
guidance and fit in with the skeletal and may also be necessary to shorten the
incisor relationship, appearance and mandibular incisors. The edges are Occlusion on Pontics
speech. If a single tooth is to be reduced horizontally to produce a flat Occlusal contacts on full-sized pontics
restored the existing guidance can be rather than bevelled incisal edge, which should be in ICP. When the canine is
readily duplicated. When all the would make it difficult to achieve stable replaced by a pontic on a fixed bridge
anterior teeth are to be restored some contacts (Figure 8), especially in Class canine, guidance can be developed,
changes to the guidance, crown II division II relationships. This will providing there are anterior and
position and appearance can be made. create harmonious movements from ICP posterior retainers. If a cantilever bridge

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is made using the premolars, group occlusion requires a high level of skill
function should be developed. and knowledge from both technician ACKNOWLEDGEMENT
The author thanks Mr Stephen Davies for his
The occlusal contacts on a simple and clinician to ensure a good result. constructive comments on these two articles.
cantilever bridge must be in ICP on A functional dynamic approach to
both units but the pontic must be free occlusion based on theoretical
of any lateral contacts. This reduces principles is a useful concept in
the lateral forces on the pontic that restorative dentistry. Most patients REFERENCES
would otherwise cause a lever effect, require little more than an acceptance of 1. Gray SJ, Davies SJ, Quayle AA. A Clinical Guide to
Temporomandibular Disorders. London: BDJ Books,
forcing the bridge to rotate outwards. their existing occlusions, ensuring that 1997; pp.39–42.
restorations fit into their individual 2. Dawson PE. Occlusal adjustment In: Evaluation,
schemes, providing they are harmonious Diagnosis and Treatment of Occlusal Problems. St Louis:
CONCLUSION and stable. There are a number of C.V. Mosby, 1974; pp194–206.
3. Bonaguro JG, Dusza GR, Bowman DC. Ability of
The basic principles in restoring approaches to extensively reorganizing human subjects to discriminate forces applied to
anterior and posterior teeth have been the occlusion that will produce an certain teeth. J Dent Res 1969; 48: 236.
discussed, highlighting the necessity acceptable result, providing the 4. Scaife PR, Holt JE. Natural occurrence of canine
guidance. J Prosth Dent 1969; 22: 225.
for careful preoperative planning. The underlying principles of each theory are
5. McHorris WH. Occlusion with particular emphasis
conformative approach is applicable to fully understood and their individual on the functional and parafunctional role of
most patients: reorganizing an practical application adhered to. anterior teeth. J Clin Orthod 1979; 13: 684.

illustrated at different stages of


BOOK REVIEW
treatment. Advantages and pitfalls of
the treatment mechanics are
Invisible Orthodontics: Current mentioned as the cases progress to
Concepts and Solutions in Lingual completion. The precision involved in
Orthodontics. By Giuseppe Scuzzo loop mechanics not only bears a
and Kyoto Takemoto. Quintessence heavy resemblance to laborious wire
Books, New Malden, 2002 (173 pp., bending in edgewise mechanics, but
£65.00 h/b). ISBN 3-87652-181-5. seems more demanding when trying
to fit these systems intra-orally.
Lingual orthodontics has been part of Sliding mechanics also requires
the orthodontic profession for some greater care because the force
time, although apparently only about moment ratios are applied differently
10,000 orthodontic cases are treated from the lingual aspect and these
using this technique in Europe, Japan then tend to tip teeth in unwanted
and the USA. Considering the high directions. In the final chapter, the
numbers of orthodontic cases treated authors describe the various ways in
each year worldwide, the number of which the finished results are retained
clinicians using lingual orthodontics with lingual retainers, clear
must be very small. to four different laboratory positioning splints and transparent
The authors have written this book techniques in the pre-clinical set-up retainers.
largely on their own experiences and of lingual orthodontics. The book This book will be of interest to
are well supported with excellent seems to emphasize the reliance upon postgraduate students and
illustrations of case studies. The good technicians and laboratory orthodontic practitioners who want to
book starts by introducing the topic facilities which may be a reason for develop a private ‘invisible
of lingual orthodontics aimed at its limited use. orthodontics’ practice. It provides an
specialist orthodontists. It skips over The well illustrated case reports excellent overview of the lingual
the diagnostic and therapeutic indicate how the lingual appliance technique and has brought to light
considerations in lingual technique can be utilized to a high the immense technical skills from both
orthodontics and suggests useful standard. The malocclusions laboratory and clinician in the
hints for successful treatment. These presented certainly require some treatment of a single case. Although
include the use of loop mechanics, lateral thinking and boldness in this book is not fully comprehensive,
power arm auxiliaries and force execution, even for most well- it does provide a structured approach
delivery systems and mechanics in seasoned orthodontists. Two to lingual orthodontics.
lingual orthodontic extraction cases. contrasting biomechanics, closing C.H. Kau and S. Richmond
Two chapters of the book are devoted loops and sliding mechanics, are Cardiff Dental School

Dental Update – May 2003 219

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