OCCLUSION IN FIXED PROSTHODONTICS

Table of contents

Introduction

Terminologies

Mandibular movements

Ideal occlusion

Concepts of occlusion

 Bilateral balanced occlusion

 Unilateral balanced occlusion
 Mutually protected occlusion

Optimum occlusion

Pathogenic occlusion

Occlusal treatment

Review of literature

References
INTRODUCTION

Most restorative procedures affect the shape of the occlusal surfaces. Proper
dental care ensures that functional occlusal contact relationships are restored in
harmony with both dynamic and static conditions. Maxillary and mandibular
teeth should contact uniformly on closing to allow optimal function, minimize
trauma to the supporting structures, and allow for uniform load distribution
throughout the dentition. Positional stability of well aligned teeth is crucial if
arch integrity and proper function are to be maintained over time.

As an aid to the diagnosis of occlusal dysfunction, it is helpful to evaluate the

condition of specific anatomic features and functional aspects of a patient’s
occlusion with reference to a concept of “optimum” or “ideal” occlusion.
Deviation from this concept can then be measured objectively and may prove to
be a useful guide during treatment planning and active treatment phases.

TERMINOLOGIES

 Occlusion is defined as

1. The act or process of closure or being closed or shut off

2. The static relationship between the incising or masticating surfaces of the

maxillary or mandibular teeth or tooth analogues.

 Articulation is defined as the static and dynamic contact relationship

between the occlusal surfaces of the teeth during function
 Centric relation : The maxillomandibular relationship in which the
condyles articulate with the thinnest avascular portion of their respective
disks with the complex in the anterior- superior position against the
shapes of the articular eminences
o This position is independent of tooth contact
o This position is clinically discernible when the mandible is directed
superior and anteriorly
o It is restricted to a purely rotary movement about the transverse
horizontal axis.
 Maximum intercuspal position: The complete intercuspation of the
opposing teeth independent of condylar position, sometimes referred to as
the best fit of the teeth regardless of the condylar position.
  Centric occlusion: The occlusion of opposing teeth when the mandible is
in centric relation. This may or may not coincide with the maximal
intercuspal position.
 In natural dentition, MI position need not coincide with CR. – When
fixed and removable prosthesis are fabricated with existing natural teeth,
they may be made to coincide with the existing normal MI position, if
sufficient natural teeth are present to guide the occlusion.
MI position is made to coincide with CR only when there are insufficient
occlusal contacts existing to guide the occlusion.

MANDIBULAR MOVEMENTS

Complex three dimensional mandibular movement can be divided into

two basic components:

 translation, in which all points within a body have identical motion

 rotation, in which the body is turning about an axis

With the condylar rotation and translation, the mandible is capable of

performing the following movements:

1. Opening
2. Protrusive
3. Lateral excursions- left and right

Opening movement

For this movement to occur, the condyle rotates in its place, in the terminal
hinge position. Pure rotation occurs only till the condyles start to translate
moving out of its centricity. Upon rotation of the condyle, the mandible opens,
and teeth are discluded. As soon as the pure rotation ends, the condyle begins to
translate, moving forward and downward on the superior and anterior walls of
the glenoid fossa, with the arc of opening changing, and the mandible opening
curther till the maximum opening position.
Protrusive movement

For this movement to occur condyles follow the form of the superior wall of the
glenoid fossa, they slide downwards and forwards as the mandible moves in
protrusion. This movement causes the separation of the posterior teeth, a state
known as Disclusion.

During this movement, the opposing inclines of the tooth should not touch each
other. The palatal cusp of the upper molar travels distally from its centric
position in the central fossa of the lower opposing tooth, while the buccal cusp
of the lower travels mesially across the central groove of the upper opposing
tooth. The cusp angle should be in harmony with the angle that the condyle
travels during the protrusive movement, or else a protrusive interference would
exist. The steeper this angle, the more allowable cuspal angle , the longer the
cusps and deeper the fossae.

Lateral excursion movement

The mandible is capable of moving towards both the right and left sides. The
side to which the mandible moves is called the working side, while the opposite
side is called the non-working side.

The working side: the condyle on the working side is called the rotating
condyle, it rotates in its fossa with a little downward and backward movement,
rotating against the superior and posterior walls of the glenoid fossa. The buccal
cusps of upper and lower molars line up, with the lower buccal stamp cusp
moving from its centric position in the fossa of the opposing tooth towards the
buccal along the buccal groove, while the stamp cusp move lingually along the
lower lingual groove. During this movement, any contact that would exist
between the lower buccal cusps or the upper palatal cusps with their opposers
would be considered as working side interferences.

The non working side: the condyle on the non working side is called the
orbiting or translating condyle. The condyle moves medially till it comes in
contact with the medial wall of the glenoid fossa, then moves downwards,
forwards and medially, on the superior and medial walls of the fossa. The
palatal cusps of upper molars line up with the buccal cusps of lower molars. The
buccal cusps of lower teeth moving lingually from their centric position across
the oblique palatal grooves of their lower opponent, during this movement any
contact that would exist between the lower buccal cusps or the upper palatal
cusps with their opposers would be considered as non working side
interferences.

Bennett movement( side shift)

This is the lateral bodily movement of the rotating ( working) condyle, with the
medial movement of the orbiting( non- working or translating) condyle. The
medial wall of the glenoid fossa on the non working side determines the amount
of this movement. The non-working condyle moves medially till it is in contact
with the medial wall.

 Initial side shift: occurs during the initial 2mm of the anterior movement.
The average initial side shift is 1.7mm medially. There is more medial
movement than there is anterior movement.
 Progressive side shift: occurs after the initial side shift, the curve of the
medial wall of the glenoid fossa begins to straighten, there is more
anterior movement with little medial movement.
 Total side shift: initial side shift + progressive side shift
 Bennett angle: angle formed between the mid sagittal plane and the
medial wall of the glenoid fossa on the non- working side (7-8 degrees)

IDEAL OCCLUSION
According to Hobo (1978), ideal occlusion is an occlusion which is compatible
with stomatognathic system providing efficient mastication and good esthetics
without creating physiologic abnormalities.
Characteristics
 Stable posterior contact with vertically directed resultant forces
 MIP coincident with CR along with freedom in centric.
 No posterior contact in eccentric mandibular movements.
 Contact of anterior teeth in harmony with functional jaw
movement.
 Occlusion in Angle’s Class 1

Importance of ideal occlusion

 Use it as a benchmark for assessment of pre treatment records and

examination (diagnostic cast)

 Correcting TMD and occlusal interferences before commencing

restorative procedures.
  For final prosthodontics rehabilitation- to accomplish this a
confirmative approach (where patients pretreatment occlusion is
retained for the prosthodontic rehabilitation), or a reorganized
approach ( where a change in occlusal scheme is planned ) is
utilized.

CONCEPTS OF OCCLUSION

Balanced occlusion

Mutually protected occlusion

Group function occlusion

Balanced occlusion

Bilaterally balanced occlusion: This requires having a maximum number of

teeth in contact in maximum intercuspation and all excursive positions. In
complete denture fabrication, this tooth arrangement helps maintain denture
stability because the nonworking contact prevents the denture from being
dislodged. However, in fixed prosthodontics, it proved to be extremely difficult
to accomplish, even with great attention to detail and with the use of
sophisticated articulators. In addition, rates of failure were high. The rate of
occlusal wear was increased, periodontal breakdown was increased or
accelerated, and neuromuscular disturbances occurred. The last were often
relieved when posterior contacts on the mediotrusive side were eliminated in an
attempt to eliminate unfavorable loading. Thus the concept of a unilaterally
balanced occlusion (group function) evolved.

Unilaterally Balanced Articulation (Group Function)

Schuyler( 1929) introduced the fundamentals of group function occlusion. He

questioned the purpose of the canine and whether it should receive all occlusal
loads during lateral movements.

This type of occlusion occurs when all facial ridges of working side teeth
contact the opposing dentition while the non working side teeth do not contact.

Beyron (1954,1969) listed characteristics of this type of occlusion:

 Teeth should receive stress along the tooth long axis

 Total stress should be distributed among the tooth segment in lateral
movement.
 No interferences occur from closure into intercuspal position.
 Keep proper interocclusal clearance
 Teeth contact in lateral movement without interferences. He felt that no
one occlusion could serve as a general basis for every individual .

In group function occlusion, on the mediotrusive side, no contact occurs

until the mandible has reached centric relation. Thus the load is distributed
among the periodontal support of all posterior teeth on the working side.
This can be advantageous if the periodontal support of the canine is
compromised. On the working side, the occlusal load during functional
movement is then distributed over the periodontal surface area of all teeth in
the quadrant while the posterior teeth on the nonworking side do not contact.
In the protrusive movement, no posterior tooth contact occurs.

Long centric: As the concept of unilateral balance evolved, it was suggested

that allowing some freedom of movement in an anteroposterior direction is
advantageous. This concept is known as long centric. Schuyler was one of
the first to advocate such an occlusal arrangement. He thought that it was
important for the posterior teeth to be in harmonious gliding contact when
the mandible translates from centric relation forward to make anterior tooth
contact. In healthy natural dentitions, centric relation only rarely coincides
with the maximum intercuspation position. However, its length is arbitrary.
At given vertical dimensions, long centric lengths ranging from 0.5 to 1.5
mm have been advocated.

Mutually protected occlusion

Advocated by Stuart and Stallard (1963) based on earlier work by D’Amico.

In this arrangement, centric relation coincides with the maximum
intercuspation position. The six anterior maxillary teeth, together with the six
anterior mandibular teeth, guide all excursive movements of the mandible,
and no posterior occlusal contacts occur during any lateral or protrusive
excursions. In a mutually protected articulation, the posterior teeth come into
contact only at the very end of each chewing stroke, minimizing horizontal
loading on the teeth. Concurrently, the posterior teeth act as stops for vertical
closure when the mandible returns to its maximum intercuspation position.
To maximize occlusal function, posterior cusps should be sharp and should
pass each other closely without contacting.

Advantages of mutually protected occlusion:

 Minimum amount of tooth contact is involved and this makes for

better penetration of food.
 A cusp to fossa relationship produces an interlocking of the upper and
lower components, thereby giving maximum support in centric
relation in all directions. The force is closer to the long axis of the
tooth.
 The arrangement of the marginal, transverse and oblique ridges os that
they have a shearing action, which makes for a much more efficient
chewing apparatus.

The term mutually protected occlusion was changed to organic occlusion

by Stallard and Stuart(1961) and then described by Thomas(1967).

In organic occlusion, the centric relation and maximum intercuspation are

coincident. The posterior teeth are in cusp-fossa relation, one tooth to one
tooth contact. Each functional cusp contacts the occlusal fossa at 3 points
while the anterior teeth disclude by 25 microns. In protrusive movement,
the maxillary 4 incisors guide the mandible and disclude the posterior
 teeth. In lateral movements, the lingual surface of the maxillary canine
guides along the distal incline of the mandibular canine and the mesial
ridge of the 1st premolar facial cusp; this also has been called disclusion.

Contraindications for mutually protected occlusion:

 When the masticatory cycle is horizontal

 The periodontium is compromised
 Missing canine or a prosthetic canine
 Arbitrary amounts of posterior disclusion

CONCEPT OF OPTIMUM OCCLUSION

In an ideal occlusal arrangement, the load exerted on the dentition should be

distributed equally. Any restorative procedures that adversely affect the occlusal
stability may affect the timing and intensity of the elevator muscle activity.

 Loading should be parallel to the long axis of the tooth.

 Horizontal forces on any teeth should be avoided.
 There should be cusp to fossa occlusal arrangement
 During excursive movements, there should be no posterior tooth contact
(decreased horizontal forces)
 The cusps of the posterior teeth should have adequate height to enhance
masticatory efficiency.

PATHOGENIC OCCLUSION

A pathogenic occlusion is an occlusal relationship capable of producing

pathologic changes in the stomatognathic system. In such occlusions,
disharmony between the teeth and the TMJs is sufficient to result in
symptoms that necessitate intervention.

Signs and symptoms:

Teeth: The teeth may exhibit hypermobility, open contacts, or abnormal

wear.

 Hypermobility of an individual tooth or an opposing pair of teeth is

often an indication of excessive occlusal force. This may result from
premature contact in centric relation or during excursive movements.
To detect such contacts, the dentist can place the tip of an index finger
 on the crown portion of the mobile tooth and ask the patient to
repeatedly tap the teeth together. Small amounts of movement
(fremitus) that otherwise might not be readily seen can often be felt
this way.
 Open proximal contacts may be the result of tooth migration because
of an unstable occlusion and should prompt further investigation
 Abnormal tooth wear, cusp fracture, or chipping of incisal edges may
be signs of parafunctional activity.
 Extensive tooth destruction is often caused by a combination of acid
erosion and attrition. In these cases, the acid may be present in the diet
(e.g., excessive citrus fruit consumption) or endogenous (caused by
regurgitation or frequent vomiting).

Periodontium :

 A widened periodontal ligament space (detected radiographically)

may indicate premature occlusal contact and is often associated with
tooth mobility
 Isolated or circumferential periodontal defects are often associated
with occlusal trauma.
 In patients with advanced periodontal disease who have extensive
bone loss, rapid tooth migration may occur with even minor occlusal
discrepancies.

Musculature:

Acute or chronic muscular pain on palpation can indicate habits associated with
tension, such as bruxism or clenching. Chronic muscle fatigue can lead to
muscle spasm and pain. Restricte opening, or trismus, may be a result of the fact
that the mandibular elevator muscles are not relaxing.

TMJ:
Pain, clicking, or popping in the TMJs can indicate temporomandibula
disorders. Clicking may also be associated with internal derangement of the
joint. A patient with unilateral clicking during opening and closing (reciprocal
click) in conjunction with a midline deviation may have a displaced articular
disk. The midline deviation typically occurs toward the side of the affected joint
because the displaced articular disk can prevent (or slow down) the normal
anterior translator movement of the condyle.
MPDS:

The myofascial pain dysfunction (MPD) syndrome manifests as diffuse

unilateral pain in the preauricular area, with muscle tenderness, clicking, or
popping noises in the contralateral TMJ and limitation of mandibular function.

Three major theories about the cause of MPD are recognized:

(1) According to the psychophysiologic theory, MPD results from bruxism and
clenching, whereby chronic muscle fatigue leads to muscle spasm and
alterations in mandibular movement. Tooth movement may follow, and the
malocclusion becomes apparent when spasm is relieved. According to this
theory, treatment should focus on emotional rather than physical therapy.

(2) According to the muscle theory, continuous muscle hyperactivity is

responsible for MPD; pain is referred to the TMJ and other areas of the head
and neck region.

(3) According to the mechanical displacement theory, malocclusion of the teeth

displaces the condyles, and the feedback from the dentition is altered, which
results in muscle spasm.

Patients with MPD may require multidisciplinary treatment involving occlusal

therapy, medications, biofeedback, and physical therapy. Extensive fixed
prosthodontic treatment should be postponed until the patient’s conditions have
been stabilized at acceptable levels.

OCCLUSAL TREATMENT

When a patient exhibits signs and symptoms that appear to be associated with
occlusal interferences, occlusal treatment should be considered.

The objectives of occlusal treatment are as follows:

1. To direct the occlusal forces along the long axes of the teeth
2. To attain simultaneous contact of all teeth in centric relation
3. To eliminate any occlusal contact on inclined plane to enhance the
positional stability of the teeth
4. To have centric relation coincide with the maximum intercuspation
position
5. To arrive at the occlusal scheme selected for the patient
Occlusal device therapy

Occlusal devices (occlusal splints /occlusal appliances, or orthotics) are used

extensively in the management of temporomandibular disorders and bruxism.
Occlusal devices are particularly helpful in determining whether a proposed
change in a patient’s occlusal scheme will be tolerated. The anticipated occlusal
scheme is mimicked in an acrylic resin overlay, which allows testing the
patient’s acceptance through reversible means, although at a slightly increased
vertical dimension. If a patient responds favorably to an occlusal device, it is
reasonable to assume that the response to restorative treatment will be positive
as well. Thus occlusal device therapy can serve as an important diagnostic
procedure before initiation of fixed prosthodontic treatment. The device can be
made for either the maxillary or mandibular arch. Some clinicians express a
preference for one or the other and cite advantages; however, both maxillary
and mandibular devices have proved satisfactory.

REVIEW OF LITERATURE

Long-term follow-up of cross-arch fixed partial dentures in patients with

advanced periodontal destruction: evaluation of occlusion and subjective
function
S.W. YI, G.E. CARLSSON, * I. ERICSSO N & J.L. WENNSTRO M
A study was done to investigate occlusal factors in fixed partial dentures
(FPDs) still in service for more than 10 years, and to assess the patients'
opinions regarding oral function with these constructions. 34 patients
with 43 FPDs were examined clinically concerning occlusion and by
means of a questionnaire on functional aspects.
The most common occlusal contact pattern was group function (51% on
hoth sides, 7% on one side) while canine protected occlusion was
recorded in 16% on both sides, 7% on one side. Balanced occlusion
(19%) was mainly found when the FPD occluded against a complete
denture and when there were few abutments and a small amount of
abutment supporting tissue.
The number and intensity of the occlusal contacts were assessed by
means of thin occlusal sheets (50 pm).
On average, one occlusal contact was observed on each dental unit with
antagonist. The average number of sheets that could be introduced
 between the antagonists when the patient bit hard in the intercuspal
position was two without significant differences between different areas
(anterior/posterior) or type of dental unit (abutment, pontics, cantilever
section). In the cantilever sections there were looser contacts (more
interocclusal sheets) more distally. Subjective function was not
significantly influenced by FPD design, occlusal factors or number of
FPD units.

Influence of Fixed Prosthodontic Treatment on Occlusal Contacts in Centric

Occlusion: A Preliminary Study

Jaafar abduo, Journal of Advances in medicine and Medical Research

A study was done to evaluate the impact of prosthodontic treatment on

intercuspal occlusal contacts in relation to contact number and contact
area. The pre-treatment and post-treatment models of 13 patients who
underwent fixed prosthodontic treatment on several teeth were retrieved.
All the models were scanned by a Micro-CT scanner and 3D virtual
images were established. Two occlusion variables were evaluated: (1)
contact number and (2) contact area. In addition, the impact of the inter-
arch location (maxillary vs. mandibular arches) and intra-arch location
(anterior vs. posterior teeth) was assessed.
It was found that the prosthodontic treatment had significantly increased
the contact number and contact area. The effect of the inter-arch location
was insignificant. The intra-arch location had significantly affected the
contact number and area, where the posterior teeth had a significantly
greater contact number and area. The posterior teeth were more
influenced by the prosthodontic treatment than the anterior teeth, while
the anterior teeth were minimally influenced.it was concluded that the
prosthodontic treatment improved the quality of occlusal contacts by
increasing the contact number and area.

CONCLUSION
Peter E Dawson states that “ without specific treatment goals, treatment
success cannot be measured”
5 requirements of occlusal stability according to Dawson:
 Stable holding contacts on all teeth when the condyles are in
centric relation
  Anterior guidance in harmony with the envelope of function
 Immediate disclusion of all posterior teeth the moment the
mandible moves forward of centric relation
 Immediate disclusion of all posterior teeth on the nonworking side
 Non interference of all posterior on the working side with either the
lateral anterior guidance or the border movements of the condyles.

All occlusal treatments should have specific goals. Criteria for success are an
essential requirement for achieving successful complete dentistry.

REFERENCES
 Rosenstiel SF, Land MF, editors. Contemporary fixed prosthodontics-e-book.
Elsevier Health Sciences; 2015 Jul 28.
 Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of
fixed prosthodontics. Quintessence Publishing Company; 1997 Jan.
 Pokorny PH, Wiens JP, Litvak H. Occlusion for fixed prosthodontics: a historical
perspective of the gnathological influence. The Journal of prosthetic dentistry.
2008 Apr 1;99(4):299-313.
 Yi SW, Carlsson GE, Ericsson I, Wennström JL. Long‐term follow‐up of cross‐
arch fixed partial dentures in patients with advanced periodontal destruction:
evaluation of occlusion and subjective function. Journal of oral rehabilitation.
1996 Mar;23(3):186-96.
 Abduo J. Influence of fixed prosthodontic treatment on occlusal contacts in
centric occlusion: a preliminary study. Journal of Advances in Medicine and
Medical Research. 2015:1580-9.
 Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier
Health Sciences; 2006 Jul 31.