Chapter: Reorganising the Occlusion

Reorganising the Occlusion

Introduction

A “reorganised occlusion” is an occlusion in which the pattern of occlusal contacts is deliberately changed or
reconstructed.1

What’s the point?

Reorganising the occlusion is done because the existing ICP is unsatisfactory for your restorations, or because
there is a specific problem that can only be solved by reorganising the occlusion. 1 This can be further
explained using some examples.

Example 1: The complete denture (Figure 1)2

When you make a set of complete dentures you are effectively rebuilding the
occlusion so that the teeth bite together without displacing the denture.
Usually we reorganise the occlusion and use the jaw position determined by
the TMJ as our starting point. This is of course Centric Relation.
Figure 1: edentulous – no
teeth, therefore no occlusion.2

Example 2: Protecting and restoring a worn dentition (Figure 2) 3

Excessive wear leads to poor appearance, poor function, sensitivity and pulp
damage. To relieve symptoms the teeth need to be covered or reconstructed
with a restorative material. The extent of treatment depends whether wear is
localised or generalised.

Localised anterior wear can be managed using a Dahl approach (Figure 2).
This aims to open the bite posteriorly allowing the posterior teeth to erupt
into the new occlusion. The anterior teeth can then be restored utilising the
space created.

Generalised wear, or when the posterior teeth require extracoronal

restorations, requires a more extensive plan. Teeth need to covered or
rebuilt so that the upper and lower teeth fit together again in a stable
scheme that spreads the occlusal load predictably around the dental arches. 1
This is what we think of classically as reorganising the occlusion. 1

Figure 2: a,b) Pre-operative view of the worn anterior teeth. c) Immediate post-operative view
in ICP following the placement of direct composite restorations 11, 21, 41 and 42 at an
increased vertical dimension of occlusion. d) Re-establishment of occlusal contacts at 3
months.3

The Principles of Reorganising

Adam Jowett
 Chapter: Reorganising the Occlusion
Principle 1: Rebuild the new occlusion around a reproducible position

In situations where there are no teeth or the existing ICP is unsatisfactory, CR is normally used as the basis for
constructing a new ICP.1 If you cannot manipulate your patient into CR, it is best not to embark on
reorganising the occlusion.1

If the patient has a TMD, the general principle is to diagnose it first, and then treat it by conservative means
before embarking on restorative work.1

Principle 2: Decide on the vertical dimension

At what position on the CR hinge axis will the occlusion be reorganised?

In complete dentures the rest position is used as a reference point. A freeway space of 2-3mm is usually used.

When teeth are present, there are no fixed rules, as the rest position readjusts to accommodate most
reasonable increases in vertical dimension, as long as a stable occlusal scheme is provided. 1 If you need to
construct aesthetic restorations, the amount of space needed for your restorations will determine the new
vertical dimension.1 A stabilisation splint may be prescribed to test any change in vertical dimension prior to
placing any expensive restorations.

Principle 3: Create stability in ICP and avoid damage in excursions – You need an occlusal scheme!

Various occlusal schemes are described in the literature and are shown in Table 1 (see below). In summary, all
schemes use CR as the starting point for construction, however they all differ in their choice of guidance teeth
and the pattern of ICP contacts.

The small differences between schemes are probably not very important. The most important thing is to have
a predetermined plan as to how your patient’s teeth will fit together and which teeth will provide guidance.

Table 1: Features of some of the best known occlusal schemes 1

Adam Jowett
 Chapter: Reorganising the Occlusion
Occlusal Scheme RCP-ICP relationship Excursive Contacts Comments
Pankey-Mann-Schuyler Area of freedom Anterior guidance Considerable potential
(1963) between ICP and RCP determined functionally for error with
(<0.5mm) and on temporaries. functionally generated
morphology functionally Canine guidance or group path technique - used to
generated. function. determine occlusal
morphology of posterior
teeth.
Gnathological (1964) Coincident, with tripod Canine Guidance. Good for cases without
contacts. Posterior disclusion in all large horizontal RCP-ICP
excursions. slide.
Anterior and Posterior Fully adjustable
contacts are mutually articulator should be
protected. ψ used.
Youdelis (1977) Coincident, with tripod Same as Gnathological, Useful where excursive
contacts. but designed to drop into parafunction cannot be
group function if canines controlled or where
wear or move. canine is compromised.
Area of freedom in Freedom between ICP Canine guided or group Useful where there has
centric ζ (1982) and RCP (0.5mm ± function. Anterior been a large horizontal
0.3mm). guidance will be delayed component in the RCP-
Cusp to fossa occlusion. during posterior contact ICP slide prior to
in area of freedom. treatment.
Area of freedom needs
careful adjustment.

ψ “Mutually protected” means that in ICP, the posterior teeth support maximum biting force while the anterior teeth are out of
contact, but in excursions the anterior teeth provide guidance to disclude the posterior teeth and protect from lateral loading. 1

ζ “Freedom in centric” occlusion occurs when the mandible is able to move anteriorly for a short distance in the same horizontal and
sagittal plane while maintaining tooth contact. 4

The new ICP

The ICP is usually quite stable, with the maxillary and mandibular teeth fitting together like a lock and key. 1
When a new ICP is built, it needs to be stable too. Cusp and fossa need to fit together securely when the jaws
are closed, otherwise teeth will drift and overerupt.

Occlusal surfaces will be stable provided that cusps and preferably fossae, rather than marginal ridges of
opposing teeth, are aligned to direct loads down long axis rather than obliquely. 1

The gnathological literature goes further, stating that the perfect cusp to fossa relationship will be a tripod
contact, consisting of three discrete contacts around the cusp tip for perfect stability. This can be difficult to
achieve and is often lost as restorations wear. 1

It is the practitioner’s responsibility to select the appropriate materials to restore the occlusal surfaces
recognising that some materials may cause excessive wear e.g. porcelain against tooth or metal therefore the
sensible option is to adopt a like-against- like policy. Metal alloys are less damaging to tooth than porcelain.

Good practice and common sense with respect to guidance when restorations are being placed during a
reorganisation1

Adam Jowett
 Chapter: Reorganising the Occlusion
1. Canines are the optimum guidance teeth for lateral excursions, provided they are not compromised
periodontally, structurally or restored with non-retentive restorations or post crowns. 1 Under such
circumstances, the guidance is best transferred to the premolars, or where possible creating group
function between all of the teeth in the buccal segment. 1
2. When the canines alone are not going to be used for guidance in lateral excursions, shared guidance
is advisable, but can be difficult to achieve. 1
3. Protrusive guidance is usually best shared between the two central incisors with equal contacts in the
edge to edge position.1 Crowned lateral incisors are structurally compromised, so if possible make
their guidance contacts light.1
4. Where there are bridge pontics, in particular cantilevers, it is best to avoid any guidance on these. 1
5. To ensure that the patient is comfortable with their reorganised occlusion, the concepts of “mutually
protected occlusion” and “freedom in centric” are helpful. 1

Further Reading and References

1. Wassell, R. Naru, A. Steele, J. Nohl, F. (2008) Applied Occlusion. Quintessence Publishing Co. Ltd.
London.
2. http://www.hammerdental.com/dentures1.htm.
3. N J Poyser, R W J Porter, P F A Briggs, H S Chana & M G D Kelleher
British Dental Journal 198, 669 - 676 (2005) Published online: 11 June 2005
doi:10.1038/sj.bdj.4812371.
4. Davies, S.J. and Gray, R.J.M. (2002) A Clinical Guide to Occlusion. British Dental Association. London.
5. Howat, A.P. Capp, N.J. Barrett, N.V.J. (1991) A Colour Atlas of Occlusion and Malocclusion. Wolfe
Publishing Ltd. London.
6. Shillingburg, H.T. (1997) Fundamentals of Fixed Prosthodontics. Third Edition. Quintessence
Publishing Co. USA.

Adam Jowett