Comparative Evaluation of Two Techniques in Achieving

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Original Article

Comparative Evaluation of Two Techniques in Achieving


Balanced Occlusion in Complete Dentures
Lt Col M Kumar', Col DSJ D'Souza+
Abstract
Background: This study was undertaken to evaluate new teehnique, whieh claims to reduce treatment time while retaining the
quality of treatment. The aim of this study was to compare complete dentures made by two techniques: with the use of face bow
and without the use of face how.
Methods: Twenty edentulous subjects were seleeted and each one received two pairs of complete dentures. Dentures were made
from duplicated casts and eaeh one followed dift'erent techniques. One teehnique used face-how. Teeth were set using individualized
wax rims as guides. In other teebnique an articulator was used, whieh avoids face-how and teeth were set by the cast-analysis
method. The number of occlusal contacts in centric relation and excursive movements were registered, in addition to this the
opinion of patients regarding denture bearing during oral fanctions were taken.
Result: Both groups had dentures with balanced occlusion, but the teehnique that avoids face-how presented better results in
regard to time taken, esthetics, comfort and stability. Balanced occlusion was provided even without face-how and could be an
alternative to obtain adequate complete dentures with a better progu08is.
Conclusion: For achieving better quality of denture in the form of esthetics, phonetics and fanction in short duration of time; a
new teehnique was used to establish balanced occlusion in complete denture prostheses.
MJAFI 2010; 66 : 362-366
Key Words: Complete dentures; Articolators; Occlusion
Introduction
O
cclusion is a factor that is common to all branches
of dentistry. It is a term generally accepted to
describe the contact relationship of the upper and lower
teeth [1]. Occlusion is defined as the static relationship
between incising and masticating surfaces of the
maxillary and mandibular teeth. There are numerous
concepts, techniques, and philosophies concerning
complete denture occlusion. There has been a perplexing
lack of concern regarding concepts, principles, theories
and methods of evaluating and understanding the
masticatory system. There are many kinds of occlusion
which are significant in complete prosthodontics.
Balanced occlusion refers to the occlusion with
simultaneous contacts of the occlusal surfaces of the
teeth on both sides of the arch, regardless of the
mandibular position.
"A phrase was coined in the mid '60s to explain the
movements of dentures that occurred irrespective of
the occlusal scheme used, which stated "enter bolus,
exit balance" [2]. In an artificial dentition, with denture
bases ouly really being controlled by muscle activities
(albeit to varying degrees), it becomes imperative that
balancing contacts occur as soon as possible into, around,
and out of centric occlusion, so as to minimize any
movement of the denture bases. Centric occlusion is
the most frequently used position during mastication but
also during swallowing, an action that occurs about 1500
times in 24 hours, and so any slide into centric occlusion,
the position adopted during swallowing, should be
balanced to minimize denture movement and undue
forces being exerted on the base. Other actions also
take place that can jeopardize even the most ideal
arrangement of artificial teeth and denture bases. The
occlusal scheme for complete dentures should be one in
which there are as many contacts around the arch as
possible at all excursive movements away from, and
back into, centric occlusion.
One of the most important requirements for successful
complete dentures is a balanced articulation. An
adequate occlusal scheme allows better distribution of
masticatory forces, improves denture efficiency and
stability. In order to achieve this, it is necessary to
reproduce centric relation and use an adequate
articulator [3]. Articulators reproduce patient
characteristics with more accuracy [4,5]. However, fully
adjustable articulators are not practical, since they
present high cost, demand knowledge on equipment and
'Reader, Depar1ment of Dental Surgery, Anned Forces Medical College, Pune-40. +Commanding Officer, 200 MDC, C/o 56 APO.
Received: 08.09.09; Accepted : 02.07.10 E-mail: manjitkiran@yahoo.com
Comparati ve Eval uati on of Two Techni ques in Achi evi ng Bal anced Occl usi on in Compl ete Dentures 363
l ong chai r si de ti me. On the other hand, nonadj ustabl e
arti cul ators are easy to handl e, but f ai l to obtai n a
bal anced occl usi on and denti st spends much ti me on
occl usal adj ust ment s [ 6,7] . Consi der i ng t he
af orementi oned statements, semi adj ustabl e arti cul ators
seem to present the most adequate ef f ecti venessl handi ng
rel ati on f or compl ete dentures. These arti cul ators are
easy to handl e and al l ow a full bal anced occl usi on duri ng
mandi bul ar excur si ons, compr i si ng i ndi vi dual
characteri sti cs of each pati ent. Face-bow i s wi del y used
to transf er the pati ent's occl usal pl ane i ncl i nati on to the
semi adj ust abl e arti cul ators. I n t he same manner,
i ndi vi dual compensati ng curves, f ol l owi ng pati ent path
angl es f or mandi bul ar movements are estabi l i shed.
However, usi ng face bow and estabi l i shi ng compensatory
curves coul d be troubl esome i n cases of el derl y and ill
pati ents. Al though the use of a f ace bow presents many
theoreti cal advantages, they not necessari l y produce
better cl i ni cal resul ts. The i nf ormati on gi ven i n thi s paper
mi ght save ti me, and thereby al l ow prosthodonti sts and
general dental of f i cers i n armed f orces to rehabi l i tate
and restore a l arge number of pati ents. It woul d al so
hel p i n a bet t er understandi ng of t he dynami cs of
compl ete denture prostheses and thus i mprove treatment
and trai ni ng i n thi s i nsti toti on.
Mat er i al and Met hods
In thi s study t wo di f f erent techni ques of compl ete dentures
const ruct i on wer e compared. The f i rst used f ace-bow and a
semi -adj ustabl e arti cul ator, Hanan H2 (Hanau Eng. CO. Buf f al o
USA ).The second used a semi -adj ustabl e arti cul ator (Stratos
100, I vocl ar, L i echtei nstei n), whi ch avoi ds t he use of f ace-
bow, usi ng an average mouot i ng based upon pat i ent ' s cast s
anal ysi s. Theref ore, t here i s a const ant endeavor to expl ore
newer techni ques t hat woul d si mpl i f y procedures and save
time.
Compl et el y edentul ous subj ects wi t h wel l f ormed ri dges
wi t h cl ass I j aw rel at i on wer e sel ected f or thi s study. Twenty
such subj ect s wer e r est or ed wi t h t wo set s of compl et e
dent ur es, f abr i cat ed by each of t he t wo t echni ques
uoderval uati on. A f t er i ni ti al exanti nati on and t he i mpressi on
procedures t he f uncti onal cast s so obt ai ned wer e dupl i cat ed
wi t h si l i cone. Cast s obt ai ned wer e separat ed i nt o t wo groups
whi ch were mouoted on t wo di f f erent types of semi adj ustabl e
arti cul ators. Casts i n t echni que I wer e mount ed usi ng a f ace
bow i n a Hanau H2 arti cul ator (Hanau Eng. CO. Buf f al o,USA).
Cast s i n t echni que I I wer e mouot ed wi t hout f ace bow r ecor d
i n a Stratos 100 arti cul ator, (I voci ar,Li echtenstei n). Fol l owi ng
arti cul ati on, t eet h set t i ng was carri ed out usi ng t he same
types of teeth set (I vostar-Gnathostar,I voci or,L ei chtenstei n).
Ther e af t er al l t he dentures wer e pr ocessed i n convent i onal
manner.
Techni que I
The upper cast was mouot ed by f ace bow techni que, (Fi g.
I ) . L ower cast s wer e t hen al i gned and f i xed t o t he arti cul ator
MIMI, Vol. 66, No.4, 2010
i n cent ri c rel at i on posi ti on. Hori zont al and l at eral condyl ar
gui dance was i ndi vi sual i sed by f ol l owi ng t he i ndi vi dual
centri c and prot rusi ve rel at i on records. The t eet h setti ng was
carri ed out and occl usi on was correct ed by means of f i ne
gri tty stones t o obt ai n a bal anced arti cul ati on i n prot rusi ve
and l ateral mandi bul ar excursi ons (Fi g. 2).
Techni que I I
Her e t he cast s wer e mouot ed on t he arti cul ators based on
average val ues. Thi s t echni que was speci f i c t o thi s t ype of
arti cul ator and was devel oped t o avoi d t he use of f ace bow.
The l ower cast was f i xed to the l ower part of t he arcon type of
arti cul ator by means of a hori zontal gui de appl i ance (Fi g. 3),
speci f i c to thi s i nst rument , whi ch det emt i ne t he arbi t rary
occl usal pl ane uti l i zi ng t he pat i ent ' s retro mol ar pad and l abi al
f renum, f or ref erence, as i t appeared on t he cast. Once t he
l ower cast was f i xed to t he arti cul ator wi t h t he pl aster, t he
ri ms i n cent ri c rel at i on wer e pl aced over t he l ower cast. Thi s
al l owed t he posi t i oni ng of t he upper cast whi ch was f i xed
wi t h pl aster. Teeth setti ng i n thi s t echni que was carri ed out
as per the method of Bi o f uncti onal Prostheti c System (I vocl or,
L i echtenstei n) wi t h t he hel p of a t wo di mensi onal t empl at e
(Fi g. 4). The t echni que descri bed by t he manuf act urer uses
cast anal ysi s, as wel l as t he rel at i on bet ween dent al arches
and anat omi c cri teri a, l i ke pal ate, ret ro mol ar pad, r ugae on
pal at e and maxi l l ar y tuberosi ti es . These procedures wer e
per f or med obser vi ng adequat e overbi t e, and t o obt ai ned
bal anced occl usi on (Fi g. 5).
The same operat or carri ed out al l procedures. The t i me
t aken i n car r yi ng out var i ous pr ocedur es t hat wer e not
common t o t he t wo techni ques was noted. A f t er f abri cati on,
each pai r of dentures was tri ed i n pat i ent ' s mouth. Occl usal
contacts of each pai r wer e regi st ered wi t h arti cul ati ng paper,
i ndi vi dual l y and a r ecor d was kept. The pat i ent was suppl i ed
wi t h one pai r of dent ures f or 10 days bef or e hel she was
recal l ed to answer a questi ouoai re. Ther e af ter t he ot her pai r
was i nser t ed and pat i ent was asked t o answer t he
quest i ouoai re af ter anot her 10 days. The resul ts concerni ng
t he number of cont act s achi eved by each t echui que and
questi ouoai re were stati sti cal l y anal yzed by Test of Proporti on
anal ysi s and Wi l coxon Test.
Resul t s
In t echni que II, f ace bow recordi ng, mount i ng on t he
art i cul at or i n t hat part i cul ar posi ti on, got hi c ar ch traci ng,
r ecor di ng of cent r i c and pr ot r usi ve check r ecor ds and
pr ogr ammi ng of Hanau H2 art i cul at or wer e avoi ded. Hence
t i me t aken i n f abri cati on of compl et e dent ure wi t h bal anced
occl usi on i n t echni que I I was ver y l ess as compar e t o
t echni que I .
A t denture del i very appoi ntment, oul y one pai r of dent ure
was gi ven t o t he pati ent. Occi usal contacts wer e regi st ered
wi t h art i cul at i ng paper. They wer e count ed at t he upper
dent ure, conf i r med at t he l ower dent ur e and si gned. To
mi ni mi ze errors, contacts were done twi ce i n each person, in
a t ot al of 20 sampl es. Pati ents wer e i nst ruct ed t o ret urn af ter
10 days and t hen answered t he Group A par t of an appropri ate
questi onnai re (Annexure I ) . The second pai r of dentures were
K umar and D'Souza
Fig. 1 : Cast mounted in the Hanau arti cul ator wi th
face-bow (Group A).
Fi g. 2 : Teeth mounti ng Pig. 3 : Hori zontal gui de of the Stratos 100 articulator
concl uded i n the Hanau pol i ti onod over the l ower cut .
articu1ator.
Fi g. 4 : Hori zontal gui de I I Pi g. 5 : Teeth mounti ng at Straws
repo&itioDCd to I he upper part 100 arti adator
of St r at oi l OO aDd posi ti on the
po!itmiOl" Iowet- teeth
then del i vered aDd procedures were repeated. Af ter weari ng
peri od. pati ents were asked to choose ODe of those pai rs,
whi ch wer e al l o si gned. Resul t s concer ni ng about
questi onnai re and number of contacts of groups A and B
were stati sti cal l y anal yzed by t he Test of Proporti on analysis
and Wi l coxon Test wi t h a significance l evel of 6%. To access
differences between t he groups about these cri teri a, WLicoxon
Test was used t o ver i f y occl usal cont act s and Test of
Proporti on Analysis was made f or questi onnai re answers.
Occl usal cont act s pr esent ed a st at i st i cal l y si gni f i cant
difference betwccn the average of Groups A and B f or centri c
rel ati on (p::O.OOS) and left.lateral movement (p::O.OI 0), in whi cl t
group B presented the greater number of contacts. A t ri ght
l ateral movement there was a tendency of group B to present
hi gher number of contactl (p=O.065), due to the proxi mi ty of
p- val ue est abUshed of 6%. Ther e was no st at i st i cal l y
si gni f i cant di f f erence bet wr en groups of dentures (p=O.331)
f or protrusi ve movements (Thbl e 1). L ateral movements were
subdi vi ded i nt o wor ki ng and non- wor ki ng si des or t he
bal anci ng si de, wher en pr ot r usi ve movement s wer e
separated i n ant eri or and post er i or contac:u. Concerni ng
worki ng si de at l ateral movements, dentures in group A
presented worse resul ts than dentures in group B. at ri ght
Iak:raJ. movcmco1S (p=(UXl7), but at left l ateral there
was no stati sti cal l y si gni f i camdi f f erence (p:::::O.I02) as shown
in Tabl e 2. Adi f f " erentsi tuati on was f ound in the non-worki ng
si de or t he bal anci ng si de. in whi ch Group A obtai ned worse
resul ts at l ef t lateral movement (p:::::O.023), No stati sti cal l y
si gni f i cant di f f er ences wer e obser ved f or r i ght l at er al
A na.sun 1
Queat l o_al n about compl et e dent ur e bear i ag
Name of t he Pati ent: ........................................... Date: ............... .
ETaJ.uattoD of Group A dentl l l 'U .... de byl l l i DI tecbni que I
L Comf ort duri n, weari ng peri od:
[ ] Bm [ ] Sari l f actory [ ] Very Good
2. Stabi l i ty:
[] Om [ J Sadl f l Ct ol ) '
3. BeariD., du.ria. 'PCIll:i.llI :
[] B.s [] Sadl f act or y
4. Be.i n, durlA, cbewi n,:
[] B.s [] Sari l f actory D Very Good
Enl Uoa of dCDt ar a IIlIM1c by Ui al tec.l l ai que D
nat e : ............... .
1. Comf ort duri n. weMiDJ peri od:
[ ] Bad [ ] Sal l i f act ory D Very Good
2. Stabi l i ty:
[ ] Bm [ ] Sari l f act ory D Very Good
3. Be.rinJ; dlJrlq: Jped.l .nl :
[ J Bm [ J Sari Jf actory [ J Very Good
4. BeariDJ Wti nl chom,:
[ ] Bad [ ] Sal l Jf actory D Very Good
Pref erence: Deotwc A Denture B
Pati etl l l paI Ul e: ................. .................................... .
movement (p=().233) m ..wi no to group B (Table 3). Reganling
protrusi ve movement (Tabl e 4), t here was no stati sti cal l y
si gni f i cant di f f er ence bet ween dent ur e gr oups bot h f or
ant er i or (p:::tO.72S) and pOl t er i or cont act s (p:::tO.373) .
Cool i deri ng all movement! anal yzed, dentures from group B,
on average. obtai ned greater number of occl usal contacts
than dentures from group A. Accordi ng to questi onnai re, it
was observed. that dent ur e B had bet t er accept ance by
pati ents. due to the anawcn " Bad" (p=O.l 7) and " V ery Good"
(p=O.057) t here was a stati sti cal l y si gni f i cant di f f erence
between groups A and B (Tabl e 5). Af ter the anal ysi s, i t coul d
be observed t hat group A wu. composed by dentures made
wi th f aco-bow usi ng techni que 1 and group B, made wi thout
fac&-bow usi ng techni que l l .
Di scussi on
I t was observed. t hat dentures i n Group B. made
wi thout use of presented hi gher number of
JUAn, \bL 66. No.4, 2010
Comparati ve Eval uati on of Two Techni ques in Achi evi ng Bal anced Occl usi on in Compl ete Dentures 365
Tabl e 1
Number of occl usal cont act s in gr oups A and B
ontacts Centric r elation Left lateral movement Right lateral movement Pr otr usive movement
Group A Group B Group A Group B Group A Group B Group A Group B
Aver age 11.90 19.10 12.40
Variance 6.77 10.10 25.38
n 20 20 20
p- val ue 0.005 0.010
n=sample size
Tabl e 2
Number of occlusal contacts at wor king side in gr oups A and
B
Working side Left lateral movement Right lateral movement
Group A Group B Group A Group B
Average 6.50 7.70 6.40 8.40
Variance 6.06 8.90 6.71 7.82
n 20 20 20 20
p-value 0.102 0.007
n=sample size
Tabl e 3
Number of occlusal contacts at balancing side in gr oups A
and B
Balancing side L eft later al movement Right later al movement
Group A Group B Group A Group B
Aver age 5.90 7.60 6.20 7.10
V ar iance 6.99 6.93 3.96 3.88
n 20 20 20 20
p- val ue 0.023 0.233
n=sample si ze
occl usal contacts i n centri c rel ati on than Group A f or al l
mandi bul ar posi ti ons. It mi ght be due to techni que, whi ch
shows an i nherent di f f i cul ty: the resi n bases have not
enough retenti on at the t i me of obtai ni ng i ndi vi dual
compensat i ng curves [ 8,9] . Theref ore; t he occl usal
pl anes coul d be i nadequatel y rel ated t o al veol ar ri dges.
In Group B denture were made usi ng the teeth mounti ng
gui de of Stratos 100 arti cul ator, whi ch al l ows t o obtai n
an arbi trary occl usal pl ane at t he t i me of teeth setti ng.
Thi s procedure avoi ds t he er r or due t o techni que used
i n Group I as descri bed above. Bot h groups presented
si mi l ar resul ts i n excursi ve j aw movements, establ i shi ng
a bal anced arti cul ati on. Sl i ghtl y better resul ts coul d be
seen f or Gr oup B, pr obabl y r ef er r ed t o t he same
i naccuracy rel ated to the use of standard gui des f or teeth
setti ng. Group B presented better estheti c than Group
A. It coul d be due t o the techni que used i n setti ng of
teeth. Group A t eet h setti ng depends on dent i st and
techni ci an's abi l i ty t o achi eve al l estheti c requi rements
duri ng wax ri ms i ndi vi dual i zati on. Group B teeth setti ng
respect s cast anal ysi s, whi ch reproduces i ndi vi dual
characteri sti cs, despi te dental staf f 's abi l i ty to reproduce
estheti cs. Group B recei ved more f avourabl e answers
MIMI, Vol. 66, No.4, 2010
15.30
27.34
20
12.60 15.50 15.70 17.40
18.93 20.06 17.34 24.93
20 20 20 20
0.065 0.331
Tabl e 4
Number of occl usal contacts at pr otr usi ve movements
between gr oups A and B
r otr usive Anter ior Poster ior
ovement Group A Group B Gr oup A Group B
Average
Variance
n
p-value
n=sample si ze
Tabl e 5
4.60
3.82
20
0.725
4.70
4.90
20
Pat i ent s answer s r egar di ng dent ur e
11.10
7.66
20
0.373
12.70
14.23
20
nswer Group A Group B p-value
Bad
Sat i sf act or y
Very good
25%
35%
40%
0%
30%
70%
0.17
0.736
0.057
than GrOUp A f or chewi ng and speaki ng f uncti ons. Thi s
resul t conf i rms t hat comf ort, stabi l i ty and l ess stress t o
t he supporti ng ti ssues come f rom an adequate bal anced
occl usi on [ 10] . Thus, si nce Group B presented greater
aestheti cs and comf ort, al l pati ents pref erred dentures
f rom thi s group.
Consi deri ng the methodol ogy appl i ed and the sampl e
anal yzed, one can concl ude t hat bot h groups obtai ned
bal anced occl usi on and occl usal cont act s i n al l
mandi bul ar excursi ons. However, Group B presented
better resul ts than Group A, even wi t hout f ace-bow.
St r at osl OO ar t i cul at or pr esent ed an unexpect ed
perf ormance and coul d be used as a source to obtai n
bal anced occl usi on duri ng compl ete denture f abri cati on.
Concl usi on
One of the most i mportant requi rements f or successf ul
compl ete dentures i s achi evi ng bal anced occl usi on. In
order t o achi eve thi s, i t i s necessary to reproduce centri c
rel ati on and use an adequate arti cul ator.
Arti cul ators reproduce pat i ent ' s characteri sti cs wi t h
more accuracy. However, f ul l y adj ustabl e arti cul ators
are not practi cal , si nce they present hi gh cost, demand
knowl edge of equi pment and requi re l ong chai r si de ti me.
On t he other hand, non adj ustabl e arti cul ators are easy
to handl e, but do not hel p i n achi evi ng bal anced occl usi on,
resul ti ng i n prol ong chai r si de ti me spent on occl usal
adj ustments. Theref ore, semi adj ustabl e arti cul ators
seem to present the most adequate ef f ecti ve tool f or
compl ete dentures. These arti cul ators have been f ound
to be easy to handl e and al l ows i n achi evi ng a f ul l
bal anced occl usi on duri ng mandi bul ar excursi ons,
accommodati ng i ndi vi dual characteri sti cs of each pati ent.
Face bows have been wi del y used to transf er pati ent's
occl usal pl ane i ncl i nati on to semi adj ustabl e arti cul ators.
However, there i s not enough evi dence to suggest that
the use of f ace bow resul t i n i ncreased cl i ni cal qual i ty.
I t i s concl uded that both groups obtai ned bal anced
occl usi on and occl usal contacts i n al l mandi bul ar
excursi ons, however, Group B presented better resul ts
than Group A, even wi thout f ace-bow. One of the most
compel l i ng chal l enges f aci ng the servi ce prosthodonti st
i s the responsi bi l i ty to provi de qual i ty dentores to an
ever-i ncreasi ng pati ent cl i ental e wi thi n the avai l abl e
constrai ns of t i me and manpower resources. Qui te
obvi ousl y, t he i ncreased amount of t i me spent i n
treatment woul d resul t i n l esser number of pati ents who
coul d be rehabi l i tated. I t i s wi th thi s background that
thi s stody was undertaken to eval uate new techni que,
whi ch cl ai med to reduce treatment ti me whi l e retai ni ng
the qual i ty of treatment.
Conf l i cts of i nt er est
Thi s st udy has been f i nanced by r esear ch grants f r om t he
0/ 0 DGAFMS, New Del hi .
I ntel l ectual Contri buti on of Authors
Study Concept : Lt Col M Kumar
Kumar and D' Souza
Dr afti ng & Manuscr i pt Revi si on: Lt Col M Kumar
Stati sti cal Anal ysi s: Col DSJ D'Souza, Lt Col M Kumar
Study Super vi si on: Lt Col M Kumar, Col DSJ D'Souza
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Engl and McGraw-Hi l l Book Company 1962.
ERRATUM
Case Report : " A Case of I ntravagi nal Forei gn Body" MJAFI Jul y 2010; 66 266-8.
For : Sqn L dr N Magon, Cl i ni cal Tutor (Dept of Obstetri c & Gynaecol ogy), AFMC, Pune-40.
Read: Sqn L dr N Magon, Resi dent (Dept of Obstetri c & Gynaecol ogy), AFMC, Pune-40.
The error i s regretted.
MI MI , Vol. 66, No.4, 2010

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