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Occlusion of crown and bridge and clinical important in prognosis of treatment

Prepared by DR .shahen arif khdir HIGH DEGREE DIPLOMA STUDENT

Occlusion(introduction)
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The way in which the upper and lower teeth relate to each other or in most of these, the maxillary and mandibuler teeth contact simultaneously when the condylar processes are fully seated in the mandibular fosse and the teeth do not interfere with harmonious movement of the mandible during function. Clinical Relevance: Occlusion is of fundamental importance in restorative dentistry, as all restorations placed in the mouth can have a profound effect on it. From Intra coronal direct placement restorations to complex crown and bridgework, the restoration must be planned to conform to an occlusal pattern. *Static Occlusion Static occlusion: stationary position of upper and lower jaw (or upper & lower teeth) in relation to each other, thats why its call static because its not moving, its a postural position, close position where the patient not moving his mandible against his maxilla. Centric occlusion (CO the occlusion the patient makes when they fit their teeth together in maximum inter cuspation CO is also called Inter- cuspal position (ICP) Bite of convenience Habitual bite

*Significance centric occlusion 1. At this position occlusal force is directed along the long axis of the teeth. As we know, its the most favorable position. It is the most histological direction of forces that will be accommodate by dental tissues & surrounding structures. 2. At this position, its an End point of chewing cycle. These positions where patient end their chewing cycle. Patient move their jaw laterally and all around when theyre chewing and the end point of the chewing is static position. .3.The position in which simple restoration are made. Usually we made our restoration in this position. Because it is reproducible, easy, simple, safe to do.

Dynamic Occlusion
Dynamic occlusion: describe occlusal contacts when the mandible is moving relative to the maxilla When you move laterally, o r protrusive , all this contact are part of dynamic occlusion. Which is very important because its the chewing action. Usually dynamic occlusion is dictated or determined or guided by the shapes teeth and the TMJ. Guidance from the teeth: Determined by the shapes of teeth and TMJ Canine guidance vs. group function Protrusive guidance
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Posterior and Anterior Determinants Anterior Guidance: The influence of the contact relationship between the labial surfaces of the mand. Incisors and the lingual surface of the max incisors on mandibular Movement Purpose Disclude posterior teeth in excursions Determined by horizontal/vertical overlap horizontal overlap A.G. vertical overlap A.G. Recorded by custom anterior guide table

The posterior determinants shape of the articular eminences, anatomy of the medial walls of the mandibular fossae , configuration of the mandibular condylar processes-cannot be controlled , nor is it possible to influence the neuromuscular responses of the patient, unless it is done by indirect means (e.g., through changes in the configuration of the contacting teeth or by the provision of an occlusal appliance) . UNILATERALLY BALANCED ARTICULATION(GROUP FUNCTION)
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In a unilaterally balanced articulation, excursive contact occurs between all opposing posterior teeth on the latero trusive (working) side only. On the medio trusive (nonworking) side, no contact occurs until the mandible has reached centric relation. Thus, in this occlusal arrangement the load is distributed among the periodontal support of all posterior teeth on the working side. This can be advantageous if, for instance, the periodontal support of the canine is compromised. MUTUALLY PROTECTED OCCLUSION(Canine-guided) Canine protected occlusion : The contact between maxillary and mandibular canine in lateral movement lead to no contact of posterior teeth on either working or balancing (non working)sides. Significance of Guidance Teeth . 1. Non-axial loading Usually contact of dynamic occlusion, when you move laterally or protrusive youre loading the teeth in contact in a nonaxial direction, in an oblique direction, those forces are destructive by nature and they need more adaptation. That would make heavily restored teeth or crown teeth at a higher risk of fracture and crown seated on this tooth usually because theyre subjected to oblique forces; theyre usually subjected to higher risk of being decementation. Other manifestation: increase wear, when you check older age patient for example most of the canine had been worn due to its role as guidance for long time. With aging
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usually the occlusion change, from canine guidance to group function (because of wear). Because the canine already become short. Cusp worn. So the guidance will be shared by another cusp of teeth, adjacent cusp of teeth. We have mobility, fracture, migration, TMJ dysfunction (possibility to have). 2. Identify guidance teeth before preparation If guidance tooth is satisfactory, I mean good, sound, strong, we should re-establish the same guidance pattern in the new restoration #If guidance tooth is weak, transfer guidance contacts to the adjacent stronger teeth.

3 .Provide clearance during preparation in excursive positions: We provide clearance during preparation in excursive movement; we have to provide adequate occlusal reduction clearance to accommodate the material of the crowns, PFM or all ceramic for example. Usually for ceramic we have to reduce huge incisal edge, it will be about /2mm, so we will have adequate bulk of material , or the metal under porcelain where the metal provide enough strength under loading and for the porcelain not to be fracture,. We should check the clearance in all movement as well, you ask your patient to move his jaw from side to side, and check if there any enough clearance in lateral movement or not. Sometimes you might have adequate clearance in CO position but not when lateral movement. This is not enough because the patient does not only occluding in static position, in
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chewing cycle the patient will start moving in lateral movement. So we have to check the clearance in all movement. 4..Select appropriate material to restore the guidance tooth If this tooth is the guidance tooth we want to restore it with strong enough and doesnt distort because it is subjective to un favorably pattern direction of forces, and subjective to excessive wear ,and again its come in contact with opposing teeth more frequently than other teeth, so it might damage the adjacent, to the opposing tooth as well, so we need to get material that are strong enough for the opposing dentition *Vertical Dimension The vertical dimension of occlusion: (VDO) is the vertical height of the face when the teeth are in maximum inter cuspation teeth are held apart in the rest position by the muscles of mastication acting on the mandible creating a freeway space or Intero cclusal distance of 24 mm *Resting vertical dimension :a measured distance between the upper and lower jaws when all forces upon the mandible are in equilibrium and the patient is in an upright position *Occlusal vertical dimension: A measured distance between the upper and lower jaws when the teeth are in full intercuspation. *Centric relation: The relation of the mandible to the maxilla when the condylesare in the
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Most superior anterior position in the glenoid fossa ,from which unstrained lateral movements can be made at the occluding vertical dimension normal for the patient(Arch to Arch relation ship). Centric occlusion(co): The centered contact position of the occlusal surfaces of the mandibular teeth against those of the maxillary teeth, irrespectives of condaylar Position (teeth to teeth relation) It can be taken when there are enough occlusal stops after preparation for a crown or bridge. Functional contacts Contacts during: Speech Swallowing Mastication Contacts are: Infrequent Glancing Low intensity

Parafunctional

Contacts

Contacts other than functional Clenching Grinding Biting on foreign objects


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Fingernails Pipes Nails.


Significance of Parafunction Increased force Intensity Frequency Duration Adverse loading Non axial Un braced mandible

Clinical findings Mobility Tooth /restoration fracture Restoration displacement Muscle pain/dysfunction TMJ pain/dysfunction Aggressive wear

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occlusal disharmony caused by improper fixed prothodontics work can cause The following adverse results:
1.Pulpitis 2 .bruxing
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3. Premature occlusal wear and restoration perforation. 4. Accelerated periodontal breakdown and teeth mobility. 5.TMJ disturbances caused by high spots and excessive lateral

forces.
6. Dislodgment of fracture of facing s caused by excessive

contents of anterior teeth in protrusion and excessive lateral forces on fixed restoration. PATHOGENIC OCCLUSION A pathogenic occlusion is defined as an occlusal relationship capable of producing pathologic changes in the stoma to gnathic system. In such occlusions sufficient disharmony exists between the teeth and the TMJs to result in symptoms that require intervention SIGNS AND SYMPTOMS There are many indications that a pathogenic occlusion may be present. Diagnosis is often complicated because patients almost always have a combination of symptoms. Teeth. The teeth may exhibit hyper mobility, open contacts, or abnormal wear. Hyper mobility of an individual tooth or opposing pair of teeth is often an indication of excessive occlusal force. This may be due to premature contact in centric relation or during excursive movements. Such contacts frequently can be detected by placing the tip of the index finger on the crown portion of the mobile tooth
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and asking the patient to repeatedly tap the teeth together .Small amounts of movement that otherwise might not be readily seen often can be felt this way. Open proximal contacts may be the result of tooth migration because of an unstable occlusion and should prompt further investigation .Diagnostic casts made during previous treatment will help assess any changes in the stability of the occlusion. Abnormal tooth wear, cusp fracture, or chipping of incisal edges may be signs of parafunction activity. Periodontium.: There is no convincing evidence that chronic periodontal disease is caused directly by occlusal overload. However, a widened periodontal ligament space(detected radio graphically)may indicate premature occlusal contactan often associated with tooth mobility Similarly ,isolated or circumferential periodontal defects are often associated with occlusal trauma. Inpatients with advanced periodontal disease who have extensive bone loss, rapid tooth migration may occur with even minor occlusal Musculature. Acute or chronic muscular pain on palpation can indicate habits associated with tension such as bruxing or clenching. Chronic muscle fatigue can lead to muscle spasm and pain.
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Temporomandibular Joints. Pain, clicking, or popping in the TMJs can indicate TM disorders .Clicking and popping may be present without the patient's awareness. A stethoscope is a useful diagnostic aid; a recent study found joint sounds are generally reliable indicators of temporo mandibular disorders. The patient may complain of TMJ pain that is actually of muscular origin and is referred to the joint Clicking may also be associated with internal derangements of the joint. A patient with unilateral clicking when opening and closing (reciprocal click)in conjunction with a midline deviation may have a displaced disk. The midline deviation will typically occur toward the side of the affected joint because the displaced disk can prevent (or slowdown) the normal anterior translator movement of the condoyle.. Discrepancies. Tooth movement may make it difficult for these patients to institute proper oral hygiene measures, and the result may be a recurrence of periodontal disease . Myofascial Pain Dysfunction. The mayo facial pain dysfunction (MPD)syndrome presents as diffuse unilateral pain in the pre auricular area, with muscle tenderness, clicking, or popping noises in the contra lateral TMJ and limitation of jaw function. Often the muscles, and not the TMJ, are the primary site, but over time the functional problem may lead to organic changes in the joint *Criteria for Ideal Occlusion

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1. Simultaneous and uniform contact of as many teeth as possible in centric occlusion. Anterior teeth may touch, but the intensity should be slightly less than the posterior teeth as the forces of occlusion are at an angle to the long axis for anterior teeth. This criterion provides for the optimum distribution of forces. 2. The forces of the occlusion are directed down the long axis of the teeth. Axial forces have been shown to be more favorably received by the attachment apparatus than horizontal or oblique forces. 3. Anterior tooth contacts compatible with functional movements. A deep vertical overlap of the anterior teeth may allow for taller/sharper posterior cusps 4. No posterior teeth should contact on the non working side during lateral excursions. 5. No posterior teeth should contact during protrusive excursions. Occlusal design 1. Distribute forces proportionate to the ability of the teeth to resist 2. Distribute forces to as many teeth as possible. 3. Direct forces most favorably relative to the supporting tissues. OCCLUSAL TREATMENT When a patient exhibits signs and symptoms that appear correlated to occlusal interferences ,occlusal treatment
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should be considered .Such treatment can include tooth movement through orthodontics, elimination of deflective occlusal contacts through selective reshaping of the occlusal surfaces of teeth, or the restoration and replacement of missing teeth resulting in more favorable distribution of occlusal force 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 planes 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 (e.g., unilateral balanced versus mutually protected)

ASSESSMEN of the OCCLUSION. The diagnostic process begins with careful history taking and clinical examination. Signs an symptoms of clicking or locking of the temporo mandibular joints, muscle spasm, excessive or uneven occlusal wear and pain on chewing must be recorded. Further investigations including radiographs, vitality tests and articulated study casts will provide additional information. The examination should include *.Extra-oral components Temporo mandibular joints, muscle hypertrophy/spasm.
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Mandibular movement painful, deviated, abnormal or restricted. *Intra-oral features: 1. Intercuspal position, retruded contact position, lateral and anterior guidance. 2. Location and extent of occlusal face tin . 3. Ease of movement between mandibular positions. 4. Extent of posterior support. 5. Over-erupted, tilted or mobile teeth. DETECTING OCCLUSAL CONTACt Articulating paper is used to mark or indicate the position of occlusal Contacts. Articulating paper Marking Contacts Teeth must be dry!!!! Use fresh paper for best results Apply Vaseline film to paper Helps transfer ink Sandblast metal / porcelain Helps with ink transfer Also Articulated study casts ,mounted on a semi-adjustable articulator using a face bow record, provide more detailed information that cannot be readily assessed in the mouth.

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High Tech Occlusal Detection T Scan system Computerized occlusal analysis Detects Presence of contacts Intensity of contacts Timing of contacts Similar to digital radiology, sensor between teeth and can detect certain things.

references 1,Restorative dentistry book(A.J. MCCULLOCK) Dent Update 2003; 30: 150-157 2 . contemporary fixed prothodontic book(3rd edition) By STEPHEN F. ROSENSTIEL, BDS, MSD and MARTIN F. LAND DDS, MSD JUNHEI FUJIMOTO, DDS, MSD, DDS c 3 .internet research

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