Journal of Oral Rehabilitation 1996 23; 321-329

Studies of changes in occlusion after the insertion of

complete dentures. Part
K.-H.

U T Z University of Bonn, Dental School, Department of Prosthetic Dentistry I, Bonn, Germany

SUMMARY. The present study aims to investigate

changes in the occlusion of complete dentures after
their insertion. A total of 85 edentulous patients were
provided with new complete dentures. Their individual hinge axes were determined using mechanical
axiography and the upper finished dentures were
transferred by facehows to Dentatus articulators.
The lower dentures were mounted according to
an intraoral central hearing point (CBP) registration
and equilibrated in terminal hinge position. An
articulator specially modified for measurements in
the condylar area was used. The differences between
the positions of the condylar balls with CBP
registration and those after equilibrating the occlusion
were determined. On average, 19 days after insertion.

Introduction
The occurrence of complete denture malocclusion post
insertion has been reported by several authors, e.g.
Bergman, Carlsson & Hedegard (1964), Brigante (1965),
Tallgren (1969), Goebel (1980), Taege & Stoica (1982)
and Berg & Knudsen (1983). In theory, occlusai changes
occurring shortly after insertion could have two main
causes: first, the settling of the dentures into the
deformable denture-bearing tissues; and second, the
changes in the afferent input from the oral cavity. Tallgren
et al. (1980) provided evidence that the electromyogram
changes after the insertion of new dentures, which might
well lead to a different position of the lower jaw. On the
other hand, when dentures have been worn for many
* These studies are dedicated to Prof. Dr Lorenz Hupfauf on his 70th
birthday.
1996 Blackwell Science Ltd

71 patients took part in a follow-up examination.

As in the first session, the terminal hinge position
was registered with the CBP method using the
apex of the Gothic arch. Thus, the positions of the
condylar balls immediately after the new registration
could be compared with those in equilibrated intercuspation 3 weeks earlier. The differences were
found to be 0-5 0-4 mm (0-2-9 mm) in the three axes
(sagittal, coronal and horizontal). They are thought
to result from settling into the denture bearing
tissues and also from neuromuscular adjustment
of the masticatory system. Compulsory remounting
of complete dentures after insertion is therefore
recommended.

years, resorption of the alveolar ridges is unlikely to cause

malocclusion within a few weeks of insertion of new
dentures.

: :

The aim of the present study was to discover and

quantify any shifts between upper and lower dentures
occurring after insertion. Furthermore, the most favourable time for remounting was to be determined.
;

Materials and methods

First session

...

Forty-one female and 44 male edentulous patients took

part in the study. Their ages ranged from 25 to 87 with
an average of 65 10 years. The mean duration of their
edentulism was 13 10 years (0-1-40 years).
321

322

K.-H.

UTZ

New dentures were constructed by students during their

final examinations. On the day of insertion, the patients'
individual hinge axes were determined. The lower jaw
clamp from the Lauritzen set*, the mandibular facebow and a modified flagbow from the SAM-Axiograph
No 2+ were used for this. The new upper dentures
were transferred with Dentatus AEK-facebows* to new
Dentatus-ARL articulators. For recording the mandibular
position, removable stainless steel Gerber (1986) CBP
plates^ were located on the dentures with light curing
acrylic''. The writing pin was positioned on the palate in
such a way that both upper and lower dentures were
loaded centrally (Utz, 1990; Utz et al., 1991). The gap
during recording was kept as small as possible and was
on average 3-8 0-9 mm (2-7 mm) in the incisal area
and 5 1 mm (3-8 mm) at the articulator's incisal
indicator pin. The Gothic arch was recorded under the
moderate manual guidance of the operator, its apex
marked with a crosshair and checked twice for
congruence. A pierced acrylic plate** was then attached
with sticky wax onto the apex of the Gothic arch in order
to lock the lower jaw. The upper and lower dentures were
then keyed with impression plaster++ and removed from
the mouth assembled (Fig. 1, record 1). The lower
denture was mounted in two stages with impression
plaster. The mounted dentures were then transferred to
a special measuring articulator**, which has been
described previously (Utz et al., 1991, 1993). The
articulator mounting plates were unscrewed and
rescrewed twice, the upper part of the measuring device
was loaded with 10 N and the position of the condylar
balls recorded electronically in three dimensions (Fig. 1,
measurement 1). The dentures were then returned to
the original articulator, equilibrated in terminal hinge
position using Hanel Foil^ of 8 |j.m thickness with special
emphasis on the depth of pits and grooves and therefore
the definition of the intercuspation (Fig. 1, equilibration 1) and then transferred back to the measuring device.

* Almorc hiternational Inc., PO Box 252 14, Portland, OR 97225, U.S.A.

+ SAM, Taxisstr. 41, D - 80637 Munich, Germany.
' Dcniatus, Jakobsdalvagen 14-16, S - 12653 Hagersien, Sweden.
*> Set No 105 and 110, "^Gerber 1986, Condylalor Service, Switzerland.
" Convertray, Wilde GmbH, D - 65396 Walluf, Germany.
** Condylator Service, Bellariastrasse48, CH-8038 Zurich, Switzerland.
tt Snow while plaster No 2, Kerr GmbH, Wiststr. 28, D - 76185
Karlsruhe, Germany.
' Ulrich Wegmann, University of Bonn, Dental School, Dept. of
Prosthetic Dentistry II, Welschnonnenstr. 17, D-53111 Bonn, Germany.
'''' Hanel GmbH, Herman-Lons-Str. 120, D - 72622 Niirtingen, Germany.

Measurement 2 was taken with the dentures in maximum

intercuspation (Figs 1 & 2) so that the difference in
condylar position between the CBP registration and the
equilibrated dentures could be calculated. The dentures were then delivered to the patient. Patients were
instructed to wear the dentures day and night during
the first 3 weeks. The mounted upper support cast and
the registration plates were kept and stored.

Second session

2nd Session

1st Session
Registration 1

<

mounting of upper & lower

denture

Measurement 1

<

mounting of lower denture

<

Measurement 3

<

in terminal hinge position 2

in terminal hinge position 1

Occlusai equilibration 1
of terminal hinge position 1 ^j
in max. intercuspation 1
^

Measurement 2

Registration 2

in maximum intercuspation 1
19 days 4

Registration 3

<

Measurement 4

<

mounting of lower denture

(for checking)

in terminai hinge position 3

Measurement 5

in maximum intercuspation 1
<
^

=
=

with interocclusal gap

Occlusai equilibration 2

in max. intercuspation

of terminal hinge position 3 < -^

in max. intercuspation 2
=

Fig. 1. Experimental set-up. Each individual measurement consisted of repeated recordings after loosening and tightening the
mounting plates.

Fig. 2. Dentures placed in the measuring device with the equilibrated terminal hinge position fixed with sticky wax.
1996 Blackwell Science Ltd, Journal of Oral Rehabilitation 23; 321-329

I N S E R T I O N OF C O M P L E T E D E N T U R E S . P A R T I

323

After 19 4 days (12-32 days), 71 of the patients were

re-examined. A short history was taken and a clinical
examination performed. Care was taken to check that
the dentures had not been altered in any way in the
interim. A second CBP registration (measurement 3) was
then made using the same equipment and method as in
the first session. Again the Gothic arch was recorded and
its apex was chosen as lower jaw position (Fig. 1,
registration 2). In order to assess the error of the method,
in 42 of the patients both the mounting of the lower
dentures with the new CBP registrations and the
measurements of the position of the condylar balls
(measurement 4) were carried out twice.

and seven patients for the lower denture. Sixty-two per

cent of the upper and 54% of the lower dentures were
worn day and night.

During the wearing period of approximately 3 weeks

an average of 0-5 0-8 (0-4) pressure spots occurred in
the upper jaw, of which 73% were located under the
functional border and 12% on the alveolar ridge, the
remaining 15% were not locatable. Sixty-nine per cent
of patients showed no sore spots in the upper, 39% no
sore spots in the lower jaw. The average number of sore
spots in the lower jaw was 1-1 1-1 (0-4), of which 69%
were located under the functional border of the denture and 14% on the ridge (the rest were not locatable).

Method 1

Error of method

The position of the condylar balls both with the new

CBP registration and with the original intercuspation equilibrated in the first session - were determined in the
measuring device (Fig. 1, measurement 5). From these
data, differences in condylar ball position between
intercuspation at insertion and 3 weeks later could be
calculated.

The reproducibility of screwing and rescrewing the

mounting plates on was found to be 0-05 0-06 mm (00-61 mm). The reproducibility of the position of the
condylar balls after repeated mounting of the lower
denture was 0-20 0-15 mm (0-0-72 mm) (Table 1).

Method 2

Furthermore, the experimental set up allowed a comparison between the position of the condylar balls in
intercuspal position in the first and the second session
(measurements 5 and 2). Only after these measurements
were finished were the dentures equilibrated in the newly
registered central occlusion and reinserted in the patient.

Statistical analysis

For statistical data analysis the program package SAS*

was used in the Computer Centre of the University of
Bonn.

Results
History and clinical examination

According to their subjective judgement, 88% of patients

coped 'weir or 'very well' with their new upper dentures,
but only 60% with their new lower dentures. Major
difficulties occurred in only two patients for the upper
* Version 5.18 84/86.
1996 Blackwell Science Ltd, Journal of Oral Rehabilitation 23; 321-329

'

Session 1

A mean difference of 0-33 0-31 mm (0-2-08 mm) was

found between the hinge axis with interposed CBP
registration and the equilibrated terminal hinge position
(Table 2).
Session 2

'

In about half of the patients (54%) the position of the

apex of the Gothic arch was found to have shifted; 20%
anterior, 20% posterior and 14% transversal. These shifts
were assessed only visually and are depicted in Fig. 3.
The differences between the condylar ball position (a) in
the first session when measured in equilibrated central
occlusion and (b) in the second session with the CBP
registration (method 1) were on average 0-51 0-42 mm
(0-2-94 mm) (Table 3). In about half the patients these
differences were bigger than 0-5 mm (Fig. 4). A shift in
only one particular direction could not be determined
(Fig. 5). The experimental set up also allows a direct
comparison of the positions between maximal intercuspation of the dentures in the first and second session,
which provides a measure of the shift between upper
and lower dentures (method 2). The results were
0-55 0-44 mm (0-2-52 mm) (Table 4) and were about
as big as those differences listed in Table 3.

324

K . - H . UTZ
Table 1. Reproducibility of the position of the condylar balls after repeated mounting in two phases of the lower denture
(n = 42)
, , , , . , . _ ^ . , , :^.. . . , , , , ,.._,._,_.. ... .. -. ..,..
: ... . . . . . . . .
.. ..
. ..
. . .

Right

r-;^;:-.. ,

'

'

'

i^ir,:,-

.,^ - ..

Mean
Standard deviation
Minimum
Maximum

Left
Transversal
(mm)

Sagittal
(mm)

Vertical

Total displacement
Right + left

(mm)

Vertical
(mm)

(mm)

(mm)

0-21
0-16
0-02
0-68

0-22
0-16
0-00
0-57

0-12
0-11
0-00
0-37

0-23
0-18
0-01
0-72

0-22
0-14
0-02
0-64

Sagittal

0-37
0-19
0-10
0-96

Table 2. Differences between the position of the condylar balls with CBP registration and after equilibration in retruded
jaw relationship ( = 83)
Right

Mean
Standard deviation
Minimum
Maximum

Sagittal
(mm)

Vertical

0-39
0-33
0-00
1-25

Left
Sagittal

(mm)

Transversal
(mm)

(mm)

Vertical
(mm)

0 33
0-36
0-00
2-08

0-25
0-24
0-00
1-21

0-34
0-32
0-01
1-69

0-33
0-32
0-00
1-75

Changes in the
Gothic arch position

Discussion

(after 19 days
n = 37 out of n = 69)

Comments on method

_J 0-1 mm
0-1 mm

Fig. 3. The points indicate the position of the apex of the Gothic
arch on the registration plates in relation to the original CBP registration (cross-hair) 19 days before.

There was no statistical significance between the shift

in position of the condylar balls, the wearing period or
wearing habits, the number or localization of sore spots
or the subjective acceptance of the dentures and age or
gender of the patients (Wilcoxon test).

Total displacement
Right + left
(mm)
0-63
0-44
0-04
2-54

A definite maximum intercuspation between upper and

lower denture is a necessary and important prerequisite
for any experimental measurements of changes in denture
position. This applies especially when comparing intercuspal positions in different sessions. In the present study
the new mounting of the lower dentures in the second
session lead to almost the same condylar ball positions.
It was therefore possible to apply different and independent calculations using method 1 and method 2. The
maximum intercuspation is therefore the essential link
for any comparisons between measurements in the first
and second session but also counts as a possible source
of error if changed during the wearing period of the
dentures. The abrasion of acrylic teeth within a period of
3 weeks ought to be negligible. Furthermore, shifts in
the patients' condylar position, the reproducibility of
the CBP registration itself, variations in screwing and
unscrewing the mounting plates when changing articulators, the reproducibility of the mounting process and
1996 Blackwell Science Ltd, Journal of Oral Rehabilitation 23; 321-329

INSERTION OF COMPLETE DENTURES. PART I

Table 3. Differences between the position of the condylar balls between the equilibrated terminal hinge axis position
(maximum intercuspation) on the first session and the CBP position in the second session
Left

Right

Mean
Standard deviation
Minimum
Maximum

Sagittal
(mm)

Vertical
(mm)

0-53
0-43
0-03
2-14

0-55
0-48
0-00
2-94

Transversal
(mm)
0-40
0-36
0-00
1-56

H ^ - . . , .

Sagittal
(mm)

Vertical
(mm)

0-55
0-44
0-00
2-42

0-54
0-41
0-01
1-85

;;

- ^ : ; ; . '

Total displacement
Right -1- left
(mm)
;

v> 0-98

0 - 5 5

0-25
3-37

The data represent the shift between upper and lower dentures in a time period of 19 4 days (71 subjects, method 1;

50.

mm

Fig. 4. The histogram depicts the amount of shift of the condylar

balls (mm) after 19 4 days depending on the number of patients
(right and left side) (n = 142).

errors in equilibrium are to be considered as source of

error when interpreting the results.
For this investigation the fixation of the mandibular
position on the apex of the Gothic arch was chosen to
achieve the best reproducibility of the CBP registration.
Although not measured in this study, its reproducibility
was recently described in three independent studies for
1996 BlackweW Science Ud, Joumal of Oral Rehabilitation 23; 321-329

a total of 112 complete denture patients who had three

registrations each as 0-26 0-22 mm (0-0-56 mm) (Utz
et al., 1991, 1993, 1995). An even settlement of the
dentures on the denture-bearing tissues, which is a pure
rotatory settlement around the hinge axis, cannot be
detected by the present method. Also the position of the
dentures in relation to the bony denture bed cannot be
assessed. Therefore, the experimental set-up does not
allow the distinction between settlement of the dentures
and a shift in mandibular position, which would have
provided additional information for the interpretation
of the present results.
The summation of the different sources of error is
unlikely as the scatter of data in all measurements was
equal for the different room directions. Also those patients
who had the biggest differences after equilibration
were not identical with those patients whose dentures
demonstrated the greatest shifts, the five maxima of each
individual measurement were checked. Despite the small
distances measured, the results seem reliable as method
2 (the comparison of the position of the condylar balls
in maximum intercuspation in the first and second
session) shows similar results to method 1. Seven out of
10 patients with extreme denture shifts were detected
by both methods independently. However, either method
has advantages and disadvantages: in method 1 the main
source of error are inaccuracies in equilibration (0-33 mm)
whereas in method 2 the inductive measuring devices
were not checked for any changes after the 3-week
interval.

General comments

.::;::'

The methodological reproducibility of the CBP registration (0-26 mm) and the reproducibility of mounting

325

326

K.-H.

UTZ

Change in the position

of the condylar spheres
after 19 days
right, mm (n =71)

lateral
-I-3

Horizontal plane

ventral

cranial

"

Transversal plane

2
3
medial

U'

l\

.\^

Fig. 5. Differences in position of the

right (a) and left (b) condylar balls
between the terminal hinge position
recorded after 19 days (coordinate
cross) and the maximum
intercuspation in the first session
(method 1). For complete denture
wearers the depicted differences of
condylar balls positions are inevitably not identical with changes in the
patients' condylar position.

medial
2

2
3

caudal

Table 4. Differences in position of the condylar balls between the equilibrated occlusion in the first session and the
intercuspal position in the second session (not newly equilibrated)
Right

Mean
Standard deviation
Minimum
Maximum

Left

Sagittal
(mm)

Vertical
(mm)

Transversal
(mm)

Sagittal
(mm)

Vertical
(mm)

Total displacement
Right -t- left
(mm)

0-56
0-43
0-00

0-60
0-50
0-02
2-52

0-48
0-37
0-04
1-89

0-54
0-45
0-00
1-78

0-56
0-43
0-00
1-73

1-05
0-55.
0-15
2-82

225

The data represent the shift between upper and lower dentures in a time period of 19 4 days (71 subjects, method 2).
\996B\acky>ieVLSc\enceUd, Journal of OralRehabilitation 23; 321-329

INSERTION OF COMPLETE DENTURES. PART I

(b)
Sagittal plane

Change in the position

of the condylar spheres
after 19 days
left, mm (n= 71)

ventral

medial
3

Horizontal plane

dorsal

Fig. 5. (continued)

the lower denture (0-20 mm) have to be borne in mind

when interpreting the data. Yet the results of this study
(0-5 0-4 mm) were found in a higher range and gain
in importance considering that about 50% of the differences measured after 3 weeks were greater than 0-5 mm
(Fig. 4). Therefore the occlusion of half the patients
changed more than the range of error of the method.
The visual assessment of the apex of the Gothic arch also
indicated that about half of the patients did not have a
congruent horizontal denture position on the first and
the second visit (Fig. 3). As this amount of denture shift
has not been observed in various recent studies on the
reproducibility of the CBP registration, the present results
seem to be different as a result of denture adaptation
1996 BlackweW Science Ud, Journal of Oral Rehabilitation 23; 321-329

between recordings, and factors other than reproducibility

seem to be involved. Features of the denture material,
such as further polymerization, water saturation or
deformation of the denture during chewing, are most
likely of minor influence in this respect, as is the closing
movement of the articulator. The resorption of the
alveolar ridge within the 3-week time span of the experiment should also be negligible as the average period of
denture wearing was 13 years. Thus the settlement of
the dentures on the denture-bearing tissues and a neuromuscular adjustment of the masticatory system should
be considered as an explanation for the denture shift.
The settling process can be defined as the difference
between the position of the denture to the cast and the

327

328

K . - H . UTZ
denture-bearing tissues, which adapt to the fitting surface
of the denture (Boucher, 1940; Lytle, 1962; Stephens,
Cox & Sharry, 1966), the settling of the post dam (Nergiz,
Proschel & Niedermeier, 1992) and any further slight
shifts of the denture position that are not due to
resorption (Hanau, 1929; Brigante, 1965; Niedermeier,
1980; Tuncay et al., 1984; Sassen, 1989). However, it
seems out of the question that the amount of shift
observed in the present study is due exclusively to the
above-mentioned phenomena. It is therefore most likely
that neuromuscular adjustments of the masticatory
system contribute. With the insertion of new dentures,
the stimuli to peripheral receptors in the mucosa, the
muscles, the tendons and the temporomandibular joints
change (Brill, 1957; Tallgren et al., 1980). For example,
if the patient had an eccentric occlusion for many years,
the new dentures will first lead to disorientation. Through
the altered peripheral input the muscles relax and the
mandible changes position as it is held and moved by
the muscles. Altered pressures on the joint might result
in a change in condylar position. The effect of the new
dentures on the stomatognathic system is therefore
similar to a splint (Jarabak, 1956; Calagna, Silvermann
& Garfinkel, 1973; Kowaleski & De Boever, 1975; Roura
& Clayton, 1975; Tallgren et ai, 1980; Serrano, NichoUs
& Yuodelis, 1984; Singh & Berry, 1985; Akerman,
Nordstrom & Hansson, 1986; Carossa etal., 1990). However, the results of the present study do not relate only
to changes in mandibular position. If one assumes that
the position of dentures in relation to denture-bearing
tissues, and therefore to the bone, does not change,
condylar deviations and the displacement of the mandible
must occur in the same room direction. Consequently, a
gothic arch, which is in the second session recorded
further dorsally than in the first session, would be
identical to a ventral shift of the mandible. In a nonarcon articulator this is identical to a dorsal shift of the
upper part. However, a dorsal displacement of the upper
part of the measuring device did not coincide with a
Gothic arch located further distally. Nor could this
correlation be found for the other room directions of
articulator displacement, as would have been the case
when the measured shifts in denture position were due
exclusively to an altered mandibular position. It can
therefore be concluded that the measured denture shifts
are based on a combination of the mentioned reasons.
Direct comparisons with other studies are not possible
because of methodological differences, but clinical
hints that the relation between upper and lower dentures

does change after insertion were given by Jakstat &

Wegmann (1990), Lenz & Goebel (1982), Nergiz et al.
(1992), Sonntagbauer & Sassen (1982) and Taege & Stoica
(1982). These studies, as well as the present study,
emphasize that the occlusion in complete dentures is
more a changeable than an unchangeable relation.

Conclusions
Within the first weeks after insertion of complete dentures
adaptive processes in the area of the denture-bearing
tissues and the masticatory system lead to a change in
relation of the upper to the lower denture.
The amount of occlusal changes in the course of time
varies considerably between individuals. Complete
dentures should be inserted.with clinically even occlusal
contacts, and sophisticated remounting should be
compulsory after only 1-3 weeks.

Acknowledgments
This study is part of the habilitation thesis of the author
and was supported by the 'Deutsche Gesellschaft fiir
Zahn-, Mund- und Kieferheilkunde'. The author is deeply
indebted to DipL- Math. Wolfgang Huntebrinker for
comprehensive data analysis and graphical display (Figs
4 and 5). Statistical advice was gratefully received from
DipL- Math. Dr Konrad Oettershagen. Many thanks are
due to Ms Gabi Reppert for fabrication of the registration
plates. Dr Axel Malchau designed Figs 1, 3 and 4.
Numerous fruitful discussions with Dr Norbert Bernard
and Professor Dr Lorenz Hupfauf as well as critical
comments on the manuscript from Dr Frauke Miiller and
Dr John Besford are greatly appreciated.

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Correspondence: Priv.-Doz. Dr K.-H. Utz, Zentrum fiir Zahn-, Mundund Kieferheilkunde, Poliklinik fiir Zahnarztliche Prothetik I der
Universitat Bonn, Welschnonnenstrasse 17, 53111 Bonn, Gerniany.

1996 Blackwell Science Ltd, Journal of Oral Rehabilitation 23; 321-329