Masticatory Efficiency between Balanced and Lingualized Occlusion

ORIGINAL ARTICLE

MASTICATORY EFFICIENCY BETWEEN BALANCED AND LINGUALIZED

OCCLUSION IN COMPLETE DENTURE WEARERS
ABDUL RAZZAQ AHMED, BDS, FCPS (PROSTHODONTICS)
MUHAMMAD USMAN MUNEER, BDS, FCPS (PROSTHODONTICS)
3
SAMAN HAKEEM, BDS, FCPS (PROSTHODONTICS)
1

ABSTRACT
The objective of the study was to compare the masticatory efficiency with balanced occlusion and
lingualized occlusion in complete denture wearers. The study was conducted in the Department of
Prosthodontics, Lahore Medical & Dental College, Lahore. Sixty edentulous patients were included
in this study; patients were randomly divided into two groups by using Statistical Package for Social
Sciences (SPSS version 10) software. Group A was provided with dentures fabricated with bilateral
balanced occlusion and Group B with lingualized occlusion. The patients masticatory efficiency was
assessed after 2 months of denture insertion using the sieving method. Masticatory efficiency was
statistically better in patients provided with complete dentures fabricated with lingualized occlusion
than dentures with bilateral balanced occlusion. It was concluded patients provided with dentures
fabricated with lingualized occlusal scheme were more comfortable with their dentures and were able
to chew properly with ease and comfort.
Key Words: Lingualized occlusion, bilateral balanced occlusion, masticatory efficiency.
INTRODUCTION
The World Health Organization (WHO) defines
health as a state of complete physical, mental and
social well-being, not merely the absence of disease or
infirmity. This modern approach to health lends itself
to oral health as well.1 Loss of teeth results in compromised facial aesthetics and loss of function. It is a very
difficult situation, even worse when the patient is
completely edentulous.2 Most of the edentulous patients are rehabilitated by providing them with complete dentures.3,4
The success of complete dentures is related to the
quality of the impressions and chewing efficiency of
the patients.5 The scheme of occlusion of complete

Correspondence: 1Dr. Abdul Razzaq Ahmed, House No. 596 PIB

Colony, Karachi. Email Address: a_razzaq1@hotmail.com
Cell Number: +92-321-2497682 Assistant Professor & HOD, of
Prosthodontics, Jinnah Medical and Dental College, Karachi
Assistant Professor, of Prosthodontics, Lahore Medical and Dental College, Lahore,
Assistant Professor & HOD of Prosthodontics, Bahria University
Medical and Dental College, Karachi
Received for Publication:
Revision Received:
Revision Accepted:

January 1, 2013
February 2, 2013
February 11, 2013

Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

denture is one of the factors which affects the chewing

pattern and masticatory efficiency of the patients.6
With dentures, the quantity and the intensity of contacts determine the amount and the direction of the
forces that are transmitted through the bases of the
denture to the residual ridges. That is why the occlusal
scheme is considered an important factor in the design
of complete dentures.7,8
Both balanced occlusion and lingualized occlusion
are recommended for complete dentures. Anatomical
as well as non-anatomical molds of teeth can be used
in both concepts. Balanced articulation is described as
the occlusal contacts of maxillary and mandibular
teeth initially in maximum intercuspation, and their
continuous contacts during movements from this position along specific working, balancing and protrusive
guidance pathways developed on the occlusal surface
of the teeth. It is considered an ideal occlusion for
complete dentures.9
Lingualized occlusion gives the patient improved
comfort, function and appearance, quality-of-life goals
sought by the clinician and patient alike. The principle
of lingualized occlusion aims at stabilizing the
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Masticatory Efficiency between Balanced and Lingualized Occlusion

prosthesis. It is based on maxillary palatal cusps

functioning as the main supporting cusp in harmony
with the occlusal surfaces of mandibular teeth.10
To date, it is unclear if patients notice differences
in their ability to chew when they wear complete
dentures manufactured with lingualized occlusal
scheme when compared with dentures made with a
bilateral balanced occlusion in Pakistan. Therefore, it
was the aim of this study to compare the masticatory
efficiency with two differently fabricated occlusal
schemes of complete dentures.
METHODOLOGY
Sixty edentulous patients between the ages of 45
65 years with no previous complete denture experience reporting to the Department of Prosthodontics for
provision of new complete dentures were included in
this study. Patients having any soft tissue abnormality e.g. epulis fissuratum, hyperplasia were excluded
from the study. Likewise, patients having any congenital defects, neurologic/psychiatric disorders were
also excluded.
Patients of both genders were randomly distributed into two groups in order to minimize the confounding effect of this variable (gender). Complete
medical/dental history, clinical examination and investigations including periapical radiograph and
orthopantomogram if required were carried out. Consent was obtained in this regard from the patients.
A computer was used to randomly divide 60 patients into two groups of 30 each, i.e. Group A and
Group B by using Statistical Package for Social Sciences (SPSS version 10) software. Later on, as the
patients came, they were numbered in a sequence of 160 according to date of arrival in the department and
placed into these pre-sorted groups. Group A patients
were provided with complete dentures fabricated with
bilateral balanced occlusal scheme while those in Group
B were provided with complete dentures fabricated
with lingualized occlusal scheme.
Upper and lower complete dentures were constructed by the same clinician following standardized
clinical techniques. The teeth setup of complete dentures with lingualized occlusion was arranged as follows: the functional maxillary palatal cusps of the
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

posterior teeth were set in the central groove of the

mandibular posterior teeth in lateral and protrusive
excursions. The maxillary buccal cusps were elevated
and had no contact with the mandibular buccal cusps
in both centric and eccentric movements. The 200 semianatomic commercial artificial teeth (Simpler AC,
manufactured by Yamahachi Dental MFG.CO. Japan)
were used for the lingualized occlusion groups teeth
arrangement.
The teeth setup of complete dentures with bilateral balanced occlusion was arranged as follows: the
functional maxillary palatal cusps of posterior teeth
were set in the central groove of the mandibular teeth,
and the maxillary buccal cusps were kept in contact
with mandibular buccal cusps. The buccal cusps and
palatal cusps were in articulation and functional in the
bilateral and protrusive excursions. The 200 semianatomic commercial artificial teeth (Naperce, manufactured by Yamahachi Dental MFG.CO. Japan) were
utilized for the bilateral balanced occlusion groups
teeth arrangement.
After the teeth setup, trial of the denture was
carried out in the patients mouth. After necessary
laboratory procedures by the same technician in the
dental laboratory within the institution, final prostheses were inserted. After insertion, in both groups,
necessary occlusal adjustments were done. Instructions were cited and follow-up visit scheduled. When
the patients were free of post insertion complaints
then patient masticatory efficiency was assessed after
2 months of denture insertion.
Masticatory efficiency test was conducted using
Sieving method. Two tests were conducted using 15
gms peanuts in each test. Peanuts were divided into
five portions of 3 gms using an electrical balance (AND
HR-200 by AND company limited, Japan) for each test.
In the first test, patients were asked to chew each
portion for 15 seconds and spit out the contents in a
given container. Patients were given a tumbler of
water and were asked to rinse thoroughly and release
the remaining contents in the same container. The
procedure was repeated 5 times with every portion of
3 gm peanuts. The chewed material was collected,
pooled and passed through a 10-mesh screen sieve
(U.S. Standard Testing Sieve by Mughal Test, Pakistan). Second test was conducted using same
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Masticatory Efficiency between Balanced and Lingualized Occlusion

methodology but patients were asked to chew each

portion till the material was ready to swallow. Rest of
the methodology was kept same. The chewed material
was left on a blotting paper for 30 minutes after it was
passed through the sieve and weighed using an electrical balance with an accuracy of 0.01g for both the tests.
Mean of both tests were calculated and analyzed.
Data were entered to statistical software SPSS
(version 10) for analysis. The variables under study
were age; gender and weight of masticated peanuts
after 15 second and at swallowing threshold with time.
Mean with standard deviation, 95% confidence interval, median with IQR were computed for age and
weight of masticated peanuts after 15 second and at
swallowing threshold with time. Qualitative variable
(gender) was calculated as frequency and percentage.
Non-parametric Mann-Whitney U test was applied
instead of independent sample t test due to not normal
continuous variables for significance of patients masticatory efficiency will be compared of both. Chi Square
test was also applied to compare gender proportion
between groups. Significance level was set at p 0.05.
RESULTS
A total of 60 edentulous patients were included in
this study. Patients were divided into two groups of 30
each by random numbering table marked as A and B.
The average age of the patients was 53.634.5 years
(95%CI: 52.47 to 54.8). The mean weights of masticated peanuts after 15 seconds and at swallowing
threshold with time are presented in table 1. Out of 60
patients, 34(56.7%) were male and 26(43.3%) were
female with 1.31:1 male to female ratio. In group A
18(60%) were male and 12(20%) were female while in
group B, 16(53%) were male and 14(46.7%) were

female. Significant difference was not observed between the groups for gender distribution (Chi-Square
value= 0.27 DF= 1 P-value= 0.602).
Comparison of weight (mean weight of 5 times
with every portion of 3 gm peanuts) of masticated
peanuts after 15 seconds between groups is presented
in figure I. The median (IQR) of mean weight of
masticated peanuts after 15 seconds was 2.22(0.56) g
in lingualized occlusion groups and 2.27(0.26) g in
balanced occlusion groups. Median difference was not
statistically significant between the groups (MannWhitney U test= 375, p=0.267). The average of mean
weight of masticated peanuts after 15 seconds for both
groups is also presented below the figure 1.
Comparison of weight (mean of 5 times with every
portion of 3 g peanuts) of masticated peanuts at swallowing threshold between groups is presented in figure 2. The median (IQR) of mean weight of masticated
peanuts at swallowing threshold was 1.24(0.52) g in
lingualized occlusion groups and 1.47(0.46) g in balanced occlusion groups. Median difference was statistically significant between the groups (Mann-Whitney
U test= 307, p=0.034). The median weight of masticated peanuts was significantly low in lingualized
occlusion groups than balanced occlusion groups at
swallowing threshold. Comparison of time (sec) of
swallowing threshold of masticated peanuts between
groups was also not significant as shown in figure 3.
DISCUSSION
The statistically significant result of this study
proved the hypothesis that masticatory efficiency is
better with complete dentures fabricated by lingualized
occlusal scheme as compared to those fabricated by
bilateral balanced occlusal scheme.

TABLE 1: DESCRIPTIVE STATISTICS OF STUDY VARIABLES (n= 60)

Study Variables (Unit)

Mean SD

95% CI

Median(IQR)

Max - Min

Age (Years)

53.63 4.5

52.47 to 54.8

53 (8)

60 46

Mean weight (gm) of masticated

peanuts after 15 seconds

2.187 0.30

2.11 to 2.26

2.3(0.28)

2.69 1.57

Mean weight (gm) of masticated

peanuts at swallowing threshold

1.31 0.37

1.21 to 1.40

1.4(0.47)

1.92 0.48

51.84 16.53

47.57 to 56.1

49.1(21.7)

93.97 26.7

Time (sec) of swallowing threshold

CI = Confidence Interval, IQR = Interquartile range, Max = maximum observation,

Min = Minimum observation, sec = seconds, gm = grams, SD = Standard Deviation
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Fig. 1: Comparison of weight (gm) of masticated peanuts after 15 seconds between groups
Statistics

Balanced occlusion

Lingualized occlusion

P-Value

Median (IQR) =

2.27(0.26) gm

2.22(0.56) gm

0.267

Mean SD =

2.230.27 gm

2.140.32 gm

Mann-Whitney U test (two tailed) = 375

Box and whisker plot shows median comparison between groups. Block line in the box shows median of mean
weight of masticated peanuts. Small circles show outliers.
Gm = grams.
Patients provided with dentures fabricated with
lingualized occlusal scheme were more comfortable
with their dentures. They were able to chew properly
with ease and comfort. No such study was conducted
before in Pakistan to assess the masticatory efficiency
of patients by comparing both the occlusal schemes.
In order to minimize the confounding effect of age,
45 to 65 year age group was included in the study.
Patients below the age of 45 years were not included in
the study in which neuromuscular coordination is
better and might have confounded the study with
reference to patient masticatory efficiency level.11
In the dental literature, many reports have been
published showing that professionally assessed quality of complete dentures does not agree with patients
subjective judgments.12 Awad and Feine13 as well as
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

Heydecke et al14 suggested that patients satisfaction

with their prostheses could not be inferred from the
clinicians impression of and satisfaction with newly
provided prostheses. Therefore, the focus of this study
was on patient chewing efficiency as the main outcome.
In this study, patients showed their ability to chew
and masticate significantly better when provided dentures were fabricated with lingualized occlusal scheme.
Koide15 investigated the masticatory performance of
edentulous patients wearing complete dentures arranged with lingualized occlusion and bilateral balanced occlusion. It was found that lingualized occlusion offered a higher ability of food crushing, showed
higher masticatory efficiency, displayed faster as well
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Masticatory Efficiency between Balanced and Lingualized Occlusion

Fig. 2: Comparison of weight (gm) of masticated peanuts at swallowing threshold between groups
Statistics

Balanced occlusion

Lingualized occlusion

P-Value

Median (IQR) =

1.47(0.46) gm

1.24(0.52) gm

0.034*

Mean SD =

1.400.46 gm

1.210.35 gm

Mann-Whitney U test (two tailed) = 307

Box and whisker plot shows median comparison between groups. Block line in the box shows median of mean
weight of masticated peanuts. Small circles show outliers
Gm = grams.
as smoother masticatory movement, and showed
chewing patterns that were closer to the chopper type
compared with bilateral balanced occlusion.
The result of this study also confirms the findings
by Gomibuchi et al16 who compared dentures with
anatomical teeth either arranged for bilateral balanced or lingualized occlusion dentures. Patients in
his study expressed better chewing ability with
lingualized occlusion dentures, suggested that
lingualized occlusion is effective in masticating or cut
food, and are the form of occlusion having a high
cutting potential compared to bilateral balanced occlusion.
Kimoto et al17 in the study found that edentulous
patients provided with complete dentures fabricated
with lingualized occlusal scheme experienced and exPakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

pressed greater satisfaction with their denture retention and resulted in greater masticatory performance.
However Ono and Hatake18 did not found any
significance in complete dentures arranged with
lingualized occlusal scheme affecting masticatory performance. It was reported that the chewing ability of
patients with lingualized occlusion and those with
bilateral balanced occlusion was 44.5% and 46.8%
respectively.
Heydecke et al19 compared the masticatory efficiency between complete dentures arranged with canine guided occlusion and lingualized occlusion. He
found that patients provided with complete dentures
of canine guided occlusal scheme showed better masticatory ability compared to complete dentures arranged with lingualized occlusion.
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Masticatory Efficiency between Balanced and Lingualized Occlusion

Fig. 3: Comparison of time (sec) of swallowing threshold of masticated peanuts between groups
Statistics

Balanced occlusion

Lingualized occlusion

P-Value

Median (IQR) =

46.6(20.5) sec

49.6(20.9) sec

0.37

Mean SD =

50.316.5 sec

53.416.7 sec

Mann-Whitney U test (two tailed) = 390

Box and whisker plot shows median comparison between groups. Block line in the box shows median of mean
time of masticated peanuts. Small circles show outliers
Sec = seconds.
A number of authors have proposed a lingualized
occlusal scheme as the most beneficial concept for
complete dentures.20
The complete dentures arranged with lingualized
occlusion significantly affect masticatory efficiency.
The concept of lingualized occlusion ought to be applying in prospect for fabrication of complete dentures.
With the use of specific moulds of teeth, the scope and
practicality of lingualized occlusal scheme can bring
forward favorable results in terms of patients satisfaction with different types of prosthesis.
CONCLUSIONS
Within the limitations of this study, the conclusion
is that the masticatory efficiency was higher in patients who were provided with complete dentures
fabricated with the lingualized occlusal scheme as
compared to those patients who received complete
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

dentures made with balanced occlusal scheme. This

was due to the fact that lingualized occlusal technique
resulted in functionally better complete dentures as
compared to the ones made by balanced occlusal technique. In addition to that more research work needs to
be carried out in our population to assess the benefits
of these occlusal schemes in the fabrication of partial
dentures and other prosthesis as well.
REFERENCES
1

Monajem S. The WHOs action plan for oral health. Int J Dent
Hyg 2009; 7: 71-3.

Zarb GA. The edentulous predicament. In: Zarb GA, Bolender

CL, Eckert SE, Jacob RF, Fenton AH, Mericske-Stern R. Prosthodontic treatment for edentulous patients; complete dentures
and implant supported prostheses. 12th ed. St Louis: Mosby;
2004: 3-5.

Anastassiadou V, Robin HM. The effect of denture quality attributes on satisfaction and eating difficulties. Gerodontology
2006; 23: 23-32.

205

Masticatory Efficiency between Balanced and Lingualized Occlusion

4

Wang MQ, He JJ, Li G, Widmalm SE. The effect of physiological nonbalanced occlusion on the thickness of the temporomandibular joint disc: a pilot autopsy study. J Prosthet Dent. 2008;
99: 148-52.

denture quality, oral condition, and flow rate of submandibular/

sublingual salivary glands. Int J Prosthodont 2003; 16: 45-48.
13

Awad MA, Feine JS. Measuring patient satisfaction with mandibular prostheses. Community Dent Oral Epidemiol 1998; 26:
400-05.

14

Heydecke G, Klemetti E, Awad MA, Lund JP, Feine JS. Relationship between prosthodontic evaluation and patient ratings
of mandibular conventional and implant prosthesis. Int J
Prosthodont 2003; 16: 307-12.

Phoenix RD, Engelmeier RL. Lingualized occlusion revisited. J

Prosthet Dent 2010; 104: 342-46.

Miyashita K, Sekita T, Minakuchi S, Hirano Y, Kobayashi K,

Nagao M. Denture mobility with six degrees of freedom during
function. J Oral Rehabil 1998; 25: 545-52.

Tarazi E, Ticotsky-Zadok N. Occlusal schemes of complete

dentures-a review of the literature. Refuat Hapeh Vehashinayim
2007; 24: 56-64, 85-86.

15

Koide K. Selection of occlusal scheme on masticatory function in

denture wearers. Nihon Hotetsu Shika Gakkai Zasshi. 2004;
48: 681-90.

Fenton AH. Selecting and arranging prosthetic teeth and occlusion for the edentulous patients. In: Zarb GA, Bolender CL,
Eckert SE, Jacob RF, Fenton AH, Mericske-Stern R. Prosthodontic treatment for edentulous patients; complete dentures
and implant supported prostheses. 12th ed. St Louis: Mosby
2004; 298-28.

16

Taizo G, Kaoru K, Satoshi H. Masticatory Function between

Lingualized Occlusion and Full Balanced Occlusion. J Jpn Soc
Prosthodont 2000, 44; 339-47.

17

Matsumaru Y. Influence of mandibular residual ridge resorption on objective masticatory measures of ligualized and fully
bilateral balanced denture articulation. J Prosthodont Res
2010; 54: 112-18.

Kimoto S, Gunji A, Yamakawa A et al. Prospective clinical trial

comparing lingualized occlusion to bilateral balanced occlusion
in complete dentures: a pilot study. Int J Prosthodont 2006; 19:
103-09.

18

Ono K, Hatake S. The form of occlusion in denture wearers. The

effect of lingualized occlusion on masticatory function. Shigaku
1988; 76: 107-37.

10

Lang BR. Complete denture occlusion. Dent Clin North Am

2004; 48: 641-65.

19

11

Fenlon MR, Sherriff M. Investigation of new complete denture

quality and patients satisfaction with and use of dentures after
two years. J Dent 2004; 32: 327-33.

Heydecke G, Akkad AS, Wolkewitz M, Vogeler M, Turp JC,

Sturb JR. Patient ratings of chewing ability from a randomised
crossover trial: lingualised vs. first premolar/canine-guided
occlusion for complete dentures. Gerodontology 2007; 24: 77-86.

20

12

Wolff A, Gadre A, Begleiter A, Moskona D, Cardash H. Correlation between patient satisfaction with complete dentures and

Ghani F. Prosthetic posterior teeth with cusps may improve

patient satisfaction with complete dentures. Evid Based Dent
2005; 6: 39-40.

Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)

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