Frequency of over eruption in unopposed posterior teeth

ORIGINAL ARTICLE

FREQUENCY OF OVERERUPTION IN UNOPPOSED

POSTERIOR TEETH
SAMAN HAKEEM, BDS, FCPS (Prosthodontics)
2
ABID MOHSIN, BDS, MPH
3
ABDUL RAZZAQ AHMED, BDS, FCPS (Prosthodontics)
1

ABSTRACT
The objective of the study was to determine the frequency and extent of over eruption in unopposed
posterior teeth. The study was conducted in the Department of Prosthodontics, Lahore Medical &
Dental College, Lahore. Fifty sites of unopposed posterior teeth were included in the study. Broadrick
flag technique was used for the generation of broadrick occlusal curve. The measurement of over
eruption of the unopposed posterior tooth was measured from the generated curve to the tip of most
occlusally projecting cusp by a vernier caliper. Forty seven (90%) of the subjects and sixty teeth (83.3%)
out of seventy two had some degree of over eruption. It was concluded that unopposed posterior teeth
lead to over eruption of antagonists with clinical and statistical significance (83.3%).
Key words: Dentition, Occlusal patterns, Spee curve
INTRODUCTION
With changing times oral health awareness has
significantly improved dental status1 this is evident as
the decrease in edentulism with more people retaining
their natural teeth until old age2 but increasing partial
edentulism has its own set of problems. Majorly, tooth
loss may lead to supra occlusion of opposing teeth3
which may compromise and complicate the prosthodontics treatment plan.
There is no evidence that eruption ceases on
contact with an antagonist4 but it continues to erupt,
compensate and adapt.4, 5 Many studies have confirmed
this notion6 of continuous tooth eruption without concomitant coronal movement of alveolar bone in teeth
which had no antagonists. These manifest themselves
as active eruption or passive eruption.7
Even the loss of occlusal contacts due to caries can
lead to the collapse of the setup with detrimental

consequences to the stability and integrity of the

interarch tooth alignment.8
Moreover, tipping9, tilting and physiological drifting may adversely affect the relative crown-root
alignment7,9 resulting in unfavorable occlusal forces
which may lead to periodontal breakdown or occlusal
trauma.11 In younger age group, the undesirable tooth
movements are more profound due to greater potential
for growth.12 Majority of them occur in the early post
extraction periods.13 Loss of periodontal support may
superimpose later as reinforced by Ainamo and Ainamo
in 1978.14
10

Understanding the effects of these types of movements is vital in the management of restorative and
prosthodontic care. Occlusal plane orientation is a key
to harmonious occlusion. This study will be an attempt
to provide a guide to the extent of over eruption. This
study may help in understanding the possible conse-

Assistant Professor & HOD, Deptt. of Prosthodontics, Bahria University Medical and Dental College, Karachi,
Pakistan
2
Assistant Professor, Deptt Of Community Dentistry, Baqai Dental College, Karachi, Pakistan
3
Assistant Professor, Deptt Of Prosthodontics, Islam Medical and Dental College, Sialkot, Pakistan
Correspondence: 41-Z/B, Block 6, PECHS, Karachi. E mail Address drshaz80@hotmail.com. Cell Number:
+92300 9257062
1

Pakistan Oral & Dental Journal Vol 32, No. 1 (April 2012)

159

Frequency of over eruption in unopposed posterior teeth

quences of over eruption, decision making process and

planning of future tooth replacement.
METHODOLOGY
Fifty cases of unopposed posterior teeth visiting
the out patient department of Prosthodontics, Lahore
Medical and Dental College were selected on the basis
of inclusion and exclusion criteria. 18 to 55 years old
patients having two or more unopposed posterior teeth
with the loss of antagonist at least 6 months backs were
included. Periodontally compromised dentition was
not included in the study. Patients who have had any
previous prosthodontics treatment or orthognathic
reconstructive surgery, or patients having congenital
or acquired defects were likewise excluded. Verbal
consent was taken. Patients demographic data was
noted. The patients were informed of the risks/benefits
of the techniques employed and materials used.
Impressions were made with irreversible hydrocolloid impression material (Chromo gel - Chromatic
Alginate by Zhermack Spa) manipulated according to
the manufacturers instructions. In case of any error,
the impressions were repeated. After disinfection casts
were poured immediately with dental stone type IV to
avoid syneresis and imbibitions.
The maxillary cast was oriented by means of an
arbitrary face bow transfer (Whip mix) on a semi
adjustable articulator (Whip mix 3040) modified for
employing Broadrick Flag technique.15, 16
Vinyl polysiloxane bite registration material (fast
setting) was employed for recording centric relation
position which was located by bimanual manipulation
of the mandible as described by Long and modified by
Dawson.17 An anterior jig18 was also constructed to
deprogram any muscle engrams, if present. The anterior jig or deprogrammer was directly fabricated in the
mouth using auto polymerizing acrylic resin. The
deprogrammer was retained in the mouth for 15 minutes to deprogram the habitual occlusion. Dawsons
bimanual manipulation was carried out consecutively
while the anterior jig was in place. The registration if
perforated was discarded.

flag. The flag was attached to the upper member of the

articulator by two custom made clear acrylic blocks
into which the flag snugly fitted. Silicone matrices
were constructed to conform to the condylar element of
the articulator. A hole was drilled into it to locate the
center for the posterior survey point required for
generation of Broadrick occlusal curve.
Using the Broadrick flag method described by
Lynch and McConnell19, the ideal occlusal plane was
created using a graphite lead in a bow compass. It was
adjusted to the radius selected. In class 1 incisal
relationships 4 inch radius, class 2 relationships 3.75
inches and class 3 incisal relationships 5 inch arc was
used respectively. The center point of the bow compass
was positioned on the anterior survey point (ASP)
which was located on the midpoint of the distoincisal
edge of the mandibular canine scribing an arc of about
3 inches on the flag. Posterior survey point (PSP) was
already located by the silicone putty matrices and
another arc was drawn which intersected the first arc.
The point of the compass adjusted to the same radius
was now placed at the intersection of the arcs. The
graphite marker was swept over the buccal surfaces of
the unopposed posterior teeth marking the Broadrick
occlusal curve on the teeth.
Vernier caliper was employed to measure the
projection of the unopposed tooth from the Broadrick
occlusal curve in vertical direction. Measurements
were taken to two decimal points. Three readings were
taken at the mesiobuccal, center and distobuccal aspect of the tooth. Readings were recorded on the
proforma and mean calculated.
Data was entered to SPSS (version 11.0) for analysis. The variables under study were age, sex, unopposed site, extent of over eruption. Numerical variable
(age, extent of over eruption) were calculated as mean
and standard deviation. Qualitative variables (sex,
unopposed sites) were calculated as frequency and
percentages.
RESULTS

Broadrick flag was constructed by 4 x 4 inch hard

card board piece 3mm thick. The card board was
covered with blank white sheet to create a double sided

Fifty two subjects with unopposed posterior teeth

were selected. The age of these patients ranged between 18- 55 years of age. Twenty three were male and
twenty nine were female subjects. Seventy two unopposed teeth were measured for over eruption. Forty

Pakistan Oral & Dental Journal Vol 32, No. 1 (April 2012)

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Frequency of over eruption in unopposed posterior teeth

TABLE 1: DISTRIBUTION OF TOOTH TYPES IN TEETH WITH OVER ERUPTION AND

IN TEETH WITHOUT OVER ERUPTION
(n=72)
Tooth type
Teeth with
over eruption

1st
premolar
Mx
Mn

Teeth without
over eruption

Mx
Mn

Rt
Lt
Rt
Lt
Rt
Lt
Rt
Lt

Total
percentage
Key:
n = number

Mx = maxillary

2nd
1st molar
premolar molar

0
0
0
1
0
0
0
1
2
2.77

3
4
4
3
0
0
0
1
15
16.67

Mn = mandibular

15
11
2
4
1
2
2
2
39
54.17
Rt = right

2nd

Total

Percentage

6
3
0
4
1
1
1
0
16
22.22

42

58.33

18

25.00

6.94

9.72

72
100
Lt = left

Fig 2: Distribution of teeth according to degree of

over eruption (mean)

Fig 1: Distribution of teeth according to date of extraction of antagonists

Out of 72 total teeth, the extraction period of the
antagonist of 23 teeth, 3 percent was between 8-20
months, of 36 teeth was between 21-60 months, 50
percent, of 11 teeth was between 61-100 months, 15.3
percent and of 1 tooth each was between 101-140
months and 141-180 months, 1.4 percent.
seven (65.28%) teeth were present in the maxillary
arch out of which twenty six were in the right and
twenty one in the left maxillary quadrant. Twenty five
(34.72%) teeth were present in the mandibular arch out
of which nine were in the right and sixteen in the left
mandibular quadrant. Forty seven (90%) of the subjects
and sixty teeth (83.3%) out of seventy two had some
Pakistan Oral & Dental Journal Vol 32, No. 1 (April 2012)

Out of sixty teeth, fourteen teeth were between 0.301.51mm, 23 percent; twenty two teeth were between
1.51-2.50mm, 37 percent; eighteen teeth were between
2.51-3.50mm, 30 percent and six teeth were between
3.51-4.50mm, 10 percent.
degree of over eruption. Mean over eruption recorded
was 2.26 mm with standard deviation of 0.94. The
smallest recorded reading was 0.32 mm and the highest
recorded reading was 4.38 mm.
DISCUSSION
One of the major influences of posterior tooth loss
is supra eruption of the antagonist.20 In this study, the
edentulous period was kept small as most of the over
eruption occurs in the early post extraction period.13
Provisional restorations in fixed prosthodontics substantiate this concept.21
161

Frequency of over eruption in unopposed posterior teeth

The fifty two subjects observed had one or more

unopposed sites. Third molars were excluded since
their period of remaining unopposed could not be
ascertained with accuracy. Periodontally compromised
dentitions were excluded since they may super impose
the initial positional changes leading to greater over
eruption.13 Unopposed tooth in this study was defined
as being completely unopposed with at least two antagonists missing. This was based on the fact that one
tooth to two tooth contact is seen in normal healthy
individuals.
This study had some limitations. The rate of over
eruption and its susceptibility in different age groups
could not be ascertained which can only be done by a
longitudinal study. Convenience sampling was employed. Few patients of posterior tooth loss may have
been missed. Age may affect the measurements of over
eruption. Increasing age may lead to periodontal involvement, gingival recession and increased tooth
wear. Relative tooth wear of adjacent teeth may have
over estimated over eruption in some teeth.
Over eruption were measured in a vertical direction only. Studies have shown that the distal aspect of
an over erupted tooth is most affected due to tipping.22
This problem was overcome by measuring three reference points on the tooth (mesiobuccal, centre and disto
buccal). Another aspect which may have been over
looked is the normal buccal inclination of the maxillary
teeth leading to greater over eruption of its mesiopalatal
cusp. Thus, over eruption may have been under estimated in some teeth.

anticipated and the actual possibility of treating such

cases without extractions.
Another significant finding was lesser number of
teeth with severe degrees of over eruption. This may
be attributed to deleterious consequences of over eruption to the tooth itself like root exposure, sensitivity,
mobility and traumatic bite leading to toothloss. The
findings of this study implicate that unopposed sites
should be monitored regularly. Preventive measures
should be considered as described by Solnit25 like
temporary acrylic removable prosthesis or adhesive
cantilever prosthesis.
These results are consistent with other studies
which also demonstrated high frequencies of over
eruption in their samples. The reproduction of the
natural occlusal curve (curve of Spee) is widely varied
in different studies. Smith in 199626 reported over
eruption to be statistically significant. He drew a
straight line between two points on the cusp tips of the
teeth adjacent to the extraction site. This flattens the
natural occlusal curve and may produce a false impression of supra eruption. Killiardis27 combined the subjects
occlusal plane and the marginal ridges of the teeth
adjacent to edentulous space by a straight line, in this
case molars unopposed for 10 years. The study displayed that 82% of the teeth had some degree of over
eruption. Measurements were not made beyond 2mm
so severe degrees of over eruption may have been
ignored in this study. Shugars28 also used the same
methodology showing over eruption between 0.1-1.0
mm ranges.

The frequency of over eruption was as high as 90%

in at least one of their unopposed teeth. 83.3% teeth
showed some degree of over eruption. Majority had
moderate to slightly severe degrees of over eruption.
The results showed that over eruption is likely to be
encountered in most of the patients. The results are
clinically significant in regard to the amount of tooth
reduction needed, the degree of complexity that may be

Craddock et al20 demonstrated 83% over eruption

in unopposed teeth which had less than 20% contact
with the antagonist. Commonly encountered values
were between 1 to 2.5mm. Only one tooth showed over
eruption of 5.39mm.The outcome of the present study
is consistent with these results and comparable as they
employed a fairly accurate method to measure over
eruption. Computer software was utilized using
Orthliebs method to generate the curve. In 2005,
Yamouka et al29 measured over eruption through
orthopantomographs. Their results showed 42.92% of
over eruption which is far below the frequencies found
in the present as well as other studies. The difference
may be due to improper measurement technique. The
radiographs were not standardized and exact measurements were not taken.

Pakistan Oral & Dental Journal Vol 32, No. 1 (April 2012)

162

Majority of teeth which were found to be unopposed

in this study comprised of first molars (54.17%). These
results are consistent with other studies on patterns of
tooth loss. Similarly, more maxillary teeth were unopposed (65.28%) implicating that missing teeth were
common in mandibular arch as evident by other studies
done both in and outside Pakistan.23, 24

Frequency of over eruption in unopposed posterior teeth

Two recent studies (2007) by Craddock et al have

been done to determine the frequency of over eruption.
. The second study displayed quite a high frequency of
over eruption (90%).30 They generated a spline curve
produced by the maximum concavities of the gingival
margins. The reason behind different results of this
study may be due to flattening of the curve in this
method.
The present study employed Broadrick Flag technique15, 16 to generate the occlusal curve. It helps fairly
accurate location of the cusp tips and demonstrates the
degree of tooth reduction or porcelain addition to be
employed. It has also been supported as a scientific
instrument and a useful tool in prosthodontics and
restorative dentistry.15, 19 The orientation of the posterior survey point, which is located on the distal molar
tooth, may not always be suitable. A study done by
Craddock et al31 concluded that tipping of the posterior
determinant has little effect on the size curve radius.
In the present study, this problem was over come by
utilizing Needles approach32 for all subjects. He suggested the use of anterior point on the condylar element as the PSP. Lynch and McConnell19 also advocated the same approach. Flattening of the curve is
possible in this method as well due to different skeletal
patterns in individuals. The radii of different values
were employed for the three skeletal patterns to avoid
discrepancy in the generated occlusal curve.16
The results of this study showed a high frequency
of over eruption. This may be attributed to a number of
factors. The correlation of lower education level, socioeconomic status and lack of dental health awareness
with delayed presentation34 and increased tooth mortality stands true for Pakistan.33 Moreover; lack of
access to dental care services was the most significant
factor as cited by Sonia et al.35 The ignorance regarding
preventive and therapeutic measures contributes to a
negative attitude towards dental treatment.36
Priorities regarding dental health care and needs
should be altered according to the local environment.
Dental health awareness programs need to be initiated
at community level.
Health care providers and community workers
need to be integrated in the dental health care system
by creating awareness regarding prevalence, consequences, preventive measures and management of
oral diseases including tooth loss
Pakistan Oral & Dental Journal Vol 32, No. 1 (April 2012)

CONCLUSIONS
Within the limitations of this study, the conclusion
is that unopposed posterior teeth lead to over eruption
of antagonists with clinical and statistical significance
(83.3%). Over eruption is likely to be encountered in
most of the patients.
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