Occlusion in fixed prosthodontics

Occlusion is the normal relation of the occlusal inclined planes

of the teeth when the jaws are closed (Angle).
Occlusion: Is the changing interrelationship of the opposing
surfaces of the maxillary and mandibular teeth, which occurs
during movements of the mandible and the terminal full contact
of the maxillary and mandibular dental arches (Gregory).
Occlusion of the teeth is not a static condition, as the mandible
can assume various positions. Occlusion may be centric, habitual,
mesial, distal, eccentric, labial, lingual, supra, inferior and may
other forms.

Ideal Occlusion:
Ideal occlusion is a hypothetical formula, which does not and
cannot exist in man. Ideal tooth form and ideal occlusion
necessitates an unblemished heredity, an optimum favorable
environment and a developmental history devoid of any accident,
diseases or occurrence, which would modify the inherent growth
pattern

Types of occlusion:
Balanced occlusion:
It is occlusion where there is simultaneous bilateral contact of
opposing occlusal contacts of some or all the teeth in all
mandibular positions.
Balanced occlusion is developed by the dental technician when
setting artificial teeth on the articulator.
There are five determinants of balanced occlusion (The Hanaus
quint):
1. Orientation of occlusal plane
This is determined by the clinician when trimming the upper
occlusal rim during jaw registration.
Average value articulators have preset distances between
the condylar components and the incisal tips.
2. Condylar guidance angle

Condylar guidance is the Mandibular guidance generated by

the condyle and the articular disc traversing the glenoid
fossa (GPT)
This is usually set at about 30 degrees for average value
articulators.
A steep condylar path requires steep compensating curve for
occlusal balance.
3. Incisal guidance angle.
This is the angle formed in the horizontal plane by drawing a
line in the sagittal plane between the incisal edges of the
maxillary and mandibular incisors when the teeth are in
centric occlusion. (GPT)
Incisal guidance angle is set at 10 15 degrees.
4. Cuspal angle.
The cuspal angles of artificial teeth are determined by the
manufacturer. There are:
a) Anatomical teeth e.g. 20, 30 and 40 degree cuspal angle.
b) Zero degree/ Cuspless teeth Used where the residual
alveolar ridge is flat or where there are problems with jaw
registration.
5. Compensating curves.
a) The curve of spee This is the antero- posterior curve,
measured with reference from the incisal tip along the
buccal cusps of maxillary teeth.
b) The curve of Wilson The Lateral curve. It runs from the
tip of the buccal cusps through the palatal cusps on one
side and through the palatal cusps to the buccal cusps on
the opposite side.
These curves compensate for mandibular movements both
in excursion and lateral excursion.
Mutually Protected Occlusion:
Also called canine protected occlusion, it is an occlusal scheme
whereby the posterior teeth prevent excessive contact of anterior
teeth in maximum intercuspation, and the anterior teeth
disengage the posterior teeth in all excursive mandibular
movements (GPT).
This reduces frictional wear of teeth.

 Group Function occlusion:

This refers to multiple contact relations between the maxillary and
mandibular teeth in lateral movements on the working side
whereby simultaneous contact of several teeth acts as a group to
distribute occlusal forces (GPT).
Absence of contacts on non-working side prevents those teeth
from being subjected to the destructive, obliquely directed forces
found on the non-working side

Temporomandibular joint:
Bony Surfaces:
The temporomandibular joint consists of articulations
between three surfaces; the mandibular fossa and articular
tubercle (from the squamous part of the temporal bone),
and the head of mandible.
This joint has a unique mechanism; the articular surfaces of the
bones never come into contact with each other they are
separated by an articular disk. The presence of such a disk splits
the joint into two synovial joint cavities, each lined by a synovial
membrane. The articular surface of the bones are covered
by fibrocartilage, not hyaline cartilage.

Ligaments

There are three extracapsular ligaments. They act to stablise the

temporomandibular joint.

Lateral ligament It runs from the beginning of the

articular tubule to the mandibular neck. It is a thickening of the
joint capsule, and acts to prevent posterior dislocation of the
joint.

Sphenomandibular ligament Originates from the

sphenoid spine, and attaches to the mandible.

Stylomandibular ligament A thickening of the fascia of

the parotid gland. Along with the facial muscles, it supports the
weight of the jaw.

Movements of the TMJ Joint

Movements at this joint are produced by the muscles of
mastication, and the hyoid muscles. The two divisions of the
temporomandibular joint have different functions.
Protrusion and Retraction The upper part of the joint allows
protrusion and retraction of the mandible the anterior and
posterior movements of the jaw. The lateral pterygoid muscle
is responsible for protrusion (assisted by the medial pterygoid),
and the geniohyoid and digastric muscles perform retraction.

Elevation and Depression. The lower part of the joint permits

elevation and depression of the mandible; opening and closing the
mouth.

Depression is mostly caused by gravity. However, if there is

resistance, the digastric, geniohyoid, and mylohyoid muscles
assist.
Elevation is very strong movement, caused by the contraction of
the temporalis, masseter, and medial pterygoid muscles.

Centric Relation:
Centric relation is a bone-to-bone relation. It is the relation
between the maxilla and the mandible when the Condyles are
in the rear most upper most mid most in the Glenoid fossae
(known as the rum position). It is a relation where the
condyle is in a hinge position.
It may also be defined as the untranslated hinge position of the
mandible in its relation to the maxilla. More simply, it may be
defined as the physiologic centering of the condyles in the
cranium. At this centered position, there is an absence of
translation.
The most recent definition is that the centric relation is the
maxillo-mandibular relationship in which the condyles articulate
with the thinnest avascular portion of their respective disks with
the complex in the anterior-superior position against the shapes
of the articular eminencies.

Centric Occlusion:
This is a relation between the lower and the upper teeth, that
is, it is a tooth-to-tooth relation.
Defined as being the occlusion of teeth as the mandible closes in
centric relation. It is a reference point from which all other
relations are eccentric.

Maximum Intercuspation:
It is the most closed complete interdigitation of mandibular and
maxillary teeth irrespective of condylar centricity.

In other words, maximum intercuspation may or may not

coincide with centric occlusion, depending on the position of the
condyle.
If in maximum intercuspation the condyles are
physiologically centered, then both the maximum intercuspal
position and the centric occlusion position are the same.
However, if maximum intercuspation occurs with the condyles
being out of centricity, then both positions would not coincide,
with the maximum intercuspation in that case, referred to as the
habitual closure, and is considered as an eccentric position. In
that case the intercuspal position is in a position forward to the
centric position, and at a lower vertical dimension.
Condylar Movements
1-Rotation
Rotation is the motion of a body around its axis. Mandibular
rotation occurs in the lower compartment of the TMJ, between the
mandibular Condyle and the articular disc.
Mandibular rotation occurs around the rotational centers of the
condyles.
The Hinge Axis: is the imaginary line connecting the rotational
centers of one condyle with that of the opposite condyle, and
around which the mandible makes the opening and closing
rotational movements.

2-Translation

Translation is the movement of a body when all its parts move at

the same time. Mandibular translation occurs in the upper
compartment of the TMJ between the disc and the glenoid fossa.

Mandibular Movements:
With the condylar rotation and translation, the mandible is
capable of performing the following movements:
A-Opening Movement
For this movement to occur, the condyle rotates in its place, in
the terminal hinge position. Pure rotation occurs only till the
condyles start to translate moving out of its centricity. Upon
rotation of the condyle, the mandible opens, and teeth are
discluded.
As soon as the pure rotation ends, the condyle begins to
translate, moving forward and downward on the superior and
anterior
Walls of the glenoid fossa, with the arc of opening changing,
and the mandible opening further till the maximum opening
position.
B-Protrusive Movement
For this movement to occur, Condyles follow the form of the
superior wall of the glenoid fossa, they slide downwards and
forwards as the mandible moves in protrusion. This movement
causes the separation of the posterior teeth, a state known as
Disclusion.
C-Lateral Excursion Movement:
The mandible is capable of moving towards both the right and left
sides. The side to which the mandible moves is called the working
side, while the opposite side is called the non-working side.

Temporomandibular joint disorders:

TMJ disorders, are a group of medical problems related to the jaw
joint. TMJ disorders can cause headaches, ear pain, bite problems,
clicking sounds, locked jaws, and other symptoms that can affect
quality of life for the patient. This reference summary explains
temporomandibular joint disorders. It reviews the anatomy of the
jaw, symptoms, causes, diagnosis, and treatment options for TMJ
disorders.

Types of TMJ Disorders

TMJ disorders can be grouped into three main categories:
Muscle Disorders
These disorders include pain in the muscles that control jaw
function, as well as the muscles of the neck and shoulder. This
type of pain is called
myofascial pain And is the most common form of TMJ disorders.
Derangement Disorders
These disorders are related to derangement of the TM joint, such
as dislocated jaw, displaced disk, and injured bone.
Degenerative Disorders
These disorders are related to wear and tear of the TM joint, such
as arthritis. They lead to the destruction of the cartilage that
covers the TM joint.
Causes:
TMJ disorders may be caused by injuries, wear due to aging, and
behavioral factors.
A severe injury to the TMJ can cause TMJ disorders.
For instance, a heavy blow to the jaw could fracture the bones of
the joint or damage the disc, disrupting the smooth motion of the
jaw and causing pain or locking of the joint.
Wear and tear of the TM joint due to aging can cause TMJ
disorders, such as arthritis. Arthritis in the jaw joint may also
result from injury.

Certain behaviors or conditions can sometimes cause TMJ

disorders.
For instance, regular gum chewing can lead to TMJ disorders in
some people.
Teeth grinding and teeth clenching can increase wear on the
cartilage of the TM joint.
This could lead to ear and jaw pain.
Sometimes people who are under stress grind and clench their
teeth.

Occlusal interferences:
Any tooth to tooth contact which hamper or hinder Smooth
guidance in excursions or closure into centric occlusion
Working side interference: An interference on the side to which
the mandible is moving
Non-working side interference (NWSI) or balancing side
interference: An interference on the side from which the
mandible is moving.
NWSI acts as a cross arch pivot, disrupting the smooth movement
and separating guidance teeth on the working side.
NWS contact excursions are guided equally by working and nonworking tooth contacts as an ideal complete denture occlusion.
Most NWSIs are on molars that are subjected to excessive oblique
damaging forces that predispose to fracture or decementation.
If inference on a tooth to be prepared, it is recommended that
interference is removed before starting tooth preparation.
Remove interference at a separate appointment prior to
preparation to allow adaptation to the new guidance pattern.

If you created an interference in the filling, the patient tries to

adapt, and this adaptation could be in the posterior guidance by
doing morphological changes, like thickening in capsule, or the
ligament adapting the disharmony which you have done.
Or it can be in the anterior guidance, in the teeth, and this
adaptation is manifested as widening in the periodontal ligament
space.
Or if this interference is so severe, this could lead to myofacial
pain dysfunction syndrome, tooth fracture, tooth mobility, or
decementation of your crown.

Occlusal adjustment:
Occlusal adjustment (odontoplasty) is the reshaping of
occlusal surfaces of teeth to create a harmonious contact
relationship between maxillary and mandibular teeth.
A primary objective of occlusal adjustment is improvement of the
functional relations of the dentition in such a way that the teeth
and the periodontium will receive uniform stimulation and the
occlusal surfaces of the teeth will be exposed to an even
physiologic wear.1
The rationale for doing an occlusal adjustment can be grouped
into the following categories:
1.

Elimination of traumatic occlusion

2.

Stabilization of orthodontic results

3.

Establishment of an optimal occlusal pattern prior to

extensive restorative procedures

Complete (full-mouth) occlusal adjustments are performed to

achieve functional relationships and improve masticatory
efficiency. It may be necessary to perform odontoplasty to occlusal
surfaces of numerous teeth to establish or maintain occlusal
harmony.
Treatment is directed toward the elimination or minimization of
excessive force or stress placed on the teeth and/or tooth.

Occlusal adjustments are necessary when they are essential to

reduce or eliminate traumatic occlusion or when teeth are
compromised from loss of periodontal support.
Occlusal adjustments may be integral to a comprehensive
restorative treatment or part of treatment to correct skeletal and
occlusal disharmonies. A complete occlusal adjustment may
require multiple visits, is considered part of comprehensive
orthodontic treatment and is integral to orthognathic surgery.
Occlusal adjustments are of limited value as the sole treatment
modality for the management or prevention of TMD.
Scientific evidence does not support the performance of occlusal
adjustment as a general method for treating a non-acute TMD,
bruxism or headaches.
Literature suggests that temporary reversible measures be
attempted prior to permanent irreversible disengagement
procedures.
Mounting of diagnostic casts, analysis and diagnosis are
considered integral to the complete adjustment.

Rehabilitation
All patients requiring full mouth rehabilitation have one problem in
common: stress and strain.
Usually the stress is due to malfunction or to poorly related parts
of the oral mechanism.
Our objective is to minimize these stresses so that they are not
destructive. Stresses should fall within the capability of the
tissues to withstand them and maintain a state of health. In order
to prevent this stress from being destructive, the best thing to do
is to distribute it evenly or an as great area as possible, over as
many teeth and as much tissue as possible, with the teeth
providing a means by which the forces are distributed.
Reasons for rehabilitation:

1 The most common reason for doing full mouth rehabilitation is

to obtain and maintain the health of periodontal tissues.
2 Temporomandibular joint disturbance is another reason.
3 Need for extensive dentistry as in case of missing teeth, worn
down teeth and old fillings that need replacement.
4 Esthetics, as in case of multiple anterior worn down teeth and
missing teeth.

Indications of occlusal rehabilitation:

Restore impaired occlusal function
Preserve longevity of remaining teeth
Maintain healthy periodontium
Improve objectionable esthetics
Eliminate pain and discomfort of teeth and surrounding
structures.
Contraindications for rehabilitation:
Malfunctioning mouths that do not need extensive dentistry and
have no joint symptoms should be best left alone. Prescribing a
full mouth rehabilitation should not be taken as a preventive
measure unless there is a definite evidence of tissue breakdown.
Classification of patients requiring occlusal rehabilitation
The patients were classified into three categories:
Category 1 - Excessive wear with loss of vertical
dimension.
Category 2 - Excessive wear without loss of vertical
dimension of occlusion but with space available.

Category 3 - Excessive wear without loss of vertical

dimension of occlusion but with limited space available

Increasing Vertical Dimension

Vertical determinants:
There are four philosophies for condylar position when
determining VD. All work on the basis of a canine protected
occlusion.
1. Gnathological
Involves use of fully adjustable articulators to determine condylar
path from the hinge axis and setting this path for a 5 degree
increase to ensure no posterior interferences. 6
2. Bioaesthetics
Works via a fixed numerical value based on incisal relationship.
Distance between gingival margins of 18-20 mm in an unworn
class one occlusion, with upper incisal length of 12 mm, lower
incisal length 10 mm, 4 mm overbite and 1 mm overjet.
3. Centric relation based
Following the principles of P. Dawson whereby CR is defined as
'when the heads of the condyles are in their most superior
position within their sockets, lateral pterygoid muscle is relaxed
and the elevator muscles are contracted with the disc properly
aligned'.
4. Neuromuscular
Based on the principles of muscle activity determined by
electromyography
Rationale for altering VD
1. Aesthetics.
2. Alter the occlusal relationship.
3. For prosthetic convenience to allow space for restorations.
Increasing Vertical Dimension
A procedure for creating a balanced occlusion with cast gold
crowns has been described. The procedure has several
advantages.

1. When the gold skeleton crowns have been placed in the mouth
and centric relation has been obtained, it is equivalent to having
located the anatomic hinge axis of the mandible accurately. There
is no fear that an error will develop when it is transferred to the
articulator.
2. When the interfering spots on the gold skeleton crowns have
been ground so the anterior teeth can come into edge to edge
contact in right and left and forward mandibular positions, the
dictates of the jaw movements have been carried out, and the
precise degree of the vertical opening necessary has been
established.
3. If there is a functional irregularity on one or both sides, the
physiologic movement (including the Bennett movement) will
have been accounted for because the data was obtained in the
mouth which is the perfect articulatorthe one no man can
duplicate.
4. When the voids in the occlusal surfaces of the gold skeleton
castings are filled with casting wax and chewed in, the small
spines that jut into the voids permit the maintenance of the
steepness of cusps and facilitate the final carvings of the occlusal
surfaces when removed from the mouth.
When the gold occlusal surfaces are cast directly to the gold
skeleton crowns, the crowns are completed, as is the problem of
the increase of the vertical dimension of occlusion.
It is to be hoped that the simplicity of this method will be a
stimulant for the practice of a much neglected phase of dentistry.