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Occlusion: 2. Occlusal Splints, Analysis and Adjustment

Article  in  Dental update · November 2003

DOI: 10.12968/denu.2003.30.8.416 · Source: PubMed

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 R E DS ET N
R E S T O R AT I V E O TR I AS TT IRVY E
Occlusion: 2. Occlusal Splints,
Analysis and Adjustment
Abstract: The first paper in this series covered maxillo-mandibular positions and jaw
movement. This paper will describe the steps involved in carrying out an occlusal
analysis and adjustment.
Dent Update 2003; 30: 416–422
Clinical Relevance: A working knowledge of the concepts of occlusal adjustment is
central to successful restorative dentistry.
O cclusal adjustment is a planned
procedure aiming to provide an
ideal functional occlusion and/or removal
of local occlusal problems, such as a
plunger cusp. Occlusal adjustment (see
later) and occlusal equilibration are not
the same, as the latter is the planned
alteration of occlusal surfaces to provide
stable jaw relationships with
simultaneous multiple even inter-occlusal
contacts. Equilibration is more difficult
than adjustment since it involves
adjustment of many teeth in two-stages:
first, adjustment and second, provision of
stability. Planning the stages of
equilibration on study casts mounted in a
semi-adjustable articulator with occlusal
surfaces painted with poster paint is
recommended and beyond the scope of
this paper. As both techniques are
irreversible, the novice would be ill-
advised to equilibrate without first
understanding the technique of
Alex Milosevic, PhD, BDS, FDS RCS, DRD
RCS(Edin.), Consultant and Honorary Senior
Lecturer in Restorative Dentistry, Liverpool
University Dental Hospital, Pembroke Place,
Liverpool L3 5PS.
416
D E N T I S T R Y
ALEX MILOSEVIC
occlusal adjustment.
The desirable features of a functional
occlusion are:
l An RCP-ICP slide of no more than
1 mm without lateral deviation;
l On lateral excursion, either canine
guidance or group function on the
working side with, importantly, an
absence of non-working side
contacts;
l On protrusion, posterior disclusion
(absence of posterior contacts).
Further desirable features were
outlined by Beyron:1
l Axial loading of occlusal forces;
l Forces to be distributed over as
many teeth as possible in ICP;
l Bilateral contact between posterior
teeth in RCP;
l Equality of masticatory performance
on left and right;
l The above should be achievable at
an acceptable Occlusal Vertical
Dimension (OVD).
A variety of occlusal concepts have
been proposed. Mutually Protected
Occlusion, the MPO theory, states that,
in ICP, the anterior teeth are only lightly
in contact so that the posterior teeth are
axially loaded and thereby protect the
anterior teeth. The anterior sextant
guide, in all excursions, thus discludes
and protects the posterior teeth.
Although Mutual Protection is a widely
accepted approach to occlusal
organization, questions remain
regarding canine protection versus
group function, point centric versus
freedom in centric and the role, if any, of
occlusal factors in the aetiology of
bruxism and TMJ dysfunction. This
paper explains the ‘how’ with respect to
occlusal analysis and adjustment but
‘when’ is perhaps more difficult to
answer. The ideal dynamic relationships
are not present in a significant
proportion of the population and yet
they do not have signs or symptoms of
disorder. Adaptation within the stomato-
gnathic system is the key. This adaptive
capacity may be reduced with age,
illness or stress. Thus, in some subjects,
a minor occlusal disturbance (e.g. tilted
Figure 1. Greenstick impression compound
over the upper incisors followed by mandibular
manipulation into RCP.
Dental Update – October 2003
 R E S T O R AT I V E D E N T I S T RY

Paste Manufacturer
overview of conditions where splint
therapy fits into occlusal management.
Doric ES bite Davis Schottlander & Davis Ltd, Letchworth, Herts, SG6 2WD, UK As stated above, in dysfunctional
Futar D Occlusion Kettenbach Dental, Kettenbach, D–35713, Eschenburg, Germany
patients, the use of a splint will
disengage the occlusion and may reduce
Memosil 2 Heraeus Kulzer GmbH & Co. KG, Gruner Weg 11, abnormal muscle activity. Alternative
D-63450 Hanau, Germany
modes of splint action have also been
Regisil PB Dentsply DeTrey GmbH, D-78467, Konstanz, Germany described. The stabilization splint, also
known as the Michigan splint, Tanner
Stat BR Kerr UK Ltd, Peterborough PE3 8SB, UK
appliance or centric relation appliance, is
VPS-Bite Henry Schein Holdings Ltd, Southall, Middx, UB2 4AU, UK deceptively difficult to make and fit.
Its features are:
Table 1. Polysiloxane bite registration pastes.
l Constructed of hard acrylic;
tooth, non-working contact) which occlusal factors and TMJPDS,2,3 the l Full occlusal coverage of either
previously was a physiological response provision of an occlusal stabilization upper or lower arch (generally
(e.g. to an extraction) becomes splint in cases of TMJ dysfunction, upper);
pathological should pain, bone loss or muscle hyperactivity or bruxism has l Removable ideal occlusion (RCP
fractured cusp occur. Generally, in the been recommended BEFORE embarking and ICP co-incident; anterior
absence of any signs or symptoms, on adjustment/equilibration.4 The guidance providing posterior
prophylactic removal of non-ideal rationale for this is that occlusal disclusion);
contacts is not advisable. Clearly, these adjustment is indicated in a patient l Worn at night but, if bruxism/
non-ideal contacts have potential to dependent upon full-time splint therapy clenching occurs during the day,
become interferences which do require for symptom relief, with symptoms daytime wear also.
occlusal adjustment. Recording and returning on splint removal. The
monitoring such contacts are of value. influence of cognitive behavioural Upper and lower alginate impressions
The above does not apply in crown and therapy, the placebo effect, should not are taken with a facebow record and an
bridgework. In this situation, should a be under-estimated as bruxists with RCP record. This is by definition a tooth
prospective bridge abutment have a severe attrition were shown to have apart record but within the retruded arc
potential interference (i.e. has a non- increased trait anxiety levels and thus of closure. The author favours an
ideal contact), then its removal prior to experience greater stress in negative anterior jig made in greenstick
preparation for a retainer will avoid its situations.5 Nonetheless, occlusal impression compound or Duralay which
re-introduction, and prevent future therapy has been shown to have both is positioned over the upper incisors
problems. Hence, the importance of subjective and objective effects on (Figure 1). The mandible is rotated
occlusal analysis before embarking on dysfunction.6 whilst the condyles are in the terminal
advanced restorative dentistry and the hinge axis (see later), so that the lower
need to plan with the aid of a dental incisors indent the soft jig with the
articulator (next paper in the series). It is THE OCCLUSAL posterior teeth about 2 mm apart. When
generally accepted that, if the anterior STABILIZATION SPLINT the jig is hard, a suitable polysiloxane
slide from RCP to ICP is more than 1 mm, AND THE RCP RECORD bite registration paste (see Table 1) is
or has a lateral component, then It is not the purpose of this section to syringed into the interocclusal posterior
adjustment is necessary. This is give a comprehensive review of splint gap bilaterally (Figure 2a and b). When
particularly the case when: therapy but to give the reader an this is set, the jig is removed, and further

l There are symptoms of

temporomandibular joint pain a b
dysfunction syndrome (TMJPDS);
l Bruxism;
l The tooth to be restored has an
interference;
l Sextant, quadrant or full mouth
rehabilitation is planned.

Given the irreversible nature of both Figure 2 (a, b). Bite registration paste is syringed into the inter-occlusal space whilst the patient
adjustment and equilibration, plus the bites on the jig in RCP
contentious relationship between

Dental Update – October 2003 417

 R E S T O R AT I V E D E N T I S T RY
a b
Figure 3. (a, b). Once the anterior jig is removed, the patient holds RCP in the posterior halves
of the registration whilst further paste is syringed into the anterior space.
a b
Figure 4. (a, b). The RCP record is used to relate the lower cast to the already mounted upper.
material is syringed anteriorly, thus
producing a single horseshoe-shaped
RCP record (Figure 3a and b). The upper
cast is mounted on the articulator using
the facebow. The lower study cast is
related to the mounted upper cast with
the RCP record (Figure 4a and b). The
Lauritzen split-cast technique7 and
instruments to check the accuracy/
reproducibility of the RCP record are
available (Denar Centricheck™ and
Vericheck™), but discussion of them is
beyond the scope of these papers,
although they will be illustrated in the
next paper in the series. After the splint is
processed in the laboratory, adjustment
in the mouth with the aid of different
coloured articulating paper is indicated in
Figure 5. Chin point guidance into RCP.
418
order to gain even occlusal contact in
RCP and on excursions, canine rise and/
or incisal guidance with the absence of
posterior contacts.
OCCLUSAL ANALYSIS
TECHNIQUE
Static relationships in ICP require
examination and the following features
should be noted:
l Incisal and skeletal pattern;
l Amount of overbite and overjet;
l Crossbite;
l Missing units;
l Overerupted teeth and their
opposing contact;
l Tooth alignment and any open
proximal contacts;
l ‘Resting’ lower lip position in
relation to the upper anterior
sextant.
CLINICAL PROCEDURES
Achieving RCP
The starting point for an occlusal
analysis is RCP. As RCP is posture
dependent, the patient should be sat
upright and be as relaxed as possible.
An explanation of the procedure and
reassurance that it is painless usually
facilitates patient co-operation. The
dentist can use one of two techniques
to achieve RCP: chin point guidance or
bilateral mandibular manipulation. The
former involves the dentist facing the
patient and placing the fingers and
thumb of one hand on the chin whilst
rotating the jaw up and down (Figure 5).
It is also possible to interpose the
thumb between the anterior teeth during
rotation. The patient is instructed to
relax the jaw, allowing it to be rotated
about its terminal hinge axis which is up
to 20 mm of inter incisal opening. The
condyles are also said to be in their
Retruded Position. The second
technique, described by Dawson,8 is the
author’s preferred method. The dentist
stands behind the patient, stabilizing the
head, and places both hands on the
mandible. The thumbs are on the chin
and the fingers over the lower border of
the mandible toward the angle (Figure
6). This hold enables the operator to
rotate the mandible about its terminal
hinge axis by placing gentle upward
pressure on the angle whilst exerting
downward pressure anteriorly.
Alternating the application of pressure
results in opening and closing of the
jaw. Clearly, the patient must be relaxed
and allow the dentist to tap the teeth
together gently. Once the teeth are in
contact, the patient is instructed to
maintain this position so that the dentist
can prise the lips apart and note RCP
contacts. The patient is then told to
slide into his/her most comfortable
Figure 6. Bilateral mandibular manipulation
into RCP. This is easier if patient is sitting upright.
Dental Update – October 2003
 R E S T O R AT I V E D E N T I S T RY
a b
Figure 7. (a, b). Occlusal Indicator Wax. Note the perforations on the mesial aspect of both
upper first premolars.
position whilst the dentist observes the
magnitude and direction of movement.
Muscle spasm, guarding or anxiety
may prevent ease of manipulation into
RCP. Asking the patient to bite on a
tongue spatula for five minutes and
checking that all teeth are out of contact
acts as a deprogrammer and should
reduce guarding. If it still proves
impossible to gain RCP, consider
provision of a full coverage occlusal
stabilization splint.
Identification of RCP (the first contact
of the mandibular teeth to the maxillary
when the condyles are in Retruded
Position) is greatly aided by placing
Occlusal Indicator Wax bilaterally over
upper premolars and molars (Figure7a
and b). This should be done after initial
manipulation and subsequent suspicion
of a prematurity. The jaw is rotated and
the teeth tapped against the wax,
resulting in discrete perforations,
usually in the premolar region. Mark the
prematurities with indelible pencil
through the perforated wax, which is
then peeled off. The mesial facing
inclines of upper premolar (palatal)
Figure 8. Prematurity identified and marked
with indelible pencil. Adjustment made with slow
speed diamond wheel (Horico, W068 045).
420
cusps are commonly involved. A slow
speed diamond wheel is used to remove
the marked area of enamel. Care is
needed to avoid over zealous grinding
and to keep within the thickness of
enamel (Figure 8).
Visualization of non-working side
contacts is difficult. Lassoing dental
floss around a suspected cuspal
interference followed by a lateral
excursion is beneficial. Upper molar
palatal cusps are common non-working
side contacts.
OCCLUSAL ADJUSTMENT –
CONCEPTS
Occlusal adjustment is the carefully
planned, selective removal by grinding
of small areas of tooth surface. The
treatment is irreversible and should not
extend to several teeth, but is usually
confined to one or two teeth and
therefore differs from equilibration. Each
adjustment is carried out using a slow
speed, small diamond wheel on the
identified enamel ‘high spot’. After each
adjustment, a check of the adjusted
contact is made as well as other
functional positions. For instance, if a
non-working side contact is adjusted,
check where the guidance has picked up
on the working side. Generally, cusp tips
are not ground down, but cuspal
inclines are adjusted. Maintenance of
the existing OVD by cusp tip to fossa or
marginal ridge contact is recommended.
The RCP Premature Contact
The elimination of an RCP prematurity
requires judicious grinding of the upper
mesial facing incline in order to allow the
mandible to close into a more distal
position, thus reducing the magnitude
of the RCP–ICP slide (Figure 9a and b).
Broadly speaking there are two types of
discrepancy to consider:
l A large vertical but small horizontal;
l A large horizontal but small vertical.
The small horizontal discrepancy
requires less adjustment, with the
resultant position being almost co-
incident with the original ICP. The larger
the horizontal discrepancy, the more
grinding is required in order to ‘distalize’
the mandible and provide an area of
freedom. This adjustment is more
difficult.
Patients presenting with increasing
mobility of anterior teeth and/or the
appearance of diastemata should have
the RCP–ICP relationship checked. This
is because anterior displacement of the
mandible can result in occlusal trauma to
the incisors, which can be manifest as
fractured restorations, drifting and loss
of lower lip control.
The Working Side Contact
The probability of a working side
interference is greater in mouths with
a
b
Figure 9. (a) Initial contact in RCP on second
premolars, marked with pencil. (b) Horizontal
and lateral slide greater than 1 mm into ICP.
Dental Update – October 2003
 R E S T O R AT I V E D E N T I S T RY

The Non-Working Side

Interference
These contacts pose special problems
SC
GC as they occur on supporting cusps
GC
Buccal Lingual
(Figure 12). Their removal, however, is
SC indicated as they are associated with an
increased risk of bone loss, mobility and
RLE
TMJ dysfunction.9 Local occlusal
instability consequent to having ground
Figure 10. Cross-sectional representation of the palatal supporting cusp tip may only Figure 12. The non-working side interference
molars showing upper palatal and lower buccal lead to re-establishment of the occurs on supporting cusps (upper buccal, lower
cusps as supporting cusps (SC) closing into lingual) in a normal bucco-lingual relationship. To
opposing fossae. Upper buccal and lower lingual interference as the upper molar may tip maintain cusp height, try grinding inclines so
cusps are guiding cusps (GC). down to re-establish contact in ICP. making the cusp narrower.
Shillingburg advocated cutting a groove
around the palatal cusp tip to provide
clearance for the lower buccal cusp.10
This is technically difficult.

RLE
RLE
Figure 11. Right working side interference.
Removal of upper buccal incline or lower
lingual incline depends on maintenance of
supporting cusp vertical dimension. Hence
BULL rule.
overerupted teeth than in fully
dentate, well aligned arches where
canine guidance or partial group
function is to be expected. For
working side interferences apply the
BULL rule. Buccal Upper and Lingual
Lower cusps are non-supporting
cusps, whereas Palatal Upper and
Lower Buccal cusps (in a normal
Class I bucco-lingual relationship)
support the Occlusal Vertical
Dimension (Figure 10) and should
not be adjusted. Interferences on
buccal upper or lower lingual cusps
are ground to provide working side
canine rise or smoother guidance
with several teeth in contact (Figure
11).
Posterior Contacts on
Protrusion
These can be eliminated by either
posterior grinding or increasing the
steepness of the anterior guidance. The
lower incisors are to all intents and
purposes akin to supporting cusps and
are thus not to be ground down. The
palatal inclines of the incisors are
equivalent to guiding cusps/inclines
and can be adjusted by grinding and
hence reducing anterior guidance or by
the addition of acrylic on provisional
restorations and so increasing anterior
guidance. Removal of posterior contacts
on protrusion follows the DUML rule,
distal facing contacts on upper teeth or
mesial facing contacts on lower teeth
(Figure 13).
THE CONFORMATIVE
APPROACH
As its name suggests, restorations
a b
Figure 14. (a, b) Painted upper cast before and after identification of initial contact in RCP on
the upper left first molar mesio-palatal cusp.
Figure 13. Posterior contacts on protrusion.
DUML applies. Distal facing inclines of Upper
teeth or Mesial facing inclines of the Lower teeth
are ground. Increasing the steepness and length
of the incisal guidance has a similar effect.
conform to the existing maxillo-
mandibular relationships such as ICP.
As mentioned previously, minimal local
adjustment is acceptable. Removal of a
plunger cusp and non-working contacts
on teeth intended for preparation fall
into this category. A prematurity on
closure into RCP can be adjusted as
mandibular repositioning during
preparation is undesirable.
The Reorganized Approach
The entire occlusal scheme is modified,

Dental Update – October 2003 421

 R E S T O R AT I V E D E N T I S T RY
which may include co-incidence of RCP
and ICP as the former becomes the
starting point for all mandibular
movement. Planning and reproducing
such extensive occlusal re-organization
in crown and bridgework requires a
semi-adjustable articulator. This will be
discussed in the next paper in the
series.
Most dental treatment is
conformative in nature. Dentists
unfamiliar with the steps involved with
occlusal analysis and adjustment would
be well advised to practice adjustment
on study casts articulated in RCP,
having painted the occlusal surfaces
with a suitably coloured poster paint
(Figure 14a and b). Removal of the RCP
record and closure through its
BOOK REVIEW
The Orthodontic Patient: Treatment and
Biomechanics. By A.J. Ireland and
F. McDonald. Oxford University Press,
Oxford, 2003 (352pp., £24.95). ISBN 0-19-
851048-9.
This is a new textbook entering the
competitive undergraduate market.
Looking at it briefly at a glance, I noticed
the small font size for the Contents
section, variation in spacing above and
below figures, some poor quality
reproduction photographs and a shortage
of important words in the Index. For
example, debonding, decalcification are
missing from the ‘D’ section.
From a potential undergraduate point of
view, with the title in mind, I would
welcome an introduction or opening
chapter with an overview of orthodontic
care with aims and scope. However, this
book opens with a Chapter entitled ‘Basic
Biological Principles’, four lines down I am
directed to Chapter 4 for ‘Growth of the
Face’. Halfway down the first page I am
invited to read more specialized texts,
which questions why am I reading this
book? The last paragraph on the first page
explains orthodontics as ‘intimately
involved with the turnover of the
skeleton’. I don’t know whether this is a
cross between a romantic and a mass
murderer! Reading the first chapter, I am
422
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thickness will result in the initial
contact being identified, marked and
adjusted. The dentist notes where this
initial contact occurred and then
assesses the new occlusal relationship.
R EFERENCES
1. Beyron H. Optimal occlusion. Dent Clin N Am
1969; 13: 537–554.
2. Forssell H, Kalso E, Koskela P, Vehmanen R,
Puukka P, Alanen P. Occlusal treatments in
temporomandibular disorders: a qualitative
systematic review of randomised controlled
trials. Pain 1999; 83: 549–561.
3. Ekberg E,Vallon D, Nilner M. Occlusal appliance
therapy in patients with temporomandibular
disorders. A double blind controlled study in a
short term perspective. Acta Odontol Scand 1998;
56: 122–128.
4. Mohl ND, Zarb GA, Carlsson GE, Rugh JD.
constantly prompted to diagrams
elsewhere in the book and to read other
references. If this is the case, I think the
Preface should lay the ground rules,
informing the reader to expect to read not
only this book but many others also!
Chapter 2 gives me more hope, starting
with the reasons for orthodontic
treatment. Only four lines in, I am sent to
‘Suggested Reading’ for the Index of
Orthodontic Treatment Need. I could not
find the ‘Suggested Reading’ section! I
found the ‘Further Reading’ section, one
reference to the authors in 1998, and
A Textbook of Occlusion. Chicago: Quintessence
Publ. Co., 1988.
5. Monteiro da Silva AM, Oakley DA, Hemmings
KW, Newman HN, Watkins S. Psychological
factors and tooth wear with a significant
component of attrition. Eur J Prosthodont Rest
Dent 1997; 5: 51–55.
6. Wassell RW. Do occlusal factors play a part in
temporomandibular dysfunction? J Dent 1989;
17: 101–110.
7. Lauritzen AG, Wolford LW. Occlusal
relationships: The split-cast method for
articulator techniques. J Prosthet Dent 1964; 14:
256–265.
8. Dawson PE. Evaluation, Diagnosis and Treatment
of Occlusal Problems, 2nd ed. St Louis: CV Mosby,
1989.
9. Yuodelis RA, Mann WV. The prevalence and
possible role of non working contacts in
periodontal disease. Periodontics 1965; 3: 219–
223.
10. Shillingburg HT, Hobo S,Whitsett LD.
Fundamentals of Fixed Prosthodontics. Chicago:
Quintessence Publ. Co., 1981.
references at the end of the chapter. There
is no reference to IOTN. Reference 22
refers to an unpublished thesis by
Richmond in 1990. I would like to inform
people that the PhD thesis was published
in 1990 and is available through the
University network! However, it is not
appropriate to direct undergraduates to a
thesis when there is a preponderance of
published material that is easily accessible.
In the opening paragraph of Chapter 3,
we are told that removable appliances are
often misunderstood. Chapter 4 is entitled
‘Functional Appliances’ and starts off with
‘Growth of the Face’. Other chapters cover
‘Fixed Appliances’, ‘Multidisciplinary
Treatments’ and ‘Iatrogenic Problems’.
In relation to some of the figures;
diagrams of teeth are used to demonstrate
classification of the buccal segment. It is
not clear which teeth are canines or
premolars. The diagrams illustrating A and
B points are not technically correct – they
appear to show A and B points where the
alveolar bone contacts the tooth.
I am not sure that enough attention was
paid to detail in this book, or whether it
went out to review before publication. It is
a shame because there is some good
material in the book, but it gets lost in the
irritating prompting to other references. I
would suggest that buyers should wait
until the second edition.
Stephen Richmond
Cardiff Dental School
Dental Update – October 2003