Contribuio especial

Functional occlusion and orthodontics: a contemporary approach

FUNCTIONAL OCCLUSION AND ORTHODONTICS: A CONTEMPORARY APPROACH Ocluso funcional e ortodontia: uma abordagem contempornea
Marco A. L. Feres 1 Marines Q. Portella 2 Renata C. L. Feres 3

Abstract
The authors have undertaken a deep review on funcional occlusion, from historical to contemporary concepts. Also the interrelationship between occlusion and orthodontic treatment was described, proposing objectives that should be achieved to establish good harmony with the stomatognatic system. Keywords: Functional occlusion; Orthodontics; Treatment goals.

Resumo
O primeiro objetivo deste trabalho foi realizar uma reviso de literatura sobre ocluso esttica e dinmica, revisando desde conceitos histricos at os conceitos mais aceitos atualmente. O segundo objetivo foi unir estes conceitos com o tratamento ortodntico, definindo, a partir da, como o ortodontista deve tratar seus casos, assegurando a harmonia de todo o aparelho estomatogntico. Palavras-chave: Ocluso funcional; Ortodontia; Objetivos de tratamento.

2 3

Professor Adjunto, Disciplina de Ocluso, PUCPR; Disciplina de Ortodontia, UFPR; Ttulo de Notrio Saber em Ortodontia, UFPR. Endereo: Rua Imaculada Conceio, 1.155 - Prado Velho - Curitiba, PR Especialista em Ortodontia; Mestre em Morfologia Aplicada/DTM Mestre em Ortodontia.

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Evolution of a concept
The word occlusion comes from the latin expression occludere which means to close. According to Galvo (1) this term is related to the estatic or dynamic arrangements that exist between opposed teeth. Occlusion also means the functional relationships of all components of the mastigatory system, such as bone, TMJ, muscles and supporting tissues. Other authors (2,3) state that the initial concept of occlusion was related to fixed relations of the jaws, but a correct analysis has to take into consideration all tissues involved, including the TMJ, as well as all stimuli that derives from the oclusal contacts like curve of Spee, cusps height, condilar guidance and the occlusal plane. Primary studies on occlusion include the area of prosthodontics (4, 31) because early specialists needed to know how teeth should get in contact. Therefore the development of the concepts of occlusion are directed related to the evolution of articulators. Since Phillip Pfaff in Germany in 1756 (1) has registered the bite thus obtaining plaster models, many other pioneers studied dental contacts through the use of articulators (4,5), including parameters to the position of the condyles into the fossae and the concept of balanced occlusion . As time occurred, some of early concepts became tested principles thus originating philosophies, the main ones consisting of the balance and the non-balanced occlusion. The first followed principles of Bonwill (5),Monson (6), Wadsworth (7), Gysi(8) and others, and its main foundation included multiple contacts of opposing teeth both in centric as well as excentric mandibular movements. In 1926 a new and organized school of occlusion was criated, the Gnatological Society of Califrnia (9, 10), defining gnatology as the science that treats the biology of the masticatory apparatus . This masticatory system should be considered as a functional unit, thus providing: 1. the coincidence between centric relation (CR) and centric occlusion (CO); 2. a well balanced occlusion during slidind movements, with bilateral multiple balanced contacts (11). In 1950 (12), opposed to the gnatological principle, eroded the concept of the long centric (12), which would mean freedom of man-

dibular closure, both in CR or CO, consisting on the Pankey-Mann Philosophy of Occlusal Reabilitation. Ramjord and Ash (13) proposed the functional occlusion approach meaning an individual attention to the demands of each patient, emphasizing the health of the masticatory system over any specific occlusal configuration. Dawson (14) stablished criteria for an ideal occlusion running from selective grinding to complete occlusal reconstruction. He recommended disoclusion in the balance side as well as group function in the working side.

Normal and ideal occlusion

Normal occlusion has referenced diagnosis and treatment planning in Orthodontics, but many times this concept has been misunderstood with ideal occlusion. This late aspect is seldom seen, thus Profit and Ackermann (15) prefer the term imaginary ideal meaning the one that provides all physiological functions of the masticatory system while preserving the health of all structures related. According to Ash and Ramjord (17), the perfect idea of 138 occlusal contacts of all 32 teeh is rarely founded. In other study (18) the same authors state that the concept of normality in any biological system presupposes a physiological break for adaptation around those values that are considered normal. Angle (19) has set the normal occlusion conditions with emphasis on the first molar relationship, stating that the mesiobuccal cusp of the upper first molars should occlude on the occlusobuccal groove of the lower first molars. Graber (20) and Moyers(21) stated that normal occlusion includes oclusal contacts, teeth alignment and good relationship to the bony structures. Beyron (22) refers to ideal or optimum including function, health and confort, not only esthetics and anatomy. When summarizing most authors opinions we come o the conclusion that an ideal occlusion shall pursuit : neuromuscular harmony oclusal stability

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Contribuio especial

Functional occlusion and orthodontics: a contemporary approach

health periodontium accepted esthetics good masticatory function normal phonetics absence of parafunctional habits no TMJ pathological evidence oclusal loads distributed along the vertical axis of teeth. adequate anterior guidance good bilateral balance minimum muscular tension plus maximum efficiency. minimum dental wearing During all functions of the masticatory system, the mandible assumes a variety of positions from centric to excentric movements. In order to analyse all the aspects involved we should consider occlusion from maximum intercuspation to all mandibular movements.

Centric Relation (CR)

It is a key reference to analyse and reconstruct the masticatory system. It is a position that is achieved when the operator takes the condyles and disc to the anterior wall of the fossae. Such position is disc oriented and is a very useful reference to check or modify interarches relationships. According to Ash (17) MIP rarely coincides with CR. For some authors (16,26,27) the best condyle-fossa relationship is the one achived in CR . During many years, RC was describe as the most retruded position of the mandible, from which lateral movements could be undertaken (28, 29, 30, 31) . After laminagraph studies (32) this concept changed dramactically, with outlined condyles well seated into the fossae. Later on, Dawson (33) defined CR as the upper position that could be reached by yhe condyles into the mandibular fossae. Eletromiografical studies (34, 35) related that the physiological position of the condyles, determined by musculature, is superior and anterior, against the posterior slope of the articular eminence. Okeson (37) refers to the ideal position of the condyle into the fossae as orthopedic stability of the mandible or muscular skeletal stability . Authors (38) founded great stability in condyles when in this upper/anterior position, in close contact with the disc. Under these circunstances, the compression forces produced by muscles are well tolerated once the disc is basically formed by dense colagenous tissue with no innervation or irrigation in the central zone. On the other hand, continuos forced derived to other areas of the disc may result in damage of the tissues involved. Masticatory forces should be distributed along the vertical axis of teeth, thus being well tolerated by all periodontal tissues while involving a maximum number of horizontal and oblique fibers. Through this approach the impact of masticatory loads is uniformed distributed along all supporting tissues. (22,18)

Maximum Intercuspal Position (MIP)

According to Lee (23) this position is reached over 5000 times a day during the masticatory cycle, with occlusal forces varing individually. Okeson (24) states that total force loaded daily during chewing and deglutition may reach 8600 kg, decreasing at night. Orthlieb e Laplanche (25) describes MIP as the oclusal position with the greatest interarches contacts with maximum intensity of isometric contractions. It is important to emphasize that such independs on the position of the condyles into the glenoid fossae. Ash and Ramjord (17) describes MIP as a tooth to tooth relationship, guided by its occlusal surfaces. This position may vary according to changes in these oclusal surfaces. The same authors refer to MIP as intercuspal, dental, acquired centric or simply habitual centric. It is important to emphasize that the expression Centric Occlusion (CO) became elected in the literature when referring to MIP. Authors (25) focus on the fact that all teeth should participate of these contacts, while failure in achieving so may be caused by muscular habits, eruption problems of skeletal imbalance.

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Mandibular movements
During ideal mandibular movements two factors are of umost importance : freedom of movement and economy of muscular energy. These conditions are provided by anterior guidance in protrusive movements and by canine protection or group function in lateral excursions. According to Fantini (39) one must differenciate total from partial group function, the latest meaning that not all teeth in the working side are involved with the disoclusion process. Neverthless, many patients include only the canines and bicuspids in such gnatological approach. In ideal occlusions anterior guidance orients mandibular movements and shall be able to provide MIP without articular or neuromuscular accommodation, which by all means represents economy in muscular energy . According to Kahn (40), canine guidance is the main mechanism to disoclude posterior teeh from the working side. On the other hand, the key factor for disoclusion in the balance side is the sliding movement of the condyle through the posterior slope of the articular eminence. The canine protected occlusion concept (41,42,43) is based upon the fact that the canine tooth is the most appropriate element to guide mandibular lateral excursion due to crown morphology, root and periodontal strength plus superior proprioceptive mechanism. Other authors (44) did some eletromiografical studies on elevator muscles relating them to group function or canine protection. Results demonstrated in group function there was a clear reduction in muscle action when compared to intercuspal position, mainly to the temporal muscle from the balance side. When analyzing canine protected occlusions, reduction in muscle activity was greater than in group function. According to Lee (23) canine guidance is optimum to : avoid excentric lateral interferences of posterior teeth. provide freedom of condilar movements. orient mandibular closure in a more vertical pattern. According to Roth (35), incisal guidance should be established by all six upper and

eight lower anterior teeth, thus dividing protrusive load. Smooth anterior guidance are vital not only to appropriate function during mandibular excursions but are strongly related to occlusal stability after orthodontic treatment. He stresses that excessive lateral load on the canines may result in lingual movement of the lower cuspids with subsequential anterior crowding.

Ideal occlusion and orthodontics

Proper adaptation of all concepts of optimun occlusion into modern orthodontic therapy demands basic atitudes related to diagnosis, treatment planning, mechanics, finishing and retention. As widely known, orthodontic treatment has a very close relationship with all components of the masticatory system, therefore the specialist needs to be expertise in all aspects of functional occlusion. The Angles classification is a good way to start with, but in no way offers adequate parameters for defining treatment goals. Many occlusions presenting solid class I relationship may present several pathological aspects. In order to achieve proper parameters, Andrews (46) studied positions and interarch relationships of all crowns of 120 models presenting optimum occlusions, which he called The Six Keys to Normal Occlusion . His method allows one to assess all pertinent aspects of the occlusion from the labial and occlusal surfaces. These six keys are : 1 Anteroposterior relationship 2 Crown angulation 3 Crown inclination. 4 No rotations 5 Solid interproximal contacts 6 Presence of Curve of Spee. Yet according to Andrews (46), the six keys are independent elements of the structural system and consist in solid foundation for occlusal assesment and treatment goals for most patients. The modern concept of occlusion in orthodontics includes all TMJ components (49). Before aplliances removal it is essential to observe mandibular movements and check for interferences. Testing the working side with canine guidance or group function thus providing no contacts in

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Functional occlusion and orthodontics: a contemporary approach

the balance side, as well as smooth anterior contacts in protrusive is of utmost importance to achieve good functional occlusion (50).

Case presentation
A15-year-old oriental boy was referred by his general dentist for evaluation of crowding, ar-

chform assimetry, anterior aesthetics and some difficulty in chewing. There was no significant medical history. His oral hygiene was good and he had received routine dental care since early childhood. Despite presenting some interferences no significant signs or symptoms of temporomandibular joint were related.

Fig. 1 Pre treatment photographs

Fig. 2 Pre treatment models

Diagnostic and etiology

The patient showed a harmonic and simetric face both from frontal and lateral, with a slight convex profile. The occlusal relationship presented a Class I molar relationship, deep overbite, crowding in the incisal area . The upper arch showed a constricted V shape, with midline deviation to the left. The following occlusal problems were listed : a) Too long and deep incisal guidance, thus leading to an excessive anterior condilar displacement in protrusive; b) Contacts on the upper

lateral incisors in working side; c) Some interferences in the balance side, right and left.

Treatment objectives
Treatment objectives were primarily dentoalveolar, improving dental positions, midline correction, overbite correction and a very accurate interarch coordination. This last procedure is a key factor to achieve a good functional occlusion, namely proper incisal guidance, desoclusion by canines in lateral movements and a final reciprocal protected occlusion.

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Fig. 3 Finishing procedures

Treatment progress
Maxillary and mandibular .022 preajusted Edgewise mechanism / Roth prescription was placed. Initial alignment and leveling were achieved with a sequence of thermoactivated niti wires. Vertical control and deep-bite correction was achieved by using one set of reverse Curve of Spee arches. After a sequence of round stainless steel arches, proper arch form and coordination was reached through rectangular .019 x .025 SS arches, with individual torque control plus finishing detailing. Appliances were removed after 22 months of active treatment. The patient was instructed to wear upper and lower Hawley retainers

full time in the first year, changing to partial time use after that.

Treatment results
The observed dentoalveolar alterations are seen in postreatment figures. Little skeletal modifications occurred, as expected. Good teeth positions were achieved, with proper overjet and overbite, midline correction and nice upper and lower arch forms. Important to note the solid intercuspal relationship obtained as well as adequate incisal guidance. The key factor in eliminating posterior interferences was the strong canine contact in the working side, sufficient enough to provide good guidance and protection in lateral movements.

Fig. 4 Post treatment photographs

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Fig. 5 - post treatment lateral movements

Conclusions
Good functional occlusion was achieved in a moderate crowed Class I malocclusion, with good patient cooperation. Timely and contemporary orthodontic procedures based on solid gnatological principles changed a poor functional occlusal environment into a nice, pleasant and functional interarch relationship, probably preventing many potential problems in the years to come.

4. 5.

Gysi A . Articulators. Dent Record 1928; 48: 38 Bonwill VGA. The geometrical and mechanical laws of articulation of the human teeth. In: Litch T. American system of dentistry. Philadelphia: Lea Bross; 1887.p. 180.

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Recebido em 20/8/2005; Aceito em 19/9/2005 Received in 8/20/2005; Accepted in 9/19/2005.

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