Normal Occlusion

Presented by: Dr Ghulam Rasool

Occlusion
The way the maxillary & mandibular teeth articulate It involves the study of the teeth, their morphology and angulations, the muscles of mastication, the skeletal structures, the TMJ & the functional jaw movements

Occlusion
The occlusion is generally considered for dentition, because rest of the components effect through dental component

To understand dental occlusion, we need to

understand the features & terminology related

with ideal dental occlusion

Curve Of Occlusion

Curve of Occlusion
In the maxilla:

It passes through the central fossa of posteriors and cingulae of anteriors

Curve of Occlusion
In the mandible It passes through the buccal cusps of posterior and incisal edges of anteriors

Tip / Angulation
Relative mesial or distal angulation of the crown and the root along the line of occlusion (e.g; mesial crown tip, same as distal root tip; distal crown tip same as mesial root tip)

Torque / Inclination
Relative crown and root inclination perpendicular to the line of occlusion ( e.g; lingual crown torque same as labial or buccal root torque ; labial or buccal crown torque, same as lingual root torque )

IN-OUT
Faciolingual relationship of the tooth crowns to the line of occlusion ( e.g, labial surface of crown is facially or lingually placed ) OFFSET Rotations described by the position of mesial and distal proximal tooth contacts in relation to the line of occlusion

Cusp Height Positioning

Described on the basis of the position of the occlusal surfaces inciso-gingivally in relation to the occlusal plane ( e.g; supra-occlusion and infra-occlusion )

CLINICAL CROWN
The amount of crown visible in late mixed dentitions and adult dentitions with gingiva that is healthy and not recessed FACIAL AXES OF THE CLINICAL CROWN (FACC) The most prominent portion of the central lobe on each crowns facial surface & for molars, the buccal groove that separates the two large facial cusps FACIAL AXES POINT (FA POINT) The point on the facial axes that separates the gingival half from occlusal half of the clinical crown

Crown Angulation

The angle formed by the FACC and a line perpendicular

to the occlusal plane

It is positive when occlusal portion of FACC is mesial to gingival portion It is negative when occlusal portion of FACC is distal to gingival portion

Crown Inclination
The angle between a line perpendicular to the occlusal plane and a line that is parallel & tangent to the FACC at its mid point (FA point)
Crown inclination is determined from proximal aspect

It is positive if the occlusal portion of the crown, tangent line or FACC is facial to its gingival portion & negative if lingual

Andrews Six Keys of Occlusion

KEY I: CORRECT INTERARCH RELATIONSHIP

KEY II: CORRECT MESIODISTAL CROWN ANGULATION KEY III: CORRECT FACIOLINGUAL CROWN INCLINATION KEY IV: ABSENCE OF TOOTH ROTATIONS KEY V: TIGHT CONTACT POINTS KEY VI: THE DEPTH OF CURVE OF SPEE RANGES FROM A FLAT PLANE TO A SLIGHTLY CONCAVE SURFACE

Key I: Correct Interarch Relationship

1) The mesiobuccal cusp of the permanent maxillary first

molar occludes in the mesiobuccal groove of the permanent mandibular first molar

key I: Correct Interarch Relationship

2) The distal marginal ridge of the maxillary first molar occludes with the mesial
marginal ridge of the mandibular second molar OR The distobuccal cusp of the maxillary first molar occludes in the embrasure between mandibular first molar and second molar

key I: correct interarch relationship

3)

The mesiolingual cusp of the maxillary first molar

occludes in the central fossa of the mandibular

first molar

key I: correct interarch relationship

4) The buccal cusps of the

maxillary premolars have a cusp-embrasure (distal)

relationship with the mandibular

premolars

key I: correct interarch relationship

5) The lingual cusps of the maxillary
premolars have a cusp-fossa (distal

triangular fossa) relationship with

the mandibular pre-molars

key I: correct interarch relationship

6) The maxillary canine has a cuspembrasure relationship with the mandibular canine and first premolar (the tip of the cusp is slightly mesial to embrasure ideally)

key I: correct interarch relationship

7) The maxillary incisors overlap mandibular incisors, horizontally and vertically (overjet & overbite) & the midlines of the arches match Overjet = 2-3 mm Overbite = 1-2 mm

key II ) Correct Mesiodistal Crown Angulation

All the crowns have a positive angulation

key III) Correct Faciolingual Crown Inclination

The inclination of the maxillary incisor crowns is generally POSITIVE and gradually becomes NEGATIVE canine through molars

The inclination of the mandibular crowns is progressively more NEGATIVE from the incisors through the second molars

KEY IV)
ABSENCE OF TOOTH ROTATIONS

KEY V) TIGHT CONTACT POINTS

KEY VI) The depth of Curve of Spee ranges from a flat plane to a slightly concave surface (0-2mm) in the lower arch

KEY VI) The Curve of Wilson is convex in the first premolars, flat in the second premolars & concave in the first molar in the upper arch

Bennett and Mc Laughlins 7th key

Correct tooth size In practice orthodontically treated occlusions seldom achieve all occlusal keys.

OCCLUSION
MALOCCLUSION :
Is the misalignment of teeth and jaws, or more simply, a "bad bite." Malocclusion can cause number of health and dental problems.

STATIC OCCLUSION :
Refers to contact between teeth when the jaw is closed and stationary.

FUNCTIONAL OCCLUSION:
Refers to occlusal contacts made when the jaw is moving, as with chewing.

Alternative names are cuspid disclusion or canine

guidance.
Immediate but gentle disclusion of all posterior teeth on any excursion from intercuspal position(ICP) Post centric stops protect anterior teeth in ICP. Canines and incisors protect anterior teeth in ICP. Anterior teeth protect posterior in occlusion.

CANINE GUIDED OCCLUSION

Canine protection : contact only on the working-side maxillary and mandibular canines

Importance of canine guidance

The strategic positioning of the canine in the arch The favorable root anatomy Presence of a better crown-root proportion The presence of dense and compact bone around the root, which better tolerates the occlusal forces compared with the medullar bone of the posterior teeth The sensorial pulse that activates less muscles when the canine teeth are in contact than when posterior teeth contact each other. The achievement of the canine guidance in orthodontics is easier than the group function. It is because mechanically it is much easier to establish the contact in a single tooth than to distribute the contacts simultaneously in all the posterior teeth.

GROUP FUNCTION OCCLUSION

Simultaneous contact of the canine and posterior teeth on the working side.

Group function must be established

When the canine teeth do not present an appropriate position to accept the horizontal forces, for example: Periodontal problems in the canines, Cases of atypical upper lateral incisor agenesis, lower incisor extraction, or In any case that the first premolar replaces the canine. In this last example, the establishment of the lateral guide should be avoided in order to prevent the development of a traumatic occlusion because premolars are not capable of supporting disocclusion.

 CENTRIC OCCLUSION is the occlusion a person makes when they close their jaw and fit their teeth together in maximum intercuspation. It is also referred to as a person's habitual bite, bite of convenience, or intercuspation position (ICP). CENTRIC RELATION: not to be confused with centric occlusion, is a relationship between the upper and lower jaw.

CENTRIC OCCLUSION

MUTUALLY PROTECTED OCCLUSION

During the jaw protrusive movement, the lower incisal borders slide on the palatal surfaces of the upper incisors, promoting total disocclusion. Likewise, during the lateral movements, the canine must perform the disocclusion. These concepts, known as "mutually protected occlusion", are important to define the occlusal pattern in subjects with complete dentition. Along those lines, the posterior teeth protect the anterior teeth of any contact in the static jaw position and during the excursive movements

Establishment of Immediate Anterior Guidance

When the patient occludes in MI, all posterior teeth must contact, and the anterior teeth must be slightly separated. As soon as the protrusive movement begins, the lower incisors must contact the palatal face of the maxillary incisors, thus allowing the immediate disocclusion of the posterior teeth. For this purpose, some orthodontic parameters must be present, for example, overjet and overbite. If the patient presents an increased overjet (more than 3 mm), a longer period is necessary for the anterior teeth to contact, which results in anterior guidance at the expense of the posterior teeth.

In 1976, Roth presented the following functional aspects of the occlusion as being fundamental for completion of the orthodontic cases: 1. Teeth must present maximum intercuspal (MI) position with the jaw in centric relation (CR) 2. In centric relation, all posterior teeth must present axial occlusal contacts, and the anterior teeth must maintain a distance of 0.0005 inches between them. 3. During laterotrusion, the canines must disocclude the posterior teeth (canine guidance). 4. During protrusion, the upper anterior teeth must occlude with the lower anterior teeth and the first premolar or the second premolar (in extraction cases), aiming at disoccluding all posterior teeth (immediate anterior guidance). 5. No interference must be present on the balancing side.

A. Make the joints and teeth simultaneously stable

Posterior contacts must be directed in the long axis of the teeth. B. Create axis loading wherever possible Anterior guidance such that the anterior teeth disclude the posterior teeth in protrusive. Canine guidance such that the canines disclude the posterior teeth in lateral excursions. No occlusal contacts on the balancing side. C. Move off axis loading as far from the fulcrum as possible

General rules for diagnosis, evaluation and treatment of occlusal problems

Make the joints and teeth simultaneously stable Posterior contacts must be directed in the long axis of the teeth. Create axis loading wherever possible

Anterior guidance such that the anterior teeth disclude the posterior teeth in protrusive.
Canine guidance such that the canines disclude the posterior teeth in lateral excursions.

No occlusal contacts on the balancing side.

Move off axis loading as far from the fulcrum as possible

MALOCCLUSION

Any deviation from the normal occlusion is the malocclusion Mal-occlusion may be resulted in one of the following systems

ULFAT

CLASSIFYING MALOCCLUSION

Qualitative Quantitative
ULFAT

Qualitative
Is a shorthand method of describing the salient features of a mal-occlusion, e.g; Angles classification
ULFAT

Quantitative
Indices are used to measure the

malocclusion quantitatively
Each feature of a malocclusion is given a score & the summed total is then recorded (PAR index) The worst feature of a malocclusion is

recorded (Index of Orthodontic

Treatment Need-IOTN)
ULFAT

Angles Classification
Angle, in 1899, described this classification It was based upon antero-posterior dental relationship Based upon permanent 1st molar relationship Divided into many classes of malocclusions

that are designated by Class I, Class II &

ULFAT

Class I Malocclusion (Neutro-occlusion)

The permanent upper & lower 1st molars are in normal relationship, but the rest of the

dentition may have deviation from

normal occlusion, e.g; crowding, rotations etc.

ULFAT

Class II Malocclusion (Disto-occlusion)

The mesio-buccal cusp of permanent upper molar occludes mesial (anterior) to the lower 1st molar mesio-buccal groove It is further divided into

Class II Div 1

ULFAT

Class II Div 1
Along with class II molar relationship, the

over jet is more than normal i.e. 2-3 mm

Molars may be in 1/4th unit, unit or full unit or supra class II relationship

ULFAT

Class II Sub-division (Rt)

Div 1

ULFAT

Class II Div 2
Along with class II molar relationship, the overjet is reduced than normal Further divided into; Type A

Type B
Type C
ULFAT

Class III (Mesio-occlusion)

The mesio-buccal cusp of permanent upper

1st molar occludes distal (posterior) to

the lower 1st molar mesio-buccal groove Class III sub-division, when one side is in class I & other side in class III (class III side will be Rt or Lt sub-division)

ULFAT

Drawbacks of Angles classification

This is only for dentition & not for skeleton Permanent 1st molars are not fixed points Only depends on AP relationship In case of extracted or missing 1st molars,

cannot be classified

ULFAT

Modifications in Angles
Classification
Lischers Classification:
He introduced the term Neutro-occlusion (same as Angles class I malocclusion) Used the term Disto-occlusion (same as

Angles class II malocclusion)

ULFAT

Modifications in Angles Classification

ULFAT

Modifications in Angles
Classification
Lischers Classification:
Used the term Version as a suffix for different individual malocclusions, e.g; Mesio-version

Linguo-version

ULFAT

Deweys Classification:
Modified Angles class I malocclusion as following; Type I Anterior crowding

Type II
Type III

Maxillary incisors in
labial version Anterior X-bite
ULFAT

Deweys Classification:
He did not made any modification for Angles class II malocclusion

But he made modification for Angles class

III malocclusion as following; Type I Normal incisor overlapping
ULFAT

British Standards Institute

Classification:
Class I Lower incisor edges occlude with

or immediately below the cingulum

plateau of the upper central incisors Class II The lower incisors edges lie upper incisors posterior to the cingulum plateau of the

ULFAT

Further divided into 2 categories; Division 1: The upper central incisors are proclined & there is an increase in overjet Division 2: The upper central incisors are

retroclined & the overjet is usually

decreased

ULFAT

Class III

The lower incisor edges lie

anterior to the cingulum plateau of the

upper central incisors & the overjet is

reduced or reversed

ULFAT

Simons Classification
It is based upon 3 dimensional relationship of the dental arches with 3 following planes

ULFAT

ULFAT

Simons Classification
Frankfort Horizontal Plane: This plane passes thru lower most border of the bony orbit to the upper border of the external

auditory meatus
This plane vertically relates dentition, closer to the plane is called as Attraction, while away from it is know as Abstraction
ULFAT

Simons Classification
Mid Sagittal Plane: This plane is perpendicular to the Frankfort Horizontal Plane

This plane transversally relates dentition,

closer to the plane is called as Contraction, while away from it is known as Distraction

ULFAT

Simons Classification
Orbital Plane: It is a plane drawn perpendicular to the Frankfort Horizontal Plane, from lower most border of the

bony orbit
This plane sagittally (A.P.) relates dentition, forward to the plane is called as Protraction, while behind from it is known as Retraction
ULFAT

Ballards Classification
This classification is based upon skeletal
relationship Skeletal Class I: There is a normal between upper & lower arches, when maxillary arch is slightly forward to the mandibular

arch

ULFAT

Ballards Classification
Skeletal Class II: The lower apical base is
relatively far back from the upper apical base

ULFAT

Ballards Classification
Skeletal Class III: The lower apical base is placed relatively far forward from the

upper apical base

ULFAT

Ackermann - Proffit Classification

One of the most recent classification that

covers all the tissues in the 3 planes of

space Venn diagram

ULFAT

WHAT IS AN INDEX ?
A RATING OR CATEGORIZING SYSTEM THAT ASSIGNS A NUMERIC SCORE TO A PERSONS
OCCLUSION / AESTHETIC LOOK AN OVERALL SCORE IS CALCULATED FOR EACH TRAIT FOR GRADING MALOCCLUSION

NEED FOR ORTHODONTIC TREATMENT INDEX

LACK OF MANPOWER IN ORTHODONTICS TO ESTABLISH A SIMPLER METHOD OR INDEX

OF ASSIGNING TREATMENT PRIORITY

TO MAKE A LIST OF TRAITS THAT DETERMINE

THE EXTENT TO WHICH TREATMENT IS NECESSARY TO TREAT LARGE NUMBER OF PATIENTS AT LOCAL LEVELS

PRINCIPLES OF ANY INDEX

Most of the indices are developed upon two components to record orthodontic treatment priority

The first of these components records need for treatment on dental health and functional grounds The second component records the aesthetic impairment of dentition on social-psychological grounds

VARIOUS ORTHODONTIC INDICES

IOTN (Index of Orthodontic Treatment Need)

TPI (Treatment Priority Index) PAR (Peer Assessment Rating)

DFI (Dento-facial Index)

OFI (Occlusal Feature Index) HMAR (Handicapping Malocclusion Assessment Record) SOI (Summers Occlusal Index)

DAI (Dental Aesthetic Index)

SCAN (Standardized Continuum of Aesthetic need)

REQUIREMENTS OF
INDEX OF ORTHODONTIC TREATMENT NEED
CLINICALLY VALID AND RELIABLE QUICK TO APPLY

EASILY LEARNED BY EXAMINERS WITHOUT SPECIALIZED TRAINING

POSSIBLE TO APPLY ON EITHER PATIENTS OR DENTAL CASTS ACCEPTABLE TO BOTH PROFESSION AND PUBLIC

BENEFICIAL USES OF IOTN

PREVALENCE OF MALOCCLUSION TREATMENT NEED OF SCHOOL POPULATION / GENERAL PUBLIC NATIONAL STUDY SURVEYS PRIORITIZING CASES FOR FUNDED PROGRAMS MONITORING AND PROMOTING STANDARDS

BENEFICIAL USES OF IOTN

UNIFORMITY IN PATIENT IDENTIFICATION

REFERRAL BY GDPs TO ORTHODONTIST AUDIT / COMPARING IN PRE- AND POST- OPERATIVE CASES MAKING HOSPITAL / CLINIC WAITING LIST RESEARCH / TEACHING

COMPONENTS OF IOTN IOTN

DENTAL HEALTH COMPONENT

DHC

AESTHETIC COMPONENT

AC

DHC IS BASED ON

GRADE I
NO NEED

GRADE II
LITTLE NEED

GRADE III
MODERATE NEED

GRADE IV
GREAT NEED

GRADE V
VERY GREAT NEED

MODIFICATION IN DHC

GRADE I & II
NO / LITTLE NEED

GRADE III
BORDER LINE NEED

GRADE IV , V
DEFINITE NEED

PRINCIPLES OF GRADING DHC

TRAITS THAT INCREASE MORBIDITY OF DENTITION AND SURROUNDING STRUCTURES
ORDER OF PRIORITY
1 2 MISSING TEETH OVERJET

3
4 5

OVERBITE
CROSS-BITE

CROWDING OF TEETH

PRINCIPLES OF GRADING DHC

TRAITS THAT INCREASE MORBIDITY OF
DENTITION AND SURROUNDING STRUCTURES

EXAMPLE OVERJET > 9mm = GRADE 5 = GRADE 1

CROWDING < 1mm

PRIORITY GIVEN TO MOST SEVERE TRAIT

AESTHETIC COMPONENT

MODIFICATIONS IN AC
PHOTOGRAPHS 1 TO 4 = NO NEED

PHOTOGRAPHS 5

TO

BORDER LINE NEED

PHOTOGRAPHS 8

TO

10 =

DEFINITE NEED

It is the possibility of having a dream come true that makes life interesting. Paulo Coelho ( The Alchemist )