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Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2012

Review Article

A possible biomechanical role of occlusal cuspfossa contact relationships


M. WANG* & N. MEHTA
*

Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military

Medical University, Xian, China and Department of General Dentistry, Craniofacial Pain Headache and Sleep Center, International Relations, Tufts University School of Dental Medicine, Boston, MA, USA

SUMMARY Biomechanical features of occlusal contacts are important in understanding the role of the occlusion contributing to masticatory function. Cuspfossa contact is the typical pattern of occlusion between upper and lower teeth. This includes static relations, such as that during clenching, and dynamic relations when mandibular teeth contact in function along the maxillary occlusal pathways, as during mastication. During clenching in the maximum intercuspal position (ICP), cuspal inclines may take the role of distributing the occlusal forces in multi-directions thus preventing excessive point pressures on the individual tooth involved. During chewing movement on the functional side, the mandible moves slightly from buccal through the maximum ICP to the contralateral side. The part of the chewing cycle where occlusal contacts occur and the pathways taken by the mandible with teeth in

occlusal contacts are determined by the morphology of the teeth. The degree of contact is associated with the activity of the jaw muscles. To obtain repeatable static and dynamic occlusal contact information provided by the morphology of the teeth, maximum voluntary clenching and chewing movements with maximum range are needed. In conclusion, in addition to the standard occlusal concepts of centric relation centric occlusion and group function cuspid protection relation, biomechanics in static and dynamic cuspfossa relationships should be included to develop an understanding of occlusal harmony which includes no interfering or deective contacts in functional occlusal contact. KEYWORDS: occlusion, biomechanics, masticatory system, biting, chewing movement Accepted for publication 22 May 2012

Introduction
Dental occlusion is understood as the contact relationship between the masticatory surfaces of maxillary and mandibular teeth (1) and is an important variable in the delivery of restorative, prosthodontic and orthodontic treatments. Racich (2) postulated that dental occlusion could be pathogenic as well as physiologic. A physiologic occlusion is an occlusion in harmony with the functions of the masticatory system, and a pathogenic occlusion is an occlusal relationship capable of producing pathologic changes in the stomatognathic system (1, 3, 4), including creating damage to teeth, such as cracked tooth syndrome (5, 6). Some asymptomatic
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occlusal schemes can become pathogenic if factors such as the degree of loading or and the individuals adaptive capability are involved (79). In biomechanics, two aspects of dental occlusion are important, namely static relations such as clenching and three-dimensional dynamic relations when mandibular teeth contact in function along the maxillary occlusal pathways. The dental arches, during both static and dynamic interactions, sustain loads from jawclosing muscle contraction indirectly through food, or directly with upper and lower tooth contact. Effective distribution of the occlusal load applied on the dentitions and the generation of a smooth glide during functional movements are important for the health of
doi: 10.1111/j.1365-2842.2012.02333.x

M. WANG & N. MEHTA


the chewing system to control loadings on teeth, periodontal tissues and temporomandibular joints. In chewing, the data indicate that the mandible moves in a teardrop motion. It rstly deviates laterally towards the bolus side and, during closure, moves medially and nally through the transcuspal and intercuspal phases. The term occlusal phase or intercuspal range (10) describes the most superior part of the cycle where foods are broken down and the maxillary and mandibular teeth often contact. The intercuspal position (ICP), commonly used in kinematic analyses, marks the beginning and end of the chewing movement (1012) where most tooth contact occurs and activity of the jaw-closing muscles generates high levels of masticatory force. Cuspfossa contact is one of the typical patterns of the occlusal contact relation, such as that between a supporting cusp and its opposing central fossa in ICP. In this review, the biomechanical role of this typical occlusal contact, the cuspfossa relation, is discussed in two situations: (i) Static situation, focusing on the distribution regularities of the occlusal loading during maximum voluntary clenching in ICP. The inuences from occlusal stability and mandibular balance equilibrium to this contact-guided loading distribution are also discussed. (ii) Dynamic occlusion, focusing on the occlusal glide during exaggerated masticatory movement. The association of the chewing cycle pattern with occlusal guidance is also analysed. Techniques for testing occlusal contacts are briey reviewed. sustained by cusp inclines is less than the vertical force generated from elevator muscles (13). In this way, periodontal tissues sustain less stress during clenching. The opposite example is that the pause in ICP was longer in patients with at occlusal surface dentures than with cusped teeth (14), indicating a more sustained biting force in at teeth to compensate for the relative inefciency of the occlusal form. In the context of effectively dispersing the vertical loading, it is here suggested not to reduce the number of contacts to one per tooth as it was reported (15). It is difcult to record accurate information of bite force directions in vivo. Dos Santos et al. (16) developed a mechanical model to simulate function and provide vector analysis based on static equilibrium of forces generated in a mandible at 10 different positions. They concluded that cusp inclines have a profound inuence on the forces acting within the dentition. Southard et al. (17) utilising a specially designed tension transducer positioned in the area of the mandibular rst molar second premolar contact in 15 subjects concluded that there is a signicant mesial component of occlusal force which is related to molar inclination. A photoelastic model system has been used to analyse the directions and magnitudes of stress in the apical region of mandibular teeth which were applied with loads vertical to occlusal plane (13). In that study, the loading position and direction on the occlusal surface of the mandibular dentition were deduced. It was found

Static occlusion
Although static clenching is often referred as a feature of bruxism (which is not included in this review), food is compressed and or fractured in the nal occlusal stage of mastication to reduce the particle size and facilitate swallowing. Thus, a simulated static clenching in ICP is often adopted for analysing the way in which the occlusal loading is sustained and how this relationship inuences the distribution of the occlusal loadings.

Cuspfossa relation distributes the occlusal loadings Masticatory efciency is desirably maximised by the multi-cusped nature of dental occlusal surfaces which increases the size of the occlusal contact area of posterior tooth crowns and serves to effectively disperse occlusal forces. In Fig. 1, each division of the force

Fig. 1. Sketch [modication of (13)] of the role of cuspal inclines in distributing occlusal loadings. The loading from jaw-closing muscles is dispersed by the cusps into divisions that perpendicular to the cuspal inclines and transferred to the apical area in different directions. Photoelastic analysis (13) indicated that, in normal, the loadings are principle (large arrows on the occlusal surfaces) on the lingual incline of the buccal cusp and the distal inclines of the cusps in mandibular teeth. Left: coronal view. Right: sagittal view. MF: Composition generated by elevator muscles. Arrows: divisions of the loading from MF.
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OCCLUSAL BIOMECHANICS
that the apical stress of occlusal loading was directed disto-lingually on the mandibular posterior teeth. This suggested that the principal loading positions of the mandibular posterior teeth in general were on the distal and lingual inclines of buccal cusps. This implies that distal and lingual inclines of mandibular molar buccal cusps take the principal occlusal loading in normal occlusion as indicated in Fig. 1. When the occlusal contact points change as in a posterior cross-bite, the enduring occlusal loading position changed from the lingual to the buccal of the mandibular buccal cusps, and the apical stress was found to be mainly directed buccally (13). The magnitude of apical stress is also inuenced by cuspfossa relationships. In a at occlusal surface, vertical loads failed to disperse as compared with cusps and fossae and induced a higher apical stress than normal occlusion (13). These data indicate that the occlusal load is initially transferred in a direction perpendicular to cuspal inclines. This is in agreement with Hidaka et al. (18) who determined that the broadened occlusal contact area would be helpful in mitigating excessive occlusal forces on the teeth. means the equalization of tooth contacts as described above (1). However, no occlusal contact indexes have been used for occlusal stability. There is currently no measuring device to directly and reliably evaluate occlusal stability. Instead, surface electromyographic (SEMG) analysis has been used as an indirect approach (29, 30) because stable occlusion allows higher jaw-closing muscle activity during clenching (4, 2933). A high level of clenching activity then could be a sign of health that can be taken as a goal of occlusal therapy. The supportive evidence is that when clenching on a cotton roll, which allows a simulated stable occlusion relationship by eliminating small variations in occlusal contacts (34), the SEMG activity is increased (35, 36). During maximal voluntary clenching in the lateral excursive position which is assumed unstable because maxillary and mandibular teeth occlude at edgeto-edge relation, the SEMG activity of masseter and temporalis muscles in both sides was observed to be higher when the dentitions were separated with a cotton roll than that without (36). The reex adjustment of periodontal feedback on jaw muscles is attributed to this phenomenon. During clenching, teeth are intruded into their sockets and the activation of periodontal mechanoreceptors increased (37). The different ring frequency may contribute to the differences in bite force level that occurs with crushing foods of varying size and textures (38). Thus, the level of SEMG activity during maximum voluntary clenching in ICP could be taken as a possible assessment of occlusal stability, with higher levels for stable and lower for unstable occlusion. As a result, recording of SEMG activity may assist in the assessment of occlusal stability based on which occlusal contact features could be repeatedly recorded and thus be investigated. Mandibular balance equilibrium Mandibular balance or equilibrium has been used to describe the positional status of the mandible, including the dentition and temporomandibular joints (39). Because mandibular balance with tooth contact is maintained by jaw-closing muscle contraction, which is modied by peripheral feedback, mandibular balance is often used interchangeably with occlusal stability. During tooth clenching, the activity of jaw-closing muscles causes rotation of the mandible upward around

Occlusal stability The term of occlusal stability is dened in prosthodontics as the equalization of tooth contacts that prevents tooth movement after closure (1), although in orthodontics it is used to describe the relapse status of a nished orthodontic occlusion, which is stable to prevent relapse and unstable in relapse cases (1921). The present review focuses on the former concept of occlusal stability which has a close association with occlusal contact. According to the denition, to check occlusal stability, a maximum voluntary clench should be recorded because at the submaximal level when clenching intensity increases, there was a tendency for moving the bite force balancing point to be bilaterally balanced (18). In addition, when clenching directly without food, the number of tooth contacts was larger with rm pressure than light pressure (18, 2224). Furthermore, occlusal contact area was reported to increase after gum chewing (25). Physiological tooth mobility and deformation of the dental arch with loading might contribute to the explanation of these pressure-related differences in occlusal contact number or area (2628). Only maximum voluntary clenching provides repeatable information of occlusal stability that, by denition,
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M. WANG & N. MEHTA


the terminal hinge axis (18, 40). Vectors produced by isometric contraction of jaw-closing muscles are between the mandibular condyle and dental arch. Each of the moment arms estimated for the forces generated by the jaw-closing muscles is shorter than the perpendicular distance between the fulcrum and the distal end of the second molars (41). According to this biomechanical feature, posterior occlusal support has a dominant role in contrast to the anterior support for maintaining the mandible in sagittal balance (42, 43). The decreased jaw elevator muscle activity during clench without molar support implies a protective mechanism operates in mandibular imbalanced situation caused by reduced occlusions (34, 35, 4345). This is illustrated in a maximum voluntary clench on a splint with six left-sided teeth removed from contact while the left second molar remained in contact, the SEMG activity in masseter and anterior temporalis muscles did not change from clenching with an equilibrated splint (42). The location of contacts which determines the balance of the mandible during clenching predominates in generating muscle bilateral force than the size or number of teeth involved (35, 36, 42, 46). suggested by Ogawa et al. (47, 55, 56) as not directly affected by tooth contact, but by muscles, joint ligaments, and possibly by the inclination of the occlusal plane. Although the approximate angle of the glide during the occlusal phase that closely correlated with the angles of the tooth cusps (47) had once being used to describe the features of chewing in relation to occlusion (11), several studies have attempted to analyse occlusal guidance by measuring its length (10, 12, 49, 50), and reported differences would be due to diet, testing method, assessing criteria and special occlusal characteristics of the subjects when recorded at the incisor as summarised in Table 1. The closing path of the chewing cycle is more often analysed. This may be as a result of the customary posterior teeth and or canine guidance for lateral excursive movements. During the closing, the buccal cusps of the maxillary teeth provide guidance, and during opening, the lingual cusps of the chewing side may not contact, or there may be light contact. The extended medial excursive movement is then more possibly guided by the buccal cusps of the contra-lateral teeth as indicated in Fig. 2. This may explain why jawopening movements are more varied than closing movements during chewing (57) and that in toothtapping tasks, the closing components indicated by nal tooth contact has a higher coincidence and lower variability than with opening (58). In this context, regular chewing that seldom covers the full range of contra-lateral guidance is not a reasonable test for checking and evaluating the effect of occlusal guidance on chewing. Instead, chewing over the full range is appropriate as tooth contact constrained by the morphology of the teeth so as to more likely reect the role of occlusal inclines in function. Thus, it is suggested here to ask the testee to chew following the occlusal guidance, both in closing and opening phases, as far long as possible. Chewing cycles Chewing cycles have been analysed by shape and duration, as well as by maximum jaw velocities (59, 60). It was reported that subjects with malocclusion have more irregular chewing patterns (61). Posterior crossbite and deepbite are often inuencing factors in studies on the effects of occlusion on chewing. Posterior unilateral crossbite is a malocclusion that may lead to a mandibular deviation. During chewing
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Dynamic occlusion
In the nal occlusal phase of the chewing cycle, the mandible may slide along the cuspal inclines (10, 47). Adams and Zander (48) classied occlusal contacts in chewing into two categories: 62% occurring during jaw closing (before centric occlusion) and 38% occurring during jaw opening (after centric occlusion).

Occlusal guidance Many studies have used several criteria to investigate the role of occlusal glide in masticatory function using several different criteria (10, 4952). Rilo et al. (53) summarised the beginning and end of the occlusal glide and suggested that occlusal guidance is where the terminal or initial parts of the chewing cycles could be superimposed on the pathways taken by the mandible during lateral excursions with occlusal contacts. It is an acquired relationship between form and function. Many studies have shown that the pattern of masticatory movement reects the individual pattern of occlusal guidance (51, 52, 54), although the masticatory path of closure outside the occlusal phase, for example, the position 5 mm from contact, was

OCCLUSAL BIOMECHANICS
Table 1. The length of occlusal guidance reported in literature Chewing materials Gum Average length of occlusal guidance 129 mm during closing, 155 mm during opening

Authors Hayasaki et al. (84)

Samples 25 women with permanent dentition

Testing methods Optoelectronic system and curved mesh diagram of mandibular excursion (CMDME) method Optoelectronic system and CMDME

Hayasaki et al. (12)

Rilo et al. (102)

Neill and Howell (59)

Suit et al. (10)

11 girls with primary dentition, from 4 years 6 months to 6 years 3 months 63 healthy dentistry students, 20 men and 43 women, 2027 years old 33 out of 97 students, 40 women and 57 men, 1929 years old 18 adults, 9 with good occlusion, 9 with malocclusion

Gum

079 mm during closing, 159 mm during opening

Gum

Kinesiography

09 mm for right-side chewing 12 mm for left-side chewing 13828 mm for ve different testing foods In good occlusion: 13 mm during closing, 09 mm during opening. In malocclusion: 10 mm during closing, 11 mm during opening

Beef, carrots, peanuts, cookies, gum Cheese

Kinesiograph

Case gnathic replicator

with unilateral crossbite, the jaw will rst move laterally before medially to disengage the teeth in crossbite, showing an increased frequency of reverse sequencing cycles (6268) with a reduced masseter activity (69). The percentage of such chewing cycles was found signicantly reduced after correction of the unilateral crossbite relation (6264), although the opposite results were also reported (64, 65, 68). Although it is the posterior teeth that take a predominant role in guiding chewing movement, the effects of anterior occlusion on the chewing cycle have also been studied. It was originally presumed that excessive overbite would produce predominantly vertical chewing strokes (70). This was initially supported by the cineuorographic analysis (71), which showed deepbite subjects had cycles that were more irregular and vertically oriented. However, these ndings were not supported by Sheppard et al. (72) who reported from cineuorography that the chewing pattern in deepbite adults was not predominantly vertical. Alexander et al. (73) reported that the presence of a deepbite does not create major disturbances in chewing. Buschang et al. (60) reported that when chewing gum, deepbite subjects displayed less inferior and greater posterior excursions during opening. They also reported that during the initial 30% of opening, on average, subjects with normal occlusion maintain the anterio-posterior
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position of the mandible, whereas deepbite subjects immediately move their mandibles posteriorly. Deepbite subjects also showed approximately 6% lateral movements to the balancing side in the initial movements in comparison with non-deepbite subjects (47, 55, 56). Besides chewing cycle patterns, slow chewing was also reported in children with unilateral posterior crossbite (64, 68) and deepbite (60), implying that greater mandibular positional or elevator muscle co-contraction adjustments are required in preparation foods for the occlusal phase (60).

Controversy of occlusal guidance in chewing movements It was reported that by 1214 years of age, the chewing pattern is characterised by anterior opening and wide lateral closure similar to adult chewing (74). This learned pattern of chewing movement continues throughout adult life even with occlusal change (64, 65, 68). Rilo et al. (53) reported that there is no signicant difference in lengths of dental contact during mastication of three types of foods. However, chewing pattern is not only controlled by the central pattern generator (CPG), but also modied by periodontal mechanoreceptors. When teeth contact, the activity from periodontal mechanoreceptors will change and thus change periodontal afferent input

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activity would, as required, modify jaw, tongue and lip movements (85). This is possibly supported by the fact that at initiation of the occlusal phase of a chewing cycle, there was a short silent period of about 25 ms, in temporal and masseter muscles (79), and also jawclosing velocity is less than opening during chewing (59, 86). The pattern of this modied muscle activity in the cycle-by-cycle chewing movements (68) at an early age may have inuence on oro-facial development (87). In a study of Class II malocclusions, the reduced vertical height of the upper second molar was correlated with a retruded and small mandible (88). Clinical assessment suggests that anterior crossbite is associated with mandibular protrusive jaw relationship and unilateral posterior crossbite with mandibular deviation. Early correction of the crossbite is helpful to prevent malocclusion from progressing. Thus, chewing cycles exhibit a complex pattern through central control and peripheral feedback. The reproducibility within subjects is expected not to be higher than between subjects. However, Hayasaki et al. (84) reported that the occlusal glide length during both closing and opening had a larger variation within subjects than between subjects, even during chewing one type of food (gum). Within-subject variation in chewing was also reported to be signicantly higher with a deepbite (60). The full range chewing recording may provide further information on this within-subjects variation in chewing pattern.

Fig. 2. Sketch of the occlusion-guided chewing movement in ctitious normal occlusion (without balancing side contacts). The mandible rstly close towards the working side (as shown in 1), then, moves with buccal side of the mandibular buccal cusp tip gliding alone lingual incline of the maxillary buccal cusp (from situation 1 to 2) and then through the maximum intercuspal position (ICP, labelled 2) to open range (from situation 2 to 3). The buccal incline of the lingual cusp of the working side maxillary molar does not actually guide much of the open path because when the mandible moves further medially from ICP, the balancing teeth would take over the guiding role. That means in the maximum chewing movement, the closing path is guided by the working side tooth teeth while the opening path might be guided by the balance side tooth teeth. In other words, because the maximum chewing cycle is constrained by the morphology of the teeth, the gliding path of laterotrusive movement in left side would be the gliding path of mediatrusive movement in right side. In this view, the left side maximum chewing range would be completely the reversal of the right side maximum chewing range, at least in occlusal phase. R and L: terminals of right and left laterotrusive movement, respectively.

(7578). Although contact in ICP during chewing is brief 80162 ms (59, 79, 80) reported with different methods the periodontal inuence on the jaw-closing muscles may operate as in a conditioned reex. The periodontal receptors provide the structural initiation of this reex. Animal studies have shown that occlusal changes in contact relationship, such as anterior crossbite and bite-raising, inuenced the function of the periodontal receptors (81, 82). This implies that the occlusal relationship could inuence jaw muscle activity through a periodontal jaw elevator muscle reex. The brief contact during chewing may evoke jaw muscles contraction in a specic pattern as a result of this reex. It is proposed that the active pattern of jaw muscles reexively evoked by occlusal stimulation during chewing will be remembered and constitutes an additional component of jaw muscle contraction primarily motivated by the CPG (83) and drives a chewing movement for the efcient breakdown of food (84). Because of jaw muscle activity being regulated in part by the changes in the activity of periodontal afferents during tooth contact (7577), the learned chewing

Techniques in testing occlusal contacts


Based on these data, the location of occlusal contacts is important in distributing occlusal load and occlusal glide factors in determining chewing patterns. Hence, the techniques to record and evaluate dental occlusal contact in both static and dynamic situations are important when analysing the biomechanical role of occlusion. However, the occlusal phase of the masticatory cycle when food is broken down through tooth contact is difcult to analyse. Tooth contacts have been recorded in a variety of groups with occlusal articulating paper (89, 90), occlusal strips or silk (55, 56, 90), alginate impressions (49, 91, 92), black silicone bite registration material (93), the Dental Prescale system (18, 94), photocclusion (95 97), gnathosonics (98, 99) and T-Scan system (90, 100, 101). Instruments that are used for measuring mandibular movements are also helpful in detecting
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OCCLUSAL BIOMECHANICS
occlusal contacts during chewing movement (11, 12, 84, 102, 103). Because the features of occlusal contacts are affected by the biting pressures as described in this review, some devices were developed to quantify the contact area together with bite force (90, 100, 101), spontaneously recorded elevator muscle EMG (104, 105), or gnathographic recording (53). However, the occlusal contact criteria are not widely accepted in practice. Kirveskari (99, 100) suggested the following two criteria: the time taken from rst contact on closure to full intercuspation measured by the T-scan system, and the length of the slide between centric relation and maximum intercuspation. However, the validity of these recordings as a measure of normal occlusion remains unanswered. Considering the ranging clinical opinions and conclusions drawn from clinical research using measurements of occlusal characteristics provided by different systems, improved occlusal registration methods and materials are needed to meet these technical and clinical requirements (99, 100). anterior tooth form, function and aesthetics, and posterior form incorporating gliding cusps, ipsilateral and contrailateral side contacts (49, 107, 110, 113). This broader concept will help determine rational occlusal management. The masticatory forces are usually generated in submaximum level (114, 115). To study contact location, the need for assessing occlusal contact intensity with criteria determined through voluntary maximum clench is proposed in this review. The exaggerated chewing motion is also recommended to assess the smoothness and ease of occlusal guided horizontal movements. These analyses may result in evaluating occlusal harmony in centric and eccentric jaw postures in which there are no deective contacts of occluding surfaces (1). Further data from carefully developed studies are needed.

Acknowledgment
The present work is supported by Nature Science Foundation of China (NSFC) No. 30772429 and No.30872870.

Summary
Functional (normal) occlusion is necessary for a healthy stomatognathic system in the provision of dental aged care, orthodontic therapy, and quality prosthetic and restorative treatment (2, 106, 107). However, as Clark and Evans (108) have indicated, the criteria that denote an ideal functional occlusion have not been conclusively established. Extensive tooth wear might be a basic design principle in the human as a mechanism for functional adaptation, but this is reduced in the contemporary humans. Whether the changes of occlusal contact features related to this reduction in tooth wear lead to an increased frequency of musculo-skeletal problems in industrialised societies remains unanswered (109). Balanced occlusion in people with natural dentitions is frequently found (22, 110) and appears an acceptable outcome of orthodontic therapy (111). Over one-third of bridge units were not in antagonistic contact (112), indicating that the clinicians are surmised to reduce the risk of the failure of restoration by over-prevention of heavy contact. All these imply that there is a necessity to provide a standard of a functional occlusal contact relation. This current review proposes the importance of cuspal inclines, as a component of a cusp or a fossa which have a role in the management of occlusal load distribution and occlusal guidance. This is in addition to the concept of occlusion used for occlusal treatment with
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Correspondence: Mei-Qing Wang, Department of Oral Anatomy and Physiology and TMD, School of Stomatology, Fourth Military Medical University, Xian 710032, China. E-mail: mqwang@fmmu.edu.cn

2012 Blackwell Publishing Ltd