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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 D E N T I S T R Y

Making Occlusion Work: 1.


Terminology, Occlusal Assessment
and Recording
A.J. MCCULLOCK

Every restoration, whether a simple


Abstract: This is the first paper in a two-part series reviewing some of the relevant amalgam filling or complex crown and
theoretical aspects of occlusion and describing its application in clinical practice. This
bridgework, that involves the occlusal
article discusses terminology, clinical examination of the occlusion, articulators and
interocclusal records. surface will affect the occlusion.
Therefore restorations should be
Dent Update 2003; 30: 150-157 planned so that they do not cause
effects that exceed the adaptive
Clinical Relevance: Occlusion is of fundamental importance in restorative tolerance.
dentistry, as all restorations placed in the mouth can have a profound effect on it. From
intracoronal direct placement restorations to complex crown and bridgework, the
restoration must be planned to conform to an occlusal pattern, and not disrupt it unless
TERMINOLOGY
for very specific reasons.
Posselt1 described the extreme or border
movements of the mandible as an
envelope of motion. They represent the
movement of the tip of the lower incisor

T he study of occlusion involves not


only the static relationship of teeth
but also their functional interrelationship
activity is usually habitual, the patient
often being unaware of the movement,
and includes bruxism, clenching, jaw
when viewed in the sagittal or frontal
plane (Figure 1).
The mandible initially opens with a
and all the components of the posturing, lip and pencil biting. These hinge movement about a horizontal axis
masticatory system. The muscles of activities can create excessive forces known as the retruded axis or terminal
mastication, the neural feedback between teeth or produce normal forces hinge axis (THA), with the condyles in
pathways, the temporomandibular joints at an abnormal frequency, producing a the retruded position (RP) (centric
and the shape of the occluding surfaces risk of: relation).This is described as the most
of the teeth influence the positions and superior position of the condyles in
movements of the mandible. The way in l fractured cusps or restorations; their fossae. The RP is clinically
which teeth meet and move over each l increased tooth mobility; reproducible in both dentate and
other must be understood so that any l muscle fatigue; and edentulous patients.
restoration placed in a mouth will be part l toothwear.
of a harmoniously functioning occlusion. l When the mandible rotates around
The occlusion achieved during normal A harmoniously functioning this axis the first tooth contact
functional mandibular movements, such occlusion allows for smooth occurs – the retruded contact
as swallowing and chewing, occurs uninterrupted movements over the area position (RCP).
within a relatively small space called the of tooth contact. Some occlusions may l The mandible then slides forwards
envelope of motion. Abnormal not permit such free movements, yet the bringing the teeth into maximum
movements are dysfunctional, caused patient does not exhibit the problems intercuspation – the intercuspal
by derangement of the articular disc and described; his/her neuromuscular position (ICP) (centric occlusion).
muscle hypertrophy. Parafunctional system has adapted to the disharmony.
However, if a restoration is placed which The discrepancy between RCP and
changes the occlusion, the adaptive ICP has both a vertical and horizontal
A.J. McCullock, BDS, MSc, FDS RCS, MRD, MRD capacity of the system may be exceeded, component and may be up to 1 mm.2
RCS(Edin.), Consultant in Restorative Dentistry, leading to the signs and symptoms However, patients with this slide usually
Lister Hospital, Stevenage, Hertfordshire.
listed above. close straight into ICP from the rest

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of the anterior teeth, creating anterior


guidance. This does not exist in anterior
open bites or edge-to-edge incisor
relationships, where during protrusion
the guidance is obtained from the
occlusal surfaces of the posterior teeth.
The angle and length of the movement is
determined by the incisor relationship.
In Class II division II occlusions the
movement is almost all vertical as the
lower incisors are locked palatal to the
upper incisors and cannot slide forward.
Their incisal guidance produces a
different tracing in Posselt’s diagram
(Figure 1).
ICP is maintained and occlusal forces
directed axially by two types of
interocclusal contact: the palatal cusps
of the maxillary teeth and buccal cusps
of the mandibular teeth (called
supporting cusps) contact the inclined
planes of the opposing dentition or the
cusp tips contact the opposing fossae.
The maxillary buccal and mandibular
lingual cusps are therefore the non-
supporting cusps. These contacts are
reversed in crossbite so it is important
that each occlusion is assessed
individually. During lateral excursions,
the side to which the mandible moves is
the working side and the opposite side
the non-working side. On the working
side, when only the canines are in
contact during lateral excursions, the
occlusion is canine guided; if two or
more pairs of teeth contact in this
movement the occlusion is in group
Figure 1. Border movements of the mandible. (A) Posselt’s triangle viewed in the sagittal plane. function. This may involve both anterior
The mandible, with the teeth in occlusion, moves from RCP through ICP to the protruded position
P. In moving from RCP to maximum opening O the mandible rotates around THA and
and posterior teeth.
translocates from Y. (B) Lateral movement of the mandible when viewed from above shows the On opening from RCP the mandible
Bennett angle (B) traced by the working side condyle and the Bennett movement described by rotates around the THA in an arc of a
the non-working-side condyle. The gothic triangle tracing of the incisor is depicted. (C) The THA circle (point Y on Figure 1). This creates
passes through the centre of both condyles. The border movement viewed from the front. (D) The an incisal separation of about 2.5 cm. On
guidance patterns produced by different incisal relationships. Reproduced with permission from
Smith BGN. Planning and Making Crowns and Bridges, 3rd edition, Martin Dunitz; figure 4.2.
further opening the condyles translate
or slide downwards and forwards along
the articular eminencies of the glenoid
fossae to a point of maximum opening
position – the habitual path of closure. rest position by the muscles of (Figure 1; O). During lateral movements,
Contact between opposing teeth can mastication acting on the mandible the working side or rotating condyle
occur in the area of this discrepancy creating a freeway space or may rotate and move laterally as well as
during swallowing, mastication and interocclusal distance of 2–4 mm. In upwards, downwards or backwards. The
parafunctional activity. When teeth are practice, this position is variable, being lateral component is termed the Bennett
in the intercuspal position the occlusal affected by posture and muscle activity. movement. The first part is called
vertical dimension (OVD) is defined as a When mandibular teeth move from immediate sideshift and is measured on
measurement of face height. When not ICP to maximum protrusion their path is average at 0.5 mm. The progressive
in contact, teeth are held apart in the determined by the articulating surfaces sideshift describes a more gradual lateral

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include lateral excursions and protrusion


a b
so both the horizontal and vertical
condylar guidance and incisal guidance
can be programmed into the articulator.

Retruded Contact Position


The RCP is located using the following
technique:
Figure 2. (a) Articulating paper held in Miller’s forceps. (b) Different occlusal indicators – wax,
paper, shimstock. l The patient is placed in the supine
position with the chin pointed
upwards.
l The operator sits behind the patient
movement. The non-working side or 1. Intercuspal position, retruded and places his or her thumbs on the
orbiting condyle moves downwards, contact position, lateral and anterior patient’s chin and fingers on the
forwards and inwards, creating the guidance. lower border of the mandible (Figure
Bennett angle (Figure 1). 2. Presence, angle and smoothness 3).
The free-sliding movement of the of any slide from RCP to ICP. l By gentle manipulation the
mandible can be disturbed by an 3. Location and extent of occlusal mandible can be moved into the
occlusal interference occurring between faceting. retruded position.
opposing teeth. The interference may 4. Ease of movement between l The patient is instructed to raise
arise as a result of tooth movement, mandibular positions as in 1. his/her hand on whichever side
over-eruption or occlusal wear in the 5. Extent of posterior support. contact is first felt. This will verify
unrestored dentition or of poorly 6. Over-erupted, tilted or mobile the clinical impression gained by
contoured restorations. To maintain teeth. the dentist.
occlusal stability there must be
adequate occlusal contact to prevent The process is repeated using
such interferences. This stability can be DETECTING OCCLUSAL articulating paper to verify the contacts.
maintained by assuring occlusal CONTACTS In those patients with a tense
contacts are not on inclined planes but Articulating paper is used to mark or musculature, who cannot relax readily,
ideally in a cusp-to-fossa or cusp-to- indicate the position of occlusal
marginal ridge position. contacts. Thin articulating paper such
as GHM occlusion foil (Hanel-GMH-
Dental GMBH, Nurtingen, Germany),
ASSESSMENT OF THE which is 19 microns thick, marks true
OCCLUSION contact points; thicker paper (70–200
The diagnostic process begins with microns) can produce inaccurate and
careful history taking and clinical often larger points. However, none of
examination. Signs and symptoms of these papers readily registers contact on
clicking or locking of the glazed porcelain or polished gold
temporomandibular joints, muscle surfaces.
spasm, excessive or uneven occlusal To show occlusal contacts the teeth Figure 3. Bimanual manipulation of the
mandible to position it in the retruded contact
wear and pain on chewing must be must be dry. Articulating paper, held in
position.
recorded. Further investigations Miller’s forceps (Figure 2), is placed
including radiographs, vitality tests and between the teeth and the mandible
articulated study casts will provide guided into whichever position is being
additional information. assessed to record the points of tooth
The examination should include: contact. Articulated study casts,
mounted on a semi-adjustable articulator
l Extra-oral components – using a facebow record, provide more
temporomandibular joints, muscle detailed information that cannot be
hypertrophy/spasm. readily assessed in the mouth. The casts
l Mandibular movement – painful, must be articulated in RP so any slide
deviated, abnormal or restricted. from this position to ICP is detectable. Figure 4. Cotton wool held between the front
l Intra-oral features: The interocclusal records must also teeth to break the proprioceptive feedback.

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ARTICULATORS
a b
Articulators (Figure 5) are mechanical
devices that hold casts to allow the
examination of occlusal relations and the
fabrication of restorations in the
laboratory. Articulators may be
classified into the following groups:5

l simple hinge;
c d
l average value;
l semi-adjustable – arcon or non-
arcon;
l fully adjustable.

Simple Hinge
The simple hinge articulator allows
rotational movement only, around a
Figure 5. Articulators: (a) simple hinge, (b) semi-adjustable non-arcon, (c) semi-adjustable arcon, horizontal axis that bears little
(d) fully adjustable. relationship to the patient’s terminal
hinge axis because a facebow transfer is
not used. This is adequate when other
unprepared teeth on the working cast
difficulty will be experienced in occlusal coverage of the upper teeth. In maintain ICP. Restorations can be made
recording the maxillomandibular acting as a diagnostic appliance it aims only in ICP and intra-oral adjustment
relationship at the position in which the to achieve muscle relaxation and allow may be necessary in lateral and
occlusal interference occurs. This condylar repositioning so the retruded protrusive movements unless there is
should be suspected when the patient axis position can be located. steep anterior guidance leading to
resists attempts to manipulate the immediate posterior disclusion.
mandible by forcibly holding the jaw in
one position and is unable to make easy Discrepancy Between RCP and
voluntary movements. It is often ICP Average Value
necessary to have several attempts to The mandible is manipulated into RCP Average value articulators allow a
educate a patient to relax. A cotton wool and the patient instructed to slide his limited range of protrusive and lateral
roll placed between the patient’s front or her teeth together until they meet in movements based, as the name
teeth for a few minutes (Figure 4) is a ICP or in the position that feels correct suggests, on the average patient
useful technique to help at the initial to them. This is identified using through a fixed condylar guidance
assessment. articulating paper. Lateral excursions mechanism.
However, to identify the occlusal are then made to detect the nature of
interference in RCP accurately, the the guidance and finally protrusive
proprioceptive feedback mechanism movement is used to demonstrate the Semi-adjustable
must be de-programmed from its habitual type of anterior guidance. Semi-adjustable articulators can be set
path of closure so the casts can be to simulate mandibular movements well
mounted on the retruded axis. An
anterior acrylic jig3 or full maxillary
coverage acrylic splint4 may be used.
Although each is designed differently, a b
the aim is the same. The anterior jig can
also usefully be incorporated into an
interocclusal record. In principle the jig,
which covers the upper central incisors,
is shaped to have contact with the lower
central incisors in RP and create a
posterior separation of 2 mm. The acrylic
Michigan splint, which is also Figure 6. (a) Denar Slidematic facebow, (b) Dentatus facebow.
constructed in RP, uses complete

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Type of Restoration Interocclusal Record Articulator Potential Interferences

Single anterior unit (C) None, ICP Not usually necessary/simple hinge RCP, protrusive

Single posterior unit (C) None or ICP Not usually necessary/simple hinge RCP, protrusive

Last standing molar (C) ICP Simple hinge RCP, lateral, protrusive

Multiple anterior units (C) ICP, protrusive Semi-adjustable plus customized incisal guidance Minimal

Multiple posterior units in one (a) ICP or Average value or RCP, lateral, protrusive
arch (RO) (b) ICP, lateral/protrusive Semi-adjustable plus facebow transfer RCP

Multiple units in both arches (RO) RCP, lateral/protrusive Semi-adjustable plus facebow transfer or fully Minimal
adjustable

A semi-adjustable articulator is suitable for most patients. C: conformative approach; RO: reorganized approach.
Table 1. Indication for occlusal records and type of articulator.

enough for many clinical situations. They are set using either interocclusal new restorations avoided.
Their condylar guidance mechanisms are records or a pantographic tracing and a Readers should refer to more detailed
set from lateral and protrusive records record of the true terminal hinge axis to texts5 for in-depth descriptions of each
and the maxillary cast is related to the duplicate mandibular movement with a type of articulator.
hinge axis of the articulator using a high degree of accuracy.
facebow transfer. There are two types of Articulators are set using
semi-adjustable articulator: interocclusal records. Semi-adjustable THE FACEBOW TRANSFER
machines use the lateral and protrusive The facebow (Figure 6) records the
l The arcon (articulator–condyle) records to set the condylar elements to relationship between the patient’s
type, for example the Denar Mark II replicate some of the posterior terminal hinge axis, whether it is true
(Denar Corporation, Anaheim CA, determinants of the occlusion (condylar (accurate) or arbitrary (imprecise) and
USA), has an adjustable condylar guidance, the Bennett angle and the maxillary teeth are enabling this to
fossa mechanism that sits on a fixed movement). RCP records allow the casts be transferred to the articulator, so
condylar sphere, attached to the to be mounted so that an existing slide relating the hinge axis of the articulator
lower member, on which it is free to between RCP and ICP can be duplicated to the maxillary cast. Casts are
move. The upper member is and potential occlusal interferences from articulated in RCP then brought together
detachable from the rest of the
articulator. It maintains the fixed
relationship of the maxillary
occlusal plane to the condylar a b
guidance angle.
l Most non-arcon types, such as
Dentatus (Pro-Care Europe Ltd,
Bradford, UK), have a moving
condylar sphere set in an adjustable
condylar track, which is not
removable.

The advantage of the arcon type is c d


that it more closely represents the
anatomical relation between the condyle
and glenoid fossa; as the upper member
is removable this type is of great help in
many laboratory-based procedures.

Fully Adjustable
Figure 7. (a) Softened interocclusal wax record. (b) Buccal cusps visible on record. (c) Record
Fully adjustable instruments are of the relined with temporary cement. (d) Rigid, stable, accurate record.
arcon design and are very sophisticated.

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record the occlusal relationship (it can


a b
also be used when whole quadrants are
prepared). An alternative technique is
discussed in the second article. The
record may be made covering only the
prepared teeth with the unprepared
teeth in occlusion.

l Extra hard base plate wax is


Figure 8. (a) Acrylic base with wax rims (b) located with zinc oxide and eugenol paste. thoroughly softened in a water
bath.
l Two thicknesses are shaped, placed
over the prepared tooth/teeth and
to examine occlusal contacts. Where a l is initially soft and fluid; the mandible guided into RCP or
patient’s occlusal vertical dimension is l does not displace the soft tissue or ICP.
to be altered using restorations, a semi- teeth; l Once cooled the record is removed
adjustable articulator with a facebow l does not interfere with mandibular from the mouth and inspected.
transfer must be used (Table 1). movements; and
The arbitrary hinge axis is adequate l is stable and accurate once set. It can be further improved by using
for most clinical procedures.6 It is zinc oxide eugenol paste or temporary
located 13 mm from the tip of the tragus Extra hard base plate wax is suitable. cement as a relining agent (Figure 7).
of the ear on a line joining this point to Other materials include zinc oxide and Where a Lucia jig has been used to help
the outer canthus of the eye. This point eugenol paste, elastomers and identify RCP, this can be incorporated in
is marked on the face and the condylar impression plaster. the wax record, the anterior part of the
rod of the facebow placed over it. Some A wax record is made of two record being cut away to accommodate
facebows use the ear as the point of thicknesses of base-plate wax that will it.
reference; this is more accurate than not distort during removal from the
other average points marked on the face mouth. The record should be about
and simplifies the clinical recording 2 mm thick to ensure that purely All Posterior Teeth Prepared in
process. rotational movement of the condyle One Arch using the
The third reference point relates the occurs (rather than translocation) when Reorganized Approach
maxillary cast to the Frankfort plane. RCP or ICP is recorded. The wax record When all the posterior teeth in one arch
Some facebows use the infra-orbital may need to be thicker for protrusive have been prepared the anterior teeth
notch and others have a plastic ‘nose excursion as there will be greater and condyle in its THA maintain the
piece’ that rests on the bridge of the separation of the posterior teeth. The occlusal vertical dimension. In making
nose during the recording. The occlusal protrusive condylar path is curved, the interocclusal record the anterior
plane in its sagittal relationship to the following the anatomy of the glenoid teeth must contact without interference
horizontal is then identified. fossa, and on some arcon articulators from the record.
this can be replicated with customized Softened baseplate wax is formed to
acrylic tables or nylon inserts. The cross the arch, providing a rigid base. A
INTEROCCLUSAL RECORDS protrusive record is taken with the teeth horseshoe-shaped piece of wax readily
These records relate the mandibular in an edge-to-edge position. The distorts during removal from the mouth
and maxillary diagnostic and working protrusive record needs to record this and should not be used.8 Once hard, the
casts in RCP, ICP, OVD, protrusion and degree of movement but no further record is removed and examined and
lateral excursions. The record should forward – except in edge-to-edge improved as above.
be made at the correct OVD in the relationships when the mandible should Where there are insufficient teeth to
absence of any temporomandibular be protruded no further than 5–6 mm. support a stable record wax, occlusal
joint or muscle dysfunction, using the rims on a stable wax or acrylic base can
appropriate mandibular guidance and be used (Figure 8). The jaw relationship
an accurate and dimensionally stable Single Posterior Tooth or and vertical dimension should be
material. To ensure the accuracy of the Quadrant Preparations using determined before tooth preparation,
mounting, it must be checked with the Conformative Approach ensuring that these parameters are
shimstock such that the intra-oral When a single standing molar tooth has maintained after the occlusal stops have
contacts and those on the casts been prepared and is the only vertical been reduced.8 Having lost its reference
coincide.7 stop on one side of the mouth the points the mandible can become
The ideal recording material: following technique is suggested to repositioned, resulting in a change in

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RCP and the vertical dimension – so l Tripodized occlusal contacts. masticatory system. The implication is
reducing the space between opposing l Canine disclusion. that individuals do not necessarily fit into
teeth and producing problems in l Importance of posterior a prescribed occlusal concept but that
identifying the correct positions for the determinants. each occlusion should be considered
restorations. l Anterior teeth concave palatally. separately and treatment needs to be
l Posterior teeth form a parabolic tailored to individual requirements.
curve.
THEORIES FOR ACHIEVING l Use of fully adjustable articulator.
OPTIMAL OCCLUSAL l All restorations done together.
CONTACT REFERENCES
1. Posselt U. Terminal hinge movement of the
There are many different occlusal
Pankey–Mann–Schulyer mandible. J Prosthet Dent 1957; 7: 787–797.
philosophies and treatment concepts that 2. Posselt U. Studies in the mobility of the human
aim to deliver optimum occlusal contact (PMS)10 mandible. Acta Odontol Scand 1952; Suppl 10.
and hence health in both the natural and l Long centric (or freedom in centric). 3. Pameijer Jan HN. Periodontal and Occlusal
Factors in Crown and Bridge Procedures.
restored dentitions. Diverse opinions l Anterior guidance all important.
Amsterdam: Dental Centers for Postgraduate
have led to much controversy as to l Group function then canine rise Courses, 1985; pp.306–309.
which concept is the best to use. Two after 1 mm of movement. 4. Geidrys-Leeper E. Night guards and occlusal
main concepts have existed in the past. l Posterior teeth flatter. splints. Dent Update 1990; 17: 325–329.
5. Hobo S, Shillingburg HT, Whitsett LD.
One is the prosthetic concept of a l Lower posteriors restored first then Articulator selection for restorative dentistry.
balanced occlusion with bilateral tooth functionally generated path J Prosthet Dent 1976; 36: 35–43.
contacts in lateral and protrusive technique. 6. Simpson JW, Hesby RA, Pfeifer DL, Pellen GB.
excursions to ensure functional stability. l Anterior teeth ledged to provide Arbitrary mandibular hinge axis location.
J Prosthet Dent 1984; 51: 819–822.
The other theory is orthodontically occlusal stops. 7. Warren K, Capp N. A review of the principles
oriented to achieve particular static cusp- and techniques for mounting working casts. Int J
fossa relationships. These two theories Devotees of these philosophies adhere Prosthodont 1990; 3: 341–348.
of ideal standards and that of dynamic strictly to them but in the past few 8. Mullick SC, Stackhoyse JA, Vincent GRV. A study
of interocclusal record materials. J Prosthet Dent
occlusal relationships are outlined below. decades a third concept – the ‘dynamic 1981; 25: 304–307.
individual occlusion’ – has emerged. The 9. Mohl ND, Zarb GA, Carlsson G, Rugh J. A
criteria for diagnosing occlusal problems Textbook of Occlusion. Chicago: Quintessence,
Gnathology9 and the indications for treatment are 1988; pp.161–175.
10. Dawson PE. Evaluation, Diagnosis and Treatment of
l Point centric – obtainable and based on an assessment of the health Occlusal Problems. St Louis: C.V. Mosby, 1989;
reproducible. and function of each individual’s pp.261–263.

BOOK REVIEW available. In its eight chapters, two are recent range of rotary preparation
devoted to basic concepts of devices and obturation techniques
Rational Root Canal Treatment in pathogenesis and diagnosis of pulpal being marketed. They will therefore
Practice. J.M. Whitworth. conditions, but the science is clearly value the description of traditional
Quintessence Publishing Co. Ltd, New related to subsequent management. hand-preparation techniques, which is
Malden, 2002 (134pp., £28.00). ISBN 1– The next five chapters cover the followed by a concise and clear
85097–055–6. traditional phases of endodontic section on newer modalities, including
therapy. Well placed emphasis is put how they are best used. A final
Designing a book which will appeal to on the importance of access, and section on realistic assessment of
general dental practitioners is not an diagrams of ideal access cavities for all success and failure rounds off this
easy task. GDPs are a heterogeneous teeth are included. Throughout the excellent book.
group, and it is difficult to identify text there are practical tips and This is not an academic treatise nor
correctly what these different problem-solving ideas, for example is it a basic manual. It contains much
individuals want or require from a text. accessing calcified teeth and rubber more than just the essentials and
However, this book will, in my opinion, dam placement. Good use is made of should be well received by all general
succeed by its choice of content and photographs, and the many line practitioners who wish to improve or
by achieving a good balance between drawings complement the text. A maintain their endodontic treatment
the practical and the scientific. shortlist of additional sources of abilities.
Although this is a short volume, it is information completes each chapter. Dominic Stewardson
primarily concise and gets across a lot Many practitioners will be interested The University of Birmingham School
of information within the space in, but also perhaps confused by, the of Dentistry

Dental Update – April 2003 157

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