Prosthodontics

Anterior guidance
Edgar O. Schweikert, Dr. med. dent.

Introduction

The anterior teeth are perhaps the most important fac-

tor in reconstructing the stomatognathic system. This
statement should not be surprising because the primary,
and later the permanent, anterior teeth erupt first and
develop the anterior stop for the mandible. The anterior
stops, that is, the contacting maxillary and mandibular
incisors, provide a guide for the posterior determinants
and permit the posterior teeth to move into their proper
position at the exact vertical dimension and centric rela-
tion.' Since this system has been successful in nature, it
seems logical that it should be applied in reconstructing
the stomatognathic system.
Fig. 1 The exact length and angulation ol maxillary anterior
teeth must be determined prior to establishing the anterior
guidance.
Definition of centric relation

Centric relation can be defined as the most posterior

superior position the condyles can attain on the poste-
rior slopes of the eminentiae articularis with the menis-
cus interposed. Centric relation is not perceived as a
fixed point but rather an area of physiologieally toler-
able range.^
After all the maxillary posterior teeth have been
prepared, it is quite simple to record centric relation,
which is the starting point for estabhshing the anterior
guidance. There are no deflective factors in the poste-
rior area which could interfere with the neuromuscular
system. The hngual contours of the maxillary anterior
teeth will automatically lead the jaw to the most poste-
rior superior position when the patient is told to bite. It Fig. 2 Centric relation ¡s the starting point for the establish-
is not a tooth-related position-the anterior teeth are ment of the anterior guidance.
merely a tool to gain centric relation. Rather, it is the
neuromuscular system, with the limiting factor of the
capsular ligaments, together with the bony structures of
the medial poles of the condyles and the medial walls of
the joint cavities, which leads to centric relation.'
Because it can be assumed that patients do not articu-
late to the point of pain, a centric relation position can
be achieved in a physiologically tolerable range (Figs. 1
429 77th Street, Brooklyn, New York 11209. and 2).

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Definition and function of the anterior guidance
Anterior guidance refers to the hngual contours of the
six maxillary anterior teeth as they contact the eight
tnandibular anterior teeth in centric occlusion and in
their protrusive, latero-protrusivc, and lateral excur-
sions {Figs. 3 to %).-*
Anterior guidance has the essential task of protecting
the posterior teeth in the protrusive and lateral move-
ments of the jaw. Through its function, no destructive,
lateral forces are applied to the posterior teeth. Pure
axial or vertical forces are the least damaging forces
which can be applied to a tooth because the force will be
absorbed by the largest number of periodontal fibers.
If the temp oro mandibular joint is compared with a
hinge joint and the two jaws with the two hinge plates,
the largest force which can he applied would be near the
hinge (the molar area). Because the anterior teeth are
located far away from the joint, they are in a more
favorable position to bear lateral forces.^
Another advantage of a canine-protected occlusion is
that it may minimize the occurrence of aTMJ problem.
A canine-protected occlusion means less tooth contacts
in mandibular movements, causing less chance of pre-
mature contacts, and therefore less chance of muscular
dysfunction.^ Because an occlusion with group function
does not automatically lead to loosening of the posterior
teeth, there must be reasons why a canine-protected
occlusion predominates in nature.
In general, nature has three different mechanisms for
preserving an efficient and functional dentition.
1. Nature can replace teeth, as is the case with the den-
tition of sharks. When one set of teeth is destroyed
through natural attrition, it is completely regener-
ated.
2. Nature can replace tooth structure, as in rodents
such as guinea pigs. The teeth grow continously and
tooth structure destroyed through natural attrition is
replaced.
3. Nature will minimize the effect of natural attrition
through a special arrangement of the teeth, as can be
seen on a canine-protected occlusion in human
beings.
The canines are designated the guarding teeth.
Because of their corner position, their size, and the
length of their roots, they have the special task of
preventing other teeth from destroying each other
during function. They accomphsh this by directing a ver-
tical rather than a lateral masticatory pattern. This
special task of the canine teeth will prevent gliding
mandibular movements which could result in excessive
254
wear on the posterior teeth. In a canine-protected occlu-
sion the wear through natural attrition is concentrated
primarily on the canine teeth. It requires years for the
bulky enamel structure of a healthy canine to wear
away.
Thus, it can be concluded that anterior guidance pro-
tects the posterior teeth by disoccluding these teeth in
all excursions of the mandible and thus preventing
damaging nonvertical or lateral forces to act on them
(Figs. 13 to 18).
Criteria for establishing anterior guidance
The unprepared maxillary anterior teeth must be
examined to ascertain whether their lingual contours
are in harmony with the functional movement of the
mandible. In an ideal case, the six maxillary anterior
teeth are in contact with the eight mandibular anterior
teeth in centric relation. If a patient complains about a
"locked-in feeling," long centric in centric relation
would be incorporated during the establishment of the
anterior guidance. Very often, long centric will be iti-
corporated automatically because at the beginning of
the protrusive pathway the lingual contour of the maxil-
lary anterior teeth are more concave and straight at the
end.-
In many cases the two central incisors are the only
teeth in group function at the end of the protrusive path-
way. If there is a hypermobility on an anterior tooth
during protrusive excursions, the lingual contour is
reshaped, reducing the steep incline. The hypermobility
of a single tooth can be felt by placing the index finger
on the labial surface of the tooth when the patient
moves the jaw forward. If there is still a movement after
the steep incline is reduced, the four incisors can be
adjusted to be in group function. To achieve this aim,
the two central incisors must be shortened to attain a
common protrusive pathway until the end of the straight
forward movement. The result could be an unpleasant
esthetic appearance, or the tips of the mandibular
canines could interfere with the maxillary lateral in-
cisors in the protrusive excursion.' A better approach,
therefore, is to splint the four incisors or preferably all
six anterior teeth (Figs. 3 and 4).
In the latero-protrusive excursion, the six anterior
teeth should all be included in the anterior guidance if
possible. The lateral incisor alone cannot carry the load
because its root is too short and not strong enough.
During lateral movement the canine will carry the
load in a canine-protected occlusion. If the canine is
unable to withstand the entire load in lateral excursion,
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 Prosthodontics

Fig. 3 The lingual contours of fhe maxillary anterior teefh Fig, 4 The anterior guidance is defermined from centric
can be finalized only with fhe precise incisai edge position, relation to fhe ineisal edge position.

Fig. 5 Right working-side position. Fig. 6 Right latero-protrusiue group function includes the
canine, iateral incisor, and central incisor.

Fig, 7 Left working-sidG position. Fig. 8 Left I ate ro-p rot rus ive group function includes fhe
canine, lateral incisor, and centrai incisor.

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other anterior and posterior teeth can be included to
achieve a group function. The most secure way is to
splint from canine to canine, or even from one premolar
to the other. In this way the protrusive and lateral in-
stabilities are eliminated at the same time (Figs. 1 toS).**
Harmonizing the lingtml contours of the maxillary
anterior teeth with the neuromuscular mechanism is the
most important factor in the stability and health of the
occlusal system. Hollcnback once commented, "The
anterior controls are properly established, what is done
behind them really does not make much difference."'^
According to his opinion, one has leeway in establishing
the Curve of Spee and the occlusa! posterior mor-
phology while still obtaining adequate function.
What influence has the TMJ on the occlusion? As long
as the anterior guidance can be established, the im-
portance of the condylar guidance is minimal because
the information for the morphology of the posterior and
anterior teeth can be attained through the anterior
guidance and clinical observation. Because the condyles
rotate on their own axes as they move along their pro-
trusive pathway, the lingual contours of the maxillary
anterior teeth do not have to duplicate the condylar
path. This rotational movement of the condyles, which
is dictated by the hngual contours of the maxillary
anterior teeth in accordance with the muscle function,
makes it possible for the anterior guidance to be well
within the limits of the condylar border movement.•*
Rather, it is the anterior guidance in connection with the
neuromuscular system which can influence the steep-
ness or flatness of the condylar path and the form of the
condyle during childhood development. This occurs
between the ages of 6 to 12 years.'" Children with
anterior open bites, often caused by thumb sucking, or
cases with a Class II. Division I configuration have flat-
ter condylar paths than children with normal anterior
guidances. A Class lit case shows a very steep condylar
path through the lack of a straight protrusive movement
during chewing. These situations make us aware of the
importance of the earhest possible orthodontic treat-
ment of such cases to achieve a normal, functional
anterior guidance. The anterior guidance, therefore, is
independent of the direction of the condylar path. The
recording of the condylar pathway will not supply
adequate information for the placement of the anterior
teeth. The criteria for the placement of the anterior
teeth are mainly of esthetic and phonetic nature, as
described by Pound."
In the lateral pathway, the canines play an important
role in establishing the occlusal form of the posterior
teeth. In a canine-protected occlusion all outer and
256
inner inclines of the involved cusps are less steep than
the lingual incline of the canine. If a group function witli
the posterior teeth is to be established, the same inchna-
tion is used on the inner inclines of the maxillary buccal
cusps as is used on the canine. There are situations,
however, where the anterior teeth cannot be used to
establish the anterior guidance. We recall patients with
Class III configuration, patients with anterior open
bites, and extreme Class II. Division I patients.
Most patients with a Class III configuration show only
vertical closure during the masticatory cycle, which
makes the disocclusion of the posterior teeth in protru-
sion unnecessary.'- In the lateral pathway a group func-
tion can be applied on the working side, without in-
cluding the second molar, to achieve clearance on the
idling side. In the case of a posterior crossbite, the
maxillary buccal and mandibular lingual cusps act as
stamp cusps and must be treated accordingly when
occlusal adjustments are needed.
Patients with anterior open bites or with extreme
Class II, Division I configurations present a serious
anterior guidance problem. Establishing the lateral
pathway should be no problem because the two pre-
molars and first molars can be brought into group func-
tion to attain occlusal clearance on the idling side.
Establishing a straight protTusive pathway, however, can
he a complicated task. One way is to build the protrusive
pathway in laboratory-fabricated temporary crowns by
adjusting them in the mouth. The technician will then
duplicate them in the'permanent restorations. For
several reasons it is advisable to finish the permanent
mandibular restorations first. The coronal reference
points of the maxillary posterior teeth can be guidelines
for the forms of the mandibular posterior teeth. Also,
occlusal errors, which may occur after cementing the
whole mandibular arch, can be adjusted on the maxil-
lary teeth. Since no posterior disocclusion can be
achieved, a Curve of Spee should be established that is
relatively low in the posterior area. In this way pre-
mature contacts in the molar area during the excursion
of the mandible can be prevented.
Another option is to use a pantograph in connection
with a Stuart or Denar articulator. In this case, the
anatomy of the TMJ and the limiting factors of the cap-
sular ligaments are used to establish a posterior occlusa!
morphology. The only information which can be ob-
tained is a posterior occlusal pattern which allows
lateral and protrusive group function without the ad-
vantage of the anterior guidance system.
A better therapy for Class II. Division I cases would
be to estabhsh an anterior guidance at the earliest age
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possible through orthodontic treatment. The gliding of
the posterior teeth in protrusive a lateral movements
could wear on the posterior teeth and could result in
bruxism and tnuscular dysfunction. A morphological
malocclusion such as a Class Hi or Class II, Division I is
not automatically a functional malocclusion. Many
patients avoid damaging functional movements. Occa-
sionally, however, parafunction (i.e.. the result of func-
tional maloccluslon such as bruxism. pressing, and
grinding of the teeth) can be observed. Parafunction is
self-propagating and once started usually worsens.
Teeth become abraded and new premature contacts are
created which then initiate what Drum calls "the auto-
destruction of the stomatognathic system."'•' The best
therapy would be to establish an anterior guidance
through orthodontics, prosthetics, or a combined sur-
gical-orthodontic approach (which, of course, is not
always possible). Such examples make us aware of the
importance of the anterior guidance for the stability and
health of the occlusal system.
In general, one can assume that the earliest possible
treatment is the best because the ability for adjustment
to a new situation seems to be the greatest in earlier
years of development. Bell has stated, "It may well be
that in some cases, the success or failure of a surgical
procedure is primarily a function of the initial stage of
the organism rather than the result of technical manipu-
lations carried out over a few hours by a surgeon."^''
However, by applying provisional restorations, we
have Ihe advantage of determining the patient's ability
to adjust to anew situation. Provisional restorations can
he used to prepare a psychological environment for the
patients acceptance of the final restorations. They can
be an excellent tool in evaluating the patient's neuro-
muscular adaption to a changed vertical dimension. By
adding or substracting acrylic material, one can
evaluate a vertical dimension which can be tolerated by
a patient. Temporary restorafions can be used lo
evaluate whether or not the anterior teeth can dis-
occlude the posterior teeth in all excursions of the
mandible. In this way the refabrication of permanent
restorations is avoided (Figs. 9 to 12)."
The anatomic factors of theTMJ such as the condyle,
capsular ligaments, and eminentia articularis are the
posterior determinants of occlusion. With the help of
the pantographic system one can determine the tracing
of the condylar path, Bennett shift, etc.. and thus form
the posterior tooth morphology. The only information
which is obtained through the pantographic system is
one form of posterior tooth morphology, which relates
to the TMJ anatomy.
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Prosthodontics
Usually the anterior guidance must also be estah-
lished. This is not related to the posterior determinant
as described earlier. When the pantograph is used in
connection with a Denar or Stuart articulator, the
anterior guidance still must be obtained independently.
What is the advantage of using a pantograph? The
efficiency of the stomatognathic system can be im-
proved because the cusp height and the so-called fossa
wall angle can be determined to a higher degree of
accuracy. The stamp and shearing cusps can be
compared with the blades of a grain mill; efficiency can
be increased by making the space between the blades
very small. In other words, the stamp and shearing
cusps arc "tuned in" very finely to one another.
One disadvantage of the pantographic system is that
the fossa wall angle must be made relatively steep to
achieve higher efficiency, and care must therefore he
taken to avoid prematurities. This is one reason why
dentists who work with a pantograph prefer instant
disocclusion of the mandible in the lateral and pro-
trusive movement."" Incorporating a long centric in a
precise, tightly structured cusp-fossa relationship could
be a complicated task.
A prerequisite for establishing the anterior guidance
is the determination of the exact length and angulation
of the maxillary anterior teeth (Fig. 1). Without the
precise incisai edge position, the lingual cotitour of the
maxillary anterior teeth cannot be finalized. The
anterior guidance is determined from centric relation to
the incisai edge position. If anterior teeth are missing, a
temporary acrylic resin fixed partial denture must be
constructed and the lingual contour on the temporary
prosthesis is finalized in the mouth." At the same time
all esthetic factors such as lip support, length of the
crowns, etc., are corrected.
To communicate the information regarding crown
length and anterior guidance to the laboratory, the
author provides a duplicate cast with the adjusted maxil-
lary anterior teeth. Final adjustments must be made in
the mouth. In cases with a normal overbite, this is a
relatively easy task, but when a deep overbite exists, it
can be a time-consuming and tedious task. Therefore, it
is helpful to apply the "alternating teeth" method, that
is, one prepares, for example, the left lateral and right
central incisors of the adjusted anterior teeth and takes
an impression of them. Next, the remaining teeth are
prepared and an impression of all teeth is taken. The
technician transfers the waxed casts or the finished
restorations, constructed according to the unprepared
teeth, to the cast with the prepared teeth. Now the
waxed or finished crowns can be used as a guide for the
257
Prosthodontics

Fig. 9 Maxillary proviyjonal restorations can be used to Fig. 10 Protrusive position. Note posterior disocclusion.
evaluate whether or not the anterior teeth can disocclude the
posterior teeth.

Fig. 11 Right working side. Note posterior clearance. Fig. 12 Left working side. Note posterior disocclusion.

Fig. 13 Centric occiusion with permanent restoration in Fig. 14 Protrusive pathway.

situ.

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Fig. 15 Right working side. Fig. 16 Lett idling side.

Fig. 17 Left working side. Fig. 18 Right idling side.

Fig, 19 Case before treatment. Fig. 20 Case after treatment.

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Prosthodontics
remaining leeth. At the same time, the technician has a
guide for the exact ineisal edge position and labiat
contour, Usualty the lingual contours of the incisors are
more concave than those of the canines. The canines
have a straighter pathway which can be more easily
adjusted in the mouth. There are a variety of methods to
capture the movement of the anterior guidance. Some
methods, such as the customized anterior guide table,
give a more precise picture of the lingual contour of the
maxillary anterior teeth,'^ Final adjustments of the
permanent restorations usuatty must be done in the
mouth.
Conclusions
The anterior guidance, in connection with centric rela-
tion and vertical dimension, must be regarded as the
most important factor in reconstructing the stomato-
gnathic system, "'The information for the posterior and
anterior tooth morphology can be attained solely
through the anterior guidance and clinical observation.
In the presence of a functional anterior guidance, the
recording of the condylar path is unnecessary. The only
information which is obtained through the pantographic
system is one form of a posterior tooth morphotogy
which retates to the TMJ anatomy.
The anterior guidance, however, with its influence on
the hnguat contours of the maxittary anterior teeth and
in connection with other factors, witi more or tess
determine the position and tength of the anterior teeth.
Its effect on tooth configuration is more obvious with
the posterior teeth, Tbe height andinchneof the cusps
and the depth of the centrat fossae are dependent on the
steepness orfiatness and tength of the anterior guidance
path.
Therefore, one can conctude that in the presence of
an anterior disocclusion, the occlusal morphotogy can
be determined by the anterior guidance system and
clinical observation.
260
Acknowledgment
The author would like to thank Mary Lou Como Schwei-
kert, M,S,, for her assistance in writing this paper.
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