CROSS-PIN FIXATION FOR PARTIAL DENTURES
the still soft cement. When the pin is seated, pressure is
again applied on the FPD. The cement is left to set undis-
turbed in a dry field. After the cement has set, the extrud-
ing part of the pin is cut to the contour of the restoration
and poliihed smooth. A varnish is applied to all margins,
including the pin margin, to initially protect the cement
from moisture.
DISCUSSION
Cross pins may be threaded or smooth. The RX-911-
Thru Lock Pin (Whaledent International, New York,
N. Y.) is an example of a threaded pin that is placed buc-
tally or lingually in the dentin. It is designed for a retrofit,
trouble-shooting system where it would be possible to plan
for its use in advance. The presented smooth-pin technique
is not suitable for retrofit and must be part of the treatment
planning. This type of pin should not be placed buccally or
lingually but on the mesial or distal surface of the abutment
preparation. The dental pulp is minimally compromised
because only half of the pin’s diameter is in the dentin.
Sufbcient sound dentin is necessary for both technniques
to prevent dentinal fracture. The low cost of the described
smooth pm system is an additional advantage.
Various methods in achieving
J. Ehrlich, D.M.D,* A. Yaffe, D.M.D.,** and N. Hochman,
Hebrew University-Hadassah School of Dental Medicine,
The anterior teeth are essential for esthetics, phoentics, and mastication
equally involved in protecting posterior teeth. A IO-year longitudinal
treatment modalities was conducted for overbite-overjet
Comprehensive treatment combining orthodontics, occlusal adjustment, and
selective restorations minimized the need for extensive restorative
treatment of selected patients with a IO-year postoperative
discussed. (J PROSTERT DENT1989;62:606-9.)
I n rehabilitation of the natural dentition, the two
factors dominating occlusion are the temporomandibular
joints and anterior guidance. Anterior guidance is deter-
mined by the contact of the lii surfaces of maxihary
anterior teeth to the in&al-facial surfaces of the mandib-
ular anterior teeth.’ In maximum intercuspation the ante-
rior teeth are usually slightly separated from the opposing
teeth.2
Anterior guidance has a prominent role in dentistry be-
cause the anterior teeth are essential for esthetics, phonet-
This investigation was supported by the Morton Amsterdam Pe-
rio-Pro&h&s Chair.
*Associate Professor, Department of Oral R&abiitation.
**Senior Lecturer, Department of Oral Rehabilitation.
1Ol1113784
TH& JOURNAL OF PROSTHETIC DENTISTRY
SUMMARY
A cross-pm technique using a smooth, tapered-post sys-
tem is described. The cross pin adds retention and resis-
tance to a fixed partial denture. Differencea between the
described smooth pin and the prefabricated threaded cross
pin are discussed.
REFERENCES
1. Schwartz NL, Wbitaett LD, Berry TG, Stewart JL. Unserviceable
crowns and tixad partial dentures: life span and cnuses for loss of ser-
viceability. J Am Dent Assoc 1970;61:1395-1401.
2. Walton JN, Gardner MF, Agar JR. A survey of crown and fixed partial
denture failures: Length of service and reasons for replacement. J
PROSTHET DENT 1986;56:416-21.
3. Glantz P-O, Ryge G, Jendresen MD, Nilner K. Quality of extensive fixed
prostbodontica after five years. J F’mwmmr DENT 1964;52:475-9.
4. Nyman S, Liidhe J. A longitudinal study of combiied periodontal and
prosthetic treatment of patients with advanced periodontal disease. J
Periodontol 1979;50:163-9.
5. Schwartz IS. A review of methods and techniques to improve the fit of
cast restorations. J PROSY DENT 1986,56:279-33.
Reprint requests to:
DR. LAMEIERT J. STUMPI%
WIL-ASTRAAT 44-A
4618 SH BREDA
THRNEITWRLANIB
anterior guidance
D.M.D.*+
Jerusalem, Israel
and are
study of
occlusal relationships.
dentistry. The
evaluation was
its, and mastication. However, an equally important func-
tion is protecting posterior teeth by anterior disclusion of
the posterior teeth during mandibuhu excursions. The bi-
ologic protective mechanism is activated by occluding on
the anterior teeth and suppressing the activity of the ele-
vator muscles.3The anterior teeth are also considered more
sensitive to pressure changes than the posterior teeth.
In normal vertical and horizontal overlap occhrsal rela-
tionships, the anterior teeth have the potential of detect-
ing pathologic changes in the posterior quadrants. In
patients lacking anterior guidance with open bites and an-
terior crossbites, the pathologic changes are magnified and
elude detection. Although the incidence of patients with
these clinical conditions is low, the treatment is arduous
and the prognosis guarded.
Dentists have attempted to control anterior guidance by
placing extensive restorations. The question remains
505

Fig. 1. Open bite after condylectomy.
Fig. 2. Tomography of condylar hyperplasia. Left side,
Maximum closure; right side, maximum opening.
whether extensive restorations are necessary to develop the
anterior guidance.
This article describes diverse treatment modalities of
various overbite-overjet occlusal relationships for natural
dentition.
METHODS AND MATERIAL
Eighteen patients aged 18 to 50 with an anterior open
bite and 11 patients with anterior crossbite were treated
from 1975 to 1985. One patient with an anterior open bite
and another with anterior crossbite could not be contacted
for postoperative evaluation but the other patients were
recalled for periodic examination during the lo-year study.
506
EHRLICH. YAFFE, AND EOCHMAN
Fig. 3. Patient in Fig. 1 after selective grinding, with sta-
ble occlusion and minimal incisal guidance at 6-year post-
operative evaluation.
Clinical considerations
Medical histories were reviewed, clinical conditions re-,
corded, and radiographic examinations conducted. The
clinical examination included pocket depth and tooth mo-
bility. Healthy oral environment was mandatory before
and during treatment; therefore, oral hygiene instructions,
scaling, and root planing were fundamental. In occlusal
treatment, the initial step was the elimination of deleteri-
ous oral habits.
The patients voicing discontent about esthetics and ex-
periencing functional disturbances in the anterior teeth
can be treated either with extensive restorative dentistry or
conservatively. This article discusses comprehensive treat-
ment that combined orthodontics, occlusal adjustment,
and selective restorations.
Open bite
Patients with an open bite commonly lacked anterior
guidance and exhibited excessive wear, including overload-
ing of posterior teeth without anterior disclusion of the
posterior teeth. Some patients complained of difficulty in
incising food, in speech problems, and an unsatisfactory
appearance.
The first step in the therapeutic sequence after the diag-
nostic casts were mounted was programmed occlusal ad-
justment by selective grinding. For certain patients, it was
the sole treatment and/or an adjunct to orthodontics and
prosthodontics. Selective grinding was stopped when min-
imal anterior guidance and disarticulation of posterior
teeth was achieved in mandibular excursions.
In specific patients with large open bites, disarticulation
was accomplished by the maxillary canines and mandibu-
lar first premolars. In the last 5 years of the longitudinal
study, results were improved by adding composite resins to
the lingual surfaces of the maxillary incisors, using the ac-
id-etch light-cured technique, and including more teeth in
NOVEMBER lSS9 VOLUME 62 NUMBER 5
METHODS IN ACHIEVING ANTERIOR GUIDANCE

Fig. 4. Second patient, incomplete overbite. Fig. 6. Second patient, anterior guidance achieved by se-
lective grinding and composite resins.

Fig. 5. Second patient in intercuspal position with sev-

eral contacting teeth. Fig. ‘7. Second patient demonstrates stable intercuspal
position.

anterior guidance. The open bite was classified as skeletal

in nature,4 acquired from oral habits or systemic diseases
such as arthritis,5 scleroderma, and a rare condylectomy.
Selected patient histories
A 38-year-old woman developed an anterior open bite
after unilateral condylectomy because of hyperplasia (Figs.
1 and 2). The patient’s symptoms were lisping, inability to
incise food, and deviation of the mandible. She was refer-
red to The Hebrew University-Hadassah School of Dental
Medicine, Department of Oral Rehabilitation where oc-
clusal adjustment by selective grinding was performed in
several visits according to guidelines by Abrams6 The se-
lective grinding procedure was accomplished in three
stages: (1) the discrepancies in the retruded path of closure
were removed, (2) the occlusal table was defined, and (3)
lateral excursions were refined. The open bite was closed
and a stable intercuspal position was achieved with mini-
mal incisal guidance.
For the last 6 years the patient demonstrated a stable
occlusion, maintaining the same cusp-to-marginal-ridge
relationship achieved as previously (supporting cusp-to-
marginal-ridge or cusp-to-fossa relationship) with a satis-
factory overjet-overbite relationship and without symp-
toms (Fig. 3).
The second patient was an 18-year-old woman who had
an incomplete overbite with craniomandibular pain after
orthodontic treatment (Figs. 4 and 5). An oral examination
revealed limited mandibular opening with clicking during
protrusive movement. After orthodontic movement was
achieved, occlusal adjustment by selective grinding was
performed to ensure a favorable result. The open-bite re-
lation was improved and anterior guidance was accom-
plished with canines by selective grinding and by adding
light-cured composite resins to the lingual surfaces of the
maxillary anterior incisors (Figs. 6 and 7).
A postoperative survey over the last 3 years confirmed

THE JOURNAL OF PROSTHETIC DENTISTRY 507


Fig. 8. Anterior crossbite with flaring of lower anterior
teeth.
Fig. 9. Patient in Fig. 8 after minor orthodontics, selec-
tive grinding, and reconstructions.
the disappearance of pain and diminished clicking in the
temporomandibular joints.
Anterior crossbite
In the absence of pathosis, an anterior crossbite rela-
tionship is stable, predictable, and the patient’s occlusion
can be maintained without professional intervention. How-
ever, a crossbite accompanied by tooth loss, periodontal
disease, tooth fractures, facial asymmetry, or temporoman-
dibular joint disturbances commonly require treatment.
The occlusal scheme developed by the dentist should be
perceptively planned with consideration whether the orig-
inal occlusion required extensive restoration or merely
modification.
The following treatment is suggested for an anterior
crossbite. The anterior crossbite patients treated had an
intercuspal-retruded contact (IC-RC) discrepancy and
were capable of moving the anterior teeth into an edge-
to-edge position. The first step after mounting the diag-
nostic casts was occlusal adjustment by selective grinding.
In specific patients it was the sole treatment, whereas for
508
EHRLICH, YAFFE, AND HOCHMAN
Fig. 10. Anterior crossbite and flaring of lower anterior
teeth.
Fig. 11. Patient in Fig. 10 with improved esthetic and
functional occlusion after occlusal adjustment and resto-
rations.
other patients, composite resins were added to select sur-
faces of the teeth to redirect the forces along the long axis
of the teeth. The composite resin was added to the facio-
incisal surfaces of the maxillary incisors and canines and to
certain surfaces of the occlusal table of posterior teeth to
achieve maximum contact. The forces were then more fa-
vorably distributed to the teeth and supporting tissues. An
acceptable plane of occlusion, a new anterior guidance, im-
proved functional relationships, and improved esthetics
were established (Figs. 8 and 9).
A 49-year-old man with an anterior crossbite, loss of
several posterior teeth, and an unserviceable fixed partial
denture was reappointed for treatment (Fig. 10). The pa-
tient was restored to an edge-to-edge incisal occlusion to
position the anterior teeth for additional support. The se-
lective grinding, predetermined on mounting diagnostic
caste, established a more appropriate occlusal plane. The
patient’s occlusion was maintained with self-cured provi-
sional restorations for a year to evaluate adaptation to the
NOVEMBER 1989 VOLUME 62 NUMBER 5
 Métodos conservadores para devolver guía anterior, es desgaste selectivo (ameloplastia) y añadir resina.
METHODS IN ACHIEVING ANTERIOR GUIDANCE
revised occlusal relationship. The final restorations were
then made in the newly accommodated relationship (Fig.
11).
RESULTS
Twenty-nine patients lacking anterior guidance were
treated differently to establish anterior guidance. Eighteen
patients had an open-bite relationship and 11 patients had
an anterior crossbite. The patients were Iauditory concern-
ing esthetics and function after treatment. The patients
who previously had an open bite reported that the ability
to incise was improved, their appearance improved, and
lisping diminished. Minimal modification of anterior guid-
ance and disarticulation of posterior teeth were achieved in
all of the patients. In most patients, resolutions of the
problems were realized merely by selective grinding. How-
ever, some patients also required the addition of compos-
ite resins to select surfaces of the teeth to establish stable
occlusion.
The patients with a former anterior crossbite reported
esthetic improvement. In most patients an edge-to-edge
anterior incisal position was accomplished, and in five pa-
tients a minimal overjet-overbite relationship was accom-
plished. In the patients with anterior crossbite, tooth mo-
bility was decreased and a stable occlusion estalished.
The sole treatment for four patients was occlusal adjust-
ment by selective grinding whereas for three patients com-
posite resin material was added for improved surface con-
tact. In one patient both selective grinding and partial
reconstruction were performed. In three patients a combi-
nation of treatment was necessary: selective grinding, mi-
nor tooth movement, and restorative dentistry.
DISCUSSION
Anterior guidance has a major role in achieving physio-
logic occlusion. These data illustrated that anterior guid-
ance can be restored in a direct, conservative manner.
Recently, treatment with selective grinding has been
augmented to include composite resin application. This
procedure has reduced the amount of enamelplasty during
selective grinding while developing a stable, reproducible
centric closure position by increasing the number of tooth
contacts. Selective grinding per se is considered a conser-
vative procedure7 but bonding with composite resins ex-
pands the limits of the timely treatment. In the patients
with anterior open bite two types of posterior occlusion
were identified. Some patients developed a flat posterior
occlusion or worn dentition with an occlusion of
convenience’ whereas others exhibited unworn posterior
teeth. The patients’ histories confirmed that flat posterior
occlusion is related to a prolonged anterior open-bite rela-
tionship whereas normal posterior cusps were related to a
brief history of an open bite.
Occlusion with flat occlusal surfaces did not allow exces-
sive selective grinding because of hypersensitivity from
dentinal exposure. Because further flat occlusal topogra-
phy also makes it difficult to improve interarch relation-
ships, the disarticulation of posterior teeth was achieved by
THE JOURNAL OF PROSTHETIC DENTISTRY
the modification of canine surfaces. Some patients required
addition of composite resin to specific teeth to ensure dis-
articulation of posterior teeth. In the second patient the
anterior guidance achieved by add-on composite resins di-
minished the clicking and this approach agreed with that
of Lees that patients with anterior guidance experienced
fewer temporomandibular disorders. In patients with short-
term open bites, the relationships are more favorable for
establishing a sound, reproducible occlusion.
The patients treated for an anterior crossbite repeatedly
voiced approval of their appearances, and the anterior
teeth were less mobile with periodontal stability, indicat-
ing a physiologic occlusion.6 Nevertheless, for patients with
an anterior open-bite relationship or anterior crossbite
treated in this manner, periodic evaluation is required to
monitor supportive tissue and provide minor occlusal ad-
justments.
SUMMARY AND CONCLUSIONS
A conservative, combined treatment approach was de-
scribed for creating anterior guidance in patients with an-
terior open bites and anterior crossbite relationships. Im-
proved interarch relationships were established through
occlusal adjustment by enamelplasty and the addition of
light-cured composite resins to select surfaces of opposing
teeth.
These procedures were economical and minimized the
need for adjunctive orthodontics and extensive restorative
dentistry. “The simplest treatment that will satisfy the
needs of the patient is the best treatment”.‘O
REFERENCES
Schuyler CH. The function and importance of incisal guidance in oral
rehabilitation. J ~ROSTHETDENT 1963;13:1011-29.
Byron H. Occlusal relations and mastication in Australian Aborigines.
Acta Odontol 1964;22:597-619.
Storey AT. Neurophysiological aspects of TM disorders. In: The Pres-
ident’s conference on the examination, diagnosis and management of
temporomandibular disorders. Chicago: American Dental Association,
198‘2;17-23.
4. Craber TM. Orthodontics. principles and practices. 3rd ed. Philadel-
phia: WR Saunders Co, 1972;592-5.
5. Mahan PE. The temporomandibular joint in function and pathofunc-
tion. In: Solberg WK, Clark GT, eds. Temporomandibular joint prob-
lems. Chicago: Quintessence Int, 1980,33-42.
6. Abrams L. Occlusal adjustment. In: Goldman HM, Cohen DW. Period-
ontal therapy. 6th ed. St Louis; CV Mosby Co, 1980;1065-111.
7. Rower D. A chairside analysis of the feasibility of selective grinding. J
PROS~HRT DENT 1981;45:30-6.
8. Kraus RS, Jordan R, Abrams L. Dental anatomy and occlusion. Ralti-
more: Williams & Wilkins Co, 1969;223-44.
9. Lee RL. Anterior guidance. In: Lundeen H, Gibbs C, eds. Advances in
wclusion. postgraduate dental handbook series. vol 14. Littleton, Mass:
John Wright PSG Inc. 1982;51-80.
10. Amsterdam M. Periodontal prosthesis. Twenty-five years in retrospect.
Alpha Omega 1974;67:8-52.
Reprint requests to:
DR. J. EHRLICH
HERHEW UNIVFXXTY-HADASSAH SCHOLL
OF DENTAL MEDICINE
JERUSALEM
I~RAEI.
509