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IMADE EASY
Collection manager: Patrick Simonet

Gerard Duminil
with Olivier Laplariche
Jean-Philippe Re and Jean-Fran~ois earlier
Translated from French by Maria Nachib

•
Presse Edition Multimedia
 I Occlusion made easy

Authors
Gerard DUMINIL
Doctor in Dental Surgery
Doctor in Dental Sciences
Private Practi ce, Nice France

Olivier LAPLANCH E
Associate Professor (Nice Sophia Antipolis University) France
Hosp ital practitioner

2
Jean-Franc;ois CARLI ER
Doctor in Dental Surgery
Former Asistant Professor at th e UFR (Teaching and Research Unit) of Reim s
France

Jean-Philippe RE
Associate Professor (Ai x- Marseille University)
Hospital practitioner (Public Hospita ls of Marseill e) France

Acknowledgm ents to

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Foreword
Peter Bausch

T oday, for many patients, aesthetically appealing prosthetic fittings

plays a major role in lifestyle. In many cases the focus is therefore on
aesthetics, where function often takes a backseat.
Occlusion - antagonist contacts between teeth in static and dynamic,
is an important key to successful therapy, therefore, the physiological
reconstruction of the chewing surfaces in static and dynamic occlusion,
taking into account the biomechanical function of the components
involved is still an important milestone for a functioning prosthetic or 3
restorative case.

This book by Dr. Gerard Duminil and Dr. Olivier Laplanche is a competent
advisor with many clinical examples for the practitioner. On the basis of
appealing 3D illustrations, complex treatment is shown in simple steps
therefore easy to follow for self studying. Similarly, the complexities of the
Stomatognathic System, neurological and muscular structures are shown
as descriptive images and explanations.

As a manufacturer of occlusion testing materials for more than 60 years,

we have continuously monitored and accompanied the development
and progress in dentistry.

In the heyday, many important principles researched on Gnathology still

endure. Dr. Gerard Duminil and Dr. Olivier Laplanche have manifested
these basics and developed them further in their book. This can be
seen as Guide and Advisor for every dentist, which aims to implement
successful therapy of prosthetic and restorative treatment in daily practice.

From our point of view, this book stands out to those that have been
written in recent years on the subject of occlusion with a scientific focus.
The authors invested a lot of time and conviction in this project for others
to benefit from their knowledge and experience. We hope that you are
as excited as we at reading this book and would like to thank the authors
Dr. Gerard Duminil and Dr. Olivier Laplanche for an outstanding result.
 Occlusion made easy

Acknowledgments
This work is the outcome of a great collaboration with Olivier Laplanche, my main co-author,
who did me a favour by sharing this adventure with me. I also wish to thank Jean-Franc;ois earlier
and Jean-Philippe Re, which used their skills to help me in the writing of two important chapters,
Patrick Simonet, who asked me to carry out this work and closely followed the process,
and the Information Dentaire staff for their involvement and the quality of their work.
The illustrations are the expression of my son's-Yann Duminil,
aka "Mooz"-, graphic designer talent.
It was a great pleasure to work with him on this project.
I 'd also like to thank Pierre Carpentier who let me use his magnificent anatomy images,
Peter Baush who was kind enough to write the foreword as well as
Jean-Daniel Orthlieb, Edith Hamou, Pierre Pedeutour and Claude Schiff for their advice
and their photographic and radiological documents.
To my mentor Jean-Franc;ois Michel, and to my colleagues and friends at the College National
d'Occlusodontologie.
Finally, I wish to dedicate this work to my wife Pascale whose patience was put to the test
by my unavailability during the writing of this book.
Preface
Patrick Simonet
Doctor in Dental Surgery
Master of Science, University of Michigan; Ann Arbor, USA
Fellow of the International College of Dentists

R eleasing a new book is always an exciting moment for a publisher.

Suddenly, a virtual idea launched months before becomes actual
and tangible. The view of an author, who dedicated a lot of time and
intellectual energy to arrange his thoughts, can finally be shared with the largest
number. The book written by Gerard Duminil brings this kind of thrill, but it also has
three other specificities. 5
it is the first book to be released in a new series published by the Groupe Espace
ID under the name ... Made easy.
The main purpose of this series is to take some distance from what already exists
in our odontological world to dig directly into the core of things, with no useless
speeches, while deliberately adopting a practical, pragmatic and pedagogical
approach. This book has brilliantly overcome all these challenges.
The topic (occlusion) stands itself at the crossroads of almost all our professional
activities. Every practitioner knows that checking and adjusting occlusion is a key
element in the success of many of our treatments.
Unfortunately, this science is still often perceived as too complicated, even
unintelligible. Here again, clinicians able to synthesize their knowledge without
making it ridiculously simplistic were needed.
The pedagogical qualities of the author and his co-authors have been
acclaimed for a long time by our profession.
Finally ahd more personally, a longtime friendship connects me to Gerard
Duminil and a genuine passion for this specialty has always permeated our
respective professional lives. I could not have dreamt of a better collaboration
and topic for this first publication.
I am deeply grateful for his spontaneous trust: from a few guidelines shared one
evening, he accepted the very visual specifications that I wished to develop in
this new book series.
After reading this book, I am convinced you will all agree that the choice of the
author was relevant and that checking and adjusting occlusion can be done ...
Made easy!
 Occlusion made easy

Editor's note
Teeth numbering used in this book is the
International Standards Organization Designation
System (ISO System) recommended by the World
Health Organization.
Contents

Foreword .. . ................ . ... . . . .......... . ......... 3

General notions . . . ......................... . .......... 8

2 Functional occlusion ... .. ........................ . .... 19

7
3 Centric relation ... . . . . .. ....... . ... . .. .. .... .. .. . ... . . 37

4 Mandibular movements . ...... . ..... . .... . ... . . . ...... 49

5 Clinical examination of the temporomandibular

disorders (TMD) ............. . .. . ... . ......... . ....... . 61

6 Examination of the occlusion . . ... . ....... . ......... . .. . 85

7 Classification of the TMD ....... .. . ... .. . ........ ~ ..... 111

8 Mounting on the articulator ..... . ..................... 131

9 Instrumental occlusal analysis ......... . ..... .. .... . ... 153

10 Occlusal splints . ..... . ...... .. ........ . ... . .. . . . . .. .. 167

11 Occlusal adjustment . . ....... . ...... . ................ 185

12 Prosthodontic in daily practice ............... . ........ 205

Afterword ....................... . .. . .......... . . . .. . . 223

 Occlusion made easy

General notions
Defining the occlusion as the relationship between the dental arches when the jaw closes is
much too restrictive. The dental arches are only one element among severa l in a biological
entity k0own as the manducatory apparatus. The manducatory apparatus controls the
functions of mastication, deglutition and phonation. It also takes part in the breathing,
yawning as well as in the mimicry. The goal of this chapter is to set the scene and present
the role of the various elements taking part in these functions.
We will not write an elaborate anatomical or physiological description, but rather provide
some basic knowledge which is necessary to understand the mechanisms of occlusion;
8 the reader can refer to more specialized books if he/she wants to learn more about these
notions.
Within the manducatory apparatus, we will describe interactive and interdependent
systems : the temporomandibular joint, the masticatory muscles and the dental arches. These
three components are traditionally called the anatomic determinants of the manducatory
appa ratus. The actions and interaction s inside this apparatus are coordinated by the centra l
nervous system, which is the fourth determinant. Let us note that a hierarchy exists in this
functioning which gives the priority to the comfort of the dental arches over the articu lar
and muscular systems.

The temporomandibular
joint
General notions
The temporomandibular joint (TMJ) presents two
remarkable specificities .cbmpa red to the other
articulations in the human body.
"
The first one is that both joints are paired, the
left and right being linked to the same bone: the
mandible . As a result, any movement on one side
simu ltaneously generates a movement on the
opposite side (Fig. 1).

1 Each movement of the mandible simultaneously

involves both articulations of the TMJ.
 1 General notions

The second specificity concerns the TMJ

movement capacity. During mandibular
movements, the TMJ is the site of complex
movements, combining at the same time
translation and rotation movements. This is
made possible thanks to the specific anatomical
structure of the TMJ which, between "the osseous
components, has an ,articular disk delimiting two
distinct joint compartments .
A brief anatomical description is necessary to understand
the specificity of these joints; for further information, the
readers are invited to turn to more specialized documents.
One osseous component is located on the mandible, the other
one under the skull:
- The mandibular condyle, also called the head of the mandible,
2 Top view showing has an oblong shape and its main transverse axis is obliquely and
the orientation
of condyles. backwards orientated (Fig. 2);
- The temporal articular surface, called the "mandibular fossa", 9
is located in front of the external auditory meatus which li mits
its posterior aspect. The articular eminence represents the
anterior part of the joint, it is convex in the sagittal direction.
The mandibular and cranial articular surfaces are covered with
fibrocartilage but are not in direct contact (Fig. 3).

External

fossa

Temporal
condyle

3 Lower view of the cranial articular cavity.

 Occlusion made easy

4 Anatomical
section of the TMJ
(P. Carpentier and
J.P. Yung).

10 A dense fibrous structure, the articular disk lies between the condyle and the mandibular
fossa. Pierre Carpentier (2011) describes here a condylar disco-m uscular appa ratus which
perfectly typifies the comp lexity of this structure in which the disk, the articular capsu le
and the insertion s of the lateral pterygoid muscle have important functional implications
(Fig. 4) .
In a parasagitta l vi ew, we can then see both compartments: the upper one located between
the sk ull and the disk, and th e lower one located between the disk and the mandibular
condyle. It allows two typ es of movements: a movement of rotation of the condyle, under
th e disk, on the lower floor, and a translation movement of the condyle/disk apparatus
aga inst t he em inence of th e tempo ral bone on the upper floor.
An art icu lar capsu le encircl es the disk and connects it, on the one hand to the condyle and
on t he other hand to the skull. The integrity of the articu lar capsu le protects the condyle/
disk apparatus and conseque nt ly gua rantees th e fluidity of the articular function . Synovial
liqu id bathes each compartment, providing lubrication.

Les muscles masticateurs

The muscular system is the driving element of the manducatory apparatus . There are levator
muscles and depressor 'muscles. The lateral pterygoid muscle plays a specif ic part, because
its comp lex ro le is determin ing in the mand ibular functioning .

Levator muscles Direct depressor muscles

Temporal Geniohyoid muscle:
M assete r mylohyoid muscle and digastric
muscle
M ed ial Pterygoid
 1 General notions

Anterior
fascicle

Posterior
fascicle

5 Temporal muscle. 6 Masseter muscle.

11

The medial The temporal muscle is the most powerful

pterygoid is
of the masticatory muscles . It is a fan-shaped,
inserted on
the medial flat, broad and voluminous muscle. There are
surface of three fascicles: anterior, medial and posterior.
the pterygoid It originates from the top of the temporal fossa
apophysis . and inserts below onto the coronoid apophysis
via a tendon. It plays a levator role for its anterior
7 Medial pterygoid and medial fascicles and also controls retraction
muscles (bottom view). for the posterior fascic le (Fig. 5).
The masseter is a thick and short muscle
covering the lateral face of the mandibular
ramus. At the top, it inserts in the lower edge of
the zygomatic arch, and at the bottom on a big
portion of the external face of the ramus up to
its basilar edge. It has two fascicles, a superficial
one orientated from top to bottom towards the
back, and a deeper and thinner one, directed
from top to bottom and from back to front,
joining the insertion of the temporal muscle on
the corono id apophysis (Fig. 6).
The medial pterygoid is a "symmetric" muscle
of the masseter. Short and thick, it is inserted
on the pterygoid apophysis. It joins the medial
8 View showing the symmetry between the surface of the mandibular angle (Fig. 7-8).
masseter and the medial pterygoid muscles.
 Occlu sion made easy

9 Lateral pterygoid. 10 Cross section showing the insertions of the two heads
of the lateral pterygoid (P. Carpentier and J.P. Yung).

12 The lateral pterygoid is made of two heads: a

superior and an inferior. The infe rior or pterygoid
head which propels t he mandible only inserts
into the lower two t hirds of th e pterygoid fovea
and has no insertion on th e TMJ . Th e superior or
sphenoid head inserts into the superior third of
the pterygoid fovea, onto th e disc, penetrating
th e medial part of the anterior rim . It also inserts
into the inferior surface of the superior arti cular
capsule (retrod isca l tendinous lamina). The
fun ctiona l role of th e superior head is comp lex:
it pulls and also provides a braking ro le during
closing by checking the position of the cond yl e
11 Lateral pterygoid (view showing the and the arti cular disc (Fig. 9-10-11).
obliquity towards the medial plane).
The depressor muscles cover th e floor of the
mouth and lift the tongue during deglutition
Mylo-
(Fig. 12).
hyo'i dien

)igastric
rnterior belly

Indirect depressor Cervical muscles

muscles
Sternothyroid Sternocleidomastoid
muscle muscle
Thyrohyoid muscle Trapezius muscl e
Sternohyoid muscle
12 Main muscles of the floor of the mouth. Omohyoid muscle
 1 General notion s

Digastric
anterior belly

Omohyoid
muscle , Sternohyoid
muscle
Sternohyoid
muscle

Trapezius
muscle
iiiiliiiE~~~ ,
13 lnfrahyoid muscles. 14 Cervical muscles.

The indirect and cervical depressor muscles are located further, but they also take part in the
13
mandibular function and in the head posture (Fig. 13-14). An elaborate balance is settled
between the skull, the neck and the nape of the neck muscles to hold the head posture.
These muscles may be compared to rubber bands balancing the skull on the cervical spine.
If a rubber band happened to break, the whole balance of the system would be broken and
the posture of the head would be altered (Fig. 15). During the clinical examination, we will
see how the practitioner can do the cliniccil assessment.

15 The postural
balance is achieved
with the combined
action of the skull,
the neck and the
nuchal muscles.
 Occlusion made easy

Dental arches
The dental arches are the most accessible components . A detailed description of the criteria
of dental occlusion will be presented in the following chapter. Let's just keep in mind for
the moment that dental arches play a role in the positioning of the mandible during the
occlusion. For example when we swa llow, the muscles, commanded by the central nervous
system, move the mandible to bring teeth in contact; the resulting engagement determines
the position of the mandible with regard to the skull. Consequently, the positioning of the
TMJ depends on the way dental arches mesh together. To the practitioner, dental arches are
the key to the manducatory apparatus (Fig. 16).

14

16 Dental
arches.

The neuromuscular regulation system

Interaction between the TMJ, muscles and teeth is supervi sed by the central nervous system
which collects peripheral information (afferents) and adapts in return the efferent muscular
motor response (Fig. 17).
Diffe~nt kinds of sensory receptors are scattered within each system to collect information
and forward them to the brain: in the TMJ, they are the Ruffini and P.acini corpuscles as
well as the free nerve endings. These encapsulated mechanoreceptors which respond to
pressure are situated in the articular capsu le; if they do provide information about the
movements and the positions of the joint, they however are not numerous and not very
accurate. The free nerve endings are located in the ligaments and the capsule. They take
part in the perception of the sensation of pain . The muscular system contains two types of
senso ry receptors: the neuromuscular spindles and the Golgi tendon organs.
 1 General notions

The neuromuscular spindles are

situated in the muscle. They are
muscular mechanoreceptors because
they are sensitive to the condition and
to the variations of the muscle length.
These spindles play several roles:
- They•p.rovide information about the
lengthening of muscle fibers;
- Their excitability degree increases
when they extend during stretching;
- Their excitability degree decreases
when they get shorter during muscle
contraction . They settle the level of
17 Neuromuscular system. involuntary muscle tone (state of
permanent tension of the spindle).

The Golgi tendon organs are situated in the musculotendinous junction . They are stretch
receptors which respond to the tendon tension. Their excitability degree increases when the 15
tension increases: the response to stretching is greater in case of active stretching than in
case of passive stretching .
Compared with the other musdes of the human body, the masticatory muscles have
proportionally a greater number of receptors. As a consequence, they provide the accurate
information needed by the brain to control the execution of complex movements such as the
movements of the manducatory apparatus (Fig. 18).

Motor response

Annulospiral ending
(proprioception)

Pacinian corpuscles
(pressure)

Golgi tendon organs

(proprioception)

18 Muscle receptors.
 Occlusion made easy

However, the most efficient receptors system is located in the dental arches. They are the
periodontal receptors : numerous and accurate, they are distributed around all the teeth .
The oral mucous membranes also contain Ruffini and Pacinian receptors whose perception
is less accurate, and we sha ll remind it, than the perception of the periodontal receptors .
Partially or completely edentu lous patients wearing mucous support prostheses encounter,
partly for this reason, more difficulties to regulate the masticatory movements.
The greatest quantity of high-quality information comes from the dental arches providing
accurate information to the brain about what is going on in the area . That's why the dental
arches are priority in the organization of the manducatory apparatus. The comfort of the
dental arches prevails, sometimes at the expense of the TMJ and/or of the muscles comfort.

Engrams
An e1:igram is a coordinated su ite of muscular actions performing a function, with no
aware action of the subject. The system automatically performs the basic functions that
are mastication and deglutition through engrams which may be compared to computer
programs located in the brain. By analogy, let us take the example of the locomotor
apparatus, which also uses engrams to allow our movements. Walking is made possible by
the combined action of agonist and antagonist muscle groups allowing to move forward
16 while keeping balance. These engrams are the result of a learning process during which the
movement is acqu ired; the memorization of the sequence of muscle actions is made in the
cortex. The sequence can be then automatical ly reproduced and performed .
According to this pattern, mastication is an automatic process until an unusual event occurs,
for example the sudden and brutal contact with an olive pit during the chewing. The shock
felt on teeth generates a reflex response which stops the mastication. The subject sudden ly
gets vigilant and analyzes the situation . If the brutal contact did not cause any lesion,
the mastication can start again in an automatic way; the state of alert is lifted. On the
other hand, if there is a lesion (a tooth fracture for example), it is necessary to adapt the
movements in order to avoid any contact with the area of the lesion . To fully understand
the situation, let's take again the analogy of the locomotion: a hiker gets a blister on
one foot. The hiker is going to modify the way he/she walks to avoid painful friction;
walking remains possible, although in a less effective and more tiring way. A new engram
is memorized. It will be possible to walk again normally only after the lesion is treated.
It's the same for mastication: after the fracture of a tooth, the subject can still eat, but he/
she must change his/her food habits. The function will be fully restored only after treatment.

Adaptation
This process is managed by our
adaptation capacity. Without it, Dysfunction periods

I~
life wou ld be impossible. We could
define adaptation as a range of
"compensatory mechanisms " which
allow the functions to perform even
when the anatomical cond itions cease Time
to be ideal.
19 Disorders appear when the adaptation is too
difficult.
 1 General notion s

Let's take again the example of locomotion : a subject with a slightly shorter leg is going to
be able to stand up and wa lk without limping by tilting his/her pelvis and by adapting his/her
spine; the resulting muscular work is asymmetric.
Nothing happens for a few years. However, these inadequate conditions may one day result in
a decompensation which ca n generate back pains, abnormal wear of joints, etc.
The manducatory apparatus follows the same principles; compensated disorder~ may result
over tim e in a symptomatology. It is not rare to see a patient coming to consult for muscular
or articular symptoms whereas no recent changes have been noticed ' in his/h er occlusion . The
reason is that, in stressful situations, the capacity of adaptation is suddenly reduced and the
mechanisms of compensation can not work any longer (Fig. 19).
After describing these notions of physiology and biomechanics, it is essential to relate the
manducatory apparatus to the patient - who is an individual capable of emotions !

Stress
Still today, stress is the subject
of controversy concerning its
involvement in the occurrence of
dysfunctions. We nevertheless
17
support this hypothesis according to
our own clinical experience.
Stress must be considered in a broad
sense; stressful situations are not only
connected to negative events such as
a mourning, a job loss or a divorce.
Events such as a birth, a promotion
at work, a marriage or a moving,
may also generate stress and can
destabilize a compensated situation.
The capacity of adaptation shows 20 Individual variation of adaptatio_n.
some limits which vary among
individuals, and also in th e same
individual according to age or to
Health Adaptation Pathology
emotional tensions (Fig. 20).
As the availab le amount of
adaptation and its limits ca nnot be
assessed , the chosen th erapeutics
will always aim at bringing the
patient back to optimal occlusal
conditions, in harmony with th e Treatment
arti cu lar and muscular components
in order to appeal as littl e as possible
to th e mechanisms of adaptation 21 Principle of treatment.
(Fig. 21 ).
 Occlusion made easy

KEY POINTS

A harmonious functioning of tile manducatory

apparatl!ls d.epends on a w hole set of anat0mical
and emotioraa l factors. In case of a diagnosed
patl:lology, the respective ro le of cofactors llilust
be estab li shed ancl our action must be lim ited to
18 our specific skill s in the occlusa l field, w hile co-
t herapists w ill hand le t he emotional aspects.

HELPFUL READING
• Ide Y, Nakazawa K. Hongo T. Tate ishi J. Anatomical atlas of the
temporomand ibu lar jo int. Quintessence pub lish ing Co, 1991.
• Se ltzer JG. Stress and the genera l adaptation syndrome or the theor ies and
concepts of Hans Se lye. J Fla M ed Assoc. 1952;38 (7):481-5 .
• Szabo S, Tache Y, Somogyi A. The legacy of Hans Se lye and t he orig ins of stress
research: a retrospect ive 75 years after his landmark brief " letter" to t he editor of
nature. Stress. 2012; Sept;15(5):472-8.
 Functional
occlusion

1 Clinical view 19
of a functional
occlusion.

This chapter describes the anatomical and morphological characteristics that we can
observe in healthy young subjects presenting what we call a functional occlusion (Fig. 1).
The dental system is the result of the mechanisms of evolution and the adaptation to our
omnivorous diet.
The dental occlusion can be defined as a static position of mutual confrontation of both
dental arches. This confrontation is ruled by anatom ica l and biomechanical mechanisms
which define a functional occlusion. They al low genera l dental practitioners to:
- Proceed to an assessment of the occlusion (compared with this model);
- Fo llow ru les of reconstruction of the occlusion in therapeutic purpose,s-restorative,
prosthetic and orthodontic.

Main principles
1. Morphologically and anatomica lly, the occlusion is ruled like a hierarchical entity:
- A functional occlusal morphology;
- A properly organ ized arch;
- An interarch confrontation following biomechanical ru les.

2. The resulting occlusa l functions allow a less tiring and less destructive, energy-saving
functioning (structura l sustainabi lity).
3. The arch itectural ru les governing the occlusion are not dogmas but rather gu ides for
diagnosis and reconstruction that are useful to practitioners.
 Occlusion made easy

Coronal and occlusal morphology

Human teeth are characterized by an occlusal morphology made of convex shapes
meeting the following physiological requirements :
- Facilitate eruption;
- Faci litate mastication;
- Reduce the fracture risk;
- Reduce the muscular work;
- Reduce the forces applied in supporting tissues;
- Avoid the biting of the cheek and the tongue;
- Favor prophylaxis .
This morphology is meaningful, it must be respected, restored or reconstructed (Fig. 2-3).
Two groups of teeth can be distinguished, taking part in different functions:
-, Teeth of the posterior sectors: premolars and molars;
- Teeth of the anterior sector: incisors and canines.

20

2 Occlusal obturation complying with the 3 Occlusal integration of an implant-supported

occlusal anatomy. crown.

Posterior teeth
The occlusal surface of the posterior teeth is made of several constituent elements, each
playing a speci fi c rol e.
The primary cusps (PC): they are the mandibular buccal cusps and
the maxillary lingu al cusps . They are occlusal supporting . Convex
shaped, they make contact with the centra l fossa, the proximal
foveas or the occlusal grooves of the antagonist teeth. The
cusp tip does not d,irectly come into contact Primary Se cc
with the receiving zones. The contact points cusps CU Sf

are J.ocated on the surfaces near the top. The

primary cusps help stabil ize the dental arches.
During the mastication phase, they help crush
the alimentary bolus (Fig. 4).

4 Primary and seconda ry cusps on both arches.


5The convex shapes facilitate the crushing and
the release of the alimentary bolus.
6 Occlusal surfaces approximately account for
two thirds of the total width of teeth.
7 The integrity of the marginal crests is
necessary for the occlusion and the intra-a rch
balance.
2 Functional occlusion
The secondary cusps (SC): they are the
mandibular lingual cusps and the maxillary
buccal cusps . Sharper than the PC, hardly
convex, they present a cuspal tip which is
always situated outside the antago'"'ist occlusal
zone during intercyspation.
'
They also protect the lips, the cheeks (maxillary
arch) and the tongue (mandibular arch) with
their external surfaces.
They help keep the alimentary bolus in the
occlusal area during mastication with their
central part and set an escape zone (free zone)
thanks to their latera l angu lation (Fig. 5).
The occlusal area: it is the masticatory
"active" part of the tooth and is made from
the conjunction of the. convex structures of the 21
occlusal surface. It is limited by the marginal
ridge, and draws an imaginary lin e including
the cusp apexes through the mesial and distal
surfaces, and through the ridge line of the
marginal crests (Fig. 6).
Marginal crests: they border the occlusal
zone in the proximal areas. They have a central
su rface which constitutes the wall of the
proximal fossa, and a peripheral surface which
is one of the limits of the occlusal embrasure.
The marginal crests of two adjacent teeth
are symmetrical. They play a role in the
occlusal stab ilization and th e deflection of the
alim entary bolus by protecting the underlying
periodontium (Fig. 7).
Grooves, fossae and foveas: the main
grooves are made from the conjunction of one
or severa l convex surfaces . Their orientation
allows the clearing of the antagonist cuspid in
the functional movements and the release of
the food bolus.
 ..
Occl usion made easy

We can see marginal foveas and, on molars

on ly, a centra l fossa (Fig. 8). Frequently
affected with caries, t hese zones must be
restored according to t he initial anatomy of the
teeth to protect their funct ions.

Occlusal relief: the cuspal anatomy is more or

less.pronounced. The cuspa l height is measured
from the cusp tip to the main groove of the
too~h; thi s represe nts th e occlusal relief. Th e 8 Fossae, fov;~s, grooves.
cuspa l slope, measuring the incl ination of the
cuspa l edge in regard with the perpendicular
to the main axis of the tooth, completes thi s
characterization. Wh en the occlusal relief is
pronounced, the masticatory effi ciency and
22 the occlusal st abi li zation are greater, but the
risks of occlusal interfere nces are also more
important (Fig. 9).

Anterior teeth
In the anterior sector, the occlusa l part of the
mandibular teeth is exclusively represented by 9 Cuspal height and cuspal angle determine
their free edge, which faces the antagonist the occlusal relief.
occlusa l surface represented by the pa lata l face
of the maxillary teeth on the marginal crests,
above the cingu lum .
The pa latal surfaces of the maxillary incisors
are concave, lined with convex ridges on which
the gu idance function is set.
The lingual surface of can ines presents a large
con vex median ridge and less pronounced
prox imal ridges (Fig.. ~O).
The... resulting guidance slope depends on the
relief of these elements and on the global axis
of the tooth.

10 Cingulums and marginal ridges of anterior

maxillary teeth.
 2 Functional occlusion

11 The mandibular
occlusal plane has an
8° angle to Camper's
.:.-.----.a. plane.
12 With an average radius of 85 millimeters,
the curve of Spee commands the masticatory
efficiency.

Dental arches arrangement 23

Every group of teeth plays a very specific role: the posterior groups in the cru shin g phase
of mastication and occlusal stability, the anterior gro ups in prehension and incision
phases of mastication, as well as in occlusal guidance. The ro les of these two groups are
complementary. There is mutual protection between the different groups: the posterior
group protects the anterior group in occlusion whil e the anterior group protects the
posteripr group during excursions. Teeth cannot work in an optimal way independently
of one anothe r, or in th e absence of one tooth or another.

Arrangement in the sagittal plane

There is no alignm ent strictly speak ing because the curv ilin ea r arrangement prevails: The
surface going through all the occlusa l faces has rather a helica l shape. The term "occlusa l
plane" remains widely used, because it is easi ly understood.
Two landmarks may help the practitioner:
- The occlusal plane, which describes the globa l sag itta l orientation of the arch, jo ins
the free edge of the mandibular incisors to the centro-bucca l cusp of the first mandibular
molar. It determines a general orientation of the arch in regard with the Camper's plane
(auditory meatu s/su bn asa le); an 8 ° divergence is norm al accord ing to Slavi cek (1983)
(Fig. 11). This plane allows to diagnose the anoma lies in teeth positioning, for examp le
overeruption;
- The curve of Spee includes the buccal cusps of all th e mandibular cuspids: it is concave
at the top. This curve allows to optimize th e forces applied on the food bolus (like pruners)
and the axial distribution of constraints along the roots of each tooth (Fig. 12). The
curved layout facilitates disocclusion and fossa-cusp re -engagement with no posterior
interferences in the functional movements.
 Occlusion m ade easy

13 Importance of the contac1

zones for the continuity
of the arch and for the
distribution of forces.

Arrangem ent in the horizontal

pl one
24 The dental arch has a global parabolic shape
which favors th e resistance and the fo rce
distribution . The size of th e contact zones is
gettin g bigger from the incisors to the molars
where constraints are the greatest. Proximal
contacts distribute th e forces applied on one
tooth to the adjacent teeth (Fig. 13).

Arrangement in the frontal 14 A front view of the "occlusai plane"

allows to determine the general orientation o
plane the arches.
The global ori entati on of the arches in the
fro ntal plane must be pe rp endicular to
the midsag ittal plane and para ll el to th e
bipupillary axis.
It can be quickly and effectively assessed wi th
a Fox pl ane plate (Fig . 14).
In the fronta l plane, denta l axes are convergent
on t he top and on the inside. On a fro nta l
secti on, we will notice 'that the occlusa l surfaces
are ~et in a ci rcl e with superi or concavity, ca ll ed
the Curve of Wilson . This curve connects in a
frontal plane th e bucca l and lin gual cusps of
a tooth to their counterparts on the opposite
side. In fact, thi s curve is neutra l or very slightly
marked in the reg ion of the second premolars,
and becomes more and more concave in the 15 Curves of compen sation in the frontal
reg ion of molars (Fig. 15). plane: Curves of Wil son.
 2 Functional occlusion

16 Contact
points of the
primary cusps
and impacts on
the antagonist
arch.

17 Proper
distribution of
contact points
in a functional
occlusion. 25

Static occlusal relationship

I Th e ma ximal intercuspa l position (ICP) is, physiologically, a mandibular reference position
in which th e dental relationship is characterized by a maximum of interarch contact points,
this position being the most stabilizin g for the mandible and for each tooth.
The t heo retica l number of contact points amounts to 70 (Fig. 16). It is rare to find naturally
this number of contact points . Physiologically, a smal ler number of properly distributed
points provides an acceptab le functional situation (Fig. 17).

Posterior occlusal relationship

In the sogittal plane
In ICP, the Angle's classification allows to determ in e t he normal line of occlusion and its
variants. This classification concerns dental relationships and not ske leta l relationsh ips.
In Ang le's classification, the class I is the most fa vorab le interarch re lationship.
The centra l cusp of the first mandibular molar is in contact with t he ce ntra l fossa of
the first maxillary molar (Fig. 18). This position, which provides optim al stability in the
three dimensions, is ca ll ed "occlusal lock" . .In mesial, the relationships will be cusp/ fossa
and cusp/m arg inal crest, which is fa vorab le to occlu sa l stab ility as well as masticatory
efficiency (Fig. 19).
 Occlusion made easy

Angle's Class I

18 Occlusion in class I (buccal and lingual 19 Clinical view of Angle's class I.

sagittal views).

Angle's Class II

26

20 Occlusion in class II (buccal and lingual 21 Clinical view of Angle's class II.
sagittal views).

Angle's Class Ill

22 Occlusion in class Ill (buccal and lingual 23 Clinical view of Angle;s class Ill.
sagittal views).

An~le's class II refers to a distal disp lacement of the arch: the centra l cusp of the first
mandibular molar is in contact with the distal embrasu re of the .first maxillary molar
(Fig. 20 -2 1). There are two different situations for the anterior teeth in this class, whi ch
will be described in the anterior occlusal relation shi p.
Angle's class Ill is a mesial displacement of at least half a cusp compared with class I
(Fig. 22-23).
These last two cla sses create globally less favo rable patterns of interarch co nfrontation.
 2 Functional occlusion

24 Different types of
cuspal contacts in the
receiving zon,,,es: central
fossa, fovea or embrasure.

In the horizontal plane

The primary cusps come in occlusion in ICP
through their mesial and distal surfaces 27
(and not with their tip s) with thre e typ es of
recei ving zones in the antagonist zone: ce ntra l
fossae, proximal pits, occlusal embrasures
(Fig. 24). Optimal stability is achieved in
cusp/fossa or cusp/pit relationship, generating
three m ntact points.
Th e constituent elements of the occlusal
morphology follow the curve of parabolic
25 Lingual and buccal occlusal lines.
arch and can provide so me precious help
for diagnosis (cf. chapter ded icated to the
examination of occlusion) (Fig. 25).

In the frontal plane

Supporting cusps and their antagon ist
receiving · zones provide zones of occlusal
st abi lity. Guiding cusps provide a free space
whi ch eases diduction movements with no
interference (Fig. 26).
Occlusal morphology, arch arrangemen t and
interarch rel ationship of the posterior teeth
are key elements in the physiology of the
occlusal functions.

26 The primary cusps provide a stability zone;

the secondary cusps provide a free space.
 Occlusion made easy

Anterior occlusal relationship

Functional
'-free space

28 Anterior occlusal relationships:

radicular angle of about 135 ° and
27 Schematic view of the occlusal contacts in ICP functional free space.
in the anterior sector.

Class I Class II
29 Various cases
of overbite and Div. 1 Div. 2
overjet in several
28 clinical situations.

---·
- ·-· -·-·-
i - ·-·i.
' i
· Afunctional

Class 111

In the horizontal plane

The incisor-ca nin e contacts are punctiform and
simultaneous. Th e incisal edges of the mandibular r·-· c·-·-
anterio r teeth are in contact with th e marginal crest s t - · --- 1 I

of the maxillary incisors and can in es . The existence ! Afunctional i !' Afunctio1
of a contact in this area is necessary for st ability
and guidance (Fig. 27). Functiona l wear grad ually
changes these contacts into more or less important
spaces.

In the sagittal plane

The incisa l relation ships particularly matter to ach ieve their functions :
The coronal radicular axis of the maxillary and mandibular cent ral in ciso rs makes an
angle of about 135 °; a fun ction al area allows t he propulsion moveme nts (Fig. 28). The
relationships of the anteri or teeth are cha racte ri zed by the ir overbite and their overjet.
These anterior relation ships are very different according to Angle's classes, and this
ge nerates co nsid erab le functional implicat io ns (Fig . 29).
 2 Functional occlusion

30 Frontal In the frontal plane

view of the
anterior sector Because of the small size of the mandibular
and mandibular
incisors, the maxillary incisors and canines are in
overbite by
maxillary teeth. occlusion one-tooth-to-two-teeth, except for the
mandibular central incisor (Fig. 30). "'

The occlusal functions

They define the functional role of the occlusal contacts. In 2013, Orthlieb suggested the
following classification: "centering, stabilization, guidance" referring to:
- A mandibular position that does not constraint structures (centering);
- A sustainable dental and mandibular stability (stabilization);
- A guide for off-centered mandibular movements (guidance).

The Centering function

The most frequent functional mandibular position (deglutition, tension) is imposed by the
maximum intercuspal occlusion, which consequently commands the position of condyles, 29
the lengths of muscular work ...
The ICP must place the mandible in an unconstrained position for the musculo-articular
components, a physiological position which corresponds to the centric relation.
ic
I. On the transverse plane. The mandibular position in centric relation relates to a globally
symmetric situation of the mandible in relation to the skull. This position corresponds to a
practically strict transversal centering of each condyle/disc complex in the mandibular fossa
(Fig. 31).

31 Centric occlusion
optimizes articular
positioning.
 Occlusion made easy

II. On t he sagittal plane . There is a littl e

bit more articu lar tolerance related to ce ntric
relation; the condyle/di sc comp lex can slide
sli ghtly along the posterior slope of the articular
tubercle, while remaining attached to be ab le
to absorb pressure. The mandibular movement
in cen t ric re lation occlusion (CRO) towards the
ICP, symmetri c, moving forward, generates no
articu lar constra ints. In the sag ittal direction,
the physiological sagitta l differential CRO/I CP
is genera lly sma ller than 1 mm.
Ill. In the vertical plane. In locked position,
in rotation around the condyles, the ICP stops
the mand ibular elevation - this defines the
occlusa l vertical dimension (OVD) related to the
lower face height. In harmony with th e ske leta l
framework, it must optimize the muscular
recruitment patterns and the resting positions. 32 The stabilization function determines
There is a tolerance in the variations of the the OVD.
30 occlusal vertica l dimension, which allows
to optimize it during occlusal therapeutics
(prosthetic, orthodontic treatments) (Fig. 32).

The stabilization function

The ICP must stab ilize each antagonistic
dental pair and, globally, the mandible. These
results are achieved with the homogeneous
distribution and the accuracy of the multiple
occlusal contact points all over the arch,
united by the proximal contacts preventing
teeth migrations . This mandibular stabi lization
counters th e strengths caused by mandibular
elevation movements (Fig. 33).
Occlusa l stabi li zation consequent ly means:
- Stability of the mandible against the maxilla;
- Stability of each tooth with its antagonist
(interarch stability); . •
- Stability of each tooth with the adjacent 33 Occlusion counteracts elevator muscles
teeth (intra -arch stability). and protects articular structures.

Mand ibu lar stabi lity in ICP facilitates deglutition (1, 500 per day) and allows to distribute
constraints during tension. A lack of stab ility generates a greater muscular activity and
t he interposit ion of the tongue. These two compe nsatory mechanisms are not ene rgy
efficient and can damage the structures.
 2 Functional occlusion

34 The guidance function determines

an access cone to ICP.

31

The stability of each dental organ on its arch is the condition of the absence of tooth
migration. The stability of each tooth in ICP is connected to the morphological elements
describ~d above:
- A proper axial inclination of the tooth;
- An arch continuity provided by interproximal contacts;
- One -tooth -to-two -teeth occlusal relationship;
- Punctiform occlusal contacts, face to face (particularly in the transverse direction: buccal
and lingual), which create bi -or tripodism.

The guidance function

During the masticatory movements, the return to ICP is guided by dental contacts. These
friction zones guide the mandibular movements, acting:
- In a mechanical way (teeth create borders, limits to the movement);
- In a proprioceptive way (proprioception and feedback limit the movement to a functional
envelope, without achieving occlusal contact). Indeed, if the limits of the movement are
defined by the occlusal contacts, the envelope of functional movements is completed
below, avoiding occlusal traumas. When these contacts are mostly anterior, the
guidance function is optimized .

Like an access cone, these guidance surfaces drive the mandibular elevation directly
towards the target that is the ICP (Fig. 34). Avoiding contacts in the area of the posterior
teeth reduces the constraints with the remoteness of the application point of the muscular
strengths and facilitates the neuromuscular coordination (increased proprioception).
 Occlusion made easy

35 incisor-
canine
guidance in the
movements
of protrusion/
retropulsion.

36 Canine
guidance in lateral
movements.

32

37 The lingual cusp of the

first maxillary premolar plays
the role of "retro control".

The mandibular movements required by the various function s are then fluid, energy-saving
and free of any dental obstacle. This proprioceptive guidance, accurate and reactive, is
made easier by th e overbite of th e mandibular teeth by the anterior maxillaries (which is
not the case in Angle's classes II and Ill ).
During a mandibular translational movement (propulsion /retropulsion, or diduc.tion), the
occlusa l contacts between the antagonist anterior teeth are the anterior guidance.
These ante ri or contacts generate a disclusion of pluricuspid teeth durin g excursion and
constitute the slopes of the access cone to the ICP of the incursive movements.
We caiq distinguish:
- The forward guidance in protrusion/retropulsion on proximal crests of th e palatal
surface of the maxillary incisors, and the distal crest of th e maxi llary can ines (Fig. 35);
- The lateral guidance (diduction or laterotrusion), can in e guidance on the mesial part of
the medial ridge of the maxillary ca nine in Angle's class I (Fig. 36);
- Guidance towards the back (retro control): in retraction I protraction, the occlusa l
contacts on th e ICP/CRO pathway are preferentially located on the mesia l part of the
lingual cusp of the maxillary first premolars (Fig. 37).
 2 Functional occlusion

Kinematic occlusal relationships

The odontologist assesses (diagnosis) or creates (occlusal restoration) the occlusal limits of
the enve lope thanks to the guidance occlusal surfaces . These are preferentially situated on
the anterior teeth (cf. infra) for severa l reasons :
- The periodontal proprioception is greater on the anterior teeth: the proprioception is
thus increased and the mandibular movements are optimized; "
- Constra ints decrease from the posterior teeth to the anterior teeth as the points of
application of the forces move away (Fig. 38). '

33

38 Constraints decrease as the point of 39 Clinical view, in propulsion: disclusion of

application of the forces moves away. the posterior teeth.

Protrl'.lsion
The movement of protrusion or mandibular
retropulsion occurs with dental contacts
(proclusion and retroclusion) which are
physiologically situated from the free edges
of the mandibular incisors on the marginal crests
of the palatal surfaces of the maxillary incisors.
During these movements, the posterior teeth are in
disocclusion to protect them from tangent constraints
(posterior disclusion) (Fig. 39). \

There are two phases in the propulsion movement.

• In the first phase, the incisa l slope formed by the palatal
face of the maxillary incisor is slight (which creates little
horizontal dental constraints). It is compensated with a steep
slope in the area of the condylar slope, which induces the
disocclusion of the posterior teeth.

• In the second phase, a steep incisal slope compensates for

40 In protrusion,
the anterior guide and the
the weakening of the condylar slope . The average slope is condylar slope generate
consistent with the posterior determinants that are the condy lar the posterior disclusion.
slopes. Th is ideal incisal slope is approximately 10° superior to
the condylar slope .
 Occlusion made easy

41 Posterior disclusion in right 42 Posterior disclusion in left 43 Group function including

lateral movement. lateral movement. lateral incisor canine and first
premolar.

The incisal and condylar slopes determine the mandibular and consequent ly the dental
movements. The more the tooth is posterior on the arch, the more its kinematics depends
on the posterior determinants (condylar slope, Bennet's angle and initial movement). The
more the tooth is anterior, the more its kinematics depends on the anterior determinants
(anterior guidance surfaces) (Fig. 40). A steep condylar slope will thus induce a more
34 vertical movement downward the mandible body during propulsion and favor the
posterior disclusion.

Diduction (laterotrusion)
The latera l movement occurs like a border movement through the contact of the tip of
the mandibular canine on the mesial slope of the palatal surface of the maxillary can in e
(in class I).
The position on the arch and the high proprioception of canines give them an essential
role in the organi zation of the lateral mandibular movements. Canine contacts generate
an ipsilateral posterior disclusion of sma ll amplitude to preserve masticatory efficiency
(Fig. 41 -42). In certain clinical situations, incisors can participate in the guidance (anterior
group function), and even premolars and molars (posterior group function) (Fig. 43).
The group function reduces the proprioception but increases the mechanical guidance,
allowing a broader distribution of lateral constraints. It provides less proprioceptive
accuracy and more mechanical resi stance.
Movements of the mandibular teeth result from the combined influ ence of the anterior
and the posterior determinants. The occlusal anatomy must be in accordance with these
movements; the or,ientation of grooves on the occlu sa l surfaces of the posterior teeth
thu s favors the release of the primary cusp ids during the variou s functional movements
(Fig. 44-45) .

Before closing thi s chapter, it seems interesting to specify a few definitions concerning
variants of so me occlu sa l situations we may find in the population; to this purpose, we
will use the classifi cation proposed by Orthlieb (2013) (Fig. 46).
 2 Functional occlusion

44 Escape pathways in the grooves of the 45 Escape pathways in the grooves of the
maxillary molars of the antagonist cusps during mandibular molars of the antagonist cusps during
functional movements. functional movements.

Normal occlusion (or neutroclusion) - is an abstract concept: an ideal occlusion. Normal

occlusion can be defined as a theoretical reference model.
35
Functional occlusion: close to normal occlusion, it respects the general characteristics
of the physiological occlusal functions (stabilization, centering, guidance). Functional
occlusion is the model that th·erapeutic occlusion (prosthetic or orthodontic) tries to
achieve.
Functional malocclusion (formerly named "convenience occlusion"): in spite of the
existenc'e of anomalies in the occlusion, the occlusal relationships enable the oral functions
without generating structural alterations with poor prognosis or functional disability at
the time of the examination.
Pathogenic malocclusion: it is a natural or iatrogenic occlusion presenting occlusal
dysfunctions with structural dental alterations and/or functional disability, which may
trigger or maintain structural or dysfunctional disorders. We can observe structural
damage (teeth, TMJ, bone) or recurrent musculo-articular disorders.
This terminology will be used in the following chapters.

Functional malocclusion Dysfunctional malocclusion

46 Various classes of occlusion (according to Orthlieb).

 Occlusion made easy

KEY POINTS

Occlwsi©'lil is iliwolved irn every der.ullal !f>roceG!wrre: ilt is 1!rne <demtis:t's "gailleway-"
to ttile fuli1ctiomin~ of the l'iTilarnducatory appara1Jws.

l'eetih, wmicrn are tt<ie basic ibools ofr ilime den:tal sy.stel'iTil, will allCi>W 11Jilasticaillioli1
but also, w.i:th the <i> <D«:ll!lsi©l'l, illrne p.©sill!i<i>ming of ~he mandi!Dl·e irn iilis rmost
cranial p<i>si:IJioms. Any inilierventiom im the area of thle occlwsal sm~aces
of tee1lh «am 11e:troact b>~ a b>iofree<d!Daek mechanisrm. Tme proi;>rioceptive
origin of this mechanism is mainly periodontal with regar<d to the other .
cor:istituernts which are the TM1 and the muscular syst em.

The knowleG:lge and tme rnl1Jilp·liarnee with the rules Qf functional ®cclusiorn
allow practitioners to assess their ~aitients, and to treat them while
preserving or ir;nproving their oeclusal situation. It is part of fundamental
principles of biology such as t!;ie pr;eservation of structures and er:iergy
36 saving.

HELPFUL READING
• Abduo J, Tennant M. Impact of lateral occlusion schemes: A Systematic Review. J
Prosthet Dent . 2015 Aug;114(2):193 -204. doi : 10.1016/j.prosdent.2014.04.032
http://www.scienced i rect.com/science/a rticle/pi i/S0022391315001250.
• Orthlieb JD . Analysis of Occlusions : The Triad of Occlusal Functions . International
Journa l of Stomatology & Occlusion Medicine 6, no. 3 (September 2013) : 83 - 84.
do i:10.1007/s12548-013-Q087-6.
 Centric relation
Centric relation is an articul ar reference whi ch is und oubtedly a key element in th e clinica l
practice becau se it is essent ial to have an independent refe rence position of teeth w hen
t he dental referent is pa thol ogica l, incompl ete or abse nt.
We use it to:
- M ake a diagnosis (Fig . 1-2),
- Restore th e occlusion (Fig. 3- 4).

37
Th e following topi cs will be revi ewed in thi s chapter:
•the definitio n of ce ntric relation,
• its practi ca l and clini ca l interest,
• th e principles of th e mandibular man ipulat ion whi ch need to be known in ord er to
record it efficiently.

1Centric relation is used as a benchmark to assess 2 In centric relation, a premature contact

the mandibular position determined by teeth can occurs in the area of premolars.
notice here a slight difference between the ICP and
the CR.

3 The dental reference (ICP) cannot be used 4 The treatment consisted in reconstructing
because of the existent destructions. an ICP in a position of centric relation .
 Occlusion made easy

How can centric relation be defined?

The definition proposed by the french National College of Occlusodontology is the object
of a wide scientific consensus:
"The centric relation is the highest referent condylar position, forming a bilateral
coaptation of the condylodiscal complex against the temporal bone, simultaneous and
transversely stabilized, suggested and achieved by unconstrained control, reiterative
in a given period of time and for a definite body posture which is recordable from a
movement of mandibular rotation with no dental contact."

Some terms of this definition need to be commented in order.to explain the

current concept of centric relation.
• The highest: it is really the highest position and not the rearmost position; the condyles
are in an anterior superior position, against the posterior slopes of the temporal bone
articular tubercles. Aiming at the rearmost position would lower the condyles. This more
retrusive condylar position is not considered as physiological because it moves away from
the functional territory of the mandibular fossa that is the temporal bone articular tubercle
and causes a distal compression as well as a stretching of the capsular ligament structures
(Fig. 5-6).
38 • Coaptation: a healthy functional position is characterized by the interposition and the
stabilization of the disk between both condyles. The definition of the centric relation
connected to the disk is the main element of modernization of the concept (Fig. 7-8).
• Simultaneous: it is about symmetry; the anatomical position can be compared both on
the right and on the left.
• Transversely stabilized: the stabilization of the rotation movement is enabled by the
medial poles of the condyles and the articular disks which provide the transverse stability of
the mandible (Fig. 9). The closing movement involves a number of muscular fibers which
participate in this stabilization (superior head of lateral pterygoid muscle, a few fibers of the
temporal and of the deep masseter).
• Suggested: i.e not commanded by a forced guidance but by a succession of movements
of opening/closing in rotation.
• Achieved by unconstrained control: the practitioner delicately controls with a simple contact
rather than by a pressure the process of a reproducible movement of mandibular rotation. We
will describe more thoroughly the phases of this manipulation further in this chapter.
• Reiterative: the stability of the articular structures enable a reprod'ucibility of the
mandibular position in a given posture. This position can vary slightly according to the
posture and time, 9ince the articular structures subjected to the functional constraints are
constantly adapting (tissue reshaping) to create, according to the widespread expression, "a
space of tolerance around the centric relation". The variation which can be measured with
experimental means has no incidence on the clinical plane.
• Recordable: the possibility of recording and transferring this position is very useful for
diagnosis and therapeutic purposes (Fig. 10).
• With no dental contact: no occlusal contact must influence this condylar position,
which remains stable during the whole terminal axial movement. This reference is situated
outside the dental arches.
 3 Centri c relation

5The action of the forces is applied through 6 A more distal position lowers the condyle and
the articular disk from the bottom up and from put some pressure on the retrodiscal zone.
rear to front.

39

7Anatomical section showing the coaptation 8 Anatomical section showing the coaptation
of the structures in a sagittal plane (P. Carpentier of the structures in a frontal plane (P. Carpentier
and J-P. Yung). and J-P. Yung).

9Centring also occurs in a frontal plane. 10 CR is recorded here with wax strips by
avoiding any dental contact.
 Occlusion made easy

Now, let's forget the concept to focus on the clinical relevance.

The position of the mandible in occlusion is imposed by teeth, i.e by the meshing of the
mandibular and the maxillary teeth.

In the fully edentulous patient, or in the absence

of proper contacts (Fig. 11), the mandibular
position is unreliable, impossible to reproduce
faithful ly in the laboratory.
If an occlusal reconstruction is envisaged, it is
necessary to find a mandibular position which is:
- Comfortable,
- Physiological,
- Repetitive,
- Reproducible with an articu lator

11 The ICP is here impossible to reproduce;

the only useful reference is the CR.
40
Practical and clinical relevance
Centric relation is physiological
It is a position of stability and comfort of the musculo-articular structures which le.ads to a
harmonious functioning of the manducatory apparatus.
Free of any articular constraint or muscular asymmetry, it takes a workload in occlusion
which is not pathogenic and this is the starting point of an optimal mandibular kinematics.
If the occlusion is made in a different position, more or less important constraints appear,
connected to direction and the amplitude of the displacement:
A sl ight and strictly anterior-sagittal displacement creates a few constraints: it imposes an
anterior position that however remains symmetric to the manducatory muscle structure;
condyles are slightly moved forward, which remains in the frame of a physiological tolerance:
there is a consensus that sets the limit of this anterior displacement to 2 millimeters
(measured at the dental level).
On the other hand, a transversal displacement may create more damage: a joint is distended,
the other one compressed . Muscles work in an asymmetric way, thus multiplying the risks
of dysfunction.

Centric relation is repetitive

Among the multitude of possible mandibular position s, two can systematically be found:
the ICP and the centric relation. ·
 3 Centric relation

The repetitiveness of centric relation is connected to the anatomy of the temporomandibular

joint: in centric relation, the position of the condyle against the disk and the temporal
eminence is a "border" position, with no physiological constraints. In normal articular
conditions, the mandibular manipulation allows to find this position. The clinical advantage
is obvious: fro.m one session to the other one, this position can be used as a benchmark.
During the mounting of the mandibular cast on articulator, this one is validated by the
repetitiveness of the registered positions. This manipulation will ,be described in a following
chapter.

Centric relation is reproducible on an articulator

In centric relation, the mandible can make a movement of pure rotation, called "terminal
hinge axis movement", easy to reproduce by a simple hinge axis, as it is the case on an
articulator (Fig. 12).

Centric relation is recordable independently of teeth and

OVD
On the closing pathway in centric relation, the interposition of recording materials allows
to record a position free of any interfering dental contact (prematurity for example). As this 41
process is carried out around a pure hinge axis, the rotation allows variations in mandibular
opening, and thus in occlusal vertical dimension (OVD).
Let's take the notion of.centric relation as an approved theorem, and let's use its advantages
so essential to the clinician!

IN SHORT
Gemlbliti<:: 11elati0n provides to
priactit ieners a physiGlogical position
~er diagnosis and trea:trmer;it.
lJ>11111irig tlile diagnosis, it is ti';ie reference
p@siroi@m wl1lich allows te assess
ibbie cil is11> la<ile1il'ilelilit 0~ tble ©Gcl.l!lsier;i amcd
!lloiru s ttio <q l!lcHilibiffiwil!me p>a ;t!hG~eraic;: nisk.
lii>rurni m~ mm e il!~ealtlil'il.e mtt, WJ.e t1se itt as a
p@siiliiIDm ®Ji 11ea0ms:t11ucltiom.
A !!JaJi> fuelliwee.m l!.'.:P amdl CB earn
!De elDservedl im ~$9/o 0f itme p.adliemlts.
~'5 a G©lilSeGfl!le'l'ilCe, urois gafi) lil'ilay
be aemsi€1ene© as sta1iisilli<::all~ morrmal.
Ille s0le dlelliecilli®n Gf suarn a !!Jap lffilLISt 12 The transverse axis
lllG>it lead tio a s~s"t!elffilat i e <::0 rrectiori oif of rotation of the mandible and
the traverse axis of rotation of
tllfue p>aibie.l'iit's G<::dusi©n.
the articulator are superposed.
 Occlusion made easy

Centric relation recording techniques

We have just evoked the interest of this position, but it is necessary to underline that,
among all the clinical procedures performed during the occlusal examination or the stages
of the mounting onto articulator, the approach to centric relation is the one which demands
actual clinical experience.
A s described in the first chapter, patients with teeth find the intercuspal position with
automated movements of their neuromuscular system.
As for edentulous patients who do not have any dental references any more, they are faced
with a situation of muscular uncertainty and are not able to help us in any way.
The gestures are both difficult to teach and hard to acquire from a book. In order to try
and achieve this goal, it is good to explain how to elude the vigilance of the neuromuscular
system, and determine the conditions in favor of this approach.
The centric relation cannot be recorded without understanding first the
guidelines for a good practice of the mandibular manipulation techniques
and this recording always requires a preliminary training of the patient.

42 Patient's position
The patient lies supine at 45° in the dental chair, with the
practitioner positioned at 9 o'clock .
The patient's head is aligned with
the body with no flexion and no
extension (Fig. 13-14-
15-16).
The atmosphere
must be quiet and
relaxed, otherwise the
practitioner's stress
might be perceived by
the patient
-
13 The patient lies in a comfortable position;
the practitioner sits at 9 o'clock.

14 The patient's head is in the 15 Head extension tends

axis of the body. to position the mandible
backwards.
 3 Centric relation

Choosing the adequate words

What we say is not necessarily what is going to be understood: just take a small test to
be aware of the fact. Tell somebody: "Lean over!" Most of the time, the person will lean
forward, and not backward or over the side. The action reflects the person's own id ea of
the instruction he/she's been given and it is also the easiest way for him/ her to perform thi s
action . All of us have also observed that when we ask a patient to clench his/h~r teeth, the
response we often get is an end-to-end occlusion, in which th~ patient applies tremendous
pressure. These examples show that terms which are obvious for the dental practitioner may
be differently understood by the patients.
Regarding the centric relation, the mandible must be, at the beginning, in a state of postural
muscle tone. What must we ask the patient to obtain this position? We suggest a few
expressions which allow to obtain this result: "ha lf-open your mouth", "drop your chin" .
These rather vague terms generally result in the needed position. The practitioner's word s
must always be positive and encouraging to the patient, even if he/she does not meet our
expectations: "It's good. Now, we are going to do this or that".

Working position
With one hand, the practitioner carefully sei zes the 43
patient's chin. The thumb and the index of the other
hand come as a support on the buccal faces of the
maxillary canines; the pulp of fingers is in contact with
the mandibu lar teeth during the closing movement
(Fig. 17). The axis of the arm is in the patient's
midsagittal plane. The movement of manipulation
of the mandible is made with a rotation of the
practitioner's elbow, the wrist and the forearm are
17 The pulp of f ingers checks
the clos ing movement, the softened
interdependent during this movement (Fig. 18). The contact reassures the patient.
orientation of the arm tends to position the mandible
upward rather than towards the back . If the movement of rotation is situated at the level of
the wrist, the manipulation is not right and tends to put the mand ible to the back (Fig. 19).

/ ''

~ 8 Proper posit ion and man ipu lation: t he wrist 19 Inadequate man ipu lation : the wrist moves
is aligned with the forearm, the rotation occurs from top to bottom , the mandible tends to move
in the area of the elbow. backwards .
 Occlusion made easy

When the practitioner's gestures are too directive, ·the patient may try to resist; gentleness
is thus necessary (pressure backwards induces protrusion, a quick elevation of the mandible
or a reflex of opening).

Taming the neuromuscular system

If we refer to the pedagogical model published by Niles Guichet in 1977, it is easy to
understand the reactions of the neuromuscular system and the techniques to avoid alerting
it during our manipulation.
First of all, we need to study the simplest element: the periodontal ligament fiber. These
fibers are elastic and this allows them to stretch to a certain limit with no risk of damage.
Beyond this limit of physiological stretching, a lesion may occur. An alarm system indicates
the closeness of this limit in order to avoid excessive loading and the risk of lesion . By
convention, we set the physiological limit at 2 loading units (Fig. 20).
Periodontal ligament fibers are not isolated; they are integrated into a radiated fascicle
arranged around the root of the tooth. If this fascicle contains 1O fibers, the bearable load
in the axis is 1O x 2 units, that is 20 units.
44 Several similar fascicles can be found all along the root. For 5 fascicles, the loading capacity
adds up to 5 x 20 = 100 loading units, if the
load is applied in the tooth axis. On the other (
hand, if the load applies obliquely, all the fibers ((
are not requested, only a smaller number of
them (Fig. 21). Let's take the example of a
group of firemen at the foot of a building on
physiologic
fire who stretch a circu lar net where someone
limit
caug ht in the flam es is about to jump. If the
person lands in the middle of the net, all the
firemen will absorb the fall; however, if the 20 An alarm starts before reaching the
person lands near the edge, a few firemen only physiological load limit.
will take part in the effort and the whole thing
will collapse.
It is the reason why the alarm is activated for
a much lighter load than the load applied in
the axis. It is exactly what we experience when
we try to obtain a more backward position
than the ICP, by requ~sting premature contacts
(Fig. 22).
Guichet suggests respecting certain rules
concerning the speed of manipulation and the 20 force
units
degree of separation of both jaws. These two 20 force
100 force
conditions are linked in practice and depend on units units
the quantity of absorption of strengths allowed
by the patient's oral condition. A patient with 21 An oblique load recruits fewer fibers; The
alarm is activated for a lighter strength.
all his/her teeth in healthy condition will allow a
 3 Centric relation

22 The manipulation in CR frequently meets with 23 Healthy arches allow to keep a certain distance
prematurities generating oblique contacts, hence during the manipulation.
the importance of a gentle manipulation.

25 % loss of supporting
structures

45

- 24 The loss of a molar reduces the potential of 25 A weakened periodontal support also decreases
absorption of the strengths; the amplitude of the amplitude of the manipulation.
the manipulation is thus reduced.

wider mouth opening than another patient

who lost some teeth or with malpositio-
ned teeth, generating prematurities as a
consequence (Fig. 23-24-25-26).

2 mm To be totally convinced, let's just clap hands.

If a 20-centimeter distance separates both
hands, it is possible to clap them with a cer-
tain energy. If the distance is only 1 cm, we
cannot slap them.

The patient's neuromuscular system once

again plays its protective role by allowing
26 Irregular arches limit the capacity to bear more or less amplitude in the manipulation
the impact of closing. process.
 Occlusion made easy

27 The practitioner gradually moves away the 28 The contact in CR is made, the patient becomes
pulp of his fingers to let the first contact occur. aware of this unusual support.

46

29 A sliding occurs, bringing the mandible in 30 Wax strips applied against the maxillary are
ICP. maintained in their mesial angle.

Without app lying any pressure, the operator guides the patient in low amplitude move-
ments of opening/closing. We may say that he/she "suggests" the movement to the pa-
tient. Here aga in, some simple words may accompany the manipulation in order to guide or
encou rage the patient: "move up", "move down", "slowly" ...
Whil e making the sma ll movements of opening/closing, the practitioner gradualry removes
the pulp of his/her fingers placed on th e maxillary. This way he can let the mandibular teeth
come in contact with t.he jaw, generally on one point. Th e gentleness of the contact allows
th e patient to identify the place properly where it occurs. From thi s contact, the practi-
tioner"' asks the patient to keep on closing : "slide". A movement towards the ICP occurs
(Fig. 27-28-29). Thanks to this type of slight contact, t he patient does not dread contact,
even premature ones, and he/she becomes aware of the skid occurring at t he end of the
closing . There is trust now in the dentist/patient re lationsh ip, and this element allows the
operator to repeat the movement while th e neuromuscular system is not on the alert.
If centric relation cannot be "seen", a little training allows "to feel" it when w e get to th e
movement of rotation. The operator ca n also feel th e first occlusal contact if t he movement
is performed with all the req uired gentleness.
 3 Centric relation

This preliminary stage is longer to describe than to carry out. It is essential before procee-
ding to the clinical recording of the centric relation. This preliminary training of the patient
is generally not necessary during the following sessions, when it will be necessary to record
the centric relation on the same patient.
We can only advise general dental practitioners to perform on all their patients this mandi-
bular manipulation (whatever the treatment they have to perform then). It will allow them
to acquire quicker the clinical experience in this field . "'
Seen in this way, achieving centric relation cannot be considerep ·as a forced position, unac-
ceptable for the patient's comfort. It simply consists, during the treatment, in making com -
fortable occlusal relationships coincide with an optimal articular position while favoring
muscular efficiency.
The polemic around the centric relation, when its therapeutic position wa s not accepted
by everyone, resulted from its former improper definitions as well as from its recording,
brutally and forcefully taught.

How can centric relation be recorded?

The recording method has just been explained. The recording of this position is based on a
simple principle: in order to make sure to record an articular position, it is necessary to avoid 47
any dental deflective contact. The recording materials must not be perforated by occlusal
contacts. They will be chosen according to the clinical situation.
When all teeth are present, the method of sectoral wax is easy-to-use and ergonomic.
Double layers of Moyco wax strips are prepared, heated in water at 52 °c (125 °F) then
applied from the canine to the second molar on every maxillary hemi-arch. The mesial angle
of these. waxes, covering the canines, help keep them immobile (Fig. 30). In the case of an
incomplete arch, waxes are placed where they can be best stabilized.
A gentle manipulation results in an immediate indentation of wax. Wax strips are removed
after having cooled and are immediately controlled: in case of perforation, poor or impro-
perly distributed indentation, they are discarded and a new recording is performed.
They are kept in a tank fill ed with cold water, waiting to be used. We sha ll describe in detail
this manipulation in the chapter dedicated to
the mounting on articulator.
The prosthetic situations and the types of
KEY POINTS
recording materials will be described in the
chapter dealing with the prosthetic occlusion lhe clil'ilical properties and advantages
in daily practice. of centric relation are obvious and
r;nake it necessary dwrir'lg the diagnosis
arid the occlUJsal rernalDilitation. Before
p110ceeding to the reconding 0f tmis
pos-ition, a fiirst test is required so that the
pat ient understarads and accepts without
relwctanae the marn!i:libw lar lililat71ipulation.
lhe e:volution of tl11e kriowledge has
resulted in a conserasus about centric
relati0n, combirning ithe fundamental
principles arn@ 1Jhe clinical pract ice.
 Occlusion made easy

When manipulating a patient turns

out to be difficult, it may be helpful
to use a very simple device to facilitate
the approach to centric relation.
A plastic plate cut to the size of a credit
card is used and interposed between
-O! the arches as a "deprogrammer" of the
patient's occlusal habits. The patient
w
:::c: makes some movements of protrusion and
I- diduction on the plate. In two to three
minutes, the mandibular manipulation is
faci Iitated.

48

HELPFUL READING
• Guichet NF. Biologic laws governing functions of muscles that move the
mandible. Part I: Occlusal programming . J Prosthet Dent. 1977;37(6):648-56.
• Guichet NF. Biologic laws governing functions of muscles that move the
mandible . Part II: Condylar position. J Prosthet Dent. 1977;Jul;38(1):35-41 .
'
• Guichet NF. Biologic laws governing functions of muscles that move the
mandible. Part Ill: Speed of closure-Manipulation of the mandible. J Prosthet
Dent. 1977;38 (2) :174-9.
• Guichet NF. Biologic laws governing functions of muscles that move the
mandible. Part IV. Degree of jaw separation and potential for maximum jaw
separation . J Prosthet Dent. 1977;38 (3) :301 -10.
• Orthlieb JD, Hernandez G, Darmouni L, Re JP, Girardeau A, Slavicek G.
Myostabilized Centric Relation: A Consensual Articular Reference Position.
International Journal of Stomatology & Occlusion Medicine 4, no. 3 (November
2011): 87- 94. doi:10.1007/s12548 -011 -0014 -7.
 Mandibular
movements
It is very easy to observe on patients the basic movements which are:
- The opening movements of the mouth,
- The latera l movements, with and without dental contacts.
This simple observation of the movement amp litude and its regularity provides information
about the health of the system. The harmonious muscular function reflects the good
49
integration of the occlusion with the muscular and articu lar components. Moreover,
the anatom ical parameters which determine these movements have an impact on the
morphology of the occlusal surfaces of the teeth, which are our daily playground.
We will also see that the recording of some specific positions and movements allows the
mounting of the casts on articu lator and the setting of the articulator.
As for the manducatory apparatus, it is necessary to distinguish three types of movements:
• t he border movements: a border movement refers to the maximal amp litude of
motion allowed by the dental, articu lar and ligam ent anatom ica l structures.
The movement is described from the position of occlusion towards off-centered positions
(centrifugal like). They are genera lly sli ghtly increased in a passive way when an external
strength is app lied . Beyond these borders, a lesion of the anatomica l structures occurs
(dislocation). The interest of these border movements and positions is that they are
reproducible, requiring in some cases to be guided by the opeTator.
• t he fundamental movements: they allow to assess the capacities of movement of
the manducatory apparatus. They are performed upon the practitioner's request during
the clinica l exam ination, sometimes requ iring some explanations because they are not
common. The positions can be performed in an active way (the patient opens his/her
mouth widely) or might be guided (the practitioner presses on the incisal edges).
• t he physiological movements: they play different types of roles: mastication and
deglutition which generate occlusal contacts, but also phonation, which usually does not
induce dental contacts and yawning.
 Occlusion made easy

The border movements

It is possible to define a maximal envelope of
motion for the border movements (a bowl)
inside which the physiological movements will
take place (the goldfish) (Fig. 1).
A detailed description wa s made by Posselt.
The Posselt's diagram (Fig. 2) can be obtained
by recording in the three planes of space the
movement of the mandibular interincisal point
during the border movements of the mandible. 1 The fishbowl represents the envelope of the
border movements the fish can do.

50

2 A stylus attached to the mandible draws the mandibular

movement in the three planes of space.

Forward movement: protrusion

In a sagittal plane, the starting point is the intercuspa l
position: the patient moves his/her mandible forward,
the mandibular incisors follow the palatal surface of
the maxillary incisors, ·and finally come into end-to-end
occlus(on, exceeding the incisal edge.
The posterior teeth are then in contact and limit the
movement upward.
At th e end of protrusion, the patient opens his/h er mouth
as much as possible. The amplitude of the movement is
t hen connected to the muscular and articular conditions.
The patient closes his/h er mouth until ICP without 3 Sagittal view of the
following a border pathway (Fig. 3). protrusion movement.
 4 Mandibular movements

4 Sagittal view of the 5 Front view of the left 6 The articulator reproduces
the envelope of the border
retraction movement. and right movements.
movements.

Backward movement: retraction

From the ICP, the patient, guided by the practitioner, moves his/her mandible backward 51
towards the centric relation while maintaining dental contacts.
From the centric relation, the op.erator guides the patient following an open ing movement
in pure rotation around an axis called the "hinge axis". This rotation is only possible in a
small amplitude (15 mm between incisors); then, the maximum opening is achieved with a
translation of the TMJ (Fig. 4).
It is also possible to observe the border movements in the frontal and horizontal planes
from the intercuspal position towards lateral positions to the right, to the left and forward
towards maximum protrusion, which allows to obtain a record (Fig. 5).
The combination of these observations in the three planes of space determines
a volume cal led "the enve lope of the border movements".
The role of the arti cu lator after adjustment is to
reproduce this envelope (Fig. 6).
The reference border movement is the terminal _ - - } · _,_ - .
hinge axis movement. The terminal hinge axis
movement is a movement of "pure" rotation - ·
which is obtained with centric relation guidance,
when the TMJ is positioned. The rotation is performed
in the condyle -disc compartment of the TMJ around a
virtual transverse axis passing through the internal pole of
the mandibular condyles (Fig. 7). The rotation amplitude
is lim ited between the incisal edges (1 O in 15 mm). Being
ab le to use this movement is very important, because it
allows to transfer the patient's information to an articulator
which also has an axis of rotation .
The cutaneous emergence of the transverse axis is located 1O millimeters
in front of the posterior edge of the tragus. Nowadays, during the
.
7 Th e termma
· 1 h' · t
mge axis movemen .
placement of a facebow aiming at the mounting on articulator,
 Occlusion made easy

the use of auditory meatus as benchmarks is a clinically reliable interpolation (see the chapter
on the mounting on articulator). We can explain in detail three fundamental movements
that may be observed on our patients: the opening, the protrusion, and the diduction
(lateral movements to the left or to the right). In a pedagogical approach, these movements
are described here from a centrifugal point of view. We will see further in this chapter that
the occlusal phases of the physiological movements are on the contrary centripetal.

The three fundamental movements

Movement of opening I closing
During a voluntary movement of opening seen in front view from the intercuspa l position,
the "dentale" (mandibular interincisa l point) follows a rectilinear path downward (Fig. 8).
At the level of the TMJ, there is a symmetric forward movement of both condyles.
Seen in a parasagittal plane, the movement of the condyle-disc assembly goes down,
following the direction of the articular tubercle . This movement is the result of a combined
movement of rotation (lower joint compartment: condyle and articu lar disc) and translation
(upper joint compartment formed by the articular disc and the temporal bone). Vi ewed
52 from the sid e, the dentale follows a curve with posterior concavity (Fig. 9).

8 Opening, symmetric
movement of both condyles.

9 Openin9: the condylar

movement combines
rotation and translation.

This movement results· from a symmetric and

synerg i_s: action of the depressor and propulsive
muscles.
The average ampl itude is 50 millimeters (three
fingerbreadths). It is necessary to take into
account the in cisa l overbite to measure the space
between the incisa l edges. The closing movement
towards the ICP is normally symmetric, involving
levator and retropulsion muscles.
 4 Mandibular movements

Movement of protrusion
It is a forward movement of the mandible with a minimal component of opening. It is
difficult to obtain on patients without precise explanations. The dentale moves sagita lly
on a rectilinear pathway, while the mandibular condyles symmetrically move forward
and lower agai'nst the articular tubercle. The rotational component of the condyle under
the disk is less pronounced than during the opening (Fig . 10-11). The clinical ir.terest of
this movement is limited to the end-to-end position which is th,e border of the patient's
functional movements. We can observe a posterior teeth separation under the double
influence of t he lowering of the condyles and the anterior guidance.

53

10 Protrusion
movement.

Lateral movement: diduction

Diduction is a lateral movement of the
11 Protrusion. mandible to the left or to the right.
It is an asymmetric movement of the
mandible with a horizontal component. At
the beginning of the intercuspal position,
the maxillary and mandibular canines are
in contact; the movement goes outward,
until the border lateral position . The
standard amplitude ranges from 15 to 20
mm between the interincisal points, which
is approximately a quarter of the maximal
amplitude of opening.
In this movement, the right and left TMJ
are the site of very different movements.
 Occlusion made easy

54
12 Lateral movement (diduction). \ .

Let's take the example of a movement to the right

The right condyle is called the "working condyle" or "rotating condyle". It globally make~
a rotation around a vertical axis. Because of its oblong shape and of its setting in the mandibula1
fossa, the condyle cannot make a strict rotation around its vertical axis without making first a latera
translation, most of the time outward, at the top and backward .
This lateral movement of the mandible is called the "Bennett movement". The Bennett movemenl
(not to be confused with Bennett's angle) is an adjustable parameter on the most of the currenl
articulators.
The left condyle is called "non -working" or "orbiting" condyle: it moves downward, forward
and towards the median plane. This movement is wider than the one on the working side. The
condyle follows the slope of the articular tubercle. The downward slope going from a reference
horizontal plane is ca ll·ed' "condylar path". The angu lar component between a parasagittal plane and
the m,edian plane forms the Bennett's ang le (Fig. 12).
These two parameters are essential settings on the articulator. .
This is the point where research meets practice. Thanks to a device designed by Lee (1969), a stud)
of the border mandibular movements conducted by Lundeen (1982) on 100 subjects showed tha1
the movement recordings of the non -working condyle presented a constant Bennett's angle of 7 °.
The variability of the path s was due to an immediate side shift occurring at the beginning of the
movement (Fig. 13).
 4 Mandibular movements

Ol
c
' At the beginning
~
.... .
of the movement,
0
$
J
the translation

All the paths are parallel and

form a 7° angle with 55
the sagittal plane.

13 Superposition of 100 recordings 14 Influence of diduction on the occlusal anatomy.

of the diduction movement
(according to Lundeen).

This element has important clinical

ke1
repercussions, because this portion of the
Jlar
path is connected to the moment when
occlusa l su rfaces get closer or separate.
According to the amplitude of the lateral
ent movement, the occlusal surf ace re lief
·ent will be more or less pronounced to avoid
functional interferences (Fig. 14).
These stud ies led to the design of a new
generation of semi-adaptable articu lators,
currently avai lab le on the market, including
the adjustment of the initial latera l
movement.
KEY POINTS
The b0rder rnar;iciibular movements,
accord inQJ to .their amp litude and to
t l1reir neQJwl'ariit ~, fi> l'lovide indications
on illme lfieal;th 0f :t"1e rnanc!luca<t0ry
apj:i>ar:atws.
They are use.cf 'lio configure the articulator
f.riorm tlote valwes recorded on the patient.
The characteristics ef these movements
have an ir.npact on the occlusa l
morpholG>gy.

ud1 The physiological movements

tha
•O
The envelopes of the physiological movements are located within the envelope of the
border movements. Let's note, however, that mastication during the occlusa l phases as
th well as deglutition coincide with the paths of the border movements . Chewing is the most
important physiological movement.
 Occlusion made easy

15 Comparison between
the envelope of border
movements and the envelope
of physiological movements.
• Border envelope
• Masticatory movements
• Phonation

The phonation occurs in an even sma ller envelope and is normally performed with no dental
contacts (Fig. 15).
The scientifi c study of the functional mandibular movements is much more recent than
the stud y of the border movements, because the required equipment to carry out such
studies [s more sophisticated and uses computers . The study published in 1980 by Lundeen
and Gibbs provided a very important fundamental knowledge base. The study included a
sample of 185 patients, of various ages, presenting or not dysfunctions or parafunctions .
We will describe here the outcome of the st ud ies on mastication, which is extremely
interesting in our clinica l practice. The system cons ists of a recording device placed on the
patient, connected to a comp uter, combined with a simu lator reproducing the movements .
56 The recording device is made of two bows, one attached to the maxillary and the other
to the mandible, with no interference with the occlusion . The patient performs border
movements, but also masticatory movements with different kinds of food. Optoelectronic
sensors col lect the information on movements and transfer them to a computer.
The recorded data are processed and exported in the form of li nes on a printer.
Theses lin es are reproduced in the area of the mandibular interincisal point, of the f irst
molars and of the condyles . The data are also processed by a device cal led "Replicator".
Replicator is a mechanical device in which the patient's casts are placed. Six stepping motors
reproduce the movements recorded on the patient, which allows to observe on casts, in
slow motion (1 O times slower), how dental contacts occur during t he masticatory cycles.
Th is study shows that there are approximately 15 chewing strokes from the time food enters
the mouth until it is swallowed. Jaw separation is maximal when food is put into the mouth
and decreases in a li near way
during the phase of trituration i ntercuspa I position
(Fig. 16). The cycle depends
~~
on the cons istency of food: in Deglutition
the presence of hard food, the
intercuspal position is not reached
during the first cycles a·nc1' th ere is
no paw;e in the movement; when
the intercuspa l position is reached,
a pause of 194 (± 38) mill iseconds
can be noticed in the subject with t im e in seconds
a proper occlusion. Subjects with -- -------- -- - - - - -- - - - - ---
a pathologica l occlusion or mobile
Entry of food into mouth
teeth rarely reach the intercuspa l
position and cannot easi ly make 16 Amplitude and pace of a sta ndard masticatory cycle.
 4 Mandibular movements

17 First phase of the masticatory cycle. 18 The working side moves sideways just before
coming back to occlusion.

breaks, even when the intercuspal position

is reach ed . We observe that the periods of
dental contacts during a meal result in little
57
cumu lative time.
These studies allowed . a better
understanding of what is a standard
masticatory cycle in a healthy subject.
The mas4:icatory cycle starts with the food being
incised and placed on the working side of a pre -
molar/molar sector.
After the food being incised, the mandible opens
downward and forward according to a midsagit-
tal course. The movement of the condyles is
. . 19 At th e en d of th e eye 1e, th e t ransverse
almost symmetric (Fig. 17). movement is the expression of Bennett's
As soon as the closing starts, the path goes movement.
sideways on the working side (Fig. 18). The
working condyle quickly moves upwards and backwards and finally ends its route forward
n in ICP. The non-working condyle simu ltaneously moves up- and backwards until ICP. As far
as the occlusion is concerned, this kinematics results in an access to ICP in a back to front
direction on the working side and in a front to back direction on the non -working side
(Fig. 19).
The movement of the condyles is asymmetric when seen from the top (Fig. 20). At point 5,
the working condyle is already in a return position . At point 8, it is sta rting the end of the
cycle by moving forwards, while on the non-working side, it has not reached the most
posterior position . On the working sid e, the end of the cycle follows the border movement
path (which is not the case on the non-working side).
A clinical consequence of this situation can for example be observed in the area of the first
molars, the movements of which are different on the working side and on the non-working
side.
 Occlusion made easy

On the working side, the closure has a

lateral-posterior approach, with a forward
component (Fig. 21). On the non-working
side, the closure goes backwards from a
median position (Fig. 22).
The masticatory cycle varies according to
food consistency and the subject's age, or
in the presence of dysfunctions.
The harder the food is, the more lateral the
/ cycles of closure are, before following a
20 Comparative superior view of the condylar vertical path when the food bolus softens.
movement. In children aged 4 to 1O years old, the
opening is not sagittal but lateral on the
working side; the cycle pattern changes at about 12 years old with the eruption of the
permanent canines.
In the case of teeth severely damaged by abrasion, the paths of the incisal point are flatter,
indicating a loss of anterior guidance; the condylar pathways feature big lateral movements,
58 the opening movement is managed by the non-working side. There is no pause at the
intercuspal position .
In a subject with multiple posterior interferences, the cycle has an irregular pace with erratic
crossed movements, does not regularly reach the intercuspal position and there is no pause
when it occurs .

Forces applied during mastication

It is difficult to measure the global force during mastication without interfering with the
occlusion . A specific device was designed by Gibbs and al. (1977) measuring the transmission
of ultrasounds between a transmitter placed on the forehead and a receiver placed on the
chin. The vibration is transmitted to the chin through teeth, muscles and TMJ (the more
intense the contacts are, the more significant the transmission). In addition, a calibration is
performed by electromyography.
In spite of a relative inaccuracy, the comparative evaluation gives an idea of the global
forces involved during mastication and the duration of their application (Tables 1 and 2).

21 Working side at the

end of cycle: anterior-
posterior component in
the area of molars.

22 Non-working side
at the end of cycle:
anterior-posterior
component
in the area of molars.
 4 Mandibu lar movements

Ta ble 1 Bite force during mastication according to

Lu ndeen
Average (KG) % Maximum
bite force

Closing force 8,3 11,2

-
Force at 26,7 36,2
occlusion
Opening fqrce 5,7 7,7
20 adu lts with a good occlusion app ly forces
KEY POINTS
wh ich are maxima l during the occlusa l phase and
reach 36,2 % of the maximum bite force in the The standard masticatory
20 subjects . cycle was defined in
the healthy subject and
Table 2 Duration of the masticatory cycle according includes wide lateral
to Lundeen closing movements. Gliding
tooth contacts occur with
Average
(Ms)
Standard
Deviation
high forces during the 59
occlusa l phase, but of short
Time of chew 672 122 cumu lative lengths during
a meal.
Time of occlusa l 194 . 38
fo rce The rmasticatory cycle
reflects the health condition
Time of high . 115 35
of the manducatory
force during
occlusa l phase apparatus.

The maximal force lasts on average

115 milli seconds, i.e 59% of the occlusal contact
duration.

HELPFUL READING
• Ide Y, Nakazawa K, Kanimura K. Anatomical at las of the temporomand ibular
joint . Quintessence publishing Co. 1991
• Gibbs CH, Mahan PE, Lundeen HC et al. Measuring masticatory force by sound
transmission, abstracted. J Dent Res. 1977;56: Special issue A, 165.
• Lee RL. Jaw movements engraved in solid p lastic for articu lar controls (part 1 & 2)
J Prosthet Dent. 1969;22 (2): 209 -24. 513 -527.
• Lundeen HC, Gibbs CH. Advances in occlusion. Postgraduate denta l handbook.
Boston W right, 1982.
• Lundeen HC, Wi rth CG. Cond ylar movement patterns engra ved in p lastic blocks . J
Prosthet Dent. 1973;30(6):866-75.
Occlusion made easy
 Clinical examination
of the temporomandibular
disorders (TMD)

Nb.
600 1- - - - - - - - - - - - - · - - · - - -

509
500 i----1 ----F""~---r-----
Q
61
•
400 1--- -i - -+ - -+ -- - i - - - - -" - -

19 Age
Treatment
1Prevalency of TMD. required 2 Prevalency men/women.
The incidence of the TMD in the general population remains difficult to appreciate. In
the literature, we can notice a big disparity in the resu lts since there is no consensus on
the criteria of diagnosis. It is difficult to objectively appreciate the , importance of the
symptoms evoked by patients. The synthesis of the stud ies conducted by Okeson (2003)
shows that a relatively high percentage of people suffers from these disorders.
To Lobbezoo et al. (2004), ch ildren and elderly people are rarely concerned, an important
peak of appearance of a symptomatology occurs during the ado lescence, and the disorders
have different natures (noises, algia, dyskinesia).

In a population of "non patients" subjects (Fig. 1):

- 75% have at least a sign of TMD;
- 41% present a muscular TMD;
- 33% present an articular TMD;
- 7% only are affected severely enough to require treatment.

TMD affect both men and women, regardless of age, although with a significant increase of
the prevalency for women (ratio men/women 1/7 to 1/9), and in the age range 15-45 years
old (Howard J.A., 1991) (Fig . 2).
 Occlusion made easy

Clinical examination of the manducatory

apparatus
This examination consists in the screening and the diagnosis of the temporomandibular
dysfunctions (TMD). A preliminary clinical interview before the examination allows to
observe the patient and to collect subjective elements (things the patient expresses). The
clinical examination collects objective elements based on a visual, auditory and palpatory
exploration (muscular and articular systems) and the functioning of theses systems. The
synthesis of this information helps make a diagnosis and determining a treatment strategy.

A few principles
The general dental practitioner's role in the screening process
The population of symptomatic patients represents 3 to 7% of the general population.
Screening the dysfunctions of the manducatory apparatus is not the sole responsibility of
the specialist, but may also be performed by the general dental practitioner. He/She may
globally be confronted with two categories of patients during the screening process:
- Patients undergoing treatment: the dentist detects an unusual sign while a
62 prosthetic treatment was envisaged : the screening aims at highlighting structural or
functional anomalies which will cause in the long term a disability and sequelae for the
patient. It will allow to optimize the global treatment process by taking into account the
patient's functional I dysfunctional condition and thus perform an oral treatment which
will be free of the constraints due to this dysfunction;
- New patients sent by a colleague doctor or by another patient who come to
consult for painful or functional disorders: in this case, the protocol is stricter aQd, once
the diagnosis has been made, the decision will be whether to start treating or to refer
the patient to a dentist more specialized in occlusal treatments, if necessary.
Ergonomics of screening
At first intention, a thorough, specialized examination of the manducatory apparatus is not
indicated. The practitioner will focus on the potential existence of revealing signs which,
if necessary, will require a more detailed examination. A panoramic X-ray is an essential
element at this stage of the screening . Numerous elements of positive or differential
diagnosis can be seen on this type of radiography.
General strategy of screening
The goal is to screen the anomalies by using "warning signs " including three main elements:
- Articular noises,
- Pains,
- A-Iterations in the mandibular movements (dyskinesia).
Recent and severe pains need to be seriously considered; in the absence of obvious causes in
the maducatory apparatus, the patient must be quickly referred to consultation with other
specialists (ENT specialist, neurologist) in order to make a differential diagnosis with a tumor
evolution . Persistent pains (more than six months old) are more reassuring concerning the
patient's vital prognosis, but the chronicity is often due to a multifactorial origin; in this
case, the treatment must be supervised by a multidisciplinary team.
 5 Clinical examination of TMD

The part. due to tics, habits or behavior in the appearance and the evolution of a TMD,
and even the perception of theses elements by the patient, is difficult to assess clinically. In
general practice, however, we must be aware of the impact that the physical or psychological
behavior may have on the manducatory function s.

Chronology of the clinical examination

1. Anamnesis and patient's assessment
2. Assessment of the mandibular kinematics
3. Articular palpation
4. Muscular palpation
5. Examination of dental arches and occlusion (a specific chapter is dedicated to this)

Preliminary interview
As soon as the patient arrives in the examination room, the practitioner carefully reads the
medical questionnaire filled by the patient in the waiting room. Certain pathologies and/or
systematic diseases such as migraines, polyarthritis or fibromyalgia can influence the health
of the manducatory apparatus.
The morphological and behavioral characteristics that are: the height, the corpulence, the
63
visible age, the general posture and the general mobility are important elements for the
diagnosis.
An empathic attitude of the practitioner and words like: "I'm listening to you" allow to get
familiar with the patient's medical history.
The practitioner can use a list of some simple questions allowing to direct the diagnosis
(Okeson,. 2005):
1) Is it difficult or painful to open your mouth widely?
2) Does your jaw sometimes remain closed, locked, or does it dislocate?
3) Is it difficult or painful to chew, speak, or yawn?
4) Are your jaws sometimes stiff, tense or tired?
5) Are the joints of your jaw noisy?
6) Do you sometimes feel pain in your cheeks, ears, temples?
7) Do your head, neck or teeth frequently ache?
8) Have you recently suffered from a trauma in the area of the neck, the head or the
joints of the jaw?
9) Have you recently noticed modifications in your occlusion?
1O) Did you get a treatment for unexplained facial pains or problems in the joints of the
jaw?
11) Have you already felt problems with your jaws: pains, articu lar noises, functional
discomfort? If so, when?

These questions can be asked by the dentist during the anamnesis or, more simply, added to
the patient's medical questionnaire which he/she fills in before his/her appointment.
 Occlusion made easy

The location of pain is an indication of its origin

(Fig. 3) and guides the examination more
particularly toward the muscles or the joints.
Pain assessment is made easier and more
reliable with the use of a visual analog scale
(VAS). VAS is a 10-centimeter plastic ruler in
millimeters, which can be presented to the
patient horizontally or vertically.
On the face shown to the patient, there is a
pointer that he/she can slide along a straight
line; one end indicates "No pain", and the other
one ''- Worst pain ever''. The patient must place
the pointer on this line, where it quantifies best
its pain.

On the other face, millimeter graduations can • Muscular pain

only be seen by the practitioner. • Articular pain
64 The position of the cursor indicates the pain
intensity, measured in millimeters. This value, 3 Articular and muscular painful zones.
registered on the patient chart, allows to
assess the evolution of the symptom during the
treatment (Fig. 4).
These moments dedicated to the interview with
the patient are important: beyond the essential
human relationship, beyond the doctor/
patient bond, they allow to handle better the
patient's psychological and behavioral context.
Tics, tensions, confusing explanations, signs
of moodiness, anxiety, exuberance, atonia
and resignation are indications of his/her
psychological state.
The patient's behavior "tells what he/she does
not", so many elements which need to be
known to correctly target the treatment.

Before going further, it is necessary to

ling~r a little over the specific profiles of
certain "occlusal patients". The general 4 Use of VAS.
dental practitioner needs to be aware that he/
she can encounter particular attitudes which we
are going to describe in (near) caricatures .

5The organized patient: his whole
story lies in his briefcase.
6.The vicious circle of stress and pain.
7"It's a miracle!".
5 Clinical examination of TMD
The organized patient comes to your office with
a thick documented file, stocked with numerous
additional examinations: panoramic X- rays,
tomographies, scanners, MRls, sometimes even
bringing the "box of splints" containing a jumble of
orthoses which the patient has more or less worn
over the last few months or years (Fig. S).The history
is accurate, the chronolpgy carefully noted on sheets
- he may even provide you with some copies "to P,ut
in his file". He has consulted a great many dentists,
all of them incompetent, of course; thank God, you
were recommended to him: he is finally going to find
a solution to his problems.
Make no mistake! You are only another practitioner
on his list, and there will certainly be others after you.
This kind of patient lives on his disease, especially if
a connection can be made with a possible accident
and that financial compensations are at stake .
Make your examination scrupulously according to 65
protocols, and keep the tracks of your observations
in the medical record (you never can tell!)
The unfortunate: she's been very unlucky for a
while; since her divorce, she's been taking care alone
of the education of her two teenage kids who are
feeling depressed because of the situation (Fig. 6).
She likes her job, but the office manager puts her
under a lot of pressure: the company's prospects are
not good and it is necessary to work hard to avoid
the bankruptcyptcy. Unfortunately persistent pains
around the temples sometimes prevent her from
going to work, which is not good at all ..
A vicious circle concern/stress/tension has settled
down. Pedagogy and reassuring information play
a predominant role in the improvement of these
patients .
You are his personal God: When he arrived
suffering from pains in his jaws, you were the first to
listen to him and you did find the solution.
Since he's been wearing the splint you made for him,
he's feeling a lot better: it's almost a miracle (Fig. 7)!
After two control sessions where everything is fine,
you tell him that the treatment is finished and that
there is no need to make another appointment. At
this point, the discomfort suddenly reappears and he
calls back for "a quick check-up". If you give in and
 Occlusion made easy

adjust the incriminated zone by polishing it, everything

gets better again! And so on and on: you are his savior!
And for you, it is sheer hell! When you run out of
patience and sever the link, you will turn into the devil
and he will leave to look for another god .
The "occlusal hyperaware": "Doctor, since you
i .
have ground my teeth, I only contact on the mesial
internal incline of the palatal cusp of my second upper .!:li.-~
bicuspid, can you see me just five minutes to adjust it?" 8 "Please doctor, just a minute!".
(Fig. 8).
What can you answer to this? It is necessary to put an
end to the adjustment process!
Follow protocols. When the occlusal contact points are
checked and satisfactory, the treatment is over. The
remaining hundredth won't make any difference, the
problem lies somewhere else.
The parafunctional: throughout the interview, he's
66 been anxious, agitated, nervous! (Fig. 9) "Doctor, my
muscles hurt, is it serious? I am worried ... it's gnawing
at me! "You definitely will have to convince him to
change some of his habits if you want your treatment
to succeed, but it's not going to be easy!
It helps me feel better! Usually sent to the
consultation by her family, she wonders why she's
there. True, she admits she may be a little bit nervous
and she clenches her teeth, but she found a solution
(Fig. 10). "I know how to get some relief: when I bite
my towel, I am feeling fine!" This type of more or less
admitted behavior rather worries friends and relatives.
A more adequate solution is necessary, for the benefit
of all.
Any reser:nblance to actual living persons is not
impossible. These hardly exaggerated portraits are
there to underline the importance to detect as soon
as possible the relative proportion of somatic and
emotional factors in the' pathology.
Som~ occupations or some recreational activities
induce strainful attitudes or postures which can
influence the health of the manducatory system.
If the professional implications can be detected with
the questionnaire, those due to hobbies remain less
obvious. The patient does not necessarily associate
a pleasurable hobby with possible harmful effects
11 Musicians put their masticatory
apparatus under a lot of
(Fig. 11).
parafunctional constraints.
 5 Clinical examination of TMD

At the end of the interview, it is very important that the practitioner asks the following
question: "What do you expect from me?" The patient's answer is not always very clear;
it ranges from "I don't know what you can do for me" to "I can't take this any longer" via
"I would like to be relieved!". The practitioner will answer: "I am going to examine you and
then I'll tell yo~ then what we can do."
The practitioner must involve the patient, give him/her responsibilities, make bim/her a
partner and not an opponent in the treatment. He/she also has to limit right from the start
his/her action to the odontology field . ·
II

If the practitioner thinks that the emotional factor is significant, he must explain that the
disease is due to several factors, that he is going to take care of the dental aspect and turn
to other specialists in order to achieve the best result thanks to a multidisciplinary staff
synergy.

Clinical examination
Observation of the patient
During this cranio-facial investigation, it is necessary to note:
- The cranial, facial (Fig. 12) cervical-scapular asymmetries requiring functional
adjustments;
67
- The anomalies in the vertical plane (excess or defect), which must be the object of
a more detailed analysis in connection with the analysis of the occlusion and of the
dental arches (Fig. 13);
- The functional anomalies: in the vision or the eyes, respiratory, in the phonation, in the
facial motricity;
- The cephalic posture, which can be abnormal for anatomical, functional reasons
(adapted posture) or ergonomic (working position) and may impact on the functioning
of the manducatory apparatus.

ry
12 Facial asymmetry. 13 Excessive height of the lower part of the face associated
with a skeletal Angle's class Ill.
 Occlusion made easy

Assessment of the mandibular kinematics

The examination of the mandibular kinematics allows to highlight a functional handicap
(difficulties in opening, chewing, speaking) consecutive to an altered kinematics. It also
allows to assess, as a consequence, the various elements of the manducatory apparatus
(condition of muscles and TMJ).
The investigated mandibular movem ents are successively:
- Active movements,
- Opening I closure,
- Propulsion I retropulsion,
- Right and left diduction.
For every movement, 3 elements must be taken into accou nt during this assessment:
- The amplitude of the movement
- The trajectory of the movement
- The presence of pain during this movement and its localization.
In order to carry out this examination, it is necessa ry to use a ruler, to stand in front of patient
who sits, and to give him/her precise instructions after explaining him/her the purpose of
this examination. Indeed, the patient's commitment and active participation are essential :
"In order to assess the condition of your jaw, I am going to ask you to perform severa'I
68 movements: please follow my instructions without tensing, I shall help you if necessary"
The instructions must be directive: "Open your mouth as widely as you can, even if it's
slightly painful"

Active mandibular movements

During the first examination, the patient performs movements freely: "move your lower
jaw in all directions". It allows to assess the general mobility of the mandible, the .patient's
ca pacity to move it, as well as to detect the preferential functioning (difficulties in moving
forwards or on one side .. . by functional adaptation).

These movements are made with slightly separated

teeth . They must be ample, symmetric, painless and
should not generate articular noises. They will be
repeated with teeth in contact.
"Slowly grind your teeth by moving your lower jaw
in this direction, as far as possible." The movement
while teeth are in contact must be fluid, smooth
and must not be hesitant or interrupted .
•
A&Sessment of mouth opening
Mouth opening is performed by a combination of
rotation and translation movements.
It is measured with the ruler at maximal opening
from incisal edge to incisal edge (the most vertical
maxillary central incisor/ antagonist mandibular
inci sor) by add ing the value of the incisal overbite
14 Measurement of the opening
amplitude.
(Fig. 14).

15 Normal opening.
16 Ligamentary hyperlaxity, cofactor of
discocondylar dysfunction.
17 Assisted opening.
5 Clin ical examination of TMD
It is necessary to assess these measurements by
repeating three times the movement in order to
confirm the relevance of the measurements .
Maximal mouth opening with no assistance
and no pain: "Open your mouth as widely as
possible and painlessly." An active mobilization
of th e mandible is performed and measured,
during the v.oluntary total oral opening ach ieved
by the only action of the patient's 9epressor
muscles . This measure gives the total functional
opening .
The average value of oral opening in the healthy
subject is about 45 mm. We speak of a limited
mouth opening (LMO) under 30 mm and of
mandibular hypermobility over 50 mm (Fig. 15).
Th ese average values are to be qualified
according to the length of the mandible: for
the same condylar movement, the incisal space 69
is larger when the mandible is long (compass
effect).
Jaw opening is performed by the combination of
a rotation and a condylar tran slation . A limited
mouth opening can be due to:
- A reduction in the muscle relaxation
(cf. Classifi cation of dysfunctions);
- A reduction in the condylar translation
(intra-articular obstacle);
- A reduction in the condylar rotation
(adherence or adhesion phenomenon, much
rarer).
It is also necessary to detect excessive mouth
opening (> 50 mm): the absence of ligamentary
lim itation in the translation and rotation
movements in case of ligamentary hyperlaxity
(Fig. 16) may block the mouth when it is wide
open (true dislocation).
Maximal assisted mouth opening:
This passive mobilization of the mandible
completes the previous measurement by
assessing the potential total opening and by
testing the articular tolerance and the muscular
elasticity:
 Occlusion made easy

As soon as the maximal opening with no

assistance is achieved, the operator places
his/her thumb on the superior central incisors
and crosses his/her index finger on the incisal
edge of lower central incisors (Fig. 17).
This position allows to apply the necessary
leverage to force the subject to open wider.
It is necessary to use a moderate pressure
to help the mouth opening without causing
important pain ("I will check if I can open
your mouth a little wider and I will stop when
you raise your hand"). 18 Limited and deviated rectilinear trajectory.
The assisted maximal opening increases the opening of about 2 mm, in a elastic and painless
way. The absence of elasticity reveals the presence of an intra-articular obstacle .
Maximal mouth opening with pain: "Open your mouth as wide as you can, even if
it slightly aches." If mouth opening aches, the practitioner writes on the patient's chart the
amplitude from which the movements ache, as well as the painful zones (articular, masseter,
temporal).
70 It might be:
- Joint pains that are very localized in the TMJ, which will be increased by the lateral finger
pressure on the TMJ or by forcing slowly the opening;
- Muscle pains, most of the time due to the presence of aches or spasms of levator muscles,
and localized on the concerned muscle.
The opening trajectory must be also analyzed.
During this examination, it's better to be situated in front of patient and to observe the
mandibular movement in the sagittal plane (generally perpendicular to the bipupillary line).
The 12 o'clock position behind the patient may generate a parallax error due to the bridge
of the nose in case of asymmetry.
Clinically, we visually evaluate the trajectory from the middle of the mandible (often
represented by the interincisal point). It is possible to use a ruler, seen from the edge, placed
in the patient's sagittal plane.

This trajectory is physiologically ample, rectilinear and sagittal. The most frequent anomalies
of trajectories in the opening are the following ones:
- A deviated rectilinear trajectory (Fig. 18), revealing a limitation in the condylar
mobility ipsilateral to the deviation (rotation and/or translation defect);
'
- A "bayonet" trajectory at the opening, including two kinematic phases (Fig. 19-20):
• ~ phase of mandibular deviation on the "affected" side : the impaired mobility of the
ipsilateral condyle forces the movement towards this side;
• a "catching up" phase: the condyle finds back a normal mobi lity (often after having
recaptured the disk) and a greater speed: the affected side "catches up" the healthy
side: The trajectory becomes normal;
- A sudden click at the end of the opening (maximal opening), bayonet-shaped (but
in the last phase), which signs a subluxation.
 5 Clinical examination of TMD

19 First phase of the opening: the disk is in 20 The disk has moved back on the condyle,
front of the condyle. the opening path is recentered.

Pain during kinematic assessment

If pain exists, is increased, or appears during the mandibular movements, it is essentia l to
write it down and specify:
71
- The type of "trigger" movement,
- Its location (right/left, bilate_ral),
- Its exact localization (articular, pre -articular, retroarticular) and thus the involved
structure (muscle or TMJ),
- Its intensity (on a 1 to 1O sca le),
- Th~ phase of the movement during which pain appears .

During mouth opening/closure, pain may:

- Increase, proving an articu lar inflammation,
- Appear on the TMJ, during the maximal opening, particularly if it is limited,
- Appear in the area of the TMJ, at the same time as a click,
- Appear on the TMJ, during the closure, near the intercuspation,
- Appear during the active movements, but disappear when the mandible. is mobilized
by the practitioner.

Articular noises during mouth opening/closure

The presence of intra-articular obstacles generates noises during the mandibu lar movements.
Their characteristics must be noted, because they are preciou s indications for the diagnosis.
• Types of noises :
- Click in g: it is a distinct, brief and sharp noise with a very clear beginning and ending;
- Crackling: it is a continuous, long -lasting noise appearing during the movements of
opening and closure. It sounds like sand or friction . It may be discreet (the patient can
hear it) or loud (people stand ing near the patient can hear it).
•Their localization: right or left TMJ.
• The moment of appearance in the kinematics: noises like clicking are limited; they occur at
the beginning, in the middle or near the end of the opening movement.
 Occlusion made easy

A close examination of the opening and closure is essential and very relevant. But
let's be careful! An opening of normal amplitude does not systematically imply structural
normality: in some specific clinical situations, a condylar hypotranslation is compensated
with a hyper-rotation . This is why it is absolutely necessary to assess the protrusion and the
diduction.

Protrusion assessment
Mandibular protrusion is almost exclusively performed by condylar translation and thus
allows to study the latter, by separating it from the rotation.
Proceeding to the measurement: we ask the patient to slightly open his/her mouth
and to move the mandible as far as possible forwards ("Slide your jaw forward as far as you
can, even if this feels uncomfortable"), while avoiding if necessary the incisal overbite which
might be. an obstacle.
It is necessary to measure the distance between the position of the incisal edge of the
mandibular central incisor in ICP and its position in maximal protrusion (Fig. 21). The
average physiological value is about
11 to 13 mm, which is a quarter of the
72 maximum mouth opening measure.
Protrusion is almost exclusively
performed with a bilateral condylar
translation. It thus allows to
accurately assess the capacity of
condylar translation .
A limited protrusion is the sign of a
condylar hypotranslation generally
due to an intra-articular anomaly.
Hypotranslation can go unnoticed
during the examination of maximum
mouth opening: a greater condylar
rotation compensates for the lack of
translation in the lower compartment
21 Protrusion.
of the TMJ .
A sign ificant increase in protrusion is due to ligamentary hyperlaxity. A deviation of the
mandible in protrusion is the sign of a limited ipsilatera l condylar translation (adherence or
displaced disk).
Articular noises: in protrusion, cracking sounds are often more perceptible than during
the ope.,riing movements (the condyle is squeezed against the articular tubercle).
On the contrary, clicking sounds tend to disappear if they are due to a reducible condyle-
disk disunion, the squee~ing of the condyle on the posterior face of the disk preventing to
go over the posterior rim.
Pains: they can be acute during the exam ination, because the patient who presents a
limited condylar translation compensates with a hyper-rotation during his/her oral functions:
as a consequence, he/she rarely uses the condylar translation in everyday life, so that this
 5 Clinica l examination of TMD

movement requested during the examination

traumatize the articu lar tissues.
It is often necessary to help the patient
protrude by manipulating the mandible with
the incisors . ·

Diduction assessment
Diduction can be quantified with the movement
of the mandibular median line (Fig. 22).
Proceeding to the measurement: the
position of the mandibular interincisal point 22 Measurement of diduction.
when the mand ible is in ICP is registered by a
mark at the level of the maxillary. We ask the patient to slightly open his/her mouth and to move
his/her mandible as far as possible to the right. We measure the distance separating the position of
the mandibular interincisal point from the initial mark.
A lot of patients find it difficu lt to perform this movement (blurred body mapping, unusual voluntary
movement). It is thus necessary to:
- Provide clear instructions: "move your jaw as far as possible to the right I left, even if it is sl ightly
73
uncomfortable, and move it back to a normal position. M ove aga in your jaw towards the right/
left ";
- Repeat the movement several times before proceed ing to the measurement in order to be
ce rtain of the maximal movement.
To avoid drawing a mark in the maxillary, it is possible to use the maxillary interincisal point as a
benchmark . If the maxillary and mandibular interincisa l points do not match, it is necessary to take
into account the in itial shift in the interincisal points: if the mandibular interincisal point is placed on
the right, the measurement of this initial shift will be subtracted from th e measurement of the right
diduction and added to the measurement of the left diduction .
The examination of diduction allows to study the contra lateral condylar trans lation on a condylar
trajectory that is slightly more internal than during the opening . It is useful in the case of a reducible
condyle-disk disunion at the opening, since the anterointerna l trajectory of the condyl e is frequently
more difficult because of the interna l position of the disk, and the disunion becomes irreducible in
contra lateral diduction: the disk obstacle reduces then the amplitude of diduction. This indication
is i mportant~ because it shows that the patient probably "operates" in permanent condyle-disk
disunion.

Articular noises: they are also rarer because of the pressure appl ied on the posterior rim of the
disk and the condylar trajectory.
Pain during diduction: because of the asymmetry of the movement, interpreting the pa inful
signs may be very discriminating:
- The appeara nce of joint pains on the working side is the sign of an inflammation of the capsu le
and the bilaminar zone of the working TMJ, compressed during the movement (Fi g. 23);
- The appearance of prearticular pains on the working side must be connected to a stiffness of
the lateral pterygoid muscle (Fig. 24).
 Occlusion made easy

23 The compression of the bilaminar zone is 24 The patient locates the pain
painful (Section: P. Carpentier, J.P Yung). in the pre-articular zone.

- The appearance of prearticular pains on the non working side (in the area of the active lateral
pterygoid) highlights a state of muscular fatigue.
The evaluation of the movements allows a relevant and effective clinical diagnosis of the functional
capac ities (potential disability degree) and articular and muscular abilities.
74 The synthesis of the collected information is the first element of a well documented diagnosis.
(Tables 1 and 2).

Table 1 Summary table Amplitude of the mandibular kinematics and diagnosis .

Stan<ila rnd
Opening 45 '> 55
Protrusion 12
Diduction 9

Opening

...

Protrusion

Diduction
 5 Clinical examination of TMD

Palpation
Purpose and methods
For this examination, it is better to stand
behind the patient, in a 12 o'clock position.
Palpation aims at assessing the muscular
and articular structures according to two
techniques: a• passive one to explore the
shape, the volume and the texture ,of
muscles and an active one during which
pressure is applied in order to trigger a
25 Comparative bilateral palpation. response from the patient (testing).
Palpation requires to focus on tacti le
sensations, in a "blind manner", by
1tera
comparing the clinica l case with normal
conditions, hence the importance to
iom Patient's name
Date systematically proceed to this examination
to acquire skil ls, expertise, as well as
lOSil Opening Protrusion Observations reference data (normality/abnormality). 75
Smm Palpation needs to be bilateral and
comparative (Fig. 25).
As for the kinematic exam ination, it is
necessary to explain the practitioner's
gestures to the patient: "I am going to
palpate your muscles and app ly a slight
pressure on several places, tell me if it aches,
Palpation and if so, where are the painful zones".
It is important that the patient says out loud
if the palpation hurts or if the pressure only
feels unpleasant.
To prevent false positive or negative results,
it is sometimes necessary to · use testing
zones (muscles of the arm, the shoulder)
intended to validate the patient's answers.
If the responses to the palpatory tests are
painful, it is necessary to repeat several
times the assessment, by chang ing the
sequence of palpation, in order to be sure
of the accuracy of the answers and ask the
patient if it is a light, moderate or severe
pain.
Like for the other stages of the examination,
the information is reported on the clinical
examination form (Fig. 26).

!.--" 26 Samp le clinical examination form.

 Occlusion made easy

27 Lateral palpation of TMJ. 28 Intra-auricular palpation of the posterior

zone of TMJ.
Articular palpation
Didactically separated from the examination of the mandibular kinematics, it is actually
concomitant, because it is possible to assess the condylar movements (more easily the
translation than the rotation) with lateral palpation (the practitioner places his/her middle
fingers on the external pole of the condyles). In this case, palpation is performed with a
slight pressure in order to better objectify the sensations.
76 Palpation also al lows to put pressure on the joints, and to assess oedema and inflammation
as well as the inherent pain.

Palpation of the lateral pole

The goal is to diagnose by applying pressure the existence of a capsular inflammation,
which would cause a swelling and pain to palpation: place the index finger one centimeter
in front of the tragus, on the patient's TMJ (Fig. 27). Ask the patient to open slightly his/
her mouth until you can feel the lateral pole of the condyle moving. The pressure must be
about 0,5 kilo (about one pound) on the palpated side while the patient's head is held with
the hand on the opposite side.
Posterior palpation
The objective is to palpate the retro -articular zone (Fig. 28) and the adjacent bilaminar
zone, site of inflammation in case of a condylar retroposition.
This site can be palpated through the inside of the externa l aud itory meatus. Place your
little fingers in the aud itory meatus. Move your fingertips forward and ask the patient to
slightly open his/her mouth (or to open it widely if necessary) in order to make sure that the
articu lar movement can be felt with the fingertips. Apply a firm pressure on the right side
and then on the left side when the patient's teeth are in ICP.
•
Muscular palpation
The palpation must ideally be symmetric. When it is not possible (intraoral palpation for
example), it is necessary to perform the muscular palpation with one hand while the other
one holds the patient's head (counter-pressure).
This palpation is performed while the patient is in a passive state (mandible in rest position
with no occlusal contacts and no tension) and when he/she is in an active state, asked to
clench his/her teeth patient (normal and maximum clenching). This is going to al low a better
loca li zation of the muscle, to assess the muscular volume and the contraction symmetry.
 5 Clinical examination of TMD

29 Flat palpation with slight pressure. 30 Deep palpation.

77

31 Palpation ~f the posterior temporal. 32 Palpation of the medial temporal.

During the muscular palpation, several techniques are used:
Flat palpation: gentle pressure along the muscle body, parallel to the direction of the muscle.
It allows to identify the muscle body and to search for contracted zones, which feel like a thick rope
within the muscle. We must follow these contracted zones to track hard and painful areas (Fig . 29).
The palpate and roll technique: the skin is pinched between the thumb and the index finger, and
successively rolled and unrolled to reach the deep muscular planes. Resistance is the sigri. of muscular
hypertonia.
The palpate and pinch technique: explores the thickness of the skeletal muscles which we can
release from the underlying osseous support (masseter muscles).
Deep palpation: the pressure is increased up to 1 kilo (about two pounds), by determining the
painful zo nes (Fig. 30).

Pal pation of the temporal muscle

Posterior temporal: palpate the posterior fibers from the back of the ears and moving over
them . Move the fingers in the direction of the patient's face towards the anterior edge of the ear
(Fig. 31).
Medial temporal: palpate the fibers in the temporal depression, approximately 4 to 5 ems lateral ly
to the externa l edge of the eyebrow (Fig. 32).
 Occlusion made easy

33 Palpation of the anterior temporal. 34 Palpation of the masseter insertion area.

35 Palpation
of the digastric
muscle.

78
36 Palpation
of the medial
pterygoid.

Anterior temporal: palpate the fibers in the infratemporal fossa right above the zygom atic
process .

Palpation of the masseter muscle

insertion area of the masseter: palpate the muscle origin point located in the area
situated one centimeter right in front of the TMJ, just below the zygomatic arch and
anteriorly palpate the edge of the muscle (Fig. 34).
Body of the masseter: start palpation right under the zygomatic process in t he anterior
edge of t he muscle. From thi s zone, palpate downwards toward the ang le of the mandible
on a surface cover ing approximately two fingerbreadths .
•
In sertion of the masseter: palpate the region situated one ce ntimeter before and above
the angle of the man dible.
Both following examinations are performed with sma ller pressure:
Posterior mandibular region (stylohyoid, posterior digastric): ask the patient to
slightly tilt his/h er head back. Localize the region situated between the insertion of the
sternocleidomastoid muscle (SCM) and the posterior edge of the mandible. Palpate t he
region which is immediately med ian and posterior to the ang le of t he mand ible (Fig. 35).
Sub-mandibular region (med ial pterygoid, supra hyoid, anterior digastric):
 5 Clini ca l examination of TMD

Localize the site under the mandible situated

2 centimeters before the ang le of the mandible.
Palpate to the top while pulling towards the
mandible. If the patient complains of acute pain
in this region, it will be necessary to determine if
it is a muscular or a nodular pain (Fig. 36).

Intra-oral muscular palpation

Inform the patient that it is necessary to palpate
the inside of his/her mouth. This kind of palpation
is difficult, because these muscles are not directly
accessible.
37 Palpation of the lateral pterygoid zone.
Lateral pterygoid region. Ask the patient to
open his/her mouth and place the index finger on
the side of the tuberosity. Make a distal, upward
and medial movement with the finger (Fig. 37).
Using the little finger is sometimes easier.
Temporalis tendon. After palpating the lateral 79
pterygoid, rotate laterally your finger near the
coronoid apophysis. Ask the patient to slightly
open his/her mouth and move your index finger
upward, toward the anterior edge of the coronoid
apophysis. Palpate the most upper part of the
apophys~s (Fig. 38).

Numerous authors think that direct muscular

palpation of certain muscles is not relevant, even
impossible to perform. 38 Palpation of the temporalis tendon.
Muscle function testing seems more appropriate.
These tests aim at stimulating muscles, active
during certain movements, to generate a
"diagnostic pain". They do not belong to the
common practice and are widely listed in the
literature (Okeson, 2005).

Screening imaging
Medical imaging provides numerous diagnostic
possibilities today. The prescription must comply
with a certa.in hierarchy adapted to the nature of
tissues to be observed: X-rays for osseous tissues
and magnetic resonance for non-mineralized 39 Cause of pain detected in a panoramic
tissues (disc apparatus). X-ray.
 Occlusion made easy

40 Hypertrophy of goniac angles due to the 41 Left condylar fracture.

hypertrophy of the masseter.

80
42 Degenerative disease of the TMJ. 43 Eagle syndrome (calcification of the
stylohyoid ligament).

Panoramic radiography
The panoramic X-ray is necessary during
the first consultation as a support for
the differential diagnosis of dental pains
(caries, infection sites, etc.) (Fig . 39).
A comparative observation of both sides
also allows to detect anomalies such
as: asymmetries, major morphological
anomalies (Fig . 40) and fractures
(Fig. 41). The panoramic radiography 44 Langenbeck disease (hypertrophy of
sometimes reveals structural peculiarities coronoid process).
with a functional origin (distortion of the
horizontal ramus and t~e goniac angles in
bruxers). It also highlights signs of sequelae from a degenerative disease (arthrosis) (Fig. 42).
"
Rarer pathologies can also be seen on the panoramic X-ray, for example the Eagle syndrome,
a calcification of the stylohyoid ligament which can generate severe cervico-facial and
oropharyngeal pains. The treatment can on ly be surgical (Fig. 43). other pathologies may
affect teenagers at the end of the adolescence: the Langen beck disease, a hypertrophy of the
coronoid apophysis, associated with an exostosis of the malar bone: the Jacob disease. The
characteristic en largement of the apophysis is detectable on the panoramic X-ray (Fig. 44).
The clin ical signs are limited mouth opening and diduction movements. The scanner and the
3D reconstructions confirm the diagnosis. The treatment is surgical.
 5 Clinical exam ination of TMD

era I Cone -bea m tomography

ylar
ures More and more avai lable in dental
offices or imaging centers, cone-beam
is the equipment of choice to complete
a panoramic X-ray.
...
The accurate three-dimensiona l
reconstructions improve the
diagnosis of some pathologies such,
as undisplaced fractures which can
generate unexplained pains despite
the clinical examination and which
require an early and adapted treatment.
Condylar fractures show consolidations
with displacement which can perfectly
be seen with 3D reconstructions
(Fig. 45).

Scanner 81
An invasive ionizing examination, the
scanner allows to explore osseous or
ca lcified elem ents as it is the case in the
Jacob disease (Fig. 46). It is currently
and favorably replaced by cone-beam,
less irradiant and more widespread

46 Scanner view of Langenbeck disease. Magnetic resonance

imaging
MRI is the imaging examination
of choice for the exp loration of a
dysfunctioning condyle and disk
apparatus. This examination must
be reserved · to the clinical situations
requiring a confirmation or a diagnostic
precision . The patient must close his/
her mouth and then open it during the
examination and according to some
devices, dynamic sequences can be
recorded. The disk and the muscles can
be identified, which al lows to visualize
the position and the condition of the
articu lar disk (Fig. 47).

47 MRI examination of a case of permanent

disk displacement on the left side.
 Occlusion made easy

Instrumental examination ·
Axiography is mentioned here for information, but is not a part of the basic examination
of the general dental practitioner. It is a kinematic study of the mandibular movement
performed with a specific device. There is a mechanical version recording the tracks of the
movement with a stylus on graph paper. These tracks provide information on the amplitude,
the regularity and the reproducibility of the paths; this information can be used for the
diagnosis, but also to configure an articulator.
The electronic version proceeds to the recordings with sensors connected to a computer.
All the recordings are stored in a useful database for the patients' follow-up and research
purposes.

82
w
Q:!
In order to perform a usefu l muscular palpation, it is necessary to calibrate
:::>
..... the pressure applied during these tests, because pressure variations wil l
en
w generate different results .
(.!) The RDC guide (Research Diagnostic Criteria Dw orkin S. , Resche L., 2002)
..... defines the pressure app lied w ith the tip of the index finger (the pulp) on ,
:c a specific site as equ ivalent to a 1-kilo (about 2 pounds) pressure for the
(.!) palpation of the extra-oral muscles (except for the posterior mandibular
Q:! region and the sub-mandibular region where a 0.5-k ilo - one pound - pressure
w is applied) and 0.5-kilo pressure for the articular palpation and the intra-oral
:c
..... muscles .
The practitioner must learn to measure the applied pressure in order to
proceed to a reproducible examination; this kind of train ing can be made
w ith a simple kitchen scale (see picture below).
 5 Clinical examination of TMD

l<EY POINTS
,•

llirne climiGa l exarnimatior;i of the rnamc;.h1.1<::atory apparatus allows to de.tect

amdl diagnose trae fwnctio111al ancl structural anomalie~ .
..
Om<ile the sigrns ancl sy;naptorm are clearly· revealed, a f!>recise nos0l0gy of
rtllnese anomalies helps to take the ad.equate therapewtic <i:lecisions and
Jii>Brifl.0rnr.i the 1lreatmemt.
11\hle c::limical examil'ilation must be metho<llica l and s•tandardized. It also
11e~l!Jires a necessary tra ining.

(John 2005)

83

HE[PFUL READING
• Dworkin SF, Le Resche L. Research diagnostic criteria for temporomandibular
disorders: review, criteria, examinations and specifications, critique. J Craniomandib
Disord . 1992 Fall; 6(4): 301 -55 .
• Howard JA. Temporomandibular joint disorders, facial pain,and dental problems
in performing artists. In : Sataloff RT, Brandfonbrener AG, Lederman RJ, eds.
Textbook of performing arts medicine. New York : Raven Press, 1991:111 -:- 69.
• John MT, Dworkin SF, Mancl L. A Reliability of clinical temporomandibular disorder
diagnoses Pain, 2005; 118(1-2) : 61 -9.
• Lobbezoo F, Drangsholt M, Peck C, Sato H, Kopp S, Svensson P. Topical
review: new insight into the pathology and diagnostic of the disorders of th e
temporomandibular joint. J Orofac Pain; 2004; 18(3):181-91.
• Okeson JP. Management of temporomandibular disorders and occlusion. 5th ed.
St Louis: Mosby, 2003.
• Ouni I, Orthlieb JD, Jeany M, Ammar S, Cheynet F. Mandibular Hypomobility
Secondary to Bilateral Coronoid Hyperplasia: Case Report. International Journal
of Stomatology & Occlusion Medicine, December 15, 2015. doi:10.1007/s12548 -015 -
0138 -2.
• Rebibo M, Darmouni L, Jouvin J, Orthlieb JD. Vertical Dimension of Occlusion :
The Keys to Decision: We May Play with the VDO If We Know Some Game's Rul es.
International Journal of Stomatology & Occlusion Medicine 2, no. 3 (September
2009): 147- 59. doi:10.1007/s12548-009 -0027-7.
 Occlusion made easy

84
 Examination
of the occlusion

85
The clinical examination of the occlusion consists in WHAT KIND OF
detecting and diagnosing the anomalies in the shape,
the position, the arrangement of teeth and the inherent EQUIPMENT?
anomalies of occlusal functions. A comparison with the
ideal model allows to detect anomalies in the shape and/
or positi9n which are often due to occlusal dysfunctions, • Miller tweezer or
equivalent
as well as the needs for an oral treatment.
• Articulating paper of
various thicknesses and
This clinical examination is completed with the observation colors (blue, red, green,
of casts, which globally follows the same methodology, black)
with some advantages (view of lingual function) and • Shimstock®
drawbacks (lack of dental mobility, analysis postponed to • Alcohol and microbrush
the delivery of the casts).

This chapter is dedicated to the description of:

- the examination of the teeth and the intermaxillary
relationship (static anatomical assessment);
- the occlusal examination in itself (dynamic assessment
of the function) .

This assessment requires a reference model (described in

chapter 2) and refers to a classification of the anomalies
allowing to identify each clinical situation with a specific
and adequate methodology.
 Occlusion made easy

Examination methods
The clinical examination investigates from detail to globality with simple observation but
also with checking procedures to materialize specific situations where teeth are in contact
or not.

Visual control of the

mandibular position
It allows to analyze the anatomy and the
arrangement of both arches but also the occlusal
relationships and the mandibular position with
regard to the jaw. The easiest benchmark is the
interincisal point of each arch (Fig. 1).

The patient's "aware" perception

It is based on the discriminating potential of 1 lnterincisal points are used as maxillary
the occlusal contacts due to the capacity of and mandibular references allowing to
analyze the mandibular position.
proprioception, which is particularly accurate:
86 capacity to perceive a 20 µ thickness (one
hair), and a 10-gram pressure (see the "Right
gesture" paragraph at the end of the chapter).
By remaining aware, when necessary, of
the effects of the local anesthetic and the
variations of the patient's head posture, and
after the patient has understood and learnt to
recognize this perception ("aware perception"),
the patient's sensations can be a useful help in
the search for the occlusal contact points. The
patient is capable of indicating the side and
the zone where the contacts are located. It will 2 The patient shows the zone where
then be necessary to materialize these contact contacts are located.
points with articulating paper (Fig. 2).

Occlusal sound checking

technique
The occlusal sound checking provides a global
' sensations in ICP,
assessment of the patient's
by aski.Iig him/her "clench teeth" repeatedly,
rhythmically; the sound uttered (sharp, clear
and unique at each closing) can be interpreted
as a reproducible and physiological position.
On the contrary, a series of disrupted noises
with variabl e intensity reveals the patient's 3 Fremitus: the pulp of the finger gently
incapacity to clench his/her teeth regularly due placed on the buccal face allows to feel
to an inadequate and uncomfortable ICP. occlusal overloads.
 6 Examination of the occlusion

The practitioner's tactile examination (fremitus)

The tactile control with the pulp of the finger placed without pressure on the buccal
surface of a tooth allows to feel a mobil ity due to an occlusal overload and thus enables to
differentiate the physiologica l from the excessive factors: an overbite, an interference or an
occlusal overload are easily perceptible by an experienced practitioner (Fig. 3). This control
can be performed on the maxi llary teeth and in the anterior sector. "

Control of the contacts with occlusa l indicators

Several types of occlusal indicators are available (Fig. 4):
- Contact mark ing indicators on support (articulating papers and films)
- Ribbons with no marking indicator (metal foil: Shimstock®)
- Elastomers
- Marking indicators with no support (powders, sprays, inks).

Marking indicators with support

Articulating papers are the most widespread method and the principle is simp le: an
impregnation of the support by a coloring agent, released by a pressure supposed to be
an occlusal pressure. The advantages and disadvantages of these marking indicators were g7
briefly described by E. Gazit, S Fitzig in 1986 (Table 1).
The behavior of each type of
occlusal . marking ribbon var.ies 4 Occlusal
according to the properties of the indicators:
support (paper, silk, synthetic film) A wide array
and the coloring agent (variable of products is
at the dentist's
ink coverage) re leased by the
disposal.
pressure. All this has an impact on
the marking of the contact points
and the resulting diagnosis (Schelb
and Kaiser, 1985; Sarac;oglu, 2003)
(Fig. 5). Several studies (Mariani,
1985; Millstein, 2001) have Table 1 Advantages and disadvantages of articulating
highlighted the following points: ribbons
- The number of marked contact Advantages Disadvantages
points varies according to the type
of paper (1 to 7 ratio) for the same • Ease of use and • Humidity interaction
immediate vi sua li zation w ith the capac ity of
contact intensity
marking and reading the
- The surface of the marks may vary marking
(1 to 8 ratio) for the same contact
intensity; • Capacity to visualize • Tendency to multiply
and differentiate the the marks (number and
- The accuracy of the contact
static contacts from the surface)
points (presence of tru ly antagonist dynamic contacts
contact points) varies from 1 to
8 (there may be fa lse contacts, • Minima l resistance to • Difficu lties to get a mark
simple marks of friction made by closing forces and lack on g lazed ceramic
of induced periodontal • Incapacity to quantify
the articu lation paper).
perception and store the information
 Occlusion made easy

5 For each specific occlusion, marking depends 6 The retention of Shimstock®pulled in a buccal
on the type of marker: on the left 200 µm; on the direction proves the existence of contact; Its
right 12 µm. release shows an absence of contact.

Ribbons with no marking support

88
They are rather thin (8 microns) metallic films which highlight contact points with no
marking effect. The ribbon width allows to assess the contact;s tooth by tooth, and even
cusp by cusp.

It is placed between the antagoni st occlusal surfaces, with a slight traction in the buccal
direction: the ribbon retention proves the existence of a contact point; its release reveal s
th e absence of contact.

Its use is particularly relevant on the anterior teeth for which the notion of "quasi -contact"
is difficult to materialize: a 200 µm occlusal ribbon will mark a contact point wh ereas
Shi mstock® can be removed, highlighting th e absence of contacts (Fig. 6).

Occlusal recording materials

Using elastomers to record the occlusion can be a good method to assess the occlusion . The
antagonist contact points are then visualized
with perforation s (Fig. 7).

Keeping the mandibular position while the

material hardens limits their use to the sole ICP.

Marking indicators. 'with no support

(sprays,
... powders, varnish)
Their use is reserved in the laboratory to mark
models.
The presence of humidity and their toxicity
forbid their use in mouth.
7 The materialization of the occlusion with
Elastomer allows to visualize the contacts
with the perforations of the material.
 6 Examination of the occlusion

8 Marking validation: it is necessary 9 Marking must be present on both antagonist

to differentiate the friction tracks from arches.
the occlusal contacts.

Recommendations for the use of articulation ribbons

Choosing...the proper type of occlusal ribbon 89
• Thick articulating papers (100 - 300 µ) must be used for "roughing" procedures;
Indeed:
- They trigger a chewing reflex which modifies the occlusion;
- Their resistance to deformation provokes frictions on the occlusal surfaces which result
in false positives and marking surfaces (and not points);
- Their fragility in a damp environment often causes damage (paper gets torn);
• Thin papers (between 8 and 20 µ) on plastic support must be chosen for the following
properties:
- Their sma ll thickness does not allow proprioceptive discrimination and does not generate
any reflex chewing or avoidance;
- Their plasticity allows the marking of the actual occlusal contacts, according to the
color and to the ink coverage of the support. They are selected accord ing to the cl inical
situation to be examined.
Drying of surfaces: occlusal surfaces must be dry, with no mucus at all. After marking,
visualization and analysis of the colored marks, these must be erased from teeth with some
alcohol. The articu lating ribbon must be changed after each use.
Validation of the marks: certain marks on the occlusa l surfaces can be due to the sole
friction of the paper on teeth. These "pseudo-marks" or false positives must be distinguished
from the actual occlusal marks (Fig. 8). To validate a mark as an actual occlusa l point, it
must appear on both antagonist occlusal surfaces (Fig. 9).
Shape of the mark: the occlusal mark must be punctiform in ICP if the coronal morphology
th is normal (convex). Apart from a morphological anoma ly of the occlusa l surfaces, an oblong
shape may reveal a slidin g movement on a prematurity.
 Occlusion made easy

On the contrary, the materialization of the

guiding surfaces must associate a single contact
on the mandibular teeth with an oblong mark
on the maxillary teeth (uninterrupted for a
guidance in protrusion for example) (Fig. 10).
Position of the contacts: ideally, they must
be distributed in a tripod or bipod manner
according to teeth. They provide mandibular
and dental stability and distribute the efforts
according to the main line of the tooth.
The contact position must also be considered in
10 Elongated marks showing guidance trace
the more general context of the manducatory on the palatal faces of the maxillary incisors.
ap~aratus: the retrusive contacts in a situation
of articular compression must be banned.

Clinical examination
The assessment methods which have just
90 been explained are performed to allow the
morphological and functional analysis of the
occlusion.

Examination of the skeletal

framework
The assessment of the skeletal typology is
made during the extra-oral examination
(Fig. 11).
It is necessary to understand the shift of 11 The skeletal typology is an indicator oft~
bones and the intermaxillary relationship. It occlusal type.
is completed by a cephalometric analysis on
teleradiographies in front and in profile in the
prospect of an orthodontic or prosthodontic
treatment.

Analysis of separate arches

The examination . of the separate arches
allows to assess first the general arrangement
or arches in all planes.
Each point of the examination must be
investigated and written down; it will take its
full etiologic and therapeutic meaning during
the examination of the functions. 12 Parabola shaped arch favoring functional
occlusion.
 6 Examination of the occlusion

13 Lyre-shaped arch: the pinching of the arch 14 Lyre-shaped arch and inherent occlusal disorders.
in the area of premolars favors malocclusions.

15 Diastemas break
the continuity of the arch,
and generate instability
and dental mobility. 91

In an occlusal plane: the perfect shape of parabolic arch positions the teeth idea lly and
favors a functional confrontation (Fig. 12). The other arch shapes (V, lyre-shaped) present
an arrangement that is less appropriate to the functions (Fig. 13-14).
The examination of the (virtual) occlusal lines of highlights the anoma lies in the shape or the
positioning of these lines which may alter the occlusal functions, namely:
- tooth gaps and their position;
- diastemas creating a break in the continu ity of the arch;
- anomalies of interproximal contact points;
These interruptions in th e continuity of the arch must be noted, because they are important
etiolog ies of functional anoma lies (stabilizing function) (Fig. 15).
In a sagittal plane: the alteration of the occlusal plane by the malposition of one or
several teeth (most of the time overeruption compensating for tooth gaps or the loss of
the antagon ist substance) needs to be assessed (Fig. 16-17). For examp le, a more or less
marked curve of Spee (its average radius is about 90 mm) can not be quantified in mouth.
Using the Fox plane on the mandibular cast allows to effectively materialize it.
 Occlusion made easy

In a frontal plane
The aesthetic alterations of the occlusal plane (general orientation in relation to the
bipupillary axis if there is no cranial asymmetry) must be noticed. It is necessary to distinguish
a tilt in the plane itself from a malposition of one or several teeth with regard to the plane
(Fig. 18-19).
Assessing the position of the maxillary and mandibular interincisal points in
relation to the median sagittal plane (intra -arch analysis) is essential. It allows to check
the symmetry of the arch, to wonder about the etiology of a malposition (secondary
compensatory movements, orthodontic treatment. ..), but also to anticipate and determine
whether the mark of the interincisal points which will be used for the examination of the
occlusion is correct or not.
The analysis of the Curves of Wilson is difficult with the naked eye but the use of a Fox plane
allows once again to materialize these curves.
In all the planes of space
Dental malpositions: overeruptions, intrusions, versions, rotations, mesializations,
distalizations must be highlighted and written down (Fig. 20-21-22).

92

16 Severe disorders of the occlusal plane due to 17 The occlusal plane is properly directed but
egression facing tooth gaps. 25 and 26 go out of the plane.

18 Tilt of
the occlusal 19 The occlusal plane allows to materialize the
plane with positioning anomalies.
asymmetry.

20 Mesial tilt of 47: loss of contact with the
antagonist.
21 Position anomaly of 11: rotation and lingual
position.
23 Flattened coronal morphology poorly
favorable to the stabilization function.
6 Exa mi natio n of the occlusion
Radicular and coronal morphology
may be favorabl e or unfavorable t o
the occlusal function s. A fl attened
morphology reduces the masticatory
effi ciency of the occlu sal surfaces and
consequently increases the number
of necessary chewin g strokes fo r the
prepa ration of the food bol us (Fig. 23).
Too steep cuspal ' slopes increase the risks of
occlu sa l interference which may generat'e
fractu res (Fig. 24).
Losses of coronal substance Treated
or not, according to their importance and
th ei r location, they generate a disturba nce
93
22 Buccal positions of 42 and 31, these two
anomalies create the conditions for an occlusal
conflict.
24 Interference and occlusal constraints caused
a fracture in 24.
 Occlu sion made easy

in th e occlu sa l functions lin ked to t he modifi ed denta l anatomy. Th ey also indicate the
need for a restorative or prosth etic treatment whi ch will aim at correcting or improving th e
occlu sion (Fig. 25).
Tooth wear: dental w ear zones have obviously an impact on th e coronal morphology, but
they must be analyze d separately, beca use th eir etiology is determining (Table 2).
Th ese lesions should not be confused with cervical w ear lesions which are defined as
pathol og ical tissue losses located in th e cervi ca l third resulting from a multifactorial process
of fri ction, tribo-erosion, abrasion, erosion and fragmentation, involving the occlusal factor
(Fig. 26 -27).
Alteration of prosthetic teeth Beyond
th e quality of the occlusa l restorati on,
th ey are indicators for anteri or occlu sa l
modification s, which most of th e tim e
appear · suddenly. Within th e clini cal
intervi ew, th ey allow to specify th e dental
anamn esis (assessment of th e tim e spent
with no compensation for tooth gaps or
subst ance losses) (Fig.28).
25 Coronal destruction, attrition and erosion
94 result in the loss of the occlusal functions.

Table 2 The various types of pathological dental wear

Type of Etiology Morpho.logy
lesion '

Erosion Chemical Lacunar, outside the occlusal zones.

Occlusal Wear due to the friction of Lesions have a hard, smooth

attrition antagonist teeth. The opposition of and polished aspect .
wear facets confirms it. · The surface is flat, the edges may
be sharp (at the borders of the
movement of bruxism), surface is
shiny when wear is active, surface is
matt when wear is a sequela .
Att rition Two -body wear with external According t o the aggressor
mechanical aggression: hard morphology.
t oothbrush, onychophagia .
Abrasion
•
Wear lesions due to the friction of Variable according to the aggressor.
3 bodies (interposition of abrasive
particles) .
Abfract ion Ce rvical subtractive lesions due to Round -shaped and smooth lesions,
the disjunction and fragmentation generally located on premol ars.
of the enamel prisms whi ch might
be provoked by constraints due
to dental fl exion under excessive
occlusal load.
 6 Examination of the occlusion

26 Cervical wear lesion resulting in a loss 27 Occlusal attrition on maxillary canine

of structure, biological damage (pulp) and generating the loss of the canine function.
considerable embrittlement.

The parameters of the occlusal reconstruction of prostheses must be analyzed in detail,

because they must be in harmony with the rest of the arch especially if they carry functional
incapacity. The importance of the occlusal table needs to be taken into account: its reduction 95
reduces the area of functional freedom, its enlargement increases the levers and creates
occlusal instability.
Dental mobility It is an important sign: its increase either reveals the reduction of the
osseous support, or the· inflammatory extension of the periodontium. Dental mobility is an
obstacle to the accurate marking of the occlusal points.
Occlusal trauma causes a gradual perceptible increase in the mobility which needs to be
assessed.
The index classification of MOhlemann, which is the most frequently used, defines four
classes of mobility (Table 3).
The assessment of the periodontium allows to make a differential diagnosis concerning the
etiology of the mobility but also to notice the consequences of the "occlusal trauma" factor
accelerating the osseous lysis (Fig. 29).

28 Occlusal attrition on the anterior maxillary 29 Absence of posterior stabilization and

teeth resulting in an embrittled morphology important inflammation causing terminal
unsuitable for the occlusal functions. stage mobilities.
 Occlusion made easy

Table 3 Muhlemann d iagnostic classification of tooth mobility

I

Mobility Clinical signs

class

Class I Physiological mobility, unperceptible.

Class II Increased mobility, lower than 1 mm in the buccal lingual direction.

Class Ill Mobility superior to 1 mm, but with no alteration of the patient's function.

Class IV Axial and tranverse mobility superior to 1 mm, visible; altered function.

Anqlysis of the arches in intercuspol position (ICP)

The analysis of the intermaxillary relationships is performed in ICP, first of all in a global way.
Occlusal relationships in the sagittal plane The determination of the anterior (canine)
and posterior (first molar) angle class, of the type of occlusion (1 tooth/2 teeth or 1 tooth/1
tooth) (Fig. 30-31-32-33) and the quantification of the anterior teeth relationships (overjet

96 and overbite) are all parameters playing an important role in the function of guidance.

30 Class I. 31 Class II, characterized by the shift of a

half-cusp and an increased anterior overjet.

32
Class 11-2, characterized by the shift of a half-cusp 33 Class Ill.
and an almost inexistent anterior overjet.
 6 Exa min ation of th e occlu sion

Ove rbite: the verti cal distance separating the point of occl usion on the palatal face of the maxillary
incisor and the free edge of the same incisor gives the value of the overbite (Fi g. 34-35-3 6). This
value is measured with a caliper (Fig. 37).
Overj et: the horizontal distance separating the vertical line of the free edge of the mandibular incisor
on the lingual surface from the free edge of the maxillary incisor (Fig. 38-3 9). If the overjet is sma ll,
it can be measured with gauges. (Fig. 40).

34 Normal overbite in class I (2 mm). 35 Very small overbite; anterior guidance not 97
possible in protrusion.

36 Very important overbite > to 6 mm 37 Measurement of the overbite with a caliper.

t. in class 11-2.

38 Important overjet typical of 39 "Negative" overjet in class Ill. 40 Assessment of overjet

class 11-1. with a thickness gauge
(Baush).
 Occlusion made easy

41 inverted occlusion 45/15. 42 Exocclusion of 24, 25.

Transve·rse occlusal relationships
Inverted occlusion: this cusp/fossa occlusal relationship inverts the supporting cusps and
the guiding cusps. Even if the situation is stable and the stabi lity preserved, there is a risk of
posterior interference (Fig. 41).
Exocclusion: means "outside the occlusion". The antagonist teeth are not in confrontation,
98 but cross ("scissor occlusion"). This is a very unstable situation (Fig. 42).

Examination of the occlusal functions

This exam ination aims at detecting the occlusa l dysfunctions, and must be performed
compared with the theoretical model described in chapter II.
The use of a classification of these disorders allows a clear nosology and an accurate
description of the anomalies in the occlusal functions (centering, stabilization and gu itlance),
which are pathogenic factors for the various constituent systems of the manducatory
apparatus.
This assessment may be completed with an occlusal instrumental analysis according to the
same methods.

Examination of the centering function

The objective is to determine whether the mandibular position in ICP is a physiological
position in the three planes of space and to look for anoma lies if necessary:
- In the vertical direction: OVD anomalies (excessive or insufficient)
- In the transverse direction: mandibular deviation in ICP,
- In the sagittal direction: mandibular pseudo-prognathism in ICP.
Examination of the ·centering function in the vertical direction: looking for
anomal~s of the OVD

The objective is to determine if the OVD is in harmony with all the anatom ica l and
neuromuscular determiners, by accepting the idea that there is an optimal tolerance space
to place the OVD, rather than an ideal OVD.
Two main groups of clinical methods allow a fast ana lysis:
The anthropometric rulers which provide a morphological eva luation .
In first intention, these methods supply a reference for what is clinica lly "acceptab le"
(Table 4; Fig. 43 -44).
 6 Examination of the occlusion

Ancient statuary ruler Willis' ruler

A=B B=C
Mc Gee's ruler Boyanov's ruler
A= C=B D=E

Glabella

.. Bipupillary
line
.A

c
Subnasal
point
· · ··· Bi-commissural
B line
E

Chin point

43 The various empirical measures of the OVD are only approximate clinical 99
benchmarks.

The functional assessments

44 Impact of the occlusal relationship on the
OVD.
Table 4 Criteria of choice and validity of
the Occlusal Vertical Dimension
Aesthetics and facial height
Skeletal typology
Overbite and overjet
Prosthetic height
TMJ and neuromuscular coordination
• Phonetic tests: in the presence of
functional anterior sectors, the use of
sibi lant consonants (S, Che, Z and F) or of
"66" is a good approach: a free space of
inocclusion of about 2 millimeters must
exist during the pronunciation of these
phonemes;
• Breathing and deglutition tests also
provide a functional eva luation (Shanahan's
test, Smith's or Fish's tests);
• The test of the free space achieved by
measuring the free space (FS) when the
mandible is in resting position (FS must be
about 2 mm).
None of these methods being scientifically
validated, they can only be approximations.
The clinical attitude to be adopted is to
compare the resu lts obtained by these
methods in order to converge to a relevant
diagnosis, which will also take into account
the decision criteria listed by Orth lieb et al.
in 2013.
 Occlusion made easy

45 Situation in CR. 46 Situation in ICP.

Examination of the centering function in the transverse and sagittal directions

The mandibular position dictated by the ICP is analyzed with regard to a physiological
mandibular position in centric relation.
The method consists in:
100
- Manipulating in CR (cf. Chapter Centric Relation) and guiding the mandible to quasi-
contact in this position;
- Locating the mandibular position the occlusal quasi-contact: CR position;
- Asking the patient to close in maximal intercuspal occlusion: ICP
- Looking for the possible gap between ICP and CR.
This differential between ICP and CR can be assessed with:
- a marking on the mandibular and maxillary teeth in centric relation occlusion, and then
by the evaluation of the quantity of displacement of the mandibular mark in ICP;
- Marks on the anterior teeth allowing to assess the transverse displacement (Fig. 45-46);
- The assessment of marks on premolars for the sagitta l displacement.
A slight CR-ICP displacement may be physiological, provided it is:
• strictly anterior in the sag ittal plane,
• of sma ll amplitude (1 mm).

In this situation, premature contacts in CR being symmetric and simultaneous, the mandibular
movement imposed by the passage CR/ICP results, in the area of the mandibular condyles,
in a sma ll, anterior displacement.
'
On the contr'ary, the transverse deviation of the mandible in ICP comes along with condylar
moverrrents and with an asymmetry of the muscular functioning.
This condylar displacement may be fully assessed by the occlusal ana lysis on articu lator but
also by the add itional examinations indicating the mandibular position: condylography.
Materialization of the occlusal premature contacts
During the chewin g movements, premature contacts are avoided by reflex, the mandible
ending directly in ICP. This avoidance generates an increase of the muscular activity in
protrusion or diduction. Clinica lly, prematurities can be materialized in the following way:
 6 Examination of the occlusion

• during the manipulation in centric relation,

the operator guides the patient toward the
first occlusal contact (CRO) : this first contact
represents the prematurity.
• the highlighting of the prematurities is
facilitated by the patient who can localize
the side of the first contact and by the use of
Shimstock®, allowing to assess the presence
or the absence of contact;
- With marking paper, the dental contacts
in centric relation are marked . Then, with
a paper of. different color, the occlusal 47Occlusal marking indicators allow
deviated trajectory OCR/ICP is marked, to visualize the prematurity and the sliding
of CR to ICP.
by asking the patient to clench gradually
until ICP. This sliding trajectory confirms
the direction of the movement (Fig. 47).
The assessment of the centering function thus allows to make a diagnosis of the mandibular
position in ICP, physiological or pathogenic (too important sagittal deviation and/or
transverse). It also allows to localize the cause. 101
Assessment of the function of stabilization
The examination of the stabilization function consists in detecting the anomalies in the
stability of the arches.
Intra-arch stabilization
The loss of proximal contact points (as well as occlusal contact points) breaks the "vault"
effect of the dental arch and generates dental migrations (tilting, egression ...) which
modify dental arches, altering the occlusal plane and consequently generating occlusal
interferences.
The intra-arch stabilizing occlusal anomaly is highlighted by the global observation of
the arch which allowed to localize diastemas, uncompensated tooth gaps or imperfect
restorations.
lnterarch stabilization
A proper distribution of the interarch contacts provides the function of stabilization
(Fig. 48-49).
The loss of posterior vertical stabilization is linked to the absence of "vertical stop" resisting
the strengths of levator muscles.
Numerous authors listed by Seligman (1991) associate a loss of posterior stabilization to an
articular pathology. In 2002, Tallents confirmed the existence of a link between these two
occlusal and articular dysfunctions. In the presence of an insufficient posterior support, the
occlusal anterior contact generates a rise and a condylar retroposition (Wang, 2009), an
occlusal overload of the anterior teeth and a reflex splinting of the upper head of the lateral
pterygoid muscle side which tries tc:i protect the TMJ.
However, according to the clinical situation, the pathogenic consequences are different.
 Occlusion made easy

48 Excellent distribution of contacts in the 49 Excellent distribution of contacts in the

maxillary in ICP. mandible in ICP.

• Loss of terminal posterior

stabilization due to bilateral tooth
gap: paradoxically, the articular constraints
102 are probably limited, since the tooth
gap creates a functional disability which
prevents from developing an important
clenching force. The remaining teeth are
exposed to overloads . (Fig. 50);
• Insufficient posterior stabilization:
It is connected to coronal destruction or
to tilting of the posterior teeth . The risk is
considerable, because the patient keeps a
50 Loss of posterior stabilization due to terminal
functional capacity and as well as a high tooth gap.
clenching force. However, the capacity
to find a posterior contact with a strong
activation of levator muscles exposes the
TMJ to constraints. It is the case for partially
restored coronal decays or prosthetic teeth
wear (Fig. 51);

• Loss of posterior and anterior

.stabilization: this case can be noticed in
the presence of anterior ,coronal decays
and migration of maxillary anteriors (tooth
gaps, aRterior wear.) The association of
losses in posterior and anterior stabilization
generates a progressive decrease in the
OVD. This situation is not very pathogenic
for the TMJ (Fig. 52). 51 insufficient posterior stabilization.
 6 Exam in ation of the occlusion

52 The loss of posterior stabilization and the 53 Posterior occlusal instability due
buccal version of the ~nterior teeth resulted to the existence of a cusp/cusp contact and to
here in a loss of OVD. the occlusal morphology.

103

54 Mandibular instability in class 11-1 with 55 Mandibular instability in class Ill.

lingual dysfunction.

• Anomaly in horizontal stabilization: the loss of horizontal posterior stabil ization

(sag ittal or transverse) corresponds to an occlusal instability generated by non stabilizing
contacts: occlusion 1 tooth/1 tooth, occlusion cusp/cusp, fl at occlusal morphology.
The mandibular instability is pathogenic, because it involves a greater participation of the
masticatory muscles to stabilize the mandible in ICP during deglutition (Fig. 53).
• Anomaly in anterior sagittal occlusal stabilization: displacements of skeletal bases
such as class 11-1, as well as class Ill, create an absence of occlusal anterior contact (Fig. 54-55).
This absence generates a mandibular instability most of the time compensated with an
adaptation of the lingual functioning patterns.

Examination of the guidance functions

Anomalies in guidance provoke occlusal interferences, either anterior or posterior. An
occlusal interference is a traumatic occlusa l contact or an obstacle on a physiologica l
mandibular trajectory during an excursive movement.
 Occlusion made easy
56 Protrusion : posterior disocclusion.
104
57 Protrusion: physiological contacts incisal
edges of mandibular anterior teeth/palatal face
of maxillary anterior teeth.
58 Diduction: anterior guidance avoids posterior
interferences.
The occlusal interference generates either an
avoidance reflex, or a lesion of the interfering
tooth (attrition, mobilization, fracture).
These obstacles to mandibular excursions are
consequently considered as harmful because
of:
- the mechanical constraints they apply on
the periodontium;
- the dental migrations they may provoke
(secondary malocclusions); •
- the mandibular movements of avoidance
they may infer, generating muscular or
iigamentary ioads;
- the reactions of muscular hyperactivity
they may cause.
The anterior functional guidance
The anterior gu idance protects the posterior
teeth during the excursive and incursive
mandibular movements . It allows the
disocclusion of the posterior teeth (Fig. 56)
by a confrontation of the incisal edges of the
six anterior mandibular teeth on the marginal
crests of the palatal faces of the six anterior
maxillary teeth (Fig. 57), in protrusion
(Fig. 58) and diduction (Fig. 59). Posterior
disclusion is about 1 mm on the working side
and 2 mm on the non working side.
59 Diduction: marks of the canine guidance on
the palatal faces of the maxillary canines.
 6 Examination of the occlusion

60 Canine protection: posterior disocclusion: 61 Canine protection: posterior disocclusio.n: non

working (approximately 1 mm). working (approximately 2 mm).

Anterior unfunctional guidance:

posterior interferences
A posterior contact during a horizontal
movement (protrusion or lateralization)
is called "interference" when there is
no simultaneous occlusal contact in the 105
anterior sector.
We distinguish occlusal posterior
interferences in protrusion and occlusal
interferences on the working side and on 62 Posterior interference causing a loss
the non working side in diduction . of anterior contacts.
This conflicting occlusal relationship is
considered extremely traumatic for the tooth itself because it is:
• isolated, i.e limited to a couple of antagonist teeth;
• close to the ICP;
• located on a posterior tooth;
• located on the non working side (linear speed and considerable lever effect).

Clinically, the guidance function can be assessed by the analysis of the posterior and anterior
occlusal contacts produced by the centrifugal mandibular movements from the ICP.
Visually, posterior disocclusion materializes an anterior functional guidance, protecting the
posterior teeth : it must be about 1 mm on the working side (Fig. 60) and 2 mm on the non
working side (Fig. 61). On the contrary, the appearance of an anterior disocclusion reveals
the existence of a posterior interference (Fig. 62).
Beware however: if the posterior disocclusion can be seen during a diduction of 1 or
2 mm, visual inspection is not enough. The disocclusion must be immediate. Right from the
beginning of the movement, the use of Shimstock® and occlusal markers is thus essential.
The interposition of Shimstock® between the antagonist posterior lateral sectors during a
diduction or protrusion movement allows to detect the existence of posterior interferences,
either working or non working. If these interferences do exist, the use of marking ribbon
will allow to locate them (elongated tracks) and differentiate them (using for example red
paper for protrusion and blue for diduction).
 Occlusion made easy

63 The presence of
guidance contacts on
the buccal faces of the
mandibular teeth is
pathognomonic of a
dysfunctional anterior
guidance.

106 Anterior dysfunctional guidance: anterior interferences

An interior interference (in protrusion or diduction) is characterized by linear frictions located
on the buccal surfaces of the incisors or the mandibular can ines (Fig. 63).
This type of anterior dysfunctional relation generates:
• wear of the antagonist elements;
• avoidance reactions altering the neuromuscular system (at the origin of reflex spl inting);
• articu lar distensions by retro-function increasing the risk of condyle -disk disunion; ,
• a limitation of the functional condylar translation;
• a reduced trophic capacity of the TMJ by the bilaminar zone.

The risk of articu lar pathology is then all the more likely when etiologica l factors are
associated, such as for example:
• ligamentary hyperlaxity (ineffective articular protection);
• absence of stabilization in retrusion (ineffective occlusal protection): the palatal cusp of
the first upper premolar does not play its stabilizing role any long er.
A too steep incisal guidance reduces the functional amplitude and forces the mandibular
function to work in the posterior sector, increasing the rotation and the distension, which
endangers the TMJ ligamentary ·system. The masticatory or phonatory function indeed
requires anteroposterior m'ovements of the mandible.

"'
The clinical highlighting procedure is mainly based on:
• the presence of contacts on the buccal surfaces of the anterior mandibular teeth in
antagon ism with the incisal edges of the maxillary teeth;
• the visualization of an often increased disengagement (Fig. 64).
 6 Examination of the occlusion

64 A dysfunctional anterior
guidance frequently generates
an overload of the maxillary
anterior teeth, an increased
disocclusion and consequently
a reduced masticatory ·
efficiency.

Anomalies of retrusive control in the posterior guidance

Physiologically,. there is a slight sagittal CR/ICP gap. The presence of so-called premature
occlusal contacts (or prematurities) is a characteristic of CR on the closing pathway in
the terminal hinge axis movement. A protrusive (or retro-control) guidance slope is thus
created, increasing the temporal condyle -disk coaptation . When there is no such pattern,
the mandible has no obstacle/control to limit the retrusion.
The presence of guidance surfaces between CR and ICP symmetrically located on the palatal
cusps of the first maxillary premolars allows to take advantage from probably more accurate
proprioceptive properties, considering the coronal-radicular anatomy of this tooth. 107
Clinically, its assessment is based on the presence of adequate contacts during the ICP and
the existence of a strictly sagittal CR/ICP gap smaller than 1 mm (Fig. 65).

65 The retrusive
control guidance allows
to avoid the mandibular
backward movement
and the condylar
retrusion.
 Occlusion made easy

In the same way as it is in silence that

the smallest noises can be heard,
getting from the patient some
information about the localization
of the occlusal contacts requires a
very tactful guidance. The lighter

-a::
w
the contact is, the more accurate
its perception is. The mandibular
manipulation procedure was described
in detail in chapter 3. We should keep
:I:
I- in mind the image of a feather gently
landing on a hand and the almost
imperceptible sensation.

KEY POINTS
The exa tilil ination of t he occlusion such as it is preserite.d herie allows to higlalight separately
108 the anomalies of shape and p0sition and the anomalies of functioning (Table 5) .
The interest of this appr@ach is to pull away frorill the paradigrins of stnict occlusal
normalization, which unequivocally binds and irn poses ver'j; invasive prosthetic
rehabilitations .
1- The analysis of the dento-maxillary relationships based on the skeletal relationships
(anat0liYil ical relationship of t he osseous st r:wct ures), on i!lile occdl!lsal t y11>es (st at ic dental
relationship) and then on their fu mct iomal implicat io111s (0coll!.lsal fiumct ions) result s in a fully
detailed ocC!l ll'.lsal diagmosis ar:id allows tto cmaract erize t he Ji> aillient's 0eclusi0r:i. •
2- ifhis diagnosis allows to highlight potent ially pat hogenic occlusal factors, to classify them
and to decide whet liler their t reatl'ililemt is ne<!lessar;y.
3- Integrated into a comprehensive occlusodorltic examination wmich will include the osseo-
art icu'lar and rleUJ r;omwscwlar S¥St erms, ill: w.ill allow t o:
• assess t he (provedl or possible) impact of pathogenic occlusal facto rs on every syst em
(demt al, 0sseo-articular and m e l!lnol'itlwscula r;~ ;
• optimize the tr;eat ments and int egrat e the restorat io>ns within the occlusal functions,
and more globally within t he manducatory functions.
4- Whatever the type of required oral treatment (compensation for missing teeth, partial
or total c0 110nal restoration, trea't!Wlemt of a periodo rntal patl1\ologv) screenimg t he occlusal
anomalies,..is essent ial, because it allows to:
• highlight an et iopathogemic fa ctor or a comseq l!.lence of a del'iltal pat f1 0logy or of its
sequelae; '
• better integrate th e ch0sen therapel!Jtics, while keepi mg in rinind tmat all owr trieatrin ents
have an incidence and a manducatory funct ional purpose in whicmthe occlusal
rel ationsmips play a key nole .
 6 Examination of the occlusion

Table 5 : occlusal functions and their anomalies: classification of the anomalies and a
few examples of occlusal etiology for occlusal dysfunctions

Function Classification Type of anomaly Examples of occlusal

etiology

Occlusal Inefficient occlusal anatomy Coronal -Oecay

anatomy
Lack of congruence of ,the Malocclusion (class II;
Masticatory Uncoordinated antagonist occlusal surfaces One tooth on one
efficiency arches tooth occlusion) ·

Compensatory Overeruption,
curves ingression

Transverse Mandibular deviation in ICP Premature contact

Sagittal Excessive ICP in anterior Premature contact

position
Vertical Coronal decay
Centering Mandibular retrus ion in ICP
Attrition
Decrease of OVD 109
Missing teeth
Excessive OVD

Occlusion Tooth mobility Antagonist missing

instability teeth
Tooth migration
Mandibular Diastema, inocclusion
instability Inaccurate ICP
Stabilization
Missing teeth, versions
Loss of posterior
stabilization Open bite, overjet

No anterior stabilization
Occlusal Posterior (unfunction al Poor guidance slope,
interference anterior guidance) abrasion, open bite

Occlusal Anterior (dysfunctional . Steep guidance slope

prematurity anterior guidance

Insufficient retrusive
Guidance control

Unfunctional anti -retrusion

guidance (premature
Abnormal occlusal
contact)
relationships
Asymmetric retro control
guidance (prematurity)
 Occlusion. made easy

HELPFUL READING
• Gazit E, Fitzig S, Lieberman MA. Reproducibility of occlusal marking techniques.
J Prosthet Dent1986; 55:505-09.
• Ito Y, Rucker LM, Hashimoto K, Takehana 5. Palpation as a method for evaluating
occlusal discrepancies. J Oral Rehabil 1991;18(6):563-8.
= Millstei n P,
Maya A. An evaluation of occlusal cont act ma rking in di cators.
A descriptive quantitative method . J Am Dent Assoc 2001;132(9):1280-6.
• Orthlieb JD. Analysis of Occlusions: The Triad of Occlusal Functions. International
Journal of Stomatology & Occlusion Medicine 6, no. 3 (September 2013): 83 -84 .
doi: 10.1007/s12548-013-0087-6.
• Saracoglu A, Ozpinar B. In vivo and in vitro evaluation of occlusal indicato
110 sensitivity. J Prosthet Dent . 2002;88(5):522-6. Comment in: J Prosthet Dent
2003;90{3):31 O; author reply 310 -1.
• Schelb E, Kaiser DA, Brukl CE. Thickness and marking characteristics of occlusal
registration strips. J Prosthet Dent 1985;54(1):122-6.
• Seligman DA, Pullinger AG. The role of interocclusal relationships in
temporomandibular disorders: a review. J Craniomandib Disord 1991;5:96-106 .
• Tallents RH. Prevalence of missing posterior teeth and intraarticular
temporomandibular disorders. J Prosthet Dent 2002;87(6):45- 50.
• Wang M. Missing posterior teeth and risk of temporomandibular disorders. J Dent
Res 2009;88(10):942-5.
 Classification ...

ofTMD
t
~ematically speaking, we can consider that the appearance of a temporomandibular
· der (TMD) generally requires the existence of an anomaly of mandibular posture,
·• '·essive constraints (time and strength-related) and an unsuitable or disproportionate
, onse of the functions, the structures and the central nervous system, most of the time
~xceeding the capacities of adaptation.
111

lobal diag·nostic approach

. diagnostic approach for TMD must be based on the current available normalized
;
standardized clinical and/or radiological methods (recommendations from the EACD
1 ~ropean Academy of Craniomandibular Disorders).

~e first requirement consists in proceeding to a diagnosis of exclusion (in order to dismiss

:.<>
f~ "non-TMD), the prognosis of which could be much worse.
!e second requirement consists in integrating into the diagnostic approach a global
iopsychosocial" vision, which largely exceeds the field of the simple manducatory
·.·.chanics. .

·. ong the elements of diagnosis, the electronic instruments have no proven utility, they
ould thus play a small role in the therapeutic decision.
edical interview and clinical examination are clearly the most important elements in the
eening and the diagnosis of the TMD (John et al., 2005), showing the reliability of this
inical exami~ation when it is properly carried out.

~.herapeutic approach
;: mong the various therapeutic methods for TM D, none of them, taken one by one, has
~:proved its superiority; as a consequence, the therapeutic strategy should above all be
;focused on the symptoms and also be as reversible, conservative and minimally invasive as
~;ossible. In the absence of scientific evidence, clinical logic and biomechanics must prevail: it
J~ necessary to reduce the harmful constraints on the various elements of the manducatory
i PParatus (teeth, TMJ, muscles) (Okeson, 2008).
'·:;.
 .•

Occlusion made easy

Dysfunctional or painful patients need to be taken care of. The therapeutic modalities
(DeBoever, 2007) are the following ones:

Information/education provided to the patient: the explanations

concerning the diagnosis, the therapeutic and the likely evolution have an influence
on the severity of the symptoms and the patient's anxiety. A good understanding
of the pathology, the involved cofactors (behavioral, biological) and of his/her
own role (compliance, behavior) in the improvement of his/her health; matter a
lot to the patient.

Occlusal splints: they are intended to modify the occlusal relationships on a

provisional basis. Their objective must be clearly defined to determine their design
and their adjustment.

Physiotherapy: aiming at mobilizing joints or reducing muscular tension, its

complementary action is very important.

Cognitive behavioral therapies: their goal is to modify the patient's

functional and psychological behavior; they go beyond the dental surgeon's area
of expertise, who must refer to a psychologist. Advice, remotivation, reassurance
112 during regular appointments can on the other hand be provided by the dental
surgeon .
Pharmacotherapy: medicine must be prescribed over a limited period of
time, and their indications/contraindications, means of delivery, dosage and side
effects must be perfectly known by the dental practitioner. They mostly include
analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and
muscle relaxants . Anxiolytics will be more rarely prescribed, with a rigorous'sense
of judgment.

Other therapeutics: they have an exceptional indication: surgical procedures

(arthroscopy, surgery itself). Because of their invasive character, there are limited
to clinical situations in which the "therapeutic outcome/ therapeutic cost" balance
has been fully assessed .

The clinical examination of the manducatory apparatus such as it was described in

chapter 5 allows to highlight clinical signs and painful or dysfunctional symptoms, either
isolated or associated . Three types of clinical signs or symptoms might be detected:
- Articular noises,
- Anomalies of the m~ndibular kinematics,
- Pains of the manducatory apparatus .
...
 7 Classification of TMD

Articular noises
Clicking can also be heard during ligamentary friction, or when the condyle goes in front
of the articular tubercle or the temporal eminence (subluxation due to hypertranslation).
Crepitation: sounding like wet sand, this type of noise generally suggests the exi stence
of morphological modifications of the articular surfaces (incompatibility of the articular
surfaces - Cf chapter 5). "'

Anomalies of the mandibular kinematics

Amount of mouth opening
Limited mouth opening (to 30 mm): frequently observed, it is due most of the time to
an intra-articular obstacle (condyle -disk disunion) but may also be related to a muscular
dysfunction (trismus, strain).
Excessive mouth opening (> 50 mm): the absence of ligamentary limitation in the
movement of translation and rotation in the case of ligamentary hyperlaxity may block the
mouth when it is wide open (true dislocation).
Mouth opening trajectory
It must be rectilinear and median . A deflection (bayonet-shaped movement) is characteristic 113
of a reducible condyle -disk disunion on the same side . Other kinematic disorders exist,
which are key elements for the diagnosis.

Pains of the manducatory apparatus

These pains can be very variable, spontaneous or triggered by manducation or palpation,
either localized (muscular or articular) or referred (remote).
It is important to define the pain as accurately as possible: its type, its location, its intensity,
its irradiation, its evolution, when it appeared, in which context, the associated signs and
their repercussions on the everyday life.

Preauricular sharp needle like pain: increased by manducation, this type of pain rather
evokes an articular dysfunction, particularly if they are increased by passive tests (m andibular
mobilization, articular tension).
Duller pains with tightening or heaviness sensations: more diffuse in th e masseter,
periarticular or temporal areas, they rather evoke a muscular dysfunction .
Remote pains (referred pains): they are more difficult to analyze and diagnose, because
of the dissoci.ation between the location of the pain and its actual site. Associ ated with
chronic pains, these' pains must be the object of a specialized, multi-disciplinary care.
However, the general dental practitioner must be aware of their existence in order to avoid
erroneous diagnoses.
A classification can specify the diagnosis made during the clinical examination, by
distinguishing the muscular dysfunctions from the articular dysfunctions.
 Occlusion made easy

Muscular dysfunctions

They are the most common disorders in general practice. These muscular TMDs generally
provoke pains and sometimes anomalies in the mandibular kinematics (limitation of the
movement amplitude, dyskinesia) but no articu lar noises (Table 1).
The accurate description of the pains made by the patient and their ana lysis by the dentist
are the main elements of the diagnosis. Pains felt in the muscles (myalgias) can be due to
muscle fascicles, tendons or fasciae. This diffuse type of pain is described as continuous,
deep, dufl, generating a tightening or pressure sensation.
Its intensity is variable and its precise location by the patient is sometimes difficult (it is more
a painful zone than a specific point), often subma lar (deep masseter), mandibular (masseter)
or temporal, more rarely preauricular (lateral pterygoid). The pain is generally functional and
aggravated by muscular palpation.
114 Muscular pains belong to the category of deep somatic pains. Consequently, they may be
accompanied with central side effects (sensory, motor, autonomous): redness, watery eyes .

Table 1 - Diagnostic classification of muscular TMD

Reflex splinting
Acute muscular TMD
Muscular strain

Spasm

Myofascial pain (trigger points)

Chronic muscular TMD Myositis

'
Contracture (myostatic or fibrous)

We will on ly describe the acute muscular dysfunctions here. The therapeutic and diagnostic
care of chron ic muscular dysfunctions must be, due to their complexity, multidisciplinary and
specialized.
 7 Classification of TMD

Muscle strain

Prolonged clenching in ICP.

Excessive use of a muscular group (trauma). For example: gum chewing, parafunctions
(onychophagia).
Prolonged r.eflex splinting (muscular contraction reflex): a vicious circle may appear, and pain
itself may generate reflex splinting.

Slight decrease of the amplitude of active

movements.
Normal amplitude during passive movements
Opening
(normal maximum mouth opening when

!'
assisted).
V'I

§i Slight pain in resting position. 115

V'I Pain aggravated by the function .
I
Pain increased at the awakening if clenching : mm

during the night or at the end of the day if

daytime clenching. · - Active mvt • Musculary pain
- Assisted mvt * Articular pain
Painful palpation of the involved muscle(s).
Increased muscular volume (perceptible during
visual examination and palpation).
Muscular weakness.

The evolution varies according to the subject's capacities of adaptation of the subject.
There is often a compensation (progressive increase of the muscular volume, self-regu lation,
bearable pain) interrupted by acute phases which bring the patient to consultation.
Exceptiona lly, pain evolves into contractures (chronic dysfunctions).

Eli mination of the etiology: voluntary muscular rest, use of an occlusal orthosis (anterior bite
spl int).
Reduction of the muscular tension by limiting the parafunctional use of these muscles.
Compliance with behavioral advice: muscular rest, techniques of muscular relaxation,
awarenes.s of a possible daytime clenching. The patient can (and must) use his/her muscles,
but always below the pain threshold.
Psychological relaxation if necessary.
Muscle reconditioning splint.
Short-term pharmacotherapy:
- Muscle relaxants (eg: thiocolchicoside 500 mg/4 hours; 3 g/day)
- Peripheral analgesics in case of pain (paracetamol -acetaminophen- 1,000mg/4hours;
3 g/day)

Pr0gm0sis: ilime p> n0gm0sis w iililil 1irea1tilinemit is exoe ll emili. Hl@w ever, a fo ll0,w-wp> is meoessary because
rt!he swbj e<!:t's mart:l!lria l f1>110p>emsi,t y to grimcil 0r @
lem ©h tee1il'l freCiJuem ~ly ~eme.rates 11e€l!meraces.
 Occlusion made easy

Reflex splinting .

Imi!lllie mn.am <ihll calb©IW aJ!>J!>ar-aib1J1s, a nefilex swli millim@ elfi :tlm e lalbenal J!>lller;w,!!,J .Gicil (i)WilJera ©arnrs.

Reflex splinting immediately appears after one of the following etiological factors:
• altered sensory or proprioceptive information: sudden appearance of an overbite (of iatrogenic ori -
gin), prolonged mouth opening (long appointment at the dentist's), clenching or bruxism, traumatic
~ local anesthetic, sudden anomaly in the condylar position (condylar retroposition);
~ • deep and permanent pain: in the muscle itself or the associated structures such as tendons, liga-
~ ments, joints or teeth;
• stress: which has an impact on the activity of the masticatory muscles by generating clenching
and bruxism.

Absence of pain when resting.

116 Pain aggravated by the function . Opening

't '
Pain during active and passive movements
VI
c but nearly no pain in resting position
Gl
·v; Limitation of the mandibular movements
m (due to pain): the patient can howe- I
.~ : mm
c ver achieve a normal amplitude during
\Ji the active movements in spite of pain - Active mvt * Musculary pain
(cf. chapter Clinical Examination of the - Assisted mvt * Articular pain
Manducatory Apparatus)
Sensation of muscular weakness.
Untreated, reflex splinting evolves into spasms or muscular stiffness.
c
0
·;:;
:J
0
>
LU

Reflex splinting being a normal protective response of the central nervous system, the treatment is
....,
essentially etiologic. Once the cause eliminated, the muscular contraction reflex quickly disappears.
~ Occlusal etiologic treatment: elimination of the occlusal anomaly,
S
m
Behavioral Advice (articular and muscular rest);
OJ App+ication of moist heat (hot terry towel) on the sore muscle;
~
Peripheral analgesics (ex: paracetamol 1,000 mg/4 hours; 3 g/day).

lilne piroC!Jnosis wi ti~ treatrnemt is fallorable once the cause has beem elillTlirilated.
 7 Classification of TMD

Muscle spasm
liletiriiiition !Wlws0le SJi>aSIWl is a sfua1:1p>, a01!1ilie, s1g1dJdem, imViGlwmd:ary arnGI G©mitiml!IG>1lls
l'ilillllsowlar C:JGl"ltllrnc'tfom, imdlwced fuy illfue oemiliral me~11i©ws S!)lsillenm wliliom t11 i!!J!!Jers a lililWS<il le
1

sf.lomllemim§J.
ltt is 1l'he ityp>ic-al sp0r~sllilam's oliamp>: a lilillllsrn la11 sp>asm cam lasit a ifew l'ililimmttJes (\VJery p>aim~w l
cliamps}, 1!© se~elia l days. 1-fo~e~er:, tmll!ISClll lar. 0ralilil11>S aJi>p>ear liarely, im itfhe @'i1@)fiacia l sproere.
>- Local conditions (muscular fatigue, electrolyte imba lance, infecl'ion): the resu lting ischaemia main-
gi tains the contraction, provoking the muscu lar fatigue. ,
G Systemic factors: they mig ht play a role in the creation of a susceptibi lity to muscle spasms, variable
'+:i
uu according to the individuals.

A spastic muscle is shortened and painful, even in rest

position, which enta ils:
- An important limitation of the movement amplitude
determined by the spastic muscle (for example of
mouth opening when masseter muscles are involved).
- An acute occlusal dysfunction: the spasm of the Open ing
inferior head of the latera l pterygoid on one side can
ro for example generate, in intercuspal position (ICP), /~" 117
v contralateral anterior contacts and an ipsilateral poste-
c rior disocclusion.
u I
: mm
- Severe pain in rest position and during the function: it
can be acute and stabbing, irrad iating towards the ear, -
-
Active mvt
Assisted mvt
** usculary pain
Articular pain
the temple or the face.
- Very painful palpation, the muscle feels hard and very
stiff. (Masseter in case of trismus).

c None.
Q)
'.j:j
:::!I
Cl>
>
• UJ.1l

The treatment must be quick to avoid the appearance of a myostatic or fibrous spasm (chronic evo-
lution of the dysfunction). The therapy is mu ltimoda l:
• short-term pharmacotherapy: peripheral analgesics (ex: paracetamol: 1,000mg/4 hours;
3 g/day), muscle relaxants (ex: thiocolchicoside 500 mg/4 hours; 3 g/day) and anti-inflammatory
drugs (corticoids: ex: prednisolone Cortancyl® 1, 5, 20 mg);
• physiotherapy: heat and massages are often effective at the beginning of treatment. After a few
days, prog~essive stretching help to restore the function;
• loca l anesthesia (if possible) of the muscle, when the contraction has resisted the initia l treatments;
• elimination of etiological factors: possible occlusa l factors, stress;
• splint for neuromuscular reconditioning and night-guard: provided clenching or bruxism are the
incriminating factors.

P~ogrn©s i s : fa vo rah> le iJ illhe 11>ar,a;fiultilcti0111s <ll isap11>ear.

 Occlusion made easy

Articu lar dysfunctions

The functiona l anatomy of the TMJ, described in the previous chapters, highlights the criteria
of an optima l funct ion ing of the TMJ: a temporal-condyle-disk coaptation, supported by a
harmonious muscular funct ion ing, and a discal apparatus preserving the integrity of this
situation, both static (in ICP) and dynamic.
The articular normality is clinica lly validated by a large, symmetric, even and with no click
condylar translation, superposable during the various mandibular movements.
Symmetric, it allows the jaw opening according to an ample trajectory (between 40 and
50 mm in the adult).
Articular TMD are a specific, well differentiated class due a posit ion ing or structura l anoma ly
of one of the TMJ elements (Tab le 2).

Table 2 - Summary of the articular dysfunctions

Group Classification Clinical signs

Anoma lies of Red ucib le co ndyl e-d isk Art icul ar clickin g
118 the con dyl e- d isun ion Bayon et traj ectory
disk apparatus Retrocapsu litis
Articu lar pain
Acute permane nt Deviated trajectory on t he invo lved side
cond yle-d isk disunion Limited mouth opening
Articu lar pain
Retro ca psu Iit is
Chronic permanent Globa l improvement of t he symptoms
condyle-disk disunion
Incompatibility shape anoma li es of the Articu lar crepitation
of the articular articu lar surfaces Sometimes altered kinematics
surfaces
Adherences Typica l, unique articu lar no ise in the morn ing
Adhesions during the f irst art icu lar mobi li zation due to the
articu lar bin d in g (ad hesion)
Limited cond yl ar tra nslation due to adherences
betw een the articu lar surfaces
Sub luxation Sudden cl ick ing and mandibu lar jump in maxima l
mouth open ing
True M outh is locked wide open
temporomandibular
luxation · '
lnflammatioos Capsu lit is Sponta neo us pa in, increased by tension, condylar
mobi lizat ion and pa lpation
Retrocapsu li t is Spontaneous pa in increased by tension, ipsi lateral
deduction and palpat ion
Arthritis Typica l pai n of t he articu lar inflammation
TMJ Osteoa rth rit i s Art icu lar crep itation, deduction is often limited
degenerative (arthros is)
disease
 7 Classification of TMD

Reducible condyle-disk disunion

Defm1t1on It 1s am amomaly of itm e dl1sk JD0S'lil:1om [<l11spla<Dedl forward! arncl
insidle' wirorn nega ndl t:o il!me mamclihll!Jlar corndl¥1e [wmiGln is jjffi ll.l!Jsrt: b>aokwa r.d1)
wme mil!me sl!lb>jeoli is irn ICP.
Anatol1ilically, tlil e o©rndlyle is mot sitl!latedl on "lime imte.rrnedliat e zome of tlile
disk am11 lilil©ne, l.\n.!lt l!lrirdler (amcl eMem bemimcl1) iilis p0ste 11i0r nidlge.
It is said! r<edll!Jcib>le, becawse in tm e mamclibl!l lar movememts imv.0lvimg a
oorncly'lar ilmamslati0rii, illme o©mcl1fle-disk 00a11>tatiom ©001iirs: rtiln e oorn<il¥1e
goes l!JliHfor :t!lile disk, l!>ef©pe rteturmi rn g to an alm0st lilOrmal p@siti©lil at
tlil e emdl ©f OJDemimg. Ol!J ~ img Jllile dlosin!!J m©vernemt, a clisl!Jrnio m ma11>11>ens
agaim.
The condylar retroposition, due to:
>.
O'l • a hyperlaxity;
~ • articular constraints (occlusal dysfunctions: retrofunction, loss of posterior stabilization, etc.);
'+; • a muscular hyperactivity due to the tensor muscles of the disk (deep masseter, superior head of the lateral
w
pterygoid and posterior temporalis).

Articular pain: at the beginning of the pathology, the pain is present and
due to a retrodiscitis (inflammation of the bilaminar zone) which goes with
the disunion and the condylar backward movement.
Reciprocal clicking: in the excursive movements of opening, protrusion or
contralateral diduction, the clicking is more or less sharp, more or less late. It
~ corresponds to a condylar projection clinically perceptible by lateral condylar
11
O'l palpation (which signs the condyle-disk recoaptation). It occurs with a sud-
"' den change in direction during the mandibular movement (pathognomonic Opening
r3 bayonet trajectory).
c The clicking is described as "reciprocal"" because it occurs both during
u mouth opening and mouth closing. It is always more distant from the ICP
during excursive movements, than during the incursive movements of return
towards the ICP.
_ Active mvt
Anomaly of the mandibular kinematics: the opening in bayonet (deviation of - Assisted mvt
the altered side and return on the median line after the click) is characteristic
of this dysfunction . The amplitude of opening is normal.
c After the acute phase, pain decreases because of the adaptation of articular tissues (chronicization). but the
.,g clicking sounds become more perceptible, later and sharper, as the condyle confronts in translation the posterior
::i ridge of the disk.
0
>
UJ

Of the pain: a pharmacotherapy with peripheral analgesics (paracetamol 1000 mg/4h <3 g/day) or anti-inflamma-
tory drugs (NSAIDs: indolics (indometacine, indocid®: 50 - 150 mg/day; Chrono- lndocid 75 LP®75 in 150 mg/j) .
....., Of the disunion: the therapeutic objective is not the disk recapturing (uncertain and not sustainable), but the seda -
~ tion of the painful symptoms and the optimization of condylar relationships by favoring the formation of a fibrous
E healing tissue between the condyle and the mandibular fossa (neodisk)). A conservative treatment is thus necessary
10 and may involve:
~ • behavioral advice;
• an occlusal splint for neuromuscu lar reconditioning or decompression.
• physiotherapy for ligamentary strengthening (treatment of the hyperlaxity which is an etiologic cofactor);
Optimization of the occlusa l functions (ex: treatment of the loss of posterior stabili zation).
Promostic : the progr.iosis depends om tlile ev0hutiom stage ancd t he context.
Im case of a liecer.it par ial disl!Jm iom, tlae prngmosis w,i1ila t neatmemt is f.av0ral!>le.
Om tme co mtra~y, an old conclyle -disk disl!Jmiorn, witm late reduct i©m clurimg tme 0ral opening, ima co ntext
of lil¥111>e~la~<iity, is ilililp©ssil!>le t0 illneat . Im slllom a <Da se amd 11>ar.aclo~icall¥, t lile best evolutiorn is a permar:ient
clisuniorn which, less symptomatic (no lil'ilOlie olickimg or an0maly in t he kinematics), will be easier to live for
t he pat iemt and easier t0 ilreat for tm e demt ist.
 Occlusion made easy

Acute permanent condyle-disk disunion

Defiimition Im ttlmis dl ia!lJrn©s!liic olass, im IOP,, llllrie Cil0 m dl ~le is l@.(;ailJedJ a~ itlme bac:::k ®~ illfu e
j:i>©Si1Je11i@rr ri<il!J.le ef 'l!im e dlisk, amdl ~eej!>S 't!hlis p>©siiti©m di11rni m!lJ illme l'ilil©~e l'il'il e mtts o,f o@mdl ~l·a li
tr.anslailli@~; it!mene is rno m mdlyle-dlisk neooa ir>tat i©m . 'WJ,,e ci.l istiA~lllis lil aornille am dl 0hriomie
pnases.

It is often an evolution of a reducible condyle-disk disunion

(with the same etiologies).
>.
O'l It is highlighted by the anamnesis: the patient speaks of articular
0
0 noises, generally painless, which have now disappeared.
~ It may appear suddenly (mandibular trauma, dental treatment
under general anesth esia [extraction of wisdom teeth], whiplash
injury, TMJ sprain, idiopathic cause).
Moderate to severe pain, located in the temporomandibular
VI joint and increased when the patient tries to open his/her Opening
c
O'l
VI
mouth . ,;;-.,
Important limitation of mouth opening, with a deflection of
"'uc the affected side and of the contralateral diduction side.
Absence (and even disappearance) of the articular noises.
u
120 Ac tive mvt
Assisted mvt

c The evolution is chronic permanent condyle -disk disunion (cf Infra).

0
'.j:J
::3
0
>
L.LJ

Pharmacotherapy: peripheral analgesics (paracetamol 1,000 mg I 4h <3 g/day), central analgesics

(paracetamol/codeine, paracetamol/tramadol) or anti-inflammatory drugs (NSAIDs: indolics:
lndometacine, lndocid®: 50 to 150 mg /day Chrono-lndocid 75 LP® 75 to 150 mg /day).
Behavioral advice: limitation of the mandibular movements and tension .
Farrar maneuver: if the disunion is recent, a recoaptation maneuver may be tempted . On the affec-
ted side, a retrotuberosity local anesthetic is performed, if possible with no vasoconstrictor. The ope-
rator holds the mandible between his/her thumb placed on the mandibular arch and the other fin-
+-' gers on the outside under the horizontal ramus of the mandible. With the other hand, the operator
c
GJ proceeds to an external slight palpation of the TMJ . He/she applies with his/her thumb an important
.§ pressure downward while his/her hand performs a movement of rotation and traction towards the
:B
\,,,;
median plan, the disk being located in an anterior-internal position (Fig. 1-2). This manipulation is
I- painful and requires that the patient is perfectly relaxed since he/she must not resist the maneuver. If
it is successful, an anti-inflammatory treatment is prescribed as well as the resting of the articu lation.
Mandibular orthopaedio;: the therapeutic objective is not the disk recapturing (uncertain and not
sustainable), but the sedation of the painful symptoms and the optimization of condylar relation -
ships-.by favoring the formation of a fibrous healing tissue (neo disk) between the condyle and the
mandibu lar fossa . A conservative treatment is thu s necessary and may use of an occlusal splint for
neuromuscular reconditioning or decompression .

Proqinosis: apart ~ro 11111 illhie excepti0nal cases of conGlyle-di sk r;eooap:tail:i <i>n acrnievedl
by tlme Pa l(rar !ilil amewver:, rtilile p11©!lJ m0sis is l!lrnfave>rable, wirorn an evol llltie>ra ttowa rds
a «m 11omic p>e nlililam em~ o©m<ilvle-ciisk Gl is ~ mie>m, vJJ\l i0m p>a 11:acle>x•ica lly rnrines alom!lJ wi1
1lh
am ililil p> li@ve11m emil: of ilirae s~l'il1lp1lo m s.
 7 Classification of TMD

121

1 Clinical view of the Farrar maneuver.

2 Diagram showing the Farrar maneuver.

 I Occlusion made easy

Chronic permanent condyle-disk disunion

- - - - - - - - - - - · - · - - - - - - - - - - - -- ----- - - - --- - - - - - - - - - - ---------

De~imi~iolil iflme G©md!Mle is alt ~Ille

baol< 0*:tlme fi>®S:IJe11·i©rr t11id~e o;fi
ilJme €1isk, am€! ~eef!>S ~l\iis Ji>G>Siiliiem
dl l!rnim!!I rome rml®~ermiemit!s @Jfi @@m<il~ la!i
rfjr;amslaibi©m. me e is m@ Q@mdl,Y:le-dlisl<
11ernaf!>'liailiiom.

>. Evolution of a reducible condyle-disk disunion or an acute permanent condyle-disk disunion. The
~ etiologies are the same.
0
·.;:::;
l!U

They are characterized by the

sedation of the symptoms
(disappearance of the pains due
to the adaptation of retrodiscal
tissues) and the normalization of
122 the mandibular kinematics thanks
Opening

I
to the compensatory condylar
c hyper-rotation or the ligamentary
~ stretching (normal condylar
ro translation). : mm
u
c It is the paradox of this clinical
u; situation: the histological - Active rnvt * Muscu ary pain
aggravation leads to the - Assisted rnvt * Articular pain
improvement of the symptoms.
This case is very frequent: more
than 20% of the general population
might suffer from chronic
permanent condyle-disk disunion,
with no symptomatology.
It varies according to the histological behavior of the articular structures: the articular
c
o relationship remains unfavorable (absence of discal interposition between the temporal and
~ condylar articular surf aces) and the a priori reduced adaptive potential results in a histologi-
~
LI.J
cal degradation (degenerative disease).

The therapeutic objective is conservative and consists in the decompression of the posterior zone
favoring th e creation of.a'space for the articular healing . A fibrosi s of the bilaminar zone can then
take place (neodisk process):
+"
~ • behavioral advice;
...... • decompression orthosis;
E
m • periodic re-assessments.
it: Remark: particular precautions need to be taken in case of extensive occlusal treatment (prosthetic
or orthodontic treatment), since there is a pathological articular relationship which, improved by the
treatment. will become a stabilized articular relationship.

Progn0sis: favCi>.liali>le Wii 111 lllrealtrmierilil:; 'llme 11edwcti0m Ci>f 'tlme constraints applied on t he
ar1Hcut l·aillicm favors tkle tissu lar hea ling.
 7 Classification of TMD

TMJ degenerative disease

De~imition Oesilirl!lc:tJ i ~e p110Gess
alll!errimg 'tme ariiliirn lar sw r~aoes @f 1!11 e
G©md1~l e or lt!me arriliim lar illl!!1bercle o~
...
tfue ttelililpGria l b0me.

It is generally the response to an overload in the area of one or both TMJ (macro or microtraumas),
but some are idiopathic. The degenerative disease of the TMJ thus relates to a disorder in the
balance between the degenerative and the repair processes in the cartilage, bone and the synovia l
liquid: the balance between the synthesis and the degradation of the components of the extracel-
lular matrix, controlled by chondrocytes, is altered, causing a degradation of the cartilage which
6) biologically causes:
® • the swelling and the softening of the carti lage (chondromalacia);
Cl>
·;;; • the localized deterioration of the collagen fibrils inside the matrix (fibrillation), and an associated
UlJ
inflammatory response with a release of proteolytic enzymes; 123
• the loss of the cartilage integrity (bulges, horizontal fissures, thinning, adhesions);
• the total destruction of the cartilage and the exposure of subchondral bone tissue;
• the formation of sclerotic bqne tissue (reshaping).

The symptomatology is generally

discreet, only the consequences of this Opening
condition (joint inflammation: capsul i-

c
tis, arthritis) generate pain.
The change in the articu lar surfaces
~ causes a crepitation which draws the
ro attention (characteristic crissing noise,
~ more rarely sharp clicking on an osteo-
'f ' I
: mm

u phytic beak). - Active rnvt :f:: Musculary pain

- Assisted rnvt :f:: Articular pain
The diagnosis will be confirmed by the
radiological exam ination (cone beam,
scanner or MRI).

As for any articu lar pathology, there are painful inflammatory phases and asymptomatic
c
o remissiori periods.
".j:i
::J
0
w>

....., The treatment mainly consists in limiting the overload within the TMJ (orthopaedic treatment) and
~ improving the trophic potential of the TMJ with a gymnotherapy exercises which increase translation
.§ and the activity of the Zenker's va scular plexus .
ro
Q)

Prognosis: with 'l:~eatm ent,

a physiopa'IJholog.y ca n develop; t he fiun c1Jioming is almost
no rmal, even wiijfl1 alte re© ariato rrn ica l structures.
 Occlusion made easy

Incompatibility of the articular surfaces

9e~initiorn f)ll,® ~(l>M©l0>~i0al 0>r lli i s,1l© l@~i0al 1im0>clli.1\i<Saitii.©ms ©ffi ltlm e ar:-llii©l!!l lar swrrr&a(iJes lilllake
1lmelili1 ifil!!lmcil:i@raally irMJGlililJilailYifi>le

Four types can be detected:

• anoma lies of the articular surfaces,
• adhesions and adherences,
• subluxation and the true temporomandibular lu xation,
• inflammation.

Anomaly in the shape of the articular surfaces

Detimitlion ml\lese diso11dle11s arie cil!le it.0 rmorpmological ehamges 0f 1Jhe arti€wlar swrfaoes 0f ibhe
124 i;rvm o~ 'lim e ©isk
Microtraumas (parafunctions, articular overload).
>.
rn Macrotraumas (sequelae of fractures).
0
0 In the disk: it is generally a thickening of the posterior ridge, a mucoid degeneration in teenagers,
&; discal calcifications (chondrocalcinosis).
Sequelae of the arthrotic pathology.
Atypical clicking or cracking during the mandibular incursive and excursive movements. ,
c If the anomaly is condylar (mand ibular or temporal): the noise is generally reproducible, at the same
·~ moment in the opening and in the closing .
cu If the anomaly is discal: cracking which may be perceptible is due to the presence of obstacles in the
·~ condylar translation, the condylar movements are anomalous irregular.
u Variable changes of the mandibular kinematics related to the type of lesion and its localization.

c Variable: progressive degradation or improvement if favorab le conditions can be achieved .

0
",+:j I

:::J
0
>
UJ

Sequelae of an old dysfynction, fhese anomalies have no specific treatment. Th e improvement of the
ar·ticular relationships by orthopaedics (moderate articular decompression (O to 2 mm) and reduction
+'
~ of th,s> constraints are the occlusal objectives for a long-term improvement.
E
+'
cu
(])

i=

Pr@~ m osis: Glil110mi<i: co111<!1itio11: slow evoluti0m wiitlh ililllproveliJle,-;i;t 0f thle possible sylililptoms
(orracking, al;teratioms ©f 1lhe ki111e11111atics)
 7 Classification of TMD

Adherences and adhesions

Adherences
9 ei ir.iition l!!J,mli~e ttme aGlmesi©ms, ttlmis R:imGI GJi "s~k~im@ " is m.e:i.ie~sili>le: ilJ me ar; iewla~
sl!lr~aoes arn.e 1lel'ilillj)Glla 11ilw adfueliermli ll>y ~me s~m©Miurnm, amdl rtJbis is 91erne11all~ ne lallleal ill© am
a11ibicrn1lar ©Me ~f§)llessurne dlwe \Ii© l'ilil i<Dr<©'l!r.awrimas ~olemdllrim~, li>lllll*is nm~.
1.1: The main clinical sign is a difficulty to open the mouth in the morning, generally followed by a single
01 noise caused by the unsticking of the synovium, with the immediate normalization of the mandibu -
~ lar moveme~ts (the noise sounds like an adhesive strip being peeled off) .
.c~

Elimination of the etiology with an occlusal night-guard preventing the "sticking" and a gymnothe-
'lt rapy intended to mobilize the TMJ and to increase the trophic potential.
(])
IE
i
It:
125

Adhesions
D.efiinittiiem F@nnmaroi.Gm 0W i 1111eve fi si~le ifiifu riows imltma-antiicrn1l·at admesiGms wh i.oh l'ililay, li>e
eiillhe11 o©nal~d0dliseal ©11 illel'ililJ1l©l1Gdl!i.s<iia l: ltlraey aloe @Willem itilile evoll!l:tion ot a<ilmesioms 0.r
l'ilil i ~m~ li>e ©lile rti© am irnroria-a mtli'<eil!l la ~ rne.l'ilfl© r:mma0e 9ffiilie1i 'tlfiat!Hllila ©r swrgery. ·
Limitation of the amplitude of one or several mandibular movements (depending on the location of
the adhesion) and articular noises.

.... The treatment depends on the symptomatology and is a gradual "response": abstention, gentle phy-
1.1:
<1.1 siotherapy in order to try to increase the condylar translation, articular "cleaning up" with arthros-
.§ro copy in the most advanced cases.
(])

r=
 Occlusion made easy

Subluxation and true luxation

Subluxation
DefiinitiaA [)rurin~ lilll©uillm
©Ji)emimg, the mamdibm lar G©111~yle
g@es over 1Jhie anticw lar itl!lbercle
o:fi the termp©!ial ID©me, carnsi111~ a ·
'tle11nporiormanciJib1J1 lar luxati©ra.
Self. redw<!:ible, this i(il'ld of ·lt1xation
is callee! a sl!lbluxation, and may be
either uni- or bilateral.

\ \

126

>. Ligamentary hyperlaxity and "facilitating" morphology of the temporal tubercle (obliquei and short
gi posterior slope).
0
'.j:l
UJ

Muffled clicking at the maximal

mouth opening, which may Opening
Vl sometimes be confused with a
~ clicking related to a condyle-disk
·v; disunion. The amplitude of mouth
(3 opening is exaggerated with a click
c at the end of movement, and the mm
u closing movement is not rectilinear.
_,.. l\ctive mvt • Musculary pain
- Assisted mvt * Articular pain

"""' The tr-eatment is palliative: with behavioral advice (avoid to open mouth at its maximum when
~ yawning or biting voluminous food) and exercises of muscular strengthening, in order to limit the
.§ condylar translation with stronger levator muscles.
ro
QJ

i.::
Prognosis: the risk of recurrence remains, because the eti0logy (li gamentary laxity)
cannot be eliminated.
 7 Classification of TMD

True TMJ luxation

li>etiAiitiiern De~imi i©m Willem ilt is m©:t sp©mlti-cltiiH1!©l!IS·I¥ 11eGll!!l(iJedJ, illhle ilielilTIJi>©l1©11lilamdiblw lar
lw~alliiom 0e:meliaroes a llil'0<1:kim·0 wkrem ~me trn1©rnltllll is <llli>em att itme emdl (i)ifi illroe 'Mamslail!i©m ©f
illme trn1amdl ib>111 lar (iJO riHil ~le, fuew,ora€1 ilifue aritlic111lar. illlllfue11Gle e~ illme illelilTlp>Grna l b©me: !alter.al
Ji>llierYi:g©idl 1il11Wscle·s amGl trn1asse1!er l'ilill!JS(iJles @@rnror;acit, ilime i;>ailli elil~ (!;am'mG>X close fu i s~mer; trn1ol!lth
amM r.r.i0rie.
It is the same etiology as the subluxation concerning the amplitude of movement, the ligamentary
hyperlaxity and the facilitating morphology. In this case, there is also a reflex muscular contraction or
a morphology of the temporal tubercle preventing the return to normal.

The "open-mouth" blocking and the presence of a moderate to severe periarticular pain sign the
diagnosis.

127
The Nelaton's maneuver, performed by the practitioner, generally allows the condyle to re-integrate
the mandibular fossa. The operator faces the patient, and holds with his/her two hands the man-
dibular arch, the thumbs placed on the occlusal faces, the other fingers under the horizontal ramus.
The thumbs apply a strong pressure downward and both hands push to the back. To facilitate the
reduction of the luxation, the pressure towards the back may be performed with a small alternate
movement left I right. Once the reduction is achieved, an anti-inflammatory treatment is prescri-
bed as well as the rest of the mandible. The long-term treatment is the same as the treatment for
subluxations.

Progir:HDsis: pa'tlienits suffering iir©lil1 this typ>e of lesion tencl 'lio mf.f.er foolilil a recwrremae
l:i>e«ause ©1f ;tJf'ileir rn~fD.erla~itt:y. Id! is wsef•wl t0 sm0w 'tlrae trn1al'ilet.1wer 'Ii© tme p>ai'tiemit's rela illi~es
ili0 a~t0id:f leaVJil'lgJ l'ilililil~fuer w,i'tlrn mis7mer 11Jil©Witifu ©ipem, waiiflirig for rbfiie C©r:IS1:Jhliati0m.
 Occlusion made easy

Inflammations
An inflammatory process located within the TMJ can be the consequence of various situations:
- Anomalies of the condyle-disk complex;
- Micro- or macrotraumas;
- Infection (rare).

The inflammation affects the articular capsule (capsulitis), the synovium (synovitis), the
bilaminar zone in charge of the vasculari zation and the innervation of the TMJ (retrodiscitis) or
the osseous tissues (arthritis).

Capsulitis I Synovitis
Defiini1!ior,i lrnflaml'ilflation of tme caJ!lsu le or the syraovium (;the clinica l clistimctiori eannot
128 lDe lililaGfe), Gf me ite a 1ITTac110 ©r rmicrGrlir;aul'iYilas and the associat ed! ant;iol!llar 0venp l'i essl!llie.

VI
Q) Pain in the extreme mandibular movements (opening and maximal contralateral diduction).
:::J
O" Absence of pain in ICP or during mastication.
c Pain under lateral palpation.
VI
Q)
c
G)
VI

Behavioral recommendations (rest of the articulation).

""'
c
Anti -inflammatory drugs:
E • NSAIDs: propionics: naproxen sodium: 1, 100 mg /day.
1U • short-acting corticoids: prednisolone Cortancyl®tablets. 1, 5, 20 mg.
Q)

i=
 7 Classification of TMD

Retrodiscitis
Deiiimitiom lrnfilarrnmaitiom o~ rie11ri.@cliscal :tiissues dwe 1J® ttjffi e articular overpliessulie and 1J0
the iliwmcti©nal or rtir.al!lrma'bic 00>r;nil~lar re:trn12>0siil!i©m.

VI
Pain in ICP or during mastication. •
~ Pain aggravated during the ipsilateral diduction or during chin pressure in distal which incre.;ises the
·;;:; pressure of the retrodiscal tissues.
~ Pain under retro-condylar palpation.
c

Behavioral advice about contraction and mandibular movements (articular resting). This kind of
advice is often already naturally followed because of the pain.
1!:Q) Anti -inflammatory drugs - non-steroids or corticoids in short cure (see above).
E Occlusal splint in slight anterior position (for a few days) which plays a protection role.
+-'
cu
~ 129

Arthritis
Definition l!l>efiiniilliom It is am irnfllal'irilllilatory a©r;mponemil: of tl:le degenerative €.lisease 0>f
rt!m e iJi M~.

VI
Pain loca lized in the TMJ during all the mandibular movements (active and passive).
c
Ol
VI

cu
u
c

'

• behavioral advice.
+-' • Anti-inftammatory drugs (see above).
c
OJ • Occlusal device of decompression.
E
+-'
cu
Q)

~
 Occlusion made easy

11 HELPFUL READING
• John MT, Dworkin SF, Mancl LA. Reliability of clinical temporomandibular disorder
diagnoses. Pain. 2005;118(1 -2):61 -9.
• De Boever JA, Nilner M, Orthlieb JD, Steenks MH. Recommandation for
examination, diagnosis, management of patients with temporomandibular
disorders and orofacial pain by the general dental practitionner. http://www.
130 eacmd.org/files/eacd _recommendations _nov_2007.pdf
• Okeson JP. Management of temporomandibular di so rders and occlusion. 7th ed. St
Louis : Mosby, 2008.
 Mounting
on the articulator

A book dedicated to occlusion must obviously contain a chapter on the mounting on

131
articulator ! This manipulation is too rarely performed: although most of the practitioners
are fully aware of its importance, they do not like to perform it because they find it too
long or too complicated. The use of an ergonomic equipment allows to make it quicker
and easier.
As an addition to the clinical examination, the mounting of the patient's casts on
the articulator allows a more thorough study of the occlusal relationships. In some
prosthodontic procedures, the mounting can facilitate the integration of prostheses in
the patient's occlusal functions, which reduces the necessary adjustments in the mouth.
The practitioner can thus save time, and the patient is more comfortable.
This manipulation must necessarily be performed in the dental office. The risks of errors
and inaccuracies are too important when the measures taken on the patient are sent to a
distant laboratory by a more or less careful courier.
The accuracy which must be achieved in this procedure requires some rigor in the carrying
out of every stage, and its validation, before starting the following one: let's keep in mind
that it is not the articulator which provides accuracy, but the operator!
 Occlusion made easy

THE NECESSARY EQUIPMENT

Assistant
• An array of non-perforated
impression trays (such as
"Rimlock") is recommended
to provide a proper
compression of the material.
: Class A alginate vvith bowls
and spatulas.
• A mixing machine to optimize
the quality of the mixture.
• An adhesive spray for
alginate.

132

Practitioner
• Articulator, face-bow and
mounting plates .
• Silicone material for occlusal
recording.
• O ~clusal recording wax
(Moyco® X hard).
•
• Heated water at 52 °C (1 25 °F)
(thermostat baby bottles for
example). "'
• 5 plastic cups filled w ith cold
water.
• Qui ck-setting mounting
pl aster (Snow-white by Kerr®).
• Bistoury or cutter.

1 Fitting of the impression tray.
3 The unsupported extension is
eliminated before pouring.
4 The palate and the vestibules
are eliminated in order to obtain
a thinner cast.
8 Mounting on the articulator
2 After drying the arch, a small quantity of
alginate is applied on the occlusal faces.
Impressions
Ideally, impressions are taken during the clinical examination
session . This way, casts can be avai lable the day of the 133
session dedicated to the mounting on articulator.
The main objective is to obtain an accurate reproduction
of the occlusal faces. For that purpose, an array of non-
perforated impression trays (such as "Rimlock") is recom -
mended to provide a proper compression of the material.
The use of a mixing machine optimizes the quality of the
mixture. The impression tray must cover all of the arch
(Fig. 1). The intrados of the impression tray is coated with
adhesive to avoid the de-cohesion of the material during
its removal.
The alg inate is prepared according to the recommended
dosages; it is mixed to obtain a smooth, lump-free paste.
The water temperature has a sign ificant impact on the set-
ting time; heat reduces the setting time. A bottle of water
kept at room temperature (21 °C, 70 °F) provides predic-
table and constant results.
The impression tray is filled and the dental arch dried with
an air jet. A sma ll quantity of alginate taken in the bowl is
applied with the finger on the occlusal surfaces (Fig. 2),
then the impression tray is inserted by avoiding any dental
contact. It is then removed with a sharp movement in one
single axis when the setting is over.
The impression is rinsed and disinfected; during the exam i-
nation, there must not be unsupported paste in the area of
the occlusal faces. After validation, the unsupported exten -
 Occlusion made easy

5 A hermetic box lined with moistened paper 6 Microbubbles are eliminated with a sharp blade.
allows the plaster to set without excessive
dehydration.

sions are cut with a cutter, the palate and the

bottom of the vestibules are also eliminated
(Fig. 3-4). The resulting cast is thus thinner,
134 allowing the making of another cast with key
grooves on its base (split cast) and no excessive
height.
If the impression is handled in the dental
office, it will be molded with hard plaster as
soo n as possible and kept in a closed and wet
conta iner until the end of the setting time: a
hermetic box lin ed with moistened paper is
perfectly suitable (Fig. 5).
If the impression is sent to the labo ratory,
it is packed in a plastic bag with some very
wet absorb ing paper. Once the impression 7 Molds can easily provide a split-cast in two
is molded, a cleaning of the casts may be successive pouring.
necessary: microbubbles on the occlusal
surfaces are then removed with a bistoury
blade (Fig. 6).The preparation of casts
described here is particularly adequate for
an . occlusal analysis. This preparation is not
required for every mounting; the priority
remains the ergonomi cs and' the economy of
procedures..,.to perform . The maxillary model
is prepared with a split cast (Fig. 7). The
mandibular model is prepared in order to be
split in three parts: a canine -to -canine anterior
sector and two posterior sectors (Fig. 8).
This preparation allows, during the occlusal
ana lysis, a quick assessment of the anterior
guide. A system of parallel pins (Pindex® for 8 The mandibular model is sectorized in
example) is the most practical for that purpose. three parts.
 8 Mounting on the articulator

Principle of the mounting on articu lator

Using an articulator al lows to have a mechanical simulator

capable of reproducing equivalents of the mandibular
movements in order to observe the static and dynamic
dental relationships on the casts.
To transfer the patient's anatomica l elements into
a mechanical device, it is necessary to define,
with an axis and a point, a common
reference plane between both.
The manducatory apparatus that
we have previously described is
an imated by complex movements
among which it is possible to isolate
a simpl e movement of rotation: the
terminal hinge axis movement. It is not a
physiological movement, but a so-ca lled
"border" movement, which is reproducible. 135
The operator guides the movement with his/her
hand. There is also a movement of rotation on the articulator:
these common axes of rotation must be used (Fig. 9). 9 The transfer
procedure allows to
match the patient's axis
of rotation with the axis
of the articulator.

The mandibular rotation has a sma ll

amp litude (approximately 10 mm from
the incisal edges). The axis of rotation
passes by the internal pole of the
mandibular condyles, and its cutaneous
emergence is situated approximately
1O mm in front of the tragus posterior
edge on a line joining the middle of the
tragus to the palpebral comm issure (Fig. 10).
In the past, this emergence was accurately
determined with a kinetic method . However, in
our daily practice, this precise local ization is not used
any more because this is a long manipulation, and the
necessary specific equipment is no longer available.

10 Emergence of the hinge axis in the cutaneous area.

 Occlusion made easy

Several authors (Bernhardt & al, 2003)

suggested cutaneous anatomical locations
stemming from statistical samples. These
points are situated in front of the tragus
and under a line connecting the upper edge
of the tragus with the external palpebral
commissure. A template allows to quickly
locate the point proposed by Guichet 1979)
(Fig. 11).

11 A template allows to draw easily the point

of emergence proposed by Guichet.

136
12 The closing radius is different
on the articulator. The occlusal
consequence is the difference A B.
This distance is smaller when the
wax strip is thinner.

13 The extrapolation of the axis

performed on the patient is reproduced
on the articulator, which makes the
procedure clinically valid.
 8 Mounting on the articulator

More ergonomic, the use of the

auditory meatuses to locate the
transverse axis is current ly the
most widespread method.
Although it represents an
approximation in apparent
contrad iction with the accuracy
wanted in the frame of this procedure,
we are going to describe its clinical
repercussion. During the clinical recording of
centric relation, the movement of rotation is
performed ar~und the patient's hinge axis. The
casts are mounted on the articu lator with this
recording but when the waxes are removed, the
rotation occurs around the axis of the articulator.
Because of the axis differential, the mandibular
cast does not fit exactly in the same place against 14 The two external auditory
the maxillary cast as the mandible against the
meatuses and the anterior point
define a reference plane in which is the
patient's maxillary. The result is an occlusal error maxillary is positioned. 137
in the antero-posterior direction (Fig. 12). The
amp litud e of this error is even sma ller, and clinically
insign ifi cant, when the wax ·recording is thin
(< 2mm).

The use of the external aud itory meatus as a

posterior reference during the placement
of the face-bow is an anatom ica l
extrapolation which is compensated
during the transfer on articu lator and
can be thus considered as clinically
acceptable (Fig. 13).
The third necessarily point to
determine a reference plane serves to
position the maxillary in the facial bone
structure. W e are going to use a mark
in the anterior sector of the patient's
face: it may be the sub -orbital point, the
nasion or another point recommended by
the manufacturer of the equipment (Fig. 14).
It allows to place the maxillary model in an anterior
posterior position at the proper distance of the
axis of rotat ion and vertically, in the middle of 15
The placement of the face-bow allows to
both upper and lower branches of the articulator record the radius of the terminal hinge axis
(Fig. 15). movement.
 Occl usion made easy

Mounting on articulator
Du ring thi s clinical session, the operator uses a
face-bow to loca lize the reference plane. He/
she records th e intermaxi llary rel ation ships in
ce ntric relation and in diduction, th en proceeds
to t he mounting of the casts on articul ator and
to the setting of the condylar housings; each
of these stages will be detailed.

Desc~iption and use of

a transfer face-bow
Wh atever the brand of the equ ipment, a face-
16 Transfer face-bow.
bow always con t ains the same elements: an
occlusal fork, a frame with auricu lar tips, an
138 indicator of anterior marks, and a connecting
rod between the fork and th e frame, fitted with
co llet fixtures (Fig. 16). A specifi c mounting
accessory may complete the device.

Placement of
the transfer face-bow
Both faces of the fork are coated with some
silicone for occlusal recording (Fig. 17). The fork 17 Silicone injection on the occlusal fork.
is then put in the mouth and placed against
the maxillary arch; the rod must be aligned on
a parallel plane to the sag ittal plane (Fig. 18)
The patient is asked to move his/h er mandibular
teeth until they come in contact with the fork in
? position of protrusion. Thi s position releases
some space in the posterior sector, avoiding
excessive pressure on the distal part of the fo rk .
Once th@ material is set, the fork is removed
from the mouth and rinsed under co ld water;
the maxillary indentations must be trimmed.
Excess is eliminated with a cutter in order to
obta in the marks of the cusp tips on ly (Fig. 19).
The maxillary model is fitted in the indentations 18 The properly positioned fork is held by
and its stability is checked (Fig . 20). the patient who clenches his/her teeth in
propulsion.
 8 Mounting on the articulator

19 Excess material is eliminated. 20 The stability of the cast is checked before the
placement of the fork in the mouth.

139

21 The patient puts himself/herself the tips into 22 The patient's hand_s hamper the operator, it
his/her auditory meatuses. is more difficult to keep the position against the
maxillary.

The fork is put back into the mouth: the

patient finds his/her position of protrusion
and holds the fork in the proper P?Sition by
clenching teeth as he/she did before.
The patient places him/herself the ear tips in
his/her auditory meatus, while the practitioner
connects the upper frame to the fork and the
connecting rod (Fig. 21).
In our opinion , the patient shou ld hold
the fork with his teeth rather than with his
hands - he absolutely does not interfere with
the practitioner's manipulations this way
(Fig. 22).

23 The frame is parallel to the bipupillary line, The anterior index is aligned on the mark
the anterior mark is the one indicated by the chosen in a frontal plane, the frame is paralle l
manufacturer of the articulator. to the bipupillary line (Fig. 23 ).
 Occlusion made easy

Torquing is performed sequentially in a

progressive way by avoiding any uncomfortable
constraint for the patient. After blocking, the
bow is removed and stored in a safe place.

Recording of
the intermaxillary
relationships
The first choice recording material for a fully
toothed patient is Moyco® wax. Used in the
proper t~rnperature (52 °C, 125 °F), softened
24 The use of a thermostatic bain -marie
device is the guarantee of an adequate
with heated water, it allows an immediate
temperature for the material.
indentation.
For a better efficiency, wax strips are cut in
advance - their width must be one and a
half the width of the posterior occlusal faces
140 and their length must go from the canine
to the last molar. They are folded to form a
two -layer strip (Fig. 24). The use of strips is
preferred to the wax plate, in order to avoid
the obstruction of the tongue.
At least three recordings in centric relation
(i.e 6 strips) mu st be planned, as well as two
recording s in diduction. In diduction, a strip
is necessary on the working side, and two 25 A preliminary manipulation is necessary
on the non-working side. It is thoughtful to before proceeding to the recording of the CR.
prepare a greater number of strips in case of
fail ed manipulations.
Before proceeding to the recording, the
movement is performed with the patient
to make him/her understand what w e
expect from him/h er. We have described
the mandibular manipulation in the chapter
dedicated to the centric rel ation. The patient
•
lies in the dental chair, his/her head in th e
alignment of the body without flexion nor
extension (Fig. 25).
With the mandible in a situation of postural
mu scle tone, a couple of wax strips is put
to soften into a bowl filled with hot water
(52 °C , 125 °F). The operator quickly puts a 26 Three recordings are made in order to
strip on each maxillary hemiarch by pinching validate the manipulation.
 8 Mounting on the articu lator

the anterior part on the can ine in order to stab ilize it (Fig. 26). Then he guides the patient
towards the maxillary contact and stops the closing movement by saying "open". Waxes
are coo led with an air jet, delicately removed and imm ed iately stored in a cup of co ld
water. Two other recordings are performed in the sa me way.
In the position of lateralization, the manipulation is simi lar to what has just been described.
The patient is guided to achieve a canine end-to-end occlusion, on the left and,,,the right

(Fig. 27). The operator checks the ava ilable

space between the teeth of the non ~
working side. It may be necessary to double
t he wa x thickness in this area to obtain a
valid recording (Fig. 28). The record ings
are performed and stored in labeled cups
(left and right).
The clinical session is over. The practitioner
can proceed to the mounting of t he casts
on the articu lator.

141
27 In left laterality, the interarch space is
bigger on the right.

28 A recording is performed in canine end to end on the left and on the right.
 Occlusion made easy

Mounting of the maxillary model

142

29 The mounting of the maxillary model separates from the frame of the transfer face-bow.

The transfer protocol is very simple. Only th e

connecting rod , the fork an d th e ant erior tabl e
are attached to repla ce th e anterior table of
the articulator; the frame is not necessary any
longer in this phase (Fig . 29).
The arti cu lator is locked in centric, the incisa l
pin is set to 0, a mounti'ng plate is placed
against t_tie upper arm. The mounting table
positions the fork in th e articulator, a support
is set up to avo id any kind of fle xion during
the introduction of plaster.
The maxillary model is placed in the indentations,
its stability is checked . Some mounting plaster
in creamy co nsistency is added to fasten the 30 The maxillary model is attached to
model to the arti cul ator (Fig. 30). the articulator.

Mounting of the mandibular model
31 The incisal pin is increased of 4 mm to
compensate for the thickness of posterior wax.
32 Wax is placed
against the maxillary
model.
33 The mounting is completed.
8 Mounting on the articulator
The mounting plate and the face-bow are
removed from the articulator, the incisa l
pin is set at + 4 (Fig. 31). This modifica -
tion aims at compensatir'tg for the
wax thickness (± 2 mm) placed
'
between the casts, wh ich al-
lows, after removal of wax;
to find a value close to Oon
the incisa l pin. A mounting
plate is fixed against the
mandibular arm .
The articu lator is placed upside
down, a pair of waxes is appli ed
against the maxillary arch (Fig . 32), any
excess in contact with the mucosae is eli-
minated. The mandibular model is then
replaced in the indentations, and the sta- 143
bility of the whole preparation is control-
led.
Mounting plaster is placed under the
base of the mandibular cast and the ar-
ticulator is closed while the models are
held by the operator.
The mounting is now over (Fig. 33).
 Occlusion made easy

Validation of the mounting

The three performed recordings will be used. Th e base of the maxillary model is split (Fig. 34).
The articu lator is opened, the maxillary model is positioned aga inst the mandibular model
by interposing the second recording. The upper arm is pulled down; both bases must match
perfectly, proof th at both recording s are identical (Fig. 35). It is not the case here (Fig. 36).
With the third record ing, however, the mounting is validated, the recordings 1 and 2 being
identical.

34 Split-cast is separated in order

to check the CR recordings.

144

35 The# 2 recording is vali~ate

two identical recordings validate
the position .

...

36 Here, the double base does not

fit, this recording is different from
the previous ones.
 8 Mounting on the articulator

Control of the models

Centric Centric
relation relation
1 1

Centric · Centric Centric Centric

relation relation
3 3

145

Centric
Remounting

D The sp lit-cast fits

D The sp li t-cast doesn't fit Centric Centric

relation relation
3 3

~a Ii dated

New recording of CR
 Occlusion made easy

Programming of the condylar housings

Principle of the programming
Non-working side
Working side Medialization of the
Lateralization of the condyle: Bennett's angle
condyle: Bennett's
movement
The condyle moves
downward: condylar slope

146
37 Diduction involves asymmetric
movements of both condyles,
the parameters are adjusted
on the non-working side.

Lb
In a movement of latera lization, both mandibular
cond yl es make asymm etric movements
(Fig . 37): th e non-working condyl e performs th e
most important movement: it moves forward,
downward and inside by following the anatomy
38 A recording of diduction is placed
between the casts.
of th e articu lar tubercle. The working condyle
moves outside, upward and backw ard .
T~e articulator is programmed from the
recmd ings performed in the lateral position.
'
The upper arm is unlocked, the condyl ar
housings cri;e set to a O 0 condyl ar slope and the
Bennett's wing is left free. L b
The maxillary model is put on the mandibular
model through a pair of waxes in diduction . Let's
take for example a rig ht latera lity, which allows
to adjust the parameters of the left housing 39 The upper arm is operated by engaging the
(Fig. 38-39). split-cast, the condylar housing on the working
side is beforehand neutralized (O 0 ).
 8 Mounting on the articulator

40 The top of the fossae is not in contact 41 The housing is lowered until it comes in
with the condylar ball. contact with the ball.

147

42 The Bennett's wing is remote 43 Here, the Bennett's wing is preset, it is

from the condylar ball. brought to contact by translation.

The upper arm of the articulator is put against the maxillary model by meshing the double
base. In the previously described conditions, the condylar ball on the left side is under the
housing top. The housing is lowered to come in contact with the ball, which determines
the angulation of the condylar guidance (Fig. 40-41). The Bennett's wing is brought to
internal contact with the condylar ball (Fig. 42-43), the angulation values of the condylar
guidance and Bennett's angle are written down on the patient's chart. In the case of a 7°
fixed Bennett's angulation, the quantity of lateral movement must be noted (in mm or in a
fraction of mm).
The protocol is carried out again to settl e on the opposite side by interposing the other
recording in lateralization .
At this stage, we work with a device able of simulating the patient's dental positions and
arches movements with an accuracy allowing to procee d to the occlusal analysis.
 Occlusion made easy

Criteria selection of an articulator

There is on the market a wide selection of models featuring almost identical characteri stics.
All of them are currently fitted with the setting of the condylar guidance and with Bennett's
angl e. They are semi -adju stable articulators enabling to perform most of the prosthodontic
procedures .
Stemming from Lee and Lundeen's studies, a new generation of semi -adjustable articula-
tors integrates th e setting of th e immediate side shift (which is a lateral t ranslation); in this
case, the articulator should be fitted with a centric latch to keep the accuracy of centering .
So, when you can do something compli cated, you can obviou sly do something simple,
can 't you?. Well, this is not always true! in current practice, an articulator fitted with many
settings may generate maladjustments, th e use in prosthetic laboratories is not always as
ca reful as we may think and the state -of-th e art properties of the device may also mean a
greater fragility. The choice of an articulator must match the use we have in mind: diagnosis
or prosthesis?
An articulator intended for diagnosis use must be program ed to fit as closely as possible th e

148 patient's parameters so that the observation of the ca sts reproduces as faithfully as possible
the clinical conditions. An articulator intended for prosthetic use must be solid; it can be
programed differently to check a movem ent envelope bigger than th e patient's envelope.

, Diagnosis Prosthesis in posterior sectors

Condylar guidance From the recordings Lower than the patient's (- 5°)
.
Bennett's angle From the recordings Higher than the patient's(+ 3°)
Latera l shift From the recordings Bigger than the patient's(+ 0.5 mm)

Why such a programming for prosthodontic

goals?
In a pro sth eti c approach of th e anterior protection, the guideline is to avoid posterior
jnterferences with th e recon structions. Th e condyl ar guidance will be lower on the articulator:
20 ° inst ead of th e 25 ° measured. As a con sequence, in a movem ent of protrusion, the
' .
lowering of the cast s on ·the arti culator will be smaller (20 °) than th e separation of teeth
in th e patient (25 °). Prostheses made on the articulator with no interferences have a safety
space during th eir insertion in t he mouth (Fig. 44) . It's th e sa me for th e lateral movements
if th e movement envelope is wider on th e arti culator; th e ri sks of interference in th e mouth
will be reduced. Th e articul ator acts like a safeguard in th e pro cess.
For a regular use, th e ease of use must prevail over oth er criteri a. Th e tran sfer face- bow
is t he key to t his ergonomi cs: t he pl acement of th e face- bow must not exceed 2 minutes;
thi s manipulation ca n thu s easily integrat e any diagnosti c or prosth eti c process. Th e devi ce
w e have describ ed meets those requirements: it is th e Denar® device fitted with a fa st and
 8 Mounting on th e articu lator

44 Teeth prepared on the articulator do not interfere. In the patient, the separation is bigger 14g
because of the more pronounced slope.

45 Fag's Quick face-bow.

46 The mounting of the maxillary requires the
use of the frame.
47 Interchangeable inserts refer to the preset
values of Bennet's angle and immediate side
shift.
 Occlusion made easy

simple to use face -bow. There are many other devices on the market, among which the
FAG system (Fig. 45-46-47), which is very wide-spread, and the SAM system (Fig. 48-51).
The cost of these devices is not a determining factor in the purchasing: the amortization over
the years totally dilutes the importance of the investment. The improvement of the work
quality, the saving of time in the prosthetic adjustments make the buying of an articulator
a good bargain in any circumstances.

150

49 An additional device allows to mount the

occlusal fork with no frame.
48 SAM face -bow.

..., !
-"" i\l
50 The condylar slope is adjustable: Bennett's 51 A spring provides the lock in centric.
angle fixed at 7 °, no adjustable translation.
 8 Mounting on the articu lator

w
~
:::> To keep a clean device and
t; facilitate the cleaning, silicone
w is sprayed on both arms of the
(.!) articulator before fixing the
1- mounting plates (see picture).
:::c:
(.!)
-
~
w
:::c:
I-

151

HELPFUL READING
• Bernhardt 0, Kuppers N, Rosin M, Meyer G. Comparative tests of arbitrary and kinematic
transverse horizontal axis recordings of mandibular movements. J Prosthet Dent.
2003;89(2):175 -179.
• Guichet NF. The Denar system and its application in everyday dentistry. Dent Clin North
Am .1979;23(2): 243 -57.
• Hobo S, Shillingburg HT Jr, Whitsett LO : Articulator selection for restorative dentistry. J
Prosthet Dent. 1976;36:35-43.
• Lee RL. Jaw movements engraved in solid plastic for articular controls - Part I and II .
J Prosthet Dent. 1969;22(2): 209-24/513-527.
• Lundeen HC, Wirth CG. Condylar movement patterns engraved in plastic blocks.
J Prosthet Dent. 1973;30(6): 866 -75.
• Morneburg TR, Proschel PA . Impact of arbitrary and mean transfer of dental casts to the
articulator on centric occlusal errors Clin Oral Invest. 2011;15: 427-434.
 Occlu sion made easy

KEY POINTS
The clinical exalll'ilimation d0es not always allow to tully assess tme
occlusal relatioriships, and especially not the therapeutic investment
necessary for time treatment. The mounting of casts om an articulator
allows to think oJ and simulate solu'bions before ariy procedure is
started on the patient.
In the case of dysfuflctions of the manducatory apparatus, the
occlusal anal;ysis 011 articulator all0ws to evaluate tme pathogenicity of
' the occlusio.n, to measure the amplitl!ld'e and the directi.on of the gap
between ICP amd cem;tric relation as well as the occlusal functions of
centring, stabilization and guidance.
The orientatio.ra 0J the occlusal plane is also easier to assess on an
articulator than in the Ailouth.
152 If a prosthetic rehabilitation must be performed, the reoq!Janization
of the fanctions is simulated, and the practitioner can measure
the importance 0f the procedures to initiate: single prosthesis or
combined treatments (occlusal adjl!lstmeAt, surgery, orthocdontics,
prosthesis).
It is easier to explain the therapeutic proposals t0 the patient
when the initial situation can be visualized, as well as the prnpose.d
adjustments, and sometimes even prosthetic models. The patient's
compliance is favored by the visualization of the treatment we
suggest. Determining a treatment plan accordimg, to these procedures
allows to save time during the different phases of the treatment,
and the time dedicated to this preliminary analysis is then largely
compensated
 Instrumental ...

occlusal arialysis

The instrumenta l occlusal analysis is an important

153
stage of the prosthetic and occlusal diagnostic
approach. It completes the interview, the clinical
and the radiological ex'aminations.
This analysis refers to the observation of the
patient's casts mounted on articulator with the
aim of examining the static and dynamic occlusal
relationships with inherent advantages: occlusal
re lationships can be observed on all the faces,
vestibular and lingual, the centric and eccentric
positions are easily and tirelessly reproducible.
The vertical dimension is measured and its
modifications can be envisaged without involving
the patient For a quick and easy assessment of
the anterior guidance, the mandibular model
can be split, allowing to iso late the premolar and 1 Splitting the model allows to remove
molar sectors of the can ine -incisa l entity (Fig. 1). both lateral sectors.
A rigorous clinical sequence allows the operator
to make an occlusal diagnosis as well as to define
a therapeutic strategy by simulatin g an occlusal
harmonization on the casts.
 Occlusion made easy

Occlusal analysis on a
natural dentition
The first step in the screening of occlusa l anoma lies
consists in examining the casts of the arches held
in our hands. We can:
- Observe the shape of the arch and the dental
malpositions (migrations, rotations, tiltings);
- Try and find the ICP by manually putting
together both casts;
- Check the stability in this position.
2 Searching a stable position in ICP.

Methodology of the occlusal analysis

The first step aims at assessing the mandibular
centering. It consists in characterizing the
154 amp litude and the direction discrepancy
between CR and ICP, which requires to be ab le
to go from one to the other position.
The mounting in articulator places the casts
in centric relation, a position determined by
the centric lock of the condylar housings . To
obtain the ICP, the upper arm of the articu lator
is unlocked, allowin g casts to reach the ICP.
The existence of a gap lower than 1 mm in the
sag ittal direction is acceptable. A transverse I
decentering is unfavorable. 3 The casts are in ICP, the incisal pin records
the VDICP.

Analysis of the vertical

differential between CR and
ICP
The articu lator is unlocked, the casts are placed
in ICP, the in cisa l pin is put in contact with the
anterior table to record the'vertical dimension
of the patient's ICP (VD ICP) (Fig. 3) .
...
Then, the articu lator is locked in CR and casts
are brought back to contact in closure: we can
then observe the occlusion (or the inocclusion)
in centr ic relation (Fig. 4).
The incisa l pin is adjusted in contact with the 4 The articulator is locked in CR, the incisal pin
anterior table, in CR. Thi s materializes the is not in contact with the anterior table any
vertica l dimension in CR (VDCR) . more.
 9 Instrumental occlusal analysis

Right anterior lateral slide of Left anteri'Or lateral slide

the mandible of the mandible
5 Two colored marks placed right 6Interpreting the direction of the sliding
under the incisal pin materialize the movement.
differential in the horizontal plane.

The values read on the incisa l pin in both positions are written down in the patient's file.
The VDICP is the benchmark value of the patient's situation; the following therapeutic
options will have to preserve it, to increase it or to reduce it.

Analysis of the horizontal (sagittal or transverse) differential 155

between CR and ICP
The differential CR/ICP may be materialized in four ways:
On the incisal table: a piece of articulating paper placed under t he pin allows to objectify
the impact point on the incisal table when the articulator is locked in CR, and then with ano-
ther color, when casts are in ICP. These two points on the anterior tab le allow to assess the
amplitude and the direction of the sh ift in the horizontal plane (Fig. 5).

If the in cisa l table is situated on the lower

7 The direction of the shift is directly read
on the incisal table; here, lateral shift on the
left.
arm of the articu lator, the point referring
to CR is located in front of the point
referring to ICP; this is due to the fact
that on the articulator, the maxillary cast
is moving instead of the mandibular cast,
which explains the inverted situation. The
CR point is always centered, the ICP point
is on the left or on the right, the direction
of the observed shift is inverted: an ICP
point on the right means a mandibular
shift on the left and vice versa (Fig. 6).
When the incisal table is carried by the
upper arm of the articu lato r (as it is the
case with SAM articulators), the CR point
is always centered, while the ICP point
is either on the left or on the right. The
direction of the sh ift can be read directly
on the incisa l plate (Fig. 7).
 Occlusion made easy

On teeth: the differential can also be

objectified by drawing marks on the maxillary
and mandibular models in the molar and incisa l
sectors. The marks are aligned in CR and present
a shift in ICP (Fig. 8). The articulator being locked
in centric relation, the occlusion is ach ieved in
CR and often shows an inocclusion because the
mandibular closing movement is stopped by
prematurities.
On the split cast: the maxillary cast is placed
in ICP, the upper arm of the articulator locked in I'\

CR is closed , neither base match. This technique tj Visualization of the shift by drawing marks
on the casts.
objectifi es the existence of a differential, but
does not quantify it as well as the other methods
(Fig. 9).
On condylar housings: on the articulator, in
156 centric relation, condylar balls are in posterior
position in the condylar fossae. In ICP, we ca n
see that condylar balls have moved. This is just
an unmeasurable, information .
The intercuspal position (ICP) is th e physiological
position which is the sta rtin g point and th e point
of arrival of the functional movements, used
during swallowing. It positions the mandible
with regard to the sku ll and thus determines the
position of the temporomandibular joints. It is
the centering function.

9 Casts in ICP: the split cast does not fit.

Control of stability
In ICP, strips of metallic film (Shimstock 8aush®) as wide as a tooth allow
to check the location of th e contact points all over the arch without
leaving marks on the cast' (Fig. 10). The greatest number of contact
points bftween the antagonist arches provides the stability of t he
position in the vertical and horizonta l directions. It is the sta bilization
function.
In the transversal plane, dental stabilization is achieved by the
engagement of the supportin g cusp in the antagon ist fossa accord ing
.........___ _.... .,. j
to three occlusal contact points A, 8, C. The opposite couples A + 8 or
8 + C provide a proper occlusa l stability. On the contrary, th e existence 10 Searching for contact
of a sin gle po int A, 8, or C or of a coup le A + C makes the occlusion points with Shimstock0 .

11 Conditions of occlusal stability.
12 Removing the lateral sectors
facilitates the analysis of guidance.
13 The posterior view clearly objectifies
the validity of the anterior guide.
9 Instrumenta l occlusal ana lysis
unsteady (Fig. 11). Let's keep in mind, however
that these three stabilizing points are not ali gned
on the same plane, as the presented diagrams
might suggest.
The distribution of the occlusal contact points
must provide a harmonious ... stab ility of the
mandibular arch on the maxillary arch, without
requiring any kind of adaptive muscular
contractions nor generating any .condylar
movement resulting in a compression on the
articular surfaces. The stability of the position is
essentially due to molar and premolar groups,
capable of absorbing the functional strengths.
Stabilization is achieved when occlusal contacts
are distributed on the whole arch in a symmetric
way, in particular in the area of molars.
Stability is considered as acceptable when five
pairs of pluricuspid teeth (among which a pair of 157
molars) present properly situated contact points.
Assessment of
the anterior guidance
The next step is the validation of the anterior
guidance. Distal sectors are removed from the
mandibular cast. The articulator is closed in
CR, the pin (set on the value of VDICP) comes
in contact with the incisal table (Fig. 12). Strips
of articu lating paper are placed between the
incisors and the canines to check the contacts
in this area.
At this stage.. several cases may be observed:
• The contacts exist in VDI CP and the functional
ang les are respected: the anterior guide is
validated (Fig. 13).
• The incisa l pin does not touch the anterior
table: this indicates the presence of an
interference in the anterior sector (Fig. 14-15).
• The incisal pin touches the table and there is
no contact in the anterior sector : the anterior
guide is described as "non-fu nctional"; several
options that we are going to evoke in the
description of clinical perspectives are related to
this situation (Fig. 16).
 Occlusion made easy

I .
14 in closing posi~ion, no contact of the 15 A premature contact occurs in the ieft
anterior pin. canine sector.

Clinical perspectives
• In a natural set of teeth, when the ICP is
158 stable but transversely off-centered, we will use
coronoplasty to modify the ICP only if it infers
few corrections.
• When ICP is unstable but centered, it is
often easy to improve its stabi lity with specific
procedures like deepening fossa and grooves.
• When ICP is unstable and eccentric, an
occlusa l adjustment is recommended. If the
dental referent is defective, a new ICP will be
defined in CR.
16 The pin touches the anterior table,
absence of contact between teeth.

The occlusal adjustment in a natural set of teeth

will be described in detail in a following chapter.
• If there are no contacts in the anterior sector,
the incisal pin is unlocked; casts are brought into
contact, which generates a decrease in OVD.
The modification can be m~de if the variation
at the incisa l pin is about' 2 mm. Due to the
effect of 13fOportionality, 2 millimeters at the pin
correspond to a reduction of 1 mm in the molar
sector, which is clinically acceptable. (Fig. 17). For
a variation superior to 2 mm in the area of the
anterior pin, the restoring of ICP can combine
coronoplasty procedures with addit ion and/
or subtraction techniques, orthodontics and/or
17 The value measured at the incisal pin
increases according to the variation in the
prosthetic reconstructions. molar sector.

18 Class 11-2 occlusion .
20 The considerab le anterior overbite leaves
no fun ctional space between inciso rs and
ca nines .
21 The eruption of mandibular incisors
ca uses traumas on the maxillary retroincisa l
pe ri odontium.
9 Instrumental occlusal analysis
19 The absence of ante ri or contact has
generated denta l migrations .
• In some specific situations of class 11-1,
the anterior guide is defecti ve: it is delayed
in t he excursive movements. Th e therapeutic
decision takes into account the patient's 159
demands and t he possibilities: orthodontics
to restore guidance, or arrangement of a
group function w ith a guidance by premolars
and an elimination of th e interferences on the
non-working side.
• Th e anterior dysfunctional guidance
observed in cl asses 11 -2 presents a highly
pathogenic potential (Fig. 18-19-20-2 1).
Correct ion is recomme nded, using th e
appropri ate t echn iques: orthodonti cs,
prosth odontics, etc.
• In the cases of class Ill in end-to-end incisal
occlusion, the absence of guidance leads to
organize contacts distributed in diduction on
the work ing side, and to avoid inte rferences
on the non-working side. Th e result ing
occlusal anatomy is more "flatter" . It is,
however, necessary to keep a ce ntered and
stable ICP.
Af ter high lighting th e guidelin es of th e
procedures to perform in th ese variou s
situ ation s, w e have to keep in mind th at
th e t hera peutic decision not on ly depends
on t he clin ica l and on th e articulato r
observat ions, but must also meet th e
pat ient's expectat ion s.
 Occlusion made easy

22 Centric relation occlusion. 23 Centric relation occlusion.

The case described here (Fig. 22-23) shows

an anterior open bite in CR. The analysis of
the anterior guidance after modification of
the VDICP reveals a potentially functional
guide (Fig. 24-25). A modification of the VD
by subtraction in the lateral sectors might
160 result in a better occlusion; an orthodontic
treatment could also restore the guidance in
the proper VD, and a prosthodontic treatment
could restore the functional conditions
previously described. However, the whole 24 Satisfactory anterior contacts.
set of teeth is natural and shows no caries,
and the periodontal support is correct. The
symptomatology described by the patient is
an occasional muscular fatigue due to periods
of stress.
The most appropriate answer here is a splint
worn periodically when the symptoms appear
(Fig. 26). Less invasive than the other options,
this treatment can always be reconsidered 25 Lingual view of contacts.
according to the results and to the evolution
of the patient's requests.

26 Muscle reconditioning splint.

 9 Instrumenta l occlusal analysis

27 Three-unit bridge. 28 Prosthetic reconstruction of a hemiarch.

Preprosthetic occlusal analysis

In the case of an occlusal analysis performed before a prosthetic reconstruction, teeth
which must be reconstructed are reduced so that they do not interfere in the occlusion any
more. The ana lysis focuses then on the remaining natural teeth ..
In the case of a sma ll reconstruction (three -unit bridge) with a functional anterior guidance
(Fig. 27), the ICP can be preserved; the prosthesis must contribute to improvin g the stability.
For a larger (econstruction (posterior hemi-arch) (Fig. 28), the other side (natural set of
teeth) can be modified with an occlusal adjustment to improve centering and stab ilization;
the prosthesis will then be made in this new position . ICP corresponds to CR . The chronology
and the loca lization of the modifications are carefu lly written down on the chart to be used
later in the mouth. Corrections are performed after preparing the teeth to reconstruct. A
new mounting on articulator for the prosthetic reconstruction allows to check the proper
fitting of these alterations and perfect them if necessary.
 Occlusion made easy

A few clinical examples

29 Clinical view of CR occlusion. 30 Clinical view of ICP. 31 In VDICP, incomplete anteri1

guidance.

162

32 Reconstruction of the anterior 33 Preparation of splinted 34 Provisional elements restori

guidance by wax-up. temporary crowns. the anterior guidance.

35 Plcicement of provisional crowns before 36 Definitive prosthesis: teeth are individual,

periodontal stabilization. a functional balance has been restored.

A - Clini cal situation requiring a periodontal and prosthetic treatment: there are
prematuriti es in the access path to centric relation (Fig. 29-30). The analysis of the casts on
articulato r shows an anterior defective guidance of the left side (Fig. 31). Wax-up restores the
required contacts (Fig. 32) and, from th is project, the lateral sectors are occlusally adjusted
and a tempora ry bridg e is prepared (Fig. 33-34). The new occlu sa l conditions are clinica lly
tested for a few weeks (Fig. 35). After vali dation of the fun ctional conditions, th e definitive
prosthesis is prepa red accordin g to the criteri a of validation (Fig . 36).
 9 Inst rum enta l occlu sa l analysis

37 Clinical view of an inverted Class Ill 38 In CR on the articulator, the incisal

occlusion. relationships are end-to-end, once the posterior
interferences have been corrected.

163

40 Placement of the provisional bridge.

39 Temporary bridge setting new occlusal

patterns.

B- Class Ill clinical situation with inverted

occlusion (actually, a "slide in protrusion" case)
(Fig. 37). The casts mounted on articulator and 41 Definitive prosthesis in the new occlusal
relationships.
observed in centric relation position (Fig. 38)
show th at a less unfavorable situation ca n be
arran ged in incisal end -to-end. First a wax- up
model, and th en tempora ry prosth eses are prepared on the arti cu lator (Fig. 39). Durin g one
session, teeth are prepared and temporary prosth eses are placed in th e mouth. The new
occlu sa l project is then tested during fo ur to six weeks (Fig. 40). Th e definitive prosthesis
based on the new validated occlu sion ca n th en be safely placed (Fig. 41).
 Occ lu sion made easy

KEY POINil1S
lil!re lil\lO'tirnitlimg 0f casts ©n articulalfi©rr f'P llOMi©es a l!llllll01ll rimore illm@ri.olll~hl
apJPr:oaem OJf: illl\ie l!'aibielilit's ©<D<r:ll!lsal siilll!laitli©m. iinllle irnstlirrmrime.mitial ©GJ€llllsal
aITTal~sis is imGJi([jatlJed in ilJ me eases <l>;f cl~sifiwmGlli0ms ©tilifu e lll\lamGlw~ailie.r-y,
app>ar.ailius 01: 0fr e~rtensive p>rosthe~ic 11es:t0r;ai1ii0ms. ill1meliaf:i>el!libic sel.Ulitlioms
a11e 'tieste@: Cl> <DOl.l!lsal aGJjl\ISilJfmernil: !:§>~ swm;tma€1liMe ®r a@did:i~e <D©ll©ril©Ji>laSil:'o/r,
pri.0s11>e.cilliMe Ji> R©s'liroetic lilil@d.lels a111cill0r ©ri'til\l0cl0m iei: se:tl-1.ll p. tA ID©lililfi>!iellie ms·iwe
itmearol'ffilenit p>lam Gal'il itlrn.em b.e p liCi>l!'e ~I¥ p>Resemitle© iii© illfue p>aitlierntt.
lihe G:l.eoisi.©'m is G!onse.lilslllally liTilaGle l:i>y ital<im~ i111ili0 a(iJ<D©l!l lilltl illme 11>altli·e·mt's
glel:i>al @G>milie~ill, incl1:.1d.li111qJ 1jfu.e l:i>i©p>syohos©cial as11>ec:t: amd keep>im9 i111 mirid
the bes·t ither:apeuti,c 1li>eraefi;t I r:isk ratio.
It is afuout eho0s·ing il!file J!>roper tr<eatment and perforr;ni111g i;t with aornracy.

w
er:::
:::> To split the cast, we
164 t-
en must cut it from the base
.w towards the arch and stop
{!) below the contact point.
t- The cast is then broken
:r:
{!) and the area of the contact
-
er::: point is left intact.
w
:r:
t-

Both parts are separated by carefully The contact point area is intact.
breaking the isthmus of the remaining plaster.
 9 Instrumental occlusal analysis

...

HELPFUL READING
• Dawson PE. Evaluation, diagnosis, and treatment of occlusal problems . CV Mosby,
1989;379-·81.

165
 Occlusion made easy

166
 Occlusal splints
Their action
in ·the treatment of TMD

167

Occlusal orthoses, commonly called "occlusal splints", are part of the therapeutic methods
which can be used in the treatment of temporomandibular joint disorders (TMD).
Little binding for the patient and easy to handle for the dentist, they also present
the advantage of being minimally invasive. Nevertheless, poorly prepared or poorly
understood, they may be a source of iatrogenicity for the patient, thus resulting in a
failed treatment of TMD.
On the contrary, when the diagnosis is relevant and their use is adequate, occlusal splints
are an interesting technique for the practitioner eager to help his/her patient. _
 Occlusion .made easy

Diagnosis of temporomandibular joint disorders

(TMD)
Three clinical signs can reveal the existence of a TMD; they are nevertheless not necessarily
present at the same time. These signs are:
- Noises in the temporomandibular joint (TMJ) during the mandibular kinematics (clicking,
cracking, crepitation)
- Craniocervical and facial pain (spontaneous, induced, modulated by movements and
palpation);·
- Dyskinesia (limitation, deflexion, deviation).
After having confirmed the diagnosis of primary TMD, i.e a disorder generated by the
dysfunction of the manducatory apparatus itself, and after having eliminated the secondary
C ~ · • r ~r ~+ T~ M"\ rLJCh aS , for e"~""nl~ ~ +,'""Or the pract'lt l"n"r ""' oc + nr"pOSe a treatment f,.,r
0

dU)e)Vl ~llVIU) l\Olllt...11c,aLUlll, VllCllllU.)ltJIU I llllVI

his/her patient.
When must we intervene? - Prescription
Three occurrences, classified according to their importance and the appearance of the clinical
signs, may appear:
168 -Acute TMD,
- Subacute TMD,
- Chronic TMD.
Acute TMDs A TMD presenting a sharp symptomatology, like a capsulitis accompanied
with protective muscle contractions, requires the immediate preparation of an occlusal splint
such as an Anterior Bite Splint (ABS).
Subacute TMDs In the presence of a persistent, articular or non-articular subacut.e TMD,
with situations of musculo-articular pains and in spite of a primary treatment, occlusal splints
such as a "Muscle Reconditioning Splint" (MRS) or sometimes an "AntePositioning Splint"
(APS) quickly prepared are particularly indicated in first intention.
Chronic TMDs Nowadays and according to a widely admitted consensus, the systematic
prescription of an occlusal splint in first intention treatment of a chronic TMD is rarer and
rarer. A first therapeutic option including advice, explanations, behavioral reeducation and
gymnotherapy based on soft and atraumatic musculo-articular movements, is often effective
(Niemela K et al., 2012). However, in case of persistence or aggravation of the symptoms and
after a 4 to 8 weeks follow-up with no invasive intervention, the prescription of an occlusal
splint such as MRS or APS must be envisaged.
There are various splints with different names or commercial brands, variou s materials
or diverse shapes. In this' book, however, in order to simplify the prescription and the
preparat,jpn, we will describe these three types of splints (ABS, MRS, APS). With the help of
these appliances, the practitioner will be able to take care effectively of a temporomandibular
joint disorder (TMD).
 10 Occlusal sp lints
Decision tree (choosing a spl int according to clinical cases)
TMD diagnosis

~~----------::~-~--------..\.
Chronic
~
Acute
Subacute
c
0
·.;; Behavioral advice Behavioral advice
Advice ....for rest
c gymnotherapy gymnotherapy
CV
+'
c
+'
,_
11'1 No splint
u...

Quickly
Follow-up in 2, 4 weeks and
reassessment after two months Splint
c
0
·.;;
c
CV Preferably MRS
+'
c
"O
c
169
0
u Follow-up in 2, 4 weeks and Follow-up in 2, 4, 8 weeks and
CV
VI reassessment after 2 months reassessment after 3 months

Success

New behavorial New behavorial

advice advice,
gymnotherapy gymnotherapy

APS APS
c continuation
0
·.;;
c
CV
+'
c : follow-up in 2, 4, 8 weeks and
,_
"O : reassessment after 3-6 months
: '-r:::--,-~~~r:-:---r--;:!..:!~~~~~~~~~~~
..c:
I-

Reassessment to 3 months
.
--- ······················~

Fallaw -up

Reassessment of TMD diagnosis

 Occlusion made easy

3 The bur is placed perpendicularly to the

indentations.
1 Anterior Bite Splint 4 The resulting
appliance.
piece is smooth,
2 A pencil stroke · the colored
facilitates the reading of marks in the
the marks. bottom of the
indentations are
still visible.

170
The anterior bite splint (ABS)
Principle
Placing a hard material between the central incisors will consequently prevent any dental
contact. This new uncomfortable mandibular position, centered, guided but not blocked,
immed iately generates muscular relaxation which will also allow to prevent the TMJ from
bearing a load which may have become too important. The ABS is a retro -incisat plane
mainly held by the maxillary centra l incisors. When reaching this plane, the mandibular
incisors stop the mandible by creating an inocclusion on all the other teeth. The space of
inocc lusion must be sufficient to prevent any forced contact.

Realization
Because of the acute symptoms of this type of TMD and the urgency to start a treatment,
the spl int is immediately prepared and directly placed in the patient's mouth - there is no
need to make an impression first. Besides, the clinica l search for a mandibular stabil ization
by creating two occlusal contact points on both sides of the centra l incisors is a fast and
si.mple procedure.
The ABS is prepared:
- in an approach of centric' relation: the operator must seek the coherence of a mandibular
rotatiQn movement without translation. To make sure of the patient's comp liance, it is
recommended to reassure him/her on the non-irreversibility of his/her condition and to
provide information about the treatment;
- In relation to the maxillary arch : the only location allowing to receive the occlusa l impact
according to the main line of the antagon ist teeth;
- By partially cover ing the arch supporting the appliance: essentially the central incisors .
-In light-cwed or self-cured hard resin.
 10 Occlusal splints

5 Only two occlusal contact

points on both sides of the
central incisors are needed to
adjust the ABS.

The operator places on the maxillary central inci -

sors a small "lump" of material the size of a ha-
zelnut. After asking the patient to bite the resin,
the practitioner controls, with a slight pressure
6 The smooth s~rface releases the mandible
on the chin, the coherence of the mandibular from any movement.
rotation movement which must avoid any trans-
lation. We will look for an inocclusion of about
171
2 mm in the area of molars, which is a small
thickness but is sufficient to separate the anta-
gonist teeth without risking contacts (Fig. 1).
The following stage is the elimination of all the
indentations in order to leave a flat and smooth
occlusal surface, perpendicular to the mandibu-
lar incisors in contact (Fig. 2, 3, 4).
The occlusal adjustment will:
- create two central occlusal points which
will contribute to mandibular centering;
- allow unstrained eccentric mandibular
movements (Fig. 5, 6).
7ABS is essentially positioned in the sector of
maxillary central incisors. ·
Wear
Because of the risks of articular compression
due to habituation and risks of egression of
the unblocked teeth, wearing this type of
splint must be limited to a few days until the
next appointment, although it should be worn
permanently except during meals (Fig. 7).
The reproducibility of the mandibular position
recordings in centric relation can easily be
achieved by the use of an ABS (Fig. 8).

8 Recording of centric relation with ABS in

the mouth.
 Occlusion made easy

The muscle reconditioning splint (MRS)

MRS remains the "gold standard" of the occlusal splints. Described in the sixties by
Ramfjord and Ash from the University of Michigan, it is certainly the most widespread
occlusal splint in the world.

Principle
Even if the placebo effect is often invoked as an
explanation (Greene CS and Laskin DM, 1972),
the splint would nevertheless have an impact
on the mu?cular reconditioning (Ekberg E and
al., on 2003) obviously generating a reduction
of the load on the temporomandibular joint.
The splint would provoke a "disturbing
dishabituation" with the new sensations it
would arouse.

172 However, the MRS is still mostly used to

"materialize" the patient's therapeutic plan; 9 Mandibular muscle reconditioning splint
it thus allows to strengthen the reeducation (MRS) in case of overbite.
of parafunctions with new proprioceptive
information.

Preparation
To avoid a long and tedious clinical session
dealing with occlusal adjustment when the
splint is positioned in the mouth, it is very highly
recommended making this type of occlusal
splint on an articulator where casts are mounted
according to the same spatial conditions as the
patient's.
The MRS is prepared: 10 Maxillary MRS in case of class 11-1.
- In centric relation: the only reference
mandibular position that is easily reproducible
in the absence of any dental reference;
- Preferabjy in the mandible, because it is more convenient to wear the occlusal splint this
way, and particularly because the natural positioning of the tongue to the palate should
not be hampered . In the case of an overbite due to a lingual dysfunction, the mandibular
MRS, by considerably hindering the "low" position of the tongue, is a helpful and additional
device among the therapeutic arsenal to favor the lingual upward movement at the back
of the maxillary incisors (Fig. 9). A pronounced Angle's class 11 -1 and a greater number of
missing teeth than in the mandibular arch are the main reasons to prescribe the wearing of
a MRS in the maxillary (Fig. 10);
 10 Occlusal splints

11 A plate is thermoformed on the cast. 12 Addition of resin in pasty phase.

13 The articulator
is closed at the
predefined
therapeutic vertical
dimension (TVD). 173

- By totally covering the arch that supports the splint in order to freeze as much as possible
the position of the supporting teeth and their antagonists;
- In hard resin, easier to adjust, but above all to avoid compulsive biting or chewing which
would have the opposite effect than the one expected (Okeson JP, 1987). The material must
look smooth.

Several techniques can be used to fabricate this type of splint:

1. Resin -reinforced thermoformed splint
The thermoformed base is coated with self-cured resin (Orthoresin®) with a sticky
consistency. The articulator is closed during the setting up to the contact incisal pin/incisal
table. After polymerization, indentations are eliminated to obtain a flat surface; only the
bottom of the indentations must be kept to provide an even distribution of the occlusal
points on th e whole splint (Fig. 11 -12-13).
 Occlusion made easy

14 The monomer/polymer
mixture is made directly in the
prepared form.

2. Resin powder splint

After boxing according to the limits of the future
174 splint, the operator adds some liquid monomer
and some powder (Orthoresin®), one after the
other, up to saturation in the wax form and until
the required volume is reached; the articulator
is kept closed until the incisal pin/incisal table
contact during the curing (Fig. 14-15).
3. Wax model, put in a flask and heat cured
resin
The splint is entirely made in wax on the 15 The indentation is made before the
articulator, pre-adjusted and then put in a flask. complete setting of the material.
The wax is boiled out and replaced by the resin
which is polymerized in hot water (Fig. 16).

Adjustment
It is performed like a conventional occlusal
adjustment: the occlusal contacts are evenly
distributed on the whole occlusa l splint and
the presence of an anterior 'guidance provides
a posterior disocclusion a minima during the
eccentric movements. The MRS is a smooth
splint, which must not be indented.
The uniform distribution of the occlusal points
on the entire splint matters more than the
number of points (Fig.17) During diduction,
a single canine guidance generates posterior
disocclusion (Fig. 18-19). 16 The wax model is put in a flask.
 10 Occlusal splints

17 The distribution of the contacts is checked. 18 The splint restores an anterior guidance.

Wear
MRS must be worn during sleep or during activiti es
that do not al low the patient to effectively control 17 5
his/her parafunctions. It must not be worn more
than approximately eight weeks; beyond this
period, the patient tends to get used to the splint
and finds back his/her deleterious habits. (Fig. 20).
The patient must stop wearing the MRS gradually.
In the case of a recurrence of the symptoms, the
patient is invited to take care of his TMD himself
by modifying his behavior and using the splint, if
necessary.
19 Canine guidance on the splint.

20 Adjusted MRS in
centric relation occlusion.
 Occlusion r:nade easy

The mandibular AntePositioning Splint (APS)

The APS will be immediately prescribed, in

cases of class II presenting a loss of occlusal
stabi lization and/or in case of overjet and/or
excessive anterior overbite or in cases of rapid
aggravation or lack of results after wearing a
MRS (Fig. 21).

Principle
Nowadays and contrary to current beliefs, the
objective of the antepositioning splint (APS)
is not to recapture the articular disk affected
with a distended condylar attachment (K lasser 21 Angle's class II showing a considerable
GD, Greene CS, 2009). The actua l purpose overbite.
is quite "simply" an improvement of the
symptomatology (Simmons HC, Gibbs SJ, 2005).
176 The APS aims at taking away the condyle from
the retrodiscal zone caus ing the inflammation
(De Boever J et al., 2008).

Preparation
The APS is made in a mandibular position
situated in front of the centric relation.
The therapeutic position may be determined
either on articu lator or clin ical ly (Fig. 22).
The desired mandibular advancement, while 22 Clinical recording of the chosen therapeutic
keeping anterior contacts, generates a posterior position on Moyco wax.
disocclusion according to Christensen's
phenomenon (Fig. 23). Moyco wax is a means
of recording the sought anteposition . The
operator watches the sagitta l movement of the
mandible and the proper achievement of the
anterior dental contacts .
Like the MRS, the APS i~ rather placed in the
mandible because it is more comfortable to
wear for the patient and less hindering for the
tongue (Fig. 24). It partially covers the arch
only in the free space in posterior. However, as
for every splint that must be worn in the long
term, all teeth of both arches must be supported
during occlusion . The anterior teeth not covered 23 The combined action of the incisal guidance
by the splint must thus necessarily show occlusal and the condylar slope generate a posterior
contacts with the antagonist teeth (Fig. 25). disocclusion.
 10 Occlusal sp lints

The impossibility to obtain natural contacts with

a suffi cient overbite in spite of the mand ibu lar
anteposition is a stri ct contra indication to a
treatment with APS; just like the initial absence
of overjet, overbite (end-to-end occlusion,
Angle's class Ill, anterior overbite) or of excessive
overjet (requiring a mandibular advancement of
more than 3 mm).
The occlusal surface of the APS, made in hard
resin, is indented and presents actual symm etri c
stops which oppose every mandibular return
movement and stabilize the mandibular
position in this therapeutic ICP (Fig. 26). After
occlusal adj ustment, the APS must present and
allow occlusal contacts as harmon ious as those 24 APS inserted in mandibular arch.
situated on the natural teeth, which preserve
the natural proprioception . The functional
anterior gu idance must lead the mandible
during th e eccentric movements. 177
Wear
The APS must be worn 24 hours a day, even
during meals and for at least 3 months. Wh ich
implies that it must be fully accepted by the
patient; the practitioner must thus clearly
explain the mechanism as well as the intended
result.
Like for the MRS, the patient must gradually stop
wearing the APS. If t he symptoms appear aga in,
25 Incisors are in direct contact with their
antagonists.
a possible prosthetic or orthodontic treatment
freez ing the asymptomatic mandibular position
must be proposed.

Fabrication step by step

Preparation .of an occlusal splint such as
the mu scle reconditioning splint (MR S)
The fabrication process of an occlusal splint
necessarily imply that a mounting on arti cu lator
in centric relation has been performed. The
articul ator may be conventionally settl ed with
a 40° cond ylar slope and a 15° Bennett's ang le.
26 An anterior guidance is restored, tooth
The use of a face -bow, allowing to position gaps are filled in and pronounced indentations
the maxillary cast in space (un li ke an arb itrary preserve the forward position.
mounting tab le), is necessary. The validation
 Occlusion made easy

27 The working cast mounted on a split cast 28 A space necessary for the preparation of the
allows to work independently of the articulator. splint is determined on the articulator.

of centri c relation (a physiological position,

independent of dental relationships) is

178 required . This validation is achieved with

the reproducibility of th e wax recordin gs
performed on the patient and the comparison
of the occlusal point(s) found on the casts with
t hose observed in the mouth.
Each model must be built with a sp lit cast
(Fig. 27). The base of the maxillary cast
magnifies errors during wax fitting while the
base of the mand ibular cast, used here as a
working model, will allow to work without the 29 The limits of the splint are drawn with a
articulator. pencil.
In order to arrange the adequate space necessary
to prepare the splint, it is recommended to
increase the vertical dimension to choose a
t herapeutic vertical dimension. This choice can
be made arbitrarily, by arrang ing a minimal
space of at least 1 mm between both casts
(Fig. 28) or in a more sensibl e way by keeping
the height given by doubl<;-thick Moyco strips.
Consideriog that th is solution does not change
the recorded vertical dimension, the operator is
freed from t he constraint of mounting with an
approximate axis, and thus from an opening/
closing radius different from the patient's -
which would de facto im ply some occlusa l
adjustments in the mouth. 30 Removal of the protective film on the
extrados of the plate.

31 Cast ready in the v~cuum thermoforming
machine.
33 After stamping, the cast is removed from
the plate.
34 Cutting is easier when the cast is taken
out of the articulator.
10 Occlusal splints
32 The heated plate is vacuum -formed on the cast.
Before sta rting the fabrication, it is recommended
drawing, with a pencil, the edges of the splint.
The outline must be situated 3 to 4 mm under
the neck of teeth on the lingual side and under
179
the line of th e biggest contour on the vestibular
side (Fig. 29).
In zones of tooth gaps, the plate will take the
shape of the sadd le of a removable partial
denture.
The splint base is made in a transparent plastic
plate, at least 2-millimeter thick, thermoformed
on the cast (Fig. 30-31-32). To faci litate the
remova l of the plate, do not forget to fill t he
undercuts with modeling clay or silicone.
The cutting of the plate, sli ghtly beyond the
drawn limits, is performed with a f issure bur
(Fig. 33-34-35 ). At t his stage, it is better not
to remove it from the cast in order to avoid any
problem of repos itioni ng. Occlusal grind ing is
often necessary to find the therapeutic vertical
dimension (Fig. 36). The in cisa l pin, set on the
previously determined measure, must necessarily
be in contact with the incisa l table.
At this stage, the plate is frosted (Fig. 37)
and impregnated with monomer, while the
antagon ist arch is coated with an insu lating
material (Fig. 38).
In zones with no occlusa l contacts, this base is
comp leted with pasty orthoresin (Orthoresin®).
 Occlusion made easy

35 Deburring of the edges with a resin bur. 36 The plate thickness is adjusted to find the
therapeutic VD.

180

37 The plate is slightly frosted on the extrados. 38 The insulating material is appli~d with a brush
on the antagonist arch.

Th e resin mixture is put on the thermoformed

plate placed on the arti culator (Fig. 39).
The articulator is closed during the setti ng,
the incisa l pin is in contact with the incisal
table (Fig. 40). Idea lly, polymerization is
performed on the articulator in occlusion, in a
p,olymerization pressure pot (water at 50 °C,
122 °F, under a pressure of 2 atmospheres, for
1O minutes). Imm ed iately after' the opening of
the arti cu!ator, the resi n presents indentations
(Fig. 41).
The cast is then removed from the articulator
thanks to t he spl it-cast. It is re levant to mark
with a pencil the bottom of the indentations
(Fig. 42).

These marks allow to quickly eliminate th e 39 Resin in pasty phase is added to fill the
spaces of inocclusion.
excess in order to obtain the fl attest surface.

40 The antagonist ca~t indents the resin.
42 The bottom of the indentations is marked
with a pencil.
43 After grinding, the bottom of the
inrl1>nt;:itinn c; rpm;:iinc; _
10 Occlusal spl ints
41 Deep indentations after polymerization.
The sp lint must not show any relief and must
only present pencil marks (Fig. 43). 181
The cast is then repositioned on the articu lator
in order to adjust more accurately the sp lint
aga inst the antagonist cast. The adjustment
aims firstly at obtaining punctual and aligned
contacts (one single contact point per
supporting cusp) on the whole sp lint. Then,
the tested eccentric movements (diduction,
protrusion) must present no interference. An
adjunction of specific resin may be necessary
to create canine bumps associated with a
protru sion sliding plan e (Fig. 44).
The last stage is th e removal of the sp lint
from the cast to all ow a careful polishing with
pumice stone and high gloss poli shing pa ste.
The second protective film is then removed
from the intrados (Fig. 45).
Before placing the spl int in the mouth, it is
decontaminated in ch lorhexidin e mouthwash,
no longer than 30 minutes to avoid co loring.
Finally, the practitioner must necessa rily explain
and supervise the placement of the splint,
because it is essential that the patient understand
the principle and the goals of the treatment.
The actual follow-up of the patient by th e
practitioner.
 Occlusion made easy

A fol low-up at 2, 4, 8 and possibly 12 weeks

is required to support th e reeducation and
assess the effect of th e treatment.
An aggravation of the symptoms w ill resu lt
in an immediate rea ssessment to provid e
further explanation s and perform th e 44 Control of contacts and guidance on the
necessary adjustme nt s.
articulator.

182
45 After polishing, the protective fil m is
removed from the intrados.

Synthesis
II
A nterior Bite Musc le recond it ion ing sp lint AntePos itioning sp lint (APS) II

Sp lint (A BS) (M RS) -

Indications acute TMD • subacute TM D (in f irst • Subacute TM D (i n first intent ion:
intention) overjet and/or excessi ve overbite, loss
• persistent TM D of stab ilization, Ang le's class II)
II
• In case of rap id aggravat ion or
lack of res ults after w earing a M RS
Principle He lping Strengthen ing perso nal Taking th e co ndyl e forward of
muscu lar comm itment t he retrod isca l zone caus ing the II
re laxation inflammation
Preparation cha ir side On articu lator: On arti cu lator:
II
- Smooth surface, - sharp occlusa l indentations, II

- Centri c re lation, - retrus ive contro l stop

.- Even ly distributed occlusa l
II
contacts
... - Gu idance can ine paths
Wear A lmost Interm ittent (essentia ll y at Continuous during 3 to 6 months
continuous night) for 2 months
(except at II
mea lt ime) Ii
Ii
during a f ew
days
 10 Occlusal splints

REQUIRED EQUIPMENT

• A maxillary model with split-cast • A spatula to mix

• A mandibular model with split-cast • A handpiece
• An articu lator • A resin bur for hand piece...
• A thermoforming machine • A cutting or fissure bur for handpiece
• A plastic plate (at least 2 mm thick) • A pencil •
• A Dappen cup • Miller's tweezers
• Transparent self cured resin (Orthoresin®) • Occlusal marking film (two different
• Insu lating liquid for plaster co lors)
• A polishing machine

183
KEY POINTS

The occlusal splint therapeutic JJ>rocedure dQes not rn.nsist in prescribing first an anterior
bite splint appliance, followed by a muscle recondliilii0ning splint and finally an ante
positioning splint.

The prescription of an occlusa l sp lint is far from be i n~ sysrtelilllatic al'ild when it is, it
will general ly be a MRS, which remains the most widespread. ABS wil l be helpful to
the practitioner in the case of an emergency consulttation for TMD or in case of a
difficult recording of centric relation. APS may be directly i;>rescribed in cases of specific
malocclusions or come after a little effective MRS in the presence of persistent symptoms .

It is however imp0rtant to think of the "after-splint' phase as soon as 1Jhis kind of

treatment is decided . If wearing ABS and MRS may be stopped gradual ly, requiring
a simp le follow-up, APS, in case of recurrence, wil l require a necessary change of the
mandibu lar positien, prosthetical ly or orthodontica lly stab ilized.

We must finally keep in mind that occlusal sp lints remain an invasive device. Invasive,
because if it fa·ils to properly stab ilize t he arches, it w ill generate denta l migrations
which wi ll obvio usly be iatrogenic. But it is also psychologica lly invasive, causing a lack of
comm itment, add iction, and occlusa l awareness.

Occlusa l sp lints are not the on ly so lution to t he dysfunctions of the manducatory

apparatus; they are j ust a part of a 9 lol:i>al therapeutic approach ma inly based on
reeducatiom.
 Occlusion mad e easy

Using the inelastic properties of a

"recycled electrical cord" allows to
lock both arms of the articulator
during polymerization, avoiding
thus any risk of deformation.

-
0:::
w
:c
I-

HELPFUL READiNG
• De Boever J, Nilner M, Orthlieb JD, Steenks MH . Recommendations by the EACD for
examination, diagnosis and management of patients with temporomandibular disorders and
orofacial pain by the general practitioner. J Orofac Pain . 2008;22:286 -77.
• Ekberg E, Vallon D, Ni Iner M. The efficacy of appliance therapy in patients with
temporomandibular disorders of mainly myogenous origin. A randomized, controlled, short
184 term trial. J Orofac Pain. 2003;17:133 -39.
• Greene CS, Laskin DM. Splint therapy for the myofascial pain-dysfunction syndrome: a
comparative study. J Am Dent Assoc. 1972;84:624-8 .
• Klasser GD, Greene CS. Oral appliances in the management of temporomandibular disorders.
Oral Surg Oral Med Oral Pathol Oral Radio! Endod. 2009;107:212-23.
• Niemela K, Korpela M, Raustia A, Ylostalo P, Sipila K. Efficacy of stabilisation splint treatment
on temporomandibular disorders. J Oral Rehabil. 2012 Nov;39(11):799-804.
• Okeson JP. The effects of hard and soft occlusal splint on nocturnal bruxism. J Am Dent
Assoc. 1987; 114:788-91.
• Re JP, Perez C, Darmouni L, earlier JF, Orthlieb JD. The occlusal splint therapy. J Stomat Occ
M ed. 2009;2 :82-86 .
• Simmons HC, Gibbs SJ. Anterior repositioning appliance therapy for TMJ disorder: specifi c
symptoms relieved and relationships to disk status on MRI. Cranio. 2005;23:89 -99.
 Occlusal
adjustment

185
During the initial clinica l examination, 1t 1s
frequent to notice occlusal anomal ies due
to the corona l decay, to abrasion, dental
migration, even to the presence of unsuitable
prosthetic restorations which generated a
pathogenic ma locclusion (Fig. 1). Besid es,
the patient may or may not suffe r from
changes in the mand ibu lar kinematics, from
articu lar disorders or from modifications 1Pathogenic ICP.
of the muscular activity, resulting from
movements generated during the occlusa l
functions. In these clin ica l situations, the
occlu sa l function s must be improved prior to any treatment, all the more if a prosthetic
rehabilitation is envisaged.
Occlusa l adjustment is a therapeutic modification of occlusa l tables by subtraction or by
addition to restore the occlusal stab ility of the arches durin g the occlusion. Most of the
time, it refers to adjustment techniques by selective grindin g of the enamel structu res
which oppose each other during the occlusa l functions, or during t he access to the ICP.
This chapter presents a technique of occlusa l adjustment performed at first on the casts
mounted on articulator in centric relation, then transferred in the mouth following a
timeline noted on a chart of mod ifications. The occlusa l adjustment is performed on a
natura l comp lete set of teeth, but t he principl es can be app lied to cases of preprosthetic
adjustment and t heir numerous indicat ions.
 Occlu sion made easy

NECESSARY EQUIPMENT

For the occlusal analysis on articulator

Equipment Use Ref
Miller tweezer Holding in place the marking BK 132 Dr Bausch
ribbons
Shimstock® metal 12 µ Checking the existence of BK 35 Dr Bausch
contacts
Red articulating paper 8 µ CR marking BK 21 Dr Bausch
Green articulating paper Guidance marking BK 22 Dr Bausch
8µ
Blue articulating paper 8 µ Interferences marking BK 23 Dr Bausch
Bistoury blades #15 Corrections on p laster
Hard toothbrush Erasing artefacts

186 Pencil 0,5 HB Marking out the corrected zones

LC Blackout Resin or wax Recreate gu idance ridges

For the adjustment in the mouth

Equipment Use Ref
Miller tweezer Holding in place the marking BK 132 - 133
ribbons Dr Bausch
Fix Clip Bite Frame Analyzing both sides BK 143 Dr Bausch
simultaneously
Red articulating paper 40 µ CR marking BK 1o Dr Bausch
Blue articulating paper 40 µ Interferences marking BK 09 Dr Bausch
FG inverted cone bur Recreate an occlusal anatomy 805 .314.01
FG olive bur 8368 -204 .016 (023) 8368-204.016 (023)
FG cylinder pointed bur Correction of external slopes 862EF.204 .012
(yellow ring or red ring) 8862.204 .012
Q tips Erasing marks between two
measurements
Silicor"fe polisher Polishing corrections at the Ceramaster Shofu
end of the sequence
Fluid composite resin I Polishing corrections at the
Recreate guidance ridges I - end of the sequence
Transfer key Transparent silicone Memosyl 2
(shore 90) Block out® Bisico
 11 Occlusal adjustment

Historica lly, we can list at least twenty techniques of occlusal adjustm ent, which differ
according to the nature of the reference position, either articular or muscular, the
sequence of correction, the concepts of lateral guidance or th~ type of stabi lization .
The first authors, (Stuart, 1930; Schuyler, 193 5; Lauritzen, 1965) followed by Ramfjord, .
Ash (1966), Dawson (1971) and So lnit (1988) suggested adjusting the defective alignment
of cusps and fossae (generating a shift in ICP) by a widening of the fossa at the expense
of the neighboring zones of contacts in centric relation. They thus made sure to follow
the main rule: do not alter the primary cusps, while creating a coincidence between CR
and ICP.
Jankelson (1955), Glickman (1958), Wirth (1976), Jeanmonod (1988), Smuck ler (1991) and
Abjean (1997) developed their app roach on a harmonious muscular functioning presenting
synchronous and symmetric contractions of the masticatory muscles supposed to result
in an optimal ICP. During the first phase, a muscle reconditioning sp lint is prescribed . The
adjustment is then performed by using the re-educated muscles to drive the mandible
187
towards ICP.
The current consensus recommends localizing the therapeutic articular reference position
(CR) with the practitioner's help such as it was described in the chapter on centric relation.
A muscular reconditioning with a splint might be necessary first (Okeson, 1998).
A meticulous clinical examination associated with an occlusal analysis on articulator allows
to put the indication of the occlusal adjustment.
The adjustment of the models on articu lator must be a systematic prerequisite which
allows to verify the feasibility of the treatment by analyzing the anterior guidance. It
allows to quantify the corrections and assess their incidence on the vertical dimension
of occlusion. An anterior functional guidance in the VDICP autho1·izes the adjustment if
there is a sma ll number of alterations.

Reminders of two important definitions often used in this chapter:

Occlusal prematurity: occlusal contact decentering the closing movement
when the mandible moves upward in centric relation. It does not affect the
translation movements.
Occlusal interference: dental obstacle limiting or deflecting the mandibular
movements of translation (diduction or protrusion). The interference can be
posterior or anterior.
 Occlusion made easy

Adjustment on the articulator

2 If the egressed tooth creates a major

interference, it must be extracted before
taking the impression.

188

3 Activating the
protrusion screw allows
the preservation of the
lateral position.

Before taking impressions, it's better to eliminate very egressed teeth, which are obvious
prematurities, and thus an obstacle in excursions (Fig. 2).
The occlusal analysis on articulator (described in a previous chapter) allows to observe
dental arches from all ang les as well as their simulated movements in all the directions.
During the searchin g and the marking of contacts, the articulator can be locked eith er
in centric, or on one side only, in order to obta in reproducib le lateral positions. Using
wedges (or protrusion scr~ws when they exist) allows the preservation of the latera l
or protrusion positions (Fig. 3). These elements easily enab le to perform an occlusal
instrumenfdl analysis compared to what it is possible to make on the patient.
Articulating paper of different co lors is used to identify sequences more easi ly.
According to the adjustment process, the successi ve corrections are noted in a grinding
index form (Fig. 4), indicating the tooth number, the cusp, the involved slope and the
corrected cusp slo pe, or marked on an occlusal diagram (Fig.5). Every corrected zone
is marked with a penci l on the plaster model, in order to avoid noting several time s the
corrections on the same tooth (Fig. 6). The grinding chart al lows to write down accurately
 11 Occlusal adjustment

ig chart
Non Working interferences

ln<lllrte Cusp Slope Incline

,..oouou••o J ~''"'''"'''' • •• ••••••••••• ••••••••• • ••• •• • ••••••••

............. ,..........,.,............. ........... ... ··· ···· ······ ···········

•••••••• "'-h••

,,0000.-00•••0 o•uouoooo.-4 ••ou••••••• • ••• •••• •••• •• • •• ••••••••• • •••••••••••

•00000-.00-0oo 'P-''ouo-.o•••o oouooo"'''' •••••••••••••• ••• •• •••••••• • • •• • ••••••

::::::::::::: .::::::::::::J~:::::::::::: :::::::::::::: ::::::::::::: :::::::::::

............. .............1............. .............. ············· ···········
:::::::::::::::::::::::]::::::::::::: ::::::::::::::::::::::::::::::::::::::

4The corrections are chronologically indicated on

~gr inding charter.

5 The localization of the 189

corrections is noted on the
occlusal index form.

the cor rections to be made on th e patient's teeth in th e order of their appearance.

Casts are retouched with a bistoury blade #15

All authors agree to carry out the following therapeutic gradient:

Rule 1 : co rrections preferentially co nce rn restored t eeth, rough filling s, inadeq uate
crowns, or misplaced teeth.
Rule 2: modifications must only be made on the enamel part of th e occlusa l surface.
Wh en a bigger alteration is needed, it is
necessary to reconstruct the tooth or prescribe
an orthodontic treatment.
Rule 3 : reli ef must be enhanced by deepening fossae and
grooves rather than by reducing cusps.
Rule 4: alteration s are equa lly distributed between both
antagon ist t eeth.
Rule 5: To Okeson (1998 ), the location of contacts in CR,
situated on the interna l wa lls of the suppo rting
cusps, directs the therapeutic attitude .

6 The zone circled with a

pencil indicates that the
correction has been made.
 Occlusion made easy

Adjustment chronology

Sequence Objective

Correction of CR//ICP Centering

discrepancy

Creation of stable Stabi lization

contacts

Correction of Guidance
translatory movements I I I
(diduction, protrusion,
elimination of the 7 Corrections are rather made in fossae
interferences) and grooves rather than on cuspal tips.
Improvement of Stabilization
stability in centric

Correction of CR / ICP discrepancy

During the closing of the articulator, the first contact
90 relates to a position of unstable occlusion . The contact
on the prematurities pushes the mandible forwards
and towards one side, right or left.
When the mandible slides to the right, re-centering
moves it backwards and to the left: the left side is cal-
led "working" (W), and the right side is called "non
working" (NW).
The articulator is locked in CR and the incisal pin •is set
on the VDICP (it does not touch the table because of
the contacts on the prematurities). Contacts may be
found on zones indicated in Fig. 8-9.

Non wo1king s ide Work ing side \'Jc1klngside Nonworl(lr.gs!de

!lucca1in!emalslopes Ungual internal Sk>pe$

U ngualin\emalslopes BtJttal ln!ema1 slopes
Ungualex.ternal s!ope.s
Lingual e.d11mal s!ope5

euccal Internal siopes

Buccal Jntomal slopu Lingual lnt ema! slopo,s
Bucc a! extomal slopes

8 Localization of zones to correct in the case 9 Localization of zones to correct in the case of a
of a right anterior shift. left anterior shift.
 11 Occlusal adjustment

.
10 The correction focuses on the sliding pathway 11 Deepening the fossae allows to increase
and preserves the contact zone in ICP. stability.

Achieving stability in centric relation

To find a stable intercuspal position in centric relation, the occlusal correc-
tions must be performed according to the following rules
Rule 1 : in the presence of contacts between the internal slopes of the primary cusps, cor-
rections must be made on the whole mark and only preserve the contacts in ICP (Fig. 10).
Rule 2: the closest mark to the occlusal line must be corrected. The main guideline is 191
to protect the cusp and accentuate the antagon ist fossa (Fig. 11). In a purpose of tissue
saving, it is necessary to verify that this cusp does not interfere in diduction . If it is the
case, the cusp tip must be ground, which allows to eliminate these two anoma lies with
a single correction. The sequence is over when the incisal pin finds the contact on the
anterior table of the articulator on the point recorded in CR.

Corrections in lateral
movements
To perform corrections in diduction, the
right condylar ball is locked in centric
to ana lyze the right lateral movement,
and vice versa for the left diduction.
Th e movement is analyzed from the
canine end to end (which is the limit of
the functional excursion) in centripetal
direction. When the articulator is fitted
with wedges, .the use of a series placed
between the condylar ball and the bot-
tom of the housing or the protrusion
screw on the non-working side allows
a more stable observation of contacts
(Fig. 12).
The progressive removal of the wedges
or the unscrewing allows the return of
the articulator upper arm to CR and thus 12 The loosening of the screw allows the return
the observation of the various lateral to CR and the observation of contacts throughout
positions. the trajectory.
 Occlu sion made easy

Boccat lnlcmal slopes

Lingual lntomal slopes Buoclll lntemal s lopes Buocal intCfnal slopes Lingual internal sklpes

13 Localization of the possible interferences 14 Localization of the possible interferences in

in right laterality. left laterality.

Purpose: in most clinica l situations, the latera l guidance is performed by the can ine only.
Corrections aim at eli minating all the contacts of the non -working sid e and leaving on ly
the contact betwe en the maxillary and mandibular can ines on the working side.
192 Correction s are alternately made on the non -working side and on th e working side accor-
ding to the appearance of the contacts to be eli minated. Zones where potential contacts
can be found are indicated in Fig. 13-14.
Some situations, such as Angle's class II or a weakened periodontium in the canine area,
can lead to associate premolars in the guidance in order to create a group function occlu-
sion. However, the increase of th e supporting surfaces reduces the proprioceptive accu-
racy: it is al ways necessary to favor th e most anterior contacts.

Non-working interfe rences

Contacts between the primary cusps of th e non -working sid e do alter th e gu idance on
the working side. Th ey can easily be detected on th e articul ator since the ball of the
working condyle is locked in centric relation during the analysis of th e latera l movements.
These interferences are the most harmful to th e manducatory apparatus.
Main rule: corrections focus on the interna l mesia l slopes of th e pa lat al cusps in
the ma xillary, and on th e internal distal slopes of the bucca l cusps in the mandi bl e.
It is necessa ry to keep the interna l mesial and dista l parts of the mark ing close to ICP,
(Fig. 15).
Working interferences ·A working interference is defin ed as a contact located on th e
working ~de of a different tooth than th e pred etermined surface of gu idance . It is for
examp le a contact betwee n two premol ars if the can ine was chose n as the surface of
guidance .
Th ey are situated on the interna l distal slopes of the maxi llary seco ndary cusps and on the
interna l mesial slopes of the mand ibular secon dary cusps in transverse direction.
Ru le 1: in th e maxillary, the interferences on th e workin g sid e can be corrected with
a grin ding of the interna l slope of th e involved secondary cusp, by creating a sma ll
 11 Occlusal adjustment

15 Correction zones
of the non-working
interferences.

16 Correction
zones of
the working
interferences.

secondary gro·ove in bucca l (from the mark in ICP) towards the cusp summ it. In the
mandible, this correction is performed accord ing to the same techn ique, but in lingual
direction. It all ow s the maxillary palatal cusp to go between both mandibular lingua l
cusps (Fig. 16).
Rule 2a: in a class I can ine function, on ly the mandibular can in e tip leaves a mark on
the proxima l mesial crest or on the mesial -pa latal face (Fig. 17).
In class II, the mark will be situated on the distal crest or on the distal -palatal face
193
(Fig. 18).
Rule 2b: in a class I group function, the guidance is id ea lly performed by the mesial
crest, or the mesial-palatal face of the canine and by the first and second premolars
(Fig. 19).
In class II, distal crests or dista l-palata l faces support these gu idance paths of the working
side, with a higher risk of interdental collisions (Fig. 20).

17 Class I canine gu.idance. 18 Class II canine guidance.

19 Class I group function. 20 Class II group function.

 Occlusion made easy

The additive technique of increasing of the palatal

surface of the maxillary can ine (or sometimes of "
the mandibular can ine tip) can avoid too many
corrections on the posterior teeth and provide a
comfortab le guidance (Fig. 21).

Corrections in protrusion
The movement is analyzed from the incisal end to
ri~·"
encl toward CR.
Purpose : eliminating interferences hindering the
contact of the anterior teeth in the protrusion 21
\\ •:,··-·~ r
_...
. _
_..
Guidance zones are increased with wax or
movement.. They are situated in the maxillary 011 resin.
the distal slopes of the buccal cusps and in the
mandible 011 the mesial slopes of the lingua l cusps (Fig. 22-23).
Rule 1: the correct ions are made on interna l distal slopes of the maxillary secondary
cusps and on the internal mesial slopes of the mandibular secondary cusps.

194 Rule 2: primary cusps must never be corrected. Like in the anterior sequence, the
add itive technique allows a better restoring of the guidance while avoid ing subtractive
correction s.
Stabilization of the occlusion
At this stage of the adjustment, since corrections are made on the casts, the occlusal
stabili zation performed on the arti cu lato r is not very accurate. The occlusion is ach ieved
when corrections are made in the mouth: tiny quantities of dental structure are , then
adjusted with burs and polishers.

Distal inclines of Buccal Distal inclines of Buccal

Protrusion
Propulsion

Mesia! inclines o f Lingual Mesial inclines of Linoua'

internal slopes internal slopes

22 Contact zones in protrusion. 23 Correction zones of interferences in protrusion.

 11 Occlusal adjustment

Occlusal adjustment: clinical session

The sequence of clinical adjustment can start if the first premature contact
detected in the oral cavity is the same as the one found on the casts mounted on
articulator. This concordance confirms the quality of the simulation performed
on the articulator. ...
The grinding index form indicates the loca lization of the contacts. The quantitative aspect
of the correction is validated by the appearance in the mouth of tne following contact, as
recorded in the grinding index form. It indicates that the first correction has been properly
made. It is then possible to continue the sequence.
The irreversible character of the adjustment and the risk of loss of vertical dimension,
inherent to the corrections on the primary cusps, requ ire the greatest care in the
adjustment process .
The patient sits in a semi-reclined position, with no hyperextension of the head. The
practitioner carefully manipulates the mandible and moves it gently upwards, to the
contact of the articulating paper placed between the occlusal surfaces. Performing the
movement severa l times is a proof of the muscular relaxation. An increasing resistance
at the approach of the occlusal position shows the existence of a muscular protection 195
reflex. The session of adjustment must be postponed and the recondit ioning sp lint must
be checked and adjusted if necessary.
The practitioner proceeds to the corrections of prematurities on the closing path. If
muscular fatigue appears during this manipulation and if a muscle reconditioning sp lint
has been prescribed, it may be placed in the mouth, allowing the patient to rest and
find the reference position. Otherwise, a simp le anterior stop, or the interposition in the
anterior sector of a device extemporaneously prepared (as described in the right gesture
at the end of chapter) can also provoke muscular relaxation.
The corrections are made by respecting the natural convexities of
the cuspal slopes. The adjustment aims at accentuating the
dental anatomy in order to increase its
efficiency (Fig. 24).

24 Corrections are
made by respecting
the natural
convexities.
 Occlu sion made easy

25 Correction zones of prematurities in 27 Correction zones of the right lateral skid in the
CR in the maxillary. maxillary.

96

26 Correction zones of prematurities in CR in 28 Correction zones of the right lateral skjd in the
the mandible. mandible.

Correction of CR I ICP discrepa ncy

In the correction of the anteroposteri or movement, th e prematurities are situated on the
mesial slopes of th e maxillary pa latal cusps and on th e dista l slopes of the mandibu lar
bucca l cu sps (Fig. 25-26).
In the correction of the late ral mo~eme n t and to all ow mandibular ce ntering, zones to be
co rrecte d are located:
• on t he work
....
in g side:
- In the maxill ary : internal slopes of bucca l cu sp and externa l slopes of th e pa latal cusps,
- In the mandible: external slopes of bucca l cusps and intern al slopes of ling ual cu sps;
• on th e non -work ing side:
- In t he maxillary : intern al slopes of palata l cu sps
- In the mandible : internal slopes of bucca l cu sps (Fig. 27-28-29 -30).

30 Correction zones of the left lateral skid in
the mandible.
31 The patient is rehearsing the
mandibular movement in front of a
mirror.
11 Occlusal adjustment
Corrections in diduction
The practitioner explains to the patient which
movements he has to make during each phase of the
analysis of contacts in the centrifugal trajectories in
diduction. These movements are not natural.
Some principles need to be respected
Principle 1: a pri>liminary training is essential,
controlled with a mirror (Fig. 31).
Principle 2: the practitioner guides the latera l
movements to highlight the possible contacts,
close to ICP, generated by the immediate side shift
(Bennett's movement) (Fig. 32).
Principle 3: the patient must avoid making a
movement in anterior direction rather than in
diduction. It may also be useful, having observed
the patient's function and having identifi ed the
teeth guiding the diduction trajectory, to indicate 19 7
by slight knocks on the tooth to stimulate the
desmodontium proprioception, those who have to
keep in touch during the analysis of the pathway
(Fig. 33).
Principle 4: the difficulty to re ad the tracks left by
the articulating paper is still greater when the arch
has teeth in rotation, in inverted occlusion or more
frequently in Angle's classes II and Ill.
32 Mandibular guidance in
a lateral movement.
33 The light impact of the
instrument on the tooth
allows the patient to locate
the involved tooth.
 Occlu sion made easy

34 Circled in green : guidance; circled in 35 Correction zones in the maxillary.

purple: working interferences; circled in blue:
non working interferences.

It is thu s esse nti al to know how to locate

mark s of guidance on th e primary and
seco ndary cusps, acco rdi ng to th e analyze d
198 movement (Fig. 34).
Principle 5: th e interfere nces of th e w o rking
side and th e non-w o rking side durin g a
lat eral movement on th e ri ght are eliminated
in th e sa me se qu ence. The sa me process is
perfo rm ed durin g th e lat eral movement on
36 Correction zones in the mandible.
th e left.

Non-working interferences
NW interferences are situated:
• in th e maxillary: on th e intern al slopes
of th e pa lata l cusps;
• in th e mandible: o n th e intern al slopes
of t he b ucca l cusps (Fig . 35-3 6).
A piece of art icu latin g paper is pl ace d
between th e teeth of t he non-workin g
side whil e th e pat ient makes an incursory
m ove m e~ t from t he free edges of teeth
contro llin g th e guidance to ICP. A non
worki ng interference is an ob liqu e mark
w hi ch app ears on t he inte rn al slopes of t he
co nt ra lat era l prim ary cusps and w hi ch brea ks
t he co ntact w it h t he gui dance teeth on t he
wo rking side (Fig. 37).
37 The non-working interference is always
diagonally placed.
 11 Occlusal adjustment

38 The patient
performs
protrusion
and retrusion
movements on
the articulating
paper.

39 The interference on 12 interrupts

the guidance track on 21 and 22 during
Working interferences protrusion.

Working interferences are situated:

• in the maxillary: on the internal slopes of
buccal cusps;
• in the mandible: on the interna l slopes of
the lingual cusps.
A break in the continu ity of the track in the
guidance pathway indicates the presence of a
199
non -working interference which it is necessary
to locate.

Corrections in protrusion
During this phase of corrections, the
practitioner asks the patient to make protrusive 40 Correction zones in protrusion in the
and retrusive movements, without his/her maxillary.
help (Fig . 38). The protrusion guidance is
performed by canine and incisors. Marks in ICP
are always preserved and only tracks located
on the trajectory may be corrected. Contacts
in incisal end to end must provide a symmetric
position, with no deviation of the mandible.
As for the anterosuperior teeth, an interference
occurs when a tooth interrupts the guidance
on the other- teeth during the pathway of
protrusion. The corrections are made on the
lingua l faces of the superior teeth, without
touching the occlusal mark of the free edges
of mandibular incisors (Fig. 39), which shows
41 Correction zones in protrusion in the
mandible.
the marking in ICP and the one in end to end .

The interferences in protrusion are situated:

• in the maxillary: on the internal distal slopes of buccal cusps;
• in the mandible: on the interna l mesial slopes of the lingual cusps (Fig. 40-41).
 Occ lusion mad e easy

42 The morphology modification is recorded on

the cast with a silicone key.

43 Addit ion of fiuid composite in t he transfer key.

Optimizing the guidance with the

additive technique
'.00 Wh en th e numb er of co rrection s in creases, 44 The key filled with fluid composite is
resulting in a major modifi cation of th e occlusa l repositioned in the mouth and light cured.
pl ane, it is wi ser to use the additive techniqu e.
Composite bonding allows to artificially increase th e guidance stru ctures of th e anteri or
teeth - particul arly to infl at e th e canin e mesia l crest o r t o org ani ze th e guidance on
premolar cu sps in th e ab sence of canin e guidance.
Th e additive correction is made on th e mod els mounted on articul ator, eith er with th e
w ax-up techni que, or with th e addition of li ght cured fluid resin (Bi sico) pl aced 011 th e
guidance stru cture to be in crease d.
A key in transparent silicon e (M emosyl®) (Fig. 4 2) is th en prep ared to reco1·d th e volum es
of th e correction . Th e key is coated with fluid compo site and reposition ed in th e mou t h
in th e sector t o be correct ed,
wh ere th e occlu sa l faces have
been prepared for bonding
(Fig. 43). Th e composite is
light-cured through th e key,
th e excesses are elimin at ed
an'd th e guidance is co ntroll ed
with some arti culating pa.p!?r
(Fig. 44).
"'
It may be enough t o recreate
th e guidance crest directly
in th e mouth w ith a fluid
co mposite syrin ge and
procee d t o adju stments to
obtain t he desired guidance 45 A fluid composite is applied on the crest to increase it and
(Fi g . 4 5). is then adjusted to provide guidance.
 11 Occlusal adjustment

Stabilization of the occlusion

Al l the existing marks in the mouth are cleaned. The patient's mandible is brought to
contact with the maxillary by a light guidance of the operator. The patient is able to detect
the slightest contact which must be marked and possibly corrected.
The patient must feel a stab le support of the mandible against the maxillary resultin,g from
simultaneous bilateral contacts during the closure. The first sequence is over when the
patient feels a sig nificant improvement in the occlusal stability.

Completion of the occlusal adjustment

This phase is generally carried out during the second clinical session of adjustment. The
contacts are verified in all the movements and in ICP: they are corrected when necessary.
The proper completion of the adjustment is achieved when the patient is comfortable again
in the ample and fluid movements of the mandible while his/her teeth are in contact and
while he/she can clench his/her teeth in a strong and rhythmic way with a clear sound.
It is thus necessary to be able to stop when the objectives are ach ieved validated by the
occlusal marks. It may be a mistake to seek the "ultimate accuracy" which would make the
patient "occlusion aware".
A control is performed one month later, and then a standard follow-up is schedu led . 2Q1

KEY POINTS
The occlusal analysis on ara articulator allows to quantify the corrections by subtraction,
to assess the complex ity of the adjustment procedure and decide to carry out this
procedure in the mouth .
The occlusal adjustment on a natural complete set of teeth remains a rare j ndication;
it is however important to master th is procedure. In daily practice, the occlusal
adjl!lstment is 0ft en performed in two sessions (one session per week), to give the
patient t ime tG> get used to the new occlusal situation. ·
However,, the described protocol is more often partia lly used in cases where the
ex•is:tir>ig Qac h11 si~ m .roust be improved before the placement of prosthetic elements. In
such cases, t me number of teetm to be adjus:t ed is sma ll er, and· the clinica l procedure is
ml!Joh m0re easier. The occlusal adjustment of prosthetic elements is based on the rules
and principles that have just been explained.
The h.tnctienal integration of prostheses is a f actor of comfort for the patient and a
fact0r of sustainabi1Ji.ty of the rest0rations.
Occlusal a<.djwstmen:t is perforrrned in da ily practice to adjust an occlusal filling, or to
stabilize in their function teeth with a weakened periodontium. The practitioner must
always keep in mind the best therapeutic profit I risk ratio when starting a treatment.
 Occ lusion .made easy

MARKING CONTACTS
The objective of the adjustment is to harmoniously distribute
cuspal contacts, in topography as in intensity.
It is thus necessary to be able to read the indications
obtained during these contacts and make the difference
between an actual contact and a mere track. In clinical
practice, the proper choice is a two -face ink band with a

-w
Q::
40µ thickness . It allows to simultaneously obtain maxillary
and mandibular marks.
Highly inked strips like blotting paper create marks by a
:c
.... simple friction on the tooth :
these are "false positive", the contact doesn't actually exist.
On the contrary, a too thin ribbon (10 µ)risks not to mark
the contact in the mouth . This type of ribbon is used during
the analysis on articulator.
It is essential to dry the occlusal, maxillary and mandibular
surfaces and to use a new ribbon for every measure. The presence of saliva alters,
hinders or erases the marking of the contact point. An already used ribbon may not
record a mark during the contact due to a lack of ink.
202 Between each stage of the adjustment, marks of the previous sequence are erased
with a Q-tip or a compress soaked with alcohol to avoid any confusion .
During the analysis of contacts in ICP, the unilateral placement of a Miller tweezer
risks to generate a ipsilateral deviation of the mandible due to the patient's
chewing reflex and/or a modification in the muscular tensions of the lips. During the
"tapping" movements on the marking ribbon, the patient might also try to clench
his/her teeth tighter on the analyzed side .
That is why it is recommended placing a tweezer on each side to try and
compensate for this reflex phenomenon. The use of a double bend twee zer'
facilitates the manipulation since the operator's hand is then free to guide the
mandible .

w
Q::
ROTARY INSTRUMENTS
:::::>
Enamel corrections necessary for the restoration of stability
t; are often tiny (smaller than 100 µ),which requires an
w
(!) extremely accurate control of the working tip.
....
:c
We will rather work V}lith the turbine, lighter and easier to
handle, used as an eraser to eliminate the unwanted marks.
~
-
Q::
A OH.i olive -shaped bur with red ring (30 µ)is particularly
suitable to mark a groove or remodel an internal cuspal
w slope. The external slopes of the primary cusps will be modified with a pointed
....:c cylinder red ring bur (30 µ)or yellow ring bur (20 µ) .
On the oth er hand, important corrections intended to remodel an occlusal table will
be performed with an inverted cone green ring bur (45 µ), more suitable to recreate
the main grooves and define cusps .
 11 Occlusal adjustment

w
~
::>
.....
U) A final polishing can be performed with tungsten carbide
w burs (40 blades) . The enamel corrections made with a
(.!) diamond bur require a polishing with white silicone tips
..... or ceramic-finishing tips (Ceramaster®, Shofu) .
:c It may be necessary to proceed to an occlusal
(.!)
-
~
"deprogramming " either before performing the
adjustment or during the session so that the patient can rest . A sma ll cut bur
w holder is filled with soft pink wax . A piece of wax is placed on the maxillary
:c
..... incisors, the flat plastic surface facing the mandibular teeth. This stiff supporting
surface generates the posterior disengagement and the memory loss of the
occlusal position.

HELPFUL READING
• Dawson P. Eva lu ation, diagnosis and treatment of occlusal problems . St Louis Mosby
203
Co, 1974.
• Harrel SK, Nunn ME. The effect of occlusal discrepancies on periodontis.
II -Relationship of occlusal treatment to the progression of periodontal disease. J
Periodont. 2001; 72(4): 495 -505.
• Jankelson A. A technic for obtaining optimum functional relationship for the
natural dentition . Dent Clin North Am . 1960: 131 -41 .
• Nunn ME, Harrel SK . The effect of occlusal discrepancies on periodontis.
1-Relationship between occlusal discrepancies to initial clini cal parameters . J
Periodont. 2001; 72(4): 485 -94.
• Okeson JP. Management of temporomandibular disorders and occlusion . St Loui s
Mosby Year Book 1998.
• Ramfjord SP, Ash MM . Occlusion. J. Prelat, Paris, 1975.
• Schuyler CH . Fundamental principles in the correct ion of occlusal disharmonynatural
and artificia l. J Am Dent Assoc. 1935; 22: 1193-202.
• Solnit A, Curnutte DC. Occlusal correction : principles and practice. Quintessence
Books Chicago, 1988.
• Smukler ·H. Equilibration in the natural and restored dentition . Quintessence Books
Chicago, 1991.
• Williamson EH, Lundquist DO . Anterior guidance : its effect on EMG activity of the
temporal and masseter muscles. J Prosthet Dent. 1983; 49: 816 -22.
 Occlusion made easy

204
 Prosthodontic
occlusion in daily
practice
205
The prosthodontic procedure aims at reconstructing or at replacing decayed or missing
teeth in order to restore the defective functional integrity. Materials used in prosthetic
reconstruction (metal, ceramic, resin, composite) do not present the same mechanical
properties as natural teeth. The functional wear which occurs between the natural teeth
is a factor of adaptation to the existing various constraints.
The response of prosthetic materials can result in a significant wear discrepancy over
the years. It is necessary in all the clinical situations to find the best way to integrate
prostheses in order to preserve as much as possible the patient's potential of adaptation.
In spite of the practitioner's and the dental prosthetist's combined efforts, the prepared
prosthesis is never definitive! It will certainly last a long time, but the term "definitive
prosthesis" should be understood as in: "to be used over a long period of time·." The
prognosis of these restorations depends on a range of factors among which some are
connected to the practitioner - the fitting accuracy, the occlusal adjustment in itself,
the proximal contact points, and the sealing quality- while others are connected to the
patient: function, parafunctions, follow-up and hygiene.
Before any prosthetic rehabilitation, the clinician is confronted with an alternative
concerning the reference position: ICP or CR?
• Must he/she use the "patient's occlusion", on the grounds that the usual occlusion
is naturally optimal to him/her? If the ICP is functional, the prosthetic treatment will
improve and complete it.
• Must he/she use by default another position, i.e the centric relation, considering that
this position is a tremendous therapeutic asset due to its almost ideal characteristics?
The prosthodontic treatment, maybe completed with occlusal adjustments, will then have
to create a new ICP, functional in this mandibular position.

I
'I
:w''j·'
"
 Occlusion made easy

Once the occlusal position (ICP or CR) has been determined, it is recommended to choose
for each case the adequate procedure to record the occlusion, that is: the choice of the
technique, the materials, and the most suitable schedule according to the clinical situation.
Once impressions have been taken, the information required to the prosthetic fabrication
must be transferred to the dental laboratory.
First decision: is it necessary or not to mount casts on articulator?
Second decision: if mounting on articulator is needed, during which phase of the
treatment may this procedure be envisaged?
The purpose of this chapter is to show, with a few concrete examples of clinical cases, how
to carry out the adequate prosthodontic procedures in our daily practice.

Preparation of a single crown

on a natural tooth
If the preparation of a posterior single crown in the presence of a canine guidance pre-
sents no specific problem, its integration in a group function is however particularly dif-
ficult.
206
Objectives
• Restoring a functional morphology from a decayed tooth or replacing a missing tooth
with an implant-supported crown. The occlusal integration of this prosthetic element
must be both static (contribute to ICP) and dynamic.
• Assessing the occlusal condition and determine if the prosthetic element must or
must not participate in the functions of mandibular guidance.

The simultaneous achievement of contacts on the whole set of teeth guiding the movement
during the ipsilateral diduction requires a perfect simulation which articulators cannot
provide with their construction technique.
In the case of the elaboration of a single crown, a simple technique allows to perform
a dynamic recording of the mandibular movement. Introduced by Pankey and Mann
(1960) and known as FGP (Functionally Generated Path), this original technique of occlusal
recording allows to record the kinematics of cuspal pathways which are antagonists to the
preparation.
The FGP does not allow to transfer
., information for the simulation; it represents the enve-
lope of movement in whic;h•the prosthesis must fit.

Indications
• Occlusal integration of intercalary prosthetic elements in the existing ICP.
• A distal tooth must be present on the arch .
• There must be an antagonist tooth and the function of guidance must first be validated .
This allows to integrate the element in a group function or to avoid its interference during
the functional movements.
 12 Prosthodontic occlusion in daily practice

1 Recording of an occlusal bite in ICP with a 2 The bite is placed on the working cast, the
silicone. plaster is directly poured into this position.

207
3The plaster key in ICP is stabilized by its mesial 4 The cap is covered with wax with no shape
rnd distal supports. memory.

Norking sequence
rirst clinical session: impression of the hemi -arch involved
n the prosthetic process and recording of an occlusal bite in
CP {Fig. 1).
3etween the first two sessions, the laboratory prepares the
Kclusal key by pouring plaster directly in the working cast {Fig.
O. Mesia! and distal supports provide the stability of the key.
lhe dental technician makes the substructure of the crown,
1sing the occlusal key in ICP {Fig. 3).
iecond clinical session 5 The patient performs lateral
movements in all directions.
1 Fitting of the cap and validation. The inelastic wax (see the
~IGHT GESTURE section at the end of the chapter) is placed on
his support {Fig. 4): Before proceeding to the recording, it is
ecommended that the patient learn how to locate the starting
)Osition and gets familiar with the movements he/she must
)erform .
' The patient is asked to close his/her mouth and, while keeping
in occlusal contact, to perform successive movements with an
1mplitude from 4 to 5 mm in protrusion as well as in ipsi- and
:ontralateral diduction {Fig. 5). The instruction "Grind your teeth
n all directions " generally produces the desired effect. Wax is
6 Occlusal aspect of the recording.
nodeled by the cuspal path s of the antagonist tooth {Fig. 6)
 Occlusion made easy

7 Some plaster is put with a brush in the wax 8 The finalized plaster block is set on mesial and
functional impression. distal teeth.

208

9 Occlusal view of the cast.

10 The three-arm occluder allows to place the
ICP or the FGP in front of the working model.
• The fragility of thi s dynamic impression
requires its pouring in the mouth with
some quick-setting plaster (such as Snow
White® pl aster) first app li ed with a bru sh;
a block will then be made and modeled
with fing ers (Fig. 7-8) . The intrados of
this block shows the antagon ist cuspal
pathways (Fig. 9) .
Between the two sessions, the block is
se nt to the laboratory with the workin g
cast and the antagon ist cast. The whol e
set can be mounted Or] a three-arm
occluder (Twin Stage Occluder®) (Fig . 10)
which all{;)ws to alternately oppose to th e
working cast th e antagonist cast and the
FG P. When building up the ceram ic, the
dental technician will use the FGP, making
sure to stay aw ay from the zones where
contact s are prohibited while searching
co ntact in the guidance zones (Fig. 11). 11 Here, the FGP key is cut to show its relation
with the crown.
 12 Prosthodontic occlusion in daily practice

12 Check and adjustment in the 13 The crown in ICP fulfills its 14 The crown is placed, the
mouth of the unglazed crown. function of stabilization. tracks show its participation. in
the guidance.

Third clinical ·session: the unglazed prosthetic element is placed and adjusted in the
mouth, which highlights its contribution in the occlusal function s of stabilization in ICP (in
red) and of guidance (in blue) (Fig. 12-13).
Fourth clinical session: after glazing, the crown is perfectly integrated into the group
function, thus contributing to guidance (Fig. 14).
This technique induces a minimal investment to achieve a proper and reproducible result of
the occlusal integration in this type of complex situations. If the ICP is stable, an alternative 209
technique consists in taking impressions of the whole arches and preparing the prosthetic
element by manually fitting the casts in static and dynamic.
The clinical stage of fitting and adjusting the unpolished prosthesis naturally remains
essential.
Limits of this technique: the existence of a stabilization distal to the reconstructed tooth is
necessary to reposition in a stable way the cast prepared in the mouth.

Implant-supported single crown

The occlusal adjustment in ICP is
slightly different.
The implant is rigidly connected
to the surrounding bone while
the natural tooth can rely on its
viscoelastic capacity to anchor
thanks to its periodontium .
Under the influence of occlusal
strengths in ICP, natural teeth
show a slight impaction which
the implant-supported tooth
cannot provide.
The adjustment . consists in
finding contacts in ICP on the
implant-supported tooth only
when natural teeth are in tight
15 Principle of the occlusal adjustment on an implant-
supported crown. (slight contact/tightly clenched teeth).
contact (Fig. 15).
 Occlusion made easy

16 The canine is assisted in the disclusion by the 17 Only an X-ray allows to make sure of the
first premolar. perfect adaptation of the components in the
implant.

In lateral sectors, axial strengths must prevail and lateral constraints must be avoided. In
the case of an implant-supported crown on a canine, the guidance may be shared with the
adjacent premolar in order to benefit from the proprioception of the natural tooth (Fig. 16).
As a matter of fact, the occlusion cannot be checked nor adjusted if the prosthetic element
is not perfectly placed . The adjustment is verified during the fitting of the cap, both visually
210 and tactilely with a probe on the periphery and with a retroalveolar X-ray when the
prosthesis is implant-supported (Fig. 17).

Preparation of two
crowns in a distal sector
Both crowns are implant-supported in this
clinical case.
Objectives
• Restoring the masticatory function and
the distal stabilization in sector 4.
•The ICP being stable and not pathogenic,
this reference is kept.
First clinical session: global impression of
18 The confrontation of the casts allows
the manufacturing of caps without occlusal
both arches and recording of an occlusal bite contact.
in the edentulous secto r if the confrontation
of the arches does not provide a satisfactory
stabilization.
Between the first two sessions, the laboratory
prepares "' the abutments and the caps
of crowns, leaving some space from the
antagonist occlusal surfaces (Fig. 18).
Second clinical session: fitting of the
frameworks and recording of the occlusion
in ICP on caps with a quick-setting self-cured
re sin (Pi-Ku-Plast®) (Fig. 19). 19 Self-cured resin covering the caps records
the stabilization in ICP.
 12 Prosthodontic occlusion in daily practice

20 Recording of the maxillary

position with a face-bow.

21 Mounting of casts on articulator in ICP.

211

22 Control of the occlusion with Shimstock® (8 µ): the 23 Checking of the occlusion on the
width of the occlusal areas is reconstructed. unglazed prostheses.

A mounting on articulator is necessary; in this case of posterior tooth gaps, a face-bow

is used to transfer the maxillary position (Fig. 20). Casts are mounted on the articulator
(Fig. 21).
The laboratory technician builds the ceramic cosmetic part and proceeds to the occlusal
adjustment on the articulator. Crowns must match the width of the occlusal areas
(Fig. 22).
Third clinical session: the unglazed crowns are placed and adjusted in the mouth
(Fig. 23).
It is better to make all the corrections at this stage; retouching a glazed ceramic creates
rough patches increasing the abrasive power of the material, which can be aggressive for
the antagonist tooth.
Between the two sessions, the dental laboratory proceeds to the glazing.
 Occlusion made easy

Fourth clinical session: last control of the occlusion and cementing of crowns
(Fig. 24 -25). If a small correction is nevertheless necessary, the zone is carefully repolished
(Polisher CeraMaster® Shofu).

24 After g~azing, crowns play their role of 25 Here, the guidance is conducted by the
stabilization. canine.

Preparation of three crowns in an intercalary

sector
212 The presence of a distal tooth provides the posterior stabilization (Fig. 26).
Objective: the ICP is stable and will not be modified (Fig. 27).

26 Assessment of the occlusal space in ICP. 27 The occlusal view shows the stability of
ICP which can be preserved.

28 An occlusal table in Moyco® wax is prepared in 29 View of the indentation in wax.

the space to be recorded.
 12 Prosthodontic occlusion in daily practice

30 Addition of temporary cement on both faces of 31 The recording was precised by the
the occlusal table. addition of cement.

Specificities regarding what has been said before

• occlusion is recorded with an occlusal table in Moyco® wax cut to the same length as
the preparation area and to the width of the arch.
• Wax is softened in hot water (53 °(, 127.6 °F) and indented in ICP (Fig. 28-29).
• In order to get a more accurate recording, temporary cement (such as Temp Bond®) 213
is put on both faces of the wax and the ICP is recorded again (Fig. 30-31). Casts are
mounted on articulator in this relation for the prosthetic elaboration .

Preparation of a three-unit bridge replacing

the canine
Objective: this clinical situation implies the restoration of the guidance function. THE ICP,
satisfactory, is preserved .
First session: before the extraction of the tooth, an occlusal key of the zone is made
to record the position of the tooth. After the extraction, using the key, the natural tooth,
deprived of its root, is temporarily bonded to the neighboring teeth, and the occlusion is
adjusted (Fig. 32).

32 13 was bonded on
its neighbors teeth to
preserve the aesthetics.
 Occlu sion made easy

33 Mounting of the casts reproducing the functional 34 Preparation of a temporary bridge.

situation in the mouth and creation of a personalized
anterior table.

~ 14

35 Mounting of the working cast facing the mandibular 36 Control of the volumes of the bridge
arch. framework.

After the healing period, the function turns out satisfactory, the tooth is still bonded. The
impression of both arches is taken with alginate. A transfer face-bow is set up, and casts are
mounted on the articulator.
Some silicone is put on the incisal table of the articulator. Casts are moved with teeth in contact,
the incisal pin prints the movements in the silicone. The outcome is the counterpart of the
guidance ~i sting between th e casts (Fig . 33).
A temporary bridge is prepared on a cast of the maxillary which will be placed after the supporting
teeth have been prepared (Fig. 34).
Second session: teeth are prepared and the working impression is taken. The resulting cast
is mounted on articulator in relation with the mandibular arch (Fig. 35). This manipulation is
called "cross mounting ". We thus have two perfectly exchangeable maxillary arches in the same
relation with the mandibular arch. The framework is fabricated with a milling machine, tested on
th e articulator, and validated in the mouth (Fig. 36).
 12 Prosthodontic occlusion in daily practice

37 Adjustment on the articulator. 38 Organization of the guidance by a group

function.

Third session: validation of the framework in the mouth.

The cosmetic elaboration is carried out by using the personalized incisal table to adjust the
function of guidance (Fig. 37).
Fourth session: adjustments are checked in the mouth, then the bridge is placed. Due to the
215
missing canine, the guidance is distributed here on several teeth from the lateral incisor to the
second premolar (Fig. 38).

Treatment of a bilateral posterior tooth gap

Objectives
• The patient wishes a fixed prosthetic device after losing her teeth in the lateral sectors.
• The anterior teeth are preserved as they are.
• The mandibular arch already fitted with bridges is not involved in the treatment.
• There is no dental reference
anymore, the centric relation
can only be used for the
reconstruction.
Before starting the treatment, the
study models are mounted on
articulator to make the prosthetic
diagnosis.
Four implants were placed in the
maxillary (Fig. 39).
First session: a global impression of
the maxillary arch is taken as well as
a silicone bite in the toothless sectors.
The anterior teeth keep the original 39 The posterior tooth gap is treated with an implant·
OVD. supported prosthesis.
 Occlusion made easy

40 A first mounting
is made with a silicone
occlusal key.

'.16

41 Occlusal tables are

connected to implants.

42 A control of the occlusal position is

made during the fitting of caps.

As previously described, a cross mounting of the maxillary cast is made in a first approach of the
occlusion (Fig. 40). On this working cast, transfer cylinders are attached to analogs to serve as
supports to an occlusal recording table in sectors 10 and 20 (Fig. 41).
Second session: a new recording of the occlusion is performed in the mouth by using these
devices fastened to the implants. The maxillary cast is mounted more accurately against the
mandibular cast, which will allow the fabrication of the bridges substructures.
Third session: during the fitting of the frameworks, the occlusion is recorded again in optimal
conditions of stability (Fig. 42).
Cosmetic surfaces can then be built up, they will be tried on and adjusted during the following
session as previously described.
 12 Prosthodontic occlusion in daily practice

Restoration of a maxillary arch

43 Maxillary arch requiring a complete 44 Panoramic X-ray of the initial situation.

rehabilitation.

This patient's maxillary arch which is partially fitted

with a removable prosthesis in sector 20, with
crowns and bridges in the other sectors, requires a
complete rehabilitation (Fig. 43-44).
An anterior temporary bridge is placed, the modified 217
removable prosthesis provides temporization during
the healing of implants (Fig. 45-46).
We make on the working cast a resin base plate
hollowed out in the area of central incisors and fitted
with two wax ridges. This occlusion base is used first
to position the fork of the face bow and to mount 45 Clinical view: during the healing of
the maxillary model on the articulator. Then, the implants, an anterior temporary bridge
occlusion is recorded in centric relation by keeping preserves the OVD.
the temporary teeth in the area of central incisors to
be used as stops of OVD (Fig. 47).

46 The modified removable prosthesis fulfills 47 Occlusal base plate on the working cast with
the therapeutic temporary work. anterior cut, allowing to leave the temporary
crowns.
 Occlusion made easy

48 Mounting of the mandibular cast.

49 Preparation of the caps: implant-supported

sectors are separated from the natural teeth.
'.18

50 Re-recording of the occlusion on caps.

Th e mandibular model is mounted in thi s

relation against th e maxillary model (Fig. 48).
At this sta ge, the accuracy of th e occlusion
is adequate to make the framework s 51 Adjustment of the unglazed prostheses in
(Fig. 49). A new recording of th e occlusion the mouth.
is performed during the valid ation of the
caps and th e mandibu lar model is mounted
again in this more accurate position (Fig. 50).
As for the implant-supportep element s, the
occlusa l morphological pa't tern provides : a
lower cusp-al slope, a w ide occlusal fos sa,
and the impact of the antagonist cusp in
the central fossa in order to axia lly point
the constra ints on the implants (Klineberg,
2007).

The unglazed prosthetic elements are

aesthetica lly and functionally adju sted in the 52 Checking the occlusion on the unglazed
mouth (Fig. 51-52). prostheses.
 12 Prosthodontic occlusion in daily practice

53 Final aspect of the. reconstructions.

54 The canine
is remote from the
rotation centers and
from the zones
of applied strengths. 219
Prostheses are glazed, th e
arch is limited to th e first
molars, whi ch relates to the
size of the antagonist arch
(Fig. 53).
On the right sid e, 13,
which is implant-supported,
performs th e guidance.
Provided that th e fun ctional
ang le is open enou gh,
the position of thi s tooth
on the arch, remote from
the rotation cente rs and
from the zones of applied
55 Satisfactory aspect three and a half years after the end of
the treatment.
stre ngths, is perfect for this
fun ct ion (Fig. 54).
The control in thre e and a
half years shows a stable
situation of th e whole
reconstruction (Fig. 55-56).

56 Control X-ray 3 and a half years later.

 Occlusion made easy

KEY POINTS
Principle 1: in the case of an isolated crown, the element is integrated into the
occlusion and the existing function.
PrinciJDle 2: materials and techniques of occlusal rernrdirig a1i e adapt ed t o 1ifil e clinical
1

situation .
Principle 3: whenever it is possible, it is necessary to prefer the rigid rernrding
mat erial to the mucosa -supported one. The silicone bite is a first st ep> t © the occlusal
recording which is specified by the r:ecording on caps durnin·g 't!he flext sessiori.
Principle 4: it! ca se of valid ated guidance, it is interesting to record it in order t o
reproduce it with a personalized incisal table .
Principle 5: the functional rehabilitation wit h implant prostheses is not fundamentally
different from the usual concepts of a careful and meticulous clinical practice. It
simply has some specificities, due to the differences of behavior between the natural
roots and the implants .
220 It is not possible to describe all the prosthetic clinical situations in a single chapter.
.These aspects are largely studied in more specialized publications.

w
0:::
:::> There is a special wax for the recording of the FGP available in the United States,
t; but it is difficult to find in Europe. On the other hand, the basic wax lining teeth
w plates for dentures is perfectly suitable, and every prosthetic laboratory has this
(.!) kind of wax in sufficient
t- amount to prepare
:I: the conditions of this
~ recording in the mouth .
0:::
w
:I:
t-
 12 Prosthodontic occlusion in daily practice

HELPFUL READING
• Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical
guidelines with biomechanical rationale. Clin Oral Implants Res. 2005 ;16(1) :"26-35.
• Klineberg I, Kingston D, Murray G. The bases for using a particular occlusal design in
tooth and implant-borne reconstructions and complete dentures. Clin Oral Implants
Res. 2007; 18 (Suppl 3) : 151 -67.
• Lindsey D, Pankey, DDS, Arvin W Mann BS. Oral rehabilitation: Part II.
Reconstruction of the upper teeth using a functionally generated path technique .
J Prosthet Dent. 1960; 10(1): 151-62.
• Curtis SR . Functionally generated paths for ceramometal restorations . J Prosthet
Dent. 1999; 81(1) : 33-6 .

221
 Occlusion made easy

222
Afterword Gerard Duminil

This book does not pretend to be exhaustive in the field of occlusion. It

describes the basic principles and their main applications in the daily
practice of odontology. We have deliberately put aside the complex
treatments, which do not fit in the frame we had set.

In a few cases, the use of the analogical method has simplified -at least we
do hope so -, the description of the biomechanical laws of the manducatory
apparatus.

We have described the ideal theoretical model of the functional occlusion 223
which is a necessary reference, but also the variants and their pathogenic
potential. It is not a question of changing all the occlusal conditions that
may be observed in order to standardize them, but rather learning how to
assess the profit / risk ratio in every situation. The interview with the patient the
observation phase, the accurate clinical examination are required to make
a diagnosis which a necessary step in any therapeutic approach. Behavioral
factors connected to the patient need to be considered during the decision-
making process in some specificic cases where symptomatology is the
expression of an emotional fragility.

Prosthodontic reconstructions do not always require a mounting on articulator,

but it is essential to be able to perform this technique.

Choosing to use a device rather than another must meet criteria of

ergonomics making the manipulation quicker and easier. The regular use
of an articulator favors the learning curve inherent to any new technique.
This kind of global approach optimizes the relationship with the patient the
presentation of the treatment plan and its implementation.

Knowledge and know-how are the basic ingredients of the recipe for success
in our practice. Occlusion is involved in our daily procedures. Applying its rules
and principles can only improve our results ... made easy!

.. It is not because it is difficult that we do not dare,

it is because we do not dare that it is difficult."
Seneca
~24