Paulo T. N.

Sarita, DDS, PhDa

Cees M. Kreulen, DDS, PhDb
Dick J. Witter, DDS, PhDc
A Study on Occlusal Stability in Martin van’t Hof, MSc, PhDd
Shortened Dental Arches Nico H. J. Creugers, DDS, PhDe

Purpose: The aim of this study was to verify the hypothesis that shortened dental arches
constitute a risk to occlusal stability. Materials and Methods: Using cluster samples, 725
subjects with shortened dental arches comprising intact anterior regions and zero to eight
occluding pairs of posterior teeth and 125 subjects with complete dental arches were
selected. Subjects with shortened dental arches were classified into eight categories
according to arch length and symmetry. Parameters for occlusal stability were interdental
spacing, occlusal tooth wear, occlusal contact of incisors in intercuspal position, and
vertical and horizontal overlap. Additionally, tooth mobility and overeruption of
unopposed teeth were assessed. Influence of independent variables (dental arch category,
age, gender, and residence) on the parameters for occlusal stability was assessed by one-
way ANOVA and Tukey’s multiple range tests. Results: Extreme shortened dental arches
(zero to two pairs of occluding premolars) had significantly more interdental spacing,
occlusal contact of incisors, and vertical overlap compared to complete dental arches.
Occlusal wear and prevalence of mobile teeth were highest in these categories. The
category with three to four occluding premolars had significantly more interdental
spacing and, for the older age group, more anterior teeth in occlusal contact compared to
complete dental arches. Age was consistently associated with increased changes in
occlusal integrity. Conclusion: Signs of increased risk to occlusal stability seemed to
occur in extreme shortened dental arches, whereas no such evidence was found for
intermediate categories of shortened dental arches. Int J Prosthodont 2003;16:375–380.

A shortened dental arch (SDA) is defined as a den-

tition with an intact anterior region and a reduc-
aAssistant Lecturer, Department of Restorative Dentistry, Faculty
of Dentistry, Muhimbili University College of Health Sciences, Dar
es Salaam, Tanzania.
bAssociate Professor, Department of Oral Function and Prosthetic
Dentistry, College of Dental Sciences, Medical Faculty, University
of Nijmegen, The Netherlands.
cLecturer, Department of Oral Function and Prosthetic Dentistry,
College of Dental Sciences, Medical Faculty, University of
Nijmegen, The Netherlands.
d Professor, Department of Preventive and Curative Dentistry,
College of Dental Sciences, Medical Faculty, University of
Nijmegen, The Netherlands.
eProfessor and Chair, Department of Oral Function and Prosthetic
Dentistry, College of Dental Sciences, Medical Faculty, University
of Nijmegen, The Netherlands.
Reprint requests: Dr Nico H. J. Creugers, Department of Oral Function
and Prosthetic Dentistry, College of Dental Sciences, University of
Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Fax:
+ 31 24 3541971. e-mail: N.Creugers@dent.umcn.nl
tion of occluding pairs of posterior teeth starting pos-
teriorly.1 This condition is considered a risk to occlusal
stability, which is the absence of the tendency for teeth
to migrate (other than slow physiologic compensatory
movements).2 Various phenomena (eg, migration of
teeth, increased number of occlusal contacts, in-
creased vertical and horizontal overlap, increased
tooth mobility, and overeruption of unopposed teeth)
have been described to occur after loss of posterior
support, but without firm scientific evidence.3–9 On
the other hand, it has been reported that SDAs with
three to four occluding pairs of posterior teeth can pro-
vide durable occlusal stability.10 It appears that minor
migrations of teeth occur after the extractions leading
to SDA, but will end in stable occlusions after time.
The World Health Organization (WHO) has adopted
as a treatment goal “the retention, throughout life, of
a functional, aesthetic natural dentition of not less than
20 teeth and not requiring recourse to prosthesis.”11

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 Occlusal Stability with Shortened Dental Arches Sarita et al

Table 1 Characteristics of Shortened Dental Arch (SDA) Groups*

Occluding
20 and  40 y
40 y
Category pairs n Mean age (SD) n Mean age (SD)

1 Slightly SDA: M1–M1/M2/M3 6–8 64 29.9 (4.0) 64 49.1 (9.1)

2 SDA I: P2–M1/M2/M3 5–7 64 31.3 (5.4) 64 49.8 (7.4)
3 SDA II: P2–P1/P2 3–4 65 30.8 (6.0) 65 52.6 (11.3)
4 Extreme SDA I: P1–P1 2 24 31.2 (5.8) 40 52.0 (8.5)
5 Extreme SDA II: C–C/P1 0–1 37 33.6 (4.6) 68 53.6 (11.4)
6 Asymmetric SDA I: P1–M1/M2/M3 4–6 25 31.6 (5.6) 42 52.6 (8.7)
7 Asymmetric SDA II: C–M1/M2/M3 3–5 12 34.3 (4.1) 27 53.5 (6.9)
8 Asymmetric SDA III: C–P2 2 17 33.2 (4.3) 47 53.5 (11.3)
9 Complete dental arches: M2/M3–M2/M3† 8–10 63 30.3 (5.5) 62 48.2 (8.9)
*Distribution of subjects by residence: SDA urban, 368; SDA rural, 357; CDA urban, 63; CDA rural, 62.
†Control group.

SD = standard deviation; M = molar; P = premolar; C = canine.

This includes SDAs comprising intact premolar re-
gions. However, the few studies concerning occlusal
stability in SDA are based on limited numbers of sub-
jects in industrialized countries with considerable den-
tal care.1,10 It can be doubted whether the conclusions
are valid for populations from developing countries
where dental care is minimal and types of food might
require more occlusal activity to be comminuted.
The aim of this study was to verify the assumption
that SDAs constitute a risk to occlusal stability. This
was done on a large sample from the population of
Tanzania. It was hypothesized that decreasing oc-
cluding pairs of posterior teeth in SDA is positively
correlated with occlusal instability. For this purpose,
interdental spacing, occlusal wear, occlusal contact
of anterior teeth, and vertical and horizontal overlap
were studied. In addition, increased tooth mobility
and overeruption of unopposed teeth were assessed.
Materials and Methods
Details of the sampling method have been described
in a previous article.12 In brief, cluster samples were
obtained from urban and rural adult populations of
the Coastal zone in Tanzania from 1998 to 2000. In
total, 5,532 subjects were involved, 2,654 from five
factories and two governmental institutions of two
cities and 2,878 from six rural villages. From these,
725 subjects (340 men and 385 women) having an
SDA could be retrieved. They were classified into
eight dental arch categories according to arch length
and symmetry (Table 1). For each category, it was ini-
tially intended to include 128 subjects stratified by
residence (rural, urban), gender, and age group
(younger:
20 and  40 years; older:
40 years).
However, during the period of inclusion, the pursued
numbers of subjects per variable could not be in-
cluded in some of the groups. As a control, 125 sub-
jects (62 men and 63 women) with complete dental
arches (CDA) were matched.
One examiner carried out the examinations with
subjects seated in an ordinary chair. Occlusal stabil-
ity was studied by clinical assessment of four para-
meters:
1. Interdental spacing, assessed for all proximal con-
tacts in the premolar and anterior regions with
metal gauges of thickness 0.1, 0.5, and 1.0 mm
and scored as: 0 =  0.1 mm spacing (considered
to be interdental contact); 1 =
0.1 to  0.5 mm
spacing; 2 =
0.5 to  1.0 mm spacing; or 3 =

1.0 mm spacing
2. Occlusal tooth wear, assessed for all occluding
teeth and scored as: 0 = no visible wear; 1 =
wear in enamel; 2 = dentin just exposed; 3 =
substantial loss of dentin; or 4 = wear into sec-
ondary dentin/pulp
3. Occlusal contact, assessed in intercuspal position
for each maxillary tooth using 13-µm-thick oc-
clusal registration strips (Arthus)13 and scored as:
1 = occlusal contact; 2 = no contact; or 3 = op-
posing tooth absent
4. Vertical and horizontal overlap, measured on the
right central incisors to the nearest whole mil-
limeter on a ruler
In addition, tooth mobility was estimated for all teeth
and scored as physiologic, slightly more, moderately
more, or severely more mobility (according to
Carranza14). Finally, overeruption of unopposed teeth
was estimated and scored into none,  3 mm, or 
3 mm of overeruption. Subjects were asked whether
the overerupted teeth hindered function.
Prior to the examinations, the examiner was cali-
brated to two researchers experienced in this field.10
Interexaminer agreements (between the examiner
and each of the two researchers) were checked by
examining 15 subjects at the beginning of the study
and 16 subjects 2 years after. Correlation coeffi-
cients between repeated registrations for vertical

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 Sarita et al Occlusal Stability with Shortened Dental Arches

Table 2 Mean Scores (Standard Deviations) for Interdental Spacing

Maxilla Mandible
Premolar Anterior Premolar Anterior
Category region region region region

CDA 0.2 (0.4) 0.7 (0.8) 0.2 (0.4) 0.4 (0.5)

Slightly SDA 0.2 (0.4) 0.6 (0.7) 0.2 (0.4) 0.4 (0.6)
SDA I 0.3 (0.4) 0.6 (0.7) 0.3 (0.4) 0.4 (0.6)
SDA II 0.3 (0.4) 0.7 (0.7) 0.5 (0.6)* 0.6 (0.8)
Extreme SDA I 0.5 (0.7) 0.7 (0.8) 0.7 (0.8)* 0.5 (0.8)
Extreme SDA II 0.8 (0.8)† 0.8 (0.7) 0.8 (0.8)*‡ 0.5 (0.6)
Asymmetric SDA I 0.3 (0.5) 0.5 (0.8) 0.3 (0.4) 0.4 (0.6)
Asymmetric SDA II 0.1 (0.3) 0.7 (0.7) 0.4 (0.4) 0.3 (0.5)
Asymmetric SDA III 0.4 (0.5) 0.8 (0.7) 0.3 (0.5) 0.5 (0.6)

Age correction

20 and  40 y –0.07 –0.10 –0.03 –0.02

40 y +0.07 +0.10 +0.03 +0.02
Significance level of age effect P  .01 P = .006 P = .05 P = .28
*Significantly different from other categories with mean = 0.2 (Tukey).
†Significantly different from other categories with mean  0.3 (Tukey).
‡Significantly different from other categories with mean  0.4 (Tukey).

CDA = complete dental arch; SDA = shortened dental arch.

and horizontal overlap ranged from .76 to .85 at Results

baseline and from .64 to .94 after 2 years. Cohen’s
kappa coefficients were lowest for occlusal tooth
wear (.55) and varied from .84 to .99 for the other
variables at baseline. After 2 years, the variation was
.75 to .99.
For interdental spacing, mean scores per subject
were calculated separately for the maxillary and
mandibular anterior regions (spaces from canine to
canine), and likewise for the maxillary and mandibu-
lar premolar regions (spaces distal of the canine up
to distal of the second premolar). For occlusal wear,
mean scores per subject were calculated for the max-
illary and mandibular anterior regions combined,
and for the premolar regions combined. For occlusal
contact, the mean number of maxillary incisors in
contact in intercuspal position per subject was cal-
culated. For tooth mobility, the maximum score for
the anterior teeth and for the posterior occluding
teeth per subject was taken into account.
For statistical analyses, the influence of the inde-
pendent variables (dental arch category, age group,
gender, and residence) on the parameters for occlusal
stability was assessed by analysis of variance (ANOVA)
and Tukey’s multiple range tests. Since equal distrib-
ution for age and gender was not completely success-
ful (Table 1), their influence was checked and corrected
for by adding the age or gender effect to the dental arch
category effect. For tooth mobility, logistic regression
analyses were applied after dichotomization (physio-
logic vs increased mobility). Data were analyzed using
the SPSS package (version 6.2 for IBM, SPSS), and a cut-
off value of P = .05 was chosen.
The older age group had significantly higher mean
scores (P  .01) for interdental spacing in the max-
illa than did the younger age group, but not in the
mandible (Table 2). Gender and residence had no
significant influence on interdental spacing. The cat-
egory extreme SDA II had the most spacing in both
maxillary (P  .001) and mandibular (P  .05) pre-
molar regions. The categories SDA II and extreme
SDA I had significantly more interdental spacing than
categories CDA and slightly SDA (P  .001). Inter-
dental spacing in anterior regions did not differ sig-
nificantly between arch categories.
Occlusal tooth wear was significantly higher in
the older than in the younger age group (P  .001)
and also in men than in women (P  .01) (Table 3).
Residence had no significant influence on occlusal
tooth wear. Although a significant overall effect was
detected for the arch categories (P  .001), interac-
tions with age precluded analyses for differences be-
tween arch categories. Occlusal tooth wear tended
to increase with decreasing number of occluding
posterior teeth. For both age groups and regions, the
mean scores were low for categories CDA, slightly
SDA, and SDA I. High mean scores were observed for
the category extreme SDA II. Increased wear was
also seen in the category extreme SDA I in the
younger age group and in the category asymmetric
SDA III in the older age group.
The older age group had significantly more in-
cisors with occlusal contact than did the younger
age group (P  .001; Table 4). Gender and residence

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 Occlusal Stability with Shortened Dental Arches Sarita et al

Table 3 Mean Scores (Standard Deviations) for Occlusal Tooth Wear

Premolar regions Anterior regions

Age
20 Age Age
20 Age
Category and  40 y
40 y and  40 y
40 y

CDA 1.1 (0.2) 1.5 (0.4) 1.1 (0.2) 1.3 (0.3)

Slightly SDA 1.2 (0.3) 1.5 (0.5) 1.0 (0.1) 1.4 (0.4)
SDA I 1.2 (0.3) 1.5 (0.5) 1.1 (0.3) 1.3 (0.3)
SDA II 1.4 (0.8) 2.1 (0.9) 1.1 (0.3) 1.8 (0.9)
Extreme SDA I 1.8 (0.6) 2.1 (0.6) 1.3 (0.5) 1.8 (0.4)
Extreme SDA II 1.7 (0.6) 2.8 (0.7) 1.5 (0.4) 2.2 (0.8)
Asymmetric SDA I 1.3 (0.3) 1.8 (0.5) 1.2 (0.3) 1.7 (0.4)
Asymmetric SDA II 1.3 (0.4) 2.0 (0.6) 1.2 (0.3) 1.7 (0.5)
Asymmetric SDA III 1.6 (0.5) 2.5 (0.8) 1.2 (0.1) 2.0 (0.8)

Gender correction
Men +0.10 +0.06
Women –0.10 –0.06
Significance level of gender effect P = .001 P = .001
CDA = complete dental arch; SDA = shortened dental arch.

Table 4 Mean No. of Incisors in Occlusal Contact in the categories extreme SDA II (3.0 ± 1.3 mm) and
Intercuspal Position asymmetric SDA III (3.1 ± 1.5 mm) had significantly
Subjects with larger (P  .05) vertical overlap than did the other cat-
occlusal Age
20 Age egories, with the exception of the categories extreme
Category contact (%) and  40 y
40 y SDA I (2.6 ± 1.3 mm) and asymmetric SDA II (2.4 ±
CDA 35 0.5 (1.1) 1.5 (1.7) 1.2 mm). The category extreme SDA I had a signifi-
Slightly SDA 33 0.4 (0.9) 1.3 (1.5) cantly larger vertical overlap than did CDA, slightly
SDA I 45 0.6 (1.1) 1.7 (1.6) SDA, and SDA I (P  .05). For horizontal overlap
SDA II 58 0.9 (1.4) 2.9 (1.5)*
Extreme SDA I 86 2.5 (1.7)* 3.2 (1.3)* (ranging from 1.8 ± 1.5 mm to 2.3 ± 1.2 mm), there
Extreme SDA II 91 3.0 (1.4)* 3.6 (1.0)* were no significant differences between the arch cat-
Asymmetric SDA I 66 0.6 (1.2) 2.9 (1.4)* egories.
Asymmetric SDA II 97 2.2 (1.3)* 3.2 (1.2)*
Asymmetric SDA III 95 2.5 (1.8)* 3.7 (0.9)* Prevalence of mobile teeth was 12% in the ante-
rior and 3% in the posterior regions. Logistic regres-
*Significantly different from other categories.
CDA = complete dental arch; SDA = shortened dental arch. sion analyses revealed a significant age effect on
tooth mobility for maxillary (older age group 8% vs
younger age group 1%; P  .001) and mandibular an-
terior teeth (older 15% vs younger 2%; P  .001), but
not for posterior regions. Gender and residence had
no significant influence. Because of the low preva-
had no significant influence. Percentage of subjects lence, valid analysis for differences between arch cat-
with occlusal contacts on incisors increased with egories could not be done. However, for the anterior
decreasing number of occluding posterior teeth. In region, tooth mobility tended to increase with re-
the younger age group, the categories extreme SDA duction of occluding pairs of posterior teeth (5%
I and II and asymmetric SDA II and III had signifi- mobility for CDA, 25% for asymmetric SDA III).
cantly higher mean numbers of incisors with oc- Nearly all subjects with SDA (98%) had one or
clusal contact than did the other categories (P  more unopposed (pre)molars. Taking the maximum
.05). In the older age group, the categories CDA, score per subject, overeruption of unopposed teeth
slightly SDA, and SDA I had significantly fewer oc- was absent or mild ( 3 mm) in 12%, severe ( 3
clusal contacts than did the other categories (P  .05). mm) in 32%, and to the opposing ridge in 56% of
The older age group had significantly higher mean subjects. Twelve subjects (2%) reported that the
values than did the younger age groups with respect overerupted teeth hindered oral function.
to vertical overlap (older 2.5 ± 1.4 mm vs younger 1.7
± 1.5 mm; P  .001) and horizontal overlap (older 2.1 Discussion
± 1.3 mm vs younger 1.9 ± 1.2 mm; P  .05). Gender
and residence had no significant influence on verti- Because clusters (seven urban institutions and six
cal and horizontal overlap. After correction for age, rural villages) were chosen, the subjects in this study

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 Sarita et al
are not a true random sample of the population.
However, internal randomization was endorsed to a
high level, and the large sample was considered rep-
resentative for adults in Coastal Tanzania. Although
it was anticipated that urban and rural residences
would differ regarding dental state because of differ-
ences in accessibility of oral health care and food pat-
terns, this expectation was not confirmed. In the lit-
erature, there is no information on the relation
between extreme or asymmetric SDAs and occlusal
stability. Therefore, we separately included these types
of SDA in our analyses despite their low prevalences.
A stable position of teeth, ie, absence of gross mi-
gration, is a result of a balance of forces. Besides oc-
clusion, other factors such as cheeks, lips, and tongue
are recognized. Changes of tooth position may be in-
duced by loss of teeth. Particularly with SDA, the oc-
clusal stability is considered to be at risk. Assessment
of occlusal stability lacks clear measures. Surrogate
variables were used in this study.
For SDA, this study showed increased interdental
spacing in the mandibular premolar region in sub-
jects with SDA II and extreme SDA I and II compared
to the CDA and slightly SDA categories. The increase
of spaces was mild, though, and was not observed in
the maxillary premolar region, with the exception of
the extreme SDA II category. In this category, subjects
had at most one pair of premolars. Obviously, wedg-
ing causes more distal migration of the premolars than
in the other categories. Overall, age had influence on
posterior spacing. In the anterior regions, no spacing
differences between dental arch categories were found.
This is consistent with data on subjects with CDA and
those with SDA comprising the premolars.10 As in that
study, maxillary anterior teeth seemed to have less in-
terdental contact than did mandibular anterior teeth.
A decrease of posterior support tended to lead to
increased occlusal tooth wear, starting from SDA II.
This is in contrast with the study cited above,10 where
tooth wear did not differ between subjects with den-
titions like SDA II and CDA. In other studies in in-
dustrialized countries,15,16 incisor wear was more
prevalent than premolar wear in populations with
mixed dental arches. This did not seem to be the case
in Tanzania. Possibly observation methods differed.
Also, diets in Tanzania might require more (posterior)
occlusal activity to be comminuted, as suggested
previously.12 This might accommodate possible wear
differences between anterior and premolar regions.
The fact that age and gender were important factors
regarding occlusal tooth wear, even in the CDA cat-
egory, was not unexpected.17–19
If wear in the posterior area increases, it can be ex-
pected that occlusal contacts on incisors in intercus-
pal position will increase. Indeed, occlusal contact on
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Occlusal Stability with Shortened Dental Arches
incisors was hardly present in the CDA and slightly
SDA groups, while reduction of posterior support led
to more contacts. Also, age was associated with the
number of occlusal contacts on incisors. An increase
of vertical overlap was observed in several extensive
SDA categories. Thus, gross shortening of the dental
arch induces larger vertical overlap. The question of
whether increase in overlap is masked by increased
wear of the incisal edges arises.
From the low frequency of mobile teeth, it appears
that reduction of posterior support is not associated
with excessive breakdown of periodontal support.
This is in accordance with findings in the above-cited
study.10 It was suggested that in SDA, the tongue
might fill the space between the edentulous ridge and
unopposed teeth, preventing clinically relevant overe-
ruption of those teeth by pressing against their occlusal
surfaces. This mechanism is not expected in inter-
rupted dental arches, since the tongue cannot be
placed in the edentulous gap. In the present study,
most subjects with SDA had unopposed teeth with
substantial overeruption. Arguments for this unex-
pected observation are that the majority of subjects
may have started with interrupted arches at a younger
age, which might increase the risk for overeruption.20
Also, gradual tooth destruction by occlusal caries
may have initiated compensatory overeruption of op-
posing teeth. Despite the observed overeruption, al-
most no subjects reported hindrance of oral function.
The findings on the parameters used in this study
only partially confirm the proposed hypothesis that a
decrease of occluding pairs of posterior teeth constitutes
a risk to occlusal stability. Changes in stability were as-
sociated with extreme types of SDA, while there was
no evidence that this is also valid for moderate types
of SDA (intact anterior and premolar regions). This
supports the treatment goal of the WHO aiming to
maintain a natural functional dentition of not less than
20 teeth for life. As age is negatively associated with
changes in occlusal stability, moderate types of SDA
at a young age are potentially disadvantageous.
Acknowledgments
This study was supported by the University of Nijmegen, The
Netherlands; Muhimbili University College of Health Sciences, Dar
es Salaam, Tanzania; WHO Collaborating Center, College of
Dental Sciences, Nijmegen, The Netherlands; and the Netherlands
Foundation for the Advancement of Tropical Research.
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Literature Abstract

Appositional bone formation in marginal defects at implants. An experimental

study in the dog.

This experiment evaluated the degree and quality of de novo bone formation and osseointegra-
tion in marginal defects adjacent to submerged titanium implants. All mandibular premolars and
molars were extracted in four Labrador dogs. Four experimental sites were identified in the right
side of the mandible. In two sites (control), custom-made implants with a sandblasted, large-grit,
acid-etched surface were placed according to the manual of the ITI system. In the two remaining
test sites, a specially designed step drill was used to widen the marginal 5 mm of the canal. A
barrier membrane was used after implant placement. All implants were submerged. One month
later, an identical procedure was performed in the left side of the mandible. Two months following
the first implant procedure, biopsies were collected. De novo bone formation started within the
walls of the surgically prepared defect. Bone-to-implant contact was first established in the apical
portion of the gap. This new bone tissue formation was in a coronal direction continuous with a
dense, nonmineralized “implant-attached” soft tissue, which also became mineralized to increase
the height of bone-to-implant contact from 1.7 mm at 1 month to 3.1 mm at 2 months. The results
suggest that healing of a wide marginal defect around an implant is characterized by appositional
bone growth (instead of contact osteogenesis) from the lateral and apical bone walls.

Botticelli D, Berglundh T, Buser D, Lindhe J. Clin Oral Implants Res 2003;14:1–9. References: 18.
Reprints: Dr Daniele Botticelli, Department of Periodontology, Faculty of Odontology, Box 450, SE 40530
Göteborg, Sweden. Fax: + (46) 31-773 3791. e-mail: daniele. boticelli@odontologi.gu.se—Tee-Khin Neo,
Singapore

The International Journal of Prosthodontics 380 Volume 16, Number 4, 2003

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