Journal of Craniomandibular Practice

ISSN: 0734-5410 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ycra19

Principles of Anterior Guidance: Development and

Clinical Applications

Clifford W. Fox D.D.S., Bernard L. Abrams D.D.S. & Asterios Doukoudakis

D.D.S.

To cite this article: Clifford W. Fox D.D.S., Bernard L. Abrams D.D.S. & Asterios Doukoudakis
D.D.S. (1983) Principles of Anterior Guidance: Development and Clinical Applications, Journal of
Craniomandibular Practice, 2:1, 23-30, DOI: 10.1080/07345410.1983.11677848

To link to this article: http://dx.doi.org/10.1080/07345410.1983.11677848

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Principles of Anterior Guidance:
Development and
Clinical Applications
Abstract

Occlusal concepts related to the anterior determinants of occlusion

have been evolving since the early days of modem dentistry. Many of
these theories have led dentists to treat natural dentitions using
techniques meant only for the construction of artificial dentures. This
can of course result in complications for the patient.
The advanced knowledge in the area of occlusion that is now
available has led most knowledgeable clinicians to a consensus of
opinion concerning criteria for a proper occlusion. Most agree that the
anterior teeth should disclude the posterior teeth in function in a
healthy dentition.
This article describes practical techniques for establishing and
reproducing this desired scheme of disclusion in the restored
dentition.

Clifford W. Fox, D.D.S.

Bernard L. Abrams, D.D.S.
Asterios Doukoudakis, D.D.S.

Clift'ord W. Fox, Jr., D.DS.

A graduate of the School of Dentistry at Ohio State University, Dr. Fox currently
maintains a full-time private practice in Akron, Ohio. He is also a consultant in restorative
dentistry at the Veterans Administration Hospital in Cleveland.
Dr. Fox is associate clinical professor at Case Western Reserve University School of
Dentistry, an assistant clinical professor at Ohio State University's Graduate Orthodontic
Department, and a member of the faculties of the Society for Occlusal Studies and the
L. D. Pankey Institute. He has presented postgraduate courses and clinics at universities in
many countries.
Dr. Fox is a fellow of the American and the International Colleges of Dentists and the
Academy of General Dentistry. He also belongs to the American Academy of Cranioman-
dibular Disorders, the American Equilibration Society, the American Prosthodontic
Society, the Pierre Fauchard Academy, and the International Academy of Gnathology.

DEC. '83-FEB. '84, VOL. 2, NO. I THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 23

OCCLUSION
Principles of Anterior Guidance:
Development and
Clinical Applications
urrent ideas of occlusion and masticatory dynamics
C are the result of an evolutionary process that proba-
bly originated in the theory of bilateral balanced occlu-
sion for complete dentures.
This theory evolved from Bonwill's 1 1854 comments
regarding the equilateral triangle, three point balance,
and lateral and protrusive movements, and from Von
Spee's 2 observations in 1890 of natural teeth function in
humans. Von Spee described how condylar movements
are synchronized with the occlusion of opposing teeth. He
also favorably compared the function of the human denti-
tion with the grinding jaw action of animals such as the
cow and the sheep, in contrast to the masticating activi-
ties of the carnivore.
Early Approaches
Von Spee's reference to the vertical overlap of the
cuspids was entirely overlooked for years. Because of this,
dentures were fabricated with the opposing teeth remain-
ing in contact during all eccentric movements of the
mandible.
Von Spee3 and Monson4 also proposed the spherical
concept, and they directed the dental profession toward
accepting the idea of a mechanically balanced occlusion.
Because this approach to fabricating complete dentures
appealed so much to dentists of that time, the same
24 DEC. '83-FEB. '84, VOL. 2, NO. 1
By Clifford W. Fox, D.D.S.
Bernard L. Abrams, D.D.S.
Asterios Doukoudakis, D.D.S.
principles were also applied for several decades to the
restoration of natural dentitions. While some of these
ideas are still followed today in denture construction,
these theories were found not to be successful when ap-
plied to natural teeth. When these principles were used in
the restoration of natural dentitions, numerous problems
were created. One such difficulty arose from establishing
excessively long mandibular lingual cusps, which then
introduced working interferences and caused trauma to
the supporting structures of the teeth.
The extensive influence of certain prosthodontists' and
periodontists' principles of occlusion gave impetus to the
growth of the theory of group function. This theory stated
that it was helpful to distribute occlusal forces to the
facial working inclines of the teeth and to remove all non-
working contacts so that horizontal stresses could be
evenly distributed. This approach was introduced mainly
as a method to help stabilize mobile, periodontally in-
volved teeth, but many practitioners felt that it could be
applied generally in restorative dentistry.
Current Theories
Although the group function approach may still be
useful in the treatment of teeth with severe periodontal
involvement, findings by D'Amico5, McCollum and
Stuart6 , Posselt7, and Guichet8 indicate that posterior
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
FOX, ABRAMS, DOUKOUDAKIS ANTERIOR GUIDANCE

teeth are not designed to resist horizontal stresses, but
function instead as vertical closure stoppers of the mandi-
ble and accept vertical stress better than horizontal. Elec-
tromyographic studies verify that the anterior teeth in
healthy occlusions immediately separate (disclude) the
posterior teeth in all excursive movements of the
mandible9 •
In 1961, D'Amico5 stated that cuspid function "is more
than a mechanical guidance of the mandible and man-
dibular teeth into centric occlusion.. .Shock contact of the
upper cuspids by the opposing mandibular teeth during
eccentric excursions causes transmission of periodontal
proprioceptive impulses to the mesencephalic root of the
fifth cranial nerve, which in turn alters the motor im-
pulses transmitted to the musculature. This involuntary
act lessens the tension of musculture, thus reducing the
magnitude of the forces being applied."
It appears from these statements that an engram or
"memory" is established in the nerves and muscles, and
this causes the teeth to avoid each other in any eccentric
movement. Posterior teeth should only touch at or near
Table J, Eccentric Oassification
Bicuspid-Type B
the maximum intercuspation position while they are in
function. If the natural overlap relation of the cuspids is
lost, eliminated, or not present, the practitioner should
assign the proprioceptive role of the cuspids to other of
the patient's teeth, preferably as close to the cuspids as
possible. This approach disagrees with the theories of
group function and bilateral balance, which state that
teeth are designed to function against each other and bear
the lateral load. This theory of disclusion states instead
that teeth are programmed by proprioception to miss
other teeth. This should help to prevent tooth migration,
fracture, and wear.
Types of Eccentric Disclusion
Using this approach, clinicians developed various
schemes for eccentric disclusion (straight lateral move-
ment). The need for consistent identification of the possi-
ble eccentric categories 10 led to the development of the
eccentric classification, shown in Table I. These
Partial Group FWICtion
Lateral-Cuspid

6-1rr-v-"~
"A" Contact
w~ "B"Contact
Cuspid-First Bicuspid

Cuspid-Type B Bicuspid-Type C

"B"Contact
"C" Contact Cuspid-First Bicuspid-Second
Bicuspid

Cuspid-Type C Progressive-First Bicuspid and Cuspid

!---l.

~'-
.
H. .~)..........~
,

"C" Contact

Progressive-Second Bicuspid-First
Bicuspid-Cuspid Group FWICtion

"A" Contact

DEC. '83-FEB. '84, VOL. 2, NO. 1 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 25

FOX, ABRAMS, DOUKOUDAKIS
classifications can be used in diagnosis and treatment
planning in order to maintain or improve the scheme of
disclusion.
In the healthy dentition, the most desirable results are
provided by cuspid disclusion. The most common forms
are types A and B. Where some type of cuspid disclusion
cannot be achieved, another scheme should be used, such
as (1) first bicuspid disclusion, or (2) progressive disclu-
sion involving the cuspid and the bicuspids. (Both of these
include a variety of choices.)
The straight lateral discluding movement is a border
movement that can be used as a test position by the
clinician, as can the straight protrusive movement. Any
movement of the mandible away from maximum inter-
cuspation that is within the confines of the area bounded
by the straight lateral and the straight protrusive move-
ments should ideally occur from cuspid to cuspid.
Anterior Guidance
Dawson has said, 11 "This dynamic relationship of the
lower anterior teeth against the upper anterior teeth
through all ranges of function is called the anterior guid-
ance."
In 1976 a group of occlusion specialists met in a special
Workshop on Occlusion Focus to examine theories of
occlusion and to establish requirements for acceptable
anterior guidance. (Many of their findings are reported in
Occlusion-the State of the Art. 12 ) The Workshop made
the following points regarding the requirements for an-
terior guidance and the function of anterior teeth:
I. In straight protrusive movement, the lower incisors
should contact the upper incisors and disclude the
posterior teeth.
2. In lateral protrusive movement, the lower incisors and
cuspids should contact the upper incisors and cuspids.
3. In straight lateral movement, only the cuspids should
be in contact. (However, if this is impossible to achieve,
use another discluding scheme described in the Ec-
centric Classification.)
4. In the centric relation occlusion position, anterior teeth
should miss each other slightly. However, if contact is
desired, the anteriors should be in a lighter contact
than the posteriors.
These requirements will satisfy the functional criteria
of anterior guidance. There are also other criteria that
should be met if anterior guidance is to be successful on a
broader level. These additional criteria are:
1. The esthetic appearance of the patient.
2. Acceptable phonetics.
26 DEC. '83-FEB. '84, VOL. 2, NO. 1
ANTERIOR GUIDANCE
This article has mainly discussed theories, but to be
successful these must be translated into practical
procedures that can be readily applied by clinicians.
Further philosophical discussion might be interesting, but
let us turn now to more practical considerations.
Anterior Guidance Methods
The following methods are currently being used for
establishing anterior guidance 13 :
I. Existing Method: This method is used when the
patient's teeth are healthy and satisfactory in terms
of esthetics and function. In this case the existing
form, position, and relationships of the anterior teeth
are maintained and duplicated (Figure 1).
Fig. I
The existing satisfactory form, position, and relationship of the anterior
teeth are duplicated for restoration.
2. Arbitrary Method: This describes the method in
which the anterior teeth are prepared with no
thought to their final position, relationship, and
form. The restorations are arbitrarily completed on
the articulator and then adjusted in the mouth. This
approach frequently leads to poor esthetics with
weak phonetics and function, and it may contribute
to occlusal disharmony. For these reasons, we cer-
tainly do not advocate this method (Figure 2).
3. Articulator Method: This approach makes use of a
fully adjustable articulator. Posterior determinants
are set on the articulator using a recording device,
and diagnostic casts are mounted in centric relation.
The anterior teeth are equilibrated and/or waxed to
the desired form on the casts, so that esthetics and
proper disclusion of the posterior teeth are obtained.
Using the equilibrated andfor waxed teeth, a cus-
tomized anterior guide table is then made from the
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
FOX, ABRAMS, DOUKOUDAKIS
Fig. 2
The anterior teeth have been prepared and casts mounted on the
articulator. In this arbitrary approach, a laboratory technician will
unfortunately attempt to complete restorations without further
information.
articulated casts, using self-polymerizing acrylic
resin. At a later stage, master casts are mounted in
the same position as the original casts. The case is
then completed on the articulator, using the
posterior and anterior determinants captured pre-
viously (Figure 3).
4. Direct Method: With this method, the anterior teeth
or provisional restorations are equilibrated or added
to directly in the mouth (Figure 4). The practitioner
must establish proper relationships in them for
centric occlusion, eccentric positions, esthetics, and
phonetics. When these relationships are satisfactory,
they should be transferred to the articulator by
duplicating casts so that a customized anterior guide
Fig. 3
A customized anterior guide table is generated from articulated modi-
fied casts, using the articulator method.
DEC. '83-FEB. '84, VOL. 2, NO. 1
ANTERIOR GUIDANCE
Fig.4
The anterior teeth have had composite acid-etching to the lingual
enamel. They are equilibrated for the function, esthetics, and phonetics
that are desired, and they are ready to be duplicated for mounting on
the articulator.
table can be fabricated. An anterior index should be
made so that the lingual concavity, incisal length
and position, and tooth width may be duplicated. 14
Making the Anterior Index
The anterior index can be used in any of the above
methods. It can be easily made by the following
procedure:
I. Mix a silicone putty and form it into a rope 3f 4 inch
in diameter.
2. Place the putty rope on the incisal and occlusal
surfaces of the articulated mandibular cast and form
it so that it locks into the lingual areas (Figure 5).
3. Then lower the maxillary cast into the putty until
tooth contact or the incisal guide pin establishes the
desired vertical dimension.
4. Next form the putty around the labial and lingual
surfaces of the maxillary anterior teeth (Figure 6).
5. After the putty has set, remove the labial section of
the putty with a scalpel, leaving the incisal edge
intact (Figure 7).
6. Articulate the master model of the prepared teeth
and wax the crowns to the index. (Lubrication is not
needed.) The index dictates the lingual concavity
and incisal length, width, and position (Figure 8).
Using the anterior index as a guide, copings or a
metal framework can be waxed in an acceptable
form. After casting and metal finishing, the index is
then used as guide for the accurate placement of the
veneering material. The labial contours may be
formed by direct observation or by using the sec-
tioned labial portion of the index.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 27
FOX, ABRAMS, DOUKOUDAKIS ANTERIOR GUIDANCE

Fig. 5 Fig. 8
A rope of silicone putty is placed on the incisal and occlusal surfaces of The crowns are waxed to the index in an acceptable form. The veneer-
the mandibular cast and is locked into the lingual area. ing material is then added, with the index being used as a guide for
accurate placement.

Goals of Anterior Guidance

Using one of the accepted methods for establishing

anterior guidance should help the practitioner reach the
following goals:
I. From cuspid to cuspid the anterior teeth should just
miss in centric relation occlusion. Artus Shim stock*
0.0005 inch should hold in the posterior segments
and just pull in the anterior segment (Figure 9). In
certain conditions, such as when there is no posterior
support, it may be necessary to have anterior
contact.
Fig.6 2. The cuspids should immediately disclude the
The maxillary cast is closed into the putty formed around the labial and posterior teeth in lateral movements.
lingual surfaces of the maxillary teeth.
3. The maxillary central, lateral, and cuspid teeth may
disclude the posterior teeth in latero-protrusive
movement.
4. The maxillary centrals should disclude the posterior
teeth in straight protrusive movements. However, in
some cases disclusion may be delegated. to the
centrals and the laterals and possibly the cuspids.
5. Freedom should be provided in the "feeding posi-
tion," as Norman Mohl 15 advocates. To accomplish
this, first mark with dental tape the anterior tooth
contacts in guided centric relation occlusion or
centric occlusion. Then seat the patient upright in
the dental chair with his or her head tilted down at
an angle of 30 degrees from horizontal. Next in-
struct the patient to make several unguided closures
to maximum intercuspation while you mark them
Fig. 7
The labial section of the set putty is removed with a scalpel, leaving the with different color tape. The marks made by the
incisal edge intact. second tape will usually be anterior to the first set of

28 DEC. '83-FEB. '84, VOL. 2, NO. I THE JOURNAL OF CRANIOMANDIBULAR PRACTICE

FOX, ABRAMS, DOUKOUDAKIS
Fig. 9
Shim Stock 0.0005 inch is used to adjust the occlusion so
that the anterior teeth just miss contact in centric relation
occlusion.
centric occlusion marks and should be hollow
ground. This will allow the patient's teeth to be free
from contact on unguided closure to maximum in-
tercuspation (Figure 10).
6. The anterior teeth should be esthetically pleasing
and should feel natural to the patient.
7. The patient should be able to speak naturally, with-
out any undue effort. To check this, use the F-S
positions described by Earl Pound 16•
8. The anterior teeth should not have any fremitus.
Fig.IO
Freedom in the Mfeeding position" is provided by hollow
grinding between the color tape marks made in unguided
closures and those made in guided centric relation
occlusion.
•Anus Corporation,lnglcwood, New Jcncy.
DEC. '83-FEB. '84, VOL. 2, NO. I
ANTERIOR GUIDANCE
Summary
This article has presented a review of changing oc-
clusal concepts as related to the anterior determinants of
occlusion. Methods for achieving good clinical results are
also described. We hope that practitioners will become
familiar with these ideas and techniques, so that our
profession's approaches to occlusal problems will con-
tinue to evolve and improve.
R~print requ~su to:
Dr. C/ifford W. Fox
175 East Wat~r/oo Road
Akron. OH 44319
References
I. Bonwill, W. G. A. The significance of the equilateral triangle.
J lttms lnttrtst 1899; 21:636.
2. Von Spec, F. G. Condylar path of the mandible in the glenoid fossa.
J So Cat Dent Assoc 1960; 28:318-338.
3. Von Spec, F. G. Die verschiebungsbahn des unterkiefers ann
schodel. Arch F Anat U Physio/1980.
4. Monson, G. S. Occlusion as applied to crown and bridge work.
JADA 1920; 7:399.
5. D'Amico, A. Functional occlusion of the natural teeth of man.
J Prosthtt Dent 1961; 11:899-915.
6. McCollum, 8.8., and Stuart, G. E. A Rtstarch Rtport. South
Pasadena, California: Scientific Press, 1955.
7. Posselt, U. Physiology of Occlusion and Rthabilitation. London:
Blackwell Scientific Publications, 1973.
8. Guichet, N. F. Occlusion. Anaheim, California: Denar Corporation,
1977.
9. Williamson, E. JCO/interviews Dr. Eugene H. Williamson on occlu-
sion and TMJ dysfunction. J Clin Orthod 1981; 15:333-350.
10. Fox, C. W., Ruzicka, S. J., and Abrams, B. L. Teaching Syllabus
for Advanced Rtstorativt Stminar. Orange, California:
Society for Occlusal Studies, 1980.
11. Dawson, P. E. Evaluation, Diagnosis and Trtatmtnt of Occlusal
Problems. St. Louis: The C. V. Mosby Company, 1979.
12. Celenza, F., and Nasedkin, J. Occlusion-tht Statt of tht Art.
Chicago: Quintessence Publishing Company, 1978.
13. Fox, C. W., and Ruzicka, S. J. Syllabus and Occlusion Manual for
Occlusion I and 11. Cleveland, Ohio: Case Western Reserve
University School of Dentistry, 1973.
14. Occlusal Trtatmtnt Planntr, Slidt Chart. Anaheim, California:
Denar Corporation, 1978.
15. Mohl, N. D. Head posture and its role in occlusion. NY Statt Dent
J 1976; 42:17-23.
16. Pound, E. The mandibular movements of speech and their seven
related values. J So Cal Dent Assoc 1966; vol. 34.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 29
FOX, ABRAMS, OOUKOUDAKIS ANTERIOR GUIDANCE

Bernard L Abra.m, D.D.S.

Dr. Abrams graduated from the Ohio State University School of Dentistry in 1943.
Following graduation he served with the U.S. Army Air Force in Europe.
Dr. Abrams is currently an associate professor of dentistry at Case Western Reserve
University School of Dentistry, where he is also chairman of the Department of
Comprehensive Dental Care. He is a fellow of the American College of Dentists and the
International College of Dentists, and he is a director of the Society for Occlusal Studies.
Dr. Abrams has published articles and chapters in books on various clinical subjects. He
has also presented table clinics and lectures in many areas of the U.S.

Asterios Doukoudakis, D.D.S.

Dr. Doukoudakis received his D.D.S. degree in 1976 from the School of Dentistry at the
University of Athens in Greece. He then obtained an M.S. degree and a Certificate in
Fixed Prosthodontics from the University of Iowa College of Dentistry. He is presently an
associate professor at Case Western Reserve University SChool of Dentistry in the
Department of Fixed Prosthodontics.
Dr. Doukoudakis has published numerous articles in the fields of prosthodontics and
occlusion. He is a member of the American Academy of Crown and Bridge, the American
Equilibration Society, the Federation Dentaire lnternationale, the Society for Occlusal
Studies, the Pierre Fauchard Academy, the International Association of Dental Students
(life member), and the Hellenic Stomatological Society. Dr. Doukoudakis was recently
appointed editor of the Compendium of the American Equilibration Society.

30 DEC. '83-FEB. '84, VOL. 2, NO. 1 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE