The six keys to normal occlusion Lawrence F. Andrews, D.D.S. San Diega, Nhe article will discuss six significant characteristics observed in « study of 120 casts of nonorthodontic patients with normal oeelusion, These constants will be referred to as the “six keys to normal oeclusion,” The article will also diseuss the importance of the six keys, individually and collectively, in successful orthodontic treatment, Orthodontists have the advantage of a classic guideline in orthodontic diag- twsis, that ix, the {given te the speeialty a half-century ago by Angle that, as a sine qua non of proper occlusion, the ensp of the upper first perma. nent molar must oeelude in the groove between the mesial and middle buceal cusps of the lower first permanent mola: But Angle, of course, had not contended that this factor alone was enough, Clinieal experience and observations of treatment exhibits at national meetings and elsewhere had incrensingly pointed to a corollary fact—that even with respect to the molar relationship itself, the po ing of that © | mesiobwe- eal eusp within that specified space could he inadequate. Too many models dis- playing that vital cusp-embrasnre relationship had, even after orthodontic treatment, obvious inadequacies, despite the acceptable molar relationship as deseribed by Angle, Recognizing conditions in treated cases that were obviously leas than ideal was not diffeult, but neither was it sufficient, for it was subjective, impression- istic, and merely negative. A reversal of approach seemed indieated|: a deliberate seeking, first, of data about what was significantly chwracteristic in models whieh, hy profesional judgment, needed ee orthodontic treatment. Sach data, if systematically reduced to ordered, coherent paradigms, could constitute a group of referents, that is, basie standards against whieh deviations could be recognized and measured, The concept was, in brief, that if one knew what con- stituted “right,” he could then direetly, consistently, and methodically identify and quantify what was wrong. A gathering of data was begun, and during # peried of four years ( 1964), 120 nonorthodentic normal models were aequired with the coopera 296 i) toFone 92 Six keys to normal occlusion 297 of loral dentists, orthodontists, and a major university, Models selected were of teeth whieh (1) had never had orthodontic treatment, (2) were straight and pleasing in appearanee, (3) had a bite which looked generally eorrect, and (4) in my judgment would not benefit from orthodontic treatment. The ereens of this multisonree collection were then studied intensively to ascertain whieh characteristics, if any, would be found consistently in all the models, Some the took form but soon had to be discarded; others required modification and then survived. Angle's molar cusp groove concept was vali- dated still again. But there was growing realization that the molar relationship in these healthy normal models exhibited two qualities when viewed buceally, not Just the classi¢ one, and that the second was cqu Other findings emerged, Angulation (mesiodistal tip) and inelination (labio- lingual or buceolingual inelination) began to show predictable matures as re lated to individual tooth types. These 120 non-orthodontic normals had no rota- tions, There were no spaces between teeth. The occlusal plane was not identical throughout the battery of examples but fell neatly into so limited a range of variation that it clearly was a differential attribute, Tentative conclusions were hed, and six charucteristics were formu- lated in general terms. However, s return was needed now to the complemen- tary bank of information made available by many of this nation’s most skilled orthndontists—the treated eases on display at national meetings, Eleven hundred fifty of these e ied, from 1965 te 1971, for the purpose of learning to what degree the six characteristics were present and whether the absence of any one permitted predietion of other error factors, such as the existence of Spaces or of poor posterior oeclusal relations. Ameriean orthodontic treatment can be considered to he about the finest in the world. Most of our leaders in this field spent 10 or 15 years in suc- cessful practice hefore submitting their work at these national meetings. There can be no disparagement of their competcney. The fact that some range of excellence was found within the 1,150 models implies no adverse eritieism; instend, that finding simply reflected the present state of the art, Few would elaim that orthodonties, even on the high level seen at the meetings, has reached its ultimate development, Last to make such o claim would be the masters whose work is there displayed for closest serutiny by pects as well as hy neophytes. Having long sinee benefited from the good examples offered by such men, Tat this point in the research assumed that a comparison of the best in treat- ment tesults (the 1,150 trented cases) and the hest in nature (the 120 nonortha- dontic normals) would reveal differences which, onee systematically identified, could provide significant insight on how we could improve ourselves ortho- dontieally, Delibera we sought those differences, The six keys The six differential qualities were thus validated. They were established as meaningful not solely because all were present in each of the 120 menortho- dontie normals, but also because the lack of even one of the six was a defeet end result in treated models, predictive of an incom298) Andrews Fig. 1. Improper molar relationship. ments involved and ters will be reported Subsequent work elaborated and refined the measu provided statistical analysis of the findings. These 1 in future papers. For the present article, # summary is offered chiefly in verbal form, The significant characteristies shar rt the ae Jontie normals. 1 by all are as follows: 1. Molar relationship. The distal surface of the distobue cusp of the upper first permanent molar made contact. and occluded with the mesial surface of the mesiobueeal cusp of the lower second molat The mesiodistal cusp of the upper first permanont molar fell within the groove between the mesinl and middle eusps of the lower first permanent molar, (‘The eunines and premolars enjoyed a eusp-embru- sure relationship buceally, and a cusp fossa relationship lingually.) 2. Crown angulation, the mesiedastal “tip” (Fig. 4), In this artiele, the term crews angulation refers to angulation (or tip) of the long axis of the erewm, not to angulation of the long axis of the ire tooth. As orthodontists, we work sperifieally with tho erowns of teeth and, therefore, erowns should be our communication hase or referent, just as they are our elinieal base. The gingival portion of the long axis of each erown was distal to the incisal portion, varying with the individual tooth type. The long axis of the crown for all teeth, except molars, is judged to he the middevelopmental ridge, whieh is the most prominent i centerminst vertical portion of the labial or buccal surface of the crown. The long axis of the molar crown is iden- tifled by the dominant vertical groove on the buccal surface of the erown, 4, Crown inclinetion (labiolingual or bueeolingual inelination). Crows inefination refers to the Jabiolingual or buceolingual inclination of the long axis of the crown, not to the inclination of the long axis ofPelente tt Sic keys to normal occlusion 299 the entire tooth, (See Fig. 6.) The inelination of all the erowns had a consistent scheme: AL ANTERIOR TRETH (CENTRAL AND LaTkea, tNerons); Upper and lower anterior crown inclination was sufficient to resist overerup- tien of anterior teeth and sufficient also to allow proper distal positioning of the contact points of the upper teeth in their rela- tionship to the lower teeth, permitting proper ocelusion of the posterior crowns, B, UPrer POSTERIOR TEETH (CANINES THROUGH woLans): A lingnal erawn inclination existed in the upper posterior crowns, It was constant and similar from eunines through the second pre- molars and was slightly more pronouneed in the molars. LOWER DOSTHROR (CANINES THROUGH MOLARS). The lingual erown inclination in the lower posterior teeth progressively inereased from the canines through the second molars, 4. Rolations. There were no rotations. 5. Spaces. There wore no spares; contact points were tight, 6. Ocelusal plane. The plane of oeelusion varied from generally flat to u slight eurve of Spee. The six keys to nermal ocelusion contribute individually and collectively to the total scheme of occlusion and, therefore, are viewed as essential to suc~ ecasful orthodontic treatment. Key f, Molar relationship. The first of the six keys is molar relationship. The novorthodontic normal models consistently demonstrated that the distal surface of the distobuecal eusp of the upper first permanent molar oceluded with the mesial surface the mesiobuceal ensp of the lower second molar (Fig. 1). Therefore, one must question the sufficieney of the traditional de- scription of normal molar relationship, As Fig. 2, 1 shows, it is possible for the mesiohueecal eusp of the upper first year molar to ovelude im the groove between the mesial und middle ew f the lower first permanent molar (os sought by Angle} while leaving a situa The « manent molar approaches the m C. wer the distal surface of the distobuceal eusp of the upper first per- surfaces of the mesiobuecal eusp of the lower second molar, the better the opportunity for normal oeelusion (Fig. 2,2, 4, 4). Fig. 1 and Fi d exhibit the molar relationship found, without exception, in every one of the 120 nonerthodontic normal models; that is, the distal surface of the upper first permanent molar contacted the mesial surface of the lower second permanent molar. Key TL Crown angulation (tip), The gingival portio long axes of all erowns was more distal than the incisal portion (Fig. ig. 4, crown tip is expressed in degrees, plus or minus. Tho degree of crown tip is the angle between the long axis of the erown (as viewed from the labial or bueeal sur- fare) and a line bearing 10 degrees from the occlusal plane. A “plus reading” is awarded when gingival portion of the long axis of the erown is distal to the incisal portion. A “minus reading” is assigned when the gingival portion of the long axis of the crown is mesial to the incisal portion.300 Andrews anos Fig. 2. 1, Improper molar relationship. 2, Improved molar relationship, 3, More improved molar relationship, 4, Proper molar relationship. Bach nonorthodontie normal model hud a distal inelination of the gingival portion of each erown; this was a eonstant, It varied with each tooth type, but hin each type the pattern was consistent from individual to indi- vidual (quite as locations of contact points were found by Wheeler, in An Aflas of Toath Form, to be consistent for cach tooth type). Normal occlusion is dependent upon proper distal erown tip, especially of the upper anterior teoth since they have the longest crowns. Let us consider that i teetangle neeu wider space when tipped than when upright (Fig. 5). Thus, the degree of tip of incisors, for example, determines the amount of moesiodistal space they consume and, therefore, has a considerable effect on posterior occlusion as well as anterior esthetics. Key HY, Crown inclination flabiolingual or bucoolingwal inclination). The third key to normal oeelusion is crown inclination ( In. this: article, erown inclination is expressed in plus or minus degrees, representing the angle formed by a line which bears ) degrees to the occlusal plane and a line that isyi Sic keys to normal ocelusia Number a Sic keys t mat occlusion 301 Fig. 3. Normally occluded teeth demonstrate gingival portion of crewn more distal than ncclusal portion af crown. (After specimen in possession of Dr. F, A. Peso, from Turner Amorican Textbook of Prosthetic Dentistry, Philadelphia, 1913, Lea & Febiger,} Fig. 4, Crown angulation (ripl—iong oxis of crown measured fram line 90 degrees to occlusal plane. tangent te the bracket site (which is im the middle of the labial or bueeal long axis of the clinical erown, as viewed from the mesial or distal), A plus reading is given if the gingival portion of the tangent line (or of the erown) is lingual ti the incisal portion, as shown in Fig. 6, A, A minus reading is reeorded when the gingival portion of the tangent line (or of the crown) is labial to the incisal portion, as illustrated in Fig. 6, B AL ANTERIOR CROWN EXCLESATION, Upper and lower anterior erown inelina- tions are intricately complementary and significantly affect overbite and pos. terior ovelusion, Properly inelined anterior erowns contribute to normal over- bite and posterior oeclusion, when too straight-up and -down they lose their302 Anderies sopteinuer td Fig. §. A rectangle that Is angulated occupies more mesiodistal space than o nonangulated rectangle (thet is, upper central and lateral incisors). Fig. & Crown inclination is determined by the resulting angle between a line 90 degrees ta the acclusal plane and a line tangent to the middle of the labial or buccal clinical crown, functional harmony and overeruption results. In Fig. 7, A the upper posterior crowns are forward of their normal position when the upper anterior erowns are insufficiently inclined. When anterior crowns are properly inelined, as on the overlay of Fig. 7, 8, one can see how the posterior teeth are encouraged into their normal positions. The contaet points move distally in concert with the increase in positive (+) upper anterior crown inclination.Sir keys to normal occlusion 303 Fig. 7. A, Improperly Inclined anterior crowns result in all wpper contact points being masial, loading to improper occlusion, B, Demonstration, on on overlay, that when the anterior crowns are properly inclined the contact points move distally, allowing for normal occlusion, Even when the upper posterior teeth are in proper occlusion with the lower posterior tecth, undesirable spaces will result somewhere between the anterior and posterior teeth, as shown in Fig, 8, if the inclination of the anterior erowns is not sufficient. This space, in treated cases, is often incorrectly blamed on tooth size discrepancy. B, POSTERION CROWN INCLINATION—UPrek. The pattern of upper posterior erown inclination was consistent in the nonorthodontie normal models. A minus304 Andrews sapien tS Fig. 8. Spaces resulting fram normally secluded posterior teeth and Inaufficiently inclined onterior teeth are often falsely blamed on tooth size descrepancy. erown inclination existed in each crown from the upper canine through the upper second premolar. A slightly more negative crown inclination existed in the upper first and second permanent molars (Fig. 9). ©. POSTERIOR CROWN INCLENATION—LOWER, The lower posterior crown inelina- tion pattern also was consistent among all the nonerthodontie normal models. AA progressively greater “minns” erown inclination existed from the lower canines through the lower second molars (Fig. 10). Tip and torque. Before continuing to the fourth key to normal occlusion, let us more thoroughly discuss a very important faetor involving the elinieal amplications of the sceond and third keys te occlusion (angulation and inelina- tion) and how they collectively affeet the upper anterior crowns and then the total occlusion, As the anterior portion of an upper rectangular arch wire is lingually torqued, a proportional aomunt of mesial tip.of the anterior crowns occurs. If you ever felt you were losing ground in tip when increasing anterior torque, you were right. To better understand the mochanies involved in tip and torque, let us pie- ture an unbent rectangular arch wire with vertical wires soldered at 90 degrees, spaced to represent the upper central and lateral incisors, as in A and B of Fig. 11, As the anterior portion of the arch wire is torqued lingually, the vertical wires begin to converge until they become the spokes of a wheel when the arch wire is torqued (4) degrees as progressively seen in Fig, 11, 0, D, and BE. The ratio is approximately 4:1. For every 4 degrees of lingual crown torque, there is 1 degree of mesial convergence of the gingival portion of theSiz heys te worniel occlusion 305 Fig. 9 Fig, 10 Fig. 9. A lingual crown inclination generally eccurs in normally occluded upper poster crowns. The inclination is constant and similar from the canines through the second. pr molars and slightly more pronounced in the molar Fig. 16. The lingual crown inclination of normally occluded lower posterior teeth pragres- sively Increases from the canines through the second molors. Land late rqued 20 deg nt 5° om age distal tip of th 0 degrees distal tip in the arch wire to tip of the crown, This mechanical problem ean be greatly eased if tip and torque are constructed in the brack rather than the arch wire. Hey IV, Kotations, The fourth key 10 normal ocelusion is that the should be free of undesirable rotations. ple of th i Fig. 12, a superimposed molar outlir we how the would arenpy more space than normal, cresting a situation unreceptive to ns, For example, as in al in h eertr ‘ees In the area of the rentr id Jateral incisor. In that ld then he neeessar omplish # clinical to place An exa ini Key V. Tight contacts. The fifth key is that the contact points should be tight (no spaces). Persons who have genuine tooth-size diserepancies pose special problems, but in the ahsence of such abnormalities tight ntact shoule exist, Without exception, the contact points on the nonorthodontie normals were tight. (Serious tonth-size discrepancies should be corrected with jackets sion306 Fig. 11. The wogon wheel. Anterior orch wire torque negates arch wire tip in a ratio of four to ore. or crowns, 8 the orthodontist will not have to close spaces at the expense of good ovelu: Key V. tie normal L curves of Spee. Even though not all of the nor ie normals had flat planes of ocelusion, T believe that a flat plane should be is a@ form of overtreatment, There is a natural tendeney for the curve of Spee to deepen with time, for the lower jaw's growth downward and forward sometimes is faster and continues longer than that of the upper jaw, and this causes the low iterior teeth, which are confined by the upper anterior teeth and lips, to be foreed back and up, result thineFolume 6 Siz keys to normal occlusion 307 Fig. 12, A rototed molar eccupies more masiodistal space, creoting o situotion unreceptive to normal occlusion. ing in crowded lower anterior teeth and/or a deeper overbite and deeper curve of Spee. At the molar end of the lower dentition, the molars (especially the third molars) are pushing forward, even after growth has stopped, creating essen- tially the same results, If the lower anterior teeth can be held until after growth has stopped and the third molar threat has been eliminated by erup- tion or extraction, then all should remain stable below, assuming that treat- ment has otherwise heen proper, Lower anterior teeth need not he retained after maturity and extraetion of the third molars, except in eases where it was not possible to honor the maseulature during treatment and those cases in which abnormal environmental or hereditary factors exist. Intercnspation of teeth is best when the plane of oeclusion ix relatively flat (Fig. 13, #). There is a tendency for the plane of ocelusion to deepen after treatment, for the reasons mentioned. It seems only reasonable to treat the plane of occlusion until it is somewhat flat or reverse to allow for this tendency, Tn most instances one must hand the seeond permanent molars to get an effee- tive foundation for leveling of the lower and upper planes of ocelusion, A deep curve of Spee results in a more contained area for the upper teeth, making normal ceclusion impossible. Im Fig, 13, A, only the upper first premolar is properly intereuspally placed. The remaining upper teeth, an- terior and posterior to the first premolar, are progressively in error,308 Andrews Fig. 13. A, A deep curve of Spee results in a more confined area for the upper teeth ing spillage of the upper teeth progressively mesially and distally. 8, A flat plane of nis most receptive to normal occlusion, €, A reverse curve of Spee results in exces- sive room for the upper teath, ment, allowing cy overtres i (Fig. 1 Spee is an extreme form h. tooth to be intereuspally p! A reverse ave ‘or exressive space Conclusion and comment are as one of a kind as snowflakes, they meverthe- 120 nonortho- Although normal persar less have muck in common. (one he ad, two arms, two legs, ete,). Thimbertt Six keys to warmal ocelusion 309 dontie normal models studied im research differed in some respects, but all shated the six characteristics desevibed in this report. The abienee of any one or more of the six results in occlusion that is proportionally less than normal, Tt is possible, of course, to visualize and to find models which have deficien- eies, such as the need for caps, preventing proper contact, but these are dental problems, not orthodontic ones, Sometimes there are compromises to be weighed, and these pose the true ehullenge to the professional judgment of the ortho dontist. As responsible specialists, we are here to attempt to achieve the maxi- mum possible benefit for eur patients, We have no better example for emula- tion than nature's best, und in the absenes of an abnormality outside our control, why should any compromise be accepted! Sueecssful orthodonti Wimont invalves many disciplines, not all of which are always within our control, Compromise treatment is aceept- able when patient cooperation or geneties demands it. Compromise: treatment should not be aceeptable when treatment limitations do not exist, In that na- ture's nonorthadontic normal models provide sueh a beautiful and consistent guideline, it seems that we should, when poss let these guidelines be our measure of the static relationship of successful orthodontic treatment. Achiey- ing the final desired oselusi the purpose of attending to the six keys to normal ocelusion. REFERENCE 1. Wheelr, R. C2 An atlas of tooth form, ed, 4, Philadelphia, 169, W, B, Saunders Company, The commen nermal peculiarity of childhood plysiognamies, between the ages from six to twelve, is thar of a slight protrusion of the upper and lower lips in relation to the other undeveloped features. By association, we intuitively and unconsciously accept this ap- pearance in late childhood and early youthhood without a thought of facial imparfection, And yel were we to analyze the facial outlines of these young people from the artistic vlewpoint of the adult perfect outlines, we would find thar a large proportion are similar to those which If seen in odult life would be truthfully denominated bimaxillary protrusion. (Case, Calvin S.: Dental Orthopedia and Correction of Cleft Palate, ed. 2, Chicago, 1921, BR. Donnelley & Sons, p. 36.)