SYSTEMATIC REVIEW

Clinical performance of and patient satisfaction with

conventional complete dentures with different occlusal
schemes: A systematic review of systematic reviews
Maria Helena Rossy Borges, DDS,a Luís Fernando Bandeira Miranda, DDS, MSc,b Caroline Dini, DDS, MSc,c
Guido Artemio Marañón-Vásquez, DDS, MSc,d Marcela Baraúna Magno, DDS, MSc, PhD,e
Lucianne Cople Maia, DDS, MSc, PhD,f and Valentim A. R. Barão, DDS, MSc, PhDg

ABSTRACT
Statement of problem. The complete denture occlusal scheme may influence clinical performance and patient satisfaction. However, a
consensus on which occlusal scheme should be used for complete denture users is lacking. As a result, many dentists choose the scheme
based on their preferences and clinical experience.
Purpose. The purpose of this review was to assess the methodological quality and summarize the scientific evidence from secondary studies
about the influence of occlusal schemes on the clinical performance of and patient satisfaction with complete dentures.
Material and methods. Ten sources were surveyed according to the patient, intervention, comparison, outcome (PICO) strategy. Systematic
reviews that evaluated the clinical performance and patient satisfaction (O) of rehabilitated edentulous patients with conventional complete
dentures (P) under different occlusal schemes (I/C) were included. Methodological quality was assessed by using A MeaSurement Tool to
Assess systematic Reviews (AMSTAR) 2 tool by 2 authors independently. The effect of each occlusal scheme in comparison with others
was summarized and classified as positive, neutral, negative, or inconclusive based on the conclusions of the systematic review
concerning clinical performance and patient satisfaction outcomes.
Results. The search led to the inclusion of 10 systematic reviews. Seven were classified as of critically low, 2 as low, and 1 as moderate
methodological quality. The following occlusal designs were included and analyzed: bilateral balanced occlusion, lingualized occlusion,
canine guidance, group function, and monoplane occlusion. Bilateral balanced occlusion and canine guidance obtained satisfactory results
for both outcomes. Lingualized occlusion showed a trend toward better results than other occlusal schemes for normal and resorbed
ridges. Group function presented mainly inconclusive results, and monoplane occlusion did not deliver satisfactory outcomes.
Conclusions. The present overview concluded that occlusal schemes might interfere with the clinical performance of and patient satisfaction
with complete dentures. Lingualized, bilateral balanced, and canine guidance are preferred compared with monoplane occlusion, but
lingualized occlusion tends to show better results in some reviews. However, the results should be carefully considered because of the
low quality of the systematic reviews included. (J Prosthet Dent 2021;-:---)

Supported by the São Paulo Research Foundation (FAPESP) (grant number: 2020/07087-8), the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)
(finance code 001), and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (grant number: 304853/2018-6). The authors declare no conflict of
interest to disclose. Presented at the IADR Brazilian Division in an online meeting on September 10, 2021.
a
Masters’ degree student, Piracicaba Dental School, University of Campinas (UNICAMP) Piracicaba, São Paulo, Brazil.
b
PhD Candidate, Piracicaba Dental School, University of Campinas (UNICAMP) Piracicaba, São Paulo, Brazil.
c
PhD Candidate, Piracicaba Dental School, University of Campinas (UNICAMP) Piracicaba, São Paulo, Brazil.
d
PhD Candidate, School of Dentistry, Federal University of Rio de Janeiro (UFRJ) Rio de Janeiro, Brazil.
e
Postdoctoral Fellow, School of Dentistry, Federal University of Rio de Janeiro (UFRJ) Rio de Janeiro, Brazil.
f
Professor, School of Dentistry, Federal University of Rio de Janeiro (UFRJ) Rio de Janeiro, Brazil.
g
Associate Professor, Piracicaba Dental School, University of Campinas (UNICAMP) Piracicaba, São Paulo, Brazil.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
The choice of occlusal scheme influences the clinical
performance of and patient satisfaction with
complete dentures. Although bilateral balanced
occlusion has been traditionally used, lingualized
occlusion tends to show better results for clinical
performance and the satisfaction of complete
denture users with normal or resorbed ridges.
The choice of the occlusal scheme influences the clinical
performance of and patient satisfaction with complete
denture.1 Furthermore, an unfavorable occlusal scheme
has been reported to impair the stomatognathic system
and induce emotional disturbances and discomfort.2 In
addition, physiological conditions such as ridge shape
and height could influence the choice of occlusal
scheme.3,4 Therefore, a suitable occlusal scheme is critical
for successful complete dentures.5
Occlusal schemes that have been proposed for complete
dentures include bilateral balanced, lingualized, canine
guidance, group function, and monoplane. These occlusal
schemes differ from each other regarding the position of the
teeth in the arch, the cusp morphology (anatomic, semi-
anatomic, or nonanatomic), and the tooth relationship
during mandibular movements.6-10 However, the superi-
ority of one occlusal scheme over others is still unclear.11-13
As a result, many dentists choose the occlusal scheme
based on their preferences and clinical experience.
The clinical performance and patient satisfaction of
complete denture users with different occlusal schemes
have been investigated.2,14-16 In addition, systematic re-
views have compiled study results and provided data to
support evidence-based clinical procedures.6,7,11,17-23 An
overview (systematic review of systematic reviews) can be
conducted to summarize information from individual
systematic reviews and assess their methodological
quality.24,25 Generally, overviews have evaluated the
evidence from several systematic reviews to assess the
effectiveness of multiple interventions to interpret or
treat a particular clinical condition.26 In addition, over-
views also appraise the risk of bias of the included sys-
tematic reviews and, hence, evaluate the methodological
quality of these reviews.27
A consensus on the ideal occlusal scheme for com-
plete dentures regarding clinical performance and patient
satisfaction is lacking. Furthermore, the authors are un-
aware of a previous study that has evaluated the meth-
odological quality of the systematic reviews on this
subject. Therefore, this overview aimed to assess the
methodological quality and summarize the scientific ev-
idence to discuss the results obtained from available
systematic reviews about the influence of occlusal
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
schemes on the clinical performance of and patient
satisfaction with complete dentures.
MATERIAL AND METHODS
This overview was undertaken and reported following
the Preferred Reporting Items for Systematic reviews and
Meta-Analyses (PRISMA) Statement,28 and the protocol
was registered at the PROSPERO database
(CRD42021225919). For this overview, self-named sys-
tematic reviews that included randomized or non-
randomized clinical trials (cross-over or parallel design)
and evaluated totally edentulous participants rehabili-
tated with bimaxillary conventional complete dentures
(P) with different occlusion schemes (I/C) on clinical
performance and patient satisfaction (O) as either a pri-
mary or secondary outcome were included.
A comprehensive literature search was conducted in
electronic databases, the homepages of systematic review
registers, and the non-peer-reviewed literature (Supple-
mental File, available online). The search was carried out
until April 1, 2021. The reference lists of all included sys-
tematic reviews were also appraised to identify potential
reviews to be included in this overview. The search strat-
egy was performed with the assistance of an expert
librarian and combined MeSH terms and synonyms
(Supplemental Table 1, available online). Publication data
and language restrictions were not applied to the searches.
Duplicates records were removed, and reviews were
selected for inclusion by title and abstract screening by 2
independent reviewers (M.H.R.B., L.F.B.M.). Selected
reviews were appraised for full-text reading. Divergences
were solved by a third reviewer (V.A.R.B.). After full-text
reading, all reviews meeting the eligibility criteria were
included in this overview, and data were extracted and
assessed for quality. Data extraction was performed by
the same 2 reviewers (M.H.R.B., L.F.B.M.) by using a
designed data extraction form (Supplemental File, avail-
able online), and a third reviewer (V.A.R.B.) was con-
sulted to resolve any differences.
The clinical performance outcomes in the included
studies, either evaluated by examiners or reported by the
participants, were considered as objective (colorimetric
beads method, electromyogram, kinesiograph, maximum
occlusal force, sirognathograph, sieve method, number
and time of mastication) or subjective (independent
questionnaires, oral health impact profile questionnaires,
oral health-related quality of life questionnaire, and vi-
sual analog scale). For patient satisfaction, the included
reviews used independent questionnaires, oral health
impact profile questionnaires, oral health-related quality
of life questionnaire, or visual analog scale. In addition,
ridge conditions, types of occlusal schemes, and tools for
outcome assessment were considered through the pri-
mary studies for data extraction.
Borges et al
- 2021 3

Identification of studies via databases Identification of studies via registers and other methods

Records identified from: Records identified from:

Identification

Database (n=325) PROSPERO (n=5)

Cochrane (n=4) Records identified before Open science framework (n=0)
Embase (n=53) screening: Systematic reviews (n=0)
LILACS (n=7) Duplicate records (n=166) Google scholar (n=1)
PubMed (n=108)
Scopus (n=72)
Web of science (n=81)

Records screened Records excluded

(n=159) (n=148)
Screening

Reports sought for Reports sought for Reports not retrieved

retrieval (n=11) retrieval (n=2) (n=1)

Reports excluded:
Reports assessed for Reports assessed for
Wrong population (n=1)
elegibility (n=11) elegibility (n=1)
Commentary article (n=1)

Studies included in the

review (n=9)
Included

Total studies included in

the review (n=10)

Figure 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart of study selection process.

The quality assessment of the included reviews was
undertaken independently by 2 reviewers (M.H.R.B.,
L.F.B.M.). The quality of the reviews was assessed by a
MeaSurement Tool to Assess systematic Reviews
(AMSTAR 2) approach.29 All reviewers discussed the
AMSTAR 2 criteria before quality assessment. Differences
between reviewers (M.H.R.B., L.F.B.M.) regarding the
AMSTAR 2 criteria were resolved by a discussion with all
reviewers. AMSTAR 2 included a 16-item checklist
covering all the steps taken during systematic review and
meta-analysis elaboration.
The effect of each occlusal scheme was compared
and classified by 2 reviewers (M.H.R.B., L.F.B.M.) as
positive, neutral, negative, or inconclusive based on the
systematic review conclusion concerning clinical per-
formance and patient satisfaction outcomes. When the
occlusal schemes were compared, the best was cate-
gorized as “positive”; when similar results were
observed for the occlusal schemes, the outcome was
classified as “neutral”; and when the occlusal scheme
presented inferior results, it was categorized as
“negative.” The occlusal scheme outcome was catego-
rized as “inconclusive” when the systematic review did
not reach a conclusion about the scheme. As objective
and subjective analyses can assess clinical performance,
data on this outcome were plotted separately. Infor-
mation on the reabsorbed and normal ridge were
grouped separately. Meta-analyses could not be
conducted in this overview because of the high het-
erogeneity of reviews.
RESULTS
A total of 325 studies were recovered from the electronic
databases. After the removal of duplicates, 159 titles and
abstracts were screened, and 11 studies were assessed for
full-text reading (Fig. 1). From the 11 studies, 2 were
excluded: 1 study evaluated the effect of occlusal schemes
in dentate participants with existing occlusion or experi-
mentally altered occlusion,30 and 1 was a commentary
article of a systematic review included in this overview31
(Fig. 1). In addition, 1 potentially relevant systematic re-
view protocol was identified on PROSPERO; however, it
was not completed and was not included in the present
study.32 One other study was identified from the non-
peer-reviewed literature and was included.19 A total of 10
systematic reviews were included in this overview (Fig. 1).
All the included reviews were published in English, except
for one in Chinese.23 The overall characteristics of the
included reviews are summarized in Table 1.
All systematic reviews6,7,11,17-23 included randomized
clinical trials, and 5 reviews also included prospective
studies.18,20-23 In addition to clinical studies, 2 reviews
included other systematic reviews,11,20 1 included an
in vitro study,22 and 2 reviews included clinical studies in
which participants were rehabilitated with partial

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Table 1. Description of included systematic reviews

Authors, Written-
Year Oriented Registered Search
(Country) Checklist Database PICO Searches Restrictions
Abduo, NR NR P: Complete denture users PubMed, reference lists of included English
201318 I/C: Occlusal schemes - BBO, CG, MO - studies, and manual search in journals
(Australia) and tooth morphology
O: Comfort, retention, stability,
mastication, speech, esthetics, number
of denture adjustments required,
maximum occlusal force, mandibular
movements, and objective mastication
tests.
Ahmed et al, Yes (PRISMA) NR P: Complete denture users PubMed, Scopus, Cochrane No
202119 I: CG Collaboration, Science Direct, Europe
(Malaysia) C: BBO PMC, and reference lists of included
O: Patient satisfaction, quality of life, studies
mastication, stability, retention, esthetics,
phonetics, and muscle activity
Bhambhani Yes (PRISMA) NR P: Complete denture users PubMed, Science Direct, Google Scholar, English
et al, 202017 I/C: BBO, LO, CG, GF Cochrane Central Register of Controlled
(India) O: Masticatory efficiency, quality of life, Trials, EBSCOhost, reference lists of
satisfaction, adjustment time, included studies, and manual search in
postoperative problems, and long-term journals
objectives
Klineberg NR NR P: Complete denture users Cochrane Database of Systematic No
et al, 200720 I/C: BBO, LO, CG, GF Reviews, Cochrane Central Register of
(Australia) O: Patient satisfaction, speech, Controlled Trials, Database of Abstracts
mastication, appearance, comfort of Reviews of Effectiveness, ACP Journal
Club, Ovid PreMedline, Ovid Medline,
Embase, and Australasian Medical Index
Lemos et al, Yes (PRISMA) Yes P: Complete denture users Pubmed, Scopus, Cochrane Library, and English
201821 (Brazil) I: BBO manual search in journals
C: LO, CG, MO
O: Quality of life, patient satisfaction,
masticatory performance, and muscle
activity
Maddula et al, NR NR P: Complete denture users PubMed, Cochrane Library, Google English
201822 (India) I/C: BBO, LO, and CG search, manual search in journals, and
O: Masticatory ability, denture retention, reference lists of reviews.
and stability
Patel et al, Yes (PRISMA) NR P: Complete denture users PubMed, EBSCOHost, Cochrane Library, English
201811 I:BBO CENTRAL database, Google Scholar, and
(United C: CG reference lists of included studies.
Kingdom) O: Functional ability and quality of life
Sutton et al, Yes (Cochrane) Yes P: Complete denture users Cochrane Oral Health Group Trials No
20056 (United I/C: Occlusal schemes with anatomic Register, Cochrane Central Register of
Kingdom) teeth, nonanatomic teeth, zero-degree Controlled Trials, PubMed, OLDMEDLINE,
teeth EMBASE, ZETOC, SIGLE, SCI, reference
O: Patient satisfaction, comfort, lists and personal contact via e-mail.
masticatory function, masticatory
efficiency, adverse effects, and cost
Zhang et al, NR NR P: Complete denture users Library of controlled clinical trials, English and
201423 (China) I: LO Cochrane Library, PubMed, EMBASE, Chinese
C: BBO CNKI, Wanfang, CBM, and manual search
O: Patient satisfaction, masticatory in journals.
ability, retention, stability, esthetic,
masticatory efficiency, number of
adjusts.
Zhao et al, NR NR P: Complete denture users PubMed, EMBASE, Cochrane Library, English and
20137 (China) I/C: AO, BBO, CG, LO, and MO CBM, CNKI, previous reviews on the topic Chinese
O: Patient satisfaction, masticatory and their reference list, and manual
ability, retention, and stability search in journals

BBO, bilateral balanced occlusion; CASP, Critical Appraisal Skills Program; CEBM, Centers for Evidence-Based Medicine; CG, canine guidance; GF, group function; GRADE, Grading of
Recommendations Assessment; LO, lingualized occlusion; MO, monoplane occlusion; NP, not performed; NR, not reported; PICO, Population, Intervention, Comparison, Outcome; PRISMA,
Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement; PROSPERO, International Prospective Register of Systematic Reviews Database; RCT, randomized clinical trial;
ROB, Risk-of-bias Tool for Randomized Trials; ROB 2, Risk-of-bias Tool for Randomized Trials 2. *Represents information collected after contacting authors by email.

removable denture or implants.19,20 However, as the re-
views met the inclusion criteria, and the results of interest
for this overview were reported separately, to allow data
extraction, none of these were excluded. None of the
included systematic reviews presented statistical analysis
or meta-analysis or evaluated the certainty of evidence
with the Grading of Recommendations, Assessment,
Development, and Evaluations (GRADE) tool. Searches
in the included reviews were conducted in electronic
databases (including register platforms in some of the

THE JOURNAL OF PROSTHETIC DENTISTRY Borges et al

- 2021 5

Table 1. (Continued) Description of included systematic reviews

Number and
Design of Included Quality of Included Meta-
Search Period Studies Risk of Bias Primary Studies analysis GRADE Conclusion by the Authors
Up to January 11 studies (9 cross- NP NP NP NP BBO, LO, and CG are preferable
2012 over, 2 prospective) to flat teeth arranged in MO. LO
is beneficial for patients with
resorbed ridges.

Up to May 2020 18 studies (11 Cochrane Low = 9 NP NP CG is better than BBO, LO, and
crossover, 4 RCTs, 3 Handbook* Moderate = 8 MO.
clinical trials) Newcastle- High = 1
Ottawa

Up to 17 studies (RCTs) RoB 2 Low = 16 NP NP BBO, LO, and CG present similar

September NR = 1 results. LO can be helpful in
2019 resorbed ridges.

Up to 15 studies (1 RCT, 2 NP NP NP NP LO is better than other occlusal

September systematic reviews, schemes.
2006 11 N-RCTs)

Up to October 17 studies (11 RCTs, RoB and Low = 11 NP NP BBO and CG present satisfactory
2017 6 Newcastle- Moderate = 2 results. However, LO can be
Prospective) Ottawa High = 4 considered a predictable
occlusal scheme for complete
dentures.

NR 5 studies (3 RCTs, 1 NP NR NP NP LO had better results with

cross-over, 1 complete dentures when
in vitro) compared with BBO and CGO.

NR 6 studies (2 CASP, CEBM, Moderate = 2 NP NP BBO and CG present similar and

uncontrolled study, RoB High* = 4 satisfactory results.
4 crossover, 1 Unknown = 1
systematic review)
Up to 1 study (RCT) Cochrane Tool High = 1 NP NP LO is better than MO occlusal
November 2004 scheme.

Up to October 5 studies (4 RCTs, 1 Jadad scale Low = 4 NP NP BBO and LO present similar
2013 prospective) High = 1 positive results; however, LO is
beneficial for patients with
resorbed ridges.

Up to April 2012 7 studies (RCTs) Independent NR NP NP BBO, LO, and CG are preferable
Tool to MO occlusal scheme.

reviews), reference lists of included studies, and a manual
search in journals.
The AMSTAR 2 results are detailed in Figure 2. One
review fulfilled AMSTAR 2 criteria (except the meta-
analysis items) and was classified as of moderate qual-
ity.6 The other 9 reviews did not meet most of the
requirements and were classified as of low11,21 or criti-
cally low quality.7,17-20,22,23 From the 10 included sys-
tematic reviews, only 2 had a written review protocol.6,21
Most of the reviews did not conduct a comprehensive
search7,11,17,18,20,22,23 and failed to explain the design of
the included studies.11,17-23 Study selection and data

Borges et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume - Issue -

Bhambhani et al., 2020

Klineberg et al., 2007

Maddula et al., 2018

Ahmed et al., 2021

Sutton et al., 2005

Lemos et al., 2018

Zhang et al., 2014

Zhao et al., 2013

Patel et al., 2018
Abduo, 2013
Item 1: Research questions and inclusion criteria included PICO

Item 2: Protocol registered prior to the conduct of the review

Item 3: Explanation of the selection of study designs for inclusion

*
Item 4: Adequacy of the literature search

Item 5: Study selection performed in duplicate

Item 6: Data extraction performed in duplicate

Item 7: List and justification for excluding studies

Item 8: Studies included described in adequate detail

Item 9: ROB from individual studies being included in the review

Item 10: Reporting sources of funding for studies included in the review

Item 11: Appropriate statistical analyses for meta-analysis

Item 12: Assessment of potential impact of ROB on meta-analysis results

Item 13: Consideration of ROB when interpreting the results of the review

Item 14: Heterogeneity satisfactorily explained and discussed

Item 15: Assessment of presence and impact of publication bias

Item 16: Reporting of potential conflicts of interest and review funding

Critically low

Critically low

Critically low

Critically low

Critically low

Critically low

Critically low
Moderate
Low

Low
Confidence in the results of the review

Yes Partial yes No No meta-analysis Only RCTs

Figure 2. AMSTAR 2 methodological evaluation of included systematic reviews. Bubbles filled with 2 different colors represent different answers for
subitems of question 9. * Represents information collected after contacting authors by email. AMSTAR, A MeaSurement Tool to Assess systematic
Reviews

extraction were not conducted (or not reported to have
been conducted) in duplicate in 417,18,20,22 and 7 re-
views,11,17-22 respectively. Six reviews did not provide a
list of potentially eligible studies that were excluded and
the reasons for exclusion,11,17-20,22 5 reviews did not
describe the included studies in adequate or partially
adequate details,11,17,18,20,23 and 9 reviews did not pro-
vide information on sources of funding of the primary
studies.7,11,17-23 Although 7 reviews assessed the risk of
bias of individual primary studies,6,7,11,17,19,21,23 only 2
reviews used appropriate tools for the assessment of all
included studies.6,7 Two reviews considered the risk of
bias of individual studies when discussing the review
results,6,11 and 4 provided a satisfactory explanation of
the heterogeneity of primary studies.6,7,19,21 Seven re-
views reported sources of funding or declared no po-
tential conflict of interest.6,17,18,21-23
The summary indicated that the occlusal scheme may
influence the clinical performance (both objective and
subjective) of and patient satisfaction with conventional
complete dentures (Fig. 3). Some systematic reviews
showed that bilateral balanced occlusion obtained satis-
factory results in clinical performance7 and patient
satisfaction,7,17 as well as canine guidance.19 However,
lingualized occlusion can have a positive effect when
compared with the other occlusal schemes when evalu-
ated by objective methods,17,18,20-22 especially for pa-
tients with resorbed ridges. In addition, lingualized
occlusion can also improve subjective clinical perfor-
mance7,21,22 and patient satisfaction.6,7,21,22 Conversely,
monoplane occlusion had a negative effect on both
clinical performance7,18 and patient satisfaction.6,7,18,21
Group function presented mainly inconclusive
results.7,11,17,18,22

THE JOURNAL OF PROSTHETIC DENTISTRY Borges et al

- 2021 7

Objective Evaluation of Clinical Performance Subjective Evaluation of Clinical Performance

5 5
6 10 2
Positive 10 3* 1* 2 Positive 10
6 2
9*
4*

2 1 4 10 1
2 1
3* 3* Neutral 9* 5
9 9 3 7 5
2 5
5 4 1
3
7
1* 3* 5 3*
Neutral 1* 3* 1*
9* 1 9 3 10 3
3
1* 4 1
9 7 7 6 10 1
Negative 6
2

6
3
Negative 6 7
7
Inconclusive
10 6 9 4
1
s

s
s

s
er

er
er

er

er

er

er

er
h

h
h

h
ot

ot
ot

ot

ot

ot

ot

ot
×

×
×

×
LO

CG
O

LO

CG

GF

O
BB

BB

M
A B

Patient Satisfaction Systematic reviews included:

6
10
5
1. Abduo, 2013 7. Patel et al, 2018
Positive 3 8 2 2
10 2. Ahmed et al, 2021 8. Sutton et al, 2005
7 9 2 5
3. Bhambhani et al, 2020 9. Zhang et al, 2014
5 1*
4 4. Klineberg et al, 2007 10. Zhao et al, 2013
Neutral 9* 2 1 3 1 3
9 9* 1*
1 3 10 7 5. Lemos et al, 2018 * Resorbed ridges
4

5
8 6. Maddula et al, 2018
Negative 6 6 1
10

10
Inconclusive 3* 7 3* 4
1* 7 9
3* 1 6
rs

rs

rs

rs

rs
he

he

he

he

he
ot

ot

ot

ot

ot
×

×
O

LO

CG

GF

O
BB

C
Amstar overall confidence:
Moderate Low Critically low

Figure 3. Summary of quantitative data. Bubble plot shows classification of included systematic review results for each occlusal scheme when
compared with others. A, For objective evaluation of clinical performance. B, For subjective evaluation of clinical performance. C, For patient
satisfaction. Systematic reviews classified as “positive” indicates superiority of occlusal scheme compared with others in evaluated outcomes; “neutral”
indicates similar results between occlusal schemes; “negative” indicates inferiority of occlusal scheme compared with others; “inconclusive” indicates
systematic review that included primary studies evaluating such occlusal scheme but did not reach a final conclusion about this scheme. Each bubble’s
diameter correlates with number of randomized clinical trial and nonrandomized clinical trial primary studies included in each systematic review.
Bubble’s color represents their AMSTAR 2 results. * Indicates systematic reviews that considered ridge condition in their results. AMSTAR, A
MeaSurement Tool to Assess systematic Reviews; BBO, bilateral balanced occlusion; CG, canine guidance; GF, group function; LO, lingualized occlusion;
MO, monoplane occlusion.

DISCUSSION carefully considered because of the low quality of the

included systematic reviews.
This overview showed that the occlusal scheme for Patient satisfaction and ability to use the dentures are
conventional complete dentures may influence clinical necessary for treatment success. The tooth arrangement
performance and patient satisfaction. Lingualized occlu- and the relationship between antagonistic teeth should
sion schemes tended to deliver more positive outcomes provide occlusal harmony and influence patient accep-
than other occlusal schemes for clinical performance and tance.8 Concerning patient satisfaction, previous re-
patient satisfaction. However, the results should be views6,7,21,22 reported the superiority of lingualized

Borges et al THE JOURNAL OF PROSTHETIC DENTISTRY

8 Volume
occlusion because of its minor denture dislocation and
greater penetration of bolus during mastication,
improving denture stability.14 These advantages could be
attributed to the lingualized occlusal force and, hence, a
lingualized occlusion mechanical property.13 Similarly,
bilateral balanced occlusion also demonstrated benefits
related to the stability and comfort of the dentures, which
may be associated with the bilateral balancing contacts
during eccentric movements.7,17 In contrast, the mono-
plane occlusion scheme showed lower rates of patient
satisfaction than the other schemes.6,7,18,21 Patients with
flat cusps reported dissatisfaction with mastication, pre-
senting higher masticatory effort to penetrate food and
needing more chairside corrections.16,21 This occlusal
scheme also provided impaired esthetics and, therefore,
lower patient satisfaction.7 Bilateral balanced occlusion,
canine guidance, and lingualized occlusion were
considered esthetic by the patients because of the natural
appearance of the anatomic and semi-anatomical pos-
terior teeth.19,22
Bilateral balanced occlusion has been reported to be
the ideal occlusal scheme as it promotes better mastica-
tory efficiency owing to its simultaneous occlusal contacts
during excursion movements.14 Nonetheless, in most of
the included studies, bilateral balanced occlusion did not
improve clinical performance in relation to other
schemes.6,11,17,18,20,23 Lingualized occlusion dentures
obtained better objective and subjective clinical perfor-
mance, being more straightforward to achieve than
bilateral balanced occlusion.7,21,22 Lingualized occlusion
results in less mastication effort because of the contact
between the cusps of opposing teeth and, consequently,
less masticatory muscle activation and mastication time
than the other designs, assuming that lingualized oc-
clusion dentures are more stable.22
Canine guidance also facilitates fabrication and provides
mastication efficiency. According to the summary of results,
canine guidance presented mainly neutral (similar) out-
comes comparable with bilateral balanced. Canine guid-
ance is indicated for patients without excessive bone
resorption and allows for modification and occlusal
adjustment when required.19 Unfortunately, it was impos-
sible to compare group function with the other schemes as
most of the included reviews presented inconclusive results
for this scheme without discussing outcomes.7,11,17,18,22 In
addition, the data from group function were analyzed with
canine guidance in some of the reviews,18,22 impairing
further conclusions on this occlusal scheme.
Although studies have reported that the stability and
success of the dentures can be affected by the conditions
of the mandibular ridge,3,12 only 4 included systematic
reviews evaluated the relationship between ridge
resorption and selection of the occlusal scheme.17,18,20,23
According to objective evaluation methods, lingualized
occlusion showed better results in masticatory efficiency
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for patients with severe ridge resorption than the other
schemes.17,18,20 Lingualized occlusion probably reduces
lateral forces, centralizes the vertical force on residual
mandibular ridges, distributes the masticatory force, and
promotes denture stability.9,10,18 Nonetheless, the re-
views included studies with different classifications and
degrees of resorbed ridges.14,17,18,20,23 Not standardizing
the ridge form can be considered a limitation because
the width, height, and condition of the ridge interfere in
the clinical performance and play an essential role in the
treatment outcome.
Some studies reported no difference among the
occlusal schemes for both clinical performance and pa-
tient satisfaction.7,11,17,18,20,21,23 Differences in the eval-
uation method, patient age, ridge condition,
maxillomandibular relationship, follow-up period, and
adaptation of patients to dentures may have confounded
the results.4,23 The comparison between different occlusal
schemes in primary studies and the way comparison
groups were established may have benefited one occlusal
scheme over the other.
The critically low methodological quality observed in
most of the included reviews demonstrated the presence
of methodological issues, which may have affected out-
comes. The main problem identified was the absence of
meta-analysis, which downgraded the methodological
quality. In addition, the AMSTAR 2 tool also addresses
whether the review authors discussed the relationship
between the risk of bias and the results obtained and
explains how the heterogeneity of the data interfered
with the results. Unfortunately, few of the review authors
carried out this discussion and, therefore, received a
negative assessment by AMSTAR 2 on this issue.
Furthermore, the information requested by AMSTAR 2,
including inclusion criteria based on the study design,
restriction justification for inclusion of studies, and
statement of the funding sources, was not reported in
most of the included reviews. Thus, even though the
AMSTAR 2 tool has been widely used, some authors are
unaware that the absence of specific data disclosure in-
fluences the methodological quality of the systematic
review and the reproducibility and reliability of the results
obtained.
The results from systematic reviews on the influ-
ence of occlusal schemes on the clinical performance
of and patient satisfaction with complete dentures
were critically and methodologically appraised. How-
ever, the low methodological quality, the nonassess-
ment of certainty of the evidence, and the presence of
methodological heterogeneity are limitations for the
present overview. These limitations did not allow
statistical analysis or the establishment of an accurate
and reliable conclusion. Therefore, to perform quan-
titative analysis, provide reproducible results, and
establish the best treatment option for the patient, it
Borges et al
- 2021
is essential to standardize the evaluation methods and
conduct well-designed clinical trials with well-
established inclusion criteria, to have similar ridge
resorption across participants, adequate sample size,
and to use appropriate methods to assess the effect of
the interventions. A cross-over study design may be
the most favorable for the study of occlusal schemes,
as it reduces the variability among individuals and
allows a smaller sample size. However, an appropriate
washout period must be used to prevent bias arising
from carryover effects.
Despite such limitations, based on the data summary
of the included systematic reviews, lingualized, bilateral
balanced, and canine guidance can be applied success-
fully in conventional complete denture fabrication.
Furthermore, considering the complexity of the scheme
choice, the results obtained here can guide clinicians in
selecting the specific occlusal scheme for the patient’s
clinical condition.
CONCLUSIONS
Based on the findings of this overview, the following
conclusions were drawn:
1. The available evidence suggests that the occlusal
scheme may interfere with the clinical performance
and patient satisfaction with complete dentures.
2. Bilateral balanced occlusion and canine guidance
obtained satisfactory results for both outcomes.
3. Lingualized occlusion showed a trend toward better
results across all occlusal schemes for normal and
resorbed ridges.
4. Monoplane occlusion did not present satisfactory
results.
5. Group function presented mainly inconclusive
results.
6. Considering that the majority of the systematic re-
views included were of low methodological quality,
further well-designed clinical trials with more
extended follow-up periods are needed to allow the
development of high-quality systematic reviews.
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Corresponding author: CRediT authorship contribution statement

Dr Valentim A. R. Barão Maria Helena Rossy Borges: Conceptualization, Methodology, Validation,
Department of Prosthodontics and Periodontology Formal analysis, Investigation, Writing e original draft, Project administration.
University of Campinas (UNICAMP) Luís Fernando Bandeira Miranda: Methodology, Validation, Formal analysis,
Piracicaba Dental School Investigation, Writing e original draft, Project administration. Caroline Dini:
Av Limeira, 901, Piracicaba Formal analysis, Writing e review & editing, Visualization. Guido Artemio
Sao Paulo 13414-903 Marañón-Vásquez: Methodology, Writing e review & editing. Marcela Bar-
BRAZIL aúna Magno: Methodology, Writing e review & editing. Lucianne Cople
Email: vbarao@unicamp.br Maia: Methodology, Writing e review & editing, Supervision. Valentim A.R.
Barão: Conceptualization, Writing e review & editing, Supervision, Funding
Acknowledgments acquisition.
The authors thank Heloisa Maria Ceccotti, librarian, for her support in the search
strategy construction. The authors also thank the correspondent authors Drs
Cleidiel A. A. Lemos, Jaafar Abduo, Jaymit Patel, and Naseer Ahmed who kindly Copyright © 2021 by the Editorial Council for The Journal of Prosthetic Dentistry.
provided information from their studies. https://doi.org/10.1016/j.prosdent.2021.10.018

THE JOURNAL OF PROSTHETIC DENTISTRY Borges et al