A Guide To Good Occlusal Practice

BDJ Clinician’s Guides
Stephen Davies
A Guide to
Good Occlusal
Practice
Second Edtiton
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Stephen Davies
A Guide to Good Occlusal

Practice
Second Edition
Stephen Davies
Specialist in Restorative Dentistry
Lecturer in Occlusal and Temporomandibular Studies
Division of Dentistry, Faculty of Biology, Medicine and Health
University of Manchester
A Lead Clinician, Temporomandibular Disorder Clinic
University Dental Hospital of Manchester
Manchester
UK
Originally published by BDJ Books, London, 2002

1st edition: © BDJ Books 2002
ISSN 2523-3327 ISSN 2523-3335 (electronic)

ISBN 978-3-030-79224-4 ISBN 978-3-030-79225-1 (eBook)
https://doi.org/10.1007/978-3-030-79225-1
© Springer Nature Switzerland AG 2002, 2022

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Preface
There is a very long list of contributors to this work. Without their expertise this
multi-disciplinary work on the provision of Good Occlusal Practice would not have
been possible. I am very fortunate to have had the expertise, support and energy of
such a loyal and kind group of professional friends. Special thanks go to Indika
Weerapperuma who, in addition to having contributed to two chapters, has been my
sounding board for ideas and has proofread the book. Each chapter has evolved
from an initial discussion with the specialist(s), from which a first draft was created.
Throughout the development, Occlusion has been kept as the central theme. After a
lifetime of teaching the Occlusion, it is my experience that both undergraduate and
postgraduate students approach the subject with the mistaken belief that it is some-
where between difficult and incomprehensible. It has been a privilege to experience
a colleague’s joyous realisation that the subject is not as difficult as they thought. It
is my sincere hope that the reader’s reaction will be the same.
At Springer/Nature: I would firstly like to thank James Sleigh for the invitation to
rewrite the 2002 BDJ book A Clinical Guide to Occlusion; my special thanks go to
Alison Wolf who has consistently supported and guided me through the publication
stage of this work.
I would like to thank Mrs Mandy Lynam, who as my dental nurse would not let
me dismiss a patient with a poorly occluding restoration even if I had wanted. Gordon
Lucas, my technician partner, has been the talented and reliable provider of all my
indirect restorations for more than 40 years. Finally, I would like to acknowledge the
clinical companionship and academic encouragement that the Manchester Dental
School and Hospital provides; I am blessed to be part of that community.
Finally, and above all others, I want to thank my wife for her patience and under-
standing. When I qualified and we married in 1971, we both thought that Dentistry
would just be my job.
2022, Manchester, UK Stephen Davies
v
Contents
1 What Is Occlusion?�� 1
2 The Examination and Recording of the Occlusion:

Why and How �� 23
3 Good Occlusal Practice in Simple Restorative Dentistry �� 43
4 Good Occlusal Practice in Advanced Restorative Dentistry�� 79
5 Good Occlusal Practice in Removable Prosthodontics�� 119
6 Occlusion and Orthodontics�� 141
7 Occlusal Considerations in Periodontics�� 165
8 Good Occlusal Practice in Children’s Dentistry �� 191
9 Bruxism�� 207
10 Occlusion and Non-carious Tooth Surface Loss�� 219

Section 10.1: General Considerations on the Management
of Non-carious Tooth Surface Loss�� 220
Section 10.2: Creating the Space for the Restoration of the Worn Teeth�� 239
Section 10.3: Case Histories to Illustrate Restorative Strategies �� 247
11 Good Occlusal Practice in the Provision of

Implant-Borne Prostheses �� 279
vii
Contributors
Chapter 3 Phillip Smith

Senior Lecturer/Hon Consultant Restorative Dentistry, School
of Dental Studies, The University of Liverpool, Liverpool, UK
Chapter 4 Phillip Smith
Senior Lecturer/Hon Consultant Restorative Dentistry, School
of Dental Studies, The University of Liverpool, Liverpool, UK
Chapter 5 J. Fraser McCord
Consultant in Restorative Dentistry, Manchester, UK
Chapter 6 Ovais Malik
Consultant in Orthodontic, University Dental Hospital of
Manchester, Manchester, UK
David Waring
Consultant in Orthodontic, University Dental Hospital of
Manchester, Manchester, UK
Chapter 7 Ian Dunn
Specialist Periodontologist, Clinic 334, Wilmslow, UK
Kevin Seymour
Professor of Periodontology, Division of Dentistry, University
of Manchester, Manchester, UK
Chapter 8 Vidya Srinivasan
Consultant in Paediatric Dentistry, University Dental Hospital
Catherine Watts
Speciality Dentist in Paediatric Dentistry, Manchester, UK
Chapter 9 Hannah Beddis
Consultant in Restorative Dentistry, Leeds Dental Institute,
Leeds, UK
ix
x Contributors
Chapter 10
Section 10.1 Hannah Beddis
Leeds, UK
Section 10.2 Amin Aminian
Specialist in Prosthodontics, Clinic 334, Wilmslow, UK
Section 10.3 Hannah Beddis
Leeds, UK
Philip Dawson
Red Rose Dental Practice, Wigan, Greater Manchester, UK
Johanna Leven
Consultant in Restorative Dentistry, University Dental Hospital
Alicia Patel
Manchester, UK
Appoline House, Grantham, UK
Indika Weerapperuma
Hon Lecturer, University of Manchester, Manchester, UK
Kinross Dental Care, Colombo, Sri Lanka
Chapter 11 Amin Aminian
Specialist in Prosthodontics, Clinic 334, Wilmslow, UK
Peter Young
Specialist in Oral Surgery, Dentist@29, Northwich, UK
Readers’ Voices
Tara Bharadia 5th Yr Dental Student Dr. Davies has always said that occlusion
is easy, and this book is the proof! In the run up to finals, a once mystical and daunt-
ing topic now seems tame and manageable. All the terms are properly explained
right at the start and there are chapters to refer to when you have specific questions
further on in your career. You will come away being confident with the theory as
well as comfortable with the practical elements of examination and treatment con-
siderations. I would recommend this book to anyone who is confused by Occlusion!
Don Jayawardena Dental Core Trainee This book has easy to understand expla-
nations regarding terminology and in taking occlusal records. Most important to me
as a DCT it gives clear guidance on when to reorganise or to conform—a question
I am often asked! The author suggests planning the occlusion using the EDEC prin-
ciple, and he highlights useful techniques for taking pre-treatment records; these are
useful in my current restorative DCT post.
Chris Needham Experienced GDP, Pre PG qualification Despite being an expe-

rienced GDP, Occlusion was a subject that I thought I might never fully compre-
hend. This book really does simplify Occlusion, explaining the common pitfalls and
how to avoid them. I have picked up many techniques that I now use daily. This is
essential reading for all General Dental Practitioners, because it will give them con-
fidence to carry out Good Occlusal Practice in all of their treatments. I feel much
more confident to pursue PG education in Advanced Restorative Dentistry.
Amy Burns Post Graduate Student A refreshing common-sense approach to

dealing with clinical scenarios from simple cases up to more advanced dentistry.
I have previously found the subject of occlusion daunting; however the step-by-
step approach in this book has broken it down into easy to grasp concepts. I feel
confident applying this to my clinical work, and it has given me a robust under-
standing which has been invaluable for studying for my MSc.
April Scholey GDP with PG qualification A brilliant summary of how occlusion

affects our everyday dentistry. Postgraduate education has taught me that occlusion
is that missing link that ties together all aspects of dentistry. It can be the cause of
restoration failure and needs to be considered at the planning stage, not as an
xi
xii Readers’ Voices
afterthought. This book is an excellent, evidence-based summary that encompasses

a long career of research and clinical practice from an inspiring practitioner—all
condensed in one place!
James Darcy Consultant in Restorative Dentistry This book seeks to demystify

Occlusion. It is logical in progression from basic to advanced aspects of Good
Occlusal Practice in Restorative Dentistry. It outlines the key information and rein-
forces the most important messages, not least the EDEC principle. This update also
discusses newer thinking on more flexible approaches to rehabilitation which intro-
duces pragmatism into case planning and delivery of treatment. I would recommend
all practitioners read and keep a copy of it on their shelves for reference.
Nick Grey Professor of Dental Education, University of Manchester and

National Teaching Fellow This book is a ‘must read’. It covers the management of
clinical issues that confront the profession and does so in a reader-friendly way.
What Is Occlusion?
1
Objective
The aim of this book is to explore the role of Occlusion in Dental Practice.
There is an enormous range of opinion within the dental profession regarding the
significance of Occlusion [1]. It is very important that the profession in general and
practising dentists in particular have a balanced view of Occlusion.
To be controversial from the start, having a broad consensus within the profes-
sion on the importance of Occlusion is more important than every patient having a
balanced occlusion.
The fact that the study of occlusion is characterised by extremes of opinion
makes it confusing and difficult for individual dentists to subscribe to a philosophy
which is in line with contemporary good practice supported by evidence from
practice-based research. I hope that this book will make it easier for individual den-
tists to find a philosophy that helps them in their everyday practising life; and that
some of the ideas expressed in this book will find favour with the profession. Above
all, I hope that the reader will detect a ‘common-sense approach’, whilst still finding
it supported by evidence.
There is some evidence that ‘Occlusion’ could be covered in undergraduate cur-
riculums with a more ‘coordinated teaching strategy’. I will be pleased if this book
can make a contribution to that aim [2].
Patients need
a balanced
occlusion
Dentists need a
balanced view
on occlusion
© Springer Nature Switzerland AG 2022 1

S. Davies, A Guide to Good Occlusal Practice, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-030-79225-1_1
2 1 What Is Occlusion?
In this chapter, we will discuss:

1. What is ‘Occlusion’.
2. Why Occlusion is important.
3. The significance of Ideal Occlusion.
Range of Opinion
At one end of the spectrum there are dentists who believe that they can go through
their working lives with scant regard for their patients’ occlusion. They seem to
believe that they can conduct their practice ignoring the occlusal consequences of
the treatments that they perform daily. Whereas all dentists know of the importance
of the good marginal adaptation of their restoration to the health of the adjoining
dental and periodontal tissues, some dentists do not appreciate the potential conse-
quences of poor occlusal contact to the opposing teeth and their supporting struc-
tures. This is bizarre given the fact that very few dental treatments do not involve the
occlusal surfaces of teeth.
Conversely there is a body of opinion that considers Occlusion to be of such
systemic import to the well-being of our patients, that ‘Occlusion’ takes on an
almost mystic importance and attracts a cult-like devotion (Table 1.1). This can
lead some dentists to advocate occlusion as being the key to resolving or prevent-
ing a range of disorders far removed from the Masticatory System, for example
prolapsed lumbar discs. Often such enthusiastic fervour is associated with a
didactic prescription of ‘occlusal rules’, to which there must be slavish adherence
in the treatment of every patient! It may be harsh to describe the devoted adher-
ence to a particular Occlusal Philosophy as a ‘cult’, but sometimes characteristics
like gurus and followers and an intolerance of any other belief can justify this
perception.
There are several dangers in these extremes:
Both may lead to inappropriate levels of care for our patients.
• The ‘Occlusion doesn’t matter’ group may undertreat patients or provide treat-
ments that can lead to iatrogenic damage.
• Whereas the ‘Correct Occlusion is the key to a whole body musculo-skeletal
harmony’ group may overtreat patients by providing irreversible treatments
without a solid evidence base.
Table 1.1 It has been claimed without evidence that occlusion causes
Temporomandibular disorders Poor posture
Excessive ear wax Speech defects
Prolapse of lumbar disc Negative influence on the craniosacral mechanism
Reduced strength in deltoid and rectus Lack of beauty
femoris muscles
Guidelines of Good Occlusal Practice 3
The Confusion and Controversy that is generated by this wide range of opinion
on the importance of Occlusion causes an anxiety in the minds of undergraduate and
postgraduate students. It makes many of them feel that Occlusion must be very
difficult.
It is not surprising that these two extreme views co-exist so easily within a think-
ing profession because the one appears to provide the justification for the other. The
‘occlusion doesn’t matter’ group probably justify their reluctance to become
‘involved in occlusion’ on what they perceive to be the exaggerated and unsubstan-
tiated claims of the group who believe occlusion to be the central pillar of holistic
care. This congregation of opinion in turn may be so frustrated by the apparent
disregard of the study of occlusion that they are led to ‘gild the lily’ by overstating
the importance of occlusion and then in the absence of what they perceive to be an
inability ‘to see the obvious’ they go on to lay down rules, which they encourage all
dentists to follow for every patient.
‘Occlusion’
There is no escape
Dentists cannot:
• Repair 

• Move  teeth
• Remove 
without being involved in occlusion
It is the objective of this book to explore the role of occlusion in dental practice
in a manner based on reason, common sense and evidence. There is good and bad
practice in occlusion as in other aspects of clinical dentistry. I hope, therefore, to
establish the concept of Good Occlusal Practice, in all of the dental disciplines.
Guidelines of Good Occlusal Practice
These Must Be Guidelines Not Rules
All patients are different, reacting to similar stimuli in different ways. This is an
accepted truth in medicine, so I do not see why it should not apply to Occlusion in
dentistry. As a consequence, I believe that a patient’s individual needs can and
should be left to the individual clinician.
It is my hope that the Guidelines of Good Occlusal Practice in this book will
appeal to my colleagues. And that, upon reflection, the reader will agree that some
are obvious, and hardly needed stating.
The fog of confusion and controversy must be cleared, because no practising
dentist can care well for their patients without having regard for Good Occlusal
Practice.
Fig. 1.1 The Masticatory Enamel

System
Dentine Pulp
Teeth
Masticatory
system
Periodontium Articulatory
system
Gingivae TMJ
Bone Periodontal Muscles Occlusion

membrane
The Importance of Occlusion in Dental Practice
Occlusion can be very simply defined: it means the contacts between teeth.
Before describing the significance of the different ways in which occlusal con-
tacts are made Occlusion needs to be put into context.
The Masticatory (or stomatognathic) System (Fig. 1.1) is generally considered to
be made up of three parts:
• Tooth Tissues.
• Periodontal Tissues.
• Articulatory System.
Many dentists feel that they qualified from their dental school with a very good
knowledge of the first two parts of the Masticatory System, namely the Teeth and
the Periodontal Structures, but they can feel vulnerable in their knowledge of the
third part: the Articulatory System. It appears that some dentists feel that their time
at university did not prepare them adequately in this area. Possibly Occlusion may
be undertaught in the undergraduate curriculum.
‘Occlusion’ = Contacts between teeth
In my view, we should not be too hard on our Schools as the undergraduate den-
tal education must, by necessity, concentrate initially on the first two parts of the
Articulatory System. Dental Schools must produce newly qualified dentists who are
Is the Articulatory System a True System? 5
able to treat patients. Only once the dental undergraduate has an understanding of
the diseases that affect the dental and periodontal tissues (parts 1 and 2 of the
Masticatory System) can the schools start to allow the student to treat patients.
There is consequently justification for the study of the Articulatory System being
considered to be chronologically the third area of study. But because of the inescap-
able fact that almost all dental treatment has an occlusal consequence, it is wrong to
consider the study of the Articulatory System to be less important than the first two
parts of the Masticatory System.
The Articulatory System is the biomechanical environment in which dentists
provide most of their treatments.
Given the increasing quantity of knowledge to be amassed in the modern under-
graduate course, it may be that those responsible for setting the dental undergradu-
ate curriculum will not be able to cover the Articulatory System as they would wish.
Now that there is a universal acceptance of the need for continuing education, it may
be more realistic to consider a comprehensive study of the Articulatory System as
the first mandatory element of a postgraduate dental education. Although it may be,
by necessity, the last to be learnt it is not less important than the other parts of the
Masticatory System.
Is the Articulatory System a True System?
A system is defined as: ‘A set or assemblage of things connected, associated, or

interdependent, so as to form a complex unity’ [3]. The Articulatory System meets
these criteria, so the answer to this question is: Yes.
In this system one can imagine the temporomandibular joints as the hinges, the
masticatory muscles as the motors and the dental occlusion as the contacts
(Fig. 1.2b).
When viewed in these mechanical terms (Fig. 1.2b), it is clear that the elements
of the Articulatory System are inescapably connected. Furthermore, it can be
argued that they are obviously interdependent because a change in any part will
clearly affect the other two parts (Fig. 1.3a). But it should be remembered that this
effect will not necessarily be an adverse one. In fact, one must suppose that the
system as a whole can, in the vast majority of cases, compensate for change. This
phenomenon can be described as Adaptive Capability and is a feature of living
systems. In contrast, a machine has been described as a ‘System that is not the
result of a fertilized egg’, i.e. it is not capable of adaptation [4]. This is an important
reassurance to clinicians, as it means that an intervention to or alteration of one
element of a system, such as the dental occlusion, will not always have an adverse
effect on another part of the system, for example, the masticatory muscles. Any
dentist who believes that a change in the occlusion will always have an adverse
effect on the muscles or the TMJs is treating the patient mechanically, which given
the definition of a machine is a damning commentary of their clinical nous. This
concept of adaptive capability is important when considering Ideal Occlusion, as
will be discussed later.
Fig. 1.2 The Articulatory a Temporomandibular

System Joints
Muscles Occlusion
b Hinges
Motors Contacts
Fig. 1.3 (a) Interconnections a

of the articulatory system.
Change Change
(b) Interconnections of the
in in
masticatory system
TMJ leads to Occlusion
Masticatory muscles
Muscles leads to Occlusion
TMJ
Occlusion leads to TMJ

Masticatory muscles
Articulatory System
b
Change Change
in in
Teeth leads to Periodontia

Articulatory muscles
Periodontia leads to Teeth

Articulatory system
Articulatory leads to Teeth

System Periodontia
Masticatory System
Static Occlusion 7
This realisation that the Articulatory System has the potential to adapt does not,
however, abrogate the clinician from responsibility. In fact, the possibility as
opposed to the certainty of an adverse reaction (lack of adaptation) makes the chal-
lenge of preventing iatrogenic injury greater.
Do No Harm
The most important elements of ‘doing no harm’ during our treatments is firstly the
ability to carry out thorough examination and monitoring protocols, and secondly to
provide treatment that will not change the occlusion or change it in a way that is
most likely to be within the adaptive capabilities of the rest of the system.
These will be presented later in the text.
The same sort of analysis of the interconnection within the Masticatory System
can be made (Fig. 1.3b).
The importance of ‘occlusion’ in dental practice is based primarily upon the
relationships that it has within these interconnected biomechanical systems. When
one considers how almost all forms of dental treatment have a potential for causing
occlusal change, the need to establish what constitutes good occlusal practice is
overwhelming and obvious.
Analysis of Occlusion
Having stated that occlusion simply means the contact between teeth, the concept
can be further simplified by defining those contacts between the teeth
• when the mandible is closed and stationary as the Static Occlusion,
• and those contacts between teeth, when the mandible is moving relative to the
maxilla as the Dynamic Occlusion.
Static Occlusion
The first essential question when considering a patient’s static occlusion is: ‘Does
Centric Occlusion occur in Centric Relation?’
This question will be clarified after defining terminology. Terminology has been
a ‘red herring’ and has been the cause of enormous and sometimes acrimonious
debate. I have preferred terms, but do not feel that they are important; it is the con-
cept behind the terms that matter.
Centric Occlusion (CO) can be described as the occlusion the patient makes
when they fit their teeth together in maximum intercuspation. Common synonyms
for this are Intercuspation Position (ICP), Bite of Convenience or Habitual Bite. It
is the occlusion that the patient nearly always makes when asked to close their teeth
together, and it is the ‘bite’ that is most easily recorded. It is, also, how unarticulated
models fit together. Finally, it should be remembered that it is the occlusion to which
the patient is accustomed.
It is interesting, but not essential, for us to analyse how this position of the
mandible to the maxilla [jaw relationship], in which the teeth fit together, is
achieved.
The shape of the occlusal surfaces of the teeth determines this jaw relationship,
and there is a centrally influenced neuromuscular control that guides the mandible
into the relationship with the maxilla. Anything, therefore, that changes either the
occlusal surfaces of the teeth or the ability of the muscles to guide the mandible to
the habitual position can change this jaw relationship.
• A restoration to a single tooth can change the overall occlusion, and so the jaw
relationship.
• Anaesthetising and/or fatiguing the masticatory muscles may prevent them artic-
ulating the mandible to the maxilla into the habitual position.
This sums up the challenge in Restorative Dentistry.

Of course, as already stated the Masticatory System will usually adapt, but not
always. And the consequences can be grave.
The reason why this book will not give Rules is that Occlusal Change does not
lead inevitably to adverse consequences. But we will give Guidelines, because when
adverse reactions do occur, they can be severe; a situation that all dentists and
patients wish to avoid.
Centric Relation (CR) [synonyms: Retruded Contact Position, Terminal Hinge
Axis Position] is not an Occlusion. CR has nothing to do with teeth because it is the
only ‘centric’ that is reproducible with or without teeth present [5].
Centric Relation is a jaw relationship: it describes a conceptual relationship
between the maxilla and mandible. All attempts to lay down rigid definitions of
centric relation are plagued by the fundamental difficulty that there is no sure or
easy way of seeing where it is.
Centric Relation has been described in three different ways: anatomically, con-
ceptionally and geometrically.
Anatomical
Centric Relation can be described as the position of the mandible to the maxilla,
with the intra-articular disc in place, when the head of the condyle is against the
most superior part of the distal facing incline of the glenoid fossa. This can be para-
phrased as uppermost and foremost (Fig. 1.4).
This is subject to debate.
Some clinicians prefer the idea that Centric Relation occurs in an ‘uppermost
and midmost’ position within the glenoid fossa whereas others support the idea that
it is in an ‘uppermost and rearmost’ position; the so-called ligamentous position.
Static Occlusion 9
Fig. 1.4 Functional
anatomy of the
temporomandibular joint
PB
el.att.
IZ
AB
BLZ
SPt
IPt
fib.att.
fib.att. = fibrous attachment to posterior neck of condyle

el.att. = elastic attachment to fossa
BLZ = bilarminar zone
PB = posterior band of meniscus
IZ = intermediate zone of meniscus
AB = anterior band of meniscus
SPt = attachment to the superior pterygoid
(superior head of lateral pterygoid)
IPt = attachment to the inferior pterygoid
(inferior head of lateral pterygoid)
The problem with the goal of placing the head of the condyle in the uppermost
and midmost position is that the radiograph that commonly used to determine this
position is not a reliable test [6].
Whereas the uppermost and rearmost [ligamentous position] offers the possibil-
ity of consistency because of the anatomical limitations of the glenoid fossa, many
practitioners, including the author, find that asking patients to curl their tongue back
and pushing on the mandible does not deliver a consistent position. This is probably
due to the reaction of the lateral pterygoid to the pressure.
There is support for the uppermost and foremost hypothesis from a study of
anatomy: the bone and fibrous articulatory surfaces are thickest in the anterior
aspect of the head of the condyle and the most superior aspect of the articular emi-
nence of the glenoid fossa.
In any event, determining where exactly the head of the condyle is in the glenoid
fossa is a futile exercise, with no clinical significance. This is because there is no
reliable means of determining that relationship. To make any head of condyle/gle-
noid/fossa relationship a specific treatment goal is for this reason flawed.
Geometrical
Centric Relation can be described ‘as the position of the mandible relative to the
maxilla, with the intra-articular disc in place, when the head of the condyle is in
‘Terminal Hinge Axis’.
In order to understand what this frequently used term means, it is easier to ini-
tially think about only one side of the mandible, and to remind ourselves the move-
ments of the head of the condyle when we open our mouths. The mandible opens by
firstly a rotation of the condyle and then a downwards, forwards and medial transla-
tion occurs. Therefore, when the mandible starts to open and when it finishes its
closure, the movement of the head of the condyle is purely rotational. If we look at
Posselt’s Envelope of Motion [7], we can see that an imaginary point on the chin
will describe a near perfect arch during the beginning of the opening cycle and the
end of the closing cycles.
Geometrical
CR
Hinge movement
terminal opening
arc
arc
ct
rfe
Pe
Mandible is in terminal hinge axis
This provides the ‘terminal hinge point’ (of rotation) of one side of the mandible.
Because the mandible is one bone with two connected sides, these two terminal
hinge points are connected by an imaginary line: the terminal hinge axis. When the
mandible rotates about this axis, it is in Centric Relation; simply because it is the
start of opening or the end of closure. Another way of saying that it is in the rota-
tional phase of mandibular movement.
Significance of Centric Relation 11
It is the fact that the mandible is describing this simple arc, when the heads of
condyle are in the terminal hinge axis that has an important clinical significance. This
will be discussed later, when the techniques for finding Centric Relation are presented.
Conceptual
Centric Relation can be described as that position of the mandible relative to the
maxilla, with the articular disc in place, when the muscles that support the mandible
are at their most relaxed and least strained position. This description is pertinent to
an understanding of ‘Ideal Occlusion’, a concept that is discussed later. This defini-
tion of Centric Relation suggests that there could be a jaw relationship that is ‘quali-
tatively better than others’ for another element of the Articulatory System, namely
the muscles.
Significance of Centric Relation
Although there may be arguments about the exact definition of Centric Relation or
how it is best found clinically, thankfully there is broad agreement between dentists
that a reproducible position of the mandible relative to the maxilla exists. Dentists
agree that this reproducibility is not provided by the occlusal surfaces of the teeth:
patients with no teeth still have a Centric Relation. Furthermore, there is inter- and
intra-operator reliability in finding it.
‘Freedom in Centric’
Another aspect of the static occlusion is the presence or absence of ‘Freedom in

Centric’, this is also known as ‘Long Centric’.
The word ‘centric’ is adjective and so strictly it should never be used without a
noun. Consequently, this long-established term would better read: Freedom in
Centric Occlusion or Long Centric Occlusion. I hope that the reader will forgive this
mild pedantry.
Freedom in Centric Occlusion is present when the mandible is able to move
slightly anteriorly in the same horizontal and sagittal plane while maintaining tooth
contact (Fig. 1.5b). Alternatively, there will be no Freedom in Centric Occlusion if
either the front teeth or the posterior occlusion does not allow this horizontal move-
ment (Fig. 1.5a).
An easier way of imagining Freedom in Centric Occlusion is to consider whether
the front teeth occlude harder or sooner than the back teeth. If they do hit together
harder or sooner then there is no Freedom in that Centric Occlusion. Two common
examples of occlusions that may not have this freedom are firstly those Angles Cl II
div (ii) incisor relationship and when anterior crowns have been provided with pala-
tal surfaces that are too thick.
Fig. 1.5 (a) No freedom a

in centric occlusion. (b)
Freedom in centric
occlusion
In Fig. 1.5a, there is no Freedom in Centric Occlusion. Another way of thinking

about this phenomenon is to consider that the occlusal contacts have ‘locked in’ the
mandible to the maxilla. In contrast Fig. 1.5b demonstrates a situation where the man-
dible can move anteriorly, for a short distance, in the same sagittal and horizontal planes.
Other aspects of the Static Occlusion that can be described are
• the extent of the posterior support,
• the Angle’s classification of the incisor relationship together with measurement
of the overbite and overjet,
• the existence of any crossbites.
The answer to the question ‘Does Centric Occlusion occur in Centric Relation?’
is a useful one, because it describes the relationship of the mandible to the maxilla
when the teeth fit together. In some ways the answer to the question ‘what is the Jaw
Relationship when the teeth fit together’ would be more useful. But given that there
is no way of reliably imaging the position of the head of the condyle in the glenoid
fossa [6], this is a question to which there is no answer.
The word ‘Centric’ is an adjective.

It should only be used to qualify a noun.
Centric what?
Dynamic Occlusion 13
Dynamic Occlusion
The dynamic occlusion refers to the occlusal contacts that are made whilst the man-
dible is moving relative to the maxilla.
The mandible is moved by neuromuscular influences. But the pathways along
which it moves are determined not only by the muscles controlled by CNS, via the
nerves, but also by two guidance systems.
The posterior guidance system [synonym: posterior determinate of mandibular
movement] of the mandible is the temporomandibular joints. As the head of the
condyle moves downwards, medially and forwards the mandible is moving along a
guidance pathway which is determined by the intra-articular disc and the articula-
tory surfaces of the glenoid fossa, all of which is enclosed in the joint capsule.
When teeth are touching during a protrusive or lateral movement of the mandible
then those touching teeth are also providing guidance to mandibular movement.
This is the anterior guidance [anterior determinate of mandibular movement].
Based upon this analysis, it is the author’s belief that whichever teeth touch during
eccentric movements of the mandible, that those teeth provide the Anterior Guidance.
Because no matter how far back these guiding teeth are, they are anterior to the
Temporomandibular Joints [the Posterior Guidance of the Mandible].
This means that a patient with a severe anterior open bite would still have Anterior
Guidance of their mandible; it could, for instance, be on the second molars. The
guidance might be on back teeth but because those teeth are still in front of the TMJs,
they are the teeth that provide the Anterior Guidance of the mandible. Therefore,
despite the ambiguity of the word ‘anterior’ in the term anterior guidance, it does not
mean that the anterior guidance of the mandible is always on the front teeth.
So logically, because all teeth are in front of the posterior guidance system of the
mandible, whichever teeth touch during an excursive movement of the mandible are
providing the anterior guidance.
This definition differs from that given in some restorative textbooks, when the
term anterior guidance is used to describe only the guidance, which involves the
front teeth. I think this definition does not stand up to critical analysis, and I think
those who subscribe to it are describing what they consider to be ideal dynamic
occlusion [see below].
There are other terms that are used to describe a patient’s Dynamic Occlusion:
• ‘Canine Guidance’ refers to a dynamic occlusion that occurs between the canines
during a lateral excursion of the mandible. A canine-protected occlusion refers to
the fact that the canine guidance is the only dynamic occlusal contact during this
excursive movement.
• Group Function. In this type of anterior guidance, the contacts are shared between
several teeth on the working side during a lateral excursion. To qualify for the
term ‘group function’, the contacts within the group that are towards the front of
the mouth should be the earliest and/or hardest contacts.
• This contrasts with the term ‘Working Side Interference’, which infers a heavy or
early occlusal contact towards the back of the mouth during an excursive movement.
• A ‘Non-Working Side Interference’ is an anterior guidance on the back teeth on

the non-working side during lateral excursion.
During a Lateral Excursion

Non-Working Side:
The side on which the head of the condyle does translate downwards, for-
wards and medially.
Working Side:
The side on which the head of the condyle does not translate downwards,
forwards and medially
Note
The Working Side [WS] is the side of the mandible towards which the mandible is
moving during a lateral excursion.
The Non-Working Side [NWS] is the side of the mandible away from which the
mandible is moving. These terms can be confusing when considering the temporoman-
dibular joints, because it is the TMJ on the Non-Working Side which is moving the most.
Ideal Occlusion
One reason why some restorative textbooks define anterior guidance as being solely
the dynamic occlusal contacts between the front teeth is that it is generally consid-
ered to be more ideal if the anterior guidance is on those front teeth. Furthermore, the
fact that the pejorative word ‘interference’ is used to describe an occlusal contact
between back teeth infers that anterior guidance on back teeth is less than ideal.
This introduces the concept of ‘ideal occlusion’ and this raises three important
considerations:
1. Which jaw relationship might be considered the most ideal for the muscles of
mastication?
2. If a dynamic occlusal contact that is between back teeth is deemed ‘a posterior
interference’, with what is it interfering?
3. If some occlusions are ideal, for what or for whom are they ideal?
Ideal Occlusion
Q. Who or what is it ideal for?
Posterior Interference
Q. Who or what is it interfering with?
Ideal Occlusion 15
Let us examine this concept of Ideal Occlusion by firstly answering the questions
posed above. Then we can determine whether the concept of Ideal Occlusion has a
useful function in routine clinical dentistry.
Answer to Q.1
It is potentially more ideal if the teeth fit together (Centric Occlusion), in a ‘position
of the mandible to the maxilla, with the disc in place, where the muscles supporting
the mandible are at their most relaxed and least strained’ (the conceptual description
of Centric Relation given above). This establishes the concept that in the realm of the
Static Occlusion the occlusion might be considered ideal or not ideal for another part
of the Articulatory System, namely the muscles of mastication (Fig. 1.6b).
Answer to Q.2
If two molars on the side from which the mandible is moving during an excursive
movement can be described as a Non-Working Side Interference, then with what are
they interfering?
The posterior guidance of the mandible is provided by the temporomandibular
joints. As the head of the condyle translates down the articular eminence on the
Non-Working Side (which, paradoxically, is the side that is moving the furthest),
then the mandible is being guided by this joint.
If, as this is happening, two posterior teeth hit against each other on the same
[NW] side, then for the simple reason that these two posterior teeth are close to the
joint, there is potential for that contact to influence or ‘interfere’ with the movement
of the condyle within that joint.
Contrast this with the situation, where the anterior guidance is provided not by
those posterior teeth [which are close to the joint] but by front teeth which are fur-
ther away. Then the likelihood of ‘interference’ of condylar movement within the
non-working side temporomandibular joint is less.
Anterior guidance, therefore, on back teeth [whilst still providing anterior guid-
ance to the mandible] is described as a Posterior Interference because it may inter-
fere with the posterior guidance system of the mandible, namely the
temporomandibular joints. Posterior interferences are, therefore, considered to be a
less ideal type of dynamic occlusion.
The term ‘ideal’ relates to whether or not it is ideal for another part of the
Articulatory System: the temporomandibular joints (Fig. 1.6a).
Answer to Q.3
An occlusion may be qualified by the terms ideal or less than ideal by the effect it
potentially can have on the other parts of the Articulatory System.
Fig. 1.6 Occlusion is a Temporomandibular

ideal for another part of the Joints
articulatory system
Muscles Ideal
occlusion
b Temporomandibular
Joints
Muscles Ideal
occlusion
Definition of Ideal Occlusion
This is given in established texts [8] as:

• The coincidence of Centric Occlusion in Centric Relation (CO = CR).
• When there is freedom for the mandible to move slightly forwards from that occlu-
sion, in the same sagittal and horizontal plane (Freedom in Centric Occlusion).
• When the mandible moves there is immediate and lasting posterior disocclusion
(or anterior guidance is on the front teeth).
There is no such thing as an intrinsically bad occlusal contact, only an intol-

erable number of times for that patient at that time in their life to function or
parafunction on it.
This historical definition of Ideal Occlusion is presented only after having con-
sidered for what or whom this type of occlusion is ideal and gives the justification
of why a particular type of occlusion could be considered as being potentially ideal
for other parts of the Articulatory System.
It is of paramount importance to appreciate that the term ‘ideal occlusion’ means
something quite different from the term ‘correct occlusion’.
The Importance of Ideal Occlusion as a Concept 17
To state that an occlusion is correct or wrong betrays a mechanistic approach to

the subject. Patients are not machines and an occlusion can only be judged on the
reaction that it produces in the tissues of the system in which it inter-reacts. That
reaction will be infinitely variable between individuals and will in some contexts
vary within an individual with time.
That is why the more recent definition of Ideal Occlusion in a later edition of the
same textbook [9] moved away from this mechanistic description [‘A machine is a
System that is not the result of a fertilized egg’ [4]] to a physiological description.
This essentially states that an occlusion is ideal
• for that patient,
• at that time in their life,
• if there are no adverse reactions to it.
This is a major change in the way that dentists are asked to consider Occlusion.
It essentially suggests:
• Dentists should examine the Occlusion before starting treatment,
• to determine whether there are any adverse reactions to that Occlusion.
• If there are none, there is no need to change anything, because that patient has an
Ideal Occlusion—for them—at that time.
By virtue of the frequently observed fact that most patients seem to adjust to
some strange looking occlusions without any adverse reaction most dentists will
welcome this approach.
‘If it is not broken don’t fix it’ is a longstanding piece of excellent advice. It is the
definition of broken that has changed in the field of dental occlusion. By broken we
now mean that there are no adverse reactions; it does not mean that the occlusion
does not conform to the mechanical definition as given above.
This is also why the term ‘Malocclusion’ can be challenged [10], and is certainly
not as descriptive as the term ‘MalAdaptive Occlusion’ [11].
We will return to these considerations, when discussing Good Occlusal Practice
in Simple Restorative Dentistry.
The Importance of Ideal Occlusion as a Concept
1. Pre-treatment Examination and Records
The first and most important reason for defining ideal occlusion is that it gives a
benchmark against which patients’ occlusion can be measured. This needs to be
done before, during and after dental treatment. This is of paramount importance to
the health of our patients, especially in the increasingly litigious environment in
which we work. It cannot be overstated how important it is for a dentist to be able

to demonstrate that their treatments did not result in a change in Occlusion, Jaw
Relationship and/or Muscle Health and Function. This is especially true if it is being
claimed the changes were beyond the patient’s adaptive capability and so resulted in
harm. The key to this is the ability to examine all parts of the Stomatognathic or
Masticatory System. If the reader takes only one message from this book, the author
hopes that it will be this one.
It is of paramount importance that dentists examine and record the pre-existing
occlusion before providing any treatment which might involve a change to the
occlusion. Mounted study models are a good way of examining and recording a pre-
treatment occlusion. This is not needed or practicable for the vast majority of den-
tists, treating the vast majority of their cases. Alternatively, and infinitely easier,
notes can be made, which describe the patient’s occlusion. These notes use the cri-
teria of Ideal Occlusion as a benchmark. To record an occlusion using only the cri-
teria of Angle’s classification is of limited value, whereas to use the benchmark of
ideal occlusion is considerably more informative (see Fig. 1.7). This concept of a
pre-treatment occlusal analysis will be discussed in much greater detail in the chap-
ter on Simple Restorative Dentistry.
2. Management of Myofascial Pain
The second reason why ideal occlusion is an important concept is found in the long-
held view that an important factor in the development of Myofascial Pain [MP] is
‘the individual patient’s lack of adaptation to a less than ideal occlusion’ [5]. This
statement does not attribute an exclusively causal relationship between a less than
ideal occlusion and MP. Different patients will have different thresholds of toler-
ances to occlusion; furthermore the same patient can have a different tolerance to
their occlusion at different times.
For these patients the provision of an ideal occlusion is, therefore, one but by no
means the only way of treating the condition. When an ideal occlusion is provided
this should always be initially in a temporary and reversible way: that is a
Stabilisation Splint [12].
3. Provision of Treatments That Affects the Occlusion [and Jaw Relationship]:

Conformative Versus Re-Organised Approaches
[These concepts and the techniques needed to follow them will be covered in much
greater detail in the chapters on Restorative Dentistry.]
In providing treatment with an occlusal element, one of the first questions to be
decided in the treatment planning stage is whether the aim is to maintain the same
occlusion during treatment. If the pre-treatment occlusion is to be preserved, then it
is described as ‘Conformative Approach’ [13, 14].
Before deciding to conform to the pre-existing occlusion, not only does that
occlusion need to be examined but, in addition, any signs of existing adverse
reactions to that occlusion must be noted. If there are signs, then there may be a
Fig. 1.7 Example of a

record of a patient’s Date Occlusal record for
occlusion, using ideal 19/3/19 Robert Black
occlusion as the 1 New St
Skeletal 1 Old Town
benchmark Angles 1
Static occlusion
Does CO occur in CR? No
If not.. prem contact in CR? Roughly: Left molar

Exactly: Disto buccal cusp of lower left 8 against
mesial marginal ridge of upper 7 and distal of upper
left 6
Direction of slide from CR to CO: 3 mm

Anterior slightly vertical and slightly to the left
Freedom in Centric Occlusion? No
Dynamic occlusion
RHS LHS
Non-working side interferences 17 (FGC) v 48 No
Working side interferences No No
Crossover position NWS Int 17 v 48 No

WS Int No No
Canine guidance Yes (bridge 13) No
Group function No No
Notes No tongue scalloping or cheek ridging Tooth

surface loss (anteriors ) and history of cuspal fracture
at tooth 17
case for occlusal adjustment; otherwise ‘trauma from occlusion’ may be

replicated.
Some dental treatment, such as most major restorative, will, however, inevitably
change the patient’s occlusion and usually it will, as a consequence, change the
relationship between the upper and lower jaws.
In the past, this has been known solely as the ‘Re-Organised Approach’. It will
be described in some detail later in this book. For now, let us define the ‘Re-Organised
Approach’ as a different Occlusion (and Jaw Relationship) from the ones that the
patient had before treatment.
Because it is ideal, as defined mechanically [see below †], it is considered to
potentially be better tolerated by the patient’s Articulatory System, than a random
change in occlusion and jaw relationship would be.
The starting point of designing an Occlusal Prescription in the Re-Organised
Approach is to find and record Centric Relation.
Implicit in the concept of the ‘Re-Organised Approach’ is the requirement to

• plan,
• design,
• prescribe the Occlusion before embarking on the treatment.
It should not be the result of happenstance, which somewhat cruelly could be paro-
died as the ‘un-organised, and I hope we get lucky and the patient can adapt’ Approach.
The problem with the binary choice between the Conformative and Re-Organised
approaches is that it does not explain the success of treatments such as the Dahl
Technique, Orthodontics or developing new occlusions and jaw relationships by the
careful application of composite restorations in worn dentition cases* [Orthodontics
and the restoration of the worn dentition are subjects of chapters in this book].
*Note: Some dentists in restoring the worn dentition by composite ‘build ups’
will have done a design phase and so have a very clear occlusal prescription to
which they are going to restore the case; this then will still fall within the definition
of the Re-Organised Approach.
Some dentists will, however, not design the end point of their restoration in this
way, but they will still provide an occlusion to which the patient will be able to suc-
cessfully adapt. It is for these cases that there is a need for some Guidelines of Good
Occlusal Practice.
The author, therefore, in consultation with colleagues, who have contributed to
this book, suggests a third option:
• It is not the Conformative Approach, because the Occlusion and the Jaw
Relationship are changed.
• It is not the Re-Organised Approach, because it does not follow the prescription
of a careful pre-treatment design phase.
It is a:
• slow,
• careful,
• adjustable,
–– development of a new Occlusion,
• that is subject to continual monitoring for signs of adverse reactions.
–– in the tooth,
–– periodontal,
–– Articulatory,
–– Systems.
This could be called ‘Monitored Developmental Approach’ [15]. The features of

this approach are:
1. All of the elements of the Masticatory System are examined for any signs of
mal-adaptative reactions to changes that the treatment is creating; before, during
and after treatment.
2. There is no pre-treatment design wax up, or any other technique that envisages
the end point of treatment.
3. The new occlusion/jaw relationship is provided over a period of time.
4. There is a degree of reversibility to the treatment modality.
The reasons for these suggestions are:

1. It is essential that the patient does not have mal-adaptative reactions that develop
during or after* treatment or are exacerbations of a pre-existing condition.
2. The Occlusion and Jaw Relationship are not being prescribed to a specific model,
and so there is no need to design this on mounted models first.
3. By evolving the Occlusion over a period of time, the adaptive capability of the
patient is supported.
4. If the constant monitoring shows some adverse reaction, it is important that the
occlusal treatment can be easily adjusted.
*If things start to go wrong post-operatively, the temporary and removable provi-
sion of an Ideal Occlusion, as defined mechanically/anatomically†, can be quickly
provided.
This can be considered instead of reversing the treatment.
It means that the dentist should be able to make, fit and adjust a Stabilisation Splint.
†
• Centric Occlusion in Centric Relation.
• No Posterior Interferences.
• Freedom in Centric Occlusion.
Risk Management
The purpose of Guidelines of Good Occlusal Practice is to increase the chances of

healthy function, by reducing the risk of damage to the inter-related tissues of the
Masticatory System.
Providing dentists these Guidelines of Good Occlusal practice and the rationales
that have helped to develop them are the two main aims of this book.

1. The examination of the patient involves the Teeth, Periodontal Tissues and
Articulatory System.
2. There is no such thing as an intrinsically bad Occlusal Contact, only an
intolerable number of times to [para]function on it.
3. The patient’s occlusion should be recorded, before any treatment is started.
to be continued ………………
References
1. Smith BGN. Occlusion: 1. General considerations. Dent Update. 1991;18:141–5.
2. O’Carroll EO, Leung A, Fine PD, Boniface D, Louca C. The teaching of occlusion in under-
graduate dental schools in the UK and Ireland. Brit Dent J. 2019;227:512–7.
3. Oxford University Press. Shorter Oxford English dictionary. Oxford: Oxford University
Press; 1973.
4. Greenfield S, editor. The private life of the brain: emotions, consciousness, and the secret of
self. London: Penguin Books. ISBN-13 978-0-141-00720-5.
5. Ash MM, Ramfjord SP. Occlusion. 4th ed. Philadelphia: Saunders; 1995. p. 76.
6. Horner GQ. The effects of positioning variations in transcranial radiographs of the temporo-
mandibular joint: a laboratory study. Br J Oralmaxillofac Surg. 1991;29:241–2.
7. Posselt UOA. Studies in the mobility of the human mandible. Acta Odontol Scand. 1952;10:19.
8. Ramfjord SP, Ash MM. Occlusion. 2nd ed. Philadelphia: Saunders; 1971. p. 178.
9. Ash MM, Ramfjord SP. Occlusion. 4th ed. Philadelphia: Saunders; 1995. p. 84–5.
10. Davies SJ. Malocclusion—a term in need of dropping or redefinition? Br Dent J. 2007;202:12.
11. Gremillion HA. Relationship between TMD and occlusion. J Evid Base Dent Pract.

2006;6:43–7.
12. Moufti MA, Lilico JT, Wassell R. How to make a well-fitting stabilization splint. Dent Update.
2007;34:398–408.
13. Wise M. Occlusion and restorative dentistry for the general dental practitioner. Br Dent
J. 1982;152:319–20.
14. Davies SJ. Occlusion in restorative dentistry: conformative, re-organised or unorganised. Dent
Update. 2004;31:334.
15. Davies SJ, et al. Occlusion: is there a third way? A discussion paper. Br Dent J. 2021;321:160–2.
The Examination and Recording
of the Occlusion: Why and How 2
Before presenting ‘how’ to examine and record of the Occlusion, some attempt
should be made to justify ‘why’ it is necessary.
A study of the influences of mandibular movements may appear to be a strange
way of justifying the need to examine a patient’s occlusion, but hopefully the reader
will agree with me that it will be helpful to have an understanding of the control
mechanisms that enable us to occlude our teeth together.

• What makes up the mandibular locomotive system.
• Why an understanding of it is important in the study of Occlusion.
• How the occlusion can be simply and quickly examined and recorded.
The mandible moves, relative to the maxilla, by virtue of two influences.

Firstly, locomotor forces are provided by the muscles under the control of the
nervous system: neuromuscular control.
Secondly, there are two hard tissue guidance systems: these are the temporoman-
dibular joints and the occlusal surfaces of the teeth.
Mandibular movement
• Controlled by the Neuromuscular system
• Influenced by two hard guidance systems: Temporomandibular joints, and
Occlusal surfaces of teeth

https://doi.org/10.1007/978-3-030-79225-1_2
24 2 The Examination and Recording of the Occlusion: Why and How
Neuromuscular Control
The Muscles
Mandibular Muscles
(The term mandibular muscles is preferable to masticatory muscles in the same way
that ‘leg muscles’ is a more embracing term than ‘walking muscles’.)
Within the articulatory system, the muscles have been simply expressed as the
‘motors’. Whereas it is the ‘hard’ occlusal surfaces of the teeth and articulatory
surfaces of the bones which provide the guidance of mandibular movement, it is
muscles which provide the locomotive force to move the mandible during function
and parafunction.
The muscles which are joined to the mandible and are therefore responsible for
its movement are singularly and collectively immensely complicated motive enti-
ties. It may be because anatomy was the first medical science that the function of a
muscle has historically been described purely by an analysis of its origin and inser-
tion. This is dangerously simplistic and has sometimes resulted in a mandibular
muscle having been labelled as simply as an ‘opening’ or ‘closing’ muscle. It takes
no account of the complex antagonistic and synergistic interrelations of muscle
function, which are responsible for supplying the motive power of mandibular
movement. Electromyographic recording when linked to either simple observation
or sophisticated jaw tracking systems offers an enhanced understanding of the func-
tions of the mandibular muscles. The lateral pterygoid muscle offers a good exam-
ple of how the understanding of its function was enhanced by electromyography,
beyond the simple anatomical assumptions previously held [1].
Individual Mandibular Muscles
The Masseter Muscle
Anatomy: The masseter originates from the zygomatic arch, inserts into the outer
surface of the angle of the mandible and comprises superficial, intermediate and
deep parts.
Function: Its principal action is to elevate the mandible, so closing the jaws; it is
also an accessory muscle in mandibular protrusion.
Parafunction: It is active in tooth clenching and is the most frequently affected
muscle by this parafunctional habit.
The Temporalis Muscle
Anatomy: This is a large, fan-shaped muscle arising from the lateral aspect of the
skull in the temporal fossa and converges to a tendinous insertion, which, running
Individual Mandibular Muscles 25
below the zygomatic arch, inserts into both the coronoid process and anterior border
of the ascending ramus of the mandible.
It is significant that the orientation of the muscle fibres varies greatly:
• The posterior fibres run almost horizontally forwards.
• The anterior fibres run vertically.
• The intermediate fibres have varying degrees of orientation.
Function: The action of this muscle depends upon which fibres are contracting:
• The anterior fibres raise the mandible when the mouth is closing.
• The horizontal posterior fibres retract the mandible. The horizontal fibres of
the temporalis muscle are the only muscle fibres that retract the mandible; no
other muscle performs this function.
Parafunction: The temporalis muscle is frequently a tender muscle in bruxists.
Lateral Pterygoid Muscle
Anatomy: This is a muscle which has two heads and, it is now thought, two inser-
tions. The smaller superior head arises predominantly from the infra-temporal sur-
face of the greater wing of the sphenoid and inserts into the anterior part of the
intra-articular disc and capsule, while the larger, inferior head arises from the lateral
surface of the lateral pterygoid plate and inserts into the neck of the mandible just
below the condyle.
Function: While it is accepted that there is some overlap of activity of the two
heads, the superior pterygoid is predominantly active during clenching and is
thought to stabilise the condyle disc assembly. In function, it is not active during
opening. Being as it is attached into the disc it might be supposed that it is respon-
sible for the forward movement of the disc during opening, whereas the disc moves
because it is attached to the head of the condyle. It is active during closing, when it
is the antagonist to the elastin fibres of the bilaminar zone .
The inferior pterygoid is active during mouth opening and draws the condyle
forwards, medially and down the slope of the articular eminence.
Therefore, when both right and left pterygoid muscles act together, mouth open-
ing and mandibular protrusion occur, but when only one muscle contracts the con-
dyle on that side is drawn forwards and the mandible pivots around the opposing
condyle. So the chin moves towards the opposite side.
Parafunction: This active/passive cycle is altered, however, in parafunction,
when it has been demonstrated that there is an overall disruption of the pattern with
both heads (or ‘muscles’; if superior and inferior bellies are considered to be sepa-
rate muscles) showing a marked and simultaneous increase in activity. This can
cause pain in the pre-auricular region. In addition, it may possibly lead to disc dis-
placement, and the patient may develop TMJ clicking and locking.
Medial Pterygoid Muscle
Anatomy: The bulk of this muscle originates from the area between the two ptery-
goid plates; there is, however, a small, more superficial head arising from the maxil-
lary tuberosity. These two heads fuse and the muscle passes posteriorly and laterally
downwards to insert into the inner aspect of the angle of the mandible. The orienta-
tion of the fibres parallels that of the anterior fibres of the masseter muscle.
Function: The action of the medial pterygoid muscle is to elevate the mandible
and it is also active during protrusion and lateral mandibular movement.
Parafunction: It is not a muscle that can reliably be palpated for tenderness, nor
tested by resisted movement, and so its involvement in parafunction can only be
surmised. It may become hypertonic in patients who parafunction in extreme man-
dibular movement.
Digastric Muscle
Anatomy: This muscle has two parts: the anterior and posterior bellies. They are
connected by a tendon which passes through a fibrous loop on the upper border of
the hyoid bone. The posterior belly arises from the mastoid notch and the anterior
belly is inserted into the mandible near the symphysis. This insertion into the man-
dible qualifies it for inclusion as a ‘mandibular muscle’.
Function: When the hyoid bone is fixed (by the infrahyoid muscles) the action of
this muscle is to assist the lateral pterygoid muscle in opening the mouth. Its action
is therefore to depress mandible. In the action of swallowing, the hyoid bone is
raised by both right and left digastric muscles contracting together.
Parafunction: Tenderness in this muscle is frequently encountered in patients
who brux or clench on their anterior teeth and manifests as pain behind the ascend-
ing ramus or under the body of the mandible.
Mylohyoid Muscle
Anatomy: This thin sheet of muscle arises from the whole length of the mylohyoid
line on the inner aspect of the mandible. The fibres meet in the median raphe, which
inserts into the body of the hyoid bone. This muscle separates the submandibular
and sublingual regions. Posteriorly the muscle has a free border.
Function: The action of this muscle is to raise the hyoid bone and the tongue
during swallowing.
Suprahyoid, Infrahyoid and Cervical Muscles
Function and parafunction: The reason why a brief consideration of the function
and parafunction of these muscles should be discussed as part of the subject of
How Does the Mandible Move? 27
occlusion is that claims are made that occlusion can have an effect on the wider
musculo-skeletal system. This supposition is based upon a consideration of head
posture.
The hyoid bone is attached to the mandible by the suprahyoid muscles. The
infrahyoid and suprahyoid muscles by stabilising the hyoid bone enable the supra-
hyoid muscles to be tangentially involved in mandibular movement. Head posture is
also affected by the action of these muscles, as shown by the fact that the head
moves slightly back as the mandible opens. Conversely, head posture could poten-
tially affect the function and health of these muscles. This may provide an explana-
tion for an association between forward head posture and myalgia of the head and
neck muscles.
Similarly, the cervical muscles are largely responsible for head posture, and there
may be an overlap between some TMD and symptoms from the cervical spine.
How Does the Mandible Move?
Before answering this question, I would like us to consider that the movement of the
mandible relative to the maxilla is one of the many Locomotor Systems in the body.
The primary functions of the Locomotor systems are supporting and moving the
body. The principal components of these locomotive systems are the joints, muscles
and bones. In addition, there is cartilage, tendons and ligaments.
So, the Mandibular Locomotor System is the system that performs the many
functions of the mouth. It can exhibit both parafunction and dysfunctions.
Neural Pathways
The mandible is controlled not only as a result of voluntary movement, but also by
reflexes, most notably a jaw closing reflex and jaw opening reflex. The jaw closing
reflex protects the mandible and associated structures during violent whole body
movement; it can result in damage to the teeth, especially if the occlusal contacts are
not flat and in line with the long axis of the root. The jaw opening reflex is to protect
the teeth during sudden and unexpected mastication of a hard object or to protect the
lips, cheeks and tongue during mastication. These voluntary and involuntary move-
ments are controlled by the central and autonomic nervous systems, via sensory and
motor nerves.
There is input to these systems from both peripheral receptors and the higher
centres. These peripheral receptors or proprioceptors are situated not only in joints,
muscles and the epithelium as in all other human locomotor systems, but also in the
periodontal membranes. It is the presence of these periodontal proprioceptors that
makes the Articulatory System unique amongst human locomotor systems.
Consequently, if the movements within this locomotor system result in teeth touch-
ing (either in function or parafunction), then these proprioceptors are stimulated.
This means that any change in a patient’s occlusion, as a result of dental treatment,
can ‘be sensed’ by the patient’s central nervous system. It is because of this consid-
eration that dentists cannot ignore the effect of changing the occlusion when provid-
ing routine care.
Neuromuscular Guidance and Motor Engrams
A motor or motion engram can be considered a permanent fragment of memory.

Movement or Motor Engrams are learned, that is to say a product of plasticity
within the Central Nervous System.
They are defined as: ‘Memorized motor patterns used to perform a movement or
a skill that are stored in the motor area of the brain’[2].
They organise and control muscle synergies and so are responsible for all of the
movements that we can make. Some are basic movement such as walking, and some
advanced ones represent special skill such as sporting activities or playing a musical
instrument.
There is a motor engram that determines the relationship between the Mandible
and Maxilla when we close our teeth together into the position of maximum inter-
cuspation [or Centric Occlusion].
This motion engram controls the mandibular muscles to establish the Jaw
Relationship of our normal bite.
Although engrams are permanent fragments of memory, they can be permanently
corrupted, for example, as a result of brain injury; or more commonly temporarily
corrupted, for example, the effect of alcohol on the ability to walk in a straight line.
Similarly, the muscles’ ability to respond accurately to a motion engram can be
compromised by fatigue, for example, the difficulty an athlete may have in walking
after completing a marathon race.
This Is an Important Consideration in Restorative Dentistry
The significance of the influences that control the relationship of the mandible to the
maxilla is apparent when we consider how dental procedures can affect the patient’s
ability to close in the jaw relationship of their normal bite.
Firstly, motion engram or the mandibular muscles’ ability to follow it can be
corrupted:
• Local anaesthetic can affect motor nerves.
• Fatigue in masticatory muscles after a prolonged dental visit can affect the mus-
cles’ ability to follow the motion engram.
Secondly, even if the motion engram and the muscles’ ability to follow it are
intact, but the dental treatment has significantly altered the occlusal surfaces of
teeth, then the motor engram will be redundant because the teeth will no longer fit
together in the jaw relationship that the motor engram will determine. This is some-
thing of which the patient will be aware once the anaesthesia has worn off, because
the periodontal proprioceptors will sense it.
The Hard Guidance Systems 29
A significant aim of this book is to provide guidance on how to avoid this treat-
ment outcome.
The Hard Guidance Systems
There are two systems that provide hard guidance during mandibular movements.
These are classified as the posterior and the anterior guidance systems; they are
sometimes called the posterior and anterior determinants. These guidance systems
are interrelated and are parts of one overarching system: the Articulatory System.
An understanding of these guidance systems is important to dentists, because the
occlusion provides the Anterior Guidance. Very few restorative treatments do not
involve the occlusal surfaces of teeth.
Posterior Guidance
The principal elements of the temporomandibular joint [TMJ] are:

• the head of the condyle,
• the intra-articular disc,
• the glenoid fossa.
The TMJ provides the posterior guidance system of the mandible. This is obvi-
ous, because the head of the condyle is the most posterior part of the mandible.
When we open our mouths, the heads of both condyles firstly rotate and then
they translate downwards, forwards and medially.
These movements can be quantified:
• The angle of downward movement is known as the ‘Condylar angle’.
• The angle of medial movement is known as the ‘Bennett angle’.
• The amount of forward and downward movement is not measured in the joint,
but can be extrapolated by measuring how wide the mouth opens.
Lateral Excursion
During a lateral excursion of the mandible, one condyle translate downwards, for-
wards and medially in much the same way that it does during a straight opening.
The direction of travel of the mandible is away from the side in which the condyle
is moving.
Whereas the head of the condyle is moving very little in the TMJ on the side to
which the mandible is moving. Somewhat confusingly the side on which the TMJ is
essentially opening [downward, forward and medial translation] is called the Non-
Working Side (NWS) and the side on which there is no significant translation is
known as the Working Side (WS). These counterintuitive terms have their origin in
the consideration of mastication.
Although there is no significant translation within the Working Side TMJ, there
can be a movement of the condyle. This is sometimes called ‘Bennett Movement’.
A better term is ‘immediate side shift’, because the movement is:
• Immediate [It occurs at the very beginning of the Lateral Excursion.]
• Non-progressive [It finishes almost as soon as it has started.]
• Lateral [obviously if the mandible is moving medially on the NWS.]
This movement
• is variable from patient to patient.
• is the consequence of the WS condyle being joined to the NWS condyle.
• is difficult to observe, measure and reproduce on an articulator.
• can be significant to the comfort of a posterior restoration.
Figure 2.1 provides an illustration on mandibular movement during a right lateral

excursion.
Bill is controlling the Working Side, and Ben is in charge of the Non-Working Side.
Condylar angle Bennet angle
H
Horizontal
plane
Vertical
plane
Ben
Bill
H
FDM
FDM
Fig. 2.1 Illustration of the direction of mandibular movement

The Hard Guidance Systems 31
Anterior Guidance
The anterior guidance system of the mandible is provided by whichever teeth touch
during the excursive movements of the mandible, whilst teeth are in contact. These
contacts are known as the Dynamic Occlusion. This definition of Anterior Guidance
or the Anterior Determinates of the Occlusion may be challenged by some, who will
define Anterior Guidance as the guidance that is exclusively on anterior teeth.
Whereas some will agree with the concept that if the Posterior Guidance [or deter-
minate] is provided by the TMJs then whichever teeth touch during an excursive
movement of the mandible must provide the Anterior Guidance, because all teeth,
even the molars, are in front of the joints.
However, it is generally considered to be more ideal if these Anterior Guidance
contacts occur at the front of the mouth, because then they are as far away as pos-
sible from the posterior guidance system. This reduces the possibility of the two
guidance systems interfering with each other. So Anterior Guidance on front teeth
can be considered ‘ideal anterior guidance’. The concept of Ideal Occlusion is
described elsewhere in this work.
Relevance of a Study of Guidance Systems to Occlusion
The reason why dentists need to concern themselves with mandibular movements
and the influences that control them is that most dental treatment involves the occlu-
sal surfaces of teeth: that is to say that dentists inevitably are changing one of the
guidance systems of mandibular movement.
There is little evidence to suggest that a change in occlusion will precipitate
morphological changes within the joint.
It would appear, therefore, that the most likely adaptation in the ‘system’ occurs
in the teeth and their supporting structures.
These ‘adaptations’ are
• wear,
• movement,
• fracture.
Articulatory System: Occlusal Harmony?
How to determine what is an occlusion that complements to the TMJ may appear to
be an impossible question to answer; in reality the solution is very simple.
The key is to carry out a competent examination of the whole of the
This will include the TMJs and the supporting muscles, which will determine
whether there is a Temporomandibular Disorder. If there is, then the first clinical
decision to take, with the patient’s involvement, is whether or not to treat it before
providing any other treatment.
Secondly, the patient’s pre-treatment occlusion is examined and recorded, as part

of this Articulatory System Examination. This will answer the question: ‘can treat-
ment be provided without changing the patient’s pre-existing occlusion?
If it can, then the Conformative Approach is adopted.
If it cannot, then it will be safer if the new occlusion is going to be more ideal
rather than less ideal. This is known as the ‘Re-Organised Approach’.
Both of these approaches constitute Good Occlusal Practice.
It would not be Good Occlusal Practice to change the Occlusion, and the Jaw
Relationship to one that was not only different but also less ideal to other elements
of the Masticatory to System: an Occlusion to which it might be more difficult for
the patient to adapt.
This introduction has brought us to the conclusion that an examination of the
patient’s pre-treatment occlusion is essential.
Examination of the Occlusion (Fig. 2.8)
Occlusal examination
• Against the benchmark of ideal occlusion
• Three essential questions
Introduction
The Occlusal Assessment is the third part of an Examination of the Articulatory System.
For this exercise, the concept of Ideal Occlusion is to provide a benchmark against
which the patient’s occlusion is compared. Using Ideal Occlusion in this way does not
infer that the provision of an Ideal Occlusion is the treatment objective; it is simply a
‘zero’ against which to evaluate the patient’s pre-treatment occlusion.
The Three Question Examination
Question 1. Does Centric Occlusion Occur in Centric Relation [Retruded

Contact Position]?
Centric Relation describes a relationship between the two jaws. It has nothing to do
with teeth and so is not an occlusion. Patients with no teeth still have Centric Relation;
in fact it is the jaw relationship that a dentist making a new set of Complete Dentures
is trying to find, because it is a consistent and reproducible position (Fig. 2.2).
When the head of the condyle is moving purely in the rotational phase of its
movement, then the mandible is in a terminal hinge axis. This concept provides one
of the three pillars of the definition of Centric Relation that is given in the previous
section. If the head of the condyle is the stationary centre about which the mandible
is rotating, then the mandible will describe an arc, during this phase of TMJ
Examination of the Occlusion 33
Static occlusion
Does CO occur in CR?
If not.. prem contact in CR?

Roughly:
Exactly:
Direction of slide from CR to CO:
Fig. 2.2 Occlusal examination—question 1
Fig. 2.3 Illustration of the relationship between the condyles moving when the mandible is in a
terminal hinge axis and a ‘perfect’ arc is experienced during gentle bimanual manipulation
movement. Whereas if the mandible is not in terminal hinge axis, then the head of
the condyle will not be purely rotating, because there will be an element of transla-
tion. As a consequence, the mandible will not describe a pure arc (Fig. 2.3).
Manipulation of patient to find the Centric Relation. It is feeling that the patient’s
mandible is describing a perfect arc during manipulation that gives the experienced
operator the confidence that the Terminal Hinge Axis of the mandible has been found.
There is one important test that provides the operator with the confidence that
Centric Relation has been found. This test is based upon the fact that the Centric
Relation is a jaw relationship not guided by teeth nor by the patient’s muscles.
Rather it is discovered by the operator arcing the mandible in Terminal Hinge Axis
towards the maxilla. If done correctly the end point of this arc will be consistent, i.e.
the same parts of the same teeth will touch each time the exercise is repeated. There
will be excellent inter- and intra-operator reliability.
The point at which the first teeth touch can be described as the Premature Contact
[in the Centric Relation]. This is why Centric Relation is the only ‘centric’ that is
consistent, with or without teeth present.
The end point of the closing arc in Terminal Hinge Axis (Centric Relation) may
not be a single contact but an even set of contacts between all of the teeth. The even
set of Occlusal Contacts is known as Centric Occlusion [or Intercuspation Position].
In this case the Centric Relation and Centric Occlusion coincide.
The positional difference between Centric Relation and Centric Occlusion can
further be examined by noting the direction and length of slide of the mandible from
the Premature Contact in Centric Relation to their Centric Occlusion. This slide can
be observed by asking the patient to squeeze their teeth together after they have
been gently guided to their consistent Premature Contact.
If Centric Relation (CR) and Centric Occlusion (CO) do not coincide, in many
ways it would make more sense to describe the jaw relationship when the teeth are
in Centric Occlusion, and not the other way round; but that is impossible to do
because there are no landmarks on the jaws that can be examined whilst the patient
is holding his or her teeth in Centric Occlusion.
So the question has to be: ‘Does CO occur in CR?’ (Fig. 2.2)
Question 2. Does the Patient Have Freedom in Centric Occlusion?

This investigation will answer the question: ‘Is the patient’s Centric Occlusion
locked in?’ This means when the patient is biting together normally on the back
teeth, do their incisor teeth hit so hard as to prevent the mandible from moving
slightly forward. It the incisor contacts do prevent this forward motion in the same
sagittal and horizontal planes, then there is No Freedom in Centric [Occlusion], and
the mandible is potentially locked in.It can be examined in one of three ways:
1. Marking the occlusal contacts and seeing if the anterior contacts are heavier than
the posterior ones.
2. Asking the patient to close together slowly and reporting which teeth hit first.
3. Feeling for tremors [fremitus] on the upper incisor teeth with our fingernail
whilst the patient repeatedly taps up into Centric Occlusion. Despite testing this
with a gloved fingernail it is an easy and reliable test (Fig. 2.4).
The way in which the static occlusion is examined is illustrated in Fig. 2.5.

Static occlusion
Freedom in Centric Occlusion?
• Operator seated comfortably

• Patient is supine, at elbow height
• Patient’s neck extended slightly
• Use both hands

• Thumbs over mental symphasis
• Fingers on the lower border of
mandible, not sublingually
• Ask the patient to relax their jaw

and let you open their mouth
• Slowly and gently arc mandible up

and down with minimum force
• Only the patient’s mandible should
be moving
• Slowly increase the upward

component of each arc,
until premature contact
is reached
• Ask the patient to put a finger
in the air when they feel
first contact
• Repeat at least three times
• Ask patient: It is the same
each time?
• Ask patient to use raised
finger to point where they
feel first contact
• Ask patient to squeeze teeth
together from premature contact,
so as to note the direction of slide
• With chairside assistance

use articulating paper or foil
to mark premature contact
Fig. 2.5 How to find the Centric Relation

Dynamic occlusion
RHS LHS
Non-working side interferences
Working side interferences
Crossover position NWS Int

WS Int
Canine guidance
Group function
Question 3. Where Is the patient’s Anterior Guidance? (Fig. 2.6)

It has already been discussed that, in the opinion of the author, the term ‘anterior
guidance’ should not be taken to mean only guidance that is on the front teeth. It is
the mandible that is being guided, by both the temporomandibular joints (the poste-
rior guidance) and whichever teeth touch during excursive movements (the anterior
guidance) (Fig. 2.7).
However, the benchmark against which the patient’s dynamic occlusion is mea-
sured is, again, the Ideal Occlusion.
In an Ideal Dynamic Occlusion the anterior guidance will be on the front teeth,
either Canine Guidance or Group Function. This is confirmed by the conventional
wisdom that if the back teeth provide the Anterior Guidance, we call them Posterior
Interferences; either on the Non-Working Side or on the Working Side.
Fig. 2.7 How to examine • Finding whether there are

anterior guidance Non working side
interferences,
by trying ‘a pull out’
• During this right lateral

excursion, there is a NWS
interference between
UL6 (26) and LL7 (37)
• Examining for the existence

of working side interferences
by marking the contact
between the teeth during a
slide to the working side
(as illustrated)
• Next mark the centric
occlusion stops in a different
colour (not illustrated)
• Example of canine guidance
• Example of a group function

Why do we use the pejorative term: interference? Because they have the poten-
tial to interfer with the Temporomandibular Joints [the Posterior Guidance].
Because Posterior Interferences are closer to the joints that the more ideal Canine
Guidance or Group Function would be. Finally, the extent and or position of the
Posterior Interferences can be recorded by seeing whether they extend up to or beyond
the Crossover Position. This is the position during a lateral excursion when, in a Class
I occlusion, the lower canine has crossed buccal to the upper canine (Fig. 2.8).
Date Occlusal record for
Skeletal
Angles
Static occlusion
Does CO occur in CR?
If not.. prem contact in CR?

Roughly:
Exactly:
Direction of slide from CR to CO:
Freedom in Centric Occlusion?
Dynamic occlusion
RHS LHS
Non-working side interferences
Working side interferences
Crossover position NWS Int

WS Int
Canine guidance
Group function
Notes
Fig. 2.8 Example of a record of a patient’s occlusion, using ideal occlusion as the benchmark
Recording of the Centric Occlusion 39
Because the paper is thin it is much easier to

use it if it is supported by a rigid holder
Fig. 2.9 Paper tissue (for drying occlusal surfaces of teeth) and two colours of thin (40 μ)
articulating paper (for making occlusal contacts) held by Miller forceps
Recording of the Centric Occlusion
It is essential to have a good record of the patient’s occlusion before any treatment
is provided that has the potential for occlusal change. There is a need to establish
easy and universally reproducible ways of recording the patient’s occlusion.
In addition, records are essential for medico-legal reasons.
These records can not only be the familiar three-dimensional ones but can aslo
be a two dimensional record of the marks left by articulating paper (Fig. 2.9).
Two-Dimensional Records of the patient’s Centric Occlusion
In the main, these rely on firstly marking the static and dynamic occlusal contacts
between the teeth using paper or silk that is impregnated with ink. Counterintuitively
a very thin layer of petroleum jelly smeared onto the articulation paper improves the
deposit of the marking ink from the paper to the tooth surface, especially if the sur-
face is polished composite or porcelain. Different coloured inks can be used to mark
the Static and Dynamic Occlusions. In the opinion of the author, the paper should
not be thicker than 40 μm. In addition to this use of articulating paper or silk to mark
the contacts, shimstock foil can be used to determine whether there is a contact by
seeing whether it will pull through an occlusal contact. Shimstock is only 8 microns
(μm) thick.
After creating the occlusal marks on the teeth, a way of recoding them is needed.
This can be by
• written description writing,
[for example: the contact anterior to the prepared tooth is between the palatal
facing incline of the buccal cusp of UR5 and the buccal facing incline of the buccal
cusp of LR5]
• diagram [see use of Occlusal Sketch [3–5] in subsequent chapters],
• photograph,
• digital scans.
With the exception of the scan all these two-dimensional techniques have the
advantage that they are means of determining the actual occlusal contacts between
the teeth. They have the disadvantage that is inherent in a two-dimensional record
of a three-dimensional entity.
Three-Dimensional Record of the patient’s Occlusion
This, of course, means study models. They have the advantage of being a permanent
copy of the patient’s occlusion, but the production of this copy of the patient’s anat-
omy immediately introduces a host of potential errors.
• The impressions have to be accurate,
• the models from those impressions must be perfectly cast,
• and accurately related to each other in a static and dynamic occlusion.
This exercise depends not only upon face bows and articulators, but also on the
correct use of a range of impression, registration and casting materials.
Discussion
Mounted study models must be accurate; otherwise they are pointless. In order to
confirm that they are accurate they must be verified. This verification must be done
against either patient’s occlusion, which would require a check visit; or against a
second record which could be a simple two-dimensional record of the patient’s
occlusion. This was the reason for the development of the Occlusal Sketch tech-
nique. The advantage of a two-dimensional occlusal is it enables the models to be
mounted without the inherent difficulties of most bite registration materials [6].
Articulators
Articulators are not essential.

Their use is not a guarantee of success or of an easy life. Articulators are useful
tools, if the dentist wishes to replicate the way in which the patient’s jaws move one
against another [7]. This is valuable information as it assists in the accurate record-
ing of the dynamic occlusion. The nearer that a particular articulator can reproduce
the patient’s movements, the closer it will be possible to construct occlusal schemes
that predictably conform to the dentist’s objectives, whatever they may be.
In deciding which articulator to use, it is important to ask the question: ‘What
movements of the mandible do I wish to reproduce, for this patient at this time?’
The key point about this approach is that it determines the level of predictability
at which the dentist and technician wish to operate. If, as often is the case, a dentist
and technician are not going to operate with very sophisticated articulators, it does
not mean that success is denied to them. It simply means that when checking the
occlusion of the restoration it is more likely that adjustment will be necessary.
Similarly, if a dentist and technician are operating with sophisticated articulation, it
References 41
does not remove the dentist from the responsibility of checking the occlusion of the
restoration at the fit appointment.
Facebows
A facebow is a device that enables the maxillary arch to be spatially related to vari-
ous anatomical landmarks on the patient’s face. This assists in mounting the maxil-
lary cast within the articulator.
The most important consequence of this is that the maxillary cast will have a
similar relationship to the hinges of the articulator as the patient’s maxilla to their
TMJs. This matters if the articulator is going to be used for anything other than the
static occlusion in Centric Occlusion. It can appear surprising that the facebow
helps mount the upper model to the hinges of the articulator, when it is the man-
dible that moves in the patient, until we remember that it is the upper member of the
articulator that moves relative to the static lower member.

4. Compare the patient’s occlusion against the benchmark of Ideal
Occlusion.
5. A simple, two-dimensional record of the patient’s occlusion taken
before, during and after treatment is an aid to Good Occlusal Practice.
References
1. Juniper RP. Temporomandibular joint dysfunction; a theory based upon electromyographic
studies of the lateral pterygoid muscle. Br J Oral Maxillofac Surg. 1984;22:1–8.
2. Kent M. The Oxford dictionary of sports science and medicine. Oxford: Oxford University
Press; 2007. ISBN-13: 9780198568506
3. Davies SJ, Gray RJM, Al-Ani MZ, Sloan P, Worthington H. Inter- and intra-operator reliability
of the recording of occlusal contacts using the ‘occlusal sketch’ acetate technique. Brit Dent
J. 2002;193:397–400.
4. Davies SJ, Al-Ani Z, Richmond R, Worthington HV, Smith PW. Occlusal sketch: a reliable
technique for technicians to check the occlusion of marked models. Eur J Prosthodont Restor
Dent. 2005;13(2):65–8.
5. Davies SJ, Al-Ani MZ, Jeremiah H, Winston D, Smith PWS. Reliability in recording
static and dynamic occlusal contact marks using transparent acetate sheet. J Prosthet Dent.
2005;94:458–61.
6. Walls AWG, Wassell RW, Steele JG. A comparison of two methods for locating the intercuspal
position (ICP) whilst mounting casts on an articulator. J Oral Rehab. 1991;18:43–8.
7. Cabot L. Using articulators to enhance clinical practice. Br Dent J. 1998;184:272–6. https://
doi.org/10.1038/sj.bdj.4809600.
Good Occlusal Practice in Simple
Restorative Dentistry 3
Many theories and philosophies of occlusion have been developed [1–12]. The dif-
ficulty in scientifically validating the various approaches to providing an occlusion
is that an ‘occlusion’ can only be judged against the reaction it may or may not
produce in a tissue system (Dental, Periodontal or Articulatory). Because of this, the
various theories and philosophies are essentially untested and so lack the scientific
validity necessary to make them ‘rules’. Often authors will present their own firmly
held opinions as ‘rules’. This does not mean that these approaches are to be ignored;
they are, after all, the distillation of the clinical experience of many different opera-
tors over many years. But they are empirical.
In developing these guidelines this book has unashamedly drawn on this body of
perceived wisdom. But the aim is also to involve and challenge the reader by asking
some basic questions, and by applying a common-sense approach to a subject that
can be submerged under a sea of dictate and dogma.

• The ‘conformative approach’ to restorative dentistry.
• Some techniques for achieving this goal.
• Can and should the occlusion be improved within the conformative approach?
Discussion
Does Occlusion Matter in Simple Restorative Dentistry?
It is easy to justify a chapter on restorative dentistry in a book on occlusion. Dentists

are constantly involved in the management of their patients’ occlusion during rou-
tine restorative dental procedures, because the occlusal surfaces of the teeth are

https://doi.org/10.1007/978-3-030-79225-1_3
44 3 Good Occlusal Practice in Simple Restorative Dentistry
usually involved in the provision of restorations. The significance of this obvious

statement lies both in the relationship that the occlusion has within the Articulatory
System and the effect that trauma from the occlusion may have on the tooth, and its
periodontal support. All dentists wish to avoid these problems: dentists want pre-
dictable success for their patients and themselves.
Successful occlusal management leads to:
• predictable fitting of restorations and prostheses,
• longevity and absence of iatrogenic problems,
• patient comfort and occlusal stability.
‘Fingers crossed’ dentistry equals stress.
The Starting Point: Examination
It is a general principle in medicine that before treatment is provided a careful clini-

cal examination is carried out. Dentistry generally holds to this principle, but with
perhaps one exemption. Some dentists were not taught at dental school to examine
and record the pre-existing occlusion before providing a restoration. Instead it has
become customary to provide the restoration and then to ‘check’ the occlusion after-
wards. If this is our habit, we should ask ourselves the question against what are we
checking the occlusion of our restoration?
It cannot be the pre-existing occlusion if we did not examine it first. In restorative
dentistry the principle of providing a new restoration that does not alter the patient’s
occlusion, or the jaw relationship of that Occlusion is described as the ‘Conformative
Approach’, and the vast majority of restorations are provided following this
principle.
The Conformative Approach
Explanation
The Conformative Approach is defined as the provision of restorations ‘in harmony

with the existing jaw relationships’ [13]. In practice this means that the occlusion of
the new restoration is provided in such a way that the occlusal contacts of the other
teeth remain unaltered [14]. If the occlusal contacts of all the other teeth are the
same, then it follows that relationship of the mandible to the maxilla remains unal-
tered. Of course, if this is not the case, then the new occlusion will require a new
motor engram* to guide the muscles to create a change in the condyle/fossa rela-
tionship i.e. a different jaw relationship.
*see Chap. 2.
The Conformative Approach 45
Justification
The answer as to why dentists should wish to adopt the Conformative Approach is
often given as being ‘because it is the easiest’. In fact, this is not the case; the easiest
approach is undoubtedly not to consider whether the new restoration changes the
patient’s occlusion, maybe hoping not to change it too much. The reason why the
Conformative Approach is favoured is not because it is the easiest but because it is
the safest.
Assuming that there are no pre-existing adverse effects on any of the tissue sys-
tems, the obvious approach is to follow the ‘if it isn’t broken, don’t fix it’ maxim. A
clinician is less likely to introduce problems for the tooth, the periodontium, the
muscles, and the temporomandibular joints, if the occlusion of a new restoration or
restorations does not change the occlusion or the jaw relationship. Conversely,
introducing change requires the patient to adapt in some way.
This is why the Conformative Approach is the safest way of providing a restora-
tion. No matter how far the pre-existing occlusion is from a mechanical description
of an Ideal Occlusion (see Chap. 1), the advice in the Conformative Approach is not
to change the Occlusion or the Jaw Relationship.
Two Requirements if you Wish to Adopt the Conformative Approach
1. The Examination Protocol is sufficiently robust to determine whether there are

any pre-existing adverse reactions to the pre-treatment Occlusion.
2. The clinician examines the Occlusion before providing treatment and potentially
changing it.
When to Use the Conformative Approach?
Q: When do you use the conformative approach?

A: Whenever you can.
The Conformative Approach is desirable and appropriate for the vast majority of
our restorative cases.
It is possible to provide a restoration to the conformative approach when:
1. The patient has an Ideal Occlusion, i.e. Centric Occlusion (CO) is in Centric
Relation (CR) with Anterior Guidance free from Posterior Interferences.
This is unusual, it is much more likely that:

2. The patient does not have an Ideal Occlusion, and that the removal of the exist-
ing occluding surface of the tooth to be restored will not result in an inevitable
change in the Centric Occlusion or Anterior Guidance.
Examples of an occasion where this will not be possible is either if the tooth that
is to be restored is a deflecting contact; i.e. it provides the principal guiding contact
from CR to CO, or if the tooth is providing a heavy posterior interference.
In the case shown in Figs. 3.1 and 3.2, it is attractive to think that the dentist
when restoring either of the lower third molars [LL8 is the premature contact in CR,
and LR8 is a non-working side posterior interference] only has to provide restora-
tions that do not ‘interfere’. The danger in this approach is that the new occlusion
may still not be an ideal one, because of the existence of other potential interfer-
ences. This new ‘less than ideal’ occlusion may be one to which the patient could
have greater difficulty to adapt to than the previous less than Ideal Occlusion. This
may lead to iatrogenic problems [‘My problems only arose after you did that fill-
ing’]. This is fingers crossed dentistry.
3. Finally there should not be an existing Temporomandibular Disorder (TMD). If

there is, the decision must be taken whether or not to treat it first, since it is possible
that the treatment of the TMD will result in a change of the patient’s occlusion.
a b
Fig. 3.1 (a) Teeth touching in CO. (b) Premature contact in CR
a b
Fig. 3.2 (a) Left lateral excursion. (b) Non-working side interference during left lateral excursion
The Conformative Approach 47
Although the principle of not changing the patient’s occlusion is paramount

within the Conformative Approach, this, of course, refers to the occlusal contacts
that the patient has between their teeth that are not being presently restored. It does
not mean that the new restoration should slavishly reproduce the exact occlusion of
the tooth in need of restoration. One of the purposes of restoring a tooth would prob-
ably be lost if that was the case. How the occlusion may be improved is best consid-
ered within the principles of ‘ideal occlusion’.
On the tooth level, ideal occlusion is described as an occlusal contact that is: ‘in
line with the long axis of the tooth and simultaneous with all other occlusal contacts
in the mouth’. This means the elimination of incline contacts. Incline contacts are
considered to be potentially harmful, because of the lateral force that they may gen-
erate. A lateral force on a tooth may have harmful sequelae, which are illustrated in
Fig. 3.3:
Fig. 3.3 Possible
consequences of an incline
contact
Tooth fracture
Tooth jiggling
Mandibular deflection
So as long as the jaw relationship is the same, it is still the Conformative

Approach. So, within the Conformative Approach it is not only possible, but advis-
able to improve the occlusion of the restored tooth by the elimination of incline
contacts either by careful design of the occlusal platform of the new restoration or
by judicious alteration of the opposing tooth.
The acid test is whether or not the occlusal contacts of the other teeth (those
which are not involved in the restoration) are changed. If the occlusal relationships
of these other teeth are changed then the approach is not the Conformative but the
Re-Organised Approach. This is not wrong, but requires a different approach and is
described later in respect of both simple and complex restorative dentistry.
Figure 3.4a, b shows a restoration that needs to be replaced. The existing amal-
gam was provided ‘low’ [15]. It has no contact against the distal marginal ridge of
opposing premolar. Figure 3.4c, d shows the new restoration, which occludes
against the lower premolar, but does not change the occlusion between any
other teeth.
a b
c d
Fig. 3.4 Improving the occulusion within the conformative approach. (a) “Low” restoration to
replaced. (b) absence of occlusal contact has probably allowed over-eruption of lower premolar.
(c) new restoration with contact against lower premolar. (d) new restoration
Technique for Following the Conformative Approach
Introducing the E.D.E.C. Principle
When considering the provision of simple restorative dentistry, no matter what type
of occlusal restoration is being provided the sequence is always the same.
The ‘E.D.E.C. principle’ that is presented here (Fig. 3.5) is a system that has been
devised to give a logical progression through the sequence of providing a restoration,
to the Conformative Approach. It can be adapted to other aspects of clinical practice,
as will be seen later in this book, and is useful in both direct and indirect restorations.
It can be summed up in one sentence: ‘Examine before you Check’.
Fig. 3.5 E.D.E.C. protocol E = Examine

D = Design
E = Execute
C = Check
E.D.E.C. Protocol for Direct Restorations
tage 1 : E. Examine
S
Firstly, examine the occlusion before picking up a handpiece. The examination is in
two parts: the static and the dynamic occlusions. The examination of the static
Technique for Following the Conformative Approach 49
a b c d
Fig. 3.6 E.D.E.C. protocol. (a) Pre-existing Occlusion. (b) Rubber Dam Ready to remove old res-
toration. (c) Initial check Is this the same? Not quite! (d) But after Minor adjustment it Conforms to 6a
occlusion in Centric Occlusion (not in Centric Relation) is done by asking the

patient to tap onto thin articulating paper or foil; this is done before any rubber dam
is placed (Fig. 3.6a, b).
When the restoration is completed, the Static Occlusion is checked against the
pre-treatment record (Fig. 3.6c). And if necessary small adjustments can be made to
ensure that there are no changes in the pre-treatment contacts of adjacent teeth
(Fig. 3.6d).
It is self-evident that in order to be sure that a new restoration allows the other
teeth to occlude exactly as they did, you need to see how they occlude before you start.
Fig. 3.7 shows that prior to the restoration of LR5 the existing occlusion has been
marked up. This enables the dentist to ensure that the occlusion of the other teeth is
not changed [Conformative Approach] when replacing the MOD amalgam and the
fractured lingual cusp. Marking up the occlusion of the adjacent teeth at the start of
the procedure will make the occlusal adjustment of the new restoration much easier
and more reliable.
Even the thinnest articulation paper/foil is thicker than Shimstock, which has a
thickness of only 8 μ. So many clinicians prefer to use this; by checking whether it
will pull out from between an occlusal contact. When the Shimstock cannot be
removed with the teeth in occlusal contact, this is called ‘a holding contact’.
Figure 3.8 shows the use of Shimstock to check that an occlusal holding contact binds.
tage 2: D. Design
S
Before starting, dentists visualise the design of the cavity preparation. Every prac-
tising dentist has an image in their mind’s eye of what the cavity will look like
before preparing a tooth for restoration. Of course, during.
tage 3: E. Execution
S
There may need to be alterations to this design because of the extent of the caries or
areas of unsupported enamel.
Visualise the end before starting the beginning.

Fig. 3.7 Prior to the

restoration of LR5 (old
MOD amalgam and
temporary repair of lingual
cusp) the Occlusion is
marked to facilitate the
Conformative Approach.
[Courtesy of Dr. Chris
Needham]
Fig. 3.8 Does occlusal

contact hold shimstock?
tage 4: C. Check
S
Often it will be found that any previous restoration is in infra-occlusion, as in Fig. 3.4b.
This is because dentists are often anxious to avoid the dreaded ‘high restoration’.
But the avoidance of a supra-occluding restoration by deliberately providing infra-
occluding restorations is not Good Occlusal Practice. It may avoid some of the
immediate problems of a ‘high’ restoration, but as a tooth, with a non-occluding

restoration, erupts into an occlusion there may be consequences such as an ‘incline
contacts’ (see Fig. 3.3).
Finally, we check the new restoration does not prevent all the other teeth from
occluding in exactly the same way as they did before the placing of the new restora-
tion. This is either done by referring to some diagrammatic record made or by
reversing the colour of the paper or foils used pre-operatively, or from memory.
The only difference in the pre-treatment visualisation under the E.D.E.C. protocol
is the suggestion is that this visualisation is better done after a simple occlusal exami-
nation (Fig. 3.6a, b). The existing occlusal marks will either be preserved by being
avoided in the preparation or will be involved in the design of the new restoration.
Under the E.D.E.C. protocol, the pre-existing occlusion is included as a factor to
consider when designing the restoration. They do not have to be exactly duplicated
as it may be possible to improve them (from being ‘incline contacts’ to being ‘cusp
tip to fossa/marginal ridge’ relationships), or it may be possible to add an occlusal
contact especially if the restoration being replaced was in infra-occlusion, or there
is a need for greater occlusal stability.
In the illustrated case (Fig. 3.6), it can be seen that the occlusal contact against
the mesial marginal ridge of the restored UL4 (24) is slightly too heavy (Fig. 3.6c);
this has prevented the palatal cusp of this tooth from occluding and has changed the
occlusion of the canine. After minimal adjustment, this has been rectified (Fig. 3.6d).
For simplicity of illustration, the dynamic occlusion has not been shown in
the series.
[Footnote on series 3.6a–d:
It is not suggested that if the restoration had been left as illustrated in Fig. 3.6c,
that there would have been significant consequences for the patient. The most likely
consequence is that the patient would have been marginally aware of a small change
in their bite, then after a few days it will have seemed to have ‘bedded in’. The point
of showing this series of photographs is that unless the pre-treatment occlusion is
marked, one cannot be confident that one has conformed.
Without the pre-treatment examination, every dentist would have assumed that
the occlusion in Fig. 3.6c was the pre-treatment occlusion.]
Checking that nothing changed, without knowing what it was before we started,
makes no sense.
E.D.E.C. Protocol for Indirect Restorations
E.D.E.C. protocol can still be followed for indirect restorations (Fig. 3.9). The
essential difference between a direct and an indirect restoration is that a second
Fig. 3.9 E.D.E.C. protocol E = Examine and record the pre-existing occlusion
for indirect restoration D = Design the restoration
E = Execute the restoration
C = Check the occlusion at the fit appointment
operator is involved, namely the laboratory technician. A more useful representation

of the working relationship between the clinic and the laboratory is to consider the
technician to be a second operator rather than an assistant. The technician has
expectations from and responsibilities to the dentist.
Figure 3.10a, b, c shows the E.D.E.C. protocol being applied to the replacement
of an upper lateral incisor by an adhesive bridge.
[Notes:
1. The incisor being replaced was restored by a post crown and suffered a cata-
strophic vertical root fracture. [Maybe a history that is suggestive of Occlusal
Trauma?]
2. This restoration was placed over 30 years ago, when it was considered to be best
practice to use two abutments, and a fixed-fixed design.
Figure 3.10a shows the pre-treatment Examination of the Dynamic Occlusion,

before the preparation.
Figure 3.10b shows that the Operator decided to avoid the risk of changing the
Dynamic Occlusion by adopting a Design of the bridge preparation that did not
Conformative Approach: Conformative Approach: Example

Example
Examine Examine
Design Design
Execute Execute
Check Check
a b
Good Occlusal Practice

in the
Conformative Approach
Examine
Design
Execute
Check
Fig. 3.10 (a) Pre-treatment dynamic occlusion. (b) design of preparation to preserve pre-treat-
ment. (c) dynamic occlusion conformation of conformative approach (use of pre-operative
photograph)
interfere with the pre-treatment Occlusal Contacts. Executing that design has proved
to be successful as the bridge has never debonded.
Finally, as Fig. 3.10c shows it was possible to Check [in this instance by a pho-
tograph] that the Dynamic Occlusion had not been changed.
ecause Indirect Restorations Need Two Operators, there Are

B
some Consequences to the Treatment Sequence
These involve the

• taking,
• transfer, of records (Fig. 3.11).
• checking
Fig. 3.11 The sequence of Dentist examines

events in a two operator Patient’s
situation (indirect pre-treatment
restorations) occlusion
Dentist record Dentist checks

pretreatment Occlusion
Occlusion at fit appointment
Dentist maintains
Occlusion by good
temporary
restorations
Technician makes
restoration on
accurately
mounted models
In the Clinic
The dentist not only has to examine the occlusion but the results of that examination
have to be accurately recorded; and then that record has to be transferred to the
technician. This is the clinician’s responsibility.
Also, because of the delay in treatment to allow for the technician to make the
restoration, the clinician has the responsibility to maintain the patient in the same
occlusion during that interval. Consequently, it is imperative that the patient is dis-
missed from the preparation appointment with a temporary restoration that has been
checked to be in occlusion [not in supra- or infra-occlusion].
In the Laboratory
The technician has the responsibility to ensure that the pre-existing occlusion is not
changed, by constantly referring to that accurate record, during the laboratory phase
of treatment.
Stage 1 of the E.D.E.C. Protocol: E. Examine
–– Stage 1a: by the Dentist.

–– Stage 1b: by the Technician.
Stage 1a: Examination by the Dentist
The examination of the patient’s pre-existing occlusion is carried out in exactly the
same way as described for the direct restoration.
But for the provision of an indirect restoration there is a need for anatomical infor-
mation to be transferred accurately to the second operator: the laboratory technician.
A record must be made.
The provision of an indirect restoration always involves the transfer of anatomi-
cal information from the clinic to the laboratory:
1. the impressions leading to a model of the patient’s dental arch on the labora-
tory bench.
In the past these records have been in the form of three-dimensional physical
records; in the future it will be done digitally.
Irrespective of the medium, the need for accuracy will remain.
2. the occlusal relationship of teeth (the ‘Bite’) is equally an important record as the
shape of the teeth (the ‘impressions’), because the technician cannot carry out
her or his responsibilities without knowing how the upper and lower models
relate to one another.
• There is no point in the technician designing the occlusion of the restora-

tion on models that do not accurately conform to the patient’s occlusion.
• The inter-arch record [the bite] must be accurate, in order to give the tech-
nician a chance of mounting the models accurately.
Inter-Arch Occlusal Records, or ‘Bites’
There are three ways in which this anatomical information can be physically
transferred:
1. Two-dimensional bite records that will require accurate interpretation.

2. Three-dimensional bite records that will require accurate handling.
3. A combination of both, where one record can be used to verify the other.
Stage 1 of the E.D.E.C. Protocol: E. Examine 55
Fig. 3.12 Photograph of

pre-existing occlusion
Patient: Job: crown on tooth LR5 (45)
There are occlusal stops as follows:
Tip of LR3 (43) against cingulum of UR3 (13)

Paiatal cusp of UR4 (14) against distal marginal ridge of LR4 (44)
Paiatal cusp of UR6 (16) against central fossa of LR6 (46)
Mesio buccal cusp of LR6 (46) against mesial marginal ridge of UR6 (16)
There is canine guidance on the right and left sides
Fig. 3.13 Example of written record of patient pre-existing occlusion
Two-Dimensional Bite Records
1. Photographs: As digital intra-oral photography becomes more available, the cli-

nician will be able to send the technician a photograph of the patient’s pre-
existing occlusion (Fig. 3.12).
2. Written record: It is quick, simple and effective in some situations for the clini-
cian to simply tell the technician what the occlusion should be when the restora-
tion is finished (Fig. 3.13).
3. Occlusal Sketch [16–18]
‘Occlusal sketching’ is a technique of recording, onto an acetate sheet, a record
of the static and dynamic occlusal marks in the patient’s mouth that have been
made by using articulating paper or foil.
The acetate strip is designed to be viewed in two different perspectives. One is

appropriate to the clinician treating a supine patient and the other is convenient for
the technician to use on the bench in conjunction with the articulated models. The
a b
c d
Fig 3.14 (a) A sketch is made of the patient’s occlusion (before preparation of a bridge) by the
dentist at the chairside. (b) This sketch is reconfigured at the laboratory as an aid to the technician
to confirm the correct mounting of the models (c) The bridge is constructed in the laboratory to
‘conform’ with the occlusion (d) At the fit stage, the dentist uses the sketch as an aid to check
conformity between the pre- and post-operative occlusions
occlusal sketch is an easy way for the clinician and the technician to check that the
occlusion of the restoration conforms to the pre-existing occlusion (Fig. 3.14a–d).
ite Registration Materials

B
Taking an accurate bite record is difficult [19]. There are many different materials
and they all have their pros and cons [20]. It is easy to be misled into believing that
when one material fails to produce a good result that a different material would have
succeeded. No particular bite registration material guarantees success; it is the tech-
nique that matters.
In reality it is nearly always a misunderstanding of the objective of the exercise
that has resulted in an inaccurate record. The objective is to record, in the ‘bite’
material, only the correct spatial relationship of the prepared tooth to its antagonists.
Other teeth should contact as before, that is to say that there should be no material
between the other teeth.
The inadequacies of models as anatomical records of the teeth and mucosal sur-
faces give rise to most of the problems. Impressions often do produce models that
are not completely accurate [21]. An incomplete impression of an occlusal fissure or
a b
Fig. 3.15 Oral soft tissue is replicated by hard model material: potential source of error
of an interdental embrasure could very likely result in a significant difference

between the occlusion of the patient’s teeth and the models. As a consequence, the
opposing model will not have a true relationship with the working model; it will
keep the ‘other teeth’ apart.
Even if the models are completely accurate and allow the bite registration mate-
rial to adapt in exactly the same relationship to the models as they had to the teeth,
then there is still the problem that in the mouth the mucosal surfaces are soft and
compressible, whereas on the models the mucosal surfaces are replicated by hard
incompressible gypsum. So, any contact between the bite registration material and
the mucosa of the models will probably hold the bite registration material away
from its true relationship with the models of the teeth (Fig. 3.15a, b). So, the oppos-
ing model will not have a true relationship with the working model: it will keep the
‘other teeth’ apart.
ifferent Bite Registration Materials

D
Before considering what material to use, dentists must acknowledge that some den-
tal technicians prefer to use:
1. Nothing
They believe that the most accurate way to occlude models in Centric Occlusion
[Intercuspation Position] is to fit them together with no material between them.
Those [most technicians] who believe this are probably right [20]. Away from their
clients, many technicians will admit to throwing the bite record in the bin.
2a. Soft Pink Wax

This commonly used material (Fig. 3.16a) has the major disadvantage that it
distorts even at room temperature (Fig. 3.16b). It cannot, therefore, be an accurate
means of transferring a bite record.
a b
Fig. 3.16 Distortable soft pink wax
2b. Hard [Beauty] Wax

This material (Fig. 3.17) has the advantage that it is more brittle at room tem-
perature, so any inaccuracies when checking in the mouth or using it in the labora-
tory are likely to cause a revealing fracture of the material. Used correctly it is
time-consuming, but can produce a rigid, brittle ‘bite’ record.
Fig. 3.17 Use of hard beauty wax

2c. Preparation Only Bites

The advantage of this technique (Fig. 3.18a, b, c) is that no material (see 2.1
above) is placed between the occlusal surfaces of all other teeth. The bite registra-
tion is restricted to only the tooth that is being prepared and its antagonist.
b c
Fig. 3.18 Use of pattern resin to make a ‘Prep. Only Bite’
It is possible to use this for multiple restorations, but it is prudent to do one at a

time, always checking with Shimstock that the original occlusal contacts are pre-
served, i.e. the bite has not been opened up.
This is known as the ‘Alternate Prep Technique’ (Fig. 3.19a, b, c, d, e).
Alternate Prep
a Technique b c
Fig. 3.19 (a–c) A hypothetical case to illustrate [the alternate preparation technique].

(d) If there is no posterior support, don’t prepare all the teeth. Instead prepare every other tooth
(e) Firstly the crowns are made on the alternative preparations; using the untouched teeth as the
occlusal guide. Then the remaining crowns can be made; using the first 3 crowns as the guide.
Clinical Sequence:
1. Prepare 3 teeth [Alternative ones]
2. Take a Bite and an Impression
3. Prepare the remaining 3 teeth, and take an Impression
3. Combination of Three-Dimensional and Two-Dimensional Bite Records

By using a two-dimensional record the accuracy of the use of a three-dimensional
bite can be checked. This is a means by which the mounting of some models can be
verified.
tage 1b: E…Examination by the Technician

S
The provision of an Indirect Restoration to the Conformative Approach is depen-
dent upon teamwork between the Dentist and the Dental Technician. Communication
is the essential requirement for any good team performance.
Once the laboratory has models of the patient’s dentition and the relationship
[Occlusion] between them, she or he can start their examination of the case.
But maybe before they examine the case, they need to be sure that the occlusion
of the models is accurate. Hence….
Model Verification
It can be useful for the technician to have some easily transferable second record of
the occlusion, because it will mean that the occlusion of the models can be checked
in the laboratory to see that it is the same as the dentist saw in the mouth. This pro-
cess is known as ‘Model Verification’ and is an essential first step of the fabrication
of the Indirect Restoration.
Let us remember that the objective is the accurate transfer of the patient’s ana-
tomical information from the clinic where it is recorded to the laboratory where it is
duplicated. This is the aim of taking impressions and bites and the subsequent cast-
ing and mounting of the models.
It follows, therefore, that there should be a stage when the laboratory technician
is able to check the accuracy of her or his mounted models. This process is called
‘Model Verification’.
If the mounting of the models is inaccurate, it is likely that Occlusion of the
Restoration will be wrong.
Figure 3.20 shows how a technician or dentist can compare the occlusion of the
models against a clinical record of the patient’s occlusion. In this case the accuracy
was not there.
Figure 3.21a, b and c shows how the Occlusal Sketch can be used by the techni-
cian and the dentist to ensure that at all stages of the restorative process the occlu-
sion can be checked to see that it has not changed.
Fig. 3.20 An Occlusal

Sketch enables the
Technician to see that the Mark on model
mounting of the models is
wrong
No mark in mouth
b c
Fig. 3.21 (a) Occlusal Sketch configured for the technician to check the occlusion of the mounted
models against the record of the patient’s occlusion. (b) Close up of the record of the patient’s
occlusion [Occlusal Sketch] and the mounted model. Note the same occlusal contacts. Technician’s
check. (c) Close up of the record of the patient’s occlusion [Occlusal Sketch] that was taken at the
preparation appointment, now used to confirm that the fitting of the inlay has not changed the
occlusion. Clinician’s check
Figure 3.22 illustrates how the Occlusal Sketch can be used in the clinic to record
the patient’s Occlusion before treatment.
I f at this Verification an Error Is Detected

then the clinician has three choices:
1. Do all or part of the process again,

2. Engage in model grooming [see below for explanation].
3. Proceed with fabrication of the restoration having decided to ignore the error,
and so with the expectation that some adjustment will need to be made in the
mouth at the fit or try in stage. If this is anticipated, it may be prudent to advise
the patient before starting to grind on the restoration [Difference between a
Reason and an Excuse].
Fig. 3.22 Using occlusal sketch to record the occlusion
Which option is chosen should depend on the case including the size of the error.
The first and last have definite drawbacks. If the error is gross, model grooming will
not help and repeating the process is the best option. Option 3 may be the only
option; it will be less than ideal for the technician, clinician and patient. However, it
will take less time than having to remake the restoration. To deliberately ignore the
inaccuracy is not a sin; it is simply an admission that the restoration delivered from
the laboratory is not going to be as accurate as it could be. Some of the predictabil-
ity, therefore, has gone, so the expectation of adjustment at the fit stage has increased.
In the ‘real world’, clinicians have to make compromises constantly; in fact, the
skill of a clinician might be judged by their ability to choose and manage compromise.
The clinician who decides to ignore an error at the verification stage has made a
conscious decision to reduce the level of predictable success and is committed to
making the adjustments to the occlusal surface of the restoration at the fit stage
whereas the clinician who is ignorant of an error is in uncharted waters and may not
be able to navigate the patient safely into port.
There is a world of difference between deciding to ignore something and

being ignorant of it.
If the error is small, then model grooming is a good option.

1 2 3
Impression making Model casting Model mounting
4
5 Check the Occlusion
laboratory fabrication
grooming of the models against
of restoration
(if necessary) Occlusal Sketch,
or other record
Fig. 3.23 The stages before starting laboratory fabrication of the restoration
Model Grooming
Model grooming is the description given to the process of adjusting the models so
that they more accurately reproduce the occlusal contacts of the patient’s dentition.
Implicit in the use of the word ‘grooming’ is understanding that these are small
not gross adjustments to the occlusal surfaces of the plaster models.
Some authorities state, quite rightly, that as soon as the technician or dentist
scratches those models, they are not a completely accurate representation of patient’s
teeth. Consequently, they object to the concept of model grooming on the grounds
that …...
….it should not be necessary.
Of course, this is self-evidently true.
If the impression, casting and mounted processes have been performed entirely
without any error, then the models will exactly duplicate the patient’s teeth and the
occlusal contacts between those teeth.
Whereas everybody involved in this process of anatomical information transfer
should strive for this perfect replication, it is almost certainly the case that nobody
achieves this high goal every time.
So, it follows that whereas model grooming should not be necessary, model
checking is always necessary (Stage 4, Fig. 3.23).
It is emphasised that this model verification stage requires providing the techni-
cian with a second occlusal record; this can be a two-dimensional record (e.g. occlu-
sal sketch, or written record or photograph).
If the models are not accurate, the process of grooming is designed not necessar-
ily to make them completely accurate, but to reduce the inaccuracy.
Figure 3.24a–h illustrates the process of grooming some models; it shows how a
very small amount of adjustments to the models can restore accuracy.
The difference between an Excuse and a Reason is Timing.

a b
Occlusion
markedon
upper
teeth
Occlusion on lower teeth,
viewed from above
d
c 1
1
e f
g h
Fig. 3.24 Case illustrating model grooming (a–h) (c) Occlusion of Mounted Models compared
with Occlusal Sketch. (d) Occlusion of upper Mounted Model compared with Occlusal Sketch and
photograph of upper dentition (e) Model Grooming in Progress (f) Model Grooming Continues:
First sign of improving accuracy [UR4] (g) Model Grooming Completed: Lower model now has
same occlusion as in the mouth. (h) Model Grooming Completed: Upper model has same occlu-
sion as in the mouth
Fig. 3.25 Trimming a

silicone bite record so that
it fits onto the models
Bite registration pastes

often need trimming
Summary of the Examination Phases
hree Important Guidelines Emerge

T
1. If possible, the bite registration material should only be used between the pre-
pared tooth and its antagonists rather than used to take a full arch record.
2. If a bite registration does record the relationship of other teeth, it must be carved
back (Fig. 3.25) so that no part of it touches the models of the mucosal surfaces
or of the embrasures.
3. The technician should check the accuracy of occlusion of her or his mounted
models before constructing the indirect restoration. It is imperative, therefore,
that the mounting of the models should be verified against a second record of the
patient’s occlusion, which the dentist should provide.
The ‘second record’ may be:

(a) a second bite registration in a different material.
For example, if an ‘easy’ material like an elastomer has been used, it may be wise
to use a harder material (in both senses) such as acrylic resin or hard wax.
(b) a two-dimensional one, such as a written record of holding tooth contacts
(see Fig. 3.13) or an Occlusal Sketch (see Fig. 3.14a, b).
4. If the models are not accurately occluded, then the mounting must be repeated,
or small modifications made to the models [Model Grooming].
Figure 3.26a, b, c, d, e Illustrates the Sequence to Record the Occlusion when

Providing an Indirect Restoration.
It illustrates the use of:
1. the Preparation Only Bite, using Pattern Resin,
2. Shimstock to check the other teeth are still touching.
a b
c d
Fig. 3.26 (a–e) The use of occlusal sketch, shimstock and preparation only bite record in the
conformative approach to PROVIDE AN INDIRECT RESTORATION AT LR6.
(a) STEP 1 Mark the occlusion, using 40 μ articulating paper. STEP 2 Record the existing
Occlusion using the Occlusal Sketch. (b) STEP 3 Find the contacts that hold the Shimstock [Shim
Check contacts]. STEP 4 Record these on the Occlusal Sketch (c) Step 5 Make the ‘Prep Only
Bite’ (d) Dental Nurse’s Job. Step 6 Ensure that the ‘Prep Only Bite’ has not separated any of the
‘Shim Check Contacts’ (e) Finally using the same holding contacts, the Dental Nurse can check
the Occlusion of the Temporary Crown
Stage 2 of the E.D.E.C. Protocol D. Design
–– Stage 2a: by the Dentist.

–– Stage 2b: by the Technician.
Stage 2a: D. Design by the Dentist
Indirect Restorations: Design of Preparation by the Dentist

but with the ‘Second Operator’ in Mind
From an occlusal point of view, the tooth preparation is designed in exactly the same
way as for a direct restoration. The fundamental differences are that firstly the tech-
nician is going to make the restoration and secondly that, dependent on the material
to be used, there will be certain requirements with regard to sufficient clearance
between the top of the preparation and the opposing teeth (Fig. 3.27).
Fig. 3.27 Use of flexible

bite gauge
If, because of clinical considerations (e.g. nearness of the pulp), the clinician
suspects that the technician may not have sufficient room, for say an adequate thick-
ness of porcelain in a metal ceramic crown, then it is much better to give the techni-
cian permission to reduce the height of the opposing tooth than to risk a high crown.
It is essential in this situation to advise the patient at the preparation appointment
that adjustment to the opposing tooth may be necessary next time, giving the reason.
Patients will accept a dentist adjusting an opposing tooth is the explanation is given
before the crown is fitted; after the crown is fitted the adjustment and its justification
likely to be interpreted as an excuse for poor workmanship.
Stage 2 of the E.D.E.C. Protocol D. Design 69
The difference between an Excuse and a Reason is Timing.
Alternatively, once the models have been cast in the laboratory, and after discus-
sions between dentist and technician, it may be decided that the best course of
action would be to further reduce the height of the preparation. In this circumstance
this can be done simply by the use of a coloured separator medium on the die, or
very accurately by the use of a transfer coping with an open top made to fit the
adjusted height of the preparation (Fig. 3.28).
Fig. 3.28 Transfer coping to indicate by how much the preparation has been reduced in the
laboratory
Stage 2b: D. Design by the Technician
When considering the design of an indirect restoration, the Occlusal Prescription

that is ideal will vary depending upon the condition and circumstance of that tooth.
Figure 3.29a shows an upper canine that had suffered a significant fracture
involving the labial subgingival aspect of the root. Clearly to have prescribed an
occlusion for the crown after post and core placement, that provided Canine
Guidance would have been foolhardy.
a b
Fig. 3.29 Canine Guidance isn’t always “ideal”. There are no rules
This despite the fact that in many situations Canine Guidance is considered the
Ideal. Here Canine Guidance would not have been ideal for this tooth.
There Are no Rules in Occlusion!
Figure 3.29a shows how the dynamic Occlusion was recorded before the restoration
of this tooth.
By marking and recording the static and dynamic occlusion of the adjacent teeth
at the Design [D of E.D.E.C.] stage, it was possible to Execute [E of E.D.E.C.] this
restoration in such a way as not to occlusally overload this tooth. It was possible to
Check [C of E.D.E.C.] the Occlusal Prescription of the final crown against the
Occlusal Sketch Record of the Dynamic and Static Occlusion before the crown was
cemented.
The design of Indirect Restoration is often done exclusively by the Technician,
although the ultimate responsibility lies with the Dentist.
Even if the dentist does leave it entirely to the technician, the dentist must pro-
vide the technician with the records that will be needed to design an appropriate
[Ideal] Occlusal Prescription. Some of these records are described.
Techniques to Aid the Design of Indirect Restorations
The Customised Anterior Guidance Table [C.A.G.T.]
This is a technique by which a template is made of the existing or designed guidance

of the upper anterior teeth. It is made to fit the Articulator. It enables the technician
to provide new restorations to the front teeth that conform to the envelope of move-
ment that the table has recorded.
It may sound a complex procedure, but in reality, it is an easy exercise to per-
form, for a dentist or dental technician.
Firstly, it will help to understand what is the aim of a C.A.G.T. Put at its most
succinct we are trying to create a ‘static record of a dynamic movement’.
This means that we will make a template that will guide the upper member of the
articulator [the part of an articulator that moves] to follow the same envelope of
movement as the patient exhibited when they move their lower jaw to each side.
So, this is a tool to use in the Conformative Approach, but now it is the Dynamic
Occlusion that is being copied.
What is being copied will depend upon the case:
1. It may be the patient’s pre-existing Occlusion.
For instance, if a patient needs some veneers or crowns on some of their upper
anterior teeth, and it has been decided to copy, for functional and aesthetic reasons,
the existing guidance on the unrestored teeth, the use of a C.A.G.T. can ensure that
the technician conformed to and not changes the pre-existing guidance.
Techniques to Aid the Design of Indirect Restorations 71
a b
Fig. 3.30 Use of Custom Anterior Guidance Table
Figure 3.10a, b shows a case where it was decided to conform by designing the
wings of the adhesive bridge that did not remove the existing Dynamic Occlusal
contacts.
If it had been decided that the wings needed to cover all of the palatal surfaces of
the abutment teeth [or nowadays: tooth], then a C.A.G.T. could have been used to
ensure that the occlusion of the bridge did not substantially change the guidance.
2. If the restoration of the upper anterior teeth has involved a Provisional Restoration
Stage, it is used to test, over an extended period of time, the function and appear-
ance of well-fitting acrylic crowns. After these provisional restorations have
proved to be aesthetically and functionally satisfactory, the guidance and shape
must be copied. A C.A.G.T. will facilitate this objective.
3. If the Design of the proposed restoration(s) has been determined by a Wax Up,
then the C.A.G.T. can facilitate the transfer of the envelope of movement of the
wax up to the articulator, before the final restoration is being made.
Figure 3.30a, b shows how a C.A.G.T. was constructed from the pre-operative
study model (Fig. 3.30a). Then when the upper anterior teeth have been prepared
[losing, for ever, the Anterior Guidance to which the patient had accommodated],
the C.A.G.T. provides a guide to the technician so that he or she could conform to
the pre-treatment Dynamic Occlusion (Fig. 3.30b).
Customised Anterior Guidance Tables may be made from many different

materials:
• Light Cured or Autopolymerising Special Tray Material.
• Light Cured Composite Material (preferably out of date material).
• TAK Hydroplastic Beads.
Functionally Generated Pathway
The great advantage of this technique is that it produces a hard record of both the
opposing static and dynamic occlusions in only three stages, two of which are car-
ried out in the mouth. There is, therefore, much less room for error.
The construction of a functionally generated pathway is often considered to be
difficult and a ‘special’ procedure in much the same way as the use of a facebow or
rubber dam. In reality and in common with these other techniques it becomes, with
practice, simple, logical and a time saver.
Technique: A soft, plastic material (e.g. tacky wax) is applied to the teeth, and the
patient is asked to perform a lateral excursive movement on that side. This carves
grooves into the wax that represents the movement, e.g. ‘pathway’ of the lower teeth
relative to the upper teeth. This impression is then cast in the mouth using a quick
setting plaster applied with a brush. The cast can then be mounted in the laboratory,
and used, in conjunction with the ‘normal’ opposing model.
Alternatively, and probably easier, the patient is asked not only to bite together
in centric occlusion (Fig. 3.31a and b) but also to go into excursive movements
(Fig. 3.31c). A pattern acrylic (e.g. Duralay or GC Pattern Resin) [22] can be built
up on the prepared tooth, and then, before it sets, the patient carves out a pathway
that the opposing tooth has taken relative to the prepared tooth (Fig. 3.31d and e).
At the laboratory, this record can be mounted on to the working model on a twin
stage articulator [22] (Fig. 3.31f), or two opposing models can be cast on a regular
articulator.
In this way, casts are made not only of the opposing tooth in Centric Occlusion
(Fig. 3.31g), but also of the movements of the opposing teeth (Fig. 3.31h).
So a Functionally Generated Pathway indicates not only where the cusp tips of
the opposing teeth are in Centric Occlusion [static occlusion], but also where they
move relative to the prepared tooth [dynamic occlusion].
Similar to the Customised Anterior Guidance Table, this is a static record of a
dynamic movement.
Dynamic Occlusion Bite Registrations
These records, which are also known as Lateral Wax Records, enable the condylar
angle to be set in the articulator to the value that is comparable with the movement
of the patient’s TMJ (Fig. 3.32a). By doing this, it is possible to accurately antici-
pate the movements of the opposing teeth during mandibular excursive movements.
Setting the condylar angles correctly will be a benefit to the technician when
designing the cuspal angles of the indirect restorations.
If the condylar angle is set wrongly on the articulator, then the model teeth will
not fit into the Lateral Wax Record (Fig. 3.32b).
These records are difficult. In the clinic it is difficult to record one position dur-
ing the patient’s lateral excursion. In the laboratory, the inherent difficulties caused
Techniques to Aid the Design of Indirect Restorations 73
a b
c d
e f
g h
Fig. 3.31 (a) Patient in Centric Occlusion. UR4 is being going to be prepared for a DO inlay. (b)
Wax record of Centric Occlusion. (c) Patient goes into right lateral excursion. (d) Duralay record-
ing the pathway of the LR5 (45) relative to upper premolars during right lateral excursion (e)
Pattern Resin [now set] record of LR5 against upper premolar, including prepared UR4 [DO Inlay
Preparation] (f) Twin stage articulator. (g) Centric Occlusion opposing the inlay preparation of
UR4 (14). Record of opposing Static Occlusion (h) The Duralay record is used to cast an opposing
model. This represents all of the movements that the opposing tooth makes against the UR4 and 5.
Record of opposing Dynamic Occlusion
Fig. 3.32 (a) Wax record is correctly seated, ...indicating that the condylar angle is 45° (scale FH)
Frankfurt Horizontal (KaVo Articulator) (b) Wax record does not fit onto the teeth accurately, ...
because the condylar angle is wrong
by the compressibility of even the hardest waxes [e.g. Aluwax, as illustrated] have
to be managed.
This is why many operators have decided to set the condylar angle to an arbitrary
value of 25 degrees. This still allows some cuspal morphology in the restoration.
Alternatively it is easy to set the condylar angles using observation of the space
or lack of it between the patient’s molars on the non-working side (Fig. 3.33a–c).
Both of these techniques will still reduce the likelihood of introducing unwanted
occlusal interferences in excursive mandibular movements.
Stage 3 of E.D.E.C. Protocol: E. Execute
From an occlusal point of view one of the most significant considerations is the
provision of a temporary restoration that duplicates the patient’s occlusion and is
going to maintain it for the duration of the laboratory phase. The temporary restora-
tion must not only be a good fit on the preparation and against the adjacent teeth but
also be made with an occlusion against the antagonistic teeth; but without changing
the occlusion of the other teeth [Conformative Approach]. In this way the temporary
crown will maintain the same spatial relationship with adjacent and opposing teeth.
By far the easiest way of achieving these aims is to make a custom temporary
crown. With a little preparation, custom temporary crowns can be made quite
quickly. Figure 3.34a–d shows the preservation of the patient’s pre-existing occlu-
sion through the temporisation, laboratory and cementation phases.
Stage 3 of E.D.E.C. Protocol: E. Execute 75
a b
Fig. 3.33 (a) The observed gap between the posterior teeth on the Non-working Side, during a
right lateral mandibular excursion (b) Adjust the Condylar Angle of the Articulator until the gap
between the model teeth is the same as the observed gap between the posterior teeth in the mouth.
(c) If the Condylar Angle is set too high [or low], then the gap between the model teeth will not be
the same as the gap between the patient’s teeth
a b
c d
Fig. 3.34 (a) Prepared tooth with occlusal marks on adjacent teeth. (b) Temporary crown in place
with occlusal marks on adjacent teeth (c) Definitive crown on mounted model (d) Definitive crown
in mouth, with occlusion marked
Stage 4 of the E.D.E.C. Protocol: C. Check
Checking the occlusion of the restoration that we have provided in the Conformative
Approach involves answering the following questions:
1. Are the Occlusal Contacts of the other teeth exactly as they were before we started?
It is impossible to answer this question unless the Pre-treatment Occlusion was
examined [and maybe recorded] before starting treatment.
2. Is the Static Occlusal Contact [Occlusal Stop] on the new restoration as ideal as
possible?
Is there a cusp tip to fossa or marginal ridge contact?
If possible, are the contacts in line with the long axes of both teeth?
[No Incline Contacts].
3. (a) Posterior Restoration:
Unless we have decided to copy an existing Posterior Interference, have we
ensured that there is no Dynamic Occlusal contact during excursive move-
ments of the mandible?
(b) Anterior Restoration:
Does our new restoration provide the same anterior guidance as the tooth did
before restoration?
an the Occlusion of Other Teeth Be Improved during

C
the Conformative Approach?
Figure 3.4a–d shows how a tooth was restored, within the Conformative Approach,
but with a better Occlusal Contact before treatment. It is still with the Conformative
Approach because the occlusion between the other teeth was altered.
Some restorative authorities advise that teeth that are not directly involved in the
restoration (tooth to be restored and its opposing tooth) can be altered to improve
the occlusion, within the ‘Conformative Approach’.
It is an attractive idea to try to improve the occlusion of the surrounding teeth, by
say removing the incline contacts. The difficulty is to be certain that a small change
to the occlusion to other teeth is not changing deflecting contacts and so changing
the jaw relationship.
If modification to these deflecting contact teeth is envisaged, with the implicit
risk of a change in Jaw Relationship, there is a need to use the Re-Organised
Approach. This is true, no matter how few teeth are being restored. Sometimes the
restoration on just a single tooth can result in a change in the jaw relationship and a
consequential unbalanced occlusion for the patient. Occlusal adjustment to multiple
teeth with a consequential change in the jaw relationship is a complex and careful
procedure requiring planning. It is called ‘Equilibration’ and will be described in
the next chapter as part of the Re-Organised Approach.
References 77
In the Conformative Approach Only modify Occlusal Contacts when you

know that they are not Deflecting Contacts [Premature Contacts in Centric
Relation].

4. Compare the patient’s occlusion against the benchmark of Ideal Occlusion.
5. A simple, two-dimensional record of the patient’s occlusion taken before,
during and after treatment is an aid to Good Occlusal Practice.
6. The Conformative Approach is the safest way of ensuring that the
occlusion of a restoration does not have potentially harmful
consequences.
7. Ensuring that the occlusion conforms to the patient’s pre-treatment
state is a product of Examination, Design, Execution and Checking
(the E.D.E.C. protocol).
References
1. Beyron H. Optimal occlusion. Dent Clin Amer. 1969;13:537–54.
2. Celenza FV, NasedkinJ N. Occlusion. The state of the art. Chicago: Quintessence Publishing
Co.; 1978.
3. Dawson PE. Evaluation, diagnosis, and treatment of occlusal problems. St Louis: C V
Mosby; 1989.
4. Gross MD, Mathews JD. Occlusion in restorative dentistry. London: Churchill
Livingstone; 1982.
5. Howatt AP, Capp NJ, Barrett NVJ. A colour atlas of occlusion and malocclusion. London:
Wolfe Publishing Ltd; 1991.
6. Lucia VO. Modern gnathological concepts. St Louis: C V Mosby Co; 1961.
7. Mann AW, Pankey LD. Oral rehabilitation. Part 1. Use of the P-M instrument in treatment
planning and restoring the lower posterior teeth. J Prosthet Dent. 1960;10:135–42.
8. Pameijet JHN. Periodontal and occlusal factors in crown sand bridge prosthetics. Dental
Centre Postgraduate Courses; 1985.
9. Schluger S, Yuodelis T, Page RC. Periodontal disease — basic phenomena. Clinical man-
agement and occlusal and restorative interrelationships. Philadelphia: Lea and Febiger; 1977.
p. 392–400.
10. Schuyler CH. The function and importance of incisal guidance in oral rehabilitation. J Prosthet
Dent. 1963;13:1011–29.
11. Stewart CE. Good occlusion for natural teeth. J Prosthet Dent. 1964;14:716–24.
12. Stuart CE, Stallard H. Principles involved in restoring occlusion to natural teeth. J Prosthet
Dent. 1960;10:304–13.
13. Celenza FV, Litvak H. Occlusal management in conservative dentistry. J Prosthet Dent.
1976;36:164–70.
14. Foster LV. Clinical aspects of occlusion:1. Occlusal terminology and the conformative

approach. Dent Update. 1992;19:345–8.
15. Applied Occlusion Page 9 Wassell Naru, Steele, Nohl Quintessence ISBN: 9781850970989.
16. Davies SJ, Gray RJM, Al-Ani MZ, Sloan P, Worthington H. Inter- and intra-operator reliability
of the recording of occlusal contacts using the ‘occlusal sketch’ acetate technique brit. Dent
J. 2002;193:397–400.
17. Davies SJ, Al-Ani MZ, Richmond R, Worthington HV. P S Smith occlusal sketch: a reliable
technique for technicians to check the occlusion of marked models Eur. JProsthodontRestDent.
2005;13:65–8.

2005;94:458–61.
19. Murray MC, Smith PW, Watts DC, Wilson NFH. Occlusal registration: science or art? IntDent
J. 1999;49:41–6.
20. Walls W. Steele a comparison of two methods for locating the intercuspal position (ICP) whilst
mounting casts on an articulator. J Oral Rehab. 1991;18:43–8.
21. Wassell RW, Ibbetson RJ. The accuracy of polyvinyl siloxane impressions made with standard
and reinforced stock trays. J Prosthet Dent. 1991;65:748–57.
22. Baylis MA, Williams JD. Using the twin-stage occluder with a functionally generated record.
Quint Dent Technol. 1986;10:361–5.
Good Occlusal Practice in Advanced
Restorative Dentistry 4
In most patients, their Occlusion is functional, comfortable and aesthetic. So, if a

tooth or teeth need to be restored, the most appropriate way to provide the
restoration(s) is not to change anything: the static and dynamic occlusions or the
jaw relationship of their pre-treatment Centric Occlusion, i.e. to adopt a
‘Conformative’ Approach.
The patient’s occlusion may not, in fact usually will not, fulfil the old fashioned
and redundant definition of an Ideal Occlusion, which is:
• ‘Centric Occlusion occurring in Centric Relation
• Free of Posterior Interferences.
• Freedom in Centric (occlusion)’.
This is because the pre-treatment occlusion and jaw relationship is ideal for that
patient. We know this because we have examined for adverse reactions to that occlu-
sion and found none.
So, following the Conformative Approach is both common sense and a good
practice. It is an example of the ‘If it isn’t broken, don’t fix it’ maxim.
There will, however, be situations where the Conformative Approach cannot be
followed. It is important to be able to recognise these and to have strategies and
protocols to be able to successfully restore a mouth to the ‘Re-Organised Approach’.
This section aims to describe what is ‘Good Occlusal Practice’ in the
‘Re-Organised Approach’.

https://doi.org/10.1007/978-3-030-79225-1_4
80 4 Good Occlusal Practice in Advanced Restorative Dentistry
In this part, we will discuss:

• The re-organised approach.
• When and how to re-organise an occlusion in restorative dentistry.
The term ‘Re-Organised Approach’ may conjure up the idea of mouth full of
crowns and bridges.
This may be the case in rare situations, but it is not only the ‘major’ cases that
need the extra thought and processes that comprise the Re-Organised Approach’.
Equally often with some care in designing the treatment plan, a complex case can
be broken down into sequences so that the Conformative Approach can be followed.
This will be illustrated in addition to a description of how to ‘re-organise’ an
occlusion.
• The ‘conformative approach’ is not always possible or appropriate for

‘small cases’.
• The ‘re-organised approach’ is not always needed or appropriate for
‘large cases’.
When Is the Conformative Approach Not Appropriate?
Answers:
1. When it is not possible.
2. When it is not wanted.
1. When it Is Not Possible
This appears to be stating the obvious. But there are some caveats.
Firstly: Changing the occlusion may not be inevitable, even in complex cases.
It may be that a carefully designed treatment plan will always leave sufficient
reference points of the pre-existing occlusion. This will mean that the new restora-
tions can be provided to an occlusion which does maintain the pre-treatment jaw
relationship. This is the Conformative Approach and is sensible to adopt it for a
patient who has had no adverse reactions to their existing Occlusion, within the
Articulatory, Dental or Periodontal Systems.
lternative Preparation (‘Prep One/Miss One’) Technique

A
Figure 4.1a–c shows a theoretical case where by preparing alternative teeth, and
taking bite registrations after the first two teeth (LL4, LL6) were prepared; the
When Is the Conformative Approach Not Appropriate? 81
a b
Fig. 4.1 (a) Pre-operative view before proposed crown preparation of LL4, 5, 6, 7 (34, 35, 36, 37).
(b) LL4 (34) and LL6 (36) are prepared and Duralay ‘bites’ taken on these teeth using occlusal
contacts on LL5 (35) and LL7 (37) to ensure the ‘conformative approach. (c) All teeth are now
prepared, but bites against LL4 and 6
pre-existing occlusion and jaw relationship is be preserved by the unprepared teeth

(LL5, LL7). The intermediate registrations, as seen in Fig. 4.1b, become the refer-
ence point after those teeth (LL5, LL7) are prepared (Fig. 4.1c). All of these prepa-
rations could have been done in the same visit; the only ‘extra’ work would have
been the intermediate bite registrations on teeth LL4 and 6. Alternatively, if this
seems a bit too complicated or risky, the dentist may choose to prepare and fit the
crowns of the first phase before starting the second phase, at a different appoint-
ment. The important thing to avoid, in this theoretical case, is simultaneous removal
of the occlusal surfaces of all four teeth by the sweep on a large diamond bur, only
to then wonder how to take an accurate bite record. That action could cruelly be
called the Un-organised Approach [1].
Figure 4.2a shows the right side of the posterior occlusion for a patient, who had
undergone a full mouth restoration that had been poorly designed. The LHS poste-
rior occlusion was also inadequate. The crowns on the lower anterior teeth needed
to be replaced before the posterior occlusion could be restored as they were ill fit-
ting with consequential gingival irritation. The dilemma was, therefore, to replace
the lower anterior crowns without changing the Jaw Relationship. This was achieved
by the Alternative Preparation Technique (Fig. 4.2b, c).
a b
c
Preps
Old Crowns
Fig. 4.2 Alternative Prep Technique
The reference points of the pre-existing occlusion may be lost with the first
sweeps of the air rotor.
‘Unorganised’: not formed into an orderly whole—Oxford English

Dictionary (OED).
‘Organise’: to give a definite and orderly structure.—OED.
• The E.D.E.C. protocol principle when restoring complex cases to the

Conformative Approach.
• E = Examine the pre-existing occlusion.
• D = Design an operative procedure which allows the conformative
approach.
• E = Execute that plan.
• C = Check that each stage of the restoration conforms to the occlusion of
the previous stage.
Fig. 4.3 (a, b) Shows a case involving the restoration of most of the teeth
Figure 4.3a illustrates the stages that were needed to ensure that it was possible
to design a Conformative treatment plan.
The stages followed the phases of the E.D.E.C. protocol.

E. Firstly in addition to an assessment of the dental and periodontal conditions,
an Articulatory System Examination was used to check for any Temporomandibular
Disorder and to record the pre-existing occlusion and jaw relationship.
D. The new occlusion was designed using a wax up of some models, but in the
same jaw relationship.
E. This design was carefully executed in a sequential treatment plan.
C. With many checks built into the process (Fig. 4.3b).
The juxtaposition to a large case that can, with careful planning, be done to the
Conformative Approach is the small case in which the clinician needs to be alert that
the Conformative Approach will not be easy. This is the situation as presented in
Fig. 4.4, where because of an incomplete examination or lack of planning it was not
recognised that the provision of a single crown for the patient without changing the
existing occlusion and jaw relationship proved very difficult.
This was because the dentist intending to restore the tooth to the pre-existing
occlusion/jaw relationship destroyed the occlusal surface of the one tooth that deter-
mined where that jaw relationship was.
It is important to realise that the jaw relationship can change by the loss of one
occlusal contact, during the preparation of one tooth. It can be avoided by following
the E.D.E.C. principle, and any of the techniques described above.
Fig. 4.4 Contrast the occlusion in the jaw relation of C.O. with C.R.
Figure 4.4 shows the mounted models of a patient who needed a crown on the
lower right second molar. The first photograph shows the patient’s habitual bite, or
Centric Occlusion (C.O.). The second photograph shows the same models mounted
in Retruded Jaw Relation or Centric Relation (C.R); the first contact in C.R. is
shown by the arrows.
This premature contact in C.R. could be described as the Deflecting Contact; that
is to say that this contact plays a role in deflecting or guiding the jaw relationship
away from the Terminal Hinge Axis of C.R. to the Jaw Relationship in which the
teeth fit together (C.O.).
Deflecting Contact
Don’t imagine a patient closing onto the first contact in C.R., then sliding into
their C.O.
It is more accurate to think that this first contact teaches the patient to avoid
it when closing. So they close directly into the jaw relationship of their C.O.,
by means of a learnt motor engram.1
Another example of maintaining the occlusion/jaw relationship that could have

been used in this case, where the tooth to be prepared provided an important Centric
Stop, is the ‘Preserving the Centric Stop’ technique. Surprisingly this technique,
first described in 1983, [2] is not commonly used. It provides a simple and elegant
solution to the problem of preserving the same occlusion when there are few occlu-
sal land marks; a situation often seen when restoring the last tooth in the arch.
Figure 4.5a–g illustrates this technique.
Preserving the Centric Stop for Bite Record

Surgery
1. Mark the Centric Stop.
2. When doing the Preparation, do not cut down the Centric Stop.
3. Take Imps and Bite.
4. Make temporary crown allowing for preserved Centric Stop (see Fig. 4.5g)
or Remove Centric Stop to Fit Temporary.
Laboratory
1. Cast Impression.
2. Mounted Models …… using.
Preserved Centric Stop and the bite record.
Only then
1. Remove Centric Stop on Model.
2. Make Crown or Bridge.
see Chap. 2 for explanation of (Motor) Engram.

1
a b
f g
Fig. 4.5 (a) Teeth prepared for crown, but with the Centric Stops preserved. (b) Small check
impression taken before rubber dam is removed. (c) Mounted Model of full arch impression. (d)
Digitised lower model AFTER technician has removed Centric Stops. (e) Crowns on mounted
models [the buccal aspects of the teeth anterior to the crowns is not accurate, because the patient
was in fixed orthodontic brackets]. (f) Checking that the occlusion of the other teeth is preserved.
(g) the temporary crowns placed onto the working model to illustrate where the Centric Stops were
When the Conformative Approach Is Not Adopted, There Are Only Two Possibilities 87
Question: When Is the Conformative Approach Not Appropriate?
1. When it is Not Possible
So far we hve discussed ways by which an initial analysis that suggested that the
Conformative Approach was not possible, would be overcome. There will, of
course, be situations that the Conformative Approach is impossible; the techniques
employed to adopt the Re-Organited Approach are discussed later.
The Second scenatio is when the Conformative Approach is not desirable:
2. When it Is Not Wanted
It may be that the treatment objectives, of the dentist and patient, exclude the
‘Conformative Approach’.
Examples would be:
• An increase in vertical height is wanted or indicated.
• A tooth or teeth is/are significantly out of position (i.e. over-erupted, tilted or
rotated).
• A significant change in appearance is wanted.
• There is a history of occlusally related failure or fracture of existing restorations.
hen the Conformative Approach Is Not Adopted, There Are

W
Only Two Possibilities
First Possibility
Plan to provide new restorations to a different occlusion, which is defined before the
work is started: ‘visualise the end before starting the beginning’. The Re-Organised
Approach. The E.D.E.C. protocol can be used to achieve this.
The E.D.E.C. Principle in the Re-Organised Approach
E = Examine
• the existing occlusion (Centric Occlusion), including jaw relationship
in which it occurs.
• Determine which teeth occlude in C.O.
• Find and Record Centric Relation (Retruded contact position, Terminal
Hinge Axis).
• Record which teeth touch in CR (Premature Contact).
• Observe the direction of the slide for the Premature contact to CO.
D = Design and plan the new occlusion. This may involve:

• Models mounted in CR.
• Equilibration of those models (Mock Equilibration), and equilibration
of the patient’s existing dentition.
• Design wax up.
E = Execute the new occlusal prescription to the Design created above.

C = Check that you are conforming to this newly designed occlusion in the
definitive restorations.
Second Possibility
Change the occlusion, without having planned the new one and the jaw relationship
in which it occurs. This occlusion will not be the same (i.e. will not conform) with
the previously well-tolerated one.
It is an occlusion that has been arrived at by accident, and one has to hope that
the patient can adapt to it. This is ‘I hope that I get lucky, and the patient can
adapt’ Approach. See section below on: ‘What are the Risks of Changing the
Patient’s Occlusion?’
What Is the Treatment Objective of a Re-Organised Occlusion?
At its very simplest, it is to provide restorations, which although changing the occlu-
sion are likely to be well tolerated by the patient, at every system level. It is not a
guarantee that the patient will be able to tolerate the new Occlusion and Jaw rela-
tionship, but by following the perceived wisdom [3] of providing:
• A Balanced Occlusion in the Ideal Jaw Relationship (Centric Occlusion in
Centric Relation).
• No Posterior Interferences in the Dynamic Occlusion (Anterior Guidance at the
front of the mouth, i.e. Canine Guidance or Group Function).
• Freedom in Centric Occlusion (the mandible is not locked in by the front teeth
contacting sooner or harder than the back teeth).
Malocclusion 89
In addition to these Guidelines, which relate to the Articulatory System, the

Occlusion would be considered ideal on the Tooth Level, if it provides:
• Multiple simultaneous contacts.
• No cuspal incline contacts.
• Occlusal contacts that are in line with the long axes of the restored teeth.
• Smooth and, wherever possible, shallow guidance contacts.
By following these Guidelines of the Re-Organised Approach, a dentist is mini-

mising the likelihood of an adverse reaction when it is either inevitable or desirable
to change the occlusion.
An adverse or poorly tolerated reaction to Occlusion may be within any of the
systems of the Masticatory or Stomatognathic System.
The adverse reactions include the following:
1. Articulatory System

Although there is no evidence that ‘poor occlusion’ can cause a Temporomandibular
Disorder, many dentists who specialise in the management of Temporomandibular
Disorders and/or complex restorative cases have experience of patients not being
able to tolerate a change in their occlusion.
2. Periodontal System

• Occlusal Trauma to the periodontal tissues can lead a reversible hypermobility.
Good Occlusal Practice in Periodontology is the subject of a separate chapter in
this book.
3. Dental Tissue System

• Fracture of restorations or of the teeth.
• Excessive tooth surface loss.
• Hypersensitivity, and even Irreversible Pulpitis [4].
Singularly or collectively these represent unwanted outcomes to dental treatment

and contravene the first rule of treatment: ‘Do No Harm’.
Most dentists who have been actively involved in the provision of extensive
restorative treatment plans have some experience of the distress that any or all of
these sequalae can create.
This is why those dentists who do provide extensive restorative treatments will
try to reduce the chances of their patient reacting adversely to the new Occlusion/
Jaw Relation. For this reason, the goal of the Re-Organised Approach is the provi-
sion of an occlusion according to the perceived wisdom as listed above.
Malocclusion
No occlusion can be said to be ‘intrinsically bad’; an occlusion may only be judged

by the patient’s reaction to it. For this reason, many prefer the term: MalAdaptive
Occlusion [5]. It puts the patient’s reaction to the occlusion at the centre of the
diagnostic assessment of an occlusion. Judging an occlusion only by the patient’s

reaction to it may mean the pejorative term; ‘Malocclusion’ is meaningless [6]. No
matter what terminology and the philosophy behind it is used, it is universally
accepted that it is indefensible for a dentist to irreversibly and invasively change a
patient’s occlusion because they do not like the look of it, or it does not conform to
what they think is a good occlusion (should we call this: “Bonocclusion”?).
How to Re-Organise an Occlusion So That It Is ‘Ideal’?
So the starting point of the Re-Organised Approach is the realisation that the Con-
formative Approach is either not possible or not appropriate to the patient’s needs.
Re-Organised Approach Has Two Stages
1. Design the New Occlusion in Centric Relation

2. Execute that Design
So essentially the only difference between the Conformative and the Re-Organised
approaches is that the Re-Organised approach is the conformative approach with the
extra and pre-treatment phase of designing a new occlusion, and then maybe execut-
ing that design in provisional restorations, before providing the definitive or ‘final’
restorations.
It is useful, therefore, to consider a major restorative case by dividing the
Re-Organised Approach into two distinct parts:
1. careful and detailed design of the new occlusion
followed by
2. meticulous adherence to that design.
This makes for a slower treatment of the patient but it will produce a successful
outcome. Those dentists and patients who opt for a ‘diving in quickly’ approach
frequently come to regret at their leisure.
In summary, it is impossible to confidently proceed directly to changes in the

occlusal scheme. For the most part some form of ‘mock up’ is employed, usually in
the form of a wax-up.
Planning (Design) and managing (Following that Design) change in occlusal
relationships is a challenge. But the changes are ideally made in the provisional
restorations, then providing the definitive restorations is a matter of copying that
design; i.e. it becomes the ‘Conformative Approach’, where the conformity refers to
copying the carefully prepared design.
HASES of Providing Restorations

P
to the Re-Organised Approach
The E.D.E.C. protocol can be used in the Re-Organised Approach to provide a

phased approach.
Step 2 The Examination Phase E.D.E.C. 91
It is similar to its use in the Conformative Approach as described in the previous

chapter.
But it is more complicated. In particular it has a much more important Design Phase.
Step by Step Technique of Providing Restorations to the Re-Organised

Approach (following the E.D.E.C. principle, see Box “The E.D.E.C. principle in
the Re-Organised Approach”).
Step 1 of the Re-Organised Approach is to try to find a way of

avoiding it.
This has been discussed above.
Step 2 The Examination Phase E.D.E.C.
A comprehensive examination of all of the Stomatognathic (or Masticatory) System

will need to be conducted. This involves:
• Teeth.
• Periodontal Tissue.
• Articulatory System.
Any active pathology in the teeth or periodontia must be identified and stabilised.
With the exception of the occlusal analysis, these examinations are outwith the ref-
erence of this book.
(E = Examine the existing occlusion)

Recording Jaw Relationships.
The first essential part of the examination is to determine whether the patient’s
existing Centric Occlusion occurs in Centric Relation.
If CO does occur in CR, then there is no need to employ the Re-Organised
Approach as, although proposed restorations may improve the occlusion, they will
be provided those restorations in the same Jaw Relationship (so we are using the
Conformative Approach).
If on the other hand, and as will usually be the case, CO does not occur in CR,
and if the dentist has decided that the Conformative Approach is not an option, the
process of restoring the mouth to the Re-Organised Approach begins.
Step 2.1 Is to Find Centric Relation and then to Record the

Teeth That Touch in the Premature (or First) Contact in
Centric Relation
This was covered in Chap. 2.

There are various ways in which these records can be taken; Fig. 4.6a–c shows a
simple technique. A small piece of warm impression compound (Greenstick) is
applied to the upper anterior teeth. Whilst it is still soft, the operator gently guides
a b
c d
e f
Fig. 4.6 Recording centric relation jaw relationship
the patient’s mandible into the compound. The mandible should be following a near
perfect arc, indicating that the head of the condyles are in Terminal Hinge Axis
(Chap. 1). This is in the rotational phase (as opposed to the translationary phase) of
TMJ movement. The rotational phase is the beginning of the opening or the end of
the closing cycle. Once the greenstick has cooled and hardened it will act as a tem-
plate to guide the patient into Centric Relation. Then inter-arch records can be taken
to record this jaw relationship.
Sometimes this record is taken at the first touch between the teeth that make up
the premature contact; at other times, because the operator can sense that as soon as
this premature contact is achieved the patient’s mandible tenses, the record is taken
just short of the premature contact. Then we must rely on the facebow record to
allow the technician to close the last bit on the articulator, without significant devia-
tion from the patient’s closing arc.
Step 2 The Examination Phase E.D.E.C. 93
Figure 4.6d–f illustrates the ‘Gothic Arch Trace Technique’ [7]. This uses a small
platform of auto-polymerising acrylic on the upper incisors, and shaped so that only the
tip of one lower incisor touches against it. The patient then makes excursive movement
with articulating paper held between the acrylic and the ‘stylus’ of the lower incisor.
This creates the traces, as shown, in Fig. 4.6a, c. This technique may have more cer-
tainty about finding Centric Relation, because the point at which the lateral and protru-
sive traces conjoin can be considered to confirm Centric Relation. But it can be a
challenge when using some bite registrations material between the back teeth to ensure
that the patient closes onto that point, so allowing for an accurate interarch record.
Step 2.2 Mount and Verify the Accuracy of some Models
In order to design the new occlusion, some models will need to be mounted in a
semi-adjustable articulator, in Centric Relation. The mounting and models must be
accurate. If the mounting of the models does not replicate what is in the mouth, their
value is nullified or at least reduced.
So, the mounted models should be verified. This can be done against the patient
or often more conveniently against records that have been taken of the occlusion.
There are various means of checking that the occlusion as marked on the models
is the same as was found in the mouth. These include photography and written
records, and the Occlusal Sketch technique [1, 8].
Figure 4.7a shows a note to the laboratory technician pointing out the occlusion on
his models was different from the record on an Occlusal Sketch which was the record
of the patient’s occlusal marks. This means that either the models or the mounting was
inaccurate. In this case it was the Centric Occlusion that was being verified. Using
Fig. 4.7b, the reader can, if they wish, see if they can spot the four differences between
the Occlusion of the models and Occlusal Sketch record of the patient’s CO.
By contrast, Fig. 4.7c illustrates how the Occlusal Analysis section of the Articulatory
System examination was used to confirm that the mounting of some models gives the
same premature contact in CR as was found in the mouth, confirming that the models
had been mounted in the patient’s Centric Relation jaw relationship.
Step 2.3. Model Grooming
If the Model Verification process shows that the mounting of the models is wildly
inaccurate, then probably to ensure any sort of predictability in our proposed resto-
rations it will be necessary to start again.
Thankfully, it is unusual that the error is that large. More commonly there will be
some minor discrepancies, which can be reduced by a procedure called Model
Grooming. This is an anathema to some authorities; they take the view if the mount-
ing of the models is inaccurate then the only option is to take the records and start
again. A more pragmatic view is if the accuracy of the models can be improved by
models adjustment then they are still useful. Consequently, the concept of Model
Grooming can be seen as a means of achieving Verifiably Accurate Mounted Models.
See Fig. 4.8a–i.
what are the differences?
MOUNTED
MODELS
MOUTH
Fig. 4.7 Model verification

Step 3 Only now the Design Phase (E.D.E.C.) can begin 95
Record of
c Premature
contact in CR
Lower Right
Fig. 4.7 (continued)
The Examination Phase (E.D.E.C.) is complete when the dentist has some
accurate Study Models, mounted in Centric Relation.
• The examination phase of the process is completed when the clinician has
a set of articulated models that are an accurate representation of the
patient’s occlusion and jaw relationship.
Step 3 Only now the Design Phase (E.D.E.C.) can begin
This is essential to the concept of Re-organising the Occlusion: the provision of new
occlusion for the patient that is prescribed to be as Ideal as possible.
This Design Phase is the essential difference between the Conformative and
Re-Organised Approaches. Once the design of the new Occlusion has been devel-
oped on the Articulator, then the challenge for the dentist and technician is to copy
that design or Conform to that design.
Fig. 4.8 (a) The Occlusal Contacts are marked on the upper teeth, and recorded on an Occlusal
Sketch. Static Occlusion is in Blue NOTE the Occlusal Contact against the Palatal Surfaces of the
Upper Anteriors and on the mesial aspect of the Palatal Cusp of the UR4. (b) Similarly the Occlusal
Contact on the lower teeth are viewed from above in the surgery. Then recorded on an Occlusal
Sketch. (c) Shows there to be some differences between the mounting of these models, and the
record of the patient's occlusion, as recorded on the Occlusal Sketch. (d) Illustrates these discrep-
ancies. (e–h) Shows that after very few minutes of adjusting the heaviest contacts on the models
that the discrepancies between the patient's occlusion, recorded by the Occlusal Sketch, and the
occlusion on the mounted models are eliminated. (h) Model grooming is completed
c d
No marks
on the models
e f
g h
The Design Phase may include:
• Mock Equilibration.
• Equilibration of Natural Teeth and Existing Restorations.
• Pre-restorative Orthodontics.
• 2Diagnostic Wax Up
• Provisional Restorations.
Step 3.1 Mock Equilibration
This is sometimes indicated and appropriate.

The aim of this procedure is to see whether by minor adjustments to the teeth that
it will be possible to create a Centric Occlusion in Centric Relation. To discover
Please note that a Wax Up is not a diagnostic procedure or test.

2
From now on the term ‘Design Wax Up’ will be used.

this, two sets of models mounted in Centric Relation will be needed. Then it will be
possible for the Clinician, Technician and patient to compare the equilibrated mod-
els to the original untouched ones.
This procedure is not ‘spot grinding’. Rather it involves careful adjustments to
the slopes of the cusps, in order to create a situation where the cusp tips hit against
a flat part of the opposing tooth, normally the central fossa or marginal ridges. When
sensitively and carefully done, it will improve the morphology of teeth rather than
will reduce or destroy morphology as spot grinding can.
Figure 4.9a–d illustrates this.
Some dentists consider this beyond their abilities; it is unlikely that it was taught at
Dental School. But with a bit of practice on some models it becomes an intuitive
a b 1
c
1
Fig. 4.9 (a) Ready to Answer the Question: Can this patient’s teeth be equilibrated to create C.O. in
C.R.? (b) Starting Point: Premature Contact in Centric Relation. (c) After minor adjustments it can
be seen on the lower arch that a more balanced Occlusion is being achieved. (d) Centric Occlusion
now occurs in Centric Relation, on the models and so can be achieved in the mouth
d
2
process. This is a skill that can be learned on mounted models. After a period of prac-
tice on models (mock equilibration), the dentist may feel confident to carry out an
equilibration for their patient. If not, then the patient would be referred to a specialist
for this phase of the treatment. But remember the specialist learned how to do it on
some models. The notes that were taken during the model equilibration will, as long
as it was done on accurate models, act as a ‘script’. Adjusting a patient’s occlusion
without seeing that a satisfactory end point is achievable, on the accurate unwanted
models first, is nerve wracking, dangerous and imprudent. Of course, no adjustment to
the models should exceed what the clinician considers to be appropriate in the mouth.
MOCK or Model Equilibration
Answers the question:

‘Can this patient’s teeth be equilibrated to provide a balanced Centric
Occlusion in Centric Relation?’
Figure 4.10a–f illustrates another case, where the difference between CO and CR
looked like it might be too big to allow for an effective equilibration. But after a
relatively short period of time it was possible to achieve CO in CR, without adjust-
ing the teeth to any significant level. It is important to never do anything to the
models that you would not be prepared to do to teeth.
So, in both these cases, the clinician could proceed with some confidence to Step 3.2.
• Duplicated and VERIFIED

Mounted Study Models
• Le Cron carver
• Articulating Paper 40µ
• A Lunchtime
b Models 1 Models 2
Identical and
Mountedin C.R.
Fig. 4.10 Model or MOCK Equilibration

c Models 1
Ready to Go
Models 2
Don’t Touch
From This
d
To This
After
10 MINUTES
Step 3.2 Equilibration of the Natural Teeth
Because the equilibration will already have been performed on the models, the end
point and the adjustments required to reach it will already be known. This is why the
‘mock equilibration’ is essential. Otherwise the clinician might start to wonder
whether they can finish what they have started!
• The aim of equilibration is to effect changes in the Centric Occlusion to give it,
as far as possible, the features of an Ideal Occlusion:
• Multiple simultaneous contacts.
• No cuspal incline contacts.
• Occlusal contacts that are in line with the long axes of the teeth.
• Smooth and, where possible, shallow guidance contacts.
• Centric Occlusion occurring in Centric Relation.
• Freedom in Centric Occlusion.
• No posterior interferences.
This aim of an equilibration (of the teeth or provisional restorations) is to achieve

Ideal Occlusion, before providing definitive restorations. The design that has been
envisaged on the models can be copied in order to realise in the mouth. The occlu-
sion that has been developed in the design phase becomes the template for the defin-
itive restorations.
The equilibration of the teeth is done over two visits with about 1 week’s inter-
val. Obviously, it is never with local anaesthetic.
Step 3.3 Move or Remove Teeth
Sometimes the Mock Equilibration process will show that a tooth or teeth present
such an obstacle to the creation of Centric Occlusion in Centric Relation that it will
need to either be moved to a position that is compatible with the aim of the treat-
ment plan [9] or, in extreme circumstances, be removed. The duplicate models used
in the mock equilibration offer the very best means of demonstrating to the patient
what can and cannot be achieved by equilibration.
Step 3.4 Design Wax Up
Often a wax up is done to fit into the existing conclusion that has been created by
the equilibration process.
However sometimes the clinician will wish to provide in an occlusion that is
much closer to what would have been present, before the premature loss of some
posterior teeth. In this case some means must be used that will design the ideal
occlusal planes on the patient’s mounted models. Accurately mounted and now
equilibrated casts are modified by the application of wax as a mock-up of the final
restorations or prostheses.
Whether this exercise is done by the clinician or the technician does not alter the
fact that the final responsibility of design of the proposed restoration of the mouth
rests with the clinician.
If, therefore, the technician does the wax up it is of paramount importance that
she or he understands that there are clinical limitations to the provision of restora-
tions. It is possible to ‘cheat’ in the laboratory but not in the mouth. To pass the sole
responsibility to the dental technician for the design of an occlusion that the dentist
is going to have to follow and to which the patient is going to have to adapt is either
an act of faith or more likely folly.
The Design Wax Up gives positive information on the occlusal scheme that can be
generated. It is a valuable guide to the treatment objective for both the clinician and
the technician. Both parties should agree on it, before the patient’s teeth are touched.
Doing a Design Wax Up has many advantages:
• It can also reveal information regarding the need for crown lengthening and
orthodontic tooth movement.
• It is a useful guide for the optimum crown preparation.
• It will provide the template for the temporary restorations.
• It gives the patient an opportunity to visualise the treatment and empowers
them to grant informed valid consent.
• It demonstrates to our technician colleagues that we are ‘going the extra mile’.
The greatest difficulty in designing the occlusion in a design wax up is to create

the occlusal planes. This can be assisted by the use of a ‘flag’ on the articulator.
The techniques used are based upon the concept of the ‘Occlusal Plane Survey
Centre’. By the use of this device an approximation of the centre of the curves of
Wilson and Spey can be made (Fig. 4.11).
Fig. 4.11 Occlusal Plane

Survey Centre after
Monson
O.P.S.C
A.S.P.
line
4 inches
(101 mm)
4 inches
Condyle (101 mm)
4 inches
(101 mm)
C.P.S.P.
A.S.P.
M.P.S.P.
Curve of Spee
Although this concept relates to work that Monson did in the 1920s and 1930s, it
still has relevance [10, 11].
It is based upon Monson’s observations that:

• In an ideal occlusion the occluding surfaces of all of the posterior teeth and
the tips of the canines would touched an imaginary sphere.
• The head of the condyles lay on the circumference of the sphere.
• This sphere would have an average radius of approximately 4 in. (or 10 cm).
• The curves of Wilson and Spee, would be arcs on this sphere.
More recently another technique [12] has employed the same concept, although
translating the arbitrary radius as 10 cm.
Although this concept was postulared many decades ago, work done in 1997
using 3-dimensional image analysis substantially confirmed its relevance [13].
Figure 4.12a–f shows the process of using the concept of the O.P.S.C. to create a
design wax up that can closely represent the occlusal planes that would have been
present if the lower left first molar had not been lost (Fig. 4.12g).
a
2
1
The
3 Broadrick 4
Flag
Technique
1-4
on Hanau
Articulator
Fig. 4.12 The use of Broadrick Flag to design an ideal Occlusion

acknowledgement:
www.authorstream.com
c 5
acknowledgement:
www.authorstream.com
5 7
d
6 8 5-8
Cutting the occulusal planesin the wax
from flat occlusal ploanes

f
to carved diagnostic wax up
g E
Design
E
C
before after
The alternative, which could be presented as an option to the patient, has been to
restore the missing lower left first molar to an occlusal plane that would have been
determined by the crown on the upper left first molar, which had over-erupted into
the space below it. In this particular case the patient opted to have the better occlusal
planes by having the crown on the upper left first molar replaced, and so this was
also waxed up (Fig. 4.12h).
Figure 4.13a–f shows an alternative system (Simplified Occlusal Plane Analyzer:
Denar S.O.P.A.) using the same principle. It can be seen (Fig. 4.13a–f) that a very
minimal adjustment to the distobuccal cusp of the opposing tooth allowed for the
lower right sextant to be restored to this prescription.
a b
c d
Fig. 4.13 Use of Simplified Occlusal Plane Analyzer S.O.P.A. [Denar] to Design Ideal Occlusion
of proposed restoration. [Acknowledgement Mr Gordon Lucas, Dental Technician] (a) S.O.P.A.
flag in place. (b) Finding Occlusal Plane Survey Centre [OPSC]. (c) Occlusal plane is carved into
the wax, using the OPSC. (d) Design Wax Up completed. (e) But, the over-erupted opposing tooth
prevents other teeth from touching. (f) A problem that can be solved by a modest modification of
the disto-buccal cusp
f
Fig. 4.14 Wax up of

complex restoration using
Broadrick Flag Technique
Summary of Flag Techniques Based upon Sphere of Monson
It is emphasised that these techniques are an aid to creating a Design Wax Up. It
does not suggest that all occlusions should be restored to a sphere that has a radius
of 4 in.! That would be ridiculous. Using these techniques gives the clinician, who
is planning the restoration of an occlusion, the opportunity to provide smooth and
harmonious occlusal planes with a predictable effect upon the existing teeth. It is an
opportunity to see the occlusal changes of the proposed restoration, before picking
up a handpiece. Figure 4.14 shows some bigger cases where a Flag Technique has
been used.
• The planning and design phase of the process is completed when the clini-
cian has a set of articulated models and is confident that they are an accu-
rate representation of the end point of the treatment plan.
Step 3.5 Provisional Restorations
Provisional restorations are often useful and sometimes essential in the Re-Organised
Approach. All the Design information regarding the occlusal scheme of the final
restorations can be programmed into the provisional restorations. It is an opportu-
nity to test the patient’s tolerance to the new Occlusion and Jaw Relationship. Subtle
changes may be required and can easily be made to the provisional restorations.
Whether you consider it to be part of the Design Phase rather than the Execute
Phase will depend on how many adjustments you have to make.
Cases when the re-organisation of the occlusion includes an increase in vertical
dimension by the provision of crown or bridges are amongst the most difficult, and
so are the most essential to plan carefully. The new occlusion, including the change
in the vertical dimension, can be tested against the patient’s tolerance by the placing
of provisional restorations.
Nowadays many patients have their worn dentitions resorted by the application
of adhesive composite. There are differences in this sort of adjustable approach and
the techniques described, in this chapter, for the restoration of a severely compro-
mised dentition using laboratory made restorations and prostheses to the
Re-Organised approach. This third approach has already been described as the
‘Monitored Developmental Approach’ [14] and is discussed in Chap. 10 Section A.
Figure 4.15a shows a patient with a reduced Overall Vertical Dimension (OVD)
and severely worn teeth (Fig. 4.15b). The treatment involved indirect restorations
and some partial dentures. It was carried out to the Re-Organised Approach, and in
contrast to some of the techniques above did not involve the adjustment of the pre-
mature Contact in Centric Relation.
The initial treatment was fit a Stabilisation Splint that also provided some veneers
(Fig. 4.15c–f). It was made to both find Centric Relation and help the patient to
decide the appearance of the upper anterior crowns.
Once Centric Relation had been found it was noted that the restoration of the
Occlusion could be done to the vertical height of the Premature Contact, because it
would provide the space for the anterior restorations and it restored the OVD
(Fig. 4.15g). Then the Provisional Anterior Crowns could be fitted once the poste-
rior occlusion had been restored to a Flag Designed Occlusion (Fig. 4.15h), fol-
lowed eventually by the Definitive Restorations (Fig. 4.15i–k). The Definitive
Crowns were made using a Custom Anterior Guidance Table (see Chap. 3) con-
structed from the template of the Provisional Crowns.
Step 4 Execute that Design in the Definitive Restorations
This involves all of the skills that have been learned in following the Conformative
Approach.
The clinician’s responsibility is to provide the technician with accurate impres-
sions and bite records. The technician’s responsibility is to verify the mounted mod-
els and then to provide restorations that conform to the Occlusal Prescription that
has been established.
Step 4 Execute that Design in the Definitive Restorations 113
a b c
d e f
g h
i j k
Fig. 4.15 (a) Patient’s profile, suggesting loss of vertical dimension. (b) Patient’s dentition exhib-
iting significant tooth surface loss. (c) Upper stabilisation splint with labial veneers to fit over
unprepared upper anteriors. (d) Mirror view of upper stabilisation splint. (e) Anterior view of
upper stabilisation splint. Note the provision of median diastema, at the patient’s request. He later
changed his mind. (f) Provisional restoration of vertical dimension and labial support by the upper
stabilisation splint. Compare with Fig. 4.14a. (g) Restoring to the Premature contact in C.R. gave
space for the restorations of the upper anteriors and restored the OVD. (h) Provisional Crowns
restored to the Premature contact in C.R. (i) Mirror view of upper definitive restoration by partial
denture and anterior crowns as developed in the ‘provisional’ phase. (j) Mirror view of upper
definitive restoration by partial denture and anterior crowns as developed in the ‘provisional’
phase. (k) Restoration of vertical dimension and labial support
This involves not only the Static Occlusion but also the Dynamic Occlusion. If,
as in the case above, anterior teeth are involved in the restoration of the occlusion, a
Custom Anterior Guidance Table is a simple and useful way of duplicating the guide
pathways developed in the provisional restorations into the definitive crowns
(Fig. 4.16a–f).
a b
c d
e f
Fig. 4.16 (a) The models, including provisional crowns on upper anterior teeth, are used to carve
a custom incisal guidance table in a slow setting autopolymerising acrylic. (b) Custom incisal
guidance table. The incisal pin of the articulator is resting in a position that is related to the centric
occlusion of the models. (c) Custom incisal guidance table is used to guide the upper working
model into the same left lateral excursion as was present in the provisional restorations. (This
would be a right lateral excursion in the patient). (d) Close up of custom incisal guidance table,
guiding upper model into a left lateral excursion. (e) Using this technique it is easy to see exactly
what the crown length and palatal contour should be to provide the same canine guidance as was
present in the provisionals. (f) Custom incisal guidance table determining the length of right canine
definitive crown
Summary 115
Summary
An advanced restorative treatment plan involving the re-organisation of a patient’s

occlusion, using laboratory made restorations and prostheses, presents a major chal-
lenge for the restorative team. Successful completion will depend on:
• Good communication and the transfer of accurate anatomical information
between the clinic and laboratory.
• Careful planning by the clinician.
• The skills of the clinician and the technician.
• The clinician will need to have:
–– An accurate record of the patient’s pre-treatment occlusion.
–– A clear idea of the occlusion of the definitive restoration, including the jaw
relationship at which it is to occur.
–– A detailed sequential plan on how the treatment will progress from the
patient’s pre-treatment occlusion to the planned restoration.
–– Clearly stated objective of every phase of treatment.
–– Ensured that the patient understands the need for this careful approach.
Although it can appear to be a very long way from the starting point to the
declared objective, ‘every long march has to start with a first step’. As long as the
objective is defined; and if the successful completion of each clearly defined step is
the foundation for the next phase, success will be the outcome.
The key is a sequential treatment plan.
It is hoped that some of the measures outlined in this chapter will be an aid to
dentists wishing to help their patients to these objectives.
The Need for the Restorations Comes First!

• Ideal occlusion is a concept in the treatment of a patient who needs multi-
ple restorations.
• It is not a treatment objective in itself.
A patient should never be provided with multiple restorations solely to

provide an ideal occlusion.
hat Are the Risks of Ignoring Good Occlusal Practice

W
in Advanced Restorative Dentistry?
Not everything that can go wrong does go wrong.

So if a dentist considers that some or all of the steps outlined in this chapter rep-
resent too big a burden for them, or for their patient to tolerate both from a time and
financial standpoint, they will probably wonder what are the consequences of ignor-
ing these guidelines.
Some dentists will consciously have decided to ignore the advice given in this
and similar publications, which is a clinical judgement; others will simply be igno-
rant of them (there goes that excuse, dear reader!).
For whatever reasons these and similar advices are ignored, these dentists will
have decided to hope that whatever occlusion and jaw relationship their full mouth
restoration provided that are ones to which their patient will be able to adapt.
When we consider how many dentists provide major restorations that do not
provide as ideal occlusion/jaw relationship as possible, and how few of those cases
go seriously wrong, one has to admire that adaptive capability of our patients. So, it
could be argued that the dentists who choose the un-organised/I hope the patient
can adapt approach may have a point. Although most patients might be able to
adapt to change, not all can; and there is no way of predicting which can and
which cannot.
Risk is a mixture of not only likelihood but also consequence. Most people when
assessing risk give consequence or outcome greater weight than likelihood.
• People wish to give up smoking not because of the likelihood of developing lung
cancer but because of the consequence of that disease.
• Nervous airline passengers are anxious not about the likelihood of the airplane
crashing, which they rationally know is very small, but because of the conse-
quence of that event.
It is the experience of all secondary or specialist referral centres that the conse-
quence of a patient not being able to adapt to a change in occlusion/jaw relationship
following extensive restorative treatment is frequently life changing severe.
These patients can present with.
• severe psychosocial distress,
• a history of repeated restoration failure,
• significant pain or articulatory system dysfunction.
The management of these cases is inevitably much more complex than doing the
case more carefully in the first place.
Those of us who take as our primary responsibility ‘to do no harm’ will want to
follow the protocols outlined above or similar ones.
References 117

intolerable number of times to (para)function on it.
6. The Conformative Approach is the safest way of ensuring that the occlu-
sion of a restoration does not have potentially harmful consequences.
7. Ensuring that the occlusion conforms to the patient’s pre-treatment state is
a product of Examination, Design, Execution and Checking (the
E.D.E.C. protocol).
8. The ‘Re-Organised Approach’ involves firstly the establishment of a
‘more ideal’ occlusion in the patient’s pre-treatment dentition or pro-
visional restorations; and then adhering to that design using the tech-
niques of the ‘Conformative Approach’.
References
1. Davies SJ. Occlusion in restorative dentistry: conformative. Re-organ Unorgan Dent Update.
2004;31:334–45.
2. Christensen LC. Preserving a centric stop for interocclusal records. J Prosthet Dent.
1983;50:558–60.
3. Ramfjord SP, Ash MM. Occlusion. 3rd ed. Philadelphia: WB Saunders; 1983. ISBN:
0721674399 OCLC:8033676
4. Neelakantan P, Subba Rao CV, Vasudevan C, Indramohan J. Can traumatic occlusion cause
endodontic problems? A case report. Gen Dent. 2011;59:e153–5.
5. Gremillion HA. The relationship between occlusion and TMD: an evidence-based discussion.
J Evid Base Dent Pract. 2006;6(1):43–7.
6. Davies SJ. Malocclusion: a term in need of dropping or redefinition? Br Dent J. 2007;202:
519–20.
7. Myers M, Dziejma R. Relation of gothic arch apex to dentist-assisted centric relation. J
Prosthet Dent. 1980;44:78–81.
2005;94:458–61.
9. Briggs PF, Bishop K, Djemal S. The clinical evolution of the ‘Dahl principle’. Br Dent
J. 1997;183:171–6.
10. Lynch CD, McConnell RJ. Prosthodontic management of the curve of Spee: use of the
Broadrick flag. J Prosthet Dent. 2002;87:593–7.
11. Gupta R, Luthra RP, Sheth HH. Broadrick’s occlusal plane analyzer: a review. Int J Appl Dent
Sci. 2019;5(1):95–8.
12. Kois Dento-facial analyzer. Panadent Worldwide Patent US6582931B1.
13. Ferrario VF, Sforza C, Miani JR. Statistical evaluation of Monson's sphere in healthy perma-
nent dentitions in man. Archs Oral Biol. 1997;42(5):365–9.
14. Davies SJ et al. Occlusion: is there a third way? A discussion paper Br Dent J 2021;231:160–2.
https://doi.org/10.1038/S41415-021-3267-6.
Suggestions for Further Reading
Galindo D, Soltys JL, Graser GN. Long-term reinforced fixed provisional restorations. J Prosthet
Dent. 1998;79:698–701.
Howat AP, Capp NJ, Barrett NVJ. A colour atlas of occlusion and malocclusion. Wolfe Publishing
Limited; 1991. p. 447–55.
Parker MW. The significance of occlusion in restorative dentistry. Dent Clin N Am. 1993;37:341–51.
Ramfjord SP, Ash MM. Reflections on the Michigan occlusal splint. J Oral Rehabil. 1994;21:491–50.
Wassell R, Nark A, Steele J, Nohl F. Applied occlusion Quintessence. ISBN-13:9781850970989.
Good Occlusal Practice in Removable
Prosthodontics 5
The loss of teeth may result in patients experiencing problems of a functional, aes-
thetic and psychological nature.
This chapter addresses the very important subject of occlusal considerations for
partial and complete dentures.
The occlusion is particularly important given the bearing that occlusal factors
have, especially on edentulous patients.
Historically complete denture prosthodontics has been at the forefront of the

• The features of an ideal occlusion in removable prosthodontics.
• Why these features make it ‘ideal’ for denture stability.
• Some techniques for achieving these aims.
study of occlusion, and many of the terms used in occlusion have their origin in this
subject. The reason that occlusion has always been a consideration in the provision
of removable complete prosthetics is because the adoption of good occlusal practice
has a significant and immediate impact on the overall success of the treatment, as it
affects denture stability. If an inappropriate occlusion is built into a denture, then the
patient will be unlikely to be able to accommodate to that denture, and the dentist
will be immediately aware that the treatment has been unsuccessful. The reason
why the correct distribution of occlusal forces is so important in the design of
removable prosthetics is because the prosthetic teeth that provide the occlusion are
not directly attached to the patient.
Students of occlusion have good reason to be grateful to the science of prosth-
odontics, and it remains a part of the undergraduate course where clear guidance on
‘good occlusal practice’ will be available.

https://doi.org/10.1007/978-3-030-79225-1_5
120 5 Good Occlusal Practice in Removable Prosthodontics
Terminology
Terms like ‘non-working side’ or the more accurate term in a prosthetic sense ‘bal-
ancing side’ are based on a study of occlusion from the perspective of complete
dentures and refer to the side of the dentures which are not being used for chewing
during a lateral excursion. This can lead to confusion when considering the tem-
poromandibular joints during that same lateral excursion because the ‘non-working
side’ joint is moving much more than the one on the ‘working side’. The terms
‘Centric Relation’ and ‘Centric Occlusion’ will be used instead of their synonyms
of ‘Retruded Contact Position and Intercuspation Position’. Additionally, the term
‘Static Occlusion’ will be used to describe occlusal contacts when the mandible is
closed and still, and the term ‘Dynamic Occlusion’ will be used to describe occlusal
contacts when the mandible is moving. These terms will be used in preference to the
‘prosthetic’ terms of ‘occlusion’ and ‘articulation’.
Terminology
Centric Relation (CR) = Retruded Contact Position (RCP).
Centric Occlusion (CO) = Intercuspation Position (ICP).
Balanced Static Occlusion = Balanced Occlusion.
Balanced Dynamic Occlusion = Balanced Articulation.
Classification
Prostheses are often considered under the categories of partial or complete den-
tures, but partial dentures may be supported by teeth, mucosa or a combination of
both, and given the fact that the nature of that support dictates the design of the ideal
occlusal platform, partial dentures are divided into the following sections:
• Tooth-supported dentures
• Tooth and mucosa-supported dentures
• Mucosa-supported dentures
Tooth-Supported Dentures
In a denture supported by teeth:

• The occlusion is sensed.
• The prostheses are less likely to cause instability, if poorly designed.
The concept of the occlusal prescription being ‘conformative’ or ‘re-organised’ has

been discussed previously. The former conforms to the constraints of the patient’s
present occlusal scheme while the latter alters or re-organises the current scheme to
Tooth-Supported Dentures 121
Fig. 5.1 Occlusal
diagnostic appliance
(stabilisation splint)
Fig. 5.2 Hybrid prosthesis
a more idealised occlusion, sometimes at a raised occlusal vertical dimension. If a

partial denture is tooth supported, then the design of the occlusion provided by that
prosthesis should be to ‘conform’ with and be complementary to the existing occlu-
sion. The only exceptions to this would be ‘rehabilitative’ prostheses, which are
occlusal diagnostic splints (Fig. 5.1) and hybrid prostheses (essentially overden-
tures) (Fig. 5.2). The difference between the two is that the splint is not intended to
be definitive, whereas the hybrid prostheses is. Conventional wisdom indicates that
the dentist must determine the patient’s ability to withstand a raised occlusal vertical
dimension with a temporary (diagnostic) prosthesis prior to prescribing the defini-
tive denture/prosthesis.
If a partial denture is totally tooth-supported, the patient’s occlusion is entirely
borne by teeth. This has two important occlusal consequences. Firstly, it means that
occlusal load will be ‘sensed’ by the proprioceptors of the periodontal membranes.
Secondly, it is less likely that a poorly designed occlusion will be immediately man-
ifested by the denture being unstable than would be the case if the support was in
part or totally mucosa supported.
Examination
The most important aspect of the examination of the patient, for whom a tooth-
borne partial denture is to be made, is to confirm that it will indeed be solely sup-
ported by the existing teeth, and not in part by the soft tissues. It is advisable, as in
all patients for whom a treatment is envisaged, to carry out a comprehensive exami-
nation not only of the dental and periodontal tissues but also of the articulatory
system.
The EDEC Principle

E = Examine the pre-existing condition.
D = Design the prosthesis.
E = Execute the prosthesis.
C = Check the occlusion at completion.
The EDEC Principle
E = Examination.
The examination of the patient’s pre-treatment occlusion is the first stage.
Treatment
D = Design.
The support for the partial denture must be provided by the abutment teeth in
such a way as to avoid a change in the occlusal contact of the other teeth, otherwise
the treatment would not be within the conformative approach. Ideally, the rests
should also be designed to transfer the occlusal load down the abutment teeth along
their long axes.
E = Execute.
The design criteria as expressed above may require modification of the abutment
teeth and/or the opposing teeth. If this is the case, a clear rationale for the changes
can be presented to the patient and is likely to be much better received than altera-
tion to the dentition after or at the fit of the prosthesis.
C = Check.
At the delivery stage, a check is made that the prosthesis has added to the patient’s
occlusal platform rather than altered its position or dynamic occlusal characteris-
tics. This is easily achieved providing a record of the patient’s pre-treatment static
and dynamic occlusal contacts has been recorded. It does not matter whether this is
a three-dimensional record such as mounted study models on a semi-adjustable
articulator, or a two-dimensional record such as a written record or ‘occlusal sketch’
Tooth and Mucosa-Supported Dentures/Prostheses 123
of articulating paper marks. It is obviously impossible to confirm that the treatment

has been provided within the conformative approach unless this pre-treatment
record exists.
Tooth and Mucosa-Supported Dentures/Prostheses
The mucosa under a denture is capable of displacement to a degree that is 20 times

greater than that of teeth via the periodontal membrane [1]. Furthermore, there is a
difference not only in the amount of displacement under load but also in the type of
deformation. The periodontal membrane of teeth, under occlusal force, undergoes a
simple elastic deformation, whereas mucosa undergoes viscoelastic deformation.
This means that the recovery from mucosal deformation is more prolonged than that
of a tooth in its socket. These quantitative and qualitative differences between tooth
support and mucosa support have an important clinical significance and obviously
could cause problems in the construction of a prosthesis in which the occlusal load
is going to be shared between what are two very different tissues.
Examination
The examination of a patient’s mouth before the provision of a tooth/mucosa-

supported removable prosthesis is designed to assess the support, retention and sta-
bility provided by the teeth, the ridges and the mucosa. A simple chart is suggested
as an aid to this objective (Chart 1).
For a patient with favourable prospects for support, retention and stability of
their tooth/ridge/mucosal tissues, the chart may appear as in Chart 2. Patient expec-
tations can be better managed if a chart similar to this is used as part of the examina-
tion phase.
Treatment
The principal consequence of occlusal loading onto the more deformable mucosa
will be the loss of occlusal contact. This is a particular problem in patients with free-
end saddles. It was for this reason that Applegate described a technique of denture
construction [2], universally known as the ‘altered cast technique’, which consists
of the following stages:
1. Following the recording of the definitive impression, the metal framework is cast
and tried in. If satisfactory, the saddle area(s) is(are) covered with light-cured
denture base material.
2. The base of the saddle areas is on-laid with light-bodied impression material and
an impression recorded of the saddle area with the dentist pressing on the tooth-
borne elements of the framework.
3. The original master cast is sectioned at the distal abutments and the saddles areas
discarded. The new saddle area(s) is(are) prepared by pouring from this new
impression.
The intention of this technique is to ensure that the occlusal pressure will still
be resisted by the ridges after the natural teeth have been minimally displaced
into their sockets.
An identical clinical procedure may be undertaken for a reline, and this may
be sufficient to restore the occlusion in saddle areas (Table 5.1).
Table 5.1 An example of a completed examination
Teeth Ridge Mucosa
Support good perio. square firm
Retention good undercuts favourable
Stability good favourable
Mucosa-Supported Dentures
1. Partial Dentures
Dentists should be under no illusion that mucosally supported partial dentures will,
within a relatively short time, lose occlusal contact with the opposing arch as the
underlying bone is resorbed; this type of denture cannot be relied upon to provide a
lasting occlusion. In addition, the problem implied in the term ‘gum strippers’ is well
known; a typical example is shown in Fig. 5.3, illustrating the iatrogenic effects of
selecting a mucosally supported design. Simple relines are only likely to exacerbate
the resorption.
However, not all such designs are necessarily examples of poor dentistry; for
instance, training dentures (Fig. 5.4) are sensible treatment options when the state
of total edentulousness is deemed to be unavoidable.
Examination
It is because of the shortfalls, occlusal and others, that such dentures must only be
used appropriately. It is, therefore, important that a comprehensive examination of
the patient enables an accurate assessment of the prognosis of the patient’s dentition.
Mucosa-Supported Dentures 125
Fig. 5.3 Gum stripper
Fig. 5.4 Training denture
Fig. 5.5 Occlusion at

insertion
Treatment
Figures 5.5 and 5.6 show an entirely mucosa-supported lower partial denture;
immediately after having been supplied to the patient (Fig. 5.5), there is an occlu-
sion between the denture and the patient’s maxillary teeth, whereas after 6 months
(Fig. 5.6), there is no occlusal contact against the opposing teeth.
Fig. 5.6 Lack of

occlusion after 6 months
2. Complete Dentures
It has been said that ‘a patient with no eyes cannot see, a patient with no legs
cannot run, yet a patient with no teeth expects to eat and act with dentures as
with natural teeth’ [3]. It is unlikely that this can be achieved, but it remains
the goal.
The design of an occlusion in complete dentures is different from that of the
dentate patient. While both are concerned with the final act of intermaxillary
closure, the absence of direct attachment between the dentures and the patient’s
musculo-skeletal system requires a different set of guidelines of good occlusal
practice.
For all these reasons, it is important to consider the role of occlusion in complete
denture philosophy. The fundamental philosophies governing the biomechanics of
complete dentures state that there is a fine inter-relationship between support, reten-
tion and stability, and the success of the prosthesis will be dependent in a very large
part on these features. Importantly, occlusion is considered a major factor governing
stability [4].
The minimal level of occlusion that any practitioner should prescribe in com-
plete dentures is balanced occlusion; this is described by the British Society for the
Study of Prosthetic Dentistry [5] as ‘even, harmonious bilateral contact between
teeth or tooth analogues in retruded contact position (RCP)’. In our terminology,
this means a ‘balanced centric occlusion in centric relation’ (CO = CR). This is a
‘static occlusion’ concept, and this type of an occlusion would ensure that, as a
patient elevated the mandible into CR, the dentition would be stable. There would
be no tilting/displacing force on the dentures, and so stability would not be com-
promised. Factors that might compromise this stability are illustrated in Fig. 5.7.
They are:
• Unilateral prematurities.
• Occlusal tables that are too large.
• Injudicious placement of teeth.
Mucosa-Supported Dentures 127
a b
Fig. 5.7 (a) Unilateral prematurity. (b) Too large an occlusal table. (c) Injudicious placement
of teeth
Fig. 5.8 Christensen
phenomenon
• For many patients, a simple occlusal prescription is all that will be required,
i.e. the patient has ‘evolved’ to using essentially vertical mandibular move-
ments with little or no lateral and protrusive mandibular movements.
• In this case, no elaborate occlusal scheme is indicated, nor is a semi-
adjustable articulator, because the dynamic occlusion can be ignored.
For other patients, however, lateral and protrusive movements are part of their
normal ‘ruminatory’ mandibular pattern, and for these patients, a balanced dynamic
occlusion (balanced articulation) is required. In other words, consideration must be
a b
Fig. 5.9 (a) F/F with compensating curves. (b) F/F with compensating curves
given not only to the static but also to the dynamic occlusal prescription. In this situ-
ation, the teeth of the maxillary denture must maintain harmonious sliding contacts
with the teeth of the mandibular denture in all excursive movements, otherwise
denture stability may be significantly compromised. For example, in a natural denti-
tion, the act of protrusion usually results in a posterior open bite (the Christensen
phenomenon, Fig. 5.8). Such a situation would lead to instability in complete den-
tures; hence, compensating curves (Fig. 5.9a, b) are incorporated into the dentures.
The same philosophy holds for lateral excursions.
This means that the ‘ideal occlusion’ for a patient with complete dentures differs
from the ‘ideal occlusion’ for a dentate patient, for example it is ‘ideal’ for complete
denture stability if there is no posterior disclusion during lateral excursions, whereas
immediate and lasting posterior disclusion is usually considered to be ideal for the
dentate patient.
It is because teeth on a denture are not attached to the patient’s neuro-muscular
skeletal system, and there is no possibility of neural stimulation via periodontal
proprioceptors that the criteria of what makes an ‘ideal occlusion’ have changed.
Although there are mechanoreceptors in the denture bearing oral mucosa, they do
not continue to send a stream of impulses to the sensory cortex.
It, therefore, beholds the dentist to determine the occlusal requirements of com-
plete denture wearers prior to prescribing complete dentures [6]. If balanced articu-
lation is required, there is no valid reason for not:
• Using a facebow.
• Accurately determining condylar angles.
• Harmonising the occlusion to match mandibular movements.
Summary
It is a prerequisite for stability in all complete dentures that posterior occlusal

contacts occur simultaneously and bilaterally; furthermore, these contacts
should occur in centric relation and at the appropriate occlusal vertical
Examination of the Complete Denture Patient 129
dimension. In some patients (those with a ruminatory chewing pattern), it will

also be necessary to harmonise the dynamic occlusion in order to ensure den-
ture stability.
Examination of the Complete Denture Patient
The purpose of the examination is to lead to the correct decisions being taken at
each stage, so that a successful treatment strategy can be made.
1. The Examination of the Denture Bearing Surfaces
An assessment of the denture bearing surfaces will involve assessment of:
• Shape of the ridges: Moses suggested a classification of ridge shape and described
the retentive and support characteristics of each (Table 5.2) [7]. The ideal occlu-
sion for the prosthesis will, therefore, relate to the ridge shape.
• Nature of denture bearing area: Firm or flabby; and sensitive or comfortable to
finger pressure. A sensitive or mobile ridge will require an occlusal prescription
that is designed to reduce the transmission of force.
• Space: If there is very little space between the ridges (usually at the poste-
rior part of the mouth), then the distal extent of the occlusal platform will
be necessarily reduced in length. It is better that the dentist discovers this
at the examination stage rather than the technician when mounting
the models.
Table 5.2 Moses classification of Ridge shapes

Fig. 5.10 Diagnostic
biscuit
2. The Examination of the Existing Dentures
Do the existing dentures exhibit?

• Inadequate freeway space.
• Evidence of excessive wear: loss of vertical dimension, crossbite and anterior
posturing.
If the answer to any of these questions is ‘yes’, then the new dentures are not
going to be made to the ‘conformative approach’, but rather the occlusion will be
changed, i.e. the ‘re-organised approach’ will be adopted.
The examination of how the patient masticates. The answer to this essential
question will in most cases determine whether the patient needs only a balanced
static occlusion in centric relation (‘balanced occlusion’), or whether in addition
they should have a balanced dynamic occlusion (‘balanced articulation’).
In order to determine whether the patient has a chewing pattern that involves
essentially only vertical mandibular movements, or also uses lateral and protru-
sive movements, they must be observed masticating.
This seems self-evident, and yet very few patients are treated after determin-
ing, by observation, the type of chewing that is used. The appropriate occlusal
prescription of the denture cannot be determined without this part of the exami-
nation which involves the use of the ‘diagnostic biscuit’ (Fig. 5.10).
Treatment
Treatment Strategy
This will have evolved during the examination:
Complete Denture 131
Should the Conformative or Re-Organised Approach Be Used?
In the vast majority of patients with a restorative/prosthetic need, the conformative

approach is the method of choice. It offers the dentist the relatively simple task of
providing treatment which conforms to the occlusion to which the patient has been
accustomed.
In the edentulous patient, the re-organised approach may be indicated if the
patient exhibits:
• A temporomandibular disorder.
• A grossly overclosed vertical dimension.
• A pre-existing inappropriate occlusal pattern that has led to denture instability.
oes the Patient Need a Balanced Dynamic Occlusion (Balanced

D
Articulation) or Only a Balanced Static Occlusion (Balanced
Occlusion)?
This question can only be answered by determining, by observation, the type of

mastication that the patient employs. This has major consequences for the treatment
of the patient, and an assessment, therefore, of the patient chewing is an essential
part of the examination of an edentulous patient.
Stages of Construction
1. The design of the fitting surfaces: ‘impression taking’.

It is the dentist’s responsibility to design the denture supporting area on some
accurate models, and it is outside the scope of this section to expand on this
aspect of full denture construction other than to say that it should not be left to
the technician.
2. Determining the interarch relationship: ‘bite registration’.
The term ‘bite registration’ is a poor one, as the patient is not asked to bite
into anything; in fact, if they do, it is likely that they will make an uncontrolled
mandibular movement away from CR.
The purpose of this stage is to record the relationship between the upper and
lower jaws, in the vertical, horizontal and anterio-posterior planes. Before this
stage can be completed, the decision whether to make the dentures to the confor-
mative or re-organised approach must have been taken. In addition, it must have
been decided whether only a balanced static occlusion (balanced occlusion) or
also a balanced dynamic occlusion (balanced articulation) is needed. If balanced
articulation is indicated, a facebow record must be taken so that the occlusal rims
can be mounted into a semi-adjustable articulator.
a b
Fig. 5.11 (a) Gothic arc trace apparatus. (b) Gothic arc trace arrowhead
Gothic Arch Trace
One means by which a balanced articulation is created on that articulator is the

gothic arch trace. This trace is made on a ‘central bearing apparatus’ (Fig. 5.11a).
This comprises upper and lower acrylic plates onto which is mounted centrally a
stylus and a platform.
These will record a ‘map’ of the patient’s range of movements, by asking the
patient to go into:
• Protrusive.
• Right lateral.
• Left lateral excursions.
The provision of full dentures will involve three stages:

Colloquial term Actual function
1. ‘Impression making’ Designing of the fitting surfaces
2. ‘Bite registration’ Determining the interarch relationship
3. ‘Setting up the teeth’ Providing the ideal occlusion
The starting point of these movements as inscribed by this trace is the arrowhead
(Fig. 5.11b) and represents centric relation (CR or RCP). If it proves impossible to
obtain an arrowhead, this means that the patient does not have a reproducible max-
illo-mandibular relationship. This is an important finding and would indicate the
need for some further pre-definitive treatment in order to discover a reproducible
jaw relationship (i.e. CR).
This could be achieved by the use of ‘pivotal appliances’. A polished pivotal
appliance (Fig. 5.12) may look unusual, but it is remarkable how well they are toler-
ated. After fitting, further adjustments are easily made to find the new occlusal verti-
cal dimension (OVD) and to provide occlusal stability. When all adjustments have
been made and the patient has been wearing the appliance comfortably for a period,
Treatment 133
Fig. 5.12 Registering CR

with a pivotal appliance
it is a simple procedure to register centric relation with a registration material placed

before and behind the pivots. Pivotal appliances may be made on acrylic bases, or
from the patient’s previous dentures. It may be wise to make a copy of the patient’s
denture with which to make the pivotal appliance. It will then be possible to return
the original denture intact to the patient.
3. Providing the ideal occlusion.

‘Setting up the teeth’.
The occlusion of the dentures that will be ‘ideal’ for the patient is the one
which will limit the tilting of the dentures and so minimalise disruption to the
peripheral seal, risking instability. As stated, this occlusal prescription will take
into account the patient’s denture bearing tissues and their chewing pattern.
On the basis of occlusal form, there are four types of posterior teeth: [8].
• Anatomic teeth: these ‘duplicate’ the anatomical form of natural teeth and typi-
cally have 30–40° cuspal angles. Modified forms have 20° cuspal angles, and
these are typically used in complete dentures, on the basis that it is easier to
obtain balanced articulation with 20° cuspal angles.
• Non-anatomic teeth: these have occlusal surfaces that are not anatomically
formed and are designed with mechanical and not anatomical principles in mind.
• Zero-degree teeth and
• Teeth without cusps: these may be used for patients who have essentially vertical
chewing movements as only their static occlusion needs to be balanced (bal-
anced occlusion), i.e. there is no need for a balanced dynamic occlusion (bal-
anced articulation).
In those patients who need a balanced dynamic occlusion, a cuspal form is

essential. The dentist has to consider what is appropriate for the patient. If large
ridges are present, anatomical teeth will probably suffice. Whereas, if the ridges
are flat or where implant-supported dentures oppose maxillary complete den-

tures, then teeth with non-anatomical cuspal form may be indicated [8, 9] as
large cusps may induce instability via a tripping effect.
• Good occlusal practice is different in the edentulous patient from that in

the dentate patient.
• The form of an ideal occlusion for a particular edentulous patient will
depend on their chewing pattern and ridge form.
The EDEC Principle in Complete Denture Construction
(E = Examine, D = Design, E = Execute, C = Check)

The construction of complete dentures is a sequential process. The successful
completion of one stage is the prerequisite of starting the next. In order to prevent
introducing errors into the sequence, it is important to consider what each stage
needs to achieve. The EDEC principle is one way of defining the objectives of the
process.
E = examine. The examination of
• The denture bearing surfaces.
• The existing dentures.
• The masticatory pattern.
will be the basis for.

D = the design of the occlusion of the prosthesis.
The first stage of full denture construction is:
E = the execution of that design.
This comprises the procedures up to and including the jaw registration.
It involves:
• Defining the relationship between the denture bearing surfaces in
three planes.
• The design of the ideal static and dynamic occlusion for that patient.
At one end of the spectrum, this design may be a copy of the patient’s previous
prosthesis: the ‘Conformative Approach’.
Alternatively, there may be need to design changes in
Combination Syndrome 135
• The vertical height.

• Jaw relationship.
• Occlusal prescription: the ‘Re-Organised Approach’.
The design will be achieved and recorded in the jaw registration, when this infor-
mation is passed on to the laboratory technician.
From that moment, the emphasis of the dentist, during the try-in and completion
stages, moves from designing and executing change.
C = checking that there is no deviation from the record supplied to the techni-
cian; i.e. from the bite registration to completion, the dentist’s responsibility is to
conform to the Design.
Combination Syndrome [10]
The final section under the heading of ‘mucosa supported dentures’ considers the
type of occlusion that is required when a full denture is opposed by teeth or a fixed
prosthesis, a condition referred as the ‘Combination Syndrome’ [10].
There are three scenarios:
1. Complete maxillary denture opposed by dentate/partly dentate mandibular arch.
2. Complete mandibular denture opposed by dentate/partly dentate maxilla.
3. Complete maxillary denture opposed by implant retained lower complete den-
ture (‘New Combination Syndrome’).
1. Complete Maxillary Denture Opposed by Dentate/Partly

Dentate Mandibular Arch
In this situation, these can be considerably displacing forces on the upper denture
resulting from mandibular movements, so the retention of the upper denture must be
maximised.
Displacing forces can be reduced by co-ordinating the maxillary teeth and maxil-
lary plane of occlusion to mandibular movement. This is achieved by:
• Using a facebow to transfer the plane of the upper arch to the condylar axis.
• Using a central-bearing screw to create an arrowhead (gothic arch) tracing.
• Setting the articulator condylar angles to accord to the border tracings on the
arrowhead tracing.
• Establishing, carefully, at trial insertion, that CR (RCP) is reproducible.
• ‘Milling in’ the occlusion to suit the patient. This will inevitably be necessary, as
cuspal inclines of the denture teeth will be unlikely to be equal to those of the
patient’s natural mandibular teeth.
• Reviewing of the patient after 3 days to refine the cuspal anatomy.
Special Case
T he Maxillary Atrophic Ridge

In this scenario, an upper complete denture has been occluding, for a long time,
against only the lower anterior natural teeth: that is to say the issue of a lack of pos-
terior occlusion has not been addressed.
Usually and maybe surprisingly, the patient has found that, for many years, the
upper complete denture has not been unretentive. The consequence of this is that,
unless the patient attends for frequent examinations to have their remaining six teeth
examined, there are very limited opportunities for the dentist to warn of the danger
inherent to this situation.
Eventually, the day usually comes when the patient finds that they cannot occlude
against the upper denture without a socially embarrassing loss of retention of their
upper denture.
Unfortunately, they are wrong, if they assume that this situation can be easily
remedied by a new conventionally made new upper complete denture. This is
because the initial examination reveals that they have a severely atrophic upper
premaxillary alveolar ridge [flabby ridge]; see Fig. 5.13a–c. [This case is kindly
provided by Mr. Indika Weerapperuma Hon Lecturer, University of Manchester and
Kinross Dental Care, Sri Lanka.]
This then is an example of a ‘Mal-Adaptive Occlusion’, on the level of the alveo-
lar bone. It represents a significant challenge to the dentist, requiring a Selective
Impression Technique, whereby the posterior maxillary impression is taken in a
muco-compressive material, and the anterior maxillary impression is taken in a
muco-static material. This is to minimise the displacement and distortion of the
a b
Fig. 5.13 Atrophic ‘flabby’ premaxillary ridge

Combination Syndrome 137
uniquely soft tissue of the upper anterior ridge [6], it is not easy and has no guaran-
tee of successful outcome.
It is relevant to mention this condition in a book on Good Occlusal Practice because,
if given the opportunity, the dentist has an obligation to warn the patient of what
may be the consequence of an upper complete denture occluding against only
lone standing lower anterior teeth.
2. Complete Mandibular Denture Opposed by Dentate/Partly

Dentate Maxilla
Success is even more difficult to achieve in this clinical scenario than the former,
and although similar techniques are recommended, two major problem areas are
often present:
• Impaired support potential of the mandibular denture-bearing tissues.
• Unfavourable peri-denture anatomical forces, i.e. muscle attachments.
3. Complete Maxillary Denture Opposed by Implant Retained

Lower Complete Denture (‘New Combination Syndrome’)
This third scenario is now encountered with increasing frequency. This application
of implants is rightly considered for the patient who is suffering because of their
unretentive and uncontrollable lower complete denture. But dentists should be
aware of the possibility of the patients developing a ‘New Combination Syndrome’.
At its simplest, this syndrome will clinically present as ineffective mastication,
often associated with a very unretentive upper denture. At its most extreme, the
patient may exhibit periods when they are unable to exert any control over their
mandible or find any position where they can rest it, exhibiting a severe mandibu-
lar tremor.
The hypothesis on how this syndrome arises is as follows:
As the lower denture becomes more retentive:
• It is known that there is a significant increase in displacing forces transmitted to
the upper denture by virtue of the increased retention afforded to the lower den-
ture by the mandibular implants. This force may be considerably in excess of the
retention that has been provided to the upper denture, a retention that was per-
fectly acceptable when it was opposed only by an unretentive lower denture
maybe on an atrophic ridge.
• It is thought that there may be a significant change in the patient’s chewing pat-
tern and that this might occur sometime after the implant retained lower prosthe-
sis has been fitted.
Before implants were used, the patient probably developed a purely vertical
chewing pattern in an attempt to accommodate to the extremely unretentive
lower denture. Once the lower denture is retained by the implants, however, the
patient may revert back to a masticatory pattern that includes lateral and protru-
sive movements (the ruminatory pattern of mastication). The occlusion of the
dentures, which was acceptable whilst the patient was chewing only with vertical
movements, could now be ‘tripping’ the upper denture.
Complete denture construction is a sequential process:

• Examination denture bearing surface existing dentures masticatory
pattern.
• Design the appropriate occlusion.
• Execute that design (up to and including jaw registration).
• Check that there is no deviation from that design (from registration to
completion).
As the chewing pattern changes, the features of the ideal occlusal prescription
also change.
Solutions
Some of the solutions include:
• The basic principles of good retention and stability are not only still needed, they
are more important.
• The occlusion should be designed to reduce the displacing or ‘tripping’ forces,
even in a patient who appears at the time of examination to have a vertical mas-
ticatory pattern (‘accommodative chomping’).
• The possibility that the patient will need some implants on the upper jaw
should be raised, ideally before the implant treatment of the lower jaw is
finalised.
Treatment Strategies and Summary
The principle is to design and provide an occlusion that is ideal—ideal for the
important criteria of denture success—stability. An occlusion is needed that will
reduce the displacing forces on the denture(s).
Treatment Strategies and Summary 139
The basic equations are:

Force Retention Instability

Force Retention Stability

The occlusal prescription provided is a major factor in determining the size of the
force applied to the dentures. The retentive capacity of the denture is defined by the
patient’s tissue and masticatory patterns.
Force > Retention = Instability
Force < Retention = Stability

7. Ensuring that the occlusion conforms to the patient’s pre-treatment state is
a product of Examination, Design, Execution and Checking (The
E.D.E.C. protocol).
8. The ‘Re-Organised Approach’ involves firstly the establishment of a ‘more
ideal’ occlusion in the patient’s pre-treatment dentition or provisional res-
torations; and then adhering to that design using the techniques of the
‘Conformative Approach’.
9. An ideal occlusion in Removable Prosthodontics is one which reduced
destabilising forces to a level that is within the denture’s retentive
capacity.
References
1. Picton DCA, Wills DJ. Viscoelastic properties of the periodontal ligament and mucous mem-
brane. J Prosthet Dent. 1990;40:263–72.
2. Applegate OC. Essentials of removable partial denture prosthesis. Philadelphia: WB Saunders
Co; 1954. p. 166–94.
3. Applebaum M. Plans of occlusion. Dent Clin N Amer. 1984;28:273–6.
4. Jacobson TE, Krol AJA. A contemporary review of the factors involved in complete denture
retention, support and stability. J Prosthet Dent. 1983;49: 5–15; 165–72, 306–13.
5. British Society for the Study of Prosthetic Dentistry. Guidelines in prosthetic and implant
dentistry. London: Quintessence Publishing Co. Ltd; 1996. p. 29–47.
6. McCord JF, Grant AA. A clinical guide to complete denture prosthetics. London: BDJ
Books; 2000.
7. Moses CH. Physical considerations in impression making. J Prosthet Dent. 1953;3:449–63.
8. Lang BR. Complete denture occlusion. Dent Clin N Amer. 1996;40:85–101.
9. Denisen HW, Kalk W, van Wass MAJ, van Os JH. Occlusion for maxillary dentures opposing
osseointegrated mandibular prostheses. J Prosthet Dent. 1993;6:446–50.
10. Kelly E. Changes caused by a mandibular partial denture opposing a maxillary complete den-
ture. J Prosthet Dent. 1972;27:140–50.
Occlusion and Orthodontics
6

1. Rationale for orthodontic treatment.
2. Benefits of orthodontic treatment.
3. Examination of the occlusion and articulatory system.
4. Treatment options.
5. Extraction or non-extraction orthodontic treatment.
6. The relationship between orthodontics and TMD.
1. Rationale for Orthodontic Treatment
Over 30 years ago, the British Dental Association defined the aims of orthodontic
treatment as being: ‘to produce improved function by the correction of irregulari-
ties and to create not only greater resistance to disease but also to improve per-
sonal appearance, which later will contribute to the mental and physical well-being
of the individual’.
Nowadays, we believe the goal of orthodontic treatment is to achieve a balanced,
harmonious and functional occlusion alongside an aesthetically pleasing appear-
ance of the teeth. There is limited evidence in the literature to support the use of
orthodontic treatment to prevent caries or periodontal disease. It is thought, how-
ever, that an improvement in the alignment of teeth and creation of a more aestheti-
cally pleasing smile, with resolution of malocclusal traits such as overjet and
spacing, has a positive effect on quality of life [1, 2]. There is also less risk of
trauma to the front teeth once a significant overjet has been reduced. There is debate
regarding the effect of orthodontics on functional occlusion and temporomandibular
disorders: this will be discussed in Sect. 6 of this chapter.

https://doi.org/10.1007/978-3-030-79225-1_6
142 6 Occlusion and Orthodontics
Table 6.1 Andrew’s six keys to occlusion

1. M
olar relationship: The mesiobuccal cusp of permanent maxillary first molar occludes in the
groove between the mesial and middle buccal cusps of the permanent mandibular first molar
2. Crown angulation (mesio-distal tip): The gingival portions of each crown are more distal
than the incisal portion and vary depending on the tooth type
3. Crown inclination (torque): The labio-lingual and bucco-lingual inclinations are correct for
both anterior teeth (positive torque) and buccal teeth (progressive lingual torque)
4. No rotations
5. No spaces
6. Flat occlusal planes
If we examine the early orthodontic literature, we find that the founder of con-
temporary orthodontics, Edward Angle, attempted to treat his patients’ occlusion
with reference to the occlusion of a skull displayed on a shelf in his surgery. This
skull was affectionately termed ‘Old Glory’ (see Table 6.2). Angle probably consid-
ered Old Glory’s occlusion to be ideal from not only an aesthetic but also a func-
tional standpoint. It must be remembered, however, that any functional assessment
of Old Glory’s occlusion was limited by the fact that Old Glory was a dried skull.
Much later, Lawrence Andrews used the features of the static occlusion to introduce
the six keys of occlusion (Table 6.1). The concept of the six keys of an ideal occlu-
sion and the pre-adjusted edgewise appliance (contemporary fixed braces) together
achieved a quantum leap for orthodontists to obtain excellence in occlusal and aes-
thetic changes.
1.1 Form Follows Function
There is fortunately a strong association between the aesthetics of the final orth-
odontic outcome (FORM) and the achievement of an optimal occlusion
(FUNCTION). This is because attainment of a perfectly aligned upper and lower
front teeth, even with a less than perfect buccal interdigitation will still provide
excellent aesthetics and an acceptable functional occlusion. Even though orthodon-
tic treatment usually changes the occlusion, the physiological forces that drive the
tooth movements are generally undertaken gradually over a period of time that
allows adaptation to the new occlusion (see Chap. 1 for discussion of ‘Monitored
Developmental Approach’).
1.2 How Much Orthodontics Is Needed to Change Occlusions?
The Department of Health (DOH) has been concerned for a number of years that the
scarce resources assigned for orthodontic treatment should be targeted on patients
with greatest need. These factors have highlighted the need for an index as a method
of grading malocclusions, assessing treatment priorities and providing equitable
explicit national guidance. Subsequently, the Index of Orthodontic Treatment Need
(IOTN) [3] was developed.
2. Benefits of Orthodontic Treatment 143
While much of orthodontics is provided to obtain aesthetically pleasing occlu-

sions, there is still an accepted need in certain cases to provide orthodontics for
functional reasons. The IOTN was used in the Children’s Dental Health Survey
(2003); on examining 12-year-old children, it was found that 43% indicated a need
for orthodontic treatment based on the IOTN scale.
Generally, it is accepted that children scoring an IOTN of 3 or above justify as
candidates for orthodontic treatment to be undertaken on the NHS.
These tend to be cases with:
• Increased overjet >9 mm.
• Impacted teeth.
• Missing teeth.
• Severe crowding >4 mm.
2. Benefits of Orthodontic Treatment
2.1 Evidence Supporting Benefits of Orthodontic Treatment
Orthodontic treatment can be used to improve both skeletal jaw and dental discrep-
ancies. Irregular tooth positions resulting in protruding teeth or teeth in an adverse
occlusal relationship can be moved to improve both the aesthetics and the function
of the dentition. The correction of tooth position will encourage a more balanced
and protective occlusion. In addition, some specific problems such as impacted
teeth or congenitally missing teeth can be addressed by orthodontic treatment.
There are other well-recognised benefits to undertaking orthodontic treatment.
When the authors use terms like ‘correct’ or ‘improve’, the reader is asked to keep
in mind that we believe that an occlusion should be qualified not only by its adher-
ence to a set of arbitrary rules but by the effects it may have on the tissue systems.
So, for instance, an incisor crossbite that a patient may find aesthetically acceptable,
and is not resulting in jiggling, migration, wear, or gingival recession, may need
monitoring rather than active correction.
There is good evidence that the reduction of a large overjet resulting in protrud-
ing teeth can reduce the risk of trauma to those front teeth. Whereas there is only
weak evidence to support the use of orthodontic treatment with the aim of improv-
ing dental health by making it easier to maintain good oral hygiene and so reduce of
caries risk.
2.2 Risks of Orthodontic Treatment
As with most interventional treatment, there are risks associated with orthodontic
treatment. While most orthodontic treatment is completed with no adverse effects,
certain risks are usually accepted as part of the consent process. Most significant
risks are staining of teeth if good oral hygiene is not maintained. Other
Benefit Evidence
Appearance Dento-facial Evidence – improved satisfaction with dental

aesthetics appearance
Function Mastication Evidence – equivocal

Speech No evidence that orthodontic treatment will
correct speech disorders
Dental Health TMD Weak link relating some malocclusions to TMD
Tooth impaction Tooth impaction - risk of dentigerous cyst, roof

resorption associated with unerupted canines
Caries and No evidence that orthodontics reduces

periodontal caries risk
disease
Trauma Reduction in OJ has been related to reduction

in trauma
Psychological Well being/self- Teasing about teeth caused distress. No

esteem evidence that malocclusion causes poor self
esteem in long-term
Fig. 6.1 The benefits of orthodontic treatment
acknowledged risks include root resorption (estimated to be approximately 1 mm),

loss of vitality and relapse (Fig. 6.1).
3. Examination of the Occlusion and Articulatory System
3.1 Extra-Oral: Orthodontics for the Face
Orthodontics was previously concentrated on achieving the ideal occlusion, often

focussing on obtaining a Class 1 incisor relationship. This was sometimes done
without consideration of the face and facial profile. In contrast, most contemporary
orthodontics is undertaken with ‘Orthodontics for the Face’ in mind. This may indi-
cate modification of the occlusion to include functional appliances or orthognathic
surgery. An examination of the skeletal pattern in all three planes (horizontal, verti-
cal and transverse) is vital to ensure the correct diagnosis and treatment is reached
(Fig. 6.2).
3. Examination of the Occlusion and Articulatory System 145
The front view will indicate any skeletal The vertical line (perpendicular to the
asymmetry. The view also provides a smile Frankfurt plane) indicates a class 2 skeletal
assessment and dental centre-lines pattern
Fig. 6.2 The extra-oral assessment
3.2 Intra-Oral: Identifying the Occlusal Pattern
While Angle described occlusion according to the molar relationship (Table 6.2), a

more meaningful relationship and classification is to assess the incisor occlusion. The
assessment of the occlusion is assessed in three planes (horizontal, vertical and trans-
verse) to fully quantify the occlusion (Fig. 6.3). The amount of incisor overjet along
with the molar and canine relationship gives an indication of the extent of discrepancy.
An assessment of crowding should also be recorded to allow a full diagnosis along
with an IOTN score. This can be achieved using an orthodontic diagnosis sheet
(Fig. 6.6a–c). A full orthodontic assessment should also generally include radiographs
which can be used to aid diagnosis and assist with treatment planning
• OPG (Fig. 6.4).
• Lateral cephalogram (Fig. 6.5).
Table 6.2 Angle’s molar classification

Class 1—The mesiobuccal cusp of the permanent maxillary first molar occludes IN the groove
between the mesial and middle buccal cusps of the permanent mandibular first molar. (“Old
Glory”)
Class II—The mesiobuccal cusp of the permanent maxillary first molar occludes ANTERIOR
to the groove between the mesial and middle buccal cusps of the permanent mandibular first
molar
Class III—The mesiobuccal cusp of the permanent maxillary first molar occludes DISTAL to
the groove between the mesial and middle buccal cusps of the permanent mandibular first molar
Class 1 molar r/s Increased overjet Increased overbite with upper Class 1 molar r/s
indicating a class incisors occluding in lower 1/3
2 div 1 incisor r/s of lower incisor crowns
Fig. 6.3 The intra-oral assessment

Fig. 6.4 An OPG The Orthopantomogram is used to detect

radiograph giving an missing teeth and an assessment of the root
overview of the dentition morphology.
and supporting tissues
The lower 2nd pre-molars are congenitally missing with

retained deciduous molars
The Lateral cephalogram is used to assist in clinical

findings. The radiograph can demonstrate
measurements of skeletal discrepancies and incisor
angulations. The standardised tracing of the
radiograph
Fig. 6.5 Lateral cephalogram and measurement tracing
3.3 Mandibular Displacement
It is important to record not only the patient’s habitual bite (Centric Occlusion [CO]
or InterCuspation Position [ICP]) but also the patient’s ideal jaw relationship
(Centric Relation [CR], alternatively referred to as Retruded Contact Position
[RCP]) or Terminal Hinge Axis.
During the examination, it should be determined if CO occurs in CR.
If it is not:
• Quantitative and qualitative assessments could be made; i.e. Q. how big and in
which direction is the slide from CR to CO?
• Which teeth provide the first contact in CR (Premature Contact in CR, or
Guidance contact(s) in CO)?
3.4 Should Treatment Be Undertaken to Create Occlusion in CR?
The short answer must be NO, because a significant proportion of the population do
not have a CO that occurs in CR; and they suffer no ill effect. However, if orthodon-
tic treatment is indicated anyway in a patient where CO does not occur in CR, then
depending on the difference between CO and CR, it may be that to provide a CO in
CR is a justified treatment objective.
Because of the large percentage of subjects who do not have any adverse reaction
to having an occlusion that does not occur in CR, clearly it is not always necessary
to undertake orthodontic treatment (or restorative treatment) to create a CO that
occurs in CR.
If, however, there is a premature contact in CR and it is easy to orthodontically
remove it, then especially in a child, it may be a justifiable treatment objective. In
adults, however, that have no adverse reactions from the fact that CO does not occur
in CR, there can be little justification because they probably will still have a com-
fortable occlusion and good function.
Of course, consideration of whether the aim of orthodontic treatment could
include an occlusion in CR, can only be made after a comprehensive examination
that includes finding CR.
3.5 Examination of the Articulatory System
The occlusal analysis comprises only one part of the Articulatory System examina-
tion: the muscles and temporomandibular joints should also be examined.
The three elements of an examination of the Articulatory System can be incorpo-
rated into an orthodontic examination protocol (Fig. 6.6). This comprehensive
examination will record the extra-oral skeletal pattern, the oral soft tissues, signs
and symptoms of the TMJs and mandibular muscles and the position of the teeth
and their occlusal contacts. It is a rapid and easily followed examination protocol
that provides a good assessment for both orthodontic diagnosis and screening for
Disease, Dysfunction or Discomfort within the Articulatory System; i.e. a
Temporomandibular Disorder.
The examination of the patient’s occlusion must not only include assessment of
the habitual bite or centric occlusion (CO), but also the occlusion in centric relation
(CR). This is because the presence of large discrepancies between CO and CR may
be a positive indication for orthodontic treatment. Equally, such discrepancies
should not be introduced during orthodontic treatment. In restorative terminology,
orthodontic treatment is not provided to the conformative approach. Whether it is to
the re-organised approach or the newly suggested ‘Monitored Developmental’
approach will be left to the reader, for fear of being pedantic. But to leave or create
a large discrepancy between CO and CR would be to provide the patient with an
occlusion to which they may have difficulty in adapting.
The conventional wisdom in restorative dentistry is that if the jaw relationship is

going to be changed, then it is safer (i.e. less likely to produce an adverse response)
if it is changed to centric relation (the re-organised approach) rather to some random
jaw relationship (the un-organised approach), when the clinician just hopes that the
patient can adapt to the change.
General Record
Patient Date
Age
Plaque control Gingivitis

Medical +
good
history ++
mod
poor +++
Jaw and Facial Examination
Skeletal Pattern 1 II III mild mod severe
TMJ
Tender to palpation? Lateralpole Intra-auricularly
Noises Clicks Right Left or Bilateral

Soft or Loud
Consistent or Intermittent
Opening or closing or both
Early Mid Late
Painful or Painless
Single or Multiple
Crepitus RightLeft or Bilateral
Painful or Painless
Range of Motion (mm) Vertical maximal comfortable

Lateral Pathway of opening
D I straight or deviating lasting
or transient to
Muscle Tenderness Centre Lines

Temporalis Masseter midface
Lateral Pterygoid
U
Lips Comp Tongue

thrust L
Incomp
Fig. 6.6 Orthodontic examination including articulatory system exam

Dental and occlusal examination
Erupted teeth
Unerupted teeth Absent teeth
Upper arch Lower arch
Crowding Inclination Crowding Inclination
mild none procliped mild none procliped
mod spaced AV mod spaced AV
sev fraenum retrocliped sev fraenum retrocliped
Incisor Class Overjet in CO Overbite

1 .............mm Increased
Average
1/1 If zero
Freedom in CO? Reduced
11/1 Yes No Edge to Edge
Overjet in CR Complete
11/11 HT
.............mm Incomplete
ST
X-Bites
scissors
IOTN
displacement no. DHC.................
AC.................
......mm R L ANT
Dental and occlusal examination (cont.)
Buccal segments
Molars
I II III
R ...unit
L ...unit
Canines
I II III
R ...unit
L ...unit
Static Occlusion
Does CO occur in CR? .............. IF NOT prem contact in CR?

Roughly or exactly
Direction of slide from CR to CO ......................................
Dynamic Occlusion
RHS LHS
Non-Working Side Interferences
Working Side Interferences
Crossover Position NWS int

WS int
Canine Guidance
Group Function
That said, orthodontic treatment has the enormous advantage that it changes
occlusions and the jaw relationship slowly (Evolution), rather than the rapid changes
that is often associated with restorative treatment plans (Revolution). It is the recog-
nition of this fact that has led to the suggestion, made in Chap. 1, of a third classifi-
cation: ‘The Monitored Developmental’ approach.
4. Treatment Options
Orthodontic treatment can be divided into three categories, depending on the aims
of treatment:
• Orthodontic camouflage.
• Growth modification.
• Orthodontics and orthognathic surgery.
To understand this, we should be familiar what an orthodontist considers to be

the aetiology of what they consider to be the malocclusion.
The aetiology consists of the following:
1. Skeletal factors
2. Dento-alveolar factors
3. Soft tissue factors
4. Habits
1. Skeletal factors should be considered in three planes: anteroposterior, vertical

and transverse. Patients can present with discrepancy of the upper and lower jaw
in any of these planes.
2. Dento-alveolar factors will generally present as crowding of the teeth as a result
of discrepancy between the overall tooth size and arch dimension.
3. Soft tissue factors can alter the teeth position if the muscular forces are imbal-
anced, as the teeth lie in a position of muscular balance between the lips, cheeks
and tongue.
4. Digit sucking is an example of habit, which can have a significant effect, depend-
ing on intensity and duration, upon the occlusion.
So, as stated, when faced with these discrepancies, the orthodontist has three
main choices:
1. Camouflage treatment, whilst accepting the skeletal pattern.
2. Attempt growth modification with functional appliances.
3. Orthognathic surgery, when patient has ceased growth.
4.1 Camouflage Treatment
If the treatment is directed at camouflage, either the orthodontist may choose to

accept the interarch relationship, attempting to camouflage the problem by only
aligning the teeth, or space can be created in the dental arches by several means:
• Extractions.
• Arch expansion.
• Distalisation of the upper buccal segments.
• Incisor advancement or interproximal enamel reduction.
4. Treatment Options 153
Once space has been created, other teeth can be moved into it in order to achieve
the treatment goals.
Whereas dental appearance can be anticipated reliably, facial appearance is less
predictable. So although a good occlusal outcome can be anticipated when planning
camouflage treatment, it might be done at the expense of facial aesthetics. From a
facial aesthetic perspective, it is more difficult to a good result by camouflage alone
(Fig. 6.7).
a b
c d
Fig. 6.7 (a–d) Patient with 2 division 1 incisor relationship on a severe skeletal 2 base with
increased overjet and overbite and incompetent lips. (e–h) Patient after two phase functional/fixed
appliance treatment showing good occlusion but disappointing facial appearance
e f
g h
This is an important point when considering occlusion and orthodontics:
I mprovement in the Occlusion Alone May Not Satisfy the Patient’s Aesthetic

Aspirations
This is the reason why there a debate in orthodontics around the detrimental
effect of camouflage treatment on facial profile. It is the reason why growth modifi-
cation treatment is favoured by many orthodontists for children with a skeletal
malocclusion.
The reason why growth modification and orthognathic surgery are discussed in a
book on occlusion is that orthodontic success cannot be judged by occlusal out-
come alone.
4.2 Growth Modification
Growth modification comprises an attempt to modify the underlying hard or soft

tissues to bring about skeletal and dentoalveolar change. In a growing child, a func-
tional appliance is most common treatment choice for a developing Class II skeletal
problem. It has the aim of enhancing mandibular growth and restrain maxillary
growth (Fig. 6.8).
a b
c d
Fig. 6.8 (a–d) Pre-treatment photographs of a Class 2 patient before functional appliance treat-
ment. (e–h) Post-treatment photographs showing good dental and facial appearance
e f
g h
. How Do Functional Appliances Work?

Q
• Do functional appliances modify growth?
• OR Do functional appliances work principally by dento-alveolar change?
Current evidence shows functional appliances cause an initial small but mean-
ingful increase in mandibular growth in young patients. But when these patients are
monitored to the completion of orthodontic treatment, no significant skeletal differ-
ences is found between the treatments started in childhood and those started in
adolescence. The only difference is lower incidence of dento-alveloar trauma in the
patient who started treatment in childhood [4].
It can be concluded, therefore, that the long-term gain in mandibular growth is
very small with functional appliances [5].
a c
b d
Fig. 6.9 (a, b) Pre-treatment photographs of a patient before orthognathic surgery. (c, d) End of
treatment photographs after orthodontic/orthognathic treatment showing good dental and facial
appearance
4.3 Orthognathic Treatment
Orthognathic treatment is considered to be the gold standard for comprehensive

correction of severe dentofacial discrepancy. It involves a combination of orthodon-
tics and orthognathic surgery (Fig. 6.9). It is undertaken by a multidisciplinary team
of clinicians involving, orthodontist and oromaxillofacial surgeon. This treatment is
undertaken at the end of growth to improve post-treatment stability. This treatment
should only be carried out for patients who have major concern with their oral func-
tion, facial and dental appearance and the quality of life [6].
5. The ‘Extraction vs Non-Extraction’ Debate
The extraction versus non-extraction debate is almost as old as the advent of orth-
odontic practice, and up to now, this debate remains. Again, the orthodontist must
look beyond the occlusal result. Lip support is dependent on the presence of teeth.
One theory is that unsuitable extractions will reduce lip support because of the ret-
roclination of the upper incisors; whereas non-extraction treatment might result in
lip fullness. Therefore, facial profile, not just occlusion, is a factor for the orthodon-
tist when considering extraction or non-extraction treatment (Fig. 6.10).
a b
c d
Fig. 6.10 (a–d) Shows 2 division 1 malocclusion patient before treatment with extractions. (a)
Demonstrating bi-maxillary proclination. (b) Lateral view. (c) Occlusal view with upper and lower
arch crowding. (d) Buccal view illustrating proclination of upper and lower teeth. (e–h) Post-
treatment photos after extraction treatment showing good dental and facial appearance
6. Orthodontics and Temporomandibular Disorders (TMD) 159
e g
f h
It is a difficult area to research as most studies are retrospective and consequently

subject to significant bias. Current evidence indicates that correctly planned and
performed orthodontic treatment including that involving premolar extractions does
not have a detrimental effect on facial profile [7].
6. Orthodontics and Temporomandibular Disorders (TMD)
This is not a book on temporomandibular disorders, but a brief examination of this

question is valid.
6.1 Does Orthodontic Treatment Cause TMD?
Based on clinical experience and the currently available evidence, it does not sup-
port any aetiological relationship.
At present, there is no strong evidence to support the theory of orthodontic
extractions and treatment causing TMD. High-quality randomised clinical trials,
with no bias, are needed to support the claims between malocclusion and TMD. More
information with regard to aetiology, diagnosis and assessment of TMD is still
required. The association between TMD and orthodontics remains contentious, but
there is no evidence to support an increase in the prevalence of TMD in patients
with malocclusion [8].
It is debated that certain form of orthodontic treatment can lead to TMD. One
theory is that premolar extraction in orthodontic treatment can cause posterior con-
dylar position (presumably because over retraction of the maxillary incisors can
happen during space closure forcing the mandible posteriorly) [9]. An alternative
theory is that first premolar extractions allow the buccal segment teeth to move for-
ward resulting in a decrease in the vertical dimension of occlusion, which results in
TMD [10].
6.2 Can Orthodontic Treatment Be Part of TMD Management?
There is no evidence that occlusion is a significant aetiological factor in the devel-

opment of TMD. Some TMD patients, however, return to being symptomatic after
the withdrawal of successful splint therapy. For these patients, there may be justifi-
cation to make some carefully prescribed changes to their occlusion. Ideally these
changes will be designed on sets of articulated study models.
So, very rarely the long-term management of a TMD patient will include, after
certain important criteria have been met, an element of:
• Tooth modification Equilibration

• Tooth restoration Restorative dentistry
• Tooth movement Orthodontics
• Tooth replacement Prosthodontics
So, it can be seen that because orthodontics is one means of changing the occlu-
sion, orthodontics will, occasionally, be one element of a treatment plan.
Consequently, it is within this broad context, and only in the few cases where
there is a demonstrable need for a dentist, who is competent in the management of
TMD, to consult with a specialist orthodontist. As a result of this collaboration,
treatment beyond the usual non-invasive and conservative TMD management may
be indicated.
Other text will need to be consulted for more detail on the management of TMD.
Conclusions 161
6.3 Summary
• The association between orthodontics and occlusion is significant.

–– Providing an improved occlusion is not the only success outcome measure by
which to judge orthodontic treatment; facial appearance is important.
• Satisfactory orthodontic treatment outcome (including a good occlusion) can be
attained by camouflage, growth modification or orthognathic treatment.
–– Extraction of teeth is required as a part of many courses of orthodontic treat-
ment. There is no evidence that orthodontic treatment with extractions dam-
aging facial appearance.
–– Orthodontic treatment with extractions has often been blamed for causing
TMD, but no statistical correlation has been found between orthodontic treat-
ment and TMD.
• The goals of orthodontic management can be multi-variable.
–– On the one hand, an argument can be made for providing an optimal occlusion.
–– But there is little evidence in the literature to suggest that this is always
necessary.
–– Lots of people do not have an optimal occlusion and do not suffer any ill
effects.
–– Some features of optimal occlusion do, however, provide pleasing aesthetics.
• In line with the first rule of medical intervention: ‘Do No Harm’, it is wise for an
orthodontist to assess, in their initial examination, whether their patient is suffer-
ing from any adverse effects to their pre-treatment occlusion. This is to avoid
exacerbation of any pre-existing problems.
• There is lack of evidence to support the theory that orthodontic treatment can
reduce the sign and symptoms of TMD.
• The aim of orthodontic treatment is to provide the patient with an appear-
ance that.
–– Is acceptable to the patient’s wishes,
–– Within society’s aesthetic norms.
–– Is within the adaptive capability of the patient’s tissue systems.
Conclusions
There is no good reason for not doing a comprehensive examination of the patient’s
articulatory system as part of the initial assessment before orthodontic treatment.
Figure 6.6 provides a protocol for doing this.

1. The examination of the patient involves the Teeth, Periodontal Tissues
and Articulatory System.
3. The patient’s occlusion should be recorded, before any treatment is
started.
Occlusion.
7. Ensuring that the occlusion conforms to the patient’s pre-treatment state
is a product of Examination, Design, Execution and Checking (the
E.D.E.C. protocol).
‘more ideal’ occlusion in the patient’s pre-treatment dentition or provi-
sional restorations; and then adhering to that design using the techniques
of the ‘Conformative Approach’.
de-stabilising forces to a level that is within the denture’s retentive
capacity.
10. The occlusal objective of orthodontic treatment is not clear, but a
large discrepancy between centric occlusion and centric relation
should not be an outcome of treatment.
11. An ‘orthodontic’ examination of the occlusion should include: the
Dynamic Occlusion; and the Jaw Relationship in which the patient
has their Centric Occlusion.
References
1. Benson PE, Da'as T, Johal A, Mandall NA, Williams AC, Baker SR, Marshman Z. Relationships
between dental appearance, self-esteem, socio-economic status, and oral health-related quality
of life in UK schoolchildren: a 3-year cohort study. Eur J Orthod. 2015;37(5):481–90. https://
doi.org/10.1093/ejo/cju076.
2. Johal A, Alyaqoobi I, Patel R, Cox S. The impact of orthodontic treatment on quality of life
and self-esteem in adult patients. Eur J Orthod. 2015;37(3):233–7. https://doi.org/10.1093/
ejo/cju047.
3. Shaw WC, Richmond S, O'Brien KD, Brook P, Stephens CD. Quality control in orthodontics:
indices of treatment need and treatment standards. Br Dent J. 1991;170(3):107–12.
4. Thiruvenkatachari B, Harrison J, Worthington H, O’Brien KD. Early orthodontic treatment for
class II malocclusion reduces the chance of incisal trauma: results of a Cochrane systematic
review. Am J Orthod Dentofac Orthop. 2015;148:47–59.
References 163
5. Tulloch JFC, Philips C, Koch G, Proffit WR. The effect of early intervervention on skeletal
pattern in class II malocclusion; a randomised contrlled trial. Am J Orthod Dentofac Orthop.
1997;111:391–400.
6. Malik OH, Waring DT, Llyod R, Misra S, Paice E. An overview of the surgical correction of
dentofacial deformity. Dent Update. 2016;43:550–62.
7. Leonardi R, Annunziata A, Licciardello V, Barbato E. Soft tissue changes following the extrac-
tion of premolars in nongrowing patients with bimaxillary protrusion: a systematic review.
Angle Orthod. 2010;80:211–6.
8. Luther F. Orthodontics and the temporomandibular joint: where are we now? Part 2. Functional
occlusion, malocclusion, and TMD. Angle Orthod. 1998;68:305–18.
9. Gianelly AA. Orthodontics, condylar position and temporomandibular joint status. Am J
Orthod Dentofac Orthop. 1989;95:521–3.
10. Luecke PE, Johnston LE. The effect of maxillary first premolar extraction and incisor retrac-
tion on mandibular: testing the central dogma of “functional orthodontics”. Am J Orthod
Dentofac Orthop. 1992;101:4–12.
Occlusal Considerations in Periodontics
7

• Whether occlusal trauma is significant in the aetiology of periodontal
disease.
• Whether occlusal treatment is indicated for patients suffering from peri-
odontal disease.
• Making a diagnosis of trauma from occlusion.
• Tooth mobility.
• Occlusal equilibration and the splinting of teeth.
Periodontal disease does not directly affect the occluding surfaces of teeth, conse-
quently some may find a section on periodontics a surprising inclusion. Trauma from
the occlusion, however, has been linked with periodontal disease for many years.
Karolyi published his pioneering paper, in 1901 ‘Beobachtungen uber Pyorrhoea
alveolaris’ (occlusal stress and ‘alveolar pyorrhoea’) [1]. However, despite extensive
research over many decades, the role of occlusion in the aetiology and pathogenesis
of inflammatory periodontitis is still not completely understood [2–4].

https://doi.org/10.1007/978-3-030-79225-1_7
166 7 Occlusal Considerations in Periodontics
hy Should Trauma from Occlusion Be Considered to Have

W
a Role in the Aetiology of Periodontal Disease?
Occlusal trauma Injury to the periodontium resulting from occlusal forces

which exceed the reparative capacity of the attachment
Periodontitis The result of an interaction between a susceptible host and bacterial

factors in dental plaque, which exceeds the protective mechanisms of the host.
Inflammatory Periodontal Disease: ‘Periodontitis is the result of an interaction

between a susceptible host and bacterial factors in dental plaque, which exceeds the
inherent protective mechanisms of the host’.
Compare this definition with the one for:
Occlusal Trauma (a Pathology) has been defined as ‘injury to the periodontium
resulting from occlusal forces which exceed the reparative capacity of the attach-
ment apparatus’: i.e. the tissue injury occurs because the periodontium is unable to
cope with the increased stresses it experiences.
Both the processes result in injury to the attachment apparatus because the peri-
odontium is unable to cope with the pathological or physical insult, which it is enduring.
It is natural, therefore, that dentists ask themselves two questions:

1. Does occlusal trauma have a role in the aetiology of periodontal disease?
2. Should occlusal treatment be considered for the patient with compromised peri-
odontal attachment?
Before attempting to answer these two questions, the different types of trauma
from occlusion need to be defined, and how to diagnose occlusal trauma needs to be
examined.
The Aim of This Chapter Is to Answer Two Questions

Question 1.
Does occlusal trauma have a role in the aetiology of periodontal disease?
Question 2.
Should occlusal treatment be considered for the patient with a compromised
periodontal attachment?
How to Classify ‘Trauma from Occlusion’ (a Force)
Historically, trauma from occlusion has been classified as either primary or

secondary.
Occlusal Trauma and Periodontitis 167
Primary occlusal trauma results from excessive occlusal force applied to a tooth
or to teeth with normal and healthy supporting tissues.
Secondary occlusal trauma refers to changes that occur when normal or abnor-
mal occlusal forces are applied to the attachment apparatus of a tooth or teeth with
inadequate or reduced supporting tissues. Recently, the distinction between primary
and secondary occlusal trauma has been challenged as meaningless since the
changes that occur in the periodontium are similar irrespective of the initial level of
periodontal attachment. More usefully, occlusal trauma can also be described as
acute or chronic.
Acute trauma from occlusion occurs following an abrupt increase in occlusal
load such as occurs as a result of biting unexpectedly on a hard object.
Chronic trauma from occlusion is more common and has greater clinical
significance.
In this chapter, occlusal trauma will mean chronic occlusal trauma.
How to Diagnose Occlusal Trauma [5]
Occlusal trauma can only be diagnosed histologically. This is not possible without
carrying out a block section biopsy, which is clinically impossible because it is a
destructive process. When it is done, it shows increased vascularisation and perme-
ability, hyalinisation/necrosis of the periodontal ligament, haemorrhage, thrombosis
and bone resorption.
Because of this, the clinician has to use clinical and radiological findings to
assume that there is occlusal trauma. These include widening of periodontal liga-
ment space, progressive tooth mobility, fremitus, occlusal disharmonies, wear fac-
ets, tooth migration, thermal sensitivity and root resorption [5].
Occlusal Trauma and Periodontitis
oes Occlusal Trauma Have a Role in the Aetiology

D
of Periodontal Disease?
This is a key question because the answer will determine:

• Whether occlusal forces influence the onset of plaque-induced inflammation.
• Whether occlusal forces enhance the rate of periodontal destruction.
Considerable energy has been directed at trying to determine the answer to these
questions, because of the possibility that trauma from occlusion might contribute to
the pathogenesis of periodontal disease. Research studies designed to examine the
effects of occlusion fall into three categories:
• Human cadaver investigations
• Animal studies
• Human clinical studies
. Human Cadaver Investigations

1
Studies published in the 1960s and 1970s were inconclusive [6, 7].
2. Animal Studies (Fig. 7.1)

In these studies, the variables were the level of periodontal attachment and the char-
acteristics of an applied force, and the way in which it might be varied (see Fig. 7.2
for a summary of the results).
The periodontal attachment is one of the three types:
1. A normal healthy periodontal support.
2. A healthy periodontal support but a reduced bone height. This is the experimen-
tal model equivalent to successful periodontal therapy.
3. An active plaque-induced periodontitis.
The type of force that can be applied to the animal tooth is:
(a) Either a jiggling force, which is produced by multi-directional displacement
of a tooth in alternating buccolingual or mesio-distal directions. This is usu-
ally created in the animal by the provision of a supra-occluding onlay or by
interproximal wedging.
(b) Or is an orthodontic force, created by a spring and is a unilateral force that
results in the deflection of the tooth away from the force.
Healthy periodontium Healthy periodontium Plaque-induced

Normal bone height Reduced bone height periodontitis
Orthodontic Increased mobility Increased mobility No progression of

force Tooth movement Tooth movement periodontal disease
No change in No gingival
position of inflammation
junctional No further loss of
epithelium or connective tissue
connective tissue attachment
attachment
Jiggling Increased Increased periodontal Gradual widening

force periodontal ligament space of the periodontal
ligament space Some loss in height ligament space
Some loss in crestal of crestal bone height Progressive mobility
bone height and and bone volume Angular bone loss
bone volume No gingival
No loss of inflammation
attachment No further loss
Increased tooth of attachment.
mobility which is Increased tooth
reversible upon mobility which is
the removal of reversible upon
the force the removal of the force
Fig. 7.1 Summary of the results from animal studies

Occlusal Trauma: Role in Aetiology of Periodontal Disease? 169
On Effect of Jiggling Forces

P.M. Mobility. Bone. Attachment.
Healthy P.M. Widening of Increased Mobility Loss of Crestal No Loss of

Normal Bone PM space Reversible bone height Attachment
and..... No Gingivitis
Healthy P.M. Widening of Increased Mobility Loss of Crestal No Loss of

Reduced Bone PM space Reversible bone height Attachment
Loss
Plaque Induced Widening of Progressive Angular
Attachment
Periodontitis PM space Mobility Bone Loss
[Bone Loss]
Conclusion: if there is Plaque Induced Periodontitis

the Adaptive Capability of the PM
is sufficiently reduced to
induce Occlusal Trauma
Fig. 7.2 Summary of experiment jiggling forces in animal studies
Summary
In 2017, a World Workshop [5] reviewing the evidence from animal studies stated:
“Based on the findings of these studies, it was concluded that without plaque-
induced inflammation, occlusal trauma does not cause irreversible bone loss
or loss of connective tissue attachment.”
“Nonetheless, the results from animal studies suggested that occlusal trauma
does not cause periodontitis, but it may be a cofactor that can accelerate the
periodontal breakdown in the presence of periodontitis.”
Comment
• There can be very few dentists left who believe that occlusion can be a causative
agent of periodontitis. But, nevertheless, it is useful to know that the evidence
from studies does not support that fallacy.
• It is, however, useful to gain some insight as to whether occlusal factors may
influence the progress and recovery of plaque induced periodontitis.
3. Human Clinical Studies
Few clinical studies have identified a clear relationship between trauma from the
occlusion and inflammatory periodontitis in humans. There is limited evidence
from human clinical studies that support the view that teeth experiencing initial
occlusal discrepancies (Trauma from Occlusion) have deeper initial probing
depths, have a worse prognosis and have greater mobility than those without
occlusal discrepancies [8]. Tooth mobility, which may be secondary to Trauma
from Occlusion, did not gain as much clinical attachment as those without mobil-
ity following periodontal treatment [9] and demonstrated significantly more clin-
ical attachment loss during the maintenance period [10]. Multiple types of
occlusal contacts, including premature contacts in centric relation, posterior pro-
trusive contact, non-working contacts, combined working and non-working con-
tacts, the length of slide centric relation to centric occlusion, were found to be
associated with significantly deeper probing depths and a less favourable prog-
nosis [11].
On the system level, ideal occlusion is or is not ideal for the rest of the articula-
tory system: the temporomandibular joints and the masticatory muscles. It has,
however, been stressed that there is no such thing as an intrinsically bad occlusal
contact, because the effect is a product of not only the ‘quality’ of the contact or
contacts but also the frequency at which the contact or contacts are made. Also, it is
widely accepted that some patients, at some times in their life, will have an articula-
tory system which is compromised by other factors that reduce their tolerance to a
less than ideal occlusion. Factors may range from a systemic disease such as rheu-
matoid arthritis to the debilitating effects of chronic long-term stress.
On the tooth level, an occlusion may or may not be ideal for the attachment appa-
ratus, and the same consideration must be given to the frequency of occlusal con-
tact, i.e. Does parafunction occur? In addition, the ability of the attachment
apparatus to withstand a less than ideal occlusion may be compromised by peri-
odontal inflammation.
This leads to the second question:
Question 2
hould Occlusal Treatment Be Considered for the Patient

S
with Compromised Periodontal Attachment?
If it is accepted that increased occlusal forces could result in a further loss of attach-
ment for teeth with an active inflammatory periodontitis, then it follows that a
Examination 171
treatment plan aimed at preserving these teeth must address both problems. This
does not mean that trauma from occlusion causes periodontitis; rather, it means that
occlusal forces may exceed the ‘resistance threshold’ of a compromised attachment
apparatus, thereby exacerbating a pre-existing periodontal lesion. While we know
that trauma from occlusion can have an effect on the supporting tissues of the teeth,
there is no evidence, at present, that trauma from occlusion is an aetiological factor
in human periodontal disease.
Even though occlusal trauma is not a proven aetiological factor in periodon-
tal disease, because dentists wish to help patients keep their teeth for as long as
possible in maximum health, comfort and function; it follows, therefore, that
ideally dentists will ideally carry out a thorough occlusal examination on their
periodontal patients. Treatment aimed at reducing occlusal forces so that they
fall within the adaptive capabilities of each patient’s dental attachment appara-
tus might benefit those patients with periodontitis or at future risk of it. It can be
argued, of course, that by resolving the periodontitis the adaptive capability of
the periodontium is increased and so may be able to resist the trauma from
occlusion. That is a chance the clinician might wish to take.
Examination
Clinical Diagnosis of Trauma from Occlusion Increased tooth mobility is not

always indicative of trauma from occlusion. It is important, however, that hypermo-
bility, which does occur as a result of trauma from occlusion, is detected in patients
with reduced periodontal attachment. The reason for this is that trauma from occlu-
sion may accelerate further reduction in attachment in a patient with active
periodontitis.
A clinical diagnosis of occlusal trauma can only be confirmed where progressive

mobility can be identified through a series of repeated measurements over an
extended period. This means that simple but reliable monitoring needs to be under-
taken. A simple monitoring protocol is needed (Fig. 7.3).
The common clinical signs of occlusal trauma are:
• Increasing tooth mobility and migration or drifting (Fig. 7.4)
• Fremitus
• Persistent discomfort on eating
The common radiographic signs of occlusal trauma are (Fig. 7.5):
• Discontinuity and thickening of lamina dura
• Widening of periodontal ligament space (‘funnelling or saucerisation’)
• Radiolucency and condensation of alveolar bone/or root resorption
Fig. 7.3 Trauma from

occlusion: monitoring Date
examination sheet
First
CI1 CI1I CIIII
Widening or
funneling of
Root
Fig. 7.4 UR 2 (12) has migrated distally. Examination of the dynamic occlusal contacts of this
tooth indicates that the marked wear facet fits closely against those of LR2 and LR1 (42, 41) during
a right lateral excursion of the mandible
Occlusal Trauma 173
Fig. 7.5 All radiographs show signs of occlusal trauma to differing degrees
Tooth Mobility
Conventional methods for measuring tooth mobility are based on the application of
a force to the crown of the tooth to assess the degree of tooth movement in the hori-
zontal and vertical directions. Pathological mobility is defined as horizontal or verti-
cal displacement of the tooth beyond its physiological boundaries. Normal
physiological movement is thought to vary between 10 μm and 150 μm and would
not be detectable on clinical examination. Clinically detectable mobility indicates
some change in the periodontal tissues (i.e. it is pathological), and the cause of the
mobility needs to be diagnosed.
Tooth mobility can be recorded using Miller’s Index:
I—up to 1 mm of movement in a horizontal direction
II—greater than 1 mm of movement in a horizontal direction
III—excessive horizontal movement and vertical movement
How Can Tooth Mobility Be Measured?
Manual evaluation of mobility is best carried out clinically using the handles of two
instruments to move the teeth buccally and lingually.
Fremitus is the movement of a tooth or teeth subjected to functional occlusal
forces; this can be assessed by palpating the buccal aspect of several teeth as the
patient taps up and down.
Periodontometers was a research tool used in the 1950s and 1960s to standardise
the measurement of even minor tooth displacement. To date, this instrument has
been used in a few clinical studies and has limited practical use.
Periotest® was produced in Germany in the late 1980s to provide a more reliable
method for determining tooth mobility. It is designed to measure the reaction of the
periodontium to a defined percussion, delivered by a tapping instrument. Again, this
is of limited use in general dental practice.
Tooth Drifting or Migration
Independent of the state of the supporting tissues of a tooth, if it has moved its
position in the mouth, then some force has been responsible for pushing or pull-
ing it. Clearly that force may be extrinsic such as can be seen in pencil chewers.
Secondarily, a soft tissue force may be responsible as with tongue thrusting or lip
position (Fig. 7.6). However, the force may be from an occlusal contact espe-
cially parafunction. A frequently encountered scenario is drifting of an upper
lateral incisor. This is a common reason for referral of an adult patient to an
orthodontist; a referral made usually at the patient’s request, with the aim of
restoring their appearance. It is important to discover the cause of the drifting
before considering any treatment.
a b
Fig. 7.6 Initial examination of the UR 1 (11), in (a) may suggest an occlusal cause of the drifting;
however, as is shown in (b) the reason is the relationship with the lower lip
Treatment Considerations 175
Discomfort Upon Eating
Tooth mobility can affect the patient by causing discomfort when eating. This is a
further measure of tooth mobility. It will have a direct influence on treatment
planning.
reatment (Occlusal Considerations in the Treatment

T
of Periodontitis)
Equilibration
Occlusal equilibration is the modification of the occlusal contacts of teeth to pro-
duce a more ideal occlusion.
I s There a Need for Occlusal Equilibration in the Periodontally

Compromised Dentition?
The 2017 World Workshop [5] reviewed the literature [12–15] stated that
‘Collectively, these clinical studies demonstrated the added benefit of occlusal ther-
apy in the management of periodontal disease, but they do not provide strong evi-
dence to support routine occlusal therapy’.
Equilibrating Mobile Teeth

In a patient with mobile teeth, it may be necessary to temporarily stabilise those
teeth before equilibration is possible (Fig. 7.7a, b). If a tooth is mobile, it is very
difficult if not impossible to effectively modify its shape with the aim of reducing
the occlusal forces acting upon it (equilibration).
a b
Fig. 7.7 (a) The lower anteriors have been temporarily immobilised by a labial splint in order to
be able to identify the premature contact. (b) It was subsequently equilibrated in order to reduce
the trauma from occlusion. (Note: The adjustment to the lower anteriors was only to the labial
aspect of the incisal edges: the exposed dentine was already present!)
Equilibration and Periodontal Splinting (Fig. 7.8)
Whether occlusal equilibration is indicated will depend upon:

• Whether the inflammatory periodontitis has been treated successfully. If there is
an inflammatory periodontal process, this should be treated initially. Subsequently,
when the periodontal condition is stable, occlusal therapy may be necessary for
some patients and could involve either occlusal equilibration or splinting.
• The radiographic appearance of the periodontal support. Occlusal equilibration
is considered an effective form of therapy for teeth with increased mobility
which has developed together with an increase in the width of the periodontal
ligament (PDL). Reducing the occlusal interference on a tooth with normal bone
support will normalise the width and height of the PDL. Eliminating any occlu-
sal interferences for a tooth which has a reduced bone height as a result of peri-
odontal disease will result in bone formation and remodelling of the alveolus
only to the pre-trauma level.
In contrast, if the hypermobile tooth has reduced bone height but normal peri-
odontal ligament width, then elimination of occlusal trauma will not alter the mobil-
ity of the tooth. In this situation occlusal equilibration is only indicated if the patient
is complaining of loss of function or discomfort.
In 1989, the World Workshop of the American Academy of Periodontology [16]
issued some guidelines for situations when occlusal equilibration may be indicated:
• When there are occlusal contact relationships that cause trauma to the periodon-
tium, joints, muscles or soft tissues
• As an aid to splint therapy
More recently, a systematic review [17] concluded: ‘The selected studies sug-
gest an association between occlusal adjustment and an improvement in peri-
odontal parameters’. But they ‘suggested the need for new trials of a higher
quality’ to improve ‘methodological issues’. ‘There is insufficient evidence at
present to presume that occlusal adjustment is necessary to reduce the progres-
sion of periodontal disease’.
In the absence of a conclusive evidence base, the decision in respect of occlu-
sal therapy in periodontal treatment will be one for the clinician to make. Some
will feel that because trauma from occlusion is not a cause of periodontal dis-
ease, reducing the frequency, direction or magnitude of that force has no place in
the management of periodontitis. Others will look to the fact that the definition
of occlusal trauma involves a non-pathogen breakdown in periodontal support
and the limited evidence that occlusal trauma may affect the progression of peri-
odontal disease as sufficient justification of an intervention.
To return to the systematic review [17]: ‘Although it is still not possible to
determine the role of occlusal adjustment in periodontal treatment, adverse
effects have not been related to occlusal adjustment. This means that the decision
made by clinicians whether or not to use occlusal adjustment in conjunction with
periodontal therapy hinges upon clinical evaluation, patient comfort, and tooth
function’.
Treatment Considerations 177
Treatment required
Clinical Radiographic
in addition to Treatment outcome
features features
periodontal therapy
Increased Increased width Occlusal equilibration Normalises PDL width.
mobility of PDL
Normal bone
height
Increased Increased width Occlusal equilibration Bone fill of angular defect.
mobility of PDL Bone level stabilised.
Reduced bone Normal width PDL
height
Increased Normal width Patient’s comfort and

mobility of PDL function may improve.
Occlusal equilibration
Patient NOT (This is not periodontal
± splinting
functioning Reduced bone therapy, but an adjunct
comfortably height to it)
Increased Normal width No occlusal No further deterioration

mobility of PDL adjustment
Patient required
functioning Reduced bone
comfortably height
Fig. 7.8 Indications for occlusal treatment and splinting
Summary: Trauma from Occlusion in the Aetiology and Treatment of

Periodontal Disease
• There is no scientific evidence to show that trauma from occlusion causes
gingivitis or periodontitis or accelerates the progression of gingivitis to
periodontitis.
• The periodontal ligament physiologically adapts to increased occlusal
loading by resorption of the alveolar crestal bone resulting in increased
tooth mobility. This is occlusal trauma and is reversible if the occlusal
force is reduced.
• Occlusal trauma may be an exacerbating factor that can increase the rate of
progression of an existing periodontal disease.
• There is a place for occlusal therapy in the management of periodontitis,
especially when related to the patient’s comfort and function.
• Occlusal therapy is not a substitute for conventional methods of resolving
plaque-induced inflammation.
If teeth are to be equilibrated, it must be done with careful planning and great
care: it is not spot grinding, which would result in the destruction of tooth morphol-
ogy. The ideal technique, involving the ‘mock’ equilibration of an accurately
mounted set of articulated models, is done first to confirm the viability of the exer-
cise without damaging the teeth. This is described earlier in this book.
Equilibration
All these stages may be
necessary
Study models
Successful mounted to CR Mock
stabilisation on asemi- equilibration
splint therapy adjustable on duplicated
articulator study models
before equilibration of the patient’s teeth can be

completed
Splinting
When should teeth be splinted together in the patient with reduced periodontal sup-
port? (Fig. 7.8).
The World Workshop in Clinical Periodontics [16] also, outlined some indica-
tions for splinting, not only restricted to patients with reduced periodontal support:
• To stabilise teeth with increased mobility that have not responded to occlusal
adjustment and periodontal treatment.
• To prevent tipping or drifting of teeth and the overeruption of unopposed teeth.
• To stabilise teeth after orthodontic treatment.
• To stabilise teeth following acute trauma.
There are two situations in which splinting may be beneficial:

• Where tooth mobility is progressive with increased periodontal ligament width
and reduced bone height, then splinting is indicated as part of periodontal therapy.
• When patient comfort and function will be improved by splinting, then it is indi-
cated, as an adjunct to periodontal therapy.
This means that if periodontal treatment results in a stable periodontal condition
which is comfortable, splinting is not needed.
Probably the most important benefit of reducing the mobility of periodontally

compromised teeth by splinting is to facilitate daily plaque removal by a compliant
Splinting 179
patient, and root surface debridement by their dentist or hygienist. It achieves this
by eliminating the discomfort associated with applying pressure to hypermo-
bile teeth.
There is, of course, a benefit to the patient that the discomfort of eating with
hypermobile teeth is also reduced. Because their teeth are much more comfortable
and feel much firmer, there is a danger in splinting. That is that the patient can
believe that their teeth are better supported by bone. In reality, there is no more bone
that there was before splinting. Patients must understand that the need for a very
high level of oral hygiene is as important as it was before splinting. The splinting of
teeth does not improve the bone support, it just makes it easier to prevent fur-
ther loss.
The other problem that some patients believe that the apparent firmness of their
teeth (often lower incisors) means that they can bite into anything. I remember a
patient returning after only 3 days following the provision of a cast metal splint to
stabilise her lower anterior teeth, because one tooth had debonded from that splint.
She complained that ‘it was only a water biscuit’: probably the hardest biscuit in
existence! Re-fixing a tooth to an existing splint is difficult and is never as a robust
attachment as the original.
There are various techniques to splint hypermobile teeth:
1. Fibre systems
2. Orthodontic wire
3. Cast metal adhesive splints
1. Fibre Splints (if it is a definitive splint, it is placed on the labial surface)

As with all adhesive techniques, moisture isolation is very important, the best
way of achieving this is by using a rubber dam (Fig. 7.9a).
Next the fibre is carefully adapted and adhered to the cleaned and etched
lingual surfaces of the teeth (Fig. 7.9b–d).
2. Orthodontic Wire Splint (Fig. 7.10a, b)
It may be necessary to first place a temporary labial splint. This is to facilitate
an equilibration of the teeth, in order to eliminate a heavy occlusal contact (see
Fig. 7.7) and to stabilise the teeth. This keeps them in a ‘neutral position’ during
the placement of the orthodontic wire splint.
The clinician must do whatever is needed to ensure that there are no prema-
ture or heavy occlusal contact against any of the teeth after the definitive splint
has been fitted.
3. Cast Metal Splints
These splints require an impression because they are made by the Dental
Technician.
In order to ensure that it will be possible to fit them under a rubber dam, it is
advisable to prepare them under the rubber dam. It is usually possible to also
take the elastomeric impression needed under the same rubber dam; if an impres-
sion tray is significantly modified.
a b
c
d
Fig. 7.9 (a) As with all adhesive techniques, moisture isolation is very important; the best way of
achieving this is by using a rubber dam. (b, c) The Fibre is carefully adapted and adhered to the
cleaned and etched lingual surfaces of the teeth. (d) Completed Fibre (Ribbond ©) Splint
a b
Fig. 7.10 (a) Orthodontic wire splint placed on lingual surface. (b) Fine splint placed on labial
surface. Temporary placement to stabilise teeth
Case Histories 181
a b
Fig. 7.11 (a) shows the prepared teeth, after placement of a split rubber dam, and a temporary
labial fibre splint. (b) shows the gingivae, at the fit appointment, immediately after removal of the
rubber dam. (c) is at 2-week review; note the improvement in gingival health. Splinting has facili-
tated cleaning
a b
Fig. 7.12 (a) Splinting of teeth using a cast metal splint that carries a pontic and has been success-
ful for 40 years. (b) It has enabled the patient to wear a lower partial denture to restore the posterior
occlusion
Case Histories
Case 1. Useful in the Long Term?
If the occlusal forces are well monitored and controlled, periodontal splinting can
enable the motivated patient to keep their teeth with compromised periodontal sup-
port for a long time (Fig. 7.12a, b).
ase 2: Occlusal Analysis in a Periodontal Patient: Use of Mounted

C
Study Models
Clinical Findings
UR1, UR2, LL5: Class III mobile, with pus from gingival margins.
Occlusal analysis
• Centric occlusion not in centric relation.
• Premature contact in CR between UL7 and LL7.
• Fremitus between UL1 and LL1 in C.O.
Treatment Plan
1. Usual periodontal therapy.
2. Occlusal therapy.
(a) Mounted study models, mounted in centric relation and centric occlusion.
(b) Equilibration of those models to see whether it will be possible to equili-
brate the patient’s dentition to provide:
• Centric occlusion in centric relation.
• Atraumatic dynamic occlusion.
• Elimination of incline contacts.
esults of Occlusal Analysis

R
See Fig. 7.13 for comparison of Clinical Occlusal Record (Occlusal Sketch) and
Static (Blue) and Dynamic (Red) Centric Occlusion marked on mounted models.
Explanations
Analysis
1. On the models, the only incisors contacting are UR1 and LR1.
Confirmed by mark on solid model, whereas in mouth the mobility of UR1
allows all other incisors to contact. Diagnosis: UR1 is in Traumatic static
Occlusion.
2. No red mark on UR2 in mouth, whereas in the mouth there was because in the
mouth UR2 is mobile.
Diagnosis: UR2 is in Traumatic dynamic Occlusion.
3. LL5: No red mark in mouth because it is mobile.
Diagnosis: Traumatic dynamic Occlusion of LL5 is confirmed.
4. LR6: There is a red mark on the buccal aspect of disto-buccal cusp, in the mouth
not on the mounted models.
Explanation: Semi-adjustable articulators cannot reliably replicate immediate
non-progressive side shift (Bennett movement).
Conclusion
In this case, occlusal analysis in the mouth and on mounted models will have helped
to formulate an appropriate Treatment Plan for this patient who has some teeth with
severely compromised periodontal support.
Case Histories 183
2
no 2
red mark
1
1
Only 1 mark
4 4
No red
red
mark
mark 3
red
mark
3 no red mark
Fig. 7.13 Comparison of patient’s occlusion (recorded on an Occlusal Sketch) against model
occlusion. Note the 4 differences
ase 3: Reduction of Occlusal Forces Might Facilitate

C
Tooth Survival
History (When Patient Presented in 1989)
• 34-year-old female patient
• Hypermobile UL1.
• She has been advised by at a Dental Hospital that it will be difficult to avoid an
upper clearance (Fig. 7.14).
Examination Finding
1. Healthy looking gingivae
2. Deep pockets
3. Radiographs show significant bone loss (Fig. 7.15)
4. Previous dentist has perforated furcation of UR7 during attempted RCT
5. Occlusal analysis
(a) CO not in CR
(b) Premature contact between UR8 and LR7
(c) Non-working side interference on RHS
(d) Poor posterior support
Fig. 7.14 Opinion from secondary care advising poor prognosis for upper dentition (dated 1989)
Fig. 7.15 Radiograph taken 1989
Treatment
Occlusal
1. Equilibrate to provide CO in CR.
2. So, eliminating premature contact between UR8 and LR7.
3. and NWS interference on RHS,
4. Provide posterior support.
UR7
• Despite attempted amalgam repair and good maintenance by patient (see
Fig. 7.16a–c), eventually this tooth had to be sectioned. A provisional restora-
tion of the palatal root and an implant at UR 6 space were provided (see
Fig. 7.17).
utcome Assessed in 2017: (See Fig. 7.18a, b)

O
• The patient has not lost any teeth since the buccal roots of UR7.
• There is no hyper-mobility.
• There has been no discernible loss of periodontal support, including at UR8.
Case Histories 185
a b c
Fig. 7.16 (a–c) Perforation of Furcation area during RCT of UR7. Despite attempted Amalgam
Repair and good maintenance by patient, this tooth had to be sectioned. See Fig. 7.18
Fig. 7.17 Taken in 2011.

Compare bone levels at
UR8 with those present
in 1989
a b
Fig. 7.18 (a) UR sextant (taken 2017). (b) UL sextant (taken 2017)
Case 4: ‘Perio/Endo’ Lesion LR6
resented in May 2011

P
• Compromised bone support for distal root of LR6.
• Good bone support at mesial root of LR6.
Treatment (See Fig. 7.19a–e)
May 2011
Separation of roots
Extraction of distal root
Root canal treatment of mesial root
May 2012
Direct composite provisional restoration of mesial root
Nov 2019
Definitive restoration of mesial root with careful adjustment of occlusion, using
Shimstock.
a b
c d e
Shimstock
Fig. 7.19 (a) (May 2011) LR6 with Perio/Endo Lesion affecting distal root. Mesial root is sup-
ported by healthy adequate bone. (b) Root canal treatment of mesial root (June 2011). (c)
Provisional restoration of mesial root of LR6 with direct composite (May 2012). (d) Definitive
restoration of mesial root of LR6 (Nov 2014) with cast gold crown. (e) Occlusion of this crown on
this reduced periodontal support is best checked by the use of Shimstock on the other side
Summary 187
a b
Fig. 7.20 (a) (2008) After root resections at LR6, LR7 and UR7. (b) (2013) After restoration of
the LHS with implant supported crowns
ase 5. Use of Hemisection of Two Lower Molars to Avoid Use

C
of Implants on the RHS
Presented
• Loss of posterior occlusion on LHS.
• Very compromised periodontal support on the RHS.
Treatment (See Fig. 7.20a, b)

1. Root resections and endodontics of several molars as provisional restoration of
RHS in 2008.
2. Provision of posterior occlusion by implant supported crowns on LHS
in 2010.
3. Review in 2013 determined no need to replace compromised molars on RHS.
Summary
• The periodontal support for human teeth is a complex structure, capable of a

remarkable adaptation to noxious stimuli, including pathogens and
adverse load.
• Overall, in the presence of occlusal trauma, occlusal therapy may slow the pro-
gression of periodontitis and improve the prognosis.
• Dentist should examine and record the occlusion of their patients with compro-
mised periodontal attachment, before and after treatment.
• The occlusion of periodontally compromised teeth should be designed to reduce
the forces to be within the adaptive capabilities of the reduced periodontal
attachment.

1. The examination of the patient involves the Teeth, Periodontal Tissues
and Articulatory System.
started.
Occlusion.
is a product of Examination, Design, Execution and Checking (the
E.D.E.C. protocol).
capacity.
10. The occlusal objective of orthodontic treatment is not clear, but a large
discrepancy between centric occlusion and centric relation should not be
an outcome of treatment.

Dynamic Occlusion; and the Jaw Relationship in which the patient has
their Centric Occlusion.
12. The occlusion of periodontally compromised teeth should be designed
to reduce the forces to be within the adaptive capabilities of the dam-
aged periodontia.
References
1. Karolyi M. Beobachtungen uber Pyorrhoea alveolaris. Ost-Unt Vjschr Zahnheilk. 1901;17:279.
2. Paesani D. Bruxism theory and practice. Chicago: Quintessence Publishing Co., Inc; 2010.
3. Lobbezoo F, Ahlberg J, Manfredini D, et al. Are bruxism and the bite causally related? J Oral
Rehabil. 2012;39(7):489–501. https://doi.org/10.1111/j.1365-2842.2012.02298.x.
4. Fernandes G, Franco AL, Goncalves DA, et al. Temporomandibular disorders, sleep bruxism,
and primary headaches are mutually associated. J Orofac Pain. 2013;27(1):14–20. https://doi.
org/10.11607/jop.921.
References 189
5. Fan J, Caton JG. Occlusal trauma and excessive occlusal forces: narrative review, case
definitions, and diagnostic considerations 2 0 1 7 WORLD WORKSHOP. J Periodontol.
2018;89(Suppl 1):S214–22.
6. Glickman I, Smulow JB. Alteration in the pathway of gingival inflammation into the underly-
ing tissues induced by excessive occlusal forces. J Periodontol. 1962;33:8–13.
7. Waerhaug J. The infrabony pocket and its relationship to trauma from occlusion and subgingi-
val plaque. J Periodontol. 1979;50:355–65.
8. Nunn ME, Harrel SK. The effect of occlusal discrepancies on periodontitis. J Periodontol.
2001;72(4):485–94.
9. Fleszar TJ, Knowles JW, Morrison EC, Burgett FG, Nissle RR, Ramfjord SP. Tooth mobility
and periodontal therapy. J Clin Periodontol. 1980;7:495–505.
10. Wang HL, Burgett FG, Shyr Y, Ramfjord S. The influence of molar furcation involvement and
mobility on future clinical periodontal attachment loss. J Periodontol. 1994;65:25–9.
11. Harrel SK, Nunn ME. The association of occlusal contacts with the presence of increased
periodontal probing depth. J Clin Periodontol. 2009;36:1035–42.
12. Burgett FG, Ramfjord SP, Nissle RR, Morrison EC, Charbeneau TD, Caffesse RG. A random-
ized trial of occlusal adjustment in the treatment of periodontitis patients. J Clin Periodontol.
1992;19:381–7.
13. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical
parameters in developing an accurate prognosis. J Periodontol. 1996;67:658–65.
14. McGuire MK, Nunn ME. Prognosis versus actual outcome. III. The effectiveness of clinical
parameters in accurately predicting tooth survival. J Periodontol. 1996;67:666–74.
15. Harrel SK, Nunn ME. The effect of occlusal discrepancies on periodontitis. II. Relationship of
occlusal treatment to the progression of periodontal disease. J Periodontol. 2001;72:495–505.
16. Proceedings of the World Workshop in Clinical Periodontics. Chicago. Consensus report:
Occlusal Trauma. The American Academy of Periodontology 1989: III- 1/III-23.
17. Foz AM, et al. Occlusal adjustment associated with periodontal therapy— a systematic review.
J Dent. 2012;40:1025–103.
Good Occlusal Practice in Children’s
Dentistry 8
The difference between paediatric dentistry and most other branches of dentistry is
that, in the child, the occlusion is constantly changing. Consequently ‘Good
Occlusal Practice’ in children is a matter of making the right clinical decisions for
the future occlusion. The clinician needs to have an awareness and be able to predict
the influence that different treatment options and skeletal growth will have on the
occlusion when the child’s development is complete.
In this chapter, we will discuss Good occlusal practice in Children’s

Dentistry.
• Decisions need to be made about the patient’s Future Occlusion.
Introduction
When considering the child’s occlusion as opposed to that of the adult, the impor-
tant difference is that the child’s occlusion changes, with skeletal growth. The key
objective in the child patient is, therefore, to increase the chances of an optimal
occlusion by predicting the effect of a clinical situation on their future occlusion.
Therefore, the objectives in management are:
1. Preservation, where possible, of the primary dentition with good preventive
care [1].
2. Identification of unusual patterns of growth and/or eruption.
3. Timely referral for specialist advice/treatment if required.

https://doi.org/10.1007/978-3-030-79225-1_8
192 8 Good Occlusal Practice in Children’s Dentistry
This chapter will present a range of common clinical presentations in the child
patient which, when well-managed, will result in the most favourable outcome for
the future occlusion.
1. Premature Loss of Primary Teeth
The primary dentition is normally fully established at 3 years of age (Fig. 8.1a)
when 40% of children exhibit spacing [2]. A combined spacing of 6mm or more in
either arch of the primary dentition is considered optimum to reduce the likelihood
of crowding in the permanent dentition [3].
The primary dentition is important as it provides guidance for the permanent
teeth into the correct position. If primary teeth are lost early, there will be a conse-
quence for the permanent dentition and developing occlusion.
Whenever there is a planned loss of a primary tooth, consideration should be
given as to whether a balancing extraction is needed to prevent a centreline shift and
disruption of the developing occlusion; although this will depend upon the age of
the patient and the tooth that has been lost prematurely:
1.1 Primary Incisor

There is no requirement to balance or compensate the loss of a primary incisor.
Typically, primary incisor teeth become more spaced prior as a result of jaw growth,
and therefore, space closure following enforced or planned primary incisor loss is
unlikely to occur.
1.2 Primary Canine

Where a primary canine is to be lost early, then a balancing extraction of the contra-
lateral canine is recommended. Unilateral loss in all but spaced dentitions will cause
a shift in the centreline in the direction of space, thereby presenting a challenge for
later correction.
1.3 First Primary Molar

In a crowded dentition, a balancing extraction may be beneficial and should be con-
sidered; however, there is no indication to compensate in the opposing arch.
1.4 Second Primary Molar

1. There is no requirement to balance the loss of a second primary molar as its loss
will have no effect on the centreline.
2. If the second primary molar is lost early, there may be a mesial shift and tilting
of the adjacent first permanent molar. This will leave less space available for the
erupting permanent teeth, typically resulting in crowding with exclusion of the
1. Premature Loss of Primary Teeth 193
Fig. 8.1 (a) Primary dentition in a 5-year old [twin of child in figure b] with minimal spacing and
well-aligned arched in the primary dentition. (b) Primary dentition in a 5-year old [twin of child in
figure a] with cross bite on the left side and midline shift due to prolonged use of pacifier in the
primary dentition
second premolars from the dental arch. A space maintainer to preserve the space
that was occupied by the second primary molar should be considered to prevent
this adverse movement of the first permanent molars.
When primary molars in three quadrants need to be extracted, then the equiv-
alent molar in the fourth quadrant should be extracted, in order to keep the devel-
opment and drift symmetrical in each quadrant.
Space Maintainers
The appropriate utilisation of space maintenance in the primary dentition following

premature loss of primary teeth can prevent a less than ideal occlusion in the perma-
nent dentition.
They are most useful when the first primary molar is lost in a very crowded arch
or following the loss of the second primary molar (Fig. 8.2a, b).
Fig. 8.2 (a) Space maintenance in the primary molar region with a lingual arch space maintainer
to hold LR6 in position and thereby maintain space for LR5, following early loss of LLE.
(b) Space maintainer in the primary molar region with a band and loop space maintainer to main-
tain space for LL4 following early loss of LLD
2. Infra-occlusion 195
2. Infra-occlusion
A ‘submerging’ primary molar lies below the occlusal plane as a consequence of

ankylosis; this can occur in 8–14% of children [4]. The term ‘infra-occluding’ is
preferred, as there is no active submergence of the tooth involved. The adjacent
teeth are erupting normally whilst the ankylosed primary tooth remains static,
resulting in infra-occlusion. If the permanent successor is present, the effect is usu-
ally transient, and the tooth is likely to exfoliate at or about the normal age. However,
it may be an indicator that the permanent successor is missing, and this should be
investigated radiographically.
The significance of the ‘infra-occluded tooth’ is that there is both loss of occlusal
contact with the opposing teeth and approximal contact with two adjacent teeth. In
particular, there are adverse consequences where loss of contact with the adjacent
first permanent molar allows it to tilt and drift mesially. This will impact on the
developing occlusion between the first permanent molars and will reduce the space
in the arch.
When the infra-occluding primary tooth is seen to be disrupting the occlusion,
then extraction of the primary unit is indicated; as long as the permanent successor
is present there. Hopefully this should encourage eruption of the premolar tooth, so
stabilising the occlusion.
If the permanent successor is missing and the decision to preserve the submerged
primary tooth is made, then restoration of the tooth with an onlay can restore the
occlusal and approximal contacts. This will prevent adverse tooth movements and
loss of space (Fig. 8.3).
Fig. 8.3 Orthopantomogram in a 5-year old which shows: Infra-occlusion LRD, LLD. Impaction
of UR6, UL6 and resorption of URE, ULE requiring close monitoring. Developmental absence of
LR5, LR4, LL4, LL5 and likely absence of UR5, UR4 requiring close monitoring
3. Retained Primary Teeth
Primary teeth retention can be due to:

• Missing or ectopic successors
• Genetic or syndromal factors
• Trauma
• Ankylosis
• Obstructions, e.g. supernumerary teeth and dental crowding
A dentist needs to be aware of the normal erupting times of the permanent teeth
(Fig. 8.4a, b). As a general rule, contralateral teeth will erupt within 6 months of
each other. If a patient does not broadly follow these sequences, they should be
investigated radiographically.
a
PRIMARY TEETH Visible on Eruption
Radiograph
Incisors Birth 6-9 months
Canines Birth 18 months
1st Molars Birth 12 months
2nd Molars Birth 24 months
b
PERMANENT Visible on Eruption
TEETH Radiograph
Central incisors 6 months 6-8 years
Lateral incisors 9-12 months 7-9 years
Canines-Mand 6 months 9-10 years
Canines-Max 6 months 11-12 years
Premolars 2-3 years 10-12 years
First molars Birth 6 years
Second molars 4 years 11-13 years
Fig. 8.4 (a) Eruption times of primary teeth. (b) Eruption times of permanent teeth
4. Habits 197
Fig. 8.5 (a) Infra-occlusion—treatment with composite Onlays LRD, LLD. (b) Infra-occlusion—
treatment with composite Onlays LRD, LLD
The absence of permanent successors requires an orthodontic assessment to aid

treatment planning. Following this assessment, if the decision is to maintain the
primary tooth, then restoration is indicated because with good dental, the primary
tooth can be preserved well into adulthood (Fig. 8.5a, b).
In cases where the permanent successor is present and/or ectopic, then extraction
of the retained primary tooth is often advisable as it can encourage eruption of the
delayed permanent tooth avoiding deflection from its eruption path. Pathway deflec-
tion of the successor permanent teeth can result in crowding, crossbite or
displacement.
4. Habits
It is common for babies and toddlers to have a sucking habit, either with dummies
or digits. Where the habit is prolonged and persistent, it will result in an abnormal
occlusion. Typically, this is seen as an anterior open bite, because the habit will
prevent the normal eruption of the incisor teeth and the over-eruption of the poste-
rior teeth [5]. Sucking habits can also cause posterior crossbites as a consequence of
the tongue positioning towards the floor of the mouth and compressive narrowing of
the upper arch (compare Fig. 8.1a, b).
Other occlusal changes brought about by prolonged sucking habits are proclina-
tion of the maxillary incisors and retroclination of the mandibular incisors, resulting
in an increased overjet and reduction in the overbite.
a b
Fig. 8.6 (a) Habit effect—Unilateral increased overjet in a 12-year old due to continued/sustained
thumb sucking habit. (b) Habit breaking appliance to deter thumb sucking
As they become older, most children will naturally stop their sucking habit. If it
is stopped by the time the permanent incisors begin to erupt, there will be no adverse
effects to the permanent occlusion. However, if the habit persists beyond this time,
then intervention may be required to prevent a lasting occlusal abnormality in the
permanent teeth (Fig. 8.6a, b) [6].
5. Ectopic First Permanent Molar
As it erupts, the first permanent molar is guided by the distal surface of the second
primary molar into position in the arch. In approximately 2–6% of children, the
erupting first permanent molar impacts against the second primary molar, causing
resorption of its distal root. This is more commonly seen in the maxillary arch and
is one indicator of a crowded dentition. In some instances, it can result in the child
complaining of symptoms such as mobility, pain or infection of the primary molar.
Asymptomatic impaction can be detected by routine clinical examination and con-
firmed by radiographic examination (Figs. 8.3 and 8.7).
Early treatment to disimpact the erupting first permanent molar is essential. If left,
the first permanent molar will continue to resorb the primary tooth and then erupt with
a rotation, resulting in mesial tipping and a less than ideal occlusion. The resulting
space loss will, also, increase the likelihood of impaction for the second premolar tooth.
Where disimpaction is not possible and the primary molar has to be extracted,
then orthodontic treatment may be needed to upright and distalise the first permanent
molar into its correct position and relationship with adjacent and opposing teeth.
6. Premature Loss of First Permanent Molars 199
Fig. 8.7 Orthopantomogram in a 7-year old—Ectopic first permanent molar (LL6) causing
pressure resorption of primary molar (LLE) root
6. Premature Loss of First Permanent Molars
Where there is caries or hypomineralisation of first permanent molars, consider-

ation must be given to their long-term prognosis. This is because early extraction of
first permanent molars with a poor long-term prognosis can result in a significantly
better outcome for the child, than loss of these teeth later in life. Planned early loss
allows successful eruption of the second permanent molars into the position of the
lost first permanent molars, followed by the eruption of third into the second molar
position.
This is a very good example of the principle that the treatment plan is aimed at
optimising the future occlusion, rather than solely addressing the presenting condi-
tion of the needs of a tooth or teeth. Although the natural instinct of the dentist may
be to restore and retain these significant teeth, an objective assessment of the long-
term prognosis is key to the best treatment for the child patient.
‘Restoration at all costs’ is not always the best option where there is extensive
caries/post-eruptive breakdown due to hypomineralisation in a first permanent
molar of a child under 10 years of age (Fig. 8.8).
Fig. 8.8 Orthopantomogram—poor prognosis first permanent molars
Restorative decisions
Consider:
• Long-term prognosis
• Developing occlusion
Treatment planning in these cases is not easy; a number of factors need to be

considered. Ideally, treatment decisions will involve both paediatric and orthodon-
tist specialists. The optimal treatment will depend upon:
• Extent of the caries/enamel hypomineralisation
• Presence of all other unerupted permanent teeth
• Developmental stage of second permanent molars
• Degree of crowding in the premolar regions
• Existing incisal and molar relationships
• Patient motivation
In addition, careful consideration should be given to the need for balancing or

compensating extractions of first permanent molars, with the aim of preserving
occlusal relationships and arch symmetry in the developing dentition [7].
7. Firm Maxillary Primary Canine 201
As discussed, the ideal time for loss of first permanent molars is between 8 and
11 years, when the bifurcation of second molars is beginning to calcify. This is
especially true in the mandible. Mesial movement of second molars is more predict-
able in the maxillary arch. The desired outcome is for the erupting second molar to
replace the missing first molar by moving forward and re-establishing the molar
relationship.
6.1 Balancing Extractions

Routine balancing extraction of a sound molar to preserve centreline is not
indicated.
6.2 Compensating Extractions

• Extraction of a maxillary molar does not require compensation by extraction of
the opposing mandibular molar.
• Extraction of a mandibular molar: a compensating extraction of the maxillary
molar is indicated and it is likely to be unopposed for a long time. This is to pre-
vent its over-eruption. If the maxillary first molar does over-erupt, it can interfere
with the desired forward movement of the mandibular second molar. This is
more likely to occur in class 1 molar relationship.
6.3 To Refer or Not to Refer?

If extractions are indicated, it is never easy to know when a specialist opinion is
advisable:
• Class 1: The decision depends on the number of carious teeth, degree of crowd-
ing and balancing/compensating considerations.
• Class 2: Space will be needed in the maxillary arch to correct a less than ideal
incisor occlusion and reduce the overjet. The orthodontist may consider stabilis-
ing the maxillary first permanent molars until the second molars have erupted.
Then second molars can be used for anchorage when the first molars have been
extracted and the resulting space used for overjet reduction.
• Class 3: Space is more likely to be needed in the lower arch to correct a less than
ideal occlusion. If mandibular first molars are lost before second molars erupt,
the second molars will drift mesially and occupy the space. In Class 3 molar rela-
tion cases, this may result in the need to extract a premolar unit to re-gain
this space.
7. Firm Maxillary Primary Canine
Permanent maxillary canines usually erupt at 11–12 years of age. Development of

the canine starts high in the maxilla. Consequently, the developing tooth has a long
path of eruption, to an ideal position that is buccal and mesial to the primary canine.
Because of this long eruption path, the maxillary canine tooth is the most common
one, after third molars, to become impacted. Deviation from the normal eruption
path can occur in either a buccal or a palatal direction. Palatal impactions may be as
high as 3%.
Because of its morphology and position, the permanent maxillary canine tooth
is the ideal tooth to provide anterior guidance during lateral excursion (canine
guidance). In addition, the best aesthetics are achieved with class 1 canine
relation.
1. Palpation for unerupted maxillary canines should be a part of the routine dental
examination of every child over 9 years old. The maxillary canine should be
palpable as a bulge in the buccal sulcus between 10 and 11 years old. Ideally, the
bulges should be symmetrical.
If the canines are not palpable, then further investigation by radiographs is
indicated to locate the permanent canine, using the parallax technique. Impacted
maxillary permanent canines can cause resorption of the adjacent tooth roots so
must be identified and treated early [8].
2. If a primary canine is still firm and the permanent canine is not palpable, then
specialist orthodontic opinion should be sought. The decision will be to extract
the firm maxillary deciduous canine, or to retain it.
a. Extraction: to encourage the permanent canines to erupt in the correct
position.
b. Retention: thereby, leaving the permanent canine unerupted. Regular radio-
graphic monitoring is required. Surgical removal of the unerupted permanent
canine may be indicated.
8. Unerupted Maxillary Permanent Incisors
Maxillary incisors usually erupt between 7 and 9 years of age, and contra-lateral
teeth will normally erupt within 6 months of each other. The eruption of the maxil-
lary incisor teeth is not only a significant time in the child’s dental development but
also a milestone in the minds of the child, their family and friends of their general
development. These teeth are vital for functioning and aesthetics. Missing or mal-
formed maxillary permanent incisor teeth can have a major impact on the child’s
self-esteem.
Delayed eruption of maxillary permanent incisor teeth should be investigated
with radiographs, and management depends upon the cause of failure of eruption,
patient age and degree of root formation [9]. The presence of a supernumerary tooth
usually a mesiodens in the anterior maxilla between the central incisors is the most
common reason for the failure of eruption of the incisor teeth (Fig. 8.9a). Other
causes for the failure of eruption may be trauma with dilaceration preventing erup-
tion, hypodontia (developmental absence), ectopic eruption due to prolonged reten-
tion of primary units (Fig. 8.9b).
9. Trauma 203
Fig. 8.9 (a) Unerupted supernumerary resulting in delayed eruption of UL1 with retained
ULA. (b) Retained primary teeth causing ectopic eruption of permanent successors
9. Trauma
Traumatic injury to anterior teeth is more common in children. If there is an

increased overjet and inadequate lip, there is a significantly increased risk.
The first priority is obviously the immediate management of the traumatised
tooth/teeth. But there also needs to be consideration for long-term consequences for
the developing occlusion [10].
1. Where avulsion occurs, and the tooth is successfully replanted/treated
There will be little effect for the developing occlusion, unless root resorption
occurs. If orthodontic tooth movement is planned, there is an increased risk of
root resorption of the traumatised tooth.
2. Where avulsion occurs and the tooth is not replanted, or is later extracted
Space maintainers should be fitted to retain the space and prevent unfavourable
tilting and movement of adjacent and opposing teeth. The purpose of the appli-
ance is to preserve the pre-existing occlusal relationships and to provide an
interim aesthetic outcome.
3. Where crown fracture has occurred
It is important to restore contact with the adjacent teeth by rebuilding the crown
form with composite restorations.
Failure to do so can result in:
• Tilting of the affected tooth
• Tilting of the adjacent teeth
• Space loss with narrowing of the arch
• Over-eruption of the opposing tooth
4. Where displacement of the traumatised tooth has occurred (Fig. 8.10a, b).
Orthodontic treatment may also be required to extrude, intrude, or reposition
teeth following displacement.
a b
Fig. 8.10 (a) Unfavourable space loss following avulsion of UR1 as a result of accidental trauma.
(b) Traumatic displacement of UR1 resulting in unfavourable space loss with mesial drift of UR2
10. Early Orthodontic Intervention
Most orthodontic management of the occlusion takes place when the permanent
dentition is established, typically around 12–13 years of age. Thus, an accurate
assessment of the required orthodontic movement can be made.
Treatment for some occlusions should and can be provided earlier:
• Functional appliances are classically prescribed between 7 and 11 years of age.
This is because these appliances utilise some growth modification during active
growth phases in order to reduce the more severe skeletal discrepancies. If left
untreated, these discrepancies could result in adverse occlusal patterns; for
example: a large overjet which carry a risk of trauma to the upper incisor teeth.
• Crossbites may need early orthodontic intervention. This is particularly impor-
tant where the crossbite causes an unfavourable occlusal contact, resulting in a
mandibular displacement. Crossbites can also cause:
–– Mobility of teeth
–– Hard or soft tissue damage
–– Gingival recession
Simple correction of the crossbite with a removable appliance is recommended.
Summary
Caring for the child patient involves the dentist examining

• Teeth
• Periodontal tissues
• Articulatory system
As part of these examinations, the occlusal relationship should be recorded

together with any facial asymmetry or mandibular deviation.
Although the occlusion in the primary dentition is not a reliable predictor of the
occlusion of the permanent dentition, the primary dentition is, nevertheless, impor-
tant. This is because the primary dentition preserves the space that is required for
the erupting permanent teeth and guides them into their correct position.
Summary 205
Good dental care for the child patient has to encompass:

• Immediate dental needs
• Management of the developing occlusion
• Identification and management of clinical situations which will have an impact
on the future occlusion
This management may be through early referral to a specialist and optimum

restorative care to preserve valuable space and interdental contacts. One of the aims
of paediatric dentistry is to stabilise the future occlusion.

1. The examination of the patient involves the teeth, periodontal tissues and
articulatory system.
started.
4. Compare the patient’s occlusion against the benchmark of ideal occlusion.
during and after treatment is an aid to good occlusal practice.
6. The conformative Approach is the safest way of ensuring that the occlu-
is a product of examination, design, execution and checking (the
E.D.E.C. protocol).
of the ‘conformative approach’.
9. An ideal occlusion in removable prosthodontics is one which reduced
capacity.

dynamic occlusion; and the jaw relationship in which the patient has their
centric occlusion.
12. The occlusion of periodontally compromised teeth should be designed to
reduce the forces to be within the adaptive capabilities of the damaged
periodontia.
13. Good occlusal practice in children is determined by the needs of the
developing occlusion; consequentially ‘restoration at all costs’ may
not be the best policy.
References
1. Delivering better oral health: an evidence-based toolkit for prevention, 3rd edn. https://assets.
publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/
Delivering_better_oral_health.pdf
2. Foster TD, Hamilton MC. Occlusion in the primary dentition. Br. Dent. J. 1969;126:76–9.
3. Leighton BC. The early signs of malocclusion. Trans Eur Orth Soc. 1969:353–68.
4. Hudson AP, Harris AM, Morkel JA, et al. Infraocclusion of primary molars: a review of the
literature. SADJ. 2007;62:114.
5. Proffit WR, Fields HW. The development of orthodontic problems. In: Contemporary ortho-
dontics. London: Elsevier; 1986.
6. BOS guidelines: advice sheet dummy and digit sucking. 2012. www.bos.org.uk
7. A guideline for the extraction of first permanent molars in children. Faculty of Dental Surgery.
2009. www.rcseng.ac.uk/fds/clinical_guidelines/index.html
8. Hussain J, Burden P, McSherry. Management of the palatally ectopic maxillary canine§.
Guidelines, Faculty of Orthodontics. 2010.
9. Management of Unerupted Maxillary Incisors. Royal College of Surgeons Guideline. 2016.
10. Dental trauma guidelines. International Association of Dental Traumatology. https://www.
iadt-dentaltrauma.org/1-9%20%20iadt%20guidelines%20combined%20-%20lr%20-%20
11-5-2013.pdf.
Bruxism
9
Introduction
In this chapter, we will consider bruxism. This is a phenomenon of which every

dentist is aware. It is included in a book on occlusion because bruxism can adversely
affect the occlusal surfaces of teeth, amongst other consequences. Given the preva-
lence and consequences, it is important that clinically active dentists understand:
• what bruxism is
• its aetiology
• how it is diagnosed
• management strategies
• the impact that bruxism may have upon some restorative procedures
The restoration of the worn dentition is the subject of the next chapter. Because
some of the views expressed in this chapter may run counter to the current views of
some dentists, the authors have referenced it to a greater extent than other chapters.
This is so the reader can research the evidence in order to form their own view.
What Is Bruxism?
Bruxism is defined as a ‘repetitive jaw-muscle activity characterised by clenching

or grinding of the teeth and/or by bracing or thrusting of the mandible’ with ‘two
distinct circadian manifestations; either occurring during sleep (sleep bruxism, SB)
or during wakefulness (awake bruxism)’ [1].
The prevalence of SB is generally considered to be around 8–13% of the general
population [2–4]. SB is more common in children (14–18%) and lower in the elderly
(around 3%) [5]. Awake bruxism is more common than SB: a 2013 systematic
review reported a prevalence of 22.1–31% [4].

https://doi.org/10.1007/978-3-030-79225-1_9
208 9 Bruxism
Bruxism may lead to tooth surface loss, masticatory muscle hypertrophy, frac-
ture of restorations or teeth, hypersensitive or painful teeth [5–9]. The excessive
forces on the teeth can lead to alveolar bone resorption, which may be visible radio-
graphically as generalised widening of the periodontal ligament space, and increased
mobility which may be transient or permanent. In the presence of periodontal dis-
ease, the trauma from the occlusion may increase the rate of disease progression.
Occlusal trauma cannot induce periodontal pocketing or attachment loss in teeth
with a healthy periodontium [10]. Investigations into the effects of bruxism on den-
tal implants and implant-retained prostheses have found no increase in biological
complications (e.g. peri-implantitis) but an increased risk of mechanical complica-
tions (e.g. fracture of implants/prostheses) [9].
What Causes Bruxism?
A disorder is the lack of normal functioning of physical or mental processes.

A parafunction is a disordered function, e.g. a normal function carried out to an
excessive extent.
It should be noted that the above definition describes bruxism as neither of these
things, but as an activity. This is in contrast to historical perspectives which view
bruxism as a dysfunctional movement, pathological condition or an ‘occlusal dis-
ease’ caused by the teeth [11].
The current understanding of bruxism is that it is a centrally controlled condi-
tion, with the activity generated by central nervous system impulses. It is not periph-
erally stimulated (i.e. by features of the occlusion). Current evidence does not
support any causal role of occlusal factors in bruxism [7].
Bruxism may be described as primary where there is no pre-existing causative
medical condition or secondary where it occurs as a result of a psychiatric or medi-
cal condition.
The aetiology of sleep bruxism is the subject of some debate and is likely to be
complex and multifactorial. As stated above, it is now generally accepted that the
pathophysiology of SB relates to activation of the central nervous system during
sleep [8, 12].
There are various risk factors that can contribute to SB, including [12]:
• Exogenous risk factors: smoking, heavy alcohol intake, caffeine, medications or
illicit drugs [13].
–– Psychosocial factors: there is a common professional and patient perception
that stress and anxiety exacerbate SB, although results of studies have
varied [2].
• Sleep disorders involving arousal from sleep (e.g. obstructive sleep apnoea).
–– Comorbidities: other disorders including obstructive sleep apnoea [13] and
gastro-oesophageal reflux disorder [14].
These advances in our knowledge of sleep bruxism have helped to disprove the
hypothesis that SB is a result of the peripheral stimulus of an uneven or
What Causes Bruxism? 209
uncomfortable bite. In fact, there is some evidence that an occlusal interference will
reduce random mandibular movement activity [15].
These are important points that will help dentists manage their bruxing patient
appropriately. Especially if the fallacy of it being a peripherally stimulated event is
taken further: that not only is sleep bruxism caused by some features of the patient’s
occlusion but also that the activity is always pathogenic.
As Frank Lobbezoo says:
It should be emphasised that while the occlusion is at the receiving end of parafunctional
activity it is not the cause of it [16].
Some patients with previous or current bruxism present with tooth surface loss,
which can be significant. In many of these patients
• In the absence of missing teeth, function e.g. chewing is not impaired.
• Pulpal exposure has not occurred due to the deposition of tertiary dentine.
• The periodontal support is good.
Some of these patients will seek restorations for aesthetic reasons: that is the
patient’s decision. Consequently, treatment should be driven by the patient’s wishes.
Whilst not encouraging the need for cosmetic improvement by the unsupported
view that treatment is required for mechanical or preventive reasons, it is perfectly
reasonable for the dentist to design a treatment plan to restore an unaesthetic worn
dentition.
However, where teeth are severely worn and the patient does not wish to have treat-
ment, the dentist must inform the patient that should further wear occur that treatment
may be more complicated or that the teeth may become unrestorable. This is an indi-
cation for, at least, careful monitoring. If a patient chooses not to have treatment, the
dentist must inform the patient of the risks of this, because the fact that a patient has
no current concerns does not mean that they do not care about having teeth.
Restoration of worn teeth for reasons of dental health will have a ‘side effect’ of
improving their appearance.
A protocol for restoring the worn dentition is covered in the next chapter.
Photo 9.1 is a case that highlights the dilemma of when to intervene:
Photo 9.1 This patient

reported that he had been
told by a dentist that unless
he had his dentition
restored his teeth would
fall out
210 9 Bruxism
• Obviously, it is very unlikely that his teeth will suddenly lose periodontal support.
• But if some of the teeth are left much longer, they might not be easy to restore;
maybe needing crown lengthening or overdentures.
The key question is whether the tooth wear is ongoing through an active bruxing
habit. In this particular case, the 50-year-old patient reported that this wear had
occurred during his 20s, and as far as he could tell had not become worse since then.
The definition of bruxism as an activity acknowledges the current perspectives
that it may indeed have a function: it has been postulated that sleep bruxism may
have a protective role during sleep, which may relate to airway maintenance [1, 17],
or in stimulating saliva flow to lubricate the oropharynx [18].
How Do We Know If Patients Are Active Bruxists?
Bruxism may involve a static clenching of the teeth, grinding or a mixture of both.
There is accompanying noise in around a third of sleep bruxists [5]. Awake bruxism
is more usually a static clenching without sounds [19], grinding whilst awake is
generally only secondarily associated with medications or neurological disorders,
e.g. dyskinesias [2].
A diagnosis of bruxism may be made by the following:
• Patient report and clinical interview
• Clinical examination
• Intraoral appliances
• Recording of muscle activity
Table 9.1 shows suitable questions to ask patients along with some clinical
observations. Reports by sleeping partners of grinding noises during sleep are a
particularly reliable indicator of SB [20]. Questionnaire alone may not be an accu-
rate means of diagnosis, as up to 80% of patients may be unaware of bruxism
[21, 22].
Many of the given clinical observations, for example tooth surface loss (TSL),
are subjective and/or may represent signs of historical, rather than current, bruxism
[16]. Tooth surface loss will be a combination of:
• Normal physiological functional wear
• Wear associated with bruxism
• Erosion from dietary or gastric sources
• Abrasion
Extent of tooth wear is also influenced by factors such as:

• Enamel quality and quantity
• The nature of any opposing restorations
• Lack of posterior tooth support
How Do We Know If Patients Are Active Bruxists? 211
Table 9.1 Questions to elicit patient-reported history of bruxism, and suggestive clinical
indicators
Questions to use during history Are you aware of grinding your teeth during sleep?
taking Has anyone told you that you grind your teeth during sleep?
On waking, do you have your jaws clenched or thrust
forward?
On waking, do you experience pain or stiffness in the jaw
muscles?
‘Brux Scale’ questions How often do you clench your teeth during sleep?
van der Meulen et al. [21] How often do you grind your teeth during sleep?
How often do you clench your teeth whilst awake?
How often do you grind your teeth whilst awake?
Findings during clinical Masseteric hypertrophy
examination suggestive of Muscle tenderness on palpation
bruxism Wear facets on occlusal surfaces either within the normal
envelope of movement or at eccentric jaw positions: termed
‘bruxofacets’
Shiny spots on restorations
Restoration or tooth fracture
Tongue scalloping and ridging on the cheek mucosa (‘linea
alba’)
Tooth surface loss cannot be used to indicate static clenching activity.

‘Bruxofacets’, i.e. tooth wear in an eccentric position of closure, may seem
more convincing evidence of bruxism than wear in the intercuspal position.
Tooth surface loss should, therefore, be taken in conjunction with other clinical
indicators.
Simple observation of wear facets on intra-oral splints would be a plausible
indicator of bruxism. Some intra-oral appliances aim to detect SB, such as via the
incorporation of electric devices detecting forces applied during clenching/grind-
ing. Extra-oral devices can be used to detect temporalis and masseter activity via
sensors attached to the skin (electromyography): although these sensors cannot
distinguish bruxism from other orofacial movements such as swallowing or
talking.
The gold standard for diagnosis of bruxism, albeit outwith the scope of normal
dental practice, is via polysomnography: a sleep study incorporating detection of
masticatory muscle activity, audio and video recording, ECG and assessment of
brain activity.
It has been recommended that self-report only will provide a ‘possible’ diagno-
sis; a diagnosis based on this plus clinical examination will be ‘probable’ and that
‘definite’ diagnosis would require PSG or EMG recording [1].
A reasonable course of action for the clinical setting would be to take into
account plausible patient report (i.e. not just based upon having been told by a
previous dentist) plus observation of a combination of the clinical signs listed in
Table 9.1.
212 9 Bruxism
Relationship with Painful Temporomandibular Disorders
Whilst many patients are unaware of having SB, in contrast, some patients may
falsely believe they do have the condition, having been told by their dentist that they
do. This may result from an erroneous assumption by the dentist that painful masti-
catory muscles are caused by bruxism. A dentist may, therefore, conclude that a
patient suffering from a painful temporomandibular disorder (TMD) must be a
bruxist. Evidence has shown that while significantly more patients with painful
TMD than controls self-report bruxism, there may be no difference on results con-
firmed by sleep study [23, 24].
What Treatment May Be Indicated?
Bruxism, as an activity or behaviour, does not require treatment. Where pathology

results from this activity, and if both the patient and dentist decide to do so, treat-
ment may be considered. Treatment is directed at the unwanted signs or symptoms
that have arisen as a result of bruxism—not at trying to prevent bruxist activity. The
reader is directed to an extensive review of management strategies by Lobbezoo
et al. [16] which was updated in a systematic review by Manfredini et al. [25].
Irreversible adjustment of the occlusal surfaces of teeth in an attempt to reduce
bruxism is not supported by the literature.
Oral Appliances
Oral appliances/splints primarily aim to protect the dentition from damage caused
by clenching/grinding along with reducing any grinding noises. Evidence for their
effects on muscle activity is conflicting, with some studies finding reduction in mus-
cle activity during their use and others finding an increase in some subjects.
Oral appliances are also used in the management of temporomandibular disor-
ders, where their therapeutic effect may be independent of their effect on bruxism.
Soft vacuum-formed splints (Soft Bite Guards) are easy to construct and fit,
although difficult to adjust and anecdotally may in some cases exacerbate bruxism.
Hard acrylic stabilisation splints may reduce muscle activity and associated mus-
cle pain [26] and may be more long-lasting than soft splints. These should be con-
structed with full occlusal coverage and provide balanced occlusal contact across
the arch (ideally in centric relation or the retruded contact position), with canine
guidance on excursions.
Partial coverage anterior splints (e.g. the nociceptive trigeminal inhibition (NTI)/
sleep clench inhibitor (SCI) splint) have been used in bruxism to reduce muscle
activity via reducing maximum clenching force. These should be used with caution
and with careful monitoring due to the risks of tooth mobility or over-eruption of
uncovered teeth and resultant occlusal changes [26].
What Treatment May Be Indicated? 213
Overeruption and occlusal changes are risks with all splints that have only partial
occlusal coverage when worn for long periods of time, and this potential iatrogenic
harm should be avoided.
A wide range of over-the-counter splints are readily available via the internet or
from non-dental outlets. Caution is advised due to concerns of unsubstantiated man-
ufacturers’ claims of efficacy, risks of unwanted tooth movement from partial cov-
erage and other adverse effects. Many of these appliances do not cover all of the
teeth. An additional risk is that they often lack professional supervision, because the
people who purchase them, sometimes as an alternative to the splint suggested by
their dentist, are unlikely to tell their dentist that they have been using one [27].
Other Measures
Behavioural measures include mindfulness, sleep hygiene and biofeedback.

Patients with awake bruxism can be counselled as to becoming mindful of this
habit in order to endeavour to reduce it. Relaxation techniques can be helpful, along
with finding ways to become reminded to check they are not clenching. Examples
include doing so every time they look in a mirror or by placing coloured stickers
around their home/place of work to act as reminders. Patients’ companions can also
help remind the patient if they observe any clenching.
Simple sleep hygiene measures aim to reduce any influence of psychological
stress on sleep bruxism: such as avoidance of caffeine close to bedtime and relax-
ation techniques before sleep, although there is little evidence for their effect [28].
Biofeedback aims to provide immediate information to the patient about their
behaviour, enabling its reduction. Biofeedback has been used for awake and sleep
bruxism [29], although there is no long-term evidence of efficacy. Devices are avail-
able which utilise muscle sensors with auditory, vibratory or electric stimulatory
feedback. If used overnight, these would intend to disrupt the bruxism activity by
arousing the patient slightly from sleep. There is a concern that this sleep disruption
may lead to excessive daytime sleepiness [30]. Another possible biofeedback strat-
egy is intervention from a sleeping partner who has been disturbed by any grind-
ing noises!
Occlusal splints may be used which release a bad taste on clenching/grinding, or
introduce occlusal interferences (localised occlusal interference splint (LOIS)) [31].
The latter should be used during awake bruxism only, and with careful monitoring
as tooth wear may result.
Pharmacological measures may include the use of benzodiazepines, anticonvul-
sants, beta-blockers, antidepressants, muscle relaxants and a number of others [16].
However, a Cochrane review found insufficient evidence to support this approach
[32], and these measures should only be considered when other conservative strate-
gies have failed, and in conjunction with medical practitioners [16].
Administration of botulinum toxin (Botox) to the muscles of mastication appears
to reduce the frequency of bruxism, although further investigation is required as to
214 9 Bruxism
long-term efficacy [33]. There are concerns that Botox administration can lead to
osteopenic changes in the condyles and sites of muscle attachment [34].
Conclusions
Sleep bruxism occurs in 8–13% of the general population. Bruxism may lead to
damage to teeth and restorations. Dentists should be aware of the potential aetiol-
ogy, pathophysiology and management strategies in order to better advise patients.
In summary:
• Diagnosis of SB in the clinical setting should be made on the basis of patient
history and clinical examination. For research purposes, additional sleep study
should be considered.
• Bruxism is now generally accepted as a centrally controlled phenomenon; it
may be associated with other parasomnias leading to arousal from sleep. As
such, dental interventions are unlikely to reduce the frequency or severity of
bruxism.
• Irreversible occlusal adjustments have no basis in evidence in the management of
bruxism.
• The presence of bruxism is not an indication for invasive and irreversible
treatment.
• Dental management of SB should be directed at protecting the oral structures
from the effects of SB. The primary aim of oral splints in bruxism is to protect
the dentition: the evidence for reducing muscle activity is conflicting.
• Behavioural strategies include biofeedback, relaxation and improvement of sleep
hygiene.
• Administration of botulinum toxin (Botox) may reduce bruxism, but more
research is required into long-term efficacy and possible adverse effects.

2. There is no such thing as an intrinsically bad occlusal contact, only an
intolerable number of times to [para] function on it.
started.
6. The conformative approach is the safest way of ensuring that the occlu-
References 215

E.D.E.C. protocol).
8. The ‘re-organised approach’ involves firstly the establishment of a ‘more
‘conformative approach’.
de-
stabilising forces to a level that is within the denture’s retentive
capacity.

centric occlusion.
periodontia.
developing occlusion; consequentially ‘restoration at all costs’ may not
be the best policy.
14. Bruxism is a centrally controlled behaviour: it is not an ‘occlusal dis-
ease’ or caused by the occlusion.
15. Occlusal adjustment has no evidence basis in the management of
Bruxism.
16. When planning restorations, consideration should be given as to
whether there is Active bruxism.
17. Management of tooth wear may simply involve protecting the denti-
tion and ongoing monitoring.
References
1. Lobbezoo F, Ahlberg J, Glaros AG, et al. Bruxism defined and graded: an international consen-
sus. J Oral Rehabil. 2013;40(1):2–4. https://doi.org/10.1111/joor.12011.
2. Lavigne GJ, Khoury S, Abe S, et al. Bruxism physiology and pathology: an overview for clini-
cians. J Oral Rehabil. 2008;35(7):476–94. https://doi.org/10.1111/j.1365-2842.2008.01881.x.
3. Lavigne GJ, Montplaisir JY. Restless legs syndrome and sleep bruxism: prevalence and asso-
ciation among Canadians. Sleep. 1994;17(8):739–43.
4. Manfredini D, Winocur E, Guarda-Nardini L, et al. Epidemiology of bruxism in adults: a sys-
tematic review of the literature. J Orofac Pain. 2013;27(2):99–110. https://doi.org/10.11607/
jop.921.
216 9 Bruxism
5. Lavigne GJ, Rompre PH, Poirier G, et al. Rhythmic masticatory muscle activity during sleep
in humans. J Dent Res. 2001;80(2):443–8.
6. Paesani D. Bruxism theory and practice. Chicago: Quintessence Publishing Co., Inc; 2010.
7. Lobbezoo F, Ahlberg J, Manfredini D, et al. Are bruxism and the bite causally related? J Oral
Rehabil. 2012;39(7):489–501. https://doi.org/10.1111/j.1365-2842.2012.02298.x.
8. Fernandes G, Franco AL, Goncalves DA, et al. Temporomandibular disorders, sleep bruxism,
and primary headaches are mutually associated. J Orofac Pain. 2013;27(1):14–20. https://doi.
org/10.11607/jop.921.
9. Lobbezoo F, Koyano K, Paesani D, et al. Sleep bruxism: diagnostic considerations. In: Kryger
M, Roth T, Dement W, editors. Principles and practice of sleep medicine. Philadelphia:
Elsevier; 2017. p. 1427–34.
10. Lindhe J, Niklaus PL, Karring T. Clinical periodontology and implant dentistry. Oxford:
Blackwell Munksgaard; 2008. p. 349–62.
11. Seven signs and symptoms of occlusal disease: the key to an early diagnosis. 2009. Available
from http://www.dentistrytoday.com/occlusion/1501%2D%2Dsp-540653346. Accessed
June 2017.
12. Carra MC, Huynh N, Lavigne G. Sleep bruxism: a comprehensive overview for the dental
clinician interested in sleep medicine. Dent Clin N Am. 2012;56(2):387–413. https://doi.
org/10.1016/j.cden.2012.01.003.
13. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general popula-
tion. Chest. 2001;119(1):53–61.
14. Miyawaki S, Tanimoto Y, Araki Y, et al. Association between nocturnal bruxism and gastro-
esophageal reflux. Sleep. 2003;26(7):888–92.
15. Michelotti A, Iodice G. The role of orthodontics in temporomandibular disorders. J Oral
Rehabil. 2010;37:411–42.
16. Lobbezoo F, van der Zaag J, van Selms MK, et al. Principles for the management of bruxism.
J Oral Rehabil. 2008;35(7):509–23. https://doi.org/10.1111/j.1365-2842.2008.01853.x.
17. Khoury S, Rouleau GA, Rompre PH, et al. A significant increase in breathing amplitude pre-
cedes sleep bruxism. Chest. 2008;134(2):332–7. https://doi.org/10.1378/chest.08-0115.
18. Miyawaki S, Lavigne GJ, Pierre M, et al. Association between sleep bruxism, swallowing-
related laryngeal movement, and sleep positions. Sleep. 2003;26(4):461–5.
19. Bader G, Lavigne G. Sleep bruxism; an overview of an oromandibular sleep movement disor-
der. Sleep Med Rev. 2000;4(1):27–43. https://doi.org/10.1053/smrv.1999.0070.
20. van der Meulen MJ, Lobbezoo F, Aartman IH, et al. Self-reported oral parafunctions and pain
intensity in temporomandibular disorder patients. J Orofac Pain. 2006;20(1):31–5.
21. Carra MC, Bruni O, Huynh N. Topical review: sleep bruxism, headaches, and sleep-disordered
breathing in children and adolescents. J Orofac Pain. 2012;26(4):267–76.
22. Thompson BA, Blount BW, Krumholz TS. Treatment approaches to bruxism. Am Fam
Physician. 1994;49(7):1617–22.
23. Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with labora-
tory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32(6):779–90.
24. Raphael KG, Sirois DA, Janal MN, et al. Sleep bruxism and myofascial temporoman-

dibular disorders: a laboratory-based polysomnographic investigation. J Am Dent Assoc.
2012;143(11):1223–31.
25. Manfredini D, Ahlberg J, Winocur E, et al. Management of sleep bruxism in adults: a qualita-
tive systematic literature review. J Oral Rehabil. 2015;42(11):862–74. https://doi.org/10.1111/
joor.12322.
26. Stapelmann H, Turp JC. The NTI-tss device for the therapy of bruxism, temporomandibular
disorders, and headache - where do we stand? A qualitative systematic review of the literature.
BMC Oral Health. 2008;8:22. https://doi.org/10.1186/1472-6831-8-22.
27. Wassell RW, Verhees L, Lawrence K, Davies S, Lobbezoo F. Over-the counter (OTC) bruxism
splints available on the Internet. Br Dent J. 2014;216:E24.
References 217
28. Valiente Lopez M, van Selms MK, van der Zaag J, et al. Do sleep hygiene measures and pro-
gressive muscle relaxation influence sleep bruxism? Report of a randomised controlled trial. J
Oral Rehabil. 2015;42(4):259–65. https://doi.org/10.1111/joor.12252.
29. Needham R, Davies SJ. Use of the Grindcare(R) device in the management of nocturnal brux-
ism: a pilot study. Br Dent J. 2013;215(1):E1. https://doi.org/10.1038/sj.bdj.2013.653.
30. Kryger M, Roth T, Dement W. Principles and practice of sleep medicine. 4th ed. Philadelphia:
Elsevier Saunders; 2005. p. 39–50.
31. Gray RMJ, Davies SJ. Occlusal splints and temporomandibular disorders: why, when, how?
Dent Update. 2017;28:4.
32. Macedo CR, Macedo EC, Torloni MR, et al. Pharmacotherapy for sleep bruxism. Cochrane
Database Syst Rev. 2014;10:CD005578. https://doi.org/10.1002/14651858.CD005578.pub2.
33. Long H, Liao Z, Wang Y, et al. Efficacy of botulinum toxins on bruxism: an evidence-based
review. Int Dent J. 2012;62(1):1–5. https://doi.org/10.1111/j.1875-595X.2011.00085.x.
34. Kun-Darbois JD, Libouban H, Chappard D. Botulinum toxin in masticatory muscles of the
adult rat induces bone loss at the condyle and alveolar regions of the mandible associated
with a bone proliferation at a muscle enthesis. Bone. 2015;77:75–82. https://doi.org/10.1016/j.
bone.2015.03.023.
Occlusion and Non-carious Tooth
Surface Loss 10
Introduction
Tooth surface loss (TSL) can be defined as ‘surface loss of dental hard tissues by
causes other than caries, trauma or developmental defects: a multifactorial condi-
tion’. The Adult Dental Health Survey 1998 found that two thirds of adults had
some anterior wear into dentine: 11% had moderate wear with extensive dentine
involvement and 1% had severe wear.
The prevalence of TSL increases with age. A systematic review of 186 preva-
lence studies [1] found that the prevalence of severe tooth wear was 3% at the age
of 20 years, rising to 17% at the age of 70 years.
Tooth Surface Loss

• High prevalence
• Probably becoming less socially acceptable
Significant Demand for Management
The management of this form of generalised TSL is included in this book because
knowledge of occlusion is needed for both the diagnosis and, when indicated, treat-
ment. There are, however, many other factors involved in the management of gener-
alised TSL other than those associated with ‘occlusion’. These will also be discussed.
The chapter is divided into three sections.
Section 10.1 addresses:

• Classification and aetiology
• Distinction between physiological and pathological TSL
• Examination protocols, including some examples of indices
• Monitoring protocols
• Restoration strategies
https://doi.org/10.1007/978-3-030-79225-1_10
220 10 Occlusion and Non-carious Tooth Surface Loss
Section 10.2 discusses the decision on how to create space for the restorations.
Section 10.3 is composed of case histories of the restoration of the worn denti-
tion, that illustrate:
• Decisions around restoration strategies
• Techniques employed
Section 10.1: General Considerations on the Management of

Non-carious Tooth Surface Loss
Aetiology
Tooth surface loss can be due to erosion, abrasion, attrition, abfraction or a combi-
nation of these.
1. Erosion
Erosion is a chemical process in which the tooth surface is removed in the absence
of bacteria. Erosive factors may be either intrinsic or extrinsic. Extrinsic sources
include drinks such as fresh fruit juices, carbonated drinks, cordials and alcoholic
beverages, some foods and industrial processes. Intrinsic sources include gastro-
esophageal reflux and eating disorders, amongst others.
2. Abrasion
External agents that have an abrasive effect on the teeth include toothbrush bristles
and dietary factors.
3. Attrition
Attrition is a process in which tooth tissue is removed as a result of opposing tooth
surfaces contacting during function or bruxism. These direct contacts occur during
empty grinding movements:
• At proximal areas
• On supporting cusps
• On guiding surfaces
4. Abfractions (Stress Lesions) (Fig. 10.1a)

It has been suggested that the stress lesion or abfraction is a consequence of
eccentric forces on the natural dentition [2, 3]. The theory propounds tooth fatigue,
flexure and deformation via biomechanical loading of the tooth structure, primar-
ily at the cervical regions. Cusp flexure causes stress at the cervical fulcrum and
results in loss of the overlying tooth structure. The lesion is typically wedge
shaped with sharp line angles. Figure 10.1b shows a cervical cavity which is sig-
nificantly subgingival and interestingly has caused a fenestration of the overlying
attached gingiva. It is highly likely, because of the protection of the overlying soft
tissue, that this lesion is an abfraction without any abrasive or erosive component.
There is even more controversy concerning occlusal abfractions. Other factors
such as erosion and abrasion may play a significant role in the tooth tissue loss,
but a biomechanical loading may be the initial force. Non-carious tooth surface
Section 10.1: General Considerations on the Management of Non-carious Tooth 221
loss is often multi-factorial. Figure 10.1c demonstrates multifactorial tooth sur-

face loss aetiology:
• The first molar occlusal surface displays cupped lesions into dentine and proud
amalgam restorations caused by acid erosion.
• The canine has a flattened tip matching the opposing tooth’s lateral excursive
movement characteristic of an attritive cause.
• Both the premolar and the first molar show cervical non-carious tooth sur-
face loss:
–– The molar appears smooth and rounded in keeping with cervical abrasion.
–– The premolar defect is angular and deep and therefore may be due to
abfraction.
Fig. 10.1 (a) Abfraction V-shaped

non-carious cavity noted on the labial a c
cervical aspect of upper right lateral incisor
which may be suggestive that abfraction is
the cause of the tooth surface loss in the
absence of other aetiological factors (Kind
permission of Prof. D Bartlett). (b) An
abfraction in the lower margin which has
resulted in the fenestration of the Attached
Gingivae. Given its location, this is
unlikely to have an erosive or abrasive
aetiology. (c) Multifactorial tooth surface
loss (kind permission of Dr. Martin James)
Despite the multi-factorial aetiology of tooth surface loss, certain clinical fea-
tures may suggest a major contributory factor. Flattening of cusps or incisal edges
and localised facets on occlusal or palatal surfaces would indicate a primarily attri-
tional aetiology. Traditionally, cervical lesions caused purely by abrasion have
sharply defined margins and a smooth, hard surface. The lesion may become more
rounded and shallower if an element of erosion is present. Once dentine is exposed,
the clinical appearance is determined by the relative contribution of the aetiological

factors. If wear is primarily attritional, then dentine tends to wear at the same rate as
the surrounding enamel. Erosive lesions cause ‘cupping’ to form in the dentine, as
dentine dissolves three or more times faster than enamel at pH 5 [4]. When erosion
affects the palatal surfaces of upper maxillary teeth, there is often a central area of
exposed dentine surrounded by a border of unaffected enamel.
Tooth Surface Loss

Physiological?
Pathological?
Physiological vs Pathological Tooth Surface Loss
Tooth surface loss may be purely physiological (Fig. 10.2) and occurs as a natural
consequence of ageing. Several factors, however, including erosion, abrasion and
attrition can render tooth surface loss pathologically. As a result of this, symptoms
may develop, and treatment may be indicated. Although this chapter will deal with
only pathological tooth surface loss, it is important to be able to recognise that some
tooth surface loss is purely physiological. It should not be assumed that all tooth
surface loss is pathological.
Fig. 10.2 Purely physiological tooth surface loss
There appears to be no consensus as to what constitutes physiological tooth sur-

face loss. It would be of assistance to practising dentists, if such criteria could be
established.
Pathological tooth surface loss may result in a change in the appearance of teeth,
considered to be excessive with respect to the age of the patient (Fig. 10.3a–c).
There may be:
• Sensitivity to thermal stimuli
• A loss in vertical height
Dentoalveolar Compensation 223
a b
Fig. 10.3 (a) Shows a young patient (18 years), who needs treatment, whereas. (b) A similar
amount of TSL in an older (75 years) patient does not necessarily warrant intervention. (c) Is 45
years old and his request for treatment is justified
• A history of frequent fracture of teeth or restorations

• Hypermobility and drifting
Dentoalveolar Compensation
Physiological tooth surface loss is normal and results in a reduction in:

• Vertical tooth height
• Horizontal tooth width
But in physiological tooth surface loss, vertical dimension is maintained by alve-

olar bone remodelling resulting in an elongation of the (dento-)alveolar process.
Similarly, proximal wear is compensated by a constant forward pressure maintain-
ing tooth-to-tooth contact.
This physiological compensatory process (dentoalveolar compensation) ensures
maintenance of occlusal contacts, maximising the efficiency of the masticatory
apparatus.
Where pathological tooth surface loss, affecting the occlusal surfaces of the
teeth, has occurred, then one might expect to see a reduction in occlusal face height
(vertical dimension of occlusion or VDO); or, expressed in a different way, an
increase in the freeway space (FWS) could be anticipated. This may be further com-
plicated by forward posturing of the mandible.
It is often observed, however, that despite overall tooth surface loss, the freeway
space and the resting facial height appear to remain unaltered.
This is because of dentoalveolar compensation.
It has been observed that in the normal adult dentition, the FWS remains constant
and even in those patients who exhibit significant tooth surface loss, the VDO is
unaffected in 80% and a normal FWS of 3 mm is exhibited [5].
This is important with respect to patient assessment. If restoration of worn teeth
is being planned, then the extent of dentoalveolar compensation should be
considered.
This will be further discussed in Sect. 10.2 of this chapter.
Sometimes, dentoalveolar compensation may lead to the incisal level of worn
teeth being maintained at approximately the same level relative to the patients lip
line, as seen in Fig. 10.4.
If treatment of a patient within this group is necessary, then crown lengthening
procedures may be indicated. Without doing so, restored teeth would appear exces-
sively long-resulting in an adverse appearance (Fig. 10.4).
Alternatively, restoration of the patient’s dentition may be provided at an
increased VDO (reduced FWS). Some may argue that any increase in FWS should
be proportionate to the degree of attrition.
Nevertheless, the fundamental question is:

Does it matter if the patient’s VDO is increased during the restoration of the
tooth surface loss (i.e. the FWS is reduced)?
The answer is different for each patient. No occlusion can be said to be
‘wrong’ rather it is the case that in certain patients, at particular times in their
lives, some occlusal patterns will not be tolerated. An occlusion can only be
judged by the reaction of the tissues surrounding it, so it is with the issue of an
increase in VDO.
The increase in OVD effected by restoration of TSL seems not to affect dentate
patients in the same way as it does to edentulous patients for whom complete
Fig. 10.4 Dento-alveolar
compensation has resulted
in the incisal edges of the
significantly worn teeth to
have the same relationship
to the lip line
denture construction needs to carefully consider the FWS. This adaptability of den-

tate patients may relate to the nature of the dentoalveolar process and its neuromus-
cular proprioception. Garnick and Ramfjord, as long ago as 1962, found that no
symptoms/muscle dysfunction were experienced until the OVD was increased by of
11–12 mm (via the provision of stabilisation splints) [6].
Examination
Clinical assessment of the patient with tooth wear involves extra-oral and intra-oral
observations.
The intra-oral examination will need to include an assessment of severity, either
one of the indexes presented above, or a similar alternative.
Extra-oral assessment should include assessment of the following in smile and
at rest:
• The position of the lip line in relation to the incisal edges
• Amount of tooth show
• Gingival display
Radiographic examination should be considered for moderate to severe cases:

Wazani, in 2012, found no PA pathology in patients with mild TSL; but that 7% of
patients with moderate TSL and 20% of patients with severe wear did have PA
pathology [7].
A protocol for examining a patient with TSL is presented in Fig. 10.5.
This is suggested to be in addition to the normal examination of the articula-
tory system.
This examination is designed to:
• Aid in distinguishing between physiological and pathological TSL
• Reveal any features that may indicate the aetiology
• Indicate whether or not treatment should be carried out
• Highlight any potential difficulties anticipated in treatment
In addition to a general examination protocol, similar to the one suggested

in Fig. 10.5 some attempts to grade the severity of the tissue that has been lost
will be useful. There are many indices to help with this. Some are sum-
marised below:
1. Tooth Wear Index [8]: Smith and Knight 1984 (Fig. 10.6)
This index requires observation of wear affecting the buccal (B), lingual (L), occlu-
sal (O), incisal (I) and cervical (C) tooth surfaces. Patients are divided into age
groups, and there is guidance as to what extent of wear is pathological according to
age. For example, it was suggested that for age 36–45 years, occlusal/incisal wear
>grade 2 would be deemed pathological.
Patient Date Age
1 Is tooth surface loss Normal

Excessive
Extreme
Is there any evidence that it is progressive ? for a patient of this age?
None
Weak
Strong
2 The following features suggest an aetiology of

EROSION
ABRASION
ATTRITION
3 Known dietary habit?

Known gastric reflux?
Known oarafunction?
Other [specify]?
4 Has dento-alveolar compensation taken place?
5 QUALTY OF LIFE ISSUES

Patientis worried about: Appearance
Tooth sensitivity Tooth or restoration fracture
Soft tissue comfort Loosening teeth
6 RECORDS taken and TESTS made
Centric Relation jaw registration Models
Photographs Tooth measurements taken
Ethyl chloride
Fig. 10.5 Initial examination of patient exhibiting tooth surface loss

Grade Tooth Clinical findings

surface
0 BLOI No loss of enamel surface characteristics
C No change in contour
1 BLOI Loss of enamel surface characteristics
C Minimal loss of contour
2 BLO Bucc/ling/occlusal enamel loss, exposing dentine <1/3 of the
surface
I Incisal enamel loss with minimal dentine exposure
C >1mm deep cervically
3 BLO Bucc/ling/occlusal enamel loss, exposing dentine >1/3 of the
surface
I Incisal enamel loss with substantial loss of dentine
C Defect 1 -2mm deep
4 BLO Bucc/ling/occlusal complete enamel loss, pulp exposure or exposure
of 2ndary dentine
I Incisal pulp exposure or exposure of 2ndary dentine
C Defect >2mm deep, pulpal exposure or exposure of 2ndary dentine
Fig. 10.6 Tooth wear index: Smith and Knight 1984
2. Basic Erosive Wear Examination (BEWE) [9]: Bartlett 2008 (Fig. 10.7)
This is a partial scoring system for severity of TSL and intended to be similar to the
BPE. This index was designed to be simple to use, easy to record, and to serve as a
demonstration that TSL had been examined and considered and encourage a pre-
ventive approach as opposed to a detailed examination allowing monitoring of pro-
gression. The BEWE was designed for use in epidemiological research and general
dental practice. Scores are allocated in terms of surface area affected, rather than
depth/exposure. The highest score in each sextant is recorded, then the scores are
added. This number then gives a guide to suggested clinical management strategy.
3. Tooth Wear Evaluation System (TWES) [10]: Wetselaar and Lobbezoo

2016 (Fig. 10.8)
This ‘modular’ system includes guidance on assessment, classification and manage-
ment of TSL. The TWES includes multiple factors including:
• A screening module with 5-point scale in each sextant. Each sextant is recorded
separately.
1. No wear
2. Visible wear within enamel
3. Wear with dentine exposure and loss of crown height <1/3
4. Loss of crown height 1/3–2/3
5. Loss of crown height >2/3
• Measurement of upper and lower anterior teeth
• Recording of TSL
0 No surface loss
1 Initial loss of enamel surface texture
2 Distinct defect, hard tissue loss <50% of surface area
3 >50% of surface area
Risk/complexity Sum of BEWE Management

level scores from all
sextants
None £2 Routine maintenance and observation
Repeat at 3-year intervals
Low 3-8 Oral hygiene and dietary assessment, and advice,
routine maintenance and observation
Repeat at 2-year intervals
Medium 9-13 Oral hygiene and dietary assessment, and advice,
identify the main aetiological factor(s) for tissue
loss and develop strategies to eliminate
respective impacts
Consider fluoridation measures or other strategies
to increase the resistance of tooth surfaces
Ideally, avoid the placement of restorations and
monitor erosive wear with study casts,
photographs, or silicone impressions
Repeat at 6 –12-month intervals
High ≥14 Oral hygiene and dietary assessment, and advice,
identify the main aetiological factor(s) for tissue
loss and develop strategies to eliminate
respective impacts
Consider fluoridation measures or other strategies
to increase the resistance of tooth surfaces
Ideally, avoid restorations and monitor tooth wear
with study casts, photographs, or silicone
impressions
Especially in cases of severe progression
consider special care that may involve
restorations
Repeat at 6 –12-month intervals
Fig. 10.7 Basic erosive wear examination (BEWE): Bartlett 2008
Mild Within enamel

Mod Dentine exposure
Severe Dentine exposure with loss of crown height, <2/3 occlusal/incisal
Extreme Dentine exposure with loss of crown height, >2/3 occlusal/incisal
Fig. 10.8 Tooth wear evaluation system (TWES): Wetselaar and Lobbezoo 2016
• Medical/social history
• Difficulty of treatment
A classification was proposed to describe TSL in terms of severity, distribution

(localised/generalised) and aetiology. Localised TSL affects 1–2 sextants; gener-
alised affects 3+.
Returning to the initial examination protocol (Fig. 10.5)

The first question is to help in the assessment: Pathological or Physiological
(Fig. 10.9)
Boxes 2 and 3 of the examination sheet (Figs. 10.10 and 10.11) consider the
likely aetiology.
Box 4 (Fig. 10.12) addresses the issue of dentoalveolar compensation, which can
have a significant bearing on management.
1 Is tooth surface loss Normal

Excessive
Extreme
for a patient of this age?
Is there any evidence that it is progressive?
None
Weak
Strong
Fig. 10.9 Question 1 of initial examination (Fig. 10.5)
2 The following features suggest an aetiology of
EROSION
ABRASION
ATTRITION

3 Known dietbry habit?
Known gastric reflux?
Known parafunction?
Other [specify]?
4 Has dento-alveolar compensation taken place?
5 QUALTY OF LIFE ISSUES

Patient is worried abour: Appearance
Tooth sensitivity Tooth or restoration fracture
Soft tissue comfort Loosening teeth
Does the Patient Want/Need Treatment?

This question gives rise to Box 5 (figure 1 of the examination sheet) (Fig. 10.13). It
is essential as in all areas of clinical practice to carefully consider the patient’s anxi-
eties and desires in addition to the clinical features before advice is given. Treatment
planning must take into account the patient’s complaints. One study found that 60%
of patients with TSL have aesthetic concerns, 40% sensitivity, 15% pain and 15%
functional difficulties [11].
There are no hard and fast rules, and the need for treatment should be established
after considering:
• The degree of wear relative to the age of the patient
• The aetiology
• The symptoms
• The patient’s wishes
Treatment Considerations
May be passive or active.
Passive Treatment
1. Monitoring
Monitoring involves taking a series of repeated examinations and certain measure-
ments over a period of time in order to assess whether a condition is progressive.
Monitoring is essential in the management of tooth surface loss as it is the only way
in which TSL can be assessed as being active or static.
In the literature, several methods of assessing tooth wear have been described
including:
• General assessment of extracted teeth
• Chemical analysis
• Physical methods (polarised light/indentation techniques/profilometry), scan-
ning electron microscopic analysis
• Digital image analysis
These are research tools that are not applicable to clinical practice. Therefore, a
monitoring protocol to assess tooth surface loss is presented (Fig. 10.14a, b). It is
easy to use, and through this method, it is easy to record the progression of tooth
surface loss.
Monitoring is, of course, only an option when baseline measurements have been
taken. This emphasises the need for the dentist to examine and record tooth surface
loss. To facilitate this, a protocol for the initial examination of a patient with TSL
has been presented (Fig. 10.5).
2. Prevention
This is the ‘treatment’ of future tooth surface loss. If the extent of existing tooth
surface loss is considered to be acceptable, the appropriate treatment is clearly to try
to prevent further TSL, which could render the patient needing restorative treat-
ment. The form of the preventive treatment will be dependent on the aetiology of the
TSL, so determining the cause is essential.
For a patient whose tooth surface loss is essentially caused by erosive fluids,
various aspects of prevention can be considered:
1. Reduction in frequency/severity. This could involve dietary advice for extrinsic
sources of erosion; or liaison with a patient’s doctor regarding intrinsic sources,
e.g. medication for reflux; support for eating disorders.
2. Enhancement of natural oral defences, e.g. stimulating saliva flow through sugar
free chewing gum.
3. Enhancing remineralisation/resistance to acid, e.g. fluoride advice, tooth mousse
(casein phosphopeptide).
4. Minimising mechanical factors that increase TSL, e.g. avoiding toothbrushing
shortly after acid exposure.
5. Mechanical protection, e.g. splints for night-time use if sleep bruxism is
suspected.
a Patient Date Age
Primary aetiology EPOSION

ABRASION
ATTRITION
RV no: DATE OF LAST RV INTERVAL
AFFECTED TEETH
Tooth surface loss
Dentine exposed
1 Mild, 2 Moderate,
3 Severe
Sensitivity
(at’s c/o)
Tooth mobility
CI I,II CI III
Fractured/Failed
restorations
Hairline fracture
lines
OTHER NOTES
Fig. 10.14 (a) Monitoring protocol P1. Page 1 of 2

b Patient Date
OTHER SIGNS
Active bruxism? Tongus scalloping
Cheek ridging
T.M.J. exam Noise

Range of motion
Tenderness to palpitation
Muscle tenderness
RECORDS TAKEN
Photographs Impressions
Measurements from A.D.J.
ASSESSMENT at this time

Non-progressive
Maybe progressive [not marked and no symptoms]
Progressive [obvious]
Progressive [obvious and symptomatic]
TREATMENT at this time
Fig. 10.14 (continued) (b) Monitoring protocol P2. Page 2 of 2

If the wear is primarily caused by abrasion, then examination and modification

of the tooth cleaning habits will be indicated.
If the wear is caused by attrition, then the patient should be advised of any pos-
sible bruxing habits. A discussion on bruxism is presented in Chap. 9.
The provision of one of three different sorts of splints could be considered:

• A soft bite guard can help in breaking a bruxing habit or simply will protect the
teeth during the bruxing habit.
• A localised occlusal interference splint is designed to help break the bruxing
habit, and it can be worn easily during the day. It should not be worn at night in
case the bruxism continues.
A stabilisation splint reduces bruxism by providing an ideal occlusion: it also

enables the clinician to locate and record centric relation [12].
Active Treatment
Non-carious loss of tooth tissue may require treatment for one or more of the fol-
lowing reasons:
• Sensitivity
• Aesthetics considerations
• Reduction in function
• Space loss in the vertical dimension
–– This may present a critical problem. Both the need for restorative treatment
and the complexity of that treatment may depend upon whether or not dento-
alveolar compensation has occurred.
Treatment planning would, as normal, take the following form:

1. Management of acute conditions
2. Prevention
3. Stabilisation of underlying pathology, e.g. caries, periodontal disease, pulpal
pathology, extraction of teeth of hopeless prognosis
4. Definitive restorations
5. Monitoring, maintenance, review
To [Actively] Treat or not to Treat?

The first decision is whether the condition warrants restoration. This will be a dif-
ficult decision that will be made after considering:
1. The objective findings of the examination and monitoring protocols
2. The subjective wishes, needs and understanding of the patient
It is a good example of the hard and soft skills that a dentist, in common with
many other healthcare professionals must have to serve the best interests of their
patients.
Examination Skill Set Needed for Care of TSL Patients

Hard Skills
• Pathological or physiological?
• Extent of tooth tissue loss
• Active or passive
• Dento-alveolar compensation
• Temporomandibular disorder?
• Active bruxist?
Soft Skills
• Effect of TSL on quality of life
• Any possibility of body dysmorphic disorder?
• Ability to reduce aetiological habits
• Understanding of risks and benefits
• Acceptance of limitations and features of Tx
Figure 10.15 is presented to help with some of the decisions that will need to
be made.
hich Approach to Adopt in the Restoration of the Worn Dentition

W
In restorative dentistry, usually two choices are considered:
1. It will either be possible to provide the restorations whilst not changing the
occlusion between the other teeth (‘habitual bite’).
2. It will not be possible or desirable to do so.
So, the binary choice is to adopt the Conformative Approach (Chap. 3), or not.
If the conformative approach is not possible or appropriate, then the occlusion

and the jaw relationship of that occlusion will change. It is generally advised that
the jaw relationship in which to build the new occlusion is centric relation [syn:
retruded contact position, terminal hinge axis], as this is the least likely to create an
adverse reaction in the other parts of the masticatory system. This is known as the
Re-Organised Approach and is discussed in Chap. 4.
As will be seen in Chap. 4, it is a complex protocol that starts with finding and
recording centric relation. It usually involves designing the proposed occlusal pre-
scription by the means of a wax up on some models mounted in centric relation. The
process is then to carefully copy that design in the provision of the subsequent res-
torations. Provisional restorations made to the new occlusal prescription are recom-
mended prior to providing indirect restorations, e.g. using materials like ceramics or
metals. Such provisional restorations may be direct composite or provisional crowns
(either chairside or laboratory construction).
There are examples of successful dental procedures that do not follow this
strict occlusal prescriptive design and copy formula, such as orthodontics and the
Tooth Surface Loss Physiological
No action
Pathological
Determine
Exam + Record
Aetiology
This will
Mild Moderate Severe affect
management
Management
Explanation and
patient education Fluoride?
Monitor
Splint?
Diet?
Prevent further loss by: Habit?
Further
referral?
Active treatment
Restore
or refer
Depends upon:
• Cost
• Time
• Operator experience
• Extent of treatment
• Patient requirement
Fig. 10.15 Management of a patient with pathological tooth surface loss
Dahl approach. In the latter, the (usually posterior) occlusion develops following
a combination of intrusion of teeth restored at an increased vertical dimension and
overeruption of unrestored teeth. One explanation for this success is that these are
procedures that take time and offer a degree of adjustment; both by patient
accommodating to the new occlusal and jaw relationships and by the dentist mak-
ing judicious changes. Maybe changing occlusions by evolution rather than by
revolution gives the patient a greater chance of successful adaptation.
Given that the worn dentition is often restored over a period of time using the
adaptable adhesive material of directly bonded composite, it could be that this
branch of dentistry can be successfully provided without the stages outlined in
Chap. 4: The Re-Organised Approach.
Best practice will still be to plan changes to the existing occlusion/jaw relation-
ship along the lines of the traditional re-organised approach.
Some clinicians, however, may opt to restore a worn dentition with direct
composites by building up the worn dentition without giving much thought to
jaw relationship. These clinicians will abbreviate this process, by building up
the dentition (occlusion) without first analysing and planning the restorations on
study models.
It could be argued that a provisional phase may not be required as the composite
restorations can ‘act as their own provisional restorations’ being adapted by addi-
tion, reduction and refinement as required.
Of course, if the Dahl approach is used, it is then not possible to plan the final
occlusal scheme of any unrestored teeth; as the eventual interocclusal relationship
of these relies on uncontrollable tooth movement (intrusion/overeruption), which
develops over months/years.
Whilst not endorsing this approach, the aim of this book is not to be too didactic,
by providing rules, or rigid answers to a set of clinical problems. The author believes
in his colleagues’ personal clinical responsibility. Rather than giving all the answers,
this book seeks to ask the right questions.
So, a question:
Is it ever justified to build up or change an occlusion/jaw relationship without a
careful and detailed design phase?
Surely if the patient tolerates the changes, it must be an acceptable treatment.
If, however, this is a clinician’s strategy, it is suggested are be two important

provisos:
1. The patient is constantly monitored for any signs of an adverse reaction to the
new occlusion or jaw relationship.
2. The restorations provided can be easily adjusted. And they have been placed on
teeth that have not suffered significant preparation.
This then could be called the ‘Monitored Developmental Approach’. It is not the
conformative approach, rather it is less prescriptive and lighter touch version of the
re-organised approach.
Choices When Restoring the Worn Dentition
1. Conformative Approach
This means that the TSL will be restored, whilst not changing the occlusion
between any other teeth and so not changing the jaw relationship in the three dimen-
sions of lateral, anterior/posterior or vertical. The techniques that can be employed
in restoring a patient using conformative approach are described in Chap. 3.
There will be limited instances when this approach is appropriate or possi-
ble; maybe:
• The restoration of the incisal edges of the lower anterior teeth which would
not result in a reduction of the overjet/overbite dimensions and which does
not significantly change the dynamic occlusion is one such instance.
• If the TSL has occurred rapidly, e.g. erosive TSL following periods of fre-
quent reflux/vomiting such as severe morning sickness; and there has not yet
been dentoalveolar compensation.
2. Re-Organised Approach
Implicit in the approach is not only that there will be a change in the jaw
relationship in at least one of the three dimensions but also that the occlusal
prescription to be provided will have been designed, usually on some accurately
mounted models. This approach often will involve the use of laboratory made
indirect restorations. It is described in Chap. 4.
3. Is there a 3rd way?
Monitored Developmental Approach [13]. https://doi.org/10.1038/s41415-
021-3267-6
The debate of this approach centres on whether there must be a physical
design to be followed. This design will usually take to form of a wax up of the
occlusion of the proposed restorations, on models mounted on an articulator to a
pre-determined and consistent jaw relationship.
Other features of the Monitored Developmental Approach are:
• The use of conventional orthodontics or the Dahl technique.
• Direct restorations in adhesive material on minimally prepared or unprepared
teeth are used.
• A degree of adjustment of the restorations is possible, in the way that is not easy
in indirect restorations. This is especially important if the Dahl technique (an
unpredictable relative axial movement of teeth) is employed.
• That the patient is carefully monitored, for any adverse reactions to the new
occlusion, before, during and after treatment.
The decisions to be taken and the techniques that can be employed in the restoration
of the worn dentition are discussed and illustrated in the second half of this chapter.
Section 10.2: Creating the Space for the Restoration of the Worn Teeth 239
Section 10.2: Creating the Space for the Restoration

of the Worn Teeth
When space must be created for the provision of a new occlusion, the bite must
be opened up. Before the restorative treatment is started, decisions have to be
made how to achieve this:
• Does centric occlusion (inter-cuspation position) occur in centric relation
(retruded contact position or terminal hinge axis)?
• If not, what is the size and nature of the slide from CO to CR?
• What is the starting point of the arc along which the bite is going to be opened?
• How much space is needed for the restoration?
In this section, several scenarios are presented, and the restorative strategy for
each is explained. These scenarios are kindly presented by Amin Aminian BDS
MSc MFDS RCPS MRD RCSEd FDS RCSEd. Specialist in Prosthodontics
This slide can be: Shorthand

Small horizontal small vertical vh
Small horizontal large vertical hV
Large horizontal small vertical Hv
Non-existent CO = CR [ICP = RCP]
Lateral
cenario 1: Slide is vh (Small Vertical; Small Horizontal)

S
Restoring to premature contact in CR creates ideal space
CO
CR
Creating space: slide CR => CO vh
Pre-operative situation
Solution to space needed
By finding the Premature Contact in Centric Relation, and providing a new

Occlusion that is in Centric Relation, the space needed for the restoration of
UL1 is achieved.
Note: It is suggested that if UR1 had not been restored by a porcelain crown
that the likely consequence of the Trauma from Occlusion would have been
Attrition in addition or instead of the migration that is evident.
This is a traditional Re-Organised Approach, because the space is created by

increasing the OVD along an arc from centric relation (Terminal Hinge Axis)
cenario 2: Slide is Vh (Large Vertical; Small Horizontal)

S
Restoring to premature contact in CR creates excessive space
CO
CR
Vh = excessive
The anterior teeth exhibited marked fremitus, confirming that there was a
complete absence of freedom in Centric Occlusion. If not for this Traumatic
Occlusion, Centric Occlusion would be at where the dotted lines meet.
Solution to space needed:
The ideal space for the new occlusion is going to be created by opening the
bite from a point that is between the Jaw Relationships of Centric Occlusion
and Centric Relation.
CO
CR
This is a Monitored Developmental Approach, because the space is created

by increasing the OVD along an arc from Jaw Relationship that is neither
Centric Relation or Centric Occlusion.
cenario 3: Slide is Vh and Is Sufficient

S
Restoring to premature contact in CR creates ideal space
Vh=Suffcient
CO
CR
Pre-operative situation Solution to space needed: Post-operative situation
By finding the Premature Contact in Centric Relation, the space needed for
the restoration of the occlusion between the anterior teeth is achieved.
Note: Subsequent treatment replaced the upper central incisors and restored
the posterior occlusion, whilst maintaining the occlusion of the CR premature
contact.
This is the Re-Organised Approach, except that the Design Phase was done in
the mouth, by restoring the Anterior Occlusion with adhesive materials.
In common with all of these scenarios:

The key to the success of this treatment is to determine, before starting the
restoration, which jaw relation will provide the space to restore the worn
dentition.
cenario 4: Slide is vh, and This is Insufficient for the Restoration

S
Restoring to Premature Contact in CR does not provide enough space
CO
CR
Vh: but need

more space
Restoring to the Premature Contact in Centric Relation will not provide the
space needed for the restoration of the lower right posterior occlusion, by
implant supported crowns.

Opening the bite from CR (Terminal Hinge Axis) will create the space.
Re-Organised Approach

cenario 5: Slide is vH
S
Restoring to the premature contact of CR is not an option (see Case 7, in next
section)
vH: too much space
CO
CR
Restoring to the vH case, represents a significant challenge, as starting from

the Premature Contact in Centric Relation will result in a massive overjet.
Will not provide the space needed for the restoration of the lower right poste-
rior occlusion, by implant supported crowns.
Solution: to creating space by increasing the OVD along an arc from Jaw
Relationship that is neither Centric Relation or Centric Occlusion.
Use the Monitored Developmental Approach.
CO
CR
Opening the bite in the Monitored Developmental Approach does not have
the consistent end point that is afforded by increasing the OVD from the start-
ing point of the premature contact in Centric Relation. This is because in
Centric Relation, also known as Terminal Hinge Axis, the head of the condyle
is in its rotational phase of movement. in contrast, when opening the bite
from the jaw relationship of Centric Occlusion, the TMJs are in their transla-
tionary phase. So increasing the OVD will result in further translation rather
than a potentially more reproducible rotation.
Monitored Developmental Approach

Needs the clinician to monitor the patient for any adverse reactions whist
developing the new Occlusion. This will require the use of adjustable restor-
ative materials, such as direct placed composite or acrylic provisional crowns.
cenario 6: Centric Occlusion = Centric Relation [No Slide]

S
Need to create space to achieve the restoration
Do we need space?
Have we created space?
How much?

The bite was opened along the arc from the Terminal Hinge Axis. The Design
Phase was done in the mouth, by restoring the Anterior Occlusion with provi-
sional crowns.
CR
CO
Post-operative situation
This is the Re-Organised Approach, because the space is created by increasing

the OVD along an arc from Centric Relation (Terminal Hinge Axis), which
also happens to coincide with the patient’s pre-treatment Centric Occlusion.
Case 1 247
Section 10.3: Case Histories to Illustrate Restorative Strategies
Introduction
In this third section of this chapter, some of the decisions that need to be taken and
techniques employed to restore the worn dentition are illustrated.
This is a relevant inclusion in a book on Good Occlusal Practice as the occlusion
can be a factor in the aetiology of non-carious tooth surface loss, and in the success
of its restoration.
These cases are presented to predominately illustrate the use of directly applied
adhesive composite material in the restoration of the worn dentition.
Each case will be presented in the same format:
Points being illustrated, then:
1. Presenting features and restorative strategy
2. Design planning, including occlusal prescription and aesthetic preview
3. Techniques employed and post-operative results
The amount of detail given in each case is restricted to that needed to illustrate a
point or features of the restoration.
This does not seek to be a comprehensive account on how restore the worn denti-
tion [1, 2].
Case 1
[This case is kindly provided by Ms Johanna Leven BDS, MFDS RCS(Ed) FDS
(Rest Dent) RCS: Consultant in Restorative Dentistry, University Dental Hospital of
Manchester]
Illustrating:
• Worn dentitions can sometimes be restored the using the conformative
approach.
• For the conformative approach to be used, the existing jaw relationship must be
maintained (see appnt 6 and 7 below).
• Some clinical techniques.
1. Presenting Features and Restorative Strategy

a. Aetiology: mainly erosive, dietary acid and intrinsic acid
b. Features:
• Overall vertical dimension (OVD) remained constant as a result of patient’s
metal ceramic crowns UR12.
• Very little dentoalveolar compensation has occurred (Figs. 10.16
and 10.17).
Fig. 10.16 Case 1:

Frontal view of presenting
condition
a b
Fig. 10.17 Case 1: Occlusal views of presenting condition
2. Design Planning, including Occlusal Prescription and Aesthetic Preview

a. Note that there is sufficient space to work in centric occlusion [ICP]
b. Meaning that the restoration can be provided able to work conformatively,
i.e. the worn teeth will be restored to the height of the existing crowns
c. Clinic: alginate impressions, facebow and CO (ICP) record
d. Laboratory: wax up worn teeth to restore full contour and to complement the
occlusion between UR12 and lower incisor crowns
Occlusal prescription: The planning in this case is minimal as we are
using the existing jaw relationship, i.e. the conformative approach.
Monitoring: It is important to emphasise that a full examination, including
the articulatory system, is carried out before the decision to use the same jaw
relationship (to conform) is taken. In addition, during and after the treatment,
the patient is monitored for any signs of occlusal intolerance in the tooth,
periodontal or articulatory systems. In summary: the new occlusion is moni-
tored whilst it is being developed (Fig. 10.18).
Case 1 249
Fig. 10.18 Aesthetic
preview
• The EDEC principle when restoring complex cases to the conformative

approach
• E = Examine the pre-existing occlusion
• D = Design an operative procedure which allows the conformative approach
• E = Execute that plan
• C = Check that each stage of the restoration conforms to the occlusion of
the previous stage
3. Techniques Employed and Post-operative Results

In this first case to be presented, the clinician has given some details of the
• Order of treatment and number of appointments
• Operative techniques employed
Appointment and Treatment Sequence

This list is not repeated for each of the subsequent Cases.
1. Initial consultation
a. Principal complaint and patient aspiration
b. History
i. Present complaint
ii. Dental
iii. Medical
iv. Social histories
c. Full examination
i. Teeth
ii. Periodontal system
iii. Articulatory system
d. Special tests, including radiographs
e. Diagnosis
f. Treatment options
g. Provisional treatment plan
2. Initial records appointments
a. Impressions, facebow, CO record
b. Photos
c. Laboratory request
3. Aesthetic preview and final TP explanation
4. Direct composite restoration of UL123 UR3 using palatal stent

5. Direct composite restoration of LL34 LR45 using full coverage stent, composite
repairs to buccal of UL56
6. Removal/repreparation of UR1 for new metal ceramic crown and also minimal
chamfer preparation of LL7 for indirect composite onlay
7. Fit of UR1 crown and LL7 onlay, minor polishing/adjustment of other restorations
Warning: if the decision had been taken to replace the UR1 crown before restor-
ing the other teeth, the conformative approach would not have been possible
8. Review following completion, no further adjustments were needed
9. Further reviews at 3–6 months
Note: patient not provided with an occlusal splint for night wear as the aetiol-
ogy was erosive
Composite build-up technique, in this case:

• Monoshade nanohybrid composite used. (Note: Could have used dual shade
composite to achieve enhanced morphological characteristics and translucency,
but its use is more technique sensitive)
• Moisture control achieved with Optragate (Ivoclar Vivodent) lip and cheek
retractor and cotton wool rolls lingually. Advantages of Optragate:
–– Provides good retraction and moisture control
–– Can be easily removed to give the patient frequent breaks
–– Allows operator to check the occlusion during treatment. Note: The patient
can usually bite together with Optragate in place but if not is easily taken in
and out of the mouth.
Note: Dental dam is considered the gold standard; in respect of moisture con-
trol, it has the disadvantage that it needs to be removed to check the occlusion.
General considerations:
Choice of full coverage stent vs palatal stent:
1. Full coverage:
a. Allows for full transfer of the wax up, facilitating fully guided restoration of
tooth contour.
b. Efficient method particularly when a number of teeth are being restored.
But:
• Cannot layer the composite so is only suitable for monoshade composite.
• Can be more difficult to control the contact points of the restoration.
• So, needs extra time removing excess composite in the polishing stage.
• Can get voids in the restorations which need to be filled in.
2. Palatal stent:
a. Allows for transfer of the palatal aspect of the occlusal contour.
b. Best technique for using dual shade composite to enhance morphological fea-
tures and translucency.
c. Less excess composite and therefore polishing stage easier.
d. Better control of contact points.
But:
• Labial aspect is restored free hand.
• So, technique is dependent on operator skill
e. Generally, is more time consuming.
Case 2 251
b c
Fig. 10.19 Case 1: Views of complete case
3. General advice on order of build-ups:

–– For a case where maxillary incisors and canines only are being restored, this
can be achieved in 1–2 visits, depending on the operator efficiency and the
patient tolerance. Restoration of alternative teeth is helpful in order to control
the contact points between restorations to allow some shaping and polishing.
If carried out in two appointments, it is best to restore the canines first and
then the incisors.
–– For a full-mouth rehabilitation, the order is similar to that employed for tradi-
tional rehabilitation with crowns. Mandibular anteriors first, maxillary anteri-
ors second, placing composite stops on posterior to prevent over eruption.
Then restoration of posterior quadrants is undertaken, usually doing each side
at different appointments (Fig. 10.19).
Case 2
[This case is kindly provided by Ms Johanna Leven]

Illustrating:
• If the conformative approach is contra-indicated because of insufficient space for
an adequate thickness of restorative material, the overall vertical dimension
(OVD) will need to be increased.
• If OVD is going to be increased, some thought needs to be given to the jaw rela-
tionship of the restorations.
• The use of a pronounced palatal cingulum on upper anterior teeth.
• The use of stents or templates as an aid to the restorative process.

a. Aetiology: mainly erosive
b. Features:
i. Marked palatal and occlusal erosion, with mild labial erosion
ii. Insufficient space in the occlusion to be successfully restored

conformatively
Warning: These cases are sometimes unsuccessfully managed. Restoring these cup-
ping defects conformatively in centric occlusion (CO/ICP), by applying just a smear
of composite, will not provide long-term success. Composite needs to be 2-mm
thick in areas of occlusal loading to be adequately strong (Fig. 10.20).
b c
Fig. 10.20 Case 2: Presenting condition

Case 2 253

a. Clinic: Records taken were alginate impressions in stock trays, facebow and
centric relation [RCP] record.
The jaw relationship is a very important consideration, in the planning of
this case, because:
i. As explained the conformative approach is not an option.
ii. As a consequence of the need for at least 2 mm of composite to restore the
occlusal surface, the overall vertical dimension (OVD) needs to be
increased.
There are two options:
Option A: Take a centric occlusion (CO) record (or even do not; relying on
the models to be hand fitted together in the laboratory); and then increase the
vertical dimension, arbitrarily, from the jaw relationship of that CO.
Option B: Take a centric relation [CR] record, at the height of the increased
OVD needed for successful occlusal restorations (see Fig. 10.21a–c).
Discussion: Because the OVD is being increased, whichever technique is used,

the patient will need to be monitored for any adverse reactions to the new jaw rela-
tionship, whilst the new occlusion is being developed.
If the new occlusion is to be provided along the opening/closing arc of terminal
hinge axis [CR/RCP], then it is generally considered to be likely better tolerated,
comfortable and functionable. (See chapter 4 for more discussion of the features of
the Re-Organised Approach).
a b
Fig. 10.21 Case 2: Record of Terminal Hinge [CR] Jaw Relationship, at an increased OVD
It may not be wrong, to adopt Option A, because the patient might adapt to the
new jaw relationship that uses CO as its starting point.
It would be wrong, however, to develop the new occlusion in that arbitrary posi-
tion without carefully monitoring the patient; and being prepared to reverse or
adjust the new occlusion in response to adverse reactions.
The problem with using CO as the starting point is that:
• It is unlikely to give a reproducible position.
• There may be problems in transferring a wax up into mouth because it may
be difficult to achieve the same occlusal scheme as was planned in the
laboratory.
• It is likely that many more adjustments will be needed.
b. Laboratory following Option B as above:

For the wax up of Class I or Class II cases, where there will be contact on the
cingulum of the maxillary teeth, a pronounced cingulum plateau should be
requested (see Fig. 10.22a). This has several advantages:
• This provides the patient with a definite occlusal location that will help them
adjust to their new occlusal scheme.
• A wide well-defined plateau area will, also, give the patient some ‘Freedom in
Centric’, so they do not feel ‘locked in’.
It also ensures that the incisor teeth are axially loaded. Without this palatal pla-
teau, the teeth then may not be axially loaded.
Notes:
There was no need to provide this at UR2 as it was never going to be in contact.
Unless this palatal plateau of the Design Wax Up is prescribed, by the dentist, the
laboratory might provide a wax up of the palatal surfaces of all the upper anterior
teeth looking like the UR2.
This is a good example of the principle that it is the clinician’s responsibility to
give clear instructions relating to the Design of the new occlusion.
a b
Fig. 10.22 Case 2: [Design] Wax Up

Case 2 255
c.
Aesthetic [and Occlusal] Preview
See Fig. 10.23a–e
a b
d e
Fig. 10.23 Case 2: Occlusal and Aesthetic Preview, using Stent made from Wax Ups

a. Build-up techniques:
i. Stents: Using a stent is means by which the Design of the wax up can
accurately Executed following the EDEC protocol, as has been illus-
trated in Chap. 4.
ii. This case used the different types of stent in the different locations of the
restoration:
–– Full coverage stents were used for the posterior teeth (Fig. 10.24a–c).
The technique involved building up the base of the restoration directly,
and then using an injection moulding technique for the top layers, so
that it is contoured using the stent.
–– A transparent palatal silicone stent was used to build up the palatal
aspect of the maxillary incisors (see Fig. 10.25a, b). An opaque
impression putty can also be used, but it has the disadvantage that it
can only be cured from the labial aspect, requiring the light to pass
through the tooth.
iii. In this case, the minimal labial build-ups of the upper anterior teeth were
carried out free hand (Fig. 10.26).
The E.D.E.C. Principle in the Re-Organised Approach

E = Examine
• the existing occlusion [Centric Occlusion], including jaw relationship in
which it occurs.
• Determine which teeth occlude in C.O.
• Find and Record Centric Relation [Retruded contact position, Terminal
Hinge Axis].
• Record which teeth touch in CR [Premature Contact].
• Observe the direction of the slide for the Premature contact to CO.
D = Design and plan the new occlusion. This may involve:

• Models mounted in CR.
• Equilibration of those models [Mock Equilibration], and equilibration of
the patient’s existing dentition.
• Design wax up.
E = Execute the new occlusal prescription to the Design created above.
C = Check that you are conforming to this newly designed occlusion in the
definitive restorations.
a b
Fig. 10.24 Case 2: Use of full coverage transparent stents to restore of lower posterior teeth
Case 3 257
a b
Fig. 10.25 Case 2: Use of transparent stent to restore of palatal aspects of upper anteriors
Fig. 10.26 Case 2:

Completed case
Case 3
[This case is kindly provided by Ms Johanna Leven]

This case is presented in an abbreviated form to illustrate two points:
• Sometimes it proves difficult or impossible to find or record a consistent jaw
relationship to use as the starting point for opening the bite on the study models.
• Recognising this, the clinician can proceed with an expectation on their and the
patient’s parts, that more adjustments will be needed (i.e. the occlusion will be
developed as a result of careful monitoring).

a. Aetiology: attrition
b. Features:
i. Increased overall vertical dimension needed.
ii. Class III incisor relationship when patient in CO (ICP) (see Fig. 10.27).
iii. Incisor edge to edge when patient in CR (RCP) (see Fig. 10.28).
iv. It was difficult to manipulate the patient into a consistent CR. This pres-
ents problems, which are compounded by the fact that a jaw relationship
needed for the mounted model need to be opened to provide sufficient
Fig. 10.27 Centric
Occlusion [ICP/habitual
bite]
Fig. 10.28 Centric
Relation [RCP/terminal
hinge axis] at
increased OVD
space for the restorations. It is easier if the record to be taken is on that

first contact, as the patient is able to confirm consistency. Compare
Fig. 10.28, which is slightly open, with Fig. 10.29 when to patient is rest-
ing on the first contact in CR/RCP.
2. Design Planning, including Occlusal Prescription and Aesthetic Preview/build-
up Review
a. Although an attempt was made to record a consistent CR record (see
Figs. 10.30a, b), given the muscle bracing, there was not a high level of oper-
ator confidence.
b. The models were mounted to this record (see Fig. 10.30c).
c. The wax up was done on these models, after having opened up the bite to
accommodate the required space to the posterior restorations.
d. At the aesthetic preview/build-up review stage, it was possible to refine the
occlusion of the proposed definitive restoration (see Fig. 10.31).
Case 3 259
Fig. 10.29 Centric
relation [RCP/terminal
hinge axis] at first contact
a b
Fig. 10.30 Case 3: Record of a Jaw Relationship *, at an increased OVD [* was this CR? see
text 2a Page 250 and point 2 page 252]
Fig. 10.31 Note: UR2 is

an implant-supported
crown that was replaced by
the GDP, after the
restoration of the worn
dentition. The patient was
advised, before treatment,
that this would be
necessary
Operator’s comments:
I thought that I may not be able to manipulate and record a true CR/RCP in this parafunc-
tioning patient. So, I anticipated that at the aesthetic and functional preview of the initial
build-up and at subsequent review stages, I would need to make some further adjustments
to the occlusion (develop the occlusion). This is because the patient is likely to ‘deprogram’
a little more once they are restored. This is very similar to the adjustments needed when
reviewing a Stabilisation Splint.
What we can learn from this case:

1. If you can
a. Find and record CR/RCP
• Either at the increased OVD to facilitate the correct thickness of the
restorations
• Or, at the point of the premature contact of CR/RCP, and then open up the
articulator in the laboratory, as will be needed to allow for adequate thick-
ness of the restorative material
b. Use facebow so the mounted models open/close to the same centre of rotation
as the patient: from terminal hinge axis (CR/RCP)
c. Do a design wax up
d. from which the templates for the build-up review is made
2. If you can’t do 1 above, because of lack of:
• Operator technique and experience
• Laboratory support
• Equipment
• Patient’s neuromuscular release
Use the ‘Monitored Developmental Approach’; this infers:

• An expectation of having to adjust at the build-up review stage (Develop the
Occlusion). In effect, this is using the build-up review stage in the same way that
provisional restorations would be used in a traditional crown and bridge case (see
Chap. 4).
• Monitoring the patient for signs of intolerance to the new occlusion and jaw
relationship, before, during and after the restorative treatment.
3. Post-Operative Results (Fig. 10.32)

Case 4 261
b c
Fig. 10.32 Case 3: Completed case
Case 4
[This case is kindly provided by Mr Indika Weerapperuma BDS (Brist), MSc

(Manc) [Fixed/Remov Pros], PG Cert [Endo], MSDS [Ed]
Hon Lecturer, University of Manchester. Kinross Dental Care, Colombo,
Sri Lanka]
Illustrating:
• Finding centric relation can help the design of the incisor relationship.
• It is possible to build up the anterior teeth freehand, providing the provisional
restorations which will establish the jaw relation for the restoration of the poste-
rior occlusion

a. Aetiology: localised TSL of upper anterior segment due to erosion and
attrition
b. Features:
i. Overall vertical dimension—has been maintained, because
ii. Dentoalveolar compensation has occurred
iii. Centric occlusion (habitual bite) is a pseudo Cl III
iv. Centric relation (CR) is a more retruded jaw relationship than that of
centric occlusion: resulting in a Cl I incisor relationship
v. o/e: no muscle tenderness, normal TMJ function, comfort and range: Nul
diagnosis of TMD
c. Restorative strategy is to build up occlusion along the opening/closing arc
from terminal hinge axis (centric relation) because the vertical dimension of
the first contact in CR does not provide enough space for the restorations
(Figs. 10.33 and 10.34).
Fig. 10.33 Case 4:

Presenting condition
a b

Case 4 263

a. Clinic: CR records, facebow, and impressions
b. Laboratory: Wax up of models mounted to CR (Fig. 10.35)
c. Clinic: aesthetic and functional preview
Fig. 10.35 Case 4:

Design Wax Up

a. Upper 3-3 restored by direct composite at an increased vertical dimension
was along opening/closing arc from terminal hinge axis (CR). These were
built up freehand.
b. Lower posterior occlusion restored by indirect restorations (Fig. 10.36).
a b
Fig. 10.36 Case 4: Restoration of Upper Anteriors by direct bonded composite and Lower Posteriors
by indirect restorations
At 1 week review:
• No muscle tenderness
• TMJ NAD
• Eating habits normal
• Aesthetics satisfactory (patient happy to stay with provisional restorations)
• Even occlusal contacts
3 month review (patient still happy to stay with provisional restorations)

Otherwise NAD
Case 5
[This case is kindly provided by Mr Indika Weerapperuma]

This case is presented to illustrate the technique of restoring alternate teeth

a. Aetiology: Attrition
b. Features:
i. Significant wear of anterior teeth, in a young patient
ii. Need to increase OVD to allow for sufficient space of composite build-up
of upper anterior teeth (Fig. 10.37)
a b

a. Wax up
b. Palatal stent construction

a. Moisture control with Optragate (Ivoclar Vivodent) (Fig. 10.38)
b. Use of palatal stent to form palatal and incisal surfaces
c. Use of PTFE tape to isolate adjacent teeth, and aid good contact area form
(Fig. 10.39)
This case is presented whilst still awaiting use of Dahl technique to restore
posterior occlusion, at increased OVD (Fig. 10.40b).
See Case 6 for a completed Dahl result.
Case 5 265
a b
Fig. 10.38 Case 5: Use of Optragate [Moisture Control], Stent [Placement of palatal and incisal
composite], and PTFE tape [isolate adjacent teeth]
a b
Fig. 10.39 Case 5: Restorative Process

a b
Fig. 10.40 (a) Pre-op. (b) Post restoration/awaiting dahl
Case 6
[This case is kindly provided by Mr Indika Weerapperuma]

This case is presented to illustrate:
• The use of a palatal stent to restore the upper anterior teeth
• The restoration of the posterior occlusion using the Dahl technique

a. Aetiology: localised TSL of upper anterior teeth, primary primarily erosive
followed by attrition
b. Features:
i. Dentoalveolar compensation has maintained the overall vertical dimen-
sion, despite significant wear
ii. Centric occlusion (habitual bite) is in a jaw relationship, resulting in an
edge-to-edge incisor relationship, with consequential wear (see
Figs. 10.41a–c and 10.42).
iii. Centric relation (CR) results in a Cl 1 incisor relationship (see Fig. 10.43).
iv. Articulatory system—NAD.
c. Restorative Strategy:
i. Restore patient to an increased vertical dimension, along the opening/
closing arc from terminal hinge axis (CR) which will create the space for
the anterior restorations
ii. Use Dahl technique to restore the posterior occlusion

a. Clinic: Find and record CR jaw relationship with aid of a deprogrammer:
Facebow and Impressions.
b. Laboratory: wax up of upper 3-3 at an increased height at CR
c. Clinic: Aesthetic and functional preview, using template made from wax up
of upper anterior teeth.
Case 6 267
a b
Fig. 10.41 Case 6: Presenting condition: Centric Occlusion [not in Centric Relation] results in
edge to edge incisor relationship
Fig. 10.42 Case 6:

Presenting condition:
Significant TSL on palatal
surfaces
Fig. 10.43 Case 6:

Presenting condition:
Finding Centric Relation
[Terminal Hinge Axis] jaw
relationship results in a
Class I incisor relationship
Notes:
Occlusal Prescription: The pre-treatment planning for this case was not exten-
sive; but it was carefully monitored during its development.
Monitoring: 3 months post-treatment to follow up of posterior teeth achieving
contact. Thereafter monitoring of any wear and tear to the composites plus occlusal
(Figs. 10.44 and 10.45)

a. Provisional Anterior Restorations by directly applied composite
i. Palatal putty stent, made from design wax up, facilitated formation of the
palatal surfaces and incisal edges
ii. Labial form was built up with freehand technique to a size and length
acceptable to the patient
b. Initial reviews
i. Normal TMJ comfort and function
ii. No muscle tenderness
iii. TMD-null diagnosis
iv. Normal eating ability
v. Aesthetics satisfactory
c. 3 month review
i. Articulatory system NAD
ii. Molar and premolar occlusion achieved, through Dahl effect
iii. Patient happy with aesthetics and function, and wishes to keep anterior
restorations as medium-term definitive restorations (Fig. 10.46)
a b
Fig. 10.44 Case 6: Completed case, which may have been Provisional; depending on results of
careful monitoring [Monitored Developmental Approach, see text]
a b
Fig. 10.45 Posterior occlusion still open

Case 7 269
a b
Fig. 10.46 Posterior occlusion has closed
Case 7
[This case is kindly provided by Mr Indika Weerapperuma.]

This case illustrates that providing a set of rules is not appropriate; every case is
different and need to be assessed. There is no ‘painting by numbers’ in dentistry.

a. Aetiology: localised TSL of upper anterior and lower anterior segment due to
primarily erosion
b. Features:
i. Deep overbite
ii. Limited inter occlusal space
c. Restorative Strategy
Try to restore patient to Centric Relation (CR) (Fig. 10.47).
a b
Fig. 10.47 Case 7: Presenting condition: Centric Occlusion [not in Centric Relation] results in
small overjet
a b
Fig. 10.48 Centric relation: note very large overjet in this jaw relationship

a. Clinic: CR records, facebow, impressions
b. Laboratory: wax up of models to CR
Analysis
This case was done by a first year MSc student1 who thought that every case needed
to follow the protocol:
a. Find and record centric relation
b. Ask the laboratory to wax up the new occlusion on CR mounted models
(Fig. 10.48)
Once the wax up was done, it became clear that this case could not be
restored at CR due the significant change in jaw relationship.
The design process should have stopped at the clinical stage when CR
was found or at least after the models were mounted and before the wax up
was done.
Case 8
[This case is kindly provided by Ms Hanah Beddis BChD (Hons), MJDF RCSEng,
MSc, MPros RCSEd, FDS (Rest Dent) Consultant in Restorative Dentistry, Leeds
Dental Institute
This case is presented to illustrate that where dentoalveolar compensation has
occurred, it may not be desirable to lengthen the teeth incisally. Where there has
been dentoalveolar compensation and/or excessive gingival display, crown length-
ening may be indicated in order to improve the aesthetics of worn upper ante-
rior teeth.
1. Presenting Features and Restorative Strategy (Fig. 10.49a, b)

a. Aetiology: Predominantly erosion with an element of attrition
The MSc student has given permission for this case to be used.
1
Case 8 271
b.
Features:
i. Short clinical crowns of maxillary anterior teeth and severe palatal tooth
surface loss
ii. High lip smile line exposing significant amounts of attached ging ivae.
Because the incisal levels of the teeth were at a reasonable level relative to
the lip line, it was not desirable to significantly increase the tooth length
incisally. This would have resulted the poor appearance of excessive
tooth length.
c.
Restorative Strategy: Perform surgical crown lengthening to upper anterior
teeth before restoration of those teeth at a slight increase in OVD. The small
increase in OVD was provided to accommodate indirect restoration of the
severely worn palatal surfaces of the upper anterior teeth.
2. Aesthetic Preview (Fig. 10.50a)

Following crown lengthening, composite restorations at a slight increase in
OVD to upper right 5 to upper left 6 (Fig. 10.50b).
3. Post-operative Results (Fig. 10.51a–c)

The incisal level of the teeth has not been significantly altered, but surgical
crown lengthening has improved the clinical crown height and reduced the
appearance of excess gingival display (Fig. 10.52).
a b
a b
Fig. 10.50 Case 8: Small increase in OVD

a b
Fig. 10.51 Case 8: Completed case
Fig. 10.52 Post- and pre-op showing. Improved aesthetics, with reduction in visible attached
gingivae, at the same OVD
Case 9 273
Case 9
[This case is kindly provided by Miss Alicia Patel BDS and Mr Philip Dawson BSc
BDS MSc DipRestDent PgCertEd]

a. Aetiology: multi-factorial:
i. Attrition, patient knows he grinds his teeth
ii. Dietary-related erosion
b. Features:
i. No TMD but masseters are hypertrophic
ii. Skeletal Class 1, with incisor edge to edge relationship
iii. Inadequate posterior occlusion due to failed restorations (Fig. 10.53)
c. Restorative Strategy
Option A: Increase vertical dimension along opening arc from terminal hinge
axis. This is the Re-Organised Approach.
Options B: Increase vertical dimension from jaw relationship of existing
occlusion (Centric Occlusion).
This is the Monitored Developmental Approach
For a discussion of these options, see:

Case 2. Sect. 10.3: Design Planning, including Occlusal Prescription and
Aesthetic Preview
and
Case 3: What we can Learn
Cases 2 and 3 were done by a consultant in restorative dentistry, whereas this
case was done by fifth-year dental student, under the supervision of very experi-
enced clinician who practised in primary care.
The consultant choose the technically more difficult Option A [Re-Organised
Approach], whereas the student’s case was done following Option B [Monitored
Developmental Approach].
2. Design Planning, including Occlusal Prescription (Option B)

Clinic:
• Impressions
• Facebow
• Centric Occlusion bite record
a b
c d
Laboratory:
• Mount models in Centric Occlusion
• Open articulator by about 4 mm
• Design Wax-Up (Fig. 10.54)
Case 9 275
a b
Fig. 10.54 Case 9: Design Wax Up
3. Treatment Sequence:
a. Restoration of anterior teeth by the addition of composite using stents made
from the design wax-up
b. Restoration of the posterior occlusion to the new jaw relationship by indirect
restorations
c. Provision of stabilisation splint
Discussion of the Monitored Developmental Approach, in this Case

This treatment had not only to meet the patient’s needs for a good aesthetic and
functional result, but it had to be appropriate to the operator’s level of clinical skills.
The features of this treatment plan are:

• It was possible to satisfy the patient’s aesthetic aspiration early in the treatment
sequence.
• Importantly the case was closely Monitoring:
• If the students or their supervisor detected any signs of an intolerance to the new
occlusion or jaw relationship, adjustments were possible, because non-invasive
and adjustable materials were used, the new occlusion could be developed, and
this could be done before the posterior indirect restorations were provided.
• Given the history of active bruxism, the patient’s consent for long-term splint
therapy was sought at the planning stage. This had the dual advantages of pro-
tecting the restorations from sleep bruxism and making the development of mya-
glia less likely.
4. Post-Operative Results (Fig. 10.55)
Fig. 10.55 Case 9:

Completed case

1. Not all tooth surface loss needs treatment, but effective monitoring is
essential
2. Dento-alveolar compensation has often occurred in patients exhibiting
marked tooth surface loss
started.
E.D.E.C. protocol).
10. The ‘re-organised Approach’ involves firstly the establishment of a ‘more
‘conformative approach’.
capacity.
References 277

centric occlusion.
periodontia.
be the best policy.
16. Bruxism is a centrally controlled behaviour: it is not an ‘occlusal disease’
or caused by the Occlusion.
17. Occlusal adjustment has no evidence basis in the management of Bruxism.
18. When planning restorations, consideration should be given as to whether
there is Active Bruxism.
19. Management of tooth wear may simply involve protecting the dentition
and ongoing monitoring.
20. Dento-alveolar compensation has often occurred in patients exhibit-
ing marked tooth surface loss.
21. The decision on how to Create Space for the restoration of the worn
dentition must be taken before starting treatment.
22. The worn dentition may be restored by either the Conformative, the
Re-Organised or the Monitored Developmental Approach.
References
1. Van’t Spijker A, Rodriguez JM, Kreulen CM, Bronkhorst EM, Bartlett DW, Creugers
NH. Prevalence of tooth wear in adults. Int J Prosthodont. 2009;22(1):35–42.
2. Braem M, Lambrechts P, Vanherle G. Stress-induced lesions. J Prosthet Dent. 1992;67:718–22.
3. Grippo JA. A new classification of hard tissue lesions. J Aesth Dent. 1988;3:14–9.
4. Ten Cate M. In situ models, physico-chemical aspects. Adv Dent Res. 1994;8:125–33.
5. Tallgren A. Changes in adult height due to aging, wear and loss of teeth and prosthetic treat-
ment. Acta Odontol Scand. 1957;15(24):73.
6. Garnick J, Ramfjord SP. Rest position: an electromyographic and clinical investigation. J
Prosth Dent. 1962;12(5):895–1.
7. El Wazani B, Dodd MN, Milosevic A. The signs and symptoms of tooth wear in a referred
group of patients. Br Dent J. 2012;213(6):10.
8. Smith B, Knight J. A comparison of patterns of tooth wear with aetiological factors. Br Dent
J. 1984;157:16–9.
9. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination [BEWE]: a new scoring system
for scientific and clinical needs. Clin Oral Investig. 2008;12(1):65–8. https://doi.org/10.1007/
s00784-007-0181-5.
10. Wetselaar P, Lobbezoo F. The tooth wear evaluation system; a modular guideline for the diag-
nosis and management planning of worn dentitions. J Oral Rehabil. 2016;43(1):69–80.
11. Kelleher M, Bishop K. Tooth surface loss: an overview. Br Dent J. 1999;186:61–6.
12. Moufti M, Lilico JT, Wassell R. How to make a well-fitting stabilization splint. Dent Update.
2007;34(7):398–408.
13. Davies SJ. et al. Occlusion: Is there a third way? A discussion paper. Br Dent J. 2021;231:
16–162.
Further Reading
Johansson A, Johansson A-K, Omar R, Carlsson GE. Rehabilitation of the worn dentition. J Oral
Rehab. 2008;35(7):548–66. https://doi.org/10.1111/j.1365-2842.2008.01897.x.
Milosevic A. Clinical guidance and an evidence-based approach for restoration of the worn denti-
tion by direct composite resin. Brit Dent J. 2018;224:301–10.
Good Occlusal Practice in the Provision
of Implant-Borne Prostheses 11
Even those general dental practitioners who are not implant providers are
likely in the future to be responsible for the maintenance of implants.
The increased use of endosseous dental implants means that many dentists will
encounter patients with dental implants in their everyday practice. Dental practitio-
ners might be actively involved in the provision of implant-borne prostheses at both
the surgical and restorative phases, or only at the restorative stage.
This chapter is written for all dentists, because most dentists will have patients
who either have or want to have implant-supported prostheses.
It aims to:
• Examine the subject of occlusion within implantology
• Provide Guidelines of Good Occlusal Practice to be used in the design of the
prosthesis that is supported or retained by one or more implants.
Implantology is based upon osseointegration.
Osseointegration
For osseointegration to occur predictably, clinical guidelines were developed as

long ago as 1993 to optimise success rates [1]:
• The implant must consist of a suitable biomaterial with appropriate surface
properties.
• Adequate vital bone must be present to support the implant.
• A precise surgical fit must be achieved between the bone and the implant.

https://doi.org/10.1007/978-3-030-79225-1_11
280 11 Good Occlusal Practice in the Provision of Implant-Borne Prostheses
• The implant must be inserted with a low-trauma technique to avoid overheating

of the bone during preparation of the receptor site.
• The implant should not be subject to functional loads during a healing period of
3–6 months.
All of these criteria seemed to have survived except for the last: immediate load-
ing has been accepted since the early 2000s.
Although these guidelines do not mention ‘occlusion’, once integrated, dental

implants must be restored sympathetically with due regard to occlusion since unfa-
vourable loading has been cited as a major cause of failure. This chapter will present
the factors that influence the occlusal schemes used for prostheses supported or
retained by endosseous dental implants.
Since relatively few studies have been designed with the sole aim of comparing
different occlusal schemes, it is difficult to be certain what is the best occlusion for
a given clinical situation. Current techniques and materials tend to be based on what
has evolved over years of clinical practice and laboratory research. They are based
on what is believed, rather than what is known, to be good occlusal practice in
implantology.
‘Osseointegration’ is the biological process that results in a close structural rela-
tionship between vital bone and a dental implant. Successfully integrated and care-
fully loaded implants have been shown to be capable of being retained by the host
tissues for many years. Osseointegration was first defined as ‘the direct structural
and functional connection between ordered living bone and the surface of a load
carrying implant’ [2]. Subsequently, it was defined as ‘a process whereby a clini-
cally asymptomatic rigid fixation of alloplastic materials is achieved and maintained
in bone during functional loading’ [3]. Obviously, the significant difference between
‘osseointegration’ and the attachment of teeth to the alveolus is the absence of a
periodontal ligament.
The absence of a periodontal ligament between an implant and the bone sig-
nificantly reduces the patient’s sensory perception of the occlusal load.
Consequences of the Differences between Teeth and Implants
The absence of a periodontal ligament is the first consideration when we are decid-
ing what is Good Occlusal Practice in Implantology. This is because the absence of
a periodontal ligament has significant consequences on the Adaptive Capability of
the prosthesis to resist occlusal forces.
This complete lack of adaptive capacity is the result of four factors:
1. No proprioceptive nerves
2. Much less blood supply
Consequences of the Differences between Teeth and Implants 281
3. No reactive movements
4. Reduced compressive displacement [4]
1. Significantly Less Proprioception
The orofacial locomotive system is unique in the body, when it is compared to all
the other locomotive systems, because it has an additional layer of sensory input to
the central nervous system.
Whereas all of the locomotive systems have sensory nerve endings in the orofa-
cial locomotive system has an extra layer of sensory input to the CNS from the
nerve endings in the periodontal membrane.
• bones
• joints
• muscles and associated soft tissues
• epithelium
This means that our patients can feel the occlusal loads that our restorations of
teeth experience. This is significantly reduced or even absent when we provide an
implant supported prosthesis.
It also means that when a tooth is extracted, the patient experiences not only the
mechanical loss of that tooth or those teeth, but they also suffer from a traumatic
de-afferentation. The disability is extreme when all teeth are lost, because it is a
total traumatic de-afferentation.
There is some mitigation in this loss of sensory input that is described as
osseoperception [5]. This suggests that there is an increased sensitivity in the
sensory motor cortex to the nerve endings in the bone to occlusal forces that the
alveolar implants transmit to the bone. This phenomenon whilst not being able to
compensate for the loss of periodontal proprioception following tooth extraction
is a useful response to disability. It is achieved through central neuroplasticity. It
probably has the ability to improve jaw function for the patient who has an implant
as opposed to mucosal supported prostheses. Similar learned pathways in the
brain stem and sensory motor cortex can explain how people with an artificial
limb can learn how to engage in activities that require a high level of sensory input
(Fig. 11.1).
This is an adaptation that occurs in the articulatory rather than tooth system.
It does not allow any reflex protective responses, and it should be considered the
‘second best’ neural capacity.
2. Much Less Blood Supply
The blood supply around an implant is significantly less than that which flows
through the well-vascularised periodontal membrane. Blood is the tissue that carries
the agents of the immune system, and so there is a reduced ability to react to
a b
Fig. 11.1 (a, b) Photographer: Tony Herr. With permission from Dr. Hugh Herr. The remarkable
ability to rock climb with prosthetic lower legs indicated that some ossseoperception transmitted
via the attachment to the upper legs is present
pathogens. Noxious stimuli to the implant include not only pathogens but also the
physical insult of occlusal overload.
3. Reactive Movements

These can be considered under two headings:
Orthodontic Movement
If a sustained force is applied to a tooth, then it will move. The discipline of
orthodontics and the phenomenon of tooth migration are the results of this reac-
tionary movement.
Implants cannot react in this way.
Reversible Hypermobility
An alternative to tooth migration is the ability within the periodontal membrane
to ‘hold’ the tooth less firmly. This hypermobility is probably a reaction to an
interrupted long-term occlusal force.
Consequences of Reduced Adaptive Capacity... 283
Reduced Compressive Displacement

Vertical Buccolingual
Teeth 25–100 μ 56–108 μ
Implants 3–5 μ 10–50 μ
Because teeth are not ankylosed to the bone, they can compensate to an acute
occlusal overload by a small and immediate movement. This stress breaking attach-
ment of natural teeth rather than rigid one of osseointergration, together with the
jaw jerk reflex, provides the immediate protective response to acute occlusal over-
load. Both are absent in implant supported prostheses.
onsequences of Reduced Adaptive Capacity, Because

C
of the Absence of Periodontal Attachment
A consistent message throughout this book has been that an occlusion should only
be judged by the tissue reactions to it, rather than any rigid set of rules based upon
some concept of mechanical perfection. We treat living systems with a very wide
range of adaptive capabilities.
The issue with implant-supported prostheses is that the nature of the attachment
of the implant, when compared to the periodontal membrane, meaning that the
adaptive capability is likely to be less than that for teeth. But what is presented are
NOT RULES, rather they are Guidelines of Good Occlusal Practice in Implantology.
It is up to individual clinicians to decide what type of occlusal prescription to
provide.
This treatment planning decision will be made after:
• A comprehensive examination, including a pre-treatment occlusal analysis
• An assessment of the patient’s needs
Because of the reduced adaptive capability of implants, an adverse reaction of

occlusal overload is likely:
• To be less predictable
• Happen quicker
• Happen with less warning
• Occur as a result of a smaller load
• Occur as a result a less frequent application of occlusal load
• To be harder for the patient to perceive
• As a consequent difficult for the patient to avoid
• To be irreversible
• To be catastrophic
This list starts with the most trivial and ends up with the most severe and poten-
tially catastrophic reactions to occlusal overload in implantology:
• Screw loosening
• Screw fracture
• Crown fracture
• Abutment fracture
• Loss of crestal bone, as in ‘funneling’. This is an example of bone loss that is the
result of trauma from occlusion without any inflammatory process
• Implant fracture
• Implant exfoliation
In contrast, the reactions to occlusal overload in teeth are:
• PDL thickening
• Mobility
• Fremitus
• Pain
• Wear facets
• Tooth and/or restoration fracture
Second Difference between Implants and Teeth
Having considered the factors that may affect the adaptive capabilities of an implant
to occlusal overload, we should now consider the mechanical consideration of the
fact that implants are often, but not always, narrower than the roots of the teeth that
they replace (Fig. 11.2).
This means that any occlusal load applied to an implant supported crown that is
not in line with the long axis of the implant will be a relatively greater force than it
would be if it was applied to the wider root supporting a similar crown.
Fig. 11.2 Implant v root.

The crown on a tooth is
supported by a much
broader base than that on
an implant
Second Difference between Implants and Teeth 285
The fulcrum for this force will be the crestal bone, which in common with the
rest of the alveolar bone is strongest when resisting compressive forces and weakest
when resisting shear forces (Fig. 11.3).
The force applied to the crestal bone by an occlusal load that is outside the long
axis of the implant is a shear force (Fig. 11.4).
The Coronal Section is

the most susceptible Occlusal
force
Load
to Bone loss
Occlusal injury
++++ Trauma
Crestal Bone
is
Fulcrum Point
+
further the Occlusal Load is from Long Axis
of the Implant...
greater the Force
a b
Fig. 11.3 An occlusal force that is distant from the long axis of the implant will result in shear
force to the crestal bone
Apical force
Vertical axis
Lingual force
Tensile
Force
ear
Sh
Mesial
force Shear Distal
Shear force
Faciolingual
ear
axis Sh
Compressive
Force
Facial force
Occlusal force
In all other directions there is a vector that is a Shear Forces
Fig. 11.4 All loads that are not in line with the long axis of the implant result in a shear force.
[reprinted with permission from Ch 5, Dental Implant Prosthetics, Misch C E, Elsevier]
a b Occlusal
Occlusal Trauma
Trauma
1. 2. 3. +++
+
Occlusal
Load Occlusal
Load
Fig. 11.5 (a) The shorter the implant, the greater the Force potential Moment on it. (b) The
increased Moment created by a reduced crown: implant ratio
The process by which bone maybe lost as a result of trauma from occlusal over-
load has been explained by the term ‘fatigue microtrauma’ [6] and is described as
when the ‘rate of fatigue microdamage exceeds the reparative rate’ [7].
If the implant to crown ratio has been adversely affected by alveolar resorption,
that has occurred before the implant is placed, then the force against the crestal
bone, generated by an occlusal load outside the long axis of the implant, is even
greater (Fig. 11.5).
Although there is a mechanical justification in suggesting that non-axial forces
should be avoided when designing the occlusion of implant supported crowns, there
is little evidence that there is a biological consequence to ignoring this advice. This
is why, as stated elsewhere in this chapter, the clinician does not have the comfort of
scientific certainty but has to rely on clinical common sense.
The evidence for the significance of non-axial forces was summarised by Koyano
et al. [8]. This reviewed random controlled trials in respect of non-axial forces under
three headings:
1. Difference in marginal bone levels between wide and narrow implant diameters
2. Implant angulation
3. Cantilevers
None of these trials found any statistically significant differences in marginal
bone levels.
Summary
• Implants have less adaptive capability to occlusal force than teeth, because of the
absence of periodontal membrane
• The occlusal forces experienced by an implant are likely to be greater than expe-
rienced by a natural tooth, if a comparable force is applied that is not in line with
the long axis of the implant.
Current Application of Oral Implants 287
Current Application of Oral Implants
The current application of implants is much more extensive than when implants
were first utilised. In stark contrast to their initial applications (when predominantly
only edentulous patients were treated with fixed dentures), implants are now
inserted into:
• Partially dentate patients with a healthy or compromised periodontium.
• Posterior regions of the maxilla and mandible
• Sites in which the bone has been augmented
In addition, many different types of prostheses may now be implant-supported:
• Crowns
• Bridges
• Precision removable dentures
• Removable overdentures (mucosa and implant supported)
Implant Success
Criteria for implant success have been outlined some years ago.
There should be an absence of:
• Mobility
• Associated radiolucency
• Pain
• Infection or iatrogenic neuropathies.
• Peri-implant vertical bone loss
–– <1.0 mm in the first year of loading
–– <0.2 mm per annum thereafter
Implant Success vs Implant Survival
‘Implant survival’ (implant retention at the end of the study) appears to be increas-
ingly used when reporting treatment outcomes [8–17]. This term might be mistak-
enly interpreted as being synonymous with implant success as defined above
[18–20]. Criteria for success are not always clearly defined and might be ‘system
specific’. Since implant survival is a crude measure of implant health, research that
uses this term cannot be considered to be as meaningful as that which defines and
measures implant success. Therefore, when evaluating clinical research studies, a
critical appraisal must be made.
Despite numerous early studies that reported success rates in excess of 90%, in
subsequent studies, lower success rates have been reported [21]. This might be
explained by the use of implants in more demanding circumstances, poor operator
technique or the use of an implant system with an unproven track record. A further
factor might be the level of experience of the surgeons that provide implant treat-
ment [22].
Implant survival does not equal implant success.
The Failing Implant
Whilst the efficacy of implants has been amply demonstrated for certain systems,
fewer studies are available for any implant system to support its effectiveness in
‘real life’ studies where, for example, selection criteria might be more relaxed [23].
As for all medical and dental treatments, we can expect the proven effectiveness of
implants to be less than their proven efficacy. Against this background, it is impor-
tant not only to define implant failure but also to examine how it might be prevented.
A failing implant can be defined as one in which the criteria for success are not met.
‘Peri-implant’ inflammation (peri-implantitis) presents a similar clinical picture to
periodontal inflammation, with bone loss as a key feature. ‘Peri-mucositis’ has been
reserved for soft tissue infection around an implant, whilst ‘peri-implantitis’ implies
accompanying bone loss (classification and review of implant failures) [24–27].
The ‘failing’ implant often presents as a chronic than terminal condition, ulti-
mately leading to implant exfoliation.
The stages of implant failure have been suggested by Newman [28] to be:
1. Gingival inflammation
2. Gingival hypertrophy
3. Progressive deepening of pockets
4. Progressive attachment loss
5. Progressive bone loss
6. Change in microbial microflora
7. ‘Osseo-disintegration’ with mobility and peri-implant radiolucency
8. Implant exfoliation
The suggested aetiological factors for implant failure are:
• Reduced host resistance
• Plaque accumulation
• Occlusal stress
• Systemic factors, e.g. diabetes and smoking
Although a wide range of techniques have been employed to stabilise failing
implants, it is recognised that the evidence to support these interventions appears
poor at present [29].
Occlusal Factors in Implant Failure
One of the aims of this chapter is to try to establish Good Occlusal Practice in
Implantology. The evidence base to aid this exercise is not strong [30].
Planning an Occlusal Prescription for Implant Supported Prostheses 289
Broadly physical and mathematical modelling, animal studies and clinical observa-
tion support the view that the stress on the cervical bone is increased [7] by:
• Increased occlusal loading (High on the Bite)
• Off axis occlusal contact (Cantilever)
• Bending movements (dynamic occlusal contacts)
This is why the conventional wisdom [4] is:
1. Due to lack of the periodontal ligament, osseointegrated implants react biome-
chanically in a different way to occlusal force, than natural teeth.
2. Consequently, it is believed that dental implants may be more prone to occlusal
overloading.
3. Overloading factors that may negatively influence on implant longevity.
These overloading factors include:
• Large cantilevers
• Parafunctions
• Improper occlusal designs
• Premature contacts
4. In order to ensure a long-term implant success.
• It is important to control implant occlusion within physiologic limit
• To provide optimal implant load
lanning an Occlusal Prescription for Implant

P
Supported Prostheses
Point 4 above highlights the importance of planning the occlusion for an implant
restoration and assessing occlusal risk factors as part of the process.
Controlling and minimising the occlusal risk form a part of the long-term moni-
toring of the restoration.
Designing an appropriate occlusal prescription can be considered in the follow-
ing treatment phases:
1. Planning phase:
–– Identify occlusal risk factors, including strategically important teeth. Then,
maintenance and monitoring of these teeth may need to be part of the plan-
ning process.
–– Occlusal analysis to help decide whether conformative approach is possible.
2. Pre-treatment. This may involve the creation of space for the definitive restora-
tion. It can be achieved restoratively, orthodontically or with a joint ortho-
restorative approach.
3. During treatment. The use of a provisional restoration may be used to trial an
occlusal scheme.
4. Post-treatment. Including monitoring and management of adjacent and opposing
dentition.
Occlusal stability of strategically important teeth/restorations needs to be estab-

lished by completion of treatment, so as to protect the implant-supported restora-
tions. In some circumstances to provide long-term stability, protection by the
provision of a splint may be necessary.
Occlusal load is a combination of:

• Force applied
• Direction of the force
• Frequency of application of the force
Some papers have sought to address the effects of the application of frequent
occlusal contacts, i.e. bruxism [31].
The conclusion were:
1. There is still insufficient evidence to support or refute a causal relationship
between bruxism and implant failure.
2. Although there is still no proof for the suggestion that bruxism may cause an
overload of dental implants and of their superstructure, we conclude that a care-
ful approach is nevertheless recommended.
3. We suggest that high mechanical stress exceeding the biological load-bearing
capacity of an osseointergrated oral implant is associated with the loss of mar-
ginal bone or failure of the osseintergration.
(The authors provide three references to support the view as expressed in point 3
[32–34].)
Research into the association between occlusion and implant failure is
ongoing [35]
It is a difficult area to research, as Graves et al. point out:
As is the case in studies of the effect of occlusion on the progression of periodontal
disease around natural teeth, there are no controlled clinical trials or prospective cohort
controlled studies that evaluate the effect of occlusion on implants in humans.
Again, as is the case with evaluating occlusion on natural teeth, any prospective trial
of untreated occlusal discrepancies in humans would be unethical [36].
But as Taylor et al. [37] say when they state that

• Little scientific evidence supports a direct cause-effect relationship between
occlusal factors and deleterious biological outcome for osseointergrated
implants.
–– An Absence of evidence that trauma from occlusion causes biological
failure of implants is not the same as evidence that trauma from occlusion
is harmless.
Sometimes ‘Common Sense might need to be Applied’ [38]
Planning an Occlusal Prescription for Implant Supported Prostheses 291
Case Responsibility
The determination of case responsibility is an important consideration for two

reasons.
Firstly, implants can and do fail, and the causes of failure are not completely
understood. Secondly, the provision of an implant-borne restoration is often a team
effort. If the same clinician carries out both surgical and restorative phases, the
responsibility for design and execution of the treatment, together with an appropri-
ate maintenance program, is unequivocal.
But when implant treatment is delivered as a ‘team’ (sometimes at one or more
sites), the question of responsibility for implant failure becomes more complex and
indeed more contentious. Failure under this regime may result in a debate, which
does the profession no credit.
When implant therapy is delivered by a ‘team’, close collaboration between the
surgeon, restorative dentist and dental technician is essential.
The surgeon must expect guidance as to the optimal implant location, from a
restorative point of view.
The restorative dentist may have to accept that the ideal implant placement is not
possible because of anatomical constraints. In this case, the planning of the occlu-
sion of the restoration may be more difficult.
The implant technician must try to adhere preferred occlusal schemes that they
have been given, by the restorative dentist.
Implants are a ‘means to an end’, they are not the ‘end itself’. They provide the
means to providing crowns or other prosthesis to replace missing teeth. In respect of
posterior teeth, this is to provide a bigger or better occlusal platform. Even in the
case of replacing missing anterior teeth, there is an occlusal element to what might
wrongly be considered purely a cosmetic treatment plan, namely the provision of
some additional or alternative dynamic occlusal contact.
So, OCCLUSION is the end of the implant’s means.
It must follow, therefore, that the occlusal prescription is the starting point of
planning a case involving implant-supported prostheses. Consequently, this means
that the restorative dentist has primary responsibility for the pre-treatment planning.
If all the treatment is to be done by one dentist, that dentist should wear their restor-
ative hat first.
No patient consults a dentist about implant treatment because they aspire to hav-
ing some titanium inserts placed into their bone; they consult because they want the
benefit of some extra teeth! In reality, the dentist who places the implant is a sub-
contractor, brought in to do a specific job. No matter how experienced the surgeon
is, the restorative dentist is the team leader.
The team leader must ensure that the joint treatment plan minimises the risk of
implant failure. This is particularly important since the current evidence to support
the efficacy of implant-rescue techniques is weak. The degree of responsibility will
vary according to the experience of the team members, but the principle that a
The Surgeon’s Tale

‘The implants were successfully integrated, but failed because of
excess loads’.
or
The Restorative Dentist’s Tale

‘The implants were poorly integrated and so failed
under normal masticatory
loads’.
either way
The Patient’s Tale

‘My implants have failed!’
patient’s treatment should not suffer through a lack of communication between the
clinicians involved is paramount. The ‘team leader’ is responsible for ensuring that
the appropriate communication exists to satisfy the needs of the case.
Pre-Surgical Planning
Having read this book this far, it will come as no surprise to you that:
• The E.D.E.C. principle is advised as an overarching protocol in implant treatment
• The examination phase of this should include:
–– The teeth
–– The periodontal status
–– The articulatory system
Pre-Surgical Planning 293
The examination of the articulatory system will help by answering the following
questions:
1. Is there a T.M.D.?
2. Are there any signs of parafunction?
3. What is the pre-existing occlusion analysis? [39]
4. Is the conformative approach possible?
5. If 4 of the above is not possible, is a pre-restorative equilibration indicated?
Figures 11.6a–f illustrate the progression of the design stage in case where it was
not prudent to restore to the conformative approach, and where because of a
Treatment Planning for

IMPLANT SUPPORTED
CROWNS: Design Stage
Question:
To which Jaw Relationship do we want to restore
this mouth Implant supported Crowns?
OPTIONS:
1 existing C.O. Conformative Approach
2 C.R. with this premature contact
3 C.R. with natural teeth touching
Re-Organised Approach
If 3
a Will it be possible to equilibrate teeth C.O. =
C.R. ?
b
Dear Dr Implantologist
RE: your patient
I have completed the mock equilibration on some mounted study casts.
This shows that a balanced occlusion will be possible to achieve in centric

relation. As well as adjustment to the premature contact between the
premolars on the right hand side some moderate reduction of the palatal
aspects of the upper incisors and the labio-incisal edges of the lower
anteriors was necessary to bring the teeth on the left hand side into
occlusion.
I think the adjustments that I made on the models fall well within the abilites
of the teeth to abdorb them and feel confident that I will be able to equilibrate
her teeth in this jaw relationship.
c cc: Patient
d
The E.D.E.C. principle

Designing the
OCCLUSAL PRESCRIPTION
1
Prem Contact in
CR
Verified models
2
C.R.O., in models
Mock Equilibration
Progression to [‘Diagnostic’]
Design Wax Up
e
3
C.R.O., in models
Mock Equilibration
f
Fig. 11.6 (a) Verification of the premature contact in centric relation. (b) These models enable the
restorative dentist to determine the design of the occlusal prescription. (c) The Mock Equilibration
on these models shows what will be possible in the mouth. (d) This information is transmitted to
the implantologist and the patient. (e) After equilibration a wax up can easily be created. (f) From
the Design Wax Up, a simple surgical stent can be made
Is this the Occlusion we wish to copy in the

Implant Supported Bridge?
Fig. 11.7 The provision of an implant supported bridge offers the Restorative Dentist the oppor-
tunity to improve the occlusion compared to the occlusion that was provided by the failed tooth
supported bridge
comprehensive examination of the articulatory system, it was seen to be possible to

equilibrate the teeth (after equilibrating some verifiably accurate centric relation
models) into a centric occlusion that was in centric relation.
From that point, it was possible to:
• Plan the occlusion of the proposed implants
• Gain valid informed consent from the patient
• Give the implantologist a template for ideal implant placement from an occlusal
viewpoint.
Of course, when the implantologist examines the scan of the bone, it may become
apparent that the ideal restorative site for the implants is surgically not ideal; in
which case, implant surgeon and restorative dentist will find a compromise to give
the patient the best possible outcome. This may involve bone augmentation in order
to facilitate optimal implant placement for a good outcome. In order to satisfy the
requirements of consent, the patient will be aware of the factors in this decision.
Figure 11.7 illustrates a case where the occlusal design has been done digitally.
But it appears that in this case the occlusion of the failing bridge has been copied
onto the proposed implant-supported bridge, probably not the best predictor of success.
Post-Surgical Planning of Implant-Supported Prosthesis
Once the implants are placed then they have to be restored. Whilst there is not a
body of evidence that enable rules to be established. It is possible, however, to pro-
vide some guidelines of good occlusal practice in implantology. The overarching
principle in these guidelines is that the Design of the Occlusal Platform should be
done in line with the limitations of implants.
Post-Surgical Planning of Implant-Supported Prosthesis 295
These guidelines are as follows:

1. Use the conformative approach to ensure that no implant-supported crown is
in supra occlusion (In the example illustrated in Fig. 11.6a–f, the conforma-
tive approach could be used after the centric occlusion has been established in
centric relation.).
2. Light occlusal load
3. Careful use of any cantilevers
4. Narrow occlusal table
5. Freedom in centric occlusion
6. Low cuspal angles [100]
7. No posterior interferences
8. No incline contacts
All of these guidelines are to reduce the inevitable non-axial forces and/or heavy
occlusal loads.
Occlusal Overload as a Cause of Implant Failure
It has been established that trauma from occlusion may be a factor in the aetiology
of implant failure [24–29]. It has been suggested that radiological appearance of
‘saucerisation or furrowing’ is associated with occlusal overload [40] (see Fig. 11.8).
Whereas the natural dentition is physiologically capable of adapting to traumatic
occlusions, the absence of a periodontal ligament means that dental implants are
more easily overloaded, and this can lead to implant failure. Left untreated, an over-
loaded implant is highly likely to ultimately exfoliate. If excessive occlusal load
(trauma from occlusion) is detected,* [see page 286] remedial action must be speed-
ily undertaken to redress that unfavourable condition.
Fig. 11.8 A possible sign

of occlusal overload:
‘funnelling’ or
‘saucerisation’
The Importance of Monitoring*
Because of the reduced adaptive capability of implants, regular monitoring is

needed; this examination should include the static and dynamic occlusal contacts.
Figure 11.9 is a suggested very simple monitoring protocol.
Patient: DoB:
Implant Annual Check Date
Implant History Site system: Size: Date Placed:
1 -PA radiograph report:

Action:
2 -Static Occlusion:
Thickness of Shimstock that binds: INCLINE CONTACT?
Action:
3 -Dynamic Occlusion:
Action:
4 -Gingivae:
Action:
5 -Mobility:
Action:
6 -Auscultation:
Action:
ANY OTHER NOTES
Report presented to patient: NEXT REVIEW .................................
DENTIST NURSE
Fig. 11.9 Annual Implant Check

The Importance of Monitoring* 297
Guidelines of Good Occlusal Practice: the Completed List

started.
E.D.E.C. protocol).
capacity.

dynamic occlusion; and the Jaw Relationship in which the patient has
their Centric Occlusion.
periodontia.
be the best policy.
14. Bruxism is a centrally controlled behaviour: it is not an ‘occlusal disease’
or caused by the Occlusion.
15. Occlusal adjustment has no evidence basis in the management of Bruxism.
16. When planning restorations, consideration should be given as to whether
there is Active Bruxism.
17. Management of tooth wear may simply involve protecting the dentition
and ongoing monitoring.
18. Dento-alveolar compensation has often occurred in patients exhibiting
marked tooth surface loss.
19. The decision on how to create space for the restoration of the worn denti-
tion must be taken before starting treatment.
20. The worn dentition may be restored by either the conformative, the re-
organised or the monitored developmental approach.
21. The occlusal prescription of an implanted supported restoration
needs to take account of the features of osseointegration.
22. The Occlusion should be planned before the implants are placed.
References
1. Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localised ridge augmentation using guided
bone regeneration 1. Surgical procedure in the maxilla. Int J Period Rest Dent. 1993;13:29–45.
2. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants
in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10:387–416.
3. Zarb G. Osseointegration: a requiem for the periodontal ligament? Int J Period Rest Dent.
1991;11:88–91.
4. Kim O, Wang M. Occlusal considerations in implant therapy: clinical guidelines with biome-
chanical rational. Clin Oral Implant Res. 2005;16:26–35.
5. Mishra SK, Chowdhary R, Chrcanovic BR, Brånemark PI. Osseoperception in dental implants:
a systemeic review. J Pros Dent. 2016;25:185–95.
6. Hoshaw SJ, Brunski JB, Cochran GVB. Mechanical loading of Brånemark implants affects
interfacial bone modelling and remodeling. Int J Oral Maxillofac Implants. 1994;9:345–60.
7. Gross MD. Occlusion in implant dentistry. A review of the literature of prosthetic determinates
and current concepts. Austr Dent J. 2008;53:S60–8.
8. Keller EE, Tolman DE, Eckert SE. Maxillary antral-nasal inlay autogenous bone graft
reconstruction of compromised maxilla: a 12-year retrospective study. Int J Oral Maxillofac
Implants. 1999;14:707–21.
9. Rosen PS, Summers R, Mellado JR, et al. The bone-added osteotome sinus floor elevation tech-
nique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac
Implants. 1999;14:853–8.
10. Mericske-Stern R, Perren R, Raveh J. Life table analysis and clinical evaluation of oral
implants supporting prostheses after resection of malignant tumors. Int J Oral Maxillofac
Implants. 1999;14:673–80.
11. Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C, van Steenberghe D. Int sur-
vival of the Branemark implant in partially edentulous jaws: a 10-year prospective multicenter
study. J Oral Maxillofac Implants. 1999;14:639–45.
12. Balshi TJ, Wolfinger GJ, Balshi SF. Second Analysis of 356 pterygomaxillary implants in
edentulous arches for fixed prosthesis anchorage. Int J Oral Maxillofac Implants. 1999;14:
398–406.
13. Froum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho SC. Sinus floor elevation using anorganic
bovine bone matrix (OsteoGraf/N) with and without autogenous bone: a clinical, histologic,
radiographic, and histomorphometric analysis. Part 2 of an ongoing prospective study. Int J
Periodontics Restorative Dent. 1998;18:528–43.
14. Ivanoff CJ, Grondahl K, Sennerby L, Bergstrom C, Lekholm U. Influence of variations in
implant diameters: a 3- to 5-year retrospective clinical report. Int J Oral Maxillofac Implants.
1999;14:173–80.
15. Morris HF, Ochi S. Hydroxyapatite- coated implants: a case for their use. J Oral Maxillofac
Surg. 1998;56:1303–11.
References 299
16. Karlsson U, Gotfredsen K, Olsson CA. 2-year report on maxillary and mandibular fixed partial
dentures supported by Astra Tech dental implants. A comparison of 2 implants with different
surface textures. Clin Oral Implants Res. 1998;9:235–42.
17. Watson R, Marinello C, Kjellman O, Rundcrantz T, Fahraeus J, Lithner B. Do healing abut-
ments influence the outcome of implant treatment? A three-year multicenter study. J Prosthet
Dent. 1998;80:193–8.
18. Albrektsson T, Zarb GA, Worthington P, Eriksson AR. The long-term efficacy of currently
used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Surg.
1986;1:11–25.
19. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: a 10–16-year
follow-up of non-submerged dental implants. Clin Oral Implants Res. 2010;21:772–7.
20. Moraschini V, da Poubel C, Ferreira VF, dos Barboza SP. Evaluation of survival and success
rates of dental implants reported in longitudinal studies with a follow-up period of at least 10
years: a systematic review. Int J Oral Maxillofac Surg. 2015;44:377–88.
21. Watson CJ, Tinsley D, Ogden AR, Russell JL, Mulay S, Davison EM. A 3- to 4-year study of
single tooth hydroxylapatite coated endosseous dental implants. Br Dent J. 1999;187:90–4.
22. Preiskel HW, Tsolka P. Treatment outcomes in implant therapy: the influence of surgical and
prosthodontic experience. Int J Prosthodont. 1995;8:273–9.
23. Weyant RJ. The case for clinical registries. In: Trotman CA, McNamara J, editors. Orthodontic
treatment: outcome and effectiveness. 1st ed. Ann Arbor: University of Michigan; 1995.
p. 319–43.
24. el Askary AS, Meffert RM, Griffin T. Why do dental implants fail? Part I. Implant Dent.
1999;8:173–85.
25. Esposito M, Lausmaa J, Hirsch JM, Thomsen P. Surface analysis of failed oral titanium
implants. J Biomed Mater Res. 1999;48:559–68.
26. Esposito M, Thomsen P, Ericson LE, Lekholm U. Histopathologic observations on early oral
implant failures. Int J Oral Maxillofac Implants. 1999;14:798–810.
27. O’Mahony A, Spencer P. Osseointegrated implant failures. J Ir Dent Assoc. 1999;45:44–51.
28. Newman MJ, Flemmig FT. Periodontal considerations of implants and implant associated
microbiota. J Dent Educ. 1988;52:737.
29. Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strate-
gies for biologic complications and failing oral implants: a review of the literature. Int J Oral
Maxillofac Implants. 1999;14:473–90.
30. Koyano K, Esaki D. Occlusion on oral implant: current clinical guidelines. J Oral Rehabil.
2015;42:153–61.
31. Lobbezoo L, et al. Bruxism: its multiple causes and its effects on dental implants - an updated.
Rev J Oral Rehabil. 2006;33:293–300.
32. Quirynen M, Naert I, Steenberghe D. Fixture design and overload influence marginal bone loss
and the future success of the Brånemark system. Clin Oral Implants Res. 1992;3:104–11.
33. Naert I, Quirynen M, Steenberghe D, Darius P. A study of 589 implants supporting complete
fixed prostheses. Part II prosthetic aspects. J Prosthet Dent. 1992;68:949–56.
34. Isidor F. Influence of forces on peri-implant bone. Clin Oral Implants Res. 2006;2:8–18.
35. Thymi T, et al. Associations between sleep bruxism and (peri-) implant complications: a pro-
spective cohort study. BDJ Open. 2017;3:17003.
36. Graves G, et al. The role of occlusion in dental implant and peri-implant condition: a review.
Open Dent J. 2016;10:594–601.
37. Taylor T, et al. Evidence-based considerations for removable prosthodontic and dental implant
occlusion: a literature review. J Prosthet Dent. 2005;94:555–60.
38. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational
challenge: systematic review of randomized controlled trials. BMJ. 2003;327:1459–61.
39. Davies S, Young P. The occlusal sketch technique: its importance in implant treatment. Aesth
Implant Dent. 2006;8:49–55.
40. Palmer R, Palmer P, Howe L. Dental implants: part 10. Complications and maintenance. Br
Dent J. 1999;187:653–8.

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More information about this series at http://www.springer.com/series/15753

A Guide to Good Occlusal

Originally published by BDJ Books, London, 2002

ISSN 2523-3327 ISSN 2523-3335 (electronic)

© Springer Nature Switzerland AG 2002, 2022

2022, Manchester, UK Stephen Davies

1 What Is Occlusion?������������������������������������������������������������������������������������ 1

2 The Examination and Recording of the Occlusion:

3 Good Occlusal Practice in Simple Restorative Dentistry ���������������������� 43

4 Good Occlusal Practice in Advanced Restorative Dentistry������������������ 79

5 Good Occlusal Practice in Removable Prosthodontics�������������������������� 119

6 Occlusion and Orthodontics��������������������������������������������������������������������� 141

7 Occlusal Considerations in Periodontics������������������������������������������������� 165

8 Good Occlusal Practice in Children’s Dentistry ������������������������������������ 191

10 Occlusion and Non-carious Tooth Surface Loss�������������������������������������� 219

11 Good Occlusal Practice in the Provision of

Chapter 3 Phillip Smith

Chris Needham Experienced GDP, Pre PG qualification Despite being an expe-

Amy Burns Post Graduate Student A refreshing common-sense approach to

April Scholey GDP with PG qualification A brilliant summary of how occlusion

afterthought. This book is an excellent, evidence-based summary that encompasses

James Darcy Consultant in Restorative Dentistry This book seeks to demystify

Nick Grey Professor of Dental Education, University of Manchester and

© Springer Nature Switzerland AG 2022 1

In this chapter, we will discuss:

Guidelines of Good Occlusal Practice

These Must Be Guidelines Not Rules

Fig. 1.1 The Masticatory Enamel

Bone Periodontal Muscles Occlusion

The Importance of Occlusion in Dental Practice

‘Occlusion’ = Contacts between teeth

Is the Articulatory System a True System?

A system is defined as: ‘A set or assemblage of things connected, associated, or

Fig. 1.2 The Articulatory a Temporomandibular

Fig. 1.3 (a) Interconnections a

Occlusion leads to TMJ

Teeth leads to Periodontia

Periodontia leads to Teeth

Articulatory leads to Teeth

This sums up the challenge in Restorative Dentistry.

fib.att. = fibrous attachment to posterior neck of condyle

Mandible is in terminal hinge axis

Significance of Centric Relation

Another aspect of the static occlusion is the presence or absence of ‘Freedom in

Fig. 1.5 (a) No freedom a

In Fig. 1.5a, there is no Freedom in Centric Occlusion. Another way of thinking

The word ‘Centric’ is an adjective.

• A ‘Non-Working Side Interference’ is an anterior guidance on the back teeth on

During a Lateral Excursion

Fig. 1.6 Occlusion is a Temporomandibular

Definition of Ideal Occlusion

This is given in established texts [8] as:

There is no such thing as an intrinsically bad occlusal contact, only an intol-

To state that an occlusion is correct or wrong betrays a mechanistic approach to

The Importance of Ideal Occlusion as a Concept

1. Pre-treatment Examination and Records

which we work. It cannot be overstated how important it is for a dentist to be able

2. Management of Myofascial Pain

3. Provision of Treatments That Affects the Occlusion [and Jaw Relationship]:

Fig. 1.7 Example of a

Does CO occur in CR? No

If not.. prem contact in CR? Roughly: Left molar

2022, Manchester, UK Stephen Davies

1 What Is Occlusion?�� 1

2 The Examination and Recording of the Occlusion:

3 Good Occlusal Practice in Simple Restorative Dentistry �� 43

4 Good Occlusal Practice in Advanced Restorative Dentistry�� 79

5 Good Occlusal Practice in Removable Prosthodontics�� 119

6 Occlusion and Orthodontics�� 141

7 Occlusal Considerations in Periodontics�� 165

8 Good Occlusal Practice in Children’s Dentistry �� 191

10 Occlusion and Non-carious Tooth Surface Loss�� 219

11 Good Occlusal Practice in the Provision of

Guidelines of Good Occlusal Practice

These Must Be Guidelines Not Rules

The Importance of Occlusion in Dental Practice

Is the Articulatory System a True System?

Significance of Centric Relation

Definition of Ideal Occlusion

The Importance of Ideal Occlusion as a Concept

Individual Mandibular Muscles

The Masseter Muscle

The Temporalis Muscle

Lateral Pterygoid Muscle

Medial Pterygoid Muscle

Suprahyoid, Infrahyoid and Cervical Muscles

How Does the Mandible Move?

Neuromuscular Guidance and Motor Engrams

This Is an Important Consideration in Restorative Dentistry

The Hard Guidance Systems

Relevance of a Study of Guidance Systems to Occlusion

Articulatory System: Occlusal Harmony?

The Three Question Examination

Recording of the Centric Occlusion