Journal Club I

Methods to check occlusal clearance during tooth

preparation
PRESENTED BY: -

Dr Humaira Shaikh
Frist year postgraduate
Department of Prosthodontics, crown and bridge & implantology
A.M.C. Dental college

GUIDED BY: -

Dr Ina Patel (MDS; HOD)

Dr Kinjal Solanki (MDS)
Dr Ravindra Chavda (MDS)
Dr Ronak Choksi (MDS)
Dr Khushali Patel (MDS)
Dr Harekrishna Raval (MDS)
Dr Diptesh Rami (MDS)

Ø Contents
• Introduction
• Base article
• Critical analysis
• Discussion
• Conclusion and Take-home message
• References

Ø Introduction

• Principles of tooth preparation include:

1. Preservation of tooth structure
2. Retention and resistance
3. Structural durability
4. Marginal integrity
5. Preservation of the periodontium

• Interocclusal clearance : The amount of reduction achieved during tooth preparation to

provide for an adequate thickness of restorative material – GPT10
• Tooth preparation in fixed partial denture is more critical and crucial phase in fixed
prosthodontics. Improper occlusal clearance will lead to fracture of the restoration and
jeopardize the structural durability of the prosthesis
• Occlusal reduction:-
Ø For all-metal crowns, 1.0 mm
Ø For metal-ceramic crowns, 2.0 mm
Ø For all-ceramic crowns, 2.0 mm

• Over preparation: Excessive occlusal clearance than the recommended amount will
lead to failure in the retention and resistance property of the prosthesis and will cause
irreversible pulpal damage.
• Under preparation: if underprepared, the structural durability of the restoration may
be compromised.
• Adequate tooth reduction is a prerequisite for function, aesthetics, and longevity of
fixed restorations.
• A tooth reduction guide may be useful for establishing the proper angulation of the
tooth and maximizing periodontal health and restorative success.
• This journal club describes versatile techniques for an accurate evaluation of tooth
reduction for fixed restorations.

Kaushik A, Chaudhary A, Khurana PR

A novel chairside technique to assess the interocclusal clearance and
abutment axial walls during tooth preparation
The Journal of Indian Prosthodontic Society. 2023 Jan 1;23(1):99-102

Ø Introduction
• Various conventional techniques and their modifications, for verifying the occlusal
clearance have been proposed
• Positive replica models have always been more convenient and effective to assess the
preparation, in terms of prepared abutment morphology and occlusal clearance,
compared to their negative form.
• Technique proposed in the article is simple and attempts to negate shortcomings of
verifying the abutment preparation three‐dimensionally.

Ø Instrument used for procedure.

• In this technique, a modified Heister mouth gag forceps is used,

• Two opposing threaded screws of 3 mm width and 5 mm height are attached at the end
of forceps arms which are precisely calibrated (up to 0.5 mm) on a curved scale, and a
slidable metal stopper block which engages a V‐shaped groove in one of the forceps
arms near its furcation junction.
• The metal stopper provides a standardized opening of 13 mm at the forceps end.
• This modified instrument acts as a mini‐hinged articulator and enables quick mounting
of the bite record.

Ø Procedure
1. Screw the forceps knob up to three turns to slightly open up the forceps arms before
the clinical appointment

2. After a tentative occlusal reduction during tooth preparation, record the bite using an
addition silicone bite registration material only in the region of prepared abutment
3. Carefully cut the excess silicone index material adjacent to the abutment margin using
a surgical blade number 22/23
4. Heat a Type 1 medium inlay wax stick over burner flame, and coat three to four layers
on the abutment and opposing occlusal surface of silicone bite index
5. Heat the threaded screws over the flame, orient the silicone index coated with inlay
wax between them, and immediately clamp the forceps arms until it contacts the metal
stopper. This enables the inlay wax to flow inside screw threads and mechanically
retain on the forceps

6. After allowing the wax to cool down on its own, screw in the forceps knob to separate
the silicone index from the inlay wax and clamp the forceps again until the arm rests
on the stopper completely. This is the 0 mm position on the graduated curved scale.

7. Slide the metal stopper sideways along the groove, from the forceps arm and clamp
both the forceps arms together until the opposing cusps meet. The reading on the scale
now obtained, depicts the minimum occlusal clearance achieved in the tooth
preparation.
 8. Modify the abutment intraorally, in accordance with the measurements obtained on
the scale.
9. Evaluate the axial morphology of the abutment, after opening the arms of the forceps.
Modify the axial walls in accordance with the undercuts, if present.

Ø Critical analysis

Ø Merits
• The modified instrument design enables the clinician to visually assess the positive
replica of the prepared abutment tooth three‐dimensionally
• Accurate measurement of interocclusal clearance, thereby allowing the rectification of
abutment morphology chairside.
• Evaluation of axial walls can also be done.
• The materials required for the procedure are readily available and cost‐effective
• As no carving or shape manipulation of wax is done , minimal residual stresses are
incorporated into the wax used.

Ø Demerits
• Fabrication/ availability of modified Heister mouth gag forceps.
• Use of a modified Heister mouth gag forceps in untrained hands could potentially
introduce inaccuracy or even distortion of the wax record.
• Time consuming.

Prasadh SS.
A novel technique using arti-spot coated on fleximeter strips to determine
the clearance during tooth preparation in fixed partial denture.
The Journal of Indian Prosthodontic Society. 2015 Jan 1;15(1):14-6

Ø Introduction
• Varying methods and techniques are used to determine the occlusal reduction, this
article describes the use of arti‐spot coated on colour coded fleximeter strips to
determine the amount of occlusal clearance during tooth preparation.
• Arti‐spot is a new easy use contact color for testing occlusal surfaces and for the inside
of castings. Arti‐spot was formulated to identify contact interferences that prevent
accurate seating of the dental restorations. Arti‐spot film is resistant to saliva, and the
thickness of the dry film is only 5–10 microns. In this technique, using an arti‐spot
spray coated on the flexi strips will give the amount of interference and the area of
insufficient reduction. Hence, the area of interference can be easily removed, and
adequate clearance will be there for the prepared tooth.

Ø Technique
1. Color coded fleximeter strips are placed on the occlusal surface of the prepared tooth.
The color-coded strips are available in 3 colours, pink, green, and blue (Bausch flexi
strips ‐ Germany)

2. The colours indicate the thickness of the strips. Pink (1mm),green (1.5mm),blue
(2mm). The surface of the strips is painted or coated with Arti‐spot and placed on the
occlusal surface of the prepared tooth.

3. After evaporation of the arti‐spot solvent, it leaves a thin film of color. Every contact
of the opposing teeth on the dry color will partially remove the pigment, making the
basic material shine through the interferences can be easily detected.
4. Any interference or lack of clearance will be indicated on the paint on the flexi strips.
Each color strips indicate the amount of clearance to be given, and the coated arti ‐spot
indicate the interference area to be reduced to give proper tooth clearance

Ø Conclusion
• The amount of occlusal clearance during tooth preparation can be accurately
determined using arti‐spot coated with fleximeter strips. The fleximeter strips gives
the amount of clearance and arti‐sport gives the areas of interference to be reduced.

Lee JH
Chairside fabrication of a tooth reduction guide to ensure adequate
occlusal clearance.
Journal of Prosthetic Dentistry. 2022 Mar 1;127(3):515-6

• With this modified technique, limitations can be efficiently overcome.

• An occlusal reduction guide used is fabricated without a laboratory procedure.

Ø Technique
1. After tooth preparation, dispense a poly-vinyl siloxane occlusal registration material
(CharmFlex Bite Fast; DentKist Inc) on the abutment tooth. Instruct the patient to
occlude in the maximal intercuspal position
2. After polymerization, retrieve the matrix from the mouth. Assess the adequacy of the
occlusal reduction with calipers (Iwansson Measuring De- vices; DIRECTA AB).
Remove the area of insufficient thickness by using a blade (No. 15 Scalpel Blade;
Paragon) and trim the excess

3. Place the matrix on the tooth. While holding the matrix, eliminate show-through areas
by using a rotary instrument (201R; SHOFU Dental Corp). Dry the matrix with air and
inject the registration material through a narrow dispensing tip (Chromaclone PVS
IntraOral Tips; Ultradent Products, Inc) into the perforated area of the matrix. Ask the
patient to occlude until the material has polymerized. Measure the modified matrix by
using calipers to determine that the modified occlusal reduction is sufficient. Repeat
the procedure if necessary.
 McGill ST, Holmes JR.
Verifying occlusal reduction during tooth preparation.
Operative Dentistry. 2012 Mar 1;37(2):216-7.

• Failure to obtain and verify adequate occlusal reduction may lead to difficulty in
fabricating appropriate functional and aesthetic occlusal surface.
• The restoration may be thin and/or weak as a result of the thickness itself or attempts
by the clinician to equilibrate high spots prior to luting. Over time, inadequate
thickness in excursive areas may lead to occlusal wear and loss of integrity (i.e.,
holes).
• Attempts by clinicians to verify adequate occlusal clearance usually rely on visual
assessment, which can be inaccurate.
• The technique described here is quick and reliable and requires no special equipment
or instrumentation but allows the clinician to verify adequate occlusal reduction in
centric occlusion as well as excursive movements

Ø Technique
1. Using blue periphery wax (Sturgident Periphery Wax, Heraeus Kulzer LLC), a small
ball of wax is placed over the tooth and the patient is instructed to close together into
centric occlusion.
2. The wax is removed from the mouth to inspect for thin spots. An approximation is
made regarding the area needing the reduction, and the process is repeated.
3. After closing into the wax in centric occlusion, the patient is then guided through
excursive movements, which produces a functionally generated wax index over the
teeth. Without removing the wax from the mouth, a periodontal probe (Williams
periodontal probe - Hu-Friedy) with millimeters marked in black is used to test and
identify areas of minimal reduction

4. A rounded-end diamond burr (Brassler 856-018) that is used for occlusal reduction is
used (through the wax) to create a divot approximately the depth needed for additional
reduction.
5. The wax is removed from the mouth, and the exact spot is identified for further
reduction. Once accomplished, the remainder of the preparation can be completed with
the assurance that excess adjustment of the restoration will not need to be done at the
delivery appointment nor will the opposing dentition need to be altered.

Yu A, Lee H.
A wax guide to measure the amount of occlusal reduction during
tooth preparation in fixed prosthodontics.
Journal of Prosthetic Dentistry. 2010 Apr 1;103(4):256-7.

• A simple method is described in the present article for easily determining the amount
of occlusal reduction in specific areas using a custom-made wax guide.
Ø Procedure
1. Fabricate the wax guide using 3 sheets of occlusal indicating wax (Occlusal Indicator
Wax; Kerr Corp, Orange, Calif ) with a thickness of 0.5 mm per piece. Leave the first
sheet in- tact. Cut off a quarter of the second sheet with a stainless-steel scalpel
(Stainless Steel Disposable Scalpel, size 15; Miltex, Inc, York, Pa). Then cut the third
sheet in half.

2. Stack the pieces on top of each other in a stepped manner so that each square has a
thickness of 0.5 mm,1mm,1.5mm and 2mm.
3. Prepare the tooth as desired.

4. Fold a new piece of occlusal indicating wax twice to obtain a final thickness of 2 mm.
Place the wax over the prepared tooth and instruct the patient to occlude onto the wax.
Carefully remove the occluded wax so as not to distort it.
5. Hold the wax shade guide and the occluded wax under the light to compare thickness
and measure the amount of reduction. If the amount of reduction is insufficient in a
certain area, identify the corresponding location on the tooth and perform further tooth
reduction until the desired reduction is obtained.

Oh WS, Saglik B, May KB.

Tooth reduction guide using silicone registration material along with
vacuum‐formed thermoplastic matrix.
Journal of Prosthodontics: Implant, Esthetic and Reconstructive
Dentistry. 2010 Jan;19(1):81-3.

• This article describes a technique for an accurate evaluation of tooth reduction for
fixed restorations.
• The technique demonstrates the fabrication of a colour-contrasting positive guide
using a silicone occlusal registration material in conjunction with a vacuum-formed
clear thermoplastic matrix.
• The silicone replica of the final restoration is quickly processed within the matrix,
separated, and cross-sectioned labiolingually or mesiodistally for visual and
quantitative inspections of its thickness outside the mouth using a caliper.
• Reseating the guide over the prepared tooth permits further intraoral evaluation and
identifies areas of adequate, under, and overreduction.
• The guide is positive, provides color contrast, and is firm for distinct and accurate
evaluation of both the occlusal/incisal and axial clearances. This method is simple,
accessible, versatile.

Ø Technique
1. Complete the diagnostic waxing to simulate the desired contour and occlusion, then
duplicate the wax cast in Type III dental stone (Microstone, Whip Mix Corp,
Louisville, KY).
2. Thermoform a clear plastic matrix (Buffalo Dental MFG, Syesset, NY) over the
duplicate cast in the conventional manner. Separate the vacuum-formed thermoplastic
matrix from the cast, trim the excess 1 mm beyond the gingiva around the prepared
tooth using a surgical blade (carbon steel surgical blade number 25, Miltex Inc., York,
PA), and make an air escape hole in the centre of the prepared tooth of the matrix
using a small round bur.

3. Seat the prepared matrix intraorally to evaluate the tooth angulation and plan the
amount of tooth reduction as indicated. Initiate the tooth preparation and visually
evaluate the amount of axial reduction and occlusal clearance with the use of the
matrix. To further evaluate the preparation, inject the fast-setting PVS bite registration
material (Regisil Rigid, Dentsply Caulk, Milford, DE) into the matrix at the prepared
tooth site when the tooth preparation appears to be satisfactory. Seat the matrix
intraorally and hold it until the material sets.
4. Remove the matrix, separate the silicone replica, and trim the excess along the margin
of the tooth preparation using scissors. Measure the thickness of the replica using a
caliper (Iwanson crown caliper, Miltex Inc.) and determine the adequacy of tooth
reduction.
5. Cross-section the replica labiolingually using a surgical blade (carbon steel surgical
blade number 25) (Fig 2A) and reseat the sectioned replica intraorally for further
evaluation. Identify the area of inadequate reduction, mark it with a lead pencil (Fig
2B), and modify the tooth preparation as indicated.
6. Proceed to fabricate an interim restoration using the same matrix when the tooth
reduction is determined to be adequate and complete

Ø Conclusion
• Initial tooth reduction is carried out with the aid of the clear vacuum-formed
thermoplastic matrix.
• The processed silicone replica is cross-sectioned labiolingually/mesiodistally and
positioned on the prepared tooth to determine the accuracy of tooth reduction.
• When the tooth reduction is complete, an interim restoration is fabricated using the
thermoplastic matrix.
• This method is convenient for all regions of the dentition.

• Review (Some other methods to check inter occlusal clearance)

2. Modelling Thermoplastic waxes are the foremost frequently used and widely
Wax accepted material. This is due to its low cost, simple manipulation
and ready availability in clinics. However, properties like high
coefficient of thermal expansion and high resistance to closure will
result in inaccuracies during recording. Nonuniform softening of
wax during heating results in build-up of internal stresses, which
leads to distortion of wax record.

3. Corrected Wax is corrected with zinc oxide eugenol material. It improves the
Wax detailed recording and prevents displacement of wax, but it
increases the vertical dimension. While making record with
corrected wax, they used double sheet of the base plate wax, and the
record is made. After the removal of record from mouth, thin layer
of zinc oxide eugenol was applied over the wax record and placed
intraorally until material is hardened

3. Metalized The metalized wax wafers contain powdered aluminium particles

Wax (Alu and retain heat longer for efficient modelling. These are found to be
wax) much more accurate than non-metalized wax as the addition of
metal particles to the modelling wax make it more conductive
which may lead to increase in the accuracy of the record
 4. Ribbon 1.Prepare the tooth as usual.
wax 2. Dry the prepared tooth surfaces.
3. Place a piece of soft ribbon wax on the dry preparation
ensuring adequate contact on the adjacent tooth surfaces
4. Wet the opposing teeth.
5. Manipulate the teeth into centric and eccentric closures
6. Separate the teeth stabilizing the wax digitally to avoid
dislodgment.
7. Insert a graduated periodontal probe into the soft wax (without
removing from preparation) in all regions of potential contact and
read the thickness of interocclusal space for the restoration
• Evaluation of their (waxes) thickness is done with an Iwanson gauge calliper or a
graduated periodontal probe

Iwanson gauge calliper Williams probe

• Ribbon wax

5. Blotting Two thicknesses of blotting paper (1 mm) in a haemostat or

paper articulating forceps is the required working tool. A piece of thin
occlusal marking paper is wrapped around half of the length of this
gauge. The articulating forceps is engaged in the middle of the
gauge holding the marking paper. This produces two short ends; one
 end secures the thin marking paper, and the other end holds the
thickness to be measured.
The thickness gauge is inserted intraorally over each reduced cusp
of a tooth, and the patient is instructed to close in centric relation for
each cusp. If the gauge slips through, enough tooth reduction has
occurred to allow 1 mm of metal on a casting. Increased thickness
of the gauge allows additional occlusal clearance. This proce-dure is
repeated for each tooth.
When the gauge doesn’t slide through, additional tooth preparation
is indicated. To find precisely where to reduce the tooth, the
articulating paper section of the gauge is placed on the reduced
occlusal surface and the
patient is asked to bite together. The high spots are marked, as are
the areas that bind the gauge from pulling through freely. The tooth
is then reduced appropriately on the marked areas. If the gauge
doesn’t pull through, the process is repeated: marking with
articulating paper, grinding, and checking for clearance. The process
is repeated as often as necessary until the gauge pulls through,
which indicates the desired reduction.

6. Check casts Techniques like pouring the check casts with salt incorporated
dental plaster have been advocated. It requires an additional
impression, laboratory work. It can be further used for fabrication of
Provisional Restoration

7. Intraoral Recently, Intraoral scanners have been successfully employed to

scanners evaluate the occlusal form three‐dimensionally, but scanning is not
cost‐effective for every practitioner.

Ø Conclusion of Journal club

• Several methods for measuring interocclusal clearance are there,
• Attempts by clinicians to verify adequate occlusal clearance usually rely on visual
assessment, which can be inaccurate. Occlusal guides such as leaf gauges or tabs of
known thickness are sometimes used but do not always easily reveal the exact location
of inadequate reduction on the occlusal surface. Arti spot can be used to know exact
location, but not cost effective.
• Positive replica models have always been more convenient and effective to assess the
preparation, in terms of prepared abutment morphology and occlusal clearance,
compared to their negative form. so,
• Out of all methods method with lesser expense, lesser chair side time, less/ No
laboratory procedure technique with Modified Heister mouth gag forceps is more
suitable.

Ø Take Home message.

METHOD ADVANTAGE DISADVANTAGE

Kaushik et al • Assessment of
Technique with positive replica
Modified Heister • Amount of clearance
mouth gag forceps can be determined
• Areas of interference
can be determined
• Material readily
available & cost
effective
• Minimal residual
stress exerted on wax
pattern
• Evaluation of axial
walls
Prasadh SS • Amount of clearance
Technique using arti- can be determined
spot coated on • Areas of interference
fleximeter strips can be determined
• Less time
Lee JH • Amount of clearance
can be determined
Fabrication of a • Less time
tooth reduction guide
with poly vinyl
siloxane to ensure
adequate occlusal
clearance.
McGill ST et al
• Amount of clearance
Verifying occlusal can be determined
reduction during • Areas of interference
tooth preparation can be determined
with wax • No any special
instrument needed
• cost effective.
• Less time
• Fabrication/ availability
of modified Heister
mouth gag forceps.
• Requires skilful operator
• Time consuming
• Expensive
• Marked area on PVS
guide may become
smudged, and fabricating
an additional matrix may
be necessary to evaluate
the tooth modification
• Expensive
• The wax is removed
from the mouth to
inspect for thin spots. An
approximation is made
regarding the area
needing the reduction,
and the process is
repeated. An inherent
problem is trying to
estimate exactly where
this under-reduced area
is once the wax is out of
the mouth.
• Residual stresses exerted
on wax
 Yu A et al • Amount of clearance • Availability of material
can be determined & Expensive
A custom wax guide • Area of interference • Interpretation of
to measure the can be determined occluded wax from
amount of occlusal • Less time custom wax guide may
reduction vary from different
operators
Oh WS et al • Assessment of • Time consuming
positive replica • Expensive
Tooth reduction • Amount of clearance • Added lab procedures
guide using silicone can be determined
registration material • Evaluation of axial
along with vacuum‐ walls
formed thermoplastic • An interim restoration
matrix. can be fabricated
using the
thermoplastic matrix.

Ø Refrences
1. Herbert T. Shillingburg Fundamentals of fixed prosthodontics 4th edition ch 9 Pg no
299-315
2. The Glossary of Prosthodontic Terms 2023. (2023, October). The Journal of Prosthetic
Dentistry, 130(4), e1–e3.
3. Prasadh SS. A novel technique using arti-spot coated on fleximeter strips to determine
the clearance during tooth preparation in fixed partial denture. The Journal of Indian
Prosthodontic Society. 2015 Jan 1;15(1):14-6
4. Oh WS, Saglik B, May KB. Tooth reduction guide using silicone registration material
along with vacuum‐formed thermoplastic matrix. Journal of Prosthodontics: Implant,
Esthetic and Reconstructive Dentistry. 2010 Jan;19(1):81-3
5. Lee JH, Chairside fabrication of a tooth reduction guide to ensure adequate occlusal
clearance. Journal of Prosthetic Dentistry. 2022 Mar 1;127(3):515-6
6. McGill ST, Holmes JR. Verifying occlusal reduction during tooth preparation.
Operative Dentistry. 2012 Mar 1;37(2):216-7.
7. Kaushik A, Chaudhary A, Khurana PR. A novel chairside technique to assess the
interocclusal clearance and abutment axial walls during tooth preparation. The Journal
of Indian Prosthodontic Society. 2023 Jan 1;23(1):99-102.
8. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations for complete crowns:
an art form based on scientific principles. The Journal of prosthetic dentistry. 2001 Apr
1;85(4):363-76.
9. Yu A, Lee H. A wax guide to measure the amount of occlusal reduction during tooth
preparation in fixed prosthodontics. Journal of Prosthetic Dentistry. 2010 Apr
1;103(4):256-7.
10. Raju S, Vivek VN, Harshakumar K, Ravichandran R. Interocclusal recording materials
and techniques: A literature review. Int J Appl Dent Sci. 2020;6(4):397-40
11. Regish KM, Sharma D, Prithviraj DR. Techniques of fabrication of provisional
restoration: an overview. International journal of dentistry. 2011 Jan 1;2011
12. Saravanamuttu R. A dynamic method for assessing the occlusal reduction of
preparations. The Journal of Prosthetic Dentistry. 1988 Jan 1;59(1):116-7.
13. Limpinsel W. Measurement of occlusal reduction for cast restorations. The Journal of
prosthetic dentistry. 1985 Jun;53(6):838-9.