Enhanced CPD DO C RestorativeDentistry

Shamir Mehta

Subir Banerji

The Application of Occlusion in

Clinical Practice Part 1: Essential
Concepts in Clinical Occlusion
Abstract: The first of this three-part series will focus on the occlusal assessment and the proposed features of the ‘ideal occlusal scheme’.
The examination of the static and dynamic relationship of the dentition is outlined, including the extra- and intra-oral examination. The
terminology associated with the intra-occlusal positions and relationships are described and a template for a comprehensive occlusal
examination is presented. Part 1 also aims to explore some of the essential concepts in clinical occlusion.
CPD/Clinical Relevance: Understanding the static and dynamic relationships of the natural and restored dentition are important steps
in the successful and long-term rehabilitation of missing and broken-down teeth. Development of familiarity and fluency with various
terms associated with the examination and relationships of the dentition in function are critical aspects when attempting to form an
appreciation of the subject of clinical occlusion.
Dent Update 2018; 45: 1003–1015

According to The Glossary of Prosthodontic
Terms 9th edn, the term ‘occlusion’ has
been defined as: ‘1. the act or process of
closure or of being closed or shut off; 2. the
static relationship between the incising
or masticating surfaces of the maxillary
or mandibular teeth or tooth analogues.’1
Shamir Mehta, BDS, BSc,
MClinDent(Prostho), MFGDP(UK),
FICD, Senior Clinical Teacher, Deputy
Programme Director MSc in Aesthetic
Dentistry, Faculty of Dentistry Oral &
Craniofacial Studies, King's College
London (FoDOCS), Conservative & MI
Dentistry, Unit of Distance Learning,
Floor 18, Tower Wing, Guy’s Campus, St
Thomas’s Street, London SE1 9RT and
Subir Banerji, BDS, MClinDent(Prostho),
PhD, MFGDP(UK), FICD, Programme
Director MSc in Aesthetic Dentistry,
(FoDOCS); Private Practice, Ealing,
London, UK.
December 2018
However, given that the masticatory
system includes anatomical
components beyond the occluding
surfaces, an alternative definition has
been proposed that describes occlusion
as ‘an integral (but not necessarily
central) part within the stomato-gnathic
system (SGS) that relates teeth, not
only to other teeth but, importantly,
to the other components of the SGS
during normal function, parafunction
and dysfunction’.2 Accordingly, the
SGS includes the temporomandibular
joints, muscles of mastication,
the periodontium along with the
mandibular and maxillary teeth.
Indeed, it is common to refer to the
articulation of the teeth as the anterior
determinants of mandibular movement
and the temporomandibular joints and
associated structures as the posterior
determinants.3
The topic of clinical
occlusion which, of course, not only
embraces the theoretical aspects but
also the more pragmatic/practical
elements, does, however, have the
potential to cause confusion amongst
dental practitioners. Some of this
confusion is likely to stem from:
 The associated terminology that can
at times seem complex and difficult to
interpret in the context of routine clinical
practice (especially with the plethora of
synonyms that are commonly used in
the literature);
 The lack of appropriate evidence to
support some of the ‘Guidelines of Good
Occlusal Practice4 often advocated;5
 Possible inconsistency in the manner
by which this subject is approached
as part of the dental undergraduate
curriculum;
 The diverse variety and design of
occlusal records and recording apparatus
that are available in the current market
place;
 A lack of clear knowledge in relation
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to the exact records and apparatus that
would serve as being most appropriate to
the presenting clinical scenario; and
 Having the confidence and
competence to execute the required
protocols to an appropriate standard.
Consequently, many
practitioners may inadvertently fall
into a habit of not giving the subject
of occlusion the level of attention that
it may duly deserve,4 which may result
not only in restorative failure, but also
contribute to other problems affecting
the SGS.
The aim of this series of
three articles on clinical occlusion is
to provide an account of many of the
concepts surrounding this subject in
relation to the dentate (or partially dentate
patient). Part 1 will focus on the occlusal
assessment and the proposed features
of the ‘ideal occlusal scheme,’ Part 2 will
aim to provide an account of the process
of taking of occlusal records and, in Part
3, the manner by which the application
of the information obtained from any
evaluations and assessments can be used
to plan and provide restorative treatment
will be described. Where possible,
throughout this series, clinical case
examples will be used to help convey
the significance and application of the
subject matter to routine practice, with
the ultimate goal of helping to improve
the delivery of patient care.
The occlusal examination
As per the FGDP (UK) Clinical
Examination and Record-Keeping; Good
Practice Guidelines 2016,6 when a patient
attends a practitioner for the first time
for a routine dental examination, an
appraisal of the nature of the occlusion
would be recommended and, where
appropriate, the presence of any occlusal
abnormality or disharmony ascertained.
Given that the relationship and alignment
of the dental arches is one of a dynamic
nature (especially evident amongst the
developing dentition, in cases of active
tooth surface loss, amongst patients with
periodontal disease, in the presence of
mesial drift and the tilting, drifting and
over-eruption of teeth into extraction
spaces),2 there may also be an indication
to perform occlusal assessments during
1004 DentalUpdate
recall examinations, to take account of any
changes that may have taken place since
the previous dental inspection.
It has been suggested that, in
the case of a new patient attendance (as
part of essential practice), an assessment
should be made of; the occluding surfaces
of the teeth, the incisal angle and molar
relationships, as well as an evaluation of
the tooth-related guidance during lateral
excursive and protrusive mandibular
movements.7
In the context of restorative
dentistry (with reference to dentate or
partially dentate patients), there are
however, some specific clinical scenarios
where the patient’s presenting signs and/or
symptoms, or indeed the actual proposed
treatment plan/treatment provided would
support the need for a comprehensive
occlusal assessment.
These include:
 A history of fracturing teeth and/or
restorations;
 When planning and making direct
restorations involving the occluding
surfaces, removable partial dentures and/
or any fixed indirect restorations that may
directly involve the occluding surfaces (or
their prescription resulting in a possible
change in the patient’s overall occlusal
scheme, for instance when increasing the
length of the anterior teeth by restorative
means);8
 In the presence of tooth wear;9
 For a patient presenting with a history
and/or symptoms of a possible diagnosis
of Cracked Tooth Syndrome, and/or
symptoms of pain where the aetiology of
the symptoms may not be obvious;
 For the diagnosis and management of
temporomandibular disorders (especially
where the provision of restorative care is
being considered);
 For a patient presenting with primary or
secondary occlusal trauma;
 Amongst patients presenting signs/
symptoms of tooth and/or teeth mobility,
and/or a history of tooth movement/drifting
(that may manifest as ‘open’ interproximal
contacts associated with food trapping)
that cannot be explained by an underlying
aetiology of periodontal disease; and
 Amongst patients who report a history of
disturbance to their bite following a prior
course of restorative treatment and/or for a
patient presenting with the condition of a
‘phantom bite’.8
The means for carrying out
such assessments is described below.
The protocol for the
undertaking an occlusal
examination
The undertaking of an occlusal
assessment will allow the clinician to
carry out an appraisal of the clinical
features that may diverge from the ‘ideal.’
The concept of the ‘ideal occlusion’ has
been discussed further below. However,
prior to carrying out the process of
conducting a clinical examination, it
is of course important to attain (and
keep contemporaneous records of ) a
detailed, accurate and contemporaneous
patient history, so as to help establish
an appropriate diagnosis. The process
of carrying out the examination may be
divided into the extra-oral and intra-oral
aspects, respectively. The account given
below will also focus on matters that are
most relevant to the restorative dental
practitioner.
The extra-oral assessment
Given the role of the TMJ and
associated musculature in the articulatory
system, the occlusal assessment
should commence with an extra-oral
examination of these components. The
process of undertaking a TMJ and muscle
examination has been described by Gray
and Al-Ani.10 This aspect of the clinical
assessment should aim to assess the
following.
The range of movement
The degree of maximum
mandibular opening should be
determined by measuring the inter-
incisal distance; any distance less than 35
mm is considered to be restricted. The
degree of maximum movements upon
the undertaking of lateral movements
should also be determined; the normal is
accepted to be about 12 mm. A note of
the presence of any mandibular deviation
upon opening and closure movements is
advised.
TMJ tenderness
The presence of any TMJ
tenderness may be initiated by the
December 2018

Figure 1. Side profile of a patient, who has a Class
I skeletal pattern, with the teeth in maximum
intercuspation.
Figure 2. Side profile of a patient, who has
a Class II skeletal pattern, with the teeth in
maximum intercuspation. Notice the position of
the chin which is further posterior compared to
the patient in Figure 1.
palpation of the anatomical features in
the pre-auricular region, and by palpation
involving the placement of the index
fingers into the external auditory meati and
concomitantly asking the patient to open
December 2018
Figure 3. Side profile of a patient, who has
a Class III skeletal pattern, with the teeth in
maximum intercuspation. Notice the position of
the chin which is further anterior compared to
the patient in Figure 1.
Figure 4. Side profile of a patient, who has severe
wear of the existing dentition, with the teeth in
maximum intercuspation.
and close, while attempting to manipulate
gently their mandible into its retruded arc
of closure.
Joint sounds
The detection of any anomalous
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joint sounds (ideally with the aid of a
stethoscope). It is appropriate to note
the presence of a ‘click’ and, if present,
to determine whether the click may be
associated with the symptom of pain. The
presence of a single or multiple clicks and
the point of the opening/closure cycle
when the sound is heard (early or late)
should also be established. Variations may
help to determine a likely diagnosis. The
presence of ‘dislocation’ or ’crepitation’
sounds should also be noted.
Muscular examination
The muscular examination
should involve the bilateral palpitation of
the masticatory muscles. This is performed
by pressing the muscles between the
thumb placed extra-orally and index finger
intra-orally whilst concomitantly noting
the presence of hypertrophy, tenderness
or discomfort, particularly in areas of
muscle insertion. The anterior and posterior
temporalis muscles and the superficial
and deep masseter muscles are perhaps
the most relevant in this context. Some
clinicians also aim to assess the anterior
digastric, sternomastoid, trapezius and
medial and lateral pterygoid muscles,
respectively. Masseteric hypertrophy has
been associated with the pattern of wear by
attrition.
The skeletal relationship of the jaws
As part of the extra-oral
examination, the skeletal relationship of
the jaws should also be ascertained, as
this can have an important effect on the
dental arch relationship. It is perhaps most
common to describe the anteroposterior
pattern with the mandible at rest or with
the teeth in the intercuspal position. A Class
I relationship occurs where the mandible
is normally related to the maxilla; Class II
when the mandible is positioned posteriorly
relative to the maxilla and Class III when the
mandible is too far forward: this can have
an impact on the facial profile when viewed
from the side with the patient’s teeth in
occlusion (Figures 1, 2 and 3).
Facial symmetry
An assessment of the patient’s
facial symmetry should also be performed,
as well as an evaluation of the amount of
maxillary incisal edge display at rest (in
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Extra-oral examination: stimulation techniques.12 Knowledge of

• Maximum opening Inter-incisal distance....mm/Range of lateral movement.... mm these dimensions can prove important
• Joints sounds Y/N – Click: single/multiple/description....... when planning future restorative care, as
• Muscle/Joint tenderness Yes… No… discussed further in part 3.
• Facial Proportions/well balanced: Y/N – comments: OVD: mm/ RVD: mm/ FWS: mm/ The intra-oral assessment
• Skeletal Pattern: I / II / III As part of the intra-oral
• Facial Symmetry: Horizontal: Y/N Vertical: Y/N assessment, an overall appraisal should
be conducted to take note of features
Intra-oral examination such as; the presence of tooth/ restoration
Incisal Relationship I / II div 1 / div 2/ III fracture(s), wear facets, lesions that
Overjet =...............mm may be of abfractive aetiology, vertical
Overbite =..............mm complete/incomplete enamel fractures,13 dental caries, signs of
Super- eruptions:............... periodontal pocketing/recession/clinical
Tilting:............... attachment loss, gingival inflammation,
Spacing:............... the standard of oral hygiene, the presence
Crowding:............... of any open contacts with signs of food
Drifting:............... trapping and tooth mobility (of particular
Fremitus:............... note, the presence of any fremitus).
Mobility/Grade of mobility I/II/III......... Fremitus has been defined as ‘a vibration
Number of tooth contacts perceptible on palpation; in dentistry, a
(Shimstock holds)...................................... vibration palpable when the teeth come into
Loss of posterior support....................... Y/N contact.’1
ICP = RCP/ ICP ≠ RCP Slide: vertical; horizontal; lateral The occlusal component of
First point of contact (RCP):................... intra-oral assessment should also take
Dynamic features/Guidance (chart into account both ‘static’ and ‘dynamic’
teeth) components of the patient’s occlusal
Protrusion: scheme. The latter terms make reference
Lateral excursion: Left: Right: to whether the mandible will be making
Canine guidance … Canine guidance … any movements in relation to the maxilla.4
Group function … Group function … Table 1 provides a summary of the
features that should be appraised and
NWSI…………… NWSI…………. recorded during the performance of an
appropriate occlusal examination.
Table 1. A summary of the features that would be appraised as part of a comprehensive occlusal
assessment for the restorative dental practitioner. The static occlusal assessment
The static occlusal examination
should commence by taking note of the
mms), commonly referred to as the lip may manifest as an increase in the freeway presence of any of the following features:
line.7 space (FWS). The latter represents the  Tooth rotations, tilting, drifting, supra-
difference between the vertical dimension eruption;
when the mandible is at rest − resting  Crowding;
Occlusal vertical dimension
 Spacing;
The term occlusal vertical vertical dimension (RVD) and the OVD.
 Overjet;
dimension (OVD) refers to the vertical It has been suggested that the
 Overbite (including open bites and
distance between two selected physiological FWS should be approximately
cross bites);
anatomical points when the maxillary 2 to 4 mm. Perhaps the most popular way
 Missing and/or supernumery erupted
teeth are occluding with the mandibular of determining the OVD, RVD and FWS
teeth.
teeth. The loss of tooth tissue may be involves the use of a set of callipers or a The assessment of the
seen amongst cases of severe tooth Willis Gauge. It should be noted, however, above features will help to establish
wear or with the loss of multiple that the latter methods are by no means the presence of any malocclusions, and
(antagonistic) teeth in general, with highly accurate.11 Other techniques that further categorize the inter-arch occlusal
some patients developing an ‘overclosed’ can be used for the evaluation of vertical relationships (such as the incisor, canine
appearance (Figure 4). The loss of OVD dimension include the use of phonetic and molar segment classifications). It
has been described to have the capacity assessments (particularly the sibilant is also important to establish the loss
to affect patient function, comfort and sounds), facial soft tissue contour analysis, of posterior support at this stage, and
aesthetics.11 The loss of OVD at this stage jaw tracking and the use of electrical muscle whether this may be a factor to consider
1006 DentalUpdate December 2018

Figure 5. Shimstock non marking articulation foil.
Figure 6. Teeth in maximal intercuspation with
the Shimstock held between the posterior
molars.
Figure 7. Single-sided articulating foil – Black.
Figure 8. Single-sided articulating foil – Red.
in cases displaying further anterior tooth
wear.
Subsequently, the inter-arch
relationships that are perhaps most relevant
to the restorative dental practitioner are
the:
 Intercuspal position (ICP); and
 The retruded contact position (RCP).
The intercuspal position (ICP)
The intercuspal position (ICP),
December 2018
commonly also referred to as the maximal
intercuspal position (MIP), centric occlusion
(CO), the bite of convenience or the habitual
bite in the dental literature,4 should be
initially appraised. The ICP is the position
when the maxillary and mandibular teeth
are maximally meshed together, when
maximum interdigitation (intercuspation)
takes place.
Intercuspal contacts may be
identified and recorded using Shimstock
articulating foil (usually of 8 to 10 μm in
thickness) (Figure 5).13 The foil is ideally
supported by a set of Mosquito forceps
or Artery forceps (Figure 6).7 Occlusal
contacts in the intercuspal position may
also be marked up using proprietary
articulating paper (ideally less than 20 μm
in thickness), however, in order to ascertain
a clear recording, it is important to make
sure that the teeth are suitably dried.13 The
use of GHM Hanel double-sided occlusal
indicating paper (GHMDental, GMBH,
Germany) supported using a set of Miller’s
forceps (Artery forceps have also been
advocated for this purpose).7 The latter
type of articulating paper is available in a
small range of differing colours, which can
prove helpful when marking up occlusal
contacts in differing mandibular positions.
It has been suggested that, amongst
younger patients (with the absence of any
signs of wear), the contacts when marked
in ICP should be of the small and discrete
variety, with multiple contacts ideally being
present on each tooth, which would help
to ensure occlusal stability.13 However,
where the contacts may be ‘broad and
rubbing’, this may be a sign suggestive of
possible occlusal instability.13 Single-sided
articulating coloured marking foil can also
prove useful when identifying occlusal
contacts (Figures 7 and 8).
The taking of high quality
photographs of the intercuspal contacts,
as established by the use of articulating
paper, may also prove to be of assistance
in relation to the recording and
documentation of the findings, as may
the use of accurate study/diagnostic casts,
as will be discussed in part 2. The use of
a digital device such as T-Scan Occlusal
Analysis System (Tekscan Inc Boston, USA)
to analyse the patency of the contacts in ICP
further (in both 2D and 3D) is also gathering
popularity.
The presence of any possible
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fremitus may also be evident by visual
inspection and/or by palpation of the
tooth/teeth as the teeth make contact in
maximum intercuspation.
It is generally accepted that,
when undertaking a limited number of
restorations that may involve a modification
of the anatomical form of the occlusal
table, the occlusal endpoint should
conform to the existing intercuspal position
unless, of course, it may be deemed
unstable (indicated by the presence of
occlusal instability), or by the signs and/
or symptoms of temporomandibular joint
dysfunction or masticatory muscle fatigue,
respectively.14 This matter will be discussed
further in part 3.
The retruded contact position
(RCP)
In the sagittal plane (dividing
the body into right and left parts) the
mandible can only exhibit rotational
and translational movement.3 The ease
with which the patient’s mandible can
be manipulated into its retruded arc of
closure should be established during
the undertaking of the clinical occlusal
examination. It has been suggested that the
initial rotational movement of the condyles
is limited to about 12 mm of incisor
separation before translational movements
of the condyle down the articular eminence
will commence.3 The latter form of
movement would be controlled by the
action of the temporomandibular ligaments
and the anatomical structures anterior to
the mastoid process (once the rotational
movement has completed).3 Translation
has been described to continue up to a
maximum inter-incisal (opening) distance
of 50 mm.2
The term centric relation (CR)
is used to refer to the maxilla-mandibular
relationship at the point where the condyles
are located in the most anterior-superior
position in the glenoid fossae. When
the mandible is at CR, only rotational
movement of the condyles within the
glenoid fossae will be possible. It is thus
imperative to be appreciative of the fact
that a centric relation, unlike that of the
intercuspal position, is a mandibular
position that is independent of any given
position of tooth contact.
Centric relation is also often
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 RestorativeDentistry
referred to as being a fixed and a relatively
reproducible position in the dental
literature.15 The latter is partly based on
the observations that CR has been found
to be reproducible within less than 0.08
mm (likely to be accounted for by the
non-elastic nature of the TMJ capsule
and associated capsular ligaments).15,16 In
addition, given that at CR the movement
of the condyles will be one that only
displays a simple hinge motion (prior to any
translatory movement taking place), this
spatial relationship (between the condyles
and glenoid fossae) should be transferrable
(or perhaps reasonably duplicitous) with
that of the condylar housing of the dental
articulator, where rotational movements of
the condylar component of the articulator
will take place against the corresponding
articular eminences of this device thereby,
to some extent, simulating what may be
taking place in-vivo, however, now in the
extra-oral environment.
Indeed, most clinicians will
most probably be aware from their time
of undergraduate training, that CR is
traditionally advocated when constructing
complete denture prostheses where there
is, of course, the lack of any teeth to provide
any occlusal guidance. The latter approach
will therefore permit the positioning
of the teeth that is consistent (‘fixed’)
between that of the dental articulator
and the patient’s mouth, as well as being
an anatomical position that is relatively
reproducible in the patient’s mouth
(between successive appointments).
In an analogous manner to
the above, it would also seem sensible
to use this position as a reference point
when undertaking complex occlusal
rehabilitation, where the intercuspal
position may not be readily identifiable
and/or is unstable/undesirable, as in the
case of a severely worn dentition, or a
heavily restored and failing dentition.17
This approach to treatment planning/
provision will not only provide a relatively
reproducible reference point that
concomitantly serves as a fixed position
between the patient and the dental
articulator, but also results in a clinical
scenario whereby the restored dentition
will now display an ICP that is co-incident
with the retruded contact position (RCP).
The latter is a term that refers to the
position of the mandible when first tooth
1008 DentalUpdate
contact occurs during its retruded arc of
closure. Where treatment is provided in this
manner, it is referred to as a re-organized
rehabilitation (and will result in the loss of
the slide between RCP and ICP) as discussed
further below.
It has been shown that, whilst
approximately 90% of adult patients have a
slide between RCP and ICP (with ICP being
anterior and superior to CR by 1.25 mm +/-
1.0 mm), amongst the remaining 10% RCP
and ICP are in fact co-incident.16 Indeed,
the discrepancy between RCP and ICP
(commonly termed the RCP-ICP slide) may Figure 9. Upper and lower dental casts mounted
in CR on a semi-adjustable articulator. The RCP
result in a level of inter-occlusal clearance
can be identified here as on the lingual cusp of
(in the vertical, lateral and/or horizontal
the patient's lower right second molar tooth.
dimension) that may prove beneficial when
attempting to provide restorative treatment
for a patient displaying tooth wear, as the
resultant space may be effectively utilized synonyms have been used. These include;
to place restorative materials (when the centric relation contact position (CRCP),
re-organizing the occlusion) and, therefore, the retruded axis position (RAP) or the
in some cases help to alleviate the need terminal hinge position (THP).15 The latter
to increase the occlusal dimension and/or can sometimes lead to confusion when
the need for subtractive tooth preparation trying to develop a better understanding
to accommodate future restorations.17 for this concept.
It may therefore be relevant to identify The term ‘long centric’ (or
the presence, direction and extent of
‘freedom in centric occlusion’) is also
any occlusal slides between ICP and RCP
often used by clinicians, and requires
(horizontal, lateral as well as vertical) when
some further discussion. This concept
planning care for such patients, as discussed
essentially describes the scenario of being
further in part 3.
able to close the mandible into RCP (or
Accordingly, it is appropriate
slightly anterior to it), without altering
to mount a set of study/diagnostic casts in
the vertical dimension of the anterior
CR, where RCP can be identified following
teeth.2,4 The absence of freedom in centric
closure of the elements of the articulator in
can sometimes be seen in cases with
the retruded arc of closure (Figure 9), which
Angle's Class II division 2 relationships
will be the position of the mandible (as per
the envelope of movement described by and/or amongst patients where multiple
Posselt16) that serves as the starting point anterior restorations have been placed
(prior to ICP and/or before the taking place (with sub-optimal contour of the occluding
of any eccentric mandibular movement). surfaces) that will only permit very limited/
This may be especially relevant when or no movement when the posterior
there may be a plan to adjust and/or to teeth are in contact, thereby having the
re-organize the occlusion (inclusive of the effect of ‘locking’ the patient’s jaw. The
need to increase the OVD, such as for a latter scenario is sometimes not very
patient with tooth wear).13,16,17 The use of well tolerated. Clinically, however, it may
mounted study casts in this manner will ultimately manifest in pain and discomfort,
allow the assessment of CR/RCP, as well premature restorative failure and have an
as any movements from this position in adverse effect on the supporting structures,
the absence of the interference of the soft and/or culminate in unwanted tooth
tissues and the patient’s neuromuscular movement. This situation may sometimes
protective mechanisms. The criteria for the be seen amongst cases where restorative
mounting of working casts in CR will be rehabilitation has been provided for
discussed further in parts 2 and 3. patients presenting with anterior tooth
Finally, in relation to the term wear.
retruded contact position, a number of The clinical location of CR,
December 2018
 RestorativeDentistry
Figure 10. Anterior incisal guidance to disclude
the posterior teeth.
however, is not always a straightforward
matter.7,15 Whilst this may sometimes
be due to the presence of protective
neuromuscular reflexes (which may
frequently be encountered amongst
patients with parafunctional habits), or
amongst cases where considerable occlusal
disharmony is present,7 there are a number
of additional factors that have been
described by Wilson and Banerjee that may
influence the ease with which CR may be
located.15 These include:
 The level of patient co-operation,
understanding of the process, state of
relaxation and head position;
 The operator’s level of experience and
training;
 The actual method used to locate CR;
 The time of day when the recording is to
be undertaken;
 Guidance of the mandible; and
 Neuromuscular conditioning.
A variety of ‘operator-guided
techniques’ for the manual manipulation
of the condyles (for dentate patients)
into the desired position recording of CR
have been described.15 The technique of
bimanual manipulation, as described by
Dawson, is frequently used and warrants
further appraisal.18 With this approach, the
patient should be comfortably seated in
the dental chair in a supine position, with
the operator seated directly behind. The
operator’s thumb and index finger of each
hand should be placed behind the angle
of the mandible and in front of the angle,
respectively, to allow the condyles to be
directed antero-superiorly. The middle
fingers should be bilaterally positioned
on the inferior border of the mandible,
the index fingers should be positioned
submentally in the midline and the thumbs
placed laterally to the symphysis.15 The
patient should then be instructed to relax
the jaw, and allow the operator to control
the jaw movements. The mandible should
1010 DentalUpdate
then be slowly and gently arced upwards the palatal surfaces of the anterior maxillary
and downwards with minimal force. The teeth and their antagonists, whilst the term
upward movement should then be gradually protrusive guidance is used to describe
increased until the first point of contact the effect stemming from the combined
is reached. If undertaken correctly, the influence of the condylar guidance
mandible will be hinged along its retruded (developed between the condyles, fossae
arc of closure; it may indeed be possible to and articular eminence during anterior
palpate this portion of the condyle by placing mandibular movement). The angle formed
a finger into the patient’s external auditory by the path of the moving condyles
meatus. within the sagittal plane compared with
It is important, however, to avoid the horizontal plane is referred to as the
the use of a forceful action with the above protrusive condylar angle and has been
technique, as it may inadvertently push the stated to be of the mean value of 45˚
mandible backwards towards a downward (within a range of 30˚ to 60˚).2
translatory movement, as well as result in Where the occlusal scheme
some level of mandibular flexion, overall is considered to be stable (‘mutually
culminating in an erroneous record as well as protective’), when the patient displays
in patient discomfort (resulting in resistance a protrusive mandibular movement,
to the applied load).15 the anterior guidance coupled with the
It is also worthwhile asking the inclination of the condylar path should
patient if he/she may be aware of the side of collectively aim to separate (or disclude)
the jaw where the first point of tooth contact the posterior teeth from each other (Figure
occurs in CR. The patient should then be 10), thereby avoiding any harmful occlusal
requested to squeeze the teeth together, with contacts which may otherwise culminate
the operator noting the direction of the slide in cuspal fractures, repeated restoration
of the jaw into ICP. The first point of tooth fracture, recurrent decementation of
contact can be marked up ideally using two indirect restorations, pathological tooth
different colours of GHM occlusal indicating wear or fremitus. This culminates from the
paper to mark up the slide from RCP to ICP. fact that the posterior teeth are closest to
In some cases, however (given the fulcrum, ie the TMJ where the forces are
some of the difficulties described above in the highest in a third order lever situation.
locating CR), the use of techniques such as In the position of maximum intercuspation,
those described above will not allow CR to be only light occlusal contacts should exist
properly determined and appraised. Under between the anterior segments, with
such circumstances, an alternative approach, occlusal loading primarily taking place
broadly involving the use of a variety of between the posterior teeth.
anterior de-programming devices, may The steepness of the anterior
prove helpful, which in general will aim to guidance provided by the anterior teeth
overcome the neuromuscular reflexes that are should also be evaluated (often described
initiated by tooth contact by causing tooth in the literature as being steep, moderate
separation and will also provide an anterior or shallow). The effect of altering the
reference point/stop to help stabilize the anterior guidance on the posterior dentition
mandible during the act of taking the record. must be carefully evaluated, especially
These devices and their clinical application to when the clinician may be contemplating
help identify and record CR will be discussed a macroscopically irreversible alteration
in the anterior guidance, such as during
at length in part 2.
the process of prescribing and providing
of multiple anterior crowns. Ideally, the
The dynamic occlusal anterior guidance should be shared
assessment between the anterior teeth to optimize
In relation to the dynamic stress distribution; however, this may
mandibular movements, it is important to not always be possible. Nevertheless,
assess the relationships during the lateral and care should be taken to avoid providing
protrusive jaw movements. protrusive guidance on a single tooth,
The term anterior (or incisal) especially that of a maxillary lateral incisor
guidance refers to the guidance provided to tooth.2 Clearly, however, the steeper the
the mandible by the contact formed between anterior guidance, the more likely it is that
December 2018

Figure 11. Canine-guided right lateral excursion.
Figure 12. The right lateral guidance in this
patient is supported by the patient's upper right
central, lateral and canine tooth. However, on
further excursion of the mandible to the right the
lateral occlusion will be just canine-guided.
Figure 13. In this patient the lower right second
molar has been restored with a metal ceramic
crown. This tooth is the only contact on the
working side when the patient moves into right
lateral excursion.
Figure 14. Shows an occlusal view of the crown
on the lower right second molar for the patient
shown in Figure 13. This crown had a working
side contact which was possibly an interference,
hence the fracture of the ceramic lingually.
December 2018
RestorativeDentistry
movement (Figure 12).
With reference to the condyle-
fossa relationships that take place during
the process of making a lateral excursive
movement, the principle movement within
the TMJs is on the non-working side (the
side away from which the mandible moves
Figure 15. For this patient there is a non-working
side contact on the lower right second molar in lateral excursion).19 During this action,
when the patient is in left lateral excursion. There the head of the condyle moves forwards,
is, however, no sign or symptom of occlusal downwards and medially. The angle of
disharmony and therefore this non-working side downward movement is referred to as the
contact is not classified as an interference. condylar angle, whilst the angle of medial
movement is referred to as the Bennet
angle.19 The latter has an average value of
7.5˚.2
posterior disclusion will take place. In the The movement that takes place
alternative scenario, however, in the presence at the working side (which is immediate)
of an incomplete overbite, there may be the is referred to as the immediate side shift or
delayed disclusion of the posterior teeth Bennett movement. The average level of
before the anterior teeth come into contact. lateral movement is approximately 1 mm.2
The orientation of the occlusal The effect of the presence of an immediate
plane will also influence the anterior side shift when undertaking restorative
guidance. In the case of a curved or steep rehabilitation of the posterior teeth has
occlusal plane (to the horizontal), posterior been detailed below.
tooth disclusion will take place less readily The presence of any occlusal
than in the case of a patient displaying a interferences (which may be considered to
relatively flat occlusal plane. The manner be undesirable contacts that occur between
by which an appropriate level of anterior opposing teeth in any mandibular position
guidance can be predictably determined which may cause mandibular displacement
when undertaking restorative rehabilitation on either the working side, the side towards
will be described at length in part 3. which the mandible moves during a lateral
In an analogous manner, the excursive movement, or non-working side,
lateral movement of the mandible is also the side away from which the mandible
influenced by the tooth relationships, as well moves in lateral excursion) should also
as the condyle-fossa arrangement during the be noted. When undertaking restorative
undertaking of such movements. The term rehabilitation involving a re-organized
‘working side’ is used to refer to the direction approach, in the ideal scenario, lateral
in which the mandible has moved during a guidance should be provided by the canine
lateral excursion; the other side being the teeth, with the absence of any occlusal
‘non-working side’. Lateral guidance to the interferences on either the working side
mandible may be provided by the canine or non-working side (Figures 13 and 14).
teeth – ‘canine guidance’ (Figure 11) or by However, it is important to appreciate the
multiple teeth, referred to as ‘group function’. fact that the presence of non-working
The morphology of the canine side contacts (when not associated with
tooth makes it a very suitable candidate to the presence of signs or symptoms of
provide guidance during lateral excursive pathology) does not necessarily constitute
movements, as discussed further below. the presence of an occlusal interference;
The presence of a canine-guided occlusion/ such contacts may be seen amongst
canine-protected occlusion helps to permit patients with malocclusions or natural
posterior tooth disclusion upon lateral occlusal schemes that do not otherwise
excursion, which may otherwise lead conform to the mechanical ideal (Figure 15).
to similar undesirable consequences as Non-working side contacts that
discussed above. Please note, a dynamic are, however, occlusal interferences, may be
relationship which may initially involve group associated with the presence of the signs
function may also be frequently observed, and symptoms of:2
but the presence of canine guidance may  Primary occlusal trauma, with increased
be noted with further lateral excursive tooth mobility without the presence of any
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 RestorativeDentistry
chronic periodontal disease;
 Secondary occlusal trauma, with increased
tooth mobility with the existing presence of
chronic periodontal disease;
 Pain or irreversible pulpitis in the absence eminence of the TMJ will have a notable
of any other clear cause;
 Palatal cusp fracture.
Excursive and protrusive contacts
can be marked using articulating paper;
ideally, they should appear smooth and
unbroken.13 It has been suggested that the
presence of an irregular, broken or dog-
legged appearance of the marked contact
relationship may be suggestive of an
interference on the tooth itself or, indeed, at
another location in the oral cavity.13
A number of alternative occlusal
schemes have also been described in
the literature, such as that of a balanced
occlusion (bilaterally balanced occlusion) or
unilaterally balanced occlusion. The former is
used to describe a relationship recommended
when undertaking complete denture
prosthodontics, to ensure denture stability
during dynamic movements. For further
details, please consult a reputable textbook
on complete denture prosthodontics.
Good quality, accurate paralleled
periapical radiographs may also be indicated
as part of the occlusal assessment. It is
important to establish the presence of any
signs of alveolar bone loss to help establish
a diagnosis. Other features that may also be
elicited upon radiographic evidence include;
the quality of the bone support, the presence
of any angular bone defects, the presence
of a widened lamina dura, the root surface
morphology, anatomy of the pulp chambers
of affected teeth, quality of pre-existing
endodontic treatment(s), presence of dental
caries, widening/disturbance of the lamina
dura, presence of retained roots or any signs
of periapical pathology (radiolucencies or
radio-opacities).8
The effect of the posterior
determinant − the TMJ and
associated structures
Hopefully, it now becomes
apparent that the anatomical relationship
between the condyle and the glenoid fossa
(particularly as the condyles move against the intercondylar width may also influence the
glenoid fossae) will have a marked influence means by which posterior teeth make contact
on jaw movement during mandibular
movements in differing directions (as will of therefore important that the intercondylar
course the teeth).
1012 DentalUpdate
The above can be seen and
described in relation to the making of a
protrusive mandibular movement, where
the steepness/inclination of the articular
impact (especially in the case of missing
anterior teeth/tooth contact or a shallow
anterior guidance) on the rate and level of
posterior tooth separation. Accordingly, in
a patient with a steep articular eminence,
posterior discussion will take place relatively
rapidly and to a relatively greater extent (than
in the case of a shallower eminence). This has
practical significance in relation to the design
of any posterior restorations or indeed for
the diagnosis of oral disease, whereby the
tolerance for longer cusps and steeper cusp
angles will be greater in the former scenario.
Conversely, if the eminence is shallow, the
cusps must be kept short to avoid clashing,
as the mandible is more likely to pursue a
horizontal pathway (in the case of a shallow
anterior guidance).3
The axes of rotation of the
condyles will also influence the morphology
of the occlusal table of the posterior teeth. In
order to permit the smooth passage of the
antagonistic teeth during a lateral excursive
movement, the cusps of the mandibular
teeth must pass through the buccal grooves
and marginal ridges of the maxillary teeth.
In the case of undertaking the restorative
rehabilitation of posterior teeth, the presence
of an immediate side shift (especially where
relatively more movement of the condyles
against the medial wall of the glenoid fossae
becomes possible) may require the clinician
to give further attention to the location of
the cusp tips and buccal grooves as the
smooth passage between opposing teeth
may not take place, often resulting in the
clashing of antagonistic cusps. Under such
circumstances, it would be appropriate
to maintain the presence of relatively
flat occlusal surfaces when undertaking
restorative treatment or, in some cases, there
may therefore be a need to ‘copy’ the existing
occlusal prescription, which can be done by
means of the use of a facebow record and
a customized guidance table, as discussed
further in part 3.
Analogously, the patient’s
during lateral excursive movements. It is
width is determined when using a dental
articulator to design restorations, which can
be done by means of the use of facebow
records, as discussed further in part 2.
The concept of the ‘ideal
occlusion’
From an orthodontic
perspective, the Angle's Class I relationship
is often considered as being ‘normal.’ As
part of this arrangement, the mesio-buccal
cusp of the maxillary first molar occludes
with the buccal groove of the mandibular
first molar, with an overjet and overbite
of 2 mm, respectively. However, from
the restorative point of view, matters are
somewhat more complex.
It is perhaps relevant at this
stage to draw distinction between the
concept of the ‘ideal occlusal scheme’
and that of a ‘correct occlusal scheme.’1
According Davies et al, an occlusal scheme
may be described at three levels:14
1. Tooth level;
2. Articulatory system level; and
3. The patient level.
In order to meet the
criteria of the ideal occlusal scheme, there
is the suggested need for the presence of
a multitude of precise features that would
be expected at each level so as to fulfil the
overall mechanical and neuromuscular
requirements. These features have been
listed in Table 2. It should be noted,
however, that much of the information
contained in relation to this ideological
concept is largely based on clinical opinion.
In contrast, an incorrect occlusal
scheme could be considered to be one that,
at the time of carrying out the examination,
would be suggestive of the presence of
occlusal dysfunction on the basis of the
presenting clinical signs and symptoms.
Such signs and symptoms may include:14
 TMJ dysfunction/disorders;
 Occlusal trauma;
 Recurrent tooth and/or restoration
fractures;
 Hypersensitivity and/or excessive tooth
surface loss.
However, it is common to
encounter patients who do not have any of
the above signs or, indeed, the presence of
an ideal occlusal scheme (Table 2), where
it may be perhaps improper to diagnose
the presence of an incorrect occlusal
scheme. Under such circumstances, for
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 RestorativeDentistry
a. At the ‘Tooth level’:
• Multiple simultaneous contacts
• No cuspal incline contacts
• Occlusal contacts that are congruent with the long axis of the tooth
• Smooth and, where possible, shallow contacts during mandibular guidance
b. At the ‘Articulatory system level’:
• Centric occlusion occurring in centric relation
• Freedom in centric occlusion
• The absence of any posterior interferences during dynamic movements, with anterior
guidance being provided at the front of the mouth
c. At the ‘Patient level’:
• An occlusal scheme that fits into the neuromuscular tolerances of patients at that point
of time in their life
Table 2. The features of an ideal occlusal scheme (adapted from Davies et al).14
instance where a patient may have signs
of some degree of TW and the lack of an
ideal occlusal scheme, caution needs to be
exercised in diagnosing the presence of an
erroneous occlusal scheme, and therefore
the temptation to prescribe invasive
treatment(s) as an attempt to attain the
mechanical ideals.
From a pragmatic perspective,
the concept of the mutually protected
occlusal scheme (MPO)20 is often applied
by many practitioners when considering
restorative rehabilitation (assuming the
absence of any crossbites, the presence of
a full complement of teeth, the presence
of an Angle's Class I occlusion and healthy
periodontal/alveolar support)3 or, indeed, as
a baseline to indicate mechanical stability.
The existence of the MPO scheme implies:
 In the intercuspal position (ICP), the
posterior teeth are axially loaded with
light occlusal contact present at the
anterior teeth, with the posterior teeth
effectively ‘protecting’ the anterior teeth
from excessive occlusal loading,21 with
1014 DentalUpdate
centric relation being co-incident with the
intercuspal position.3
 During dynamic mandibular movements
(protrusive as well as lateral excursive), the
anterior sextants (including all six anterior
pairs of teeth) provide guidance culminating
in the separation (disclusion) and protection
of the posterior teeth from unwanted (non-
axially directed forces),3 with shared/even
occlusal contacts during anterior guidance/
protrusive movements with the anterior
guidance being in harmony with the border
movements of the envelope of function.
 With a MPO, at the end of the chewing
stroke, only the posterior teeth come into
contact, providing the stops for vertical
closure and returning the mandible back to
the intercuspal position.3
Additional features that may be
desirable of a functional occlusion include:
 An RCP (retruded contact position) to ICP
slide of no more than 1 mm without any
lateral deviation.21
 Canine guided/canine protected occlusion
− a form of mutually protected articulation,
whereby the vertical and horizontal overlap
of the antagonistic canine teeth ensures
posterior disclusion during lateral excursive
movements, with planned group function
upon the loss of canine guidance (or where
the canine tooth may be unsuitable as
a guiding unit), and the absence of any
working or non-working side occlusal
interferences during the undertaking of a
lateral excursive movement.
A canine-guided occlusion
is relatively easier to accomplish from
a technical/clinical perspective when
undertaking restorative rehabilitation (as a
means of providing lateral guidance) when
compared with the scenario of mandibular
guidance being provided by a number of
posterior teeth on the working side (group
function), especially when aiming to ensure
that working aide and non-working side
interferences on lateral excursion are duly
avoided.22
Indeed, canine teeth (of good
health, form and bone support) are suited
to the role of absorbing occlusal forces, on
the basis of:
 Their favourable crown to root ratio;
 Root morphology (with a relatively longer
root offering a relatively superior root
surface area with relatively greater levels
of periodontal ligament attachment and
periodontal proprioceptors);22
 The anatomical form of a typical canine
clinical crown, often presenting with a
concave palatal surface − suggested to
be ideally suited to providing movements
during dynamic movements;22
 Their position in the arch as a ‘corner
stone’ with increased bony support; and
 Their favourable distance from the
‘fulcrum’ − the TMJ; thereby helping to resist
unwanted levering forces, which may be
encountered as the distance between the
point where the load is applied and the
fulcrum reduces.
However, it should be noted that
there is no substantial evidence to support
the notion of a canine-guided occlusion as
being superior to any other form of occlusal
scheme (such as that of group function).5
Furthermore, it would appear as if canine-
guided occlusal schemes (as opposed to
group function) only exist in about half
of the population; with group function
being more common amongst older
patients (likely to be accounted for by the
progressive wear of the canine teeth).13 It is
December 2018

Figure 16. In this patient it is possible to speculate that, following the wearing down of the canine
teeth, the premolars have come into contact during the right lateral excursive movement of the
mandible and therefore these teeth are exhibiting wear facets. Note cervical area of the upper right
first molar tooth.
Figure 17. The intercuspal position of a patient
with pathological tooth wear.
neither uncommon to find the presence of
canine guidance on one side of the patient’s
mouth and group function on the other or,
indeed, the presence of group function at
the start of the lateral excursive movement,
followed by canine guidance at the end of
the motion.2
It has, however, been suggested
by Eliyas and Martin that, in relation to the
management of a worn dentition of a dentate
patient, a mutually protective occlusion
or a canine-protected occlusion should be
considered as an appropriate and desirable
end point.22 The latter is of course based
on the assumption that the canine tooth
is suitable for this purpose. The manner by
which the above features can be predictably
incorporated into a patient’s occlusal scheme
when undertaking restorative rehabilitation
of a severe and/or pathologically worn
dentition will be discussed in part 3. Figures
December 2018
16 and 17 show examples where, following
tooth wear, the contact relationships have
been influenced during excursion and the
static relationship.
Conclusion
In part 1 of this series an attempt 15.
has been made to provide the definitions and
description of the terminology that is often
encountered when dealing with the subject 16.
of occlusion. Parts 2 and 3 will focus on the
application of the principles and further
elaboration of the clinical significance of the 17.
various components.
References
1. The Academy of Prosthodontics Foundation. The
Glossary of Prosthodontic Terms 9th edn.
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2. Milosevic A. Occlusion: 1. Terms, mandibular
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3. Rosenstiel SF, Land MF, Fujimoto J. Contemporary
Fixed Prosthodontics 5th edn. Oxford: Elsevier,
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4. Davies S, Gray R. What is occlusion?
Br Dent J 2001; 191: 235−245.
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