CRA~NXO~MANT>KBULAR FUNCTION AND DYSFUNCTION

SEC’I,lN EI)I’ICR

GEORGE .4. ;‘AIII

The influence of anterior coupling on mandibular

movement
Mark 0. Brose, D.D.S., M.S.,* and Robert A. Tanquist, D.D.S.**
Ohio State University, College of Dentistry, Columbus, Ohio

A nterior restorations are often designed with empha-

sis on esthetics and on the longevity and handling
REVIEW OF THE LITERATURE
Historically, anterior guidance was either overlooked
characteristics of the materials from which the restora- or ignored by early writers and researchers. Shaw’ and
tions are made. Although esthetics and choice of dental Friel,’ writing for orthodontists in the 192Os,recognized
materials are important, emphasis should be placed on the esthetics and maximum shearing ability of the
the functional relationship between the palatal surfaces blade-shaped anterior teeth that had a vertical and
of the maxillary anterior teeth and the incisal edges of horizontal overlap. They did not, however, relate this to
the mandibular anterior teeth. an incisal guide angle and its role in posterior disclusion.
Successful treatment of patients needing extensive Shaw’ noted that “an edge-to-edge relationship was
restorative procedures requires an understanding of the inefficient for shearing food.” An edge-to-edge relation-
combined effect that anterior teeth and the temporoman- ship also renders the anterior teeth ineffective as a
dibular joints (TMJ) exert on mandibular movement. guiding and stabilizing influence for lateral and protru-
To treat mandibular movement therapeutically, changes sive mandibular movements. Such a relationship also
that involve the structures affecting it must be made. prevents the anterior teeth from acting as discluders of
Although mandibular pathways cannot be altered con- the posterior teeth. Disclusion is thought to protect the
servatively, inhibited mandibular movement can be posterior teeth from the lateral forces of direct tooth
released by changing the proprioceptive influences from contact in eccentric excursions.
the posterior teeth and by coupling the anterior guidance Gradually, the concepts, methods, and articulators
with the functional temporomandibular pathways. Ante- used in complete denture construction were adapted for
rior guidance is a dynamic relationship observed in the the reconstruction of natural dentitions.‘-” The adapta-
normal arrangement of the natural dentition. tion was gradual, but progressive until it was realized
Because separation of the posterior teeth by the that these concepts needed modification before they could
canines and incisors produces an immediate relaxation of be applied to the reconstruction of a natural dentition.
the masseter and medial pterygoid muscles, the potential During the 1920s and 1930s the McCollum Gnatholog-
for excessive and lateral loading of the teeth and TM J is ical Study Group studied and defined the condylar
eliminated. If the premolars and molars contact because control of mandibular movement.‘2 In the early develop-
of a nonexistent or deficient anterior coupling, these ment of their treatment philosophy, Mann and Pankey13
powerful closing muscles continue to contract during accepted the Monson l4 theory of a spherical basis for
function and parafunction.‘-4 This common observation human occlusion and combined this theory with Mey-
in patients with myofascial pain is the rationale for er’s15functionally generated path technique for develop-
therapeutic devices that change the occlusal scheme to ing occlusal form. Schuyler16 later realized that the
bring relief.5, 6 guidance created by the vertical-horizontal overlap of the
This article will (1) describe the relationship of anterior teeth affected the shape and height of the
anterior guidance to TM J movement pathways, and (2) posterior cusps in complete denture construction. He did
recommend clinical guidelines and occlusal considera- not, however, recognize its importance in protecting
tions for enhanced functional harmony without compro- posterior teeth in a natural dentition. When Stuart
mising the esthetics of the maxillary anterior teeth. introduced his fully adjustable articulator and the man-
dibular movement recorder in the 195Os, anterior guid-
ance was identified and appreciated for its importance,
Presented at the Carl 0. Boucher Prosthodontic Conference, Colum- mostly as a result of Schuyler’s” work.
bus, Ohio. Although Schuyler is identified with the Pankey-
*Assistant Professor, Department of Restorative and Prosthetic Den-
tistry. Mann group, whose treatment philosophy often con-
**Associate Professor, Department of Restorative and Prosthetic flicted with some gnathologists, the Pankey-Mann
Dentistry. group and the gnathologists agree that both the anterior

THE JOURNAL OF PROSTHETIC DENTISTRY 345

 BROSE AND TANQUIST

Fig. 2. Incisal guide angle is less than angle of condylar

path. An “anterior open bite“ relationship results dur-
Fig. 1. Incisal guide angle is greater than angle of ing protrusion (inset). Note the 30-degree dotted line
condylar path. Incisors will provide molar separation that mandibular incisors would follow if molars and
during eccentric movements. condyle paths did not dictate otherwise.

and condylar guidances control mandibular move- affects the occlusal form of each posterior tooth. Ideally,
ment.‘8,‘9 in a normal skeletal relationship, the height and slope
As the various occlusion treatment philosophies have angles of the cusps of the posterior teeth should be
matured, they have become similar in their treatment harmonious with the condylar and anterior guidances.
alterations of the anterior teeth. Each treatment philoso- Where such harmony does not exist, the teeth can be
phy expects to achieve physiologic and biologic equaliza- reshaped to a more desirable contour by adjusting or
tion of stressesimparted by functional and parafunction- restoring them to eliminate trauma and lessen the
al movements. Whichever occlusal restorative philoso- harmful effects of parafunction.
phy is followed, the angle and directions of anterior
guidance must be steeper than the anatomic condylar COMPARISON OF REHABILITATIVE
guide angles and directions to provide the desired TREATMENT PHILOSOPHIES
separation of the posterior teeth during excursive move- The two dominant occlusion groups, Pankey-Mann
ments (Figs. 1 and 2). Unless group function or bilateral and gnathology, differ in the sequencing of procedures
balance is arbitrarily desired, posterior separation must leading to the establishment of the anterior control. The
be observed and evaluated when restorations are being early Pankey-Mann philosophy developed the anterior
planned, before they are inserted, and when they are guidance arbitrarily as the initial step in the restorative
adjusted. procedure. It then used this arbitrary guidance to serve
Anterior guidance is the dentist-variable determinant as the anterior vertical stop and as the individually
for influencing mandibular excursions (Fig. 3). By customized inclination for developing the functionally
knowing the effects of anterior tooth form on mandibular generated posterior occlusion.‘3a’4 The posterior occlu-
movement, the dentist can control the contour of the sion was then harmonious with the anterior teeth in all
palatal surface of restorations for maxillary anterior excursions. Working-side group function was estab-
teeth. Mandibular movements are affected by the inter- lished, with disclusion on the balancing side and in
relationships of (1) TM J anatomy, (2) immediate and protrusion to minimize stress on any one tooth.lR An area
progressive side shift, (3) habitual neuromuscular func- of centric relation (“long” centric) occlusion was cre-
tion patterns, (4) horizontal and vertical overlap of the ated.
anterior teeth, and (5) the postural position of the head. This technique produced a sliding contact on the
Only the relationship of the anterior teeth is operator- anterior teeth that continued from the centric relation
controlled. Habitual neuromuscular function might be occlusion position to full protrusive position. More than
reprogrammed.” 50 years ago, House” observed the effects of a bilaterally
The coupling of the anterior guidance and the TMJ balanced natural occlusion on the stomatognathic sys-

346 MARCH 1987 VOLUME 57 NUMBER 3

INFLUENCE OF ANTERIOR COUPLING

Fig. 3. Anterior coupling can be shown by observing a

sagittal view of Posselt’s envelope of motion. Anterior
guidance is tooth contacting portion of envelope of
motion. AG, Anterior guidance; EE, edge-to-edge posi-
tion; IP, intercuspal position; BP, retruded contact posi-
tion; Y, rest postural position; and h, habitual (closing)
path.

tern. He found that this constant contact of the tooth

surfaces in all excursions demonstrated more rapid wear.
This finding was supported by observations of Stallard
Fig. 4. Edge-to-edge contact of anterior teeth provides
and Stuart2’ that this occlusal wear produced interfer- separation of posterior teeth equal to vertical overlap of
ences that further contributed to parafunctional activity.’ anterior teeth. Central incisors alone, A, or four maxil-
Electromyographic studies have since confirmed and lary incisors, B, can provide vertical stop in this posi-
aided understanding of this phenomenon.2 tion.
The Pankey-Mann group has modified many of its
principles through the years as it has followed up its
patients and refined treatment procedures. Changes
include a significant shortening of the previously recom-
mended “long centric” relation occlusion.22
Early gnathologic rehabilitations incorporated a bal-
anced occlusion. As gnathologists observed the effects of
balanced occlusion on posterior tooth surface wear and
on the neuromuscular bruxing response, they also recog-
nized the need for modifications. As the gnathologic
treatment philosophy matured, an anterior guidance
steeper than the condylar guidance was determined to be
necessary to eliminate all but vertical forces from the
posterior teeth.23,24
The gnathologists prefer to record condylar border Fig. 5. Arcs formed during hinge opening are greater
movements by using precise instrumentation. As the anteriorly than posteriorly. Note that for any given
occlusal scheme is developed, disclusion from centric amount of anterior guidance, a proportionately lesser
amount of posterior separation is produced.
relation occlusion is provided in the lateral and protru-
sive excursions by anterior coupling. A precise occlusal
contactz4 is developed on the posterior teeth with a
0.0005-inch freedom of contact between the anterior posterior teeth is to support the vertical occlusal forces
teeth.25,26If possible, a canine-only disclusion is recom- and maintain the vertical dimension of occlusion. This is
mended with the incisors and posterior cusps clearing in termed a “mutually protected” occlusion in which the
all lateral excursions. The incisors provide disclusion in various segments of the arches guard each other from
protrusive movement with the canines and posterior receiving forces they are not designed to with-
teeth clearing (Fig. 4). The prime function of the stand.20s” 27

THE JOURNAL OF PROSTHETIC DENTISTRY 347

 BROSE AND TANQUIST

ANGLE CLASS II

Fig. 7. With large horizontal overlaps of anterior teeth,

Fig. 6. Absence of vertical overlap of anterior
teeth a complex restorative problem necessitates short, flat
eliminates molar separation during excursive move- cusps for excursive freedom before lift-off. Anterior
ments. Flat cusps and shallow fossae will minimize coupling is not possible without orthodontic or surgical
interferences during excursions. intervention.

Table I. First molar cusp heights at various incisal edge measurements

Incisal edge
Incisal edge horizontal overlap (mm)
vertical overlap
(mm deep) 1 2 3 4 5 6 (extreme)

(4.30) 6 3.80 3.4 3.00 2.70 2.40 2.15

(3.60) 5 3.13 2.70 2.16 2.00 1.80 1.60
(2.90) 4 2.41 1.80 1.65 1.45 1.24 1.07
(2.14) 3 1.70 1.33 1.07 0.70 0.61 0.46
(1.40) 2 1.00 0.70 0.50 0.40 0.32 0.30
(0.70) 1 0.35 0.25 0.15 0.11 0.10 0.07

Numeric values shown in this table are the maximum molar cusp heights possible at various amounts of vertical and horizontal overlap. Values in
parentheses are derived from Woelfel’s measurementG8 showing the 0.7: 1 ratio between molar and incisal openings with no allowance for
side-shift.

FACTORS AFFECTING OCCLUSAL TOOTH Horizontal and vertical overlap relationships of the
FORM anterior teeth play a significant role in the posterior
Vertical and horizontal overlap functional relationships of cusps and fossae. If horizontal
In the natural dentition, the cusps decrease gradually overlap, at a predetermined vertical overlap, is little or
in height and size from the canines to the third molarP none, the posterior cusps may be longer and the fossae
(Fig. 5). To produce a harmonious articulation, posteri- deeper because the lift-off is immediate. As the horizon-
or cusp heights can be modified only by appropriately tal overlap increases, the posterior cusps must become
changing the vertical and horizontal overlap of the shorter and the fossae more shallow to prevent interfer-
anterior teeth and/or the vertical dimension of occlu- ence in eccentric movements.
sion.29 Assuming an acceptable vertical dimension of The amount of vertical overlap of the anterior teeth
occlusion, the only alterable factor of the envelope of also affects the posterior cusp length and fossa depth-
motion is the border movement dictated by the palatal the greater the amount of vertical overlap, the longer the
contours and incisal edges of the maxillary incisors when cusps and the deeper the fossae may be. Woelfel et a1.32
contacted by the mandibular incisal edges30(Fig. 3). measured 25 natural dentitions and found that 1 mm of
Many writers agree that the ability to alter the incisal hinge axis opening in the first molar region requires 1.4
guidance makes the anterior control the most important mm of incisal opening. Conversely, the absence of
factor in developing occ1usion.8~I62“3 “5 3’ vertical overlap of anterior teeth requires short cusps and

348 MARCH 1987 VOLUME 57 NUMBER 3

INFLUENCE OF ANTERIOR COUPLING

Fig. 8. Bulbous crowns show overcontoured, convex lingual surface on A, maxillary

incisor crowns and B, canine crown.

Table II. Effects of immediate side-shift

Maxillary anterior Maxillary/mandibular posterior occlusal
Immediate side-shift palatal cavitv morphologv

Little (1 mm or less) Minimum May have steepercusps;deeper fossae

Average (1-2 mm) Average anatomic form Average anatomic form
Great (2 mm plus) Maximum Must have flatter cusps; shallower and wider fossae

Table indicates the effect that the amount of immediate side-shift has on maxillary anterior palatal and posterior occlusal tooth form. An
inverse anterior-posterior tooth form relationship exists according to the amount of side-shift present.

shallow fossae to prevent eccentric contacts of posterior of the maxillary anterior teeth. With flatter eminentiae
teeth because no anterior lift is provided by the anterior angles, the separation in the molar region is slower and
teeth during excursive movements (Fig. 6). Further the excursive movements are directed more forward or
complexities are introduced when there is a combination horizontally for each millimeter of opening.24a25
of steep vertical overlap with considerable horizontal
overlap as in retrognathic relationships (Fig. 7 and Immediate side-shift
Table I). When the mandible moves laterally without tooth
contact, it follows a path influenced by the down and
Eminentia forward excursion of the orbiting (balancing) condyle
When properly coupled with the anterior teeth, the and the composite rotation and complex outward move-
slopes of the eminentia have a definite effect on cusp ment of the working condyle. This excursive path is
height and fossa depth of posterior teeth and on the unique to each individual, exhibiting an immediate
palatal inclines of the anterior teeth. Steep angles of the and/or progressive side-shift. This side-shift cannot be
eminentia permit longer cusps and deeper fossae of the observed clinically but can be recorded and visualized in
posterior teeth and a shallower concavity of the palatal a pantographic tracing or in a stereographic analog
surfaces of the anterior teeth because the eminentiae recording. Immediate side-shift is thought to be the most
provide for rapid separation in molar regions upon important factor in determining posterior fossa depth
mandibular movement. Flatter angles of the eminentiae and width and the contour of the palatal concavities of
require shorter cusps and shallower fossae of the poste- the maxillary anterior teeth.24,33,34Immediate side-shift
rior teeth and a deeper concavity of the palatal surface3 requires that the fossae be wide enough to permit the

THE JOURNAL OF PROSTHETIC DENTISTRY 349

 BROSE AND TANQUIST

Fig. 11. Interferences (A) and adjusted contours (B)

with head tipped 30 degrees forward.

Fig. 12. Shaded areas are those most commonly

adjusted when perfecting occlusal scheme into a cou-
pled relationship without interferences.

Fig. 9. Overcontoured lingual surface of maxillary CLINICAL APPLICATION

anterior crowns cause A, wear facets in opposing teeth Treatment planning
and B, severe reduction of incisal edges of mandibular Following a complete patient examination, treatment
anterior teeth.
planning should include incorporation or refinement of
anterior coupling. An occlusal restoration or alteration of
EFFECT OF POSTURAL POSITION ON THE
existing occlusion is specific to each individual. Occlu-
HABITUAL CLOSING PATH OF THE MANDIBLE sion should include (1) a stable centric relation-centric
A h /n
occlusion closure, (2) a vertical dimension of occlu-
sion in harmony with rest position, (3) anterior disclu-
sion, and (4) consideration for existing side-shift. Selec-
tion of the occlusal scheme should be consistent with a
patient’s needs. Whether for mutually protected occlu-
sion or for group function, however, the scheme must
assure that the treatment produces no interferences with
anterior guidance and that a harmonious occlusion
30°FOAWAHD results.
Extensive occlusal rehabilitation and development of
IJPRIQHT
anterior coupling must be carefully planned on an
Fig. 10. Effect of posture on mandibular physiologic appropriately set adjustable articulator with properly
rest position (0). mounted casts. A customized incisal guide table as
described by McHorris36a 37 is. used to reproduce and
transfer the diagnostically determined anterior guidance
cusps functioning in them to move laterally before they to working casts. Modification of acrylic resin provision-
are lifted out. It also requires that the posterior ridge and al restorations and interim metal castings have been used
groove directions provide an escape pathway without successfully by Schweitzer38x39and others.29 Another
interferences.35 The greater the extent of the immediate method uses composite additions modified to accommo-
side-shift, the more palatal concavity must be provided in date excursive movements.
the anterior teeth to permit their harmonious functioning
without “locking in” the posterior occlusion (Table II). Treatment outcome
Existing side-shift is a nonalterable occlusal determinant Most anterior restorations require adjustment when
with each patient, the extent of its effect depending upon the restoration is fitted to the prepared tooth. These
the food bolus and the masticatory effort required to adjustments may be needed because of (1) articulators
reduce it.3’,3 that do not simulate an accurate closing hinge arc, (2)

350 MARCH 1987 VOLUME 57 NUMBER 3

INFLUENCE OF ANTERIOR COUPLING

Fig. 13. Eccentric positions shown are protrusive, A; right quartering, B; and right
lateral, C. Note that more incisors are in contact in quartering position.

arbitrary hinge axis mountings, (3) absence of face-bow Clinical adjustment of anterior guidance
transfer procedures, (4) underpreparation of teeth The functioning surface of the concavity of the maxil-
resulting in premature contact at maximum intercuspa- lary incisors nearest to maximum intercuspation can be
tion, (5) the covering of the palatal surface of the metal evaluated and adjusted intraorally by using the method
casting with excessive porcelain, (6) cast-positioning described by Moh1.42 His observation recognizes the
error that resulted in a greater anterior error because of effects of postural position on the habitual path of
its greater distance from the hinge axis (Fig. 5), and (7) closure of the mandible42z”” (Fig. 10). When the head is
the common practice of overbuilding restorations tipped backward, physiologic rest position and the
because it is easier to reduce than add restorative unguided path of closure approach the hinge-axis border
material when inserting the restorations (Fig. 8). path of closure. 30.44This phenomenon is commonly used
Excessive steepness of restored maxillary anterior when recording centric jaw relation. As the head is
palatal surfaces or distortions in the contour of maxillary progressively tipped forward, the physiologic rest posi-
palatal marginal ridges and fossae may interfere with tion migrates forward and the unguided path of closure
the functional side-shift pathway and lock the occlusion of the mandibular incisors approaches, and they may rub
in one or more eccentric position2’ (Fig. 8). Heavy wear against, the palatal surfaces of the maxillary anterior
of the opposing teeth may also result4’ (Fig. 9). teeth, which is an interference near maximum intercus-
An immediate side-shift will require a specific modi- pation. The closing path found with the head inclined 30
fication in the contour of the palatal incline of the degrees forward can be used in adjusting the palatal
maxillary canine. This modification prevents trauma contours of the maxillary incisors. Adjustment is made
from a heavy contact during chewing action near the until the mandible closes on the habitual closing path
centric relation-centric occlusion. When performing an into maximum intercuspation without anterior interfer-
equilibration or an insertion adjustment for a restora- ences6(Fig. 11). This provides the freedom that Daw-
tion, the heavy contact resulting from immediate side- sonz2described as “long centric.” Lundeen4’ referred to it
shift can be detected by evaluating fremitus at centric as the “area of horizontal freedom between maximum
relation-centric occlusion and at the beginning of the intercuspation and anterior lift-off.” StuartI described
lateral or lateral-protrusive excursion4’ the collective palatal surfaces of the maxillary anterior

THE JOURNAL OF PROSTHETIC DENTISTRY 351

 BROSE AND TANQUIST

Fig. 14. Left quartering test position is used, A, to verify anterior guidance in
unrestored dentition, B, to determine relative lengths of incisors and canine when
adjusting a new restoration, and C, to compare relative lengths of restored incisors to an
existing unrestored canine.

teeth as “one large fossa in which the six mandibular In straight protrusive excursion, ideally, the mandible
anterior teeth function as a (single) large cusp.” The is supported by the TM Js and an even contact between
contours are determined by the condylar pathways and the six contacting incisors. In right and left lateral
the teeth must move eccentrically in harmony with the excursions, the mandible is supported by the TM Js and
TMJ. one pair of opposing canines (Fig. 13, C). On the
Anterior guidance can be altered clinically once neu- horizontal arc between these positions the contacts
romuscular relaxation has been assured9 (Fig. 12). progressively change from the six contacting incisors to
Incisal-edge alterations must permit the mandible to the two opposing central and two opposing lateral
glide smoothly from a median protrusive position, incisors, and finally to the canines only (Fig. 13).
through quartering, to a full lateral excursive position Adjustment of the incisal edges in the natural or restored
without posterior tooth interferences46 (Figs. 13 and 14). dentition to this series of contacts will relate condylar
“Quartering” is an edge-to-edge position the mandibu- guidance and posterior tooth separation to anterior tooth
lar anterior teeth assume when the mandible is halfway length and esthetics.
between straight protrusive (Fig. 13, B) and extreme
lateral excursion (Fig 13, C).* Although interferences in SUMMARY AND CONCLUSIONS
quartering should be removed, disparate anterior tooth The need for and use of anterior coupling in occlusal
lengths are not necessarily interferences unless one or rehabilitation has been discussed. The anterior teeth can
more teeth are traumatized. The horizontal concave often be coupled to the posterior controls by modifying
palatal contour may also need reshaping if mandibular contours with selective grinding, full or partial coverage
side-shift is extensive.“,” The correct contours avoid the restorations, or composite. When anterior guidance is
application of pathologic stresses to one or more of the provided, the anterior teeth should harmonize with the
opposing anterior teeth during function and parafunc- TMJs so that the posterior teeth will disclude in
tion (Fig. 3). excursive mandibular movements. Significant function-
al, esthetic, and phonetic alterations that change the
*Tanner H: Personal communication, Postgraduate lectures, Univer- anterior guidance must be carefully planned because the
sity of Southern California, Los Angeles, Calif., 1963-64. anterior guidance affects all excursive tooth contacts.

352 MARCH 1987 VOLUME 57 NUMBER 3

INFLUESCE OF ANTERIOR COUPLING

Anterior coupling, as described, is often an overlooked 22. Dawson PE. Evaluation, diagnosis, and treatment of occlusal
problems. St Louis: The CV Moshy Co, 1979;78.
entity in restorative dentistry. Evidence of its role in
23. Kepron D. Experiences with modern occlusal concepts. Dent
separating the posterior teeth, reducing parafunctional Clin North Am 1971;15:595-610.
activity, and harmonizing the temporomandibular com- 24. Lucia VO. The gnathological concept of articulation. Dent Clin
plex has been presented. North Am 1962;15:183-97.
25. H&man R, Regenos J. Principles of occlusion. 8th ed. Colum-
We arc grateful to Drs. Ralph H. Rosenblum and Julian B. bus, Ohio: H & R Press, 1980.
Woelfel, The Ohio State University, College of Dentistry, for their 26. Walker PM. A technique for the adjustment of castings in a
editing assistance and encouragement. We also thank Mrs. Amy Boye remount procedure. J PR~STHET DENT 1981;46:263-70.
and Mr. Ralph Ulhrich, Visual Aids Department, College of Dentist- 27. Stuart CE. Divergent concepts in case planning and treatment.
ry, and his. Mitzi Presser, Biomedical Communications Division, Fortnightly Review of the Chicago Dental Society, Sept 1,
School of .\llied Medical Professions, The Ohio State University, for 1962.
their assistance in producing the drawings and photographs. 28. Contino RM, Stallard H. Instruments essential for determining
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