OCCLUSAL CONSIDERATION IN FULL MOUTH REHABILITATION57

Determination of occlusal morphology

The occlusal anatomy of the teeth functions in harmony with structures controlling the movement patterns of the mandible.
The structures that control mandibular movement are divided into two types:

Those that influence the movement of anterior portion of the mandible (Anterior controlling factor). Posterior teeth are
positioned between these controlling factors and thus can be affected by both to varying degrees.

Posterior controlling factor: (condylar guidance)

The two TMJs providing the guidance for the posterior portion of the mandible are largely responsible for determining the
character of the mandibular movement posteriorly.

The condylar guidance is considered to be fixed factor since in healthy patients it is unalterable. It can be altered, however
under certain conditions of the such as TMJ (Trauma, pathosis, surgical procedure).

Anterior controlling factor

Anterior teeth determine how the anterior portion of the mandible moves. As the mandible protrudes or moves laterally
incisal edge of the mandibular teeth occlude with the lingual surface of the maxillary anterior teeth.

Anterior guidance is considered to be not fixed but a variable factor. It can be altered by dental procedure such as
restorations, orthodontics, and extractions.

Vertical determinant of occlusal morphology :

Following factors that influence the height of the cusp and depth of the fossa are the vertical determinants of occlusal
morphology.

1. Anterior guidance
2. Condylar guidance
3. Nearness of the cusp to the controlling factor

Effect of condylar guidance and anterior guidance on cusp height:

The steeper the eminence, the more the condyle is forced to move inferiorly as it shifts anteriorly, Therefore it can be stated
that steeper angle of the eminence (condylar guidance) allows the steeper posterior cusp.

An increase in the horizontal overlap leads to decrease in the anterior guidance angle, less the vertical component of
mandibular movement and flattened posterior cusps.
An increase in vertical overlap produces an increased anterior
guidance, angle, more vertical component to the mandibular movement and steeper posterior cusps.

EFFECT OF BENNETT MOVEMENT ON CUSP HEIGHT:

Fig. 18 Effect of bennett movement on cusp height

During lateral excursion the orbiting condyle moves downward, forward and inward in the mandibular fossa around
axis located in opposite (rotating condyle).

Degree of inward movement of the orbiting condyle is determined by two factors.

-Morphology of the medial wall of the mandibular fossa

-Inner horizontal portion of the TM ligament

As the Bennett movement increases the bodily shift of the mandible dictates the posterior cusps to be shorter to permit
mandibular shift without creating contact between the maxillary and the mandibular posterior teeth.

shift without creating contact, between the maxillary and mandibular posterior teeth.

The lateral superior movement of rotating condyle will require shorter posterior cusps than with a straight lateral
movement. Likewise a lateral inferior movement will permit longer posterior cusps than with a straight lateral movement.

When the Bennett movement occurs early, a shift is seen even

before the condyle begins to translate from the fossa. This is called an
immediate side shift. More the immediate side shifts shorter the posterior
teeth

Horizontal determinants of occlusal morphology:

It includes the relationships that influence the direction of ridge

of grooves on the occlusal surface. Since during eccentric movements
cusps passes between ridge over grooves, the horizontal determinants
also influence the placement of cusps.
Effect of distance from rotating condyle and midsagittal plane on
ridge and groove direction.

Greater the distance of tooth from axis of rotation (rotating condyle) wider will be the angle formed by laterotrusive and
mediotrusive pathway

As the tooth is positioned further from midsagittal plane, the angle formed by the laterotrusive and mediotrusive pathways
will increase. The combination of the two positional relationships is what determines the exact pathway of the centric cusp
tips. Generally as the distance from rotating condyle increases, its distance from midsagittal plane decreases.

Bennett movement also influences the direction of ridges and grooves. As the amount of it increases, the angle between
laterotrusive and mediotrusive pathways generated by centric cusp tips increases.

As the inter condylar distance increases the distance between the condyle and tooth in given arch configuration increases.
This tends to cause wider angle between laterotrusive and mediotrusive pathways.

As the inter condylar distance decreases, a tooth is placed near the midsagittal plane distance. These tend to decrease the
angle generated.

The studies seem to indicate that the angle of articular eminence is not related to any specific occlusal relationships. In the
other words, the ACFS and PCFS are independent of each other. They are independent, yet they still function together in
dictating mandibular movement.

This is an important concept, since the ACFS can be influenced by dental procedure. Alteration of ACFS can play an
important part in the treatment of functional disturbances of the masticatory system.

Occlusal concept:

There are five concepts of'occlusion and articulation which are as follows :

1. "Gnathology as a basis for a concept of occlusion" as presented by Kaplan.

2. "What kind of occlusion should recuspated teeth be given”? presented by Stallard and Stuart.
3. "A a system based on rotational centers of the mandible as presented by De Pietro.

4. The P.M. philosophy of occlusal rehabilitation" as presented by Mann and Pankey.

5. "Transographics and the evaluation of the Transograph", as presented by Mid states odonto-occlusal symposium
represented by Messennan and Walsh.
It was impossible to include all concepts of occlusion by Messennan and Walsh
 1) Gnathology as a basis for concept of occlusion116

Gnathology is a study of temporomandibular joint movement, their selective measurement, reproduction and use
as determinants in the diagnosis and treatment of occlusion.

It was concerned with both static and dynamic occlusion. Their aim was to fabricate an occlusion in which there
would be multitudinous simultaneous contacts of the upper and lower cusps in centric as well as, in eccentric positions.

Bennett movement has been described in the following, manner center around which the lateral movement of the jaw rotate
lie back of the hinge axis, then in the lateral movements there is a definite side shift in the condyle heads, this is-known as
Bennett movement. If the centers of the lateral movements of the jaw lies in the hinge axis then (here is no side shift in the
lateral movements of the condyle

Bennett path influence on the cusps of the teeth

Envelop of motion is recorded posterior teeth should be arranged to encourage the envelop of motion through a lateral
excursion

Instrument used in taking the records is called the Gnathograph, the articulator to which records arc transferred is known as
the Gnathoscope. A bilateral balance is intended.

McCollum stated that temporomandibular joint, guides and controls the mandibular movements and they do not change
from childhood to old age.

Opening and closing axis is a moving axis that moves with the mandible. Completed occlusion must permit a rest position
without tooth contact.

Occasionally the rest position is decreased as part of a generalized increase in toxicity following thyroidectomy in
which parathyroid is injured and there is subsequent alteration of serum calcium levels. Centric occlusion should coincide
with the centric relation closure and should permit the lowest vertical dimension of the occlusion. The functional occlusal
and incisal surface should harmonize with occlusal determinants in the temporomandibular joint.

The anterior teeth should incise and shear without posterior interference.

Lateral anterior guidance should permit positive contacts of the posterior teeth during rotations through lateral excursions.
Lateral protrusive anterior guidance should prevent them

(2) Organic occlusion - Siallard & Stuart117

The salient features of this occlusion are -

Each upper lingual cusp occludes in a fossa of its lower fossa

Each lower buccal cusp occludes in a fossa of its upper fossa

The lower cuspids and incisors occlude in the fossae of upper cuspids and incisors respectively.
All the lower teeth close evenly against the upper teeth at the same time about the transverse intercondylar axis when jt is in
its rearmost position.

On the lateral diagostic position of the jaw, only the opposing cuspids make contacts. In the lateroprotrusive diagnostic test,
the lateral incisors may also enter into contacts along with the cuspids.

In the pure protrusive diagnostic closure the lower six anterior teeth make contacts with the upper incisors and the lower
first premolars' buccal cusp may touch the cusp of upper cuspids.

The fit of the cusps in fossae should be such that the lower teeth
reach centric closure and come to dead stops without sliding beyond or without having skidded on opposing teeth on the
way.

The plural cuspid teeth make occlusal contacts in the centrically related closure but none in the eccentric jaw positions. The
multicusped teeth are arranged by occlusion and alignment so that the lower lingual marginal occlusal edges and the upper
buccal marginal occlusal edges have no contacts in the centric closure, or in the eccentric positions of the mandible during
the chewing strokes.

Justification for this occlusion depended on how well the occlusion subscribes to physiology principles.

The occlusion should satisfy the 5 relations of gnathic system which are endodontic, periodontal, musculocondylar,
buccolingual, labiolingual.

3) A system based on rotational centers of the mandible118

An occlusal concept must be intimately co-related with the influencing factors of the temporomandibular articulation and
incisal guidance. Merely to conceive an occlusal concept and proceed to construct it without a complete understanding
concept to the logical system associated with mastication physiology does not and can't justify its existence.

De pietro suggested that mandible being able to rotate in three dimension and therefore "each condyle element must present
three rotational centers that form one. Since the condyle is an irregular body and since it bears against two other irregular
bodies while it rotates it cannot have a point center or rotation

Each condylar element must present. There rotational centers at a center or motion for each plane.

1. Horizontal centers
2. Sagittal centers
3. Vertical center
The path traced by the horizontal axis in protrusive movement is a curved path in 99.3% of cases. The
protrusive path is a travel in the above percentages of cases represent collinear transition and demand that a curved path
must be standard equipment on an articulation and it is to accuracy duplicate the protrusive movements.

Both these factors directly influences the morphology of the occlusal forms to be constructed

4. PANKEY-MANN philosophy of occlusal rehabilitation119

Initially diagnosis and complete treatment plan must be worked out on study casts mounted on two Hanau articulators and a
PM. Instrument. The lower is then rebuilt to the most ideal line and plane of occlusion on the P.M. Instrument

Incisal guidance, as described bv Schuyler, is next established by grinding and/or rebuilding the anterior teeth and finally
the occlusal surface of the upper posterior teeth are reconstructed using the functional generated path as described by
Meyer
Static contact in centric relation is established on as many teeth as possible, utilizing the basic principles of long-centric or
"free centric" occlusion. Make the patient more comfortable and allows for increased functional efficiency and health.
The important basic principle that functional centric occlusion is an area not a point.
P.M. theory believes that there should be a harmony of contact on all working incline of both anterior and posterior teeth as
determined by the patient’s incisal guidance.
No attempt is made to reconstruct posterior teeth to harmonize with protrusive inclines of these anterior teeth. The teeth on
the non-working side should not come in contact when the patient functions on the working incline
P.M. theory based upon the old Monson theory - In the Pankey-Mann concept, the terminal hinge position is recorded and
good imprint of the lower teeth is required when taking the face bow. In the P.M. technique only voluntary movements on
the horizontal plane are recorded. Neither functional nor voluntary movement in the frontal or sagittal planes is recorded.
Pankey-Mann believe that the technique described accomplishes the objective of oral rehabilitation better and in a
more practical way than other technique.

Many advantages result from completing the lower reconstruction before starting the work on the upper teeth .Discomfort
is minimized because only one arch is operated on at a time. We are able to complete the work on the lower teeth more
rapidly. So the patient is not required to wear temporary restoration for an extensive period of time. Correct orientation of
centric relation, occlusal vertical dimension and root relations are never lost. Functional generated path technique is used to
rebuild the upper posterior teeth.

The instruments used in the technique are not complicated. Only P.M. instrument is needed in addition to
conventional dental instruments. Extensive and complicated extraoral registrations of functional jaw movements are
eliminated.

5) Transographic and the Evaluation of the Transograph 119:

In 1951, a theory of occlusion known as transographics was presented to the profession. Transograph is an articulator that
duplicates all terminal jaw function in terminal functional orbit (TFO).

Terminal functional orbit is most critical area of closing stroke named by Dr. Theodore Messerman.

Transographics claims to study kinematic jaw function as the basis of articulation.

Transverse axis in one joint is completely independent of its make in other joint. So its proponents claim to have the first
patient for split axis.

In transograph Bennett movement was mechanical phenomenon instead of a physiologic phenomenon. Bennett movement
is result of the collateral bodily movement of the jaw in opening and closing. To incorporate Bennett movement in
transograph required pin-in-sleeve joints.
With rotation centers and their respective radius in all three dimensions captured and transferred to the transograph and
Bennett movement automatically included, the gross envelop of motion.

In transographic only the borders of the functional envelop which is well within the total envelope.

They regard centric relation as a static position of the condyles and mandible which is impossible to locate and even if
located, is impossible to transfer on the articulator. Transographic make use of hinge axis, cranial plane and hinge bite to
relate the casts on the articulator and copy kinematic jaw function. It was simple to make both occlusal curves automatic in
the transograph.

The antero-posterior occlusal carve is a product of the radii from the transverse axes to the individual teeth modified by the
mandible angle. V'ilson curve or transverse curve is a product of radii from the vertical and sagittal axis to the individual
teeth modified by the lateral borders ol the functional envelope.

With tridimensional radii already captured, the transograph needs only an adjustable angle between upright or ramus arms
and horizontal or mandible arms. These arms are adjusted to the subject's mandible angle.

In transographics the occlusal curve is a result of the combined

influence of hinge axis and the mandible angle plus the borders of the
functional envelop of motion.

Transograph should be simple, quick, consistently accurate in producing an equilibrated centric occlusion in combination
with "centric" or hinge relation.

Types of occlusion

Ideal occlusion can be defined as an occlusion compatible with stomatognathic system, providing efficient mastication and
good esthetic without creating physiologic abnormalities (Hobo, 1978).

Guichet45 (1970) described standards for ideal occlusion as following:

Criteria 1: Incorporate-in the occlusion those factors which have to do with reduction of vertical stress.

Criteria 2: Provide for maximum intercuspation of the teeth with condyles in centric relation.

Criteria 3: Provide for horizontal movement of the mandible from centric related intercuspal position, until those teeth
most capable of bearing the horizontal load come into function.

Accepted ideal occlusal scheme include balanced occlusion, mutually protected occlusion and group function occlusion.

1. BALANCED OCCLUSION45:

Balanced occlusion has all teeth contact in maximum intercuspation during eccentric mandibular movement.

Balanced occlusion refers to simultaneous tooth contact during eccentric movement (Scaife, Holt 1969). Lateral forces
generated during movement are shared by all teeth and temporomandibular joint (Granger 1954, Kaplan, 1963).
 Balanced occlusion

At the beginning of the century this type of occlusion was used in treatment of dentulous as well as edentulous patients.
MacCollum used balanced occlusion as an ideal occlusion for oral rehabilitation and accepted without question.

Lucia120 (1962) used balanced occlusion for twelve years for oral rehabilitations. However, after five to ten years few
patients developed abnormal condition with discrepancies between centric relation position and maximum intercuspation.

Lucia described the failure of balanced occlusion as follows :

The cusp-to-fossa relationship exists only in part of the molar contacts, bicuspid cusps function in the opposing embrasures,
making wedging and tooth drifting possible.

There are large areas of tooth contact and broad occlusal surfaces.

In such a "tight" occlusion, slight changes produce a readily visible discrepancy.

Errors in full-mouth balance are error on commission not omission.

When restoration is fully balanced, incision is frequently difficult..

In order to produce a full ballance, it may be necessary to increase the vertical dimension to a dangerous degree

Another criticism of balanced occlusion is that it is difficult to fabricate,

2. MUTUALLY PROTECTED OCCLUSION45

Where posterior teeth protect the anterior teeth in centric position. The centric stops on the posterior teeth also help prevent
excessive loading transferred to the TMJ structure (Ito et al 1980). The incisor protects the canine and posterior teeth during
protrusiye movement and canines protect the incisors and posterior teeth during lateral movements. (Lucia 1961, Hobo
1978,
 MUTUALLY PROTACTED OCCLUSION

Lucia120 (1961) describes the advantages as following: "Minimum amount of tooth contact is involved and this helps for
better penetration of the food. A cusp-to-fossa relationship produces an interlocking of the Upper and lower components,
thereby giving maximum support in centric relation in all direction .The force is closure to long axis of each tooth . The
arrangement of the marginal, transverse, oblique ridge is such that they have a shearing action which makes up for much
more efficient chewing apparatus.

All the lateral stresses must be resisted solely by therefore capability of the cuspid to withstand the entire lateral stress load
without any help from other teeth must be determined

The fact is that lateral stresses are minimal if the lingual contours are in harmony with the functional border movement. In
natural mutually protected occlusions the pattern of function is rather vertical so the mandible does not use lateral
movement that would subject the cuspid to stress in direction rather. Anatomic evidences to support the canine as key
element includes the good crown root ratio. Their long fluted roots, the amount of hard, compact bone surrounding the
tooth, and location far from the temporomandibular joint thus receiving less stress.

For simplicity mutually protection can be divided into two categories

1. Posterior disclusion by cuspid inclines that are in harmony with functional border movement

2.Posterior disclusion by cuspid inclines that restrict mandibular

movements within habitual functional movement

A mutually protected occlusion is contraindicated when the masticatory cycle is horizontal and peridontium is
compromised

Dawson18 (1974) stated that when canine cannot be used, lateral movement have posterior disclussion guided by
anterior teeth on the working side,instead of the canines alone. He called this the anterior group function.

LUCIA(1961) when anterior teeth are strong, a mutually protected occlusion is used.

GROUP FUNCTION OCCLUSION45 :

Schuyler (1929) introduced the fundamentals of group function occlusion.

 Group function refers to the distribution of lateral forces to a group of teeth rather than protecting those teeth from
contact in function by assigning all the forces to one particular tooth.

Group function occlusion has had broad support (Mann, Pankey 1960, Ramfjord and Ash 1966, Posslet 1968, Lauritzen
1974). %

Characteristics of group function occlusion include :

The theory of long centric

The concept of working side teeth sharing lateral pressure during lateral movement.

The concept of non-working side teeth free from contact during lateral movements.

In group function occlusion, lateral pressure are distributed to all working side teeth, in contrast to a mutually
protected occlusion where lateral pressure are directed only to the working side canine Schuyler felt all working side teeth
should bear lateral pressures during lateral movement by eliminating non working contacts.

Schuyler (1956) did not discuss the pressure difference on molars compared to anterior teeth.

Guichet77 (1970) stated that the lateral pressure on the canine is a I, proximately one-eighth that on second molars.
When sharing the load on the working side, molar bears a greater burden and not all teeth share the same amount of load.

Group function occlusion

Group function of working side is indicated .whenever the arch relationship does not allow the anterior guidance to do its
job of discluding the non-functioning side.

1. The anterior guidance cannot do its job in the following situations.

2. Class II occlusion with extreme overjet
3. Class III occlusion when all lower anterior teeth are outside of the upper anterior
4. Some end-to-end bites
 Group function occlusion does not have the harmful effect as seen with balanced occlusion and not as difficult to
fabricate as a mutually protected occlusion.

When using posterior group function the following rule applies contacting incline must be perfectly harmonized to border
movements of the condyles and the anterior guidance. Convex to convex contact cannot be used to accomplish this.
Posterior group function refers to allowing some of the posterior teeth to share the load in excursions while other contact
only in centric relation.

It tooth is weak laterally, it should contact in centric relation only. If a tooth is firm, let that tooth share the lateral stress
and wear.

There is no one type of occlusal form that is optimum for all patients. The first objective of occlusal form is proper
direction of forces So the starting point in designing occlusion contour is to shape and locate the centric contacts so that the
forces are directed as nearly parallel as possible to the long axes of both upper and lower teeth.

Second requirement of occlusal form, stability, the addition of more contact is often needed to fulfill this requirement

In the planning of occlusal contour for each individual patient, a major determination that must be made is concerned
with distribution of lateral stresses.

Clinician may elect to place all the lateral stresses on only one tooth or he may distribute the stresses over more teeth.
His choices range from cuspid-protected occlusion to group function of entire working side. His selection of which type of
occlusion to use should be based on individual clinical factor rather than technique-oriented concept.

There are three basic decisions to make regarding the design of posterior occlusal contours.

1. Selection of the type of centric holding contacts.

2. Determination of the type and distribution of contact in lateral excursions

3. Selection of most practical method of providing stability to the occlusal form.

Types of centric holding contacts 18

There are three basic ways by which centric contact is usually established.

1. Surface-to-surface contact
2. Tripod contact
3. Cusp tip-to-fossa contact
1.surface-to-surface contact (Mashed Potato Occlusion) :

It is stress full and produces lateral interferences in anything other than near vertical chop-chop function. There is never any
valid reason for using this type of contact
 SURFACE TO SURFACE CONTACT

2.Tripod Contact:

In tripod contact the tip of the cusp never touches the opposing tooth. Instead, contact is made on the sides of the cusps that
are conversely shaped.

Tripod contact can be done as long as the anterior teeth are capable of discluding the posterior teeth in all excursion.

TRIPOD CONTACT

For patients whose functional movements, anterior periodontal support, arch relation and tooth position are best
served by posterior disclusion, tripod contact can be very comfortable functional and beautiful to behold.

Tripod contact-should not be used when lateral stress distribution is best served by including posterior teeth into group
function to help out weak or missing anterior teeth or when the arch relationship does not permit anterior guidance to do its
job.

It is more difficult to achieve, is hard to adjust and its limited in its use

4. CUSP TIP TO FOSS CONTACT

This type of occlusion offers excellent function and stability. it is the easiest occlusion to equilibrate. Resistance to wear is
excellent. Location of the cusp tip-to-fossa contact decided according to the best interest of each tooth on the basis of
direction offers as near parallel to the long axis of each tooth as possible and stabilitity without interference to eccentric
movements.

CUSP TIP TO FOSSA CONTACT

Selecting the occlusal form

Assuming the cusp-fossa relationships are correctly placed for ideal direction of stress. Number of contacting cusps
that are needed for maximum stability under different conditions must be decided.

Four basic types to choose from in normal arch relationships.

Type 1:

Lower buccal cusps contact upper fossae. There are no other centric contact working side excursive function is limited to
the lingual inclines of upper buccal cusp.

It is easiest to contour to fabricate when restoring posterior teeth. Only disadvantage to this type of occlusal
relationship is its lack of dependable buccolingual stability. It is an acceptable choice of occlusal form whenever
buccolingual stability has been assured bv splinting. Fig. 25.1

LOWER BUCCAL CUSPS CONTACT UPPER FOSSA, THERE ARE NO OTHER CENTRIC CONTACTS

Type 2 :
Centric contact on the tips of lower buccal cusps and upper lingual cusps. Working side excursive function is limited to the
lingual inclines of the upper buccal cusps. There is no excursive function on any lower incline.

It is comfortable and functional and its stability is as good or better than any other type of occlusal relationship. It fulfils all
the requirements of good occlusal form

CENTRIC CONTACT ON TIPS OF LOWER BUCCAL CUSPS AND UPPER LINGUAL CUSPS

Type 3:

Centric contacts on tips of lower buccal cusps and upper lingual cusps. Working excursion contact is limited to the lingual
incline of upper buccal cusps and buccal incline of lower lingual cusps.

Fig. 25.3 Centric contact on tips of lower buccal cusps and upper lingual cusps.

This type of occlusal contour is identical to type two except that the buccal incline of the lower lingual cusp becomes a
functioning incline. Only disadvantage of type 3 occlusal form is complexity of fabrication.

Type 4:

Tripod contact. There are two types of tripod contact:

1) Contact on the sides of cusp and walls of fossa : It was contraindicated for any patient who requires a "long centric".
 It may be used in vertical or near vertical functional cycles with either cuspid protected occlusion or anterior
protected occlusion. Tripod contact is most difficult of all occlusal forms to fabricate.

2) Centric contact on the brims of fossae and top of wide cusp tips with no contact in eccentric excursions. This type of
tripod contact can be made to function with any type of anterior guidance because if permits horizontal lateral movement
without interference. It cannot be used when posterior group function is indicated. There are several types of occlusal form
that can be used to restore posterior teeth .whatever contour is selected should be chosen because it.

contact on the sides of cusps and the wails of fossae

Centric contact on the brims of the fossae: and the top of wide cusps tips with no contact in eccentric excursions

1. Direct the lateral stress to as possible to the long axis of each tooth
2. Distributes the lateral stress to maximum advantage in varying situations of periodontal support.
3. Provide optimum stability
4. Provide optimum wearabilitv
5. Provide optimum function for griping and grinding.

Practicability of fabrication is a factor that should be considered when selecting effort and expense are required to produce
the same clinical result that can be accomplished with greater ease of the patient, and all probability taken the place of goal
orientation.