Philosophies of Occlusion for Implants

Implant Occlusion Single Crown Single Crown Fixed Partial Dentures Fixed Partial Dentures Full arch prostheses (screw retained) Full arch prostheses (screw retained) Overdentures Overdentures Single Crown Single Crown Fixed Partial Dentures Fixed Partial Dentures Full arch prostheses (screw retained) Full arch prostheses (screw retained) Overdentures Overdentures

Many Philosophies of Occlusion No definitive scientific studies to prove:  one type of tooth form  one type of occlusal scheme  to be clearly preferred by patients  to be more efficient than another No definitive scientific studies to prove:  one type of tooth form  one type of occlusal scheme  to be clearly preferred by patients  to be more efficient than another

Tooth Forms Occlusal Schemes Anatomic Anatomic Non Anatomic Non Anatomic Anatomic Anatomic Non Anatomic Non Anatomic Canine Guidance (Mutually Protected) Group Function Lingualized (Balanced) Monoplane Canine Guidance (Mutually Protected) Group Function Lingualized (Balanced) Monoplane

Denture Tooth Forms and Occlusal Forms

Occlusion & Implants Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94: No Preferred occlusal scheme No Preferred occlusal scheme Clinicians advocate axial loading of implants, Clinicians advocate axial loading of implants, but no evidence, at present, demonstrating benefits Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94: No Preferred occlusal scheme No Preferred occlusal scheme Clinicians advocate axial loading of implants, Clinicians advocate axial loading of implants, but no evidence, at present, demonstrating benefits

Occlusion & Implants Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94: No evidence at present that No evidence at present that  progressive occlusal loading of implant is beneficial  occlusal overload is detrimental to implants Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94: No evidence at present that No evidence at present that  progressive occlusal loading of implant is beneficial  occlusal overload is detrimental to implants

Absence of Scientific Evidence Not proof against! Follow best available clinical principles Do not build in heavy non-axial loading or overloading Not proof against! Follow best available clinical principles Do not build in heavy non-axial loading or overloading

Clinical Principles for Occlusion Based on Clinical Experience Not Scientific Evidence Based on Clinical Experience Not Scientific Evidence

General Principles Improve denture stability or axial loading of single teeth Centric contacts on flat surfaces, not inclines Centric contacts on flat surfaces, not inclines Improve denture stability or axial loading of single teeth Centric contacts on flat surfaces, not inclines Centric contacts on flat surfaces, not inclines

General Principles Posterior Overjet to Avoid Cheek Biting

General Principles Improve denture stability or single tooth loading Center occlusal contacts over ridge Center occlusal contacts over ridge Simultaneous posterior contacts in centric Simultaneous posterior contacts in centric Improve denture stability or single tooth loading Center occlusal contacts over ridge Center occlusal contacts over ridge Simultaneous posterior contacts in centric Simultaneous posterior contacts in centric

General Occlusal Principles For overdentures or full arch prostheses opposing a CD: No anterior contacts in centric No anterior contacts in centric  Minimizes anterior resorption Grazing anterior contacts in excursions Grazing anterior contacts in excursions  Incising For overdentures or full arch prostheses opposing a CD: No anterior contacts in centric No anterior contacts in centric  Minimizes anterior resorption Grazing anterior contacts in excursions Grazing anterior contacts in excursions  Incising

Occlusal Schemes Canine Guidance Canine Guidance Group Function Group Function Lingualized Lingualized Monoplane Monoplane Canine Guidance Canine Guidance Group Function Group Function Lingualized Lingualized Monoplane Monoplane Dentures Single Teeth FPD’s Single Teeth FPD’s

Crowns or FPD’s Either canine guidance or group function works - no preference Either canine guidance or group function works - no preference Use what the patient has Use what the patient has Use what would be easiest Use what would be easiest Either canine guidance or group function works - no preference Either canine guidance or group function works - no preference Use what the patient has Use what the patient has Use what would be easiest Use what would be easiest

Overdentures or Full Arch Prostheses ALL Occlusal Schemes Devised to Maximize Denture Stability

Lingualized Occlusion Maxillary cusped tooth Maxillary cusped tooth Mandibular cuspless or shallow cusped tooth Mandibular cuspless or shallow cusped tooth Maxillary lingual cusp balances like a mortar in a pestle Maxillary lingual cusp balances like a mortar in a pestle Maxillary cusped tooth Maxillary cusped tooth Mandibular cuspless or shallow cusped tooth Mandibular cuspless or shallow cusped tooth Maxillary lingual cusp balances like a mortar in a pestle Maxillary lingual cusp balances like a mortar in a pestle

Lingualized Occlusion Lingual cusp contacts opposing central fossaeLingual cusp contacts opposing central fossae Mandibular cuspal inclines are shallow (0°, 10°)Mandibular cuspal inclines are shallow (0°, 10°) Less lateral displacementLess lateral displacement Lingual cusp contacts opposing central fossaeLingual cusp contacts opposing central fossae Mandibular cuspal inclines are shallow (0°, 10°)Mandibular cuspal inclines are shallow (0°, 10°) Less lateral displacementLess lateral displacement

Lingualized Occlusion How Stability is Improved Simultaneous bilateral anterior and posterior in all excursions Simultaneous bilateral anterior and posterior in all excursions Tilting forces theoretically neutralized Tilting forces theoretically neutralized Simultaneous bilateral anterior and posterior in all excursions Simultaneous bilateral anterior and posterior in all excursions Tilting forces theoretically neutralized Tilting forces theoretically neutralized

Enter Bolus Exit Balance? Many patients chew bilaterally Many patients chew bilaterally Biting forces maximum close to intercuspation (where balance most effective) Biting forces maximum close to intercuspation (where balance most effective) Non-functional aspects (swallow) Non-functional aspects (swallow) Many patients chew bilaterally Many patients chew bilaterally Biting forces maximum close to intercuspation (where balance most effective) Biting forces maximum close to intercuspation (where balance most effective) Non-functional aspects (swallow) Non-functional aspects (swallow)

Point of Loading Affects Stability Browning, 1986 Browning, 1986  Loaded centrally, M, D, L, B  B caused unseating  Central loading better than distal loading M D L B C

Lingualized Contacts Balancing Side Working Side Only buccal cusp contact is inner incline of mandibular teeth (balancing) Only buccal cusp contact is inner incline of mandibular teeth (balancing)

‘IIF’ Rule IIF you have contacts on the Inner Inclines of Functional cusps they are balancing contacts IIF you have contacts on the Inner Inclines of Functional cusps they are balancing contacts

Test!

Rules for Balancing Contacts Balancing contacts should be lines, not points Balancing contacts should be lines, not points Balancing contacts should never be heavier than working contacts Balancing contacts should never be heavier than working contacts Balancing contacts should be lines, not points Balancing contacts should be lines, not points Balancing contacts should never be heavier than working contacts Balancing contacts should never be heavier than working contacts

Balanced Occlusion (Lingualized) Indirect evidence that balanced occlusion may: Indirect evidence that balanced occlusion may:  reduce ridge resorption ( Maeda & Wood, 1989)  reduce ridge resorption ( Maeda & Wood, 1989)  allow for increased functional forces in excursions ( Miralles et al, 1989) Indirect evidence that balanced occlusion may: Indirect evidence that balanced occlusion may:  reduce ridge resorption ( Maeda & Wood, 1989)  reduce ridge resorption ( Maeda & Wood, 1989)  allow for increased functional forces in excursions ( Miralles et al, 1989)

Lingualized Cusp Angles Always use steep cusped maxillary tooth (33°) Always use steep cusped maxillary tooth (33°) When condylar guidance is steeper use more cusp angle in mandible (10°) When condylar guidance is steeper use more cusp angle in mandible (10°) Always use steep cusped maxillary tooth (33°) Always use steep cusped maxillary tooth (33°) When condylar guidance is steeper use more cusp angle in mandible (10°) When condylar guidance is steeper use more cusp angle in mandible (10°)

Lingualized Occlusion Balance cannot be set without an articulator Balance cannot be set without an articulator Clinical remount on an articulator - fewer adjustments Clinical remount on an articulator - fewer adjustments Balance cannot be set without an articulator Balance cannot be set without an articulator Clinical remount on an articulator - fewer adjustments Clinical remount on an articulator - fewer adjustments

Condylar Inclination Posterior teeth separate as working condyle moves forward (and downward) Posterior teeth separate as working condyle moves forward (and downward) Anterior teeth contact Anterior teeth contact Closer to condyle, more separation Closer to condyle, more separation More anterior separation of Premolars if steep anterior guidance More anterior separation of Premolars if steep anterior guidance Posterior teeth separate as working condyle moves forward (and downward) Posterior teeth separate as working condyle moves forward (and downward) Anterior teeth contact Anterior teeth contact Closer to condyle, more separation Closer to condyle, more separation More anterior separation of Premolars if steep anterior guidance More anterior separation of Premolars if steep anterior guidance

Effect of Mandible Moving Downward During Excursions

Maintaining Balancing Contacts Change occlusal plane angle Change occlusal plane angle Increase compensating curves Increase compensating curves Increase cusp angles or effective cusp angles Increase cusp angles or effective cusp angles Change occlusal plane angle Change occlusal plane angle Increase compensating curves Increase compensating curves Increase cusp angles or effective cusp angles Increase cusp angles or effective cusp angles

Checking for Balance Feels Smoo oo oo th in excursions  - Fingers on max. canines  - Check on articulator Feels Smoo oo oo th in excursions  - Fingers on max. canines  - Check on articulator

Assess Contacts: Centric Stops Centric Stops Excursions Excursions Centric Stops Centric Stops Excursions Excursions

Improving Denture Occlusion Most important cusp - maxillary lingual Most important cusp - maxillary lingual Mandibular buccal cusps more lateral - more tipping Mandibular buccal cusps more lateral - more tipping Most important cusp - maxillary lingual Most important cusp - maxillary lingual Mandibular buccal cusps more lateral - more tipping Mandibular buccal cusps more lateral - more tipping

When Not to Balance Difficulty in obtaining repeatable centric record Difficulty in obtaining repeatable centric record  incoordination,  muscle splinting Dramatic malocclusions Dramatic malocclusions Severe ridge resorption Severe ridge resorption  lateral forces displace the denture  Implants tend to negate this factor Difficulty in obtaining repeatable centric record Difficulty in obtaining repeatable centric record  incoordination,  muscle splinting Dramatic malocclusions Dramatic malocclusions Severe ridge resorption Severe ridge resorption  lateral forces displace the denture  Implants tend to negate this factor

Monoplane Occlusion Cuspless teeth set on a flat plane with mm overjet Cuspless teeth set on a flat plane with mm overjet No cusp to fossa relationship No cusp to fossa relationship No anterior contacts present in centric position No anterior contacts present in centric position No overbite No overbite Cuspless teeth set on a flat plane with mm overjet Cuspless teeth set on a flat plane with mm overjet No cusp to fossa relationship No cusp to fossa relationship No anterior contacts present in centric position No anterior contacts present in centric position No overbite No overbite

Monoplane Occlusion How Stability is Improved Elimination of cusps Elimination of cusps  Lateral forces reduced, improving stability  Simplifies denture tooth arrangement Elimination of cusps Elimination of cusps  Lateral forces reduced, improving stability  Simplifies denture tooth arrangement

Monoplane Occlusion With Condylar Inclination

Ensure Teeth Set Over Ridge Minimize tilting/tipping Minimize tilting/tipping Maximize stability Maximize stability Minimize contacts on buccal of flat cusps Minimize contacts on buccal of flat cusps

Monoplane Occlusion Functional, but unesthetic Functional, but unesthetic Not balanced - flat Not balanced - flat Zero degree teeth can be balanced if condylar inclinations are shallow Zero degree teeth can be balanced if condylar inclinations are shallow Functional, but unesthetic Functional, but unesthetic Not balanced - flat Not balanced - flat Zero degree teeth can be balanced if condylar inclinations are shallow Zero degree teeth can be balanced if condylar inclinations are shallow

Monoplane Occlussion - When? Jaw size discrepancies, malocclusions Jaw size discrepancies, malocclusions  cross-bite, Cl II, III Minimal ridge Minimal ridge  reduces horizontal forces  implants help Uncoordinated jaw movements Uncoordinated jaw movements Jaw size discrepancies, malocclusions Jaw size discrepancies, malocclusions  cross-bite, Cl II, III Minimal ridge Minimal ridge  reduces horizontal forces  implants help Uncoordinated jaw movements Uncoordinated jaw movements

Summary No definitive studies to show one type of occlusion is best No definitive studies to show one type of occlusion is best Follow established clinical principles Follow established clinical principles Assess each case - adapt to clinical situation Assess each case - adapt to clinical situation Continue to read the literature Continue to read the literature No definitive studies to show one type of occlusion is best No definitive studies to show one type of occlusion is best Follow established clinical principles Follow established clinical principles Assess each case - adapt to clinical situation Assess each case - adapt to clinical situation Continue to read the literature Continue to read the literature