The Importance of Occlusion

Introduction:
Occlusion is a widely studied and debated topic in several specialties of
dentistry because it is the key to treatment planning, success, and
maintenance of treatment results and overall oral health. The main purpose of
studying occlusion is to establish balance and stability within the masticatory
system throughout treatment planning and execution.
Occlusion in many dictionaries is defined as process of closing or being
closed and most specialties in dentistry view occlusion in static state and how
certain parts of certain maxillary teeth contact specific parts of opposing
mandibular teeth but with time it became clearer that to reach optimum
treatment objectives the concept of occlusion cannot be confined to that
definition, that’s why the modern concept of occlusion includes functional
criteria, which lead many to prefer the term gnathology for being the science
that studies the whole masticatory system and function including the
morphology, anatomy, physiology and the therapeutics of the jaw and teeth as
they all connect and affect the diagnostics, therapeutics and rehabilitation
procedures.
When it comes to occlusion there is no such topic in dentistry to ignite
controversy and confusion making it that much important to study and
understand.
The term gnathology first came up by Stallard in 1924, In 1926 McCollum
established the Gnathologic Society and in 1930 McCollum and Stuart
designed the first instrument to duplicate the exact movement of the
mandible, but it’s in 1961 when “Modern Gnathology Concepts” was published
by Mosby, which served as the first complete reference book covering
gnathology in depth.
There is no unified concept to follow in practicality of occlusion because some
ideas has been formed around orthodontics or complete dentures or full
mouth rehabilitation but the concept of functional instead of static relationship
of Occlusal surfaces has become more important in the sense that functional
disturbances of the masticatory system are recognized to be relevant to
malocclusion, Occlusal dysfunction, and disturbance of oral motor behavior

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including bruxism. (Nelson, 2015: 267; Rinchusea and Kandasamy, 2009:
322; Lusia, 1988: 3-5)

Overview:
For young dentists studying occlusion in dental school, it doesn’t seem to be
relevant to clinic practice, but the crucial need for a coherent and
comprehensive understanding of dental occlusion manifest as soon as we
start our clinical training and more so questions start’s to surface:
• In full mouth rehabilitation cases do we start with maxillary or mandibular
teeth?
• Do we construct the anterior or posterior first?
• Do we need to increase the vertical dimension?
• Do we work in re-organized or conformative way?
• How do we build a harmonious and cohesive treatment plan?
• What are the rules and principles we should follow?

It is time for dentists to work in knowledge-based criteria rather than trial and
error which is what a dentist resorts to with the lack of knowledge of the basic
principles which leads us to commonly face problems such as sore teeth,
bone loss, cusp fracture, headaches, tooth wear, resorption, temporo-
mandibular joint (TMJ) disorders, and orofacial pain. And only by
understanding we can tackle these problems with confidence and achieve
predictable functional and aesthetic results. There are two schools of thoughts
that have been presented in this field which are the Gnathology school of
thought and the Neuromuscular (Panky-Mann-Schuyler) school of thought.
(Hoffman and Reugenous, I-B-2)
Commonly Used Terms:
RAP: retruded axis position and to PMS (CR) centric relation. The RAP is an
area, not a pinpoint.
RCP: retruded contact position.
ICP: intercuspal position
(Phulari, 2014: 305)

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Principles of Occlusion:
1) RCP equals ICP around RAP
To establish maximum intercuspation (ICP) that it coincide with retruded axis
position (RAP) which cannot be viewed in a simplified two-dimensional
direction but rather in a three-dimensional way which is why it was then
described as Rear most, Upper most, Middle most but the most recent and
accurate description is with the input of anatomists and physiologists as
slightly anterior to RUM position, it all comes down to describe RAP as
reproducible, bone braced, muscle relaxed (unrestrained or passive inferior
lateral pterygoid muscles, medial pterygoid and masseter), time-independent
and the TMJ can accept firm compressive loading with
no sign of tenderness or tension.
In gnathology tooth wear is considered pathological whilst in PMS it’s
considered a normal physiological inevitable process, because gnathology is
a science built on understanding the masticatory structure so it is essential to
determine the RAP and work around it, on the other hand PMS is a technique
and steps to follow where we work on an arbitrary CRO, thus it isn’t
reproducible and there is no scientific evidence on this technique. (Klineberg,
Eckert,2016: 59; Nelson, 2015:287)

2) Mutually protected occlusion: In the gnathology teaching they advocate the

concept of mutually protected occlusion, which states that anterior teeth
protect the posterior in protrusive movement and the posterior teeth protect
the anterior in vertical movement. (Pokorny,Wiens and Litvak, 2008: 301)
while the neuromuscular group adopted the unilateral balanced occlusion.
Stuart and Stallard were fascinated by D’Amico’s research and they adopted
mutually protected occlusion replacing the concept of balanced occlusion, and
to accomplish a mutually protected occlusion:
a) The mandible should be in centric relation while posterior teeth close in
centric occlusion.
b) Only opposing canine contact, in lateral extrusion.
c) Only anterior teeth contact, in protrusion.

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d) Mutual protection was defined as posterior teeth contact in centric
occlusion to protect anterior teeth, and anterior teeth contacting in incisive
position protects the cusp tips of posteriors. (Schwartz, 1986: 22)
3) Anterior guidance: anterior guidance comes side by side with centric
relation in importance to achieve harmony, it is disocclusion or separation of
opposing teeth during lateral movement, anterior and posterior teeth have
different load threshold, but the canines has an anatomically and biologically
unique design to withstand and protect the occlusal form with it’s robust crown
and long root, (Klineberg, Eckert,2016: 98) Stuart and Stallard developed
canine guidance as part of their gnathological concept in mutually protected
articulation after viewing anthropological studies that showed severe wear in
native American Indians and Australian aborigines and this is where canine
guidance concept was originated from. (Pokorny, Wiens and Litvak, 2008:
301) but the neuromuscular concept advocates have suggested that
disocclusion should be brought forward to the anterior teeth and that the
distribution of forces shouldn’t be relying on one tooth (canine guidance) and
that there is less muscular force if compared to group function, Schuyler lead
the philosophy against balanced occlusion which was formulated to keep
stability of complete dentures, but it was problematic in natural dentition. His
logic viewed occlusal wear as a normal physiological adaptive process to
compensate and distribute stress to create a normal functional relationship,
which is described as maximum intercuspation in centric relation, no
balancing side contact on lateral movement, disocclusion of posterior teeth
during anterior protrusion and simultaneous contact of anterior and posterior
teeth on the working side during lateral extrusion. (Thornton,1990: 480-481)

4) No non-working side interferences: A key requirement of successful

occlusion is non-interfering contacts on the non-working side, this means
posterior teeth should not interfere with the anterior guidance during
protrusive movement or interfere with the complete seating of jaw joints, and
so Ideally no posterior teeth should be in contact when the condyle moves
from centric relation into anterior guidance. When the condyles are seated
completely in centric relation the posterior teeth will have equally distributed
intensity on all posterior teeth in the same instant that the anterior teeth

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contact. So if anterior teeth can contact in centric relation the only contact on
posterior teeth should be in centric relation. Meaning the posterior teeth
should disclude as soon as the mandible moves in any other direction.
(Dawson, 2007: 208)
In the past, balanced occlusion was the criteria in practice built around
denture stability but it has been proven to be harmful to natural dentate
patients by both groups (gnathology and PMS) although each group has its
own technique and individual characteristic in instrumentation. In the late
1950’s both groups recognized the problems caused by balancing contact
approach. Patients often suffered from heavy non-working side contacts
which appeared to cause wear, fracture, and mobility. So both groups
abandoned the balanced contact approach and replace it with their own
concept of what works best with natural dentition. Canine guidance for
gnathology concept and group function for PMS (Wassell et al, 2008: 56-57)
5) Posterior stability: A dynamic understanding of occlusal contact in
intercuspal relation in ICP or CR is essential, whether for natural dentition or a
planned restoration of dentition. Centric stops are areas of the supporting the
cusp that makes contact with opposing teeth in centric occlusion. (Nelson,
2015: 280) for each approach to occlusion, there is a type cuspal contact that
will round off the concept to a better occlusal contact stability. In the
gnathology concept which follows the canine guidance the relation should be
cusp to fossa and we should have three points of contact on each posterior
tooth, but they formulated a disclusion type of contact which requires that all
posterior teeth contact evenly in RAP and the anteriors barely miss in centric
position and in excentric position there shouldn’t be any posterior contact on
the balancing contact or when we have the anteriors contacting in protrusive
movement, and for the working side to have the maxillary cuspid contact the
mandibular cuspid edge to edge and even permitted to have anterior teeth
contact, but no posterior teeth should contact anywhere other than centric
relation .
PANKEY-MANN-SCHYLER concept follows the unilateral balanced occlusion
approach it should be cusp to fossa as well but the requirements for contact
change from that of the gnathology concept. In centric position all posterior
teeth contact evenly in centric relation and anterior teeth may or may not

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contact, but in excentric position the maxillary buccal cusp incline evenly with
the mandibular buccal cusp inclines on the working side with absolutely no
contact on the balancing side, and when the anterior teeth contact in
protrusive position there should be absolutely no posterior teeth contact.
(Hoffman & regenos, I-A-18,19)
Conclusion:
Occlusion has been proven to be an important and essential science to the
clinical work of every dental practitioner, but it is the lack of evidence-based
research that made it so controversial, that doesn’t undermine the techniques
and treatment modality that have been suggested by the different schools of
thoughts or make us completely disregard a theory over the other.
The dental practitioner must be aware of the complications he or she might
face with the patients as in not to attempt heavy restorative treatment or
occlusal adjustments on patient with an active late stage TMD or patient with
sever click as it will exacerbate the problem. Another precaution that must be
taken, if the patient has horizontal slide on closure we should avoid re-
organized approach in occlusal adjustments because it makes us lose contact
in the anterior (anterior guidance). And if in protrusive movement the central
is root filled we can take the guidance to the lateral or give the patient a splint,
likewise in lateral movement if the canine is compromised we can go to group
function or premolar guidance. It might be wise to avoid occlusal adjustments
in patients suffering from occlusal dysesthesia or occlusal hypervigilance and
patient should be referred to a specialist for treatment of emotional, cognitive
and affective disorder. (Dawson, 2007: 49)
Otherwise following the principles of occlusion with the chosen approach can
lead to equally predictable and stable results by providing accurate transfer of
information and translating it to a functional fabrication of the prosthesis with a
satisfying quality of treatment.

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References:
Dawson P., (2007) Functional Occlusion: From TMJ to Smile Design,
Missouri: Elsevier Mosby.

Klineberg I., Eckert S. (ed) (2016) Functional Occlusion In Restorative

Dentistry And Prosthodontics, Missouri: Elsevier Mosby.

Lucia V., (1988) ‘A. History of Gnathology’, The Journal of Gnathology, vol.7,
no.1, pp. 3-17.

Nelson S. (2015) Wheeler’s Dental Anatomy, Physiology, And Occlusion, 10th

edition, Las Vegas: Elsevier Sauders.

Phulari R. (ed.), (2014) Text Book Of Dental Anatomy Physiology and

Occlusion, India: Jaypee Brothers Medical Publishers.

Pokorny P., Wiens J., and Litvak H, (2008) ‘Occlusion for fixed
prosthodontics: A historical perspective of the gnathological influence’, The
Journal Of Prosthetic Dentistry, vol. 99, no. 4, April, pp. 299-313.

Rinchusea D. and Kandasamy S.,(2009) ‘Myths of orthodontic gnathology’

American Journal of Orthodontics and Dentofacial Orthopedics, vol. 36, no.3,
September, pp.322-330.

Schwartz H.,(1986) ‘Occlusal Variations for Reconstructing the Natural

Dentition’ The Journal Of Prosthetic Dentistry, vol. 55, no.1,January, pp. 101-
105.

Thornton L., (1990) ‘Anterior guidance: group function/canine guidance. A

literature review’ The Journal Of Prosthetic Dentistry, vol 64, no.4, October,
pp. 479-482.

Wassel R. et al, (2008) Applied Occlusion, London, Berlin, Chicago, Paris,

Milan, Barcelona, Istanbul, Sãulo, Tokyo, New Delhi, Moscow, Prague,
Warsaw: Quintessence Publishing Co. Ltd.