Philosophies of Occlusion for Implants

Philosophies of Occlusion for Implants

Implant OcclusionImplant Occlusion

Single CrownSingle Crown Fixed Partial DenturesFixed Partial Dentures Full arch prostheses (screw retained)Full arch prostheses (screw retained) OverdenturesOverdentures

Single CrownSingle Crown Fixed Partial DenturesFixed Partial Dentures Full arch prostheses (screw retained)Full arch prostheses (screw retained) OverdenturesOverdentures

Many Philosophies of OcclusionMany Philosophies of Occlusion

NoNo definitivedefinitive scientificscientific studiesstudies to prove: to prove: one type of one type of tooth formtooth form one type of one type of occlusal schemeocclusal scheme to be clearly to be clearly preferredpreferred by patients by patients to be more to be more efficientefficient than another than another

NoNo definitivedefinitive scientificscientific studiesstudies to prove: to prove: one type of one type of tooth formtooth form one type of one type of occlusal schemeocclusal scheme to be clearly to be clearly preferredpreferred by patients by patients to be more to be more efficientefficient than another than another

Tooth Forms Occlusal SchemesTooth Forms Occlusal Schemes

AnatomicAnatomic Non AnatomicNon Anatomic

AnatomicAnatomic Non AnatomicNon Anatomic

Canine Guidance Canine Guidance (Mutually Protected)(Mutually Protected)

Group FunctionGroup Function Lingualized Lingualized

(Balanced)(Balanced) MonoplaneMonoplane

Canine Guidance Canine Guidance (Mutually Protected)(Mutually Protected)

Group FunctionGroup Function Lingualized Lingualized

(Balanced)(Balanced) MonoplaneMonoplane

Denture Tooth Forms and Denture Tooth Forms and Occlusal FormsOcclusal FormsDenture Tooth Forms and Denture Tooth Forms and Occlusal FormsOcclusal Forms

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Occlusal Scheme & Axial LoadingOcclusal Scheme & Axial Loading

Evidence Based Reviews Evidence Based Reviews • Taylor, Wiens et al. J Prosthet Dent 2005;94:555-Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560560• Carlsson. Odontology 2009; 97:8-17Carlsson. Odontology 2009; 97:8-17

No Preferred occlusal schemeNo Preferred occlusal scheme Clinicians advocate axial loading of implants, Clinicians advocate axial loading of implants,

but but no evidenceno evidence, , at present,at present, demonstrating benefitsdemonstrating benefits

Evidence Based Reviews Evidence Based Reviews • Taylor, Wiens et al. J Prosthet Dent 2005;94:555-Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560560• Carlsson. Odontology 2009; 97:8-17Carlsson. Odontology 2009; 97:8-17

No Preferred occlusal schemeNo Preferred occlusal scheme Clinicians advocate axial loading of implants, Clinicians advocate axial loading of implants,

but but no evidenceno evidence, , at present,at present, demonstrating benefitsdemonstrating benefits

Loading and OverloadingLoading and Overloading

Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560

No evidenceNo evidence at presentat present that that progressive occlusal loading of implant is progressive occlusal loading of implant is

beneficialbeneficial occlusal overload is detrimental to implantsocclusal overload is detrimental to implants*** At least one case study now - unstable * At least one case study now - unstable

prosthesis, bone loss reversedprosthesis, bone loss reversedInt J Oral Maxillofac Impl 2008;23:153-157.Int J Oral Maxillofac Impl 2008;23:153-157.

Evidence Based Review Evidence Based Review Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560

No evidenceNo evidence at presentat present that that progressive occlusal loading of implant is progressive occlusal loading of implant is

beneficialbeneficial occlusal overload is detrimental to implantsocclusal overload is detrimental to implants*** At least one case study now - unstable * At least one case study now - unstable

prosthesis, bone loss reversedprosthesis, bone loss reversedInt J Oral Maxillofac Impl 2008;23:153-157.Int J Oral Maxillofac Impl 2008;23:153-157.

Occlusal Table & C/R RatiosOcclusal Table & C/R Ratios

Evidence Based Review Evidence Based Review Carlsson 2008Carlsson 2008

No evidence of risk No evidence of risk at presentat present from: from: Increased Crown/Root RatioIncreased Crown/Root Ratio Increased occlusal tableIncreased occlusal table Porcelain vs. AcrylicPorcelain vs. Acrylic

Evidence Based Review Evidence Based Review Carlsson 2008Carlsson 2008

No evidence of risk No evidence of risk at presentat present from: from: Increased Crown/Root RatioIncreased Crown/Root Ratio Increased occlusal tableIncreased occlusal table Porcelain vs. AcrylicPorcelain vs. Acrylic

Absence of Scientific EvidenceAbsence of Scientific Evidence

Not proof against!Not proof against!

Follow best available clinical Follow best available clinical principlesprinciples

Do not build in heavy non-axial Do not build in heavy non-axial loading or overloadingloading or overloading

Not proof against!Not proof against!

Follow best available clinical Follow best available clinical principlesprinciples

Do not build in heavy non-axial Do not build in heavy non-axial loading or overloadingloading or overloading

Clinical Principles for OcclusionClinical Principles for Occlusion

Based on Clinical ExperienceBased on Clinical Experience

Not Scientific EvidenceNot Scientific Evidence

Based on Clinical ExperienceBased on Clinical Experience

Not Scientific EvidenceNot Scientific Evidence

General PrinciplesGeneral Principles

Improve denture stability or axial Improve denture stability or axial loading of single teethloading of single teeth

Centric contacts on flat surfaces, Centric contacts on flat surfaces, not inclinesnot inclines

Improve denture stability or axial Improve denture stability or axial loading of single teethloading of single teeth

Centric contacts on flat surfaces, Centric contacts on flat surfaces, not inclinesnot inclines

General PrinciplesGeneral Principles

a

1-2 mmNonanatomicsetup1-2 mmAnatomic setupCenter overlower ridge

a

1-2 mmNonanatomicsetup1-2 mmAnatomic setupCenter overlower ridge

Posterior Posterior Overjet to Overjet to Avoid Cheek Avoid Cheek BitingBiting

Posterior Posterior Overjet to Overjet to Avoid Cheek Avoid Cheek BitingBiting

General Principles

Improve denture Improve denture stability or single stability or single tooth loadingtooth loading

Center occlusal contacts Center occlusal contacts over ridgeover ridge

Simultaneous posterior Simultaneous posterior contacts in centriccontacts in centric

Improve denture Improve denture stability or single stability or single tooth loadingtooth loading

Center occlusal contacts Center occlusal contacts over ridgeover ridge

Simultaneous posterior Simultaneous posterior contacts in centriccontacts in centric

General Occlusal PrinciplesGeneral Occlusal Principles

For overdentures or full arch For overdentures or full arch prostheses opposing a CD:prostheses opposing a CD:

No anterior contacts in centricNo anterior contacts in centric Minimizes anterior resorptionMinimizes anterior resorption

Grazing anterior contacts in Grazing anterior contacts in excursionsexcursions IncisingIncising

For overdentures or full arch For overdentures or full arch prostheses opposing a CD:prostheses opposing a CD:

No anterior contacts in centricNo anterior contacts in centric Minimizes anterior resorptionMinimizes anterior resorption

Grazing anterior contacts in Grazing anterior contacts in excursionsexcursions IncisingIncising

Occlusal SchemesOcclusal Schemes

Canine GuidanceCanine Guidance Group FunctionGroup Function LingualizedLingualized MonoplaneMonoplane

Canine GuidanceCanine Guidance Group FunctionGroup Function LingualizedLingualized MonoplaneMonoplane DenturesDentures

Single Teeth

FPD’s

Single Teeth

FPD’s

Crowns or FPD’sCrowns or FPD’s

Either canine guidance or group function Either canine guidance or group function works - no preferenceworks - no preference

Use what the patient has Use what the patient has Use what would be easiestUse what would be easiest

Either canine guidance or group function Either canine guidance or group function works - no preferenceworks - no preference

Use what the patient has Use what the patient has Use what would be easiestUse what would be easiest

Overdentures or

Full Arch Prostheses

Overdentures or

Full Arch Prostheses

ALLALL Occlusal Schemes Devised to Occlusal Schemes Devised to Maximize Denture StabilityMaximize Denture Stability

ALLALL Occlusal Schemes Devised to Occlusal Schemes Devised to Maximize Denture StabilityMaximize Denture Stability

Lingualized OcclusionLingualized Occlusion

Maxillary cusped toothMaxillary cusped tooth Mandibular cuspless or shallow cusped Mandibular cuspless or shallow cusped

toothtooth Maxillary lingual cusp Maxillary lingual cusp balancesbalances

like a mortar in a pestle like a mortar in a pestle

Maxillary cusped toothMaxillary cusped tooth Mandibular cuspless or shallow cusped Mandibular cuspless or shallow cusped

toothtooth Maxillary lingual cusp Maxillary lingual cusp balancesbalances

like a mortar in a pestle like a mortar in a pestle

Lingualized OcclusionLingualized Occlusion

• Lingual cusp contacts Lingual cusp contacts opposing central fossaeopposing central fossae

• Mandibular cuspal inclines Mandibular cuspal inclines are shallow (0°, 10°)are shallow (0°, 10°)

• Less lateral displacementLess lateral displacement

• Lingual cusp contacts Lingual cusp contacts opposing central fossaeopposing central fossae

• Mandibular cuspal inclines Mandibular cuspal inclines are shallow (0°, 10°)are shallow (0°, 10°)

• Less lateral displacementLess lateral displacement

Lingualized OcclusionHow Stability is ImprovedLingualized OcclusionHow Stability is Improved

Simultaneous bilateralSimultaneous bilateral anterior and posterior in anterior and posterior in all all excursionsexcursions

Tilting forces theoretically Tilting forces theoretically neutralizedneutralized

Simultaneous bilateralSimultaneous bilateral anterior and posterior in anterior and posterior in all all excursionsexcursions

Tilting forces theoretically Tilting forces theoretically neutralizedneutralized

Enter Bolus Exit Balance?Enter Bolus Exit Balance?

Many patients chew bilaterallyMany patients chew bilaterally Biting forces maximum close to intercuspation Biting forces maximum close to intercuspation

(where balance most effective)(where balance most effective) Non-functional aspects (swallow)Non-functional aspects (swallow)

Many patients chew bilaterallyMany patients chew bilaterally Biting forces maximum close to intercuspation Biting forces maximum close to intercuspation

(where balance most effective)(where balance most effective) Non-functional aspects (swallow)Non-functional aspects (swallow)

Point of Loading Affects Stability

Browning, 1986Browning, 1986

Loaded centrally, Loaded centrally, M, D, L,M, D, L, BB

BB caused unseating caused unseating

Central loading better than Central loading better than distal loadingdistal loading

MM

DD

LL

BBCC

Lingualized ContactsLingualized Contacts

Balancing SideBalancing SideBalancing SideBalancing Side

Working SideWorking SideWorking SideWorking Side

Only buccal cusp Only buccal cusp contact is inner contact is inner incline of incline of mandibular teeth mandibular teeth (balancing)(balancing)

‘IIF’ Rule‘IIF’ Rule

a

Inner Inclines (inside of cusp)Outer Inclines(outside of cusp)

B LBL

WorkingContacts

a

Inner Inclines (inside of cusp)Outer Inclines(outside of cusp)

B LBL

WorkingContacts IIFIIF you have contacts on the you have contacts on the IInner nner IInclines of nclines of FFunctional cusps unctional cusps

they are balancing contactsthey are balancing contacts

IIFIIF you have contacts on the you have contacts on the IInner nner IInclines of nclines of FFunctional cusps unctional cusps they are balancing contactsthey are balancing contacts

Test!Test!

Rules for Balancing ContactsRules for Balancing Contacts Balancing contacts should be lines, not Balancing contacts should be lines, not

pointspoints Balancing contacts should never be heavier Balancing contacts should never be heavier

than working contactsthan working contacts

Balancing contacts should be lines, not Balancing contacts should be lines, not pointspoints

Balancing contacts should never be heavier Balancing contacts should never be heavier than working contactsthan working contacts

Balanced Occlusion (Lingualized)Balanced Occlusion (Lingualized)

Indirect evidence that balanced occlusion may:Indirect evidence that balanced occlusion may: reduce ridge resorption reduce ridge resorption ((Maeda & WoodMaeda & Wood , 1989), 1989)

allow for increased functional forces in allow for increased functional forces in excursions excursions ((Miralles et al, 1989)Miralles et al, 1989)

Indirect evidence that balanced occlusion may:Indirect evidence that balanced occlusion may: reduce ridge resorption reduce ridge resorption ((Maeda & WoodMaeda & Wood , 1989), 1989)

allow for increased functional forces in allow for increased functional forces in excursions excursions ((Miralles et al, 1989)Miralles et al, 1989)

Lingualized Cusp AnglesLingualized Cusp Angles

Always use steep cusped Always use steep cusped maxillary tooth (33°)maxillary tooth (33°)

When condylar guidance is When condylar guidance is steeper use more cusp angle steeper use more cusp angle in mandible (10°)in mandible (10°)

Always use steep cusped Always use steep cusped maxillary tooth (33°)maxillary tooth (33°)

When condylar guidance is When condylar guidance is steeper use more cusp angle steeper use more cusp angle in mandible (10°)in mandible (10°)

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

adjustmentsadjustments

Balance cannot be set without an articulatorBalance cannot be set without an articulator Clinical remount on an articulator - fewer Clinical remount on an articulator - fewer

adjustmentsadjustments

Condylar InclinationCondylar Inclination Posterior teeth separate as working Posterior teeth separate as working

condyle moves forward (and condyle moves forward (and downward)downward)

Anterior teeth contact Anterior teeth contact Closer to condyle, more separationCloser to condyle, more separation More anterior separation of More anterior separation of

Premolars if steep anterior guidancePremolars if steep anterior guidance

Posterior teeth separate as working Posterior teeth separate as working condyle moves forward (and condyle moves forward (and downward)downward)

Anterior teeth contact Anterior teeth contact Closer to condyle, more separationCloser to condyle, more separation More anterior separation of More anterior separation of

Premolars if steep anterior guidancePremolars if steep anterior guidance

Effect of Mandible Moving Downward During Excursions

Maintaining Balancing ContactsMaintaining Balancing Contacts

Change occlusal plane angleChange occlusal plane angle Increase compensating curvesIncrease compensating curves Increase cusp angles or effective cusp Increase cusp angles or effective cusp

anglesangles

Change occlusal plane angleChange occlusal plane angle Increase compensating curvesIncrease compensating curves Increase cusp angles or effective cusp Increase cusp angles or effective cusp

anglesangles

Checking for BalanceChecking for Balance

Feels Feels SmSmoooooooooooothth in excursions in excursions

- Fingers on max. canines- Fingers on max. canines - Check on articulator- Check on articulator

Feels Feels SmSmoooooooooooothth in excursions in excursions

- Fingers on max. canines- Fingers on max. canines - Check on articulator- Check on articulator

Assess Contacts:Assess Contacts:

Centric StopsCentric Stops ExcursionsExcursions

Centric StopsCentric Stops ExcursionsExcursions

Improving Denture OcclusionImproving Denture Occlusion

Most important cusp - maxillary lingual Most important cusp - maxillary lingual Mandibular buccal cusps more lateral - more Mandibular buccal cusps more lateral - more

tippingtipping

Most important cusp - maxillary lingual Most important cusp - maxillary lingual Mandibular buccal cusps more lateral - more Mandibular buccal cusps more lateral - more

tippingtipping

When Not to BalanceWhen Not to Balance

Difficulty in obtaining repeatable centric Difficulty in obtaining repeatable centric record record incoordination, incoordination, muscle splintingmuscle splinting

Dramatic malocclusionsDramatic malocclusions Severe ridge resorption Severe ridge resorption

lateral forces displace the denturelateral forces displace the denture Implants tend to negate this factorImplants tend to negate this factor

Difficulty in obtaining repeatable centric Difficulty in obtaining repeatable centric record record incoordination, incoordination, muscle splintingmuscle splinting

Dramatic malocclusionsDramatic malocclusions Severe ridge resorption Severe ridge resorption

lateral forces displace the denturelateral forces displace the denture Implants tend to negate this factorImplants tend to negate this factor

Monoplane OcclusionMonoplane Occlusion

Cuspless teeth set on a flat plane with 1.5- 2 Cuspless teeth set on a flat plane with 1.5- 2 mm overjetmm overjet

No cusp to fossa relationship No cusp to fossa relationship No anterior contacts present in centric No anterior contacts present in centric

positionposition No overbiteNo overbite

Cuspless teeth set on a flat plane with 1.5- 2 Cuspless teeth set on a flat plane with 1.5- 2 mm overjetmm overjet

No cusp to fossa relationship No cusp to fossa relationship No anterior contacts present in centric No anterior contacts present in centric

positionposition No overbiteNo overbite

Monoplane OcclusionHow Stability is ImprovedMonoplane OcclusionHow Stability is Improved

Elimination of cuspsElimination of cusps

Lateral forces reduced, improving stabilityLateral forces reduced, improving stability

Simplifies denture tooth arrangementSimplifies denture tooth arrangement

Elimination of cuspsElimination of cusps

Lateral forces reduced, improving stabilityLateral forces reduced, improving stability

Simplifies denture tooth arrangementSimplifies denture tooth arrangement

Monoplane Occlusion With Condylar Inclination

Monoplane Occlusion With Condylar Inclination

Monoplane OcclusionWith Condylar InclinationMonoplane OcclusionWith Condylar Inclination

Ensure Teeth Set Over Ridge

Minimize tilting/tippingMinimize tilting/tipping Maximize stabilityMaximize stability Minimize contacts on Minimize contacts on buccalbuccal of flat cusps of flat cusps

Monoplane OcclusionMonoplane Occlusion Functional, but unestheticFunctional, but unesthetic

Not balanced - flatNot balanced - flat Zero degree teeth can be Zero degree teeth can be

balanced if condylar balanced if condylar inclinations are shallowinclinations are shallow

Functional, but unestheticFunctional, but unesthetic Not balanced - flatNot balanced - flat Zero degree teeth can be Zero degree teeth can be

balanced if condylar balanced if condylar inclinations are shallowinclinations are shallow

Monoplane Occlussion - When?Monoplane Occlussion - When?

Jaw size discrepancies, malocclusions Jaw size discrepancies, malocclusions cross-bite, Cl II, IIIcross-bite, Cl II, III

Minimal ridgeMinimal ridge reduces horizontal forcesreduces horizontal forces implants helpimplants help

Uncoordinated jaw movementsUncoordinated jaw movements

Jaw size discrepancies, malocclusions Jaw size discrepancies, malocclusions cross-bite, Cl II, IIIcross-bite, Cl II, III

Minimal ridgeMinimal ridge reduces horizontal forcesreduces horizontal forces implants helpimplants help

Uncoordinated jaw movementsUncoordinated jaw movements

SummarySummary

No definitive studies to show one type No definitive studies to show one type of occlusion is bestof occlusion is best

Follow established clinical principlesFollow established clinical principles Assess each case - adapt to clinical Assess each case - adapt to clinical

situationsituation Continue to read the literatureContinue to read the literature

No definitive studies to show one type No definitive studies to show one type of occlusion is bestof occlusion is best

Follow established clinical principlesFollow established clinical principles Assess each case - adapt to clinical Assess each case - adapt to clinical

situationsituation Continue to read the literatureContinue to read the literature