Full mouth rehabilitation FINAL PRESENTATION

FULL MOUTH
REHABILITATION
Presented by
Dr.Namitha AP
3rd MDS
1

CONTENTS
• INTRODUCTION
• DEFFINITIONS
• EVOLUTION OF OCCLUSION
• GOALS OF FMR
• INDICATIONS OF FMR
• REASONS FOR FMR
• LIMITATIONS OF FMR
• MASTICATORY SYSTEM DISORDER
• INSTRUMENTS USED FOR OCLLUSAL
ANALYSIS AND TREATMENT
• DIAGNOSTIC WAX UP
• OCCLUSAL EQUILIBERATION/PRINCIPLES OF
OCCLUSAL CORRECETION
• ROLE OF OCCLUSAL SPLINT IN FMR
• EXAMINATION, DIAGNOSIS AND TREATMENT
PLANNING IN FMR
• PREPARING THE MOUTH FOR FMR
• TREATMENT PROCEDURES AND TECHNIQUES IN
FMR
• FINAL RESTORATIONS FOR FMR
• COMMON PROBLEMS AND DIFFICULTIES IN FMR
• POST OP CARE
• TECH FUTURE IN FMR
• CONCLUSION
• REFERENCES
2

Ultimate goal -
Optimum oral
health
Introduction
• The term ‘full mouth rehabilitation’ is used to indicate extensive and
intensive restorative procedures in which the occlusal plane is modified in
many aspects in order to accomplish “equilibration”.
Multidisciplinary
Approach
Both function and health can be
restored in badly detiorated, diseased
mouths by utilizing modern
techniques of oral rehabilitation
3

Definition (GPT9)
• Full mouth rehabilitation is defined as the restoration of the
form and function of the masticatory apparatus to as nearly a
normal condition as possible
The word rehabilitate implies ‘ To restore to good condition or to restore to former privilege’.
Reynolds JM. Modern gnathological concepts—Updated: By Victor O. Lucia, DDS, FACD Chicago, 1983, Quintessence
Publishing Co., Inc. 439 pages, illustrated, indexed.
All the procedures necessary to produce healthy, esthetic, well
functioning, and self-maintaining masticatory mechanism.
4

Objectives of FMR
• A static centric occlusion in harmony with centric
relation.
• Even distribution of stresses in centric occlusion and on
eccentric functional inclines.
• Equalization of forces directed against supporting
structures
• Restoration of normal healthy function of the
masticating apparatus
Irving Goldman: The goal of full mouth rehabilitation, J PROSTHET DENT 1951, vol 2, 246-251
5

Reasons for full mouth rehabilitation
• Obtain and maintain the health of periodontal tissues.
• Temperomandibular joint disturbance
• Need for extensive dentistry as in case of missing teeth, worn
down teeth and old fillings that need replacement.
• Esthetics as in case of multiple anterior worn down teeth and
missing teeth.
6

INDICATIONS
• Restore impaired occlusal
function
• Preserve longevity of remaining
teeth
• Maintain healthy periodontium
• Improve objectionable esthetics
• pain and discomfort of teeth
and surrounding structures
CONTRAINDICATIONS
• Malfunctioning mouths that do not need
extensive dentistry and have no joint
symptoms should be best left alone.
• Prescribing a full mouth rehabilitation
should not be taken as a preventive
measure unless there is a definite evidence
of tissue breakdown.
• No pathology- No treatment.
7

Classification of patients requiring
occlusal rehabilitation
Classification by Turner and Missirlain (1984)
The patients were classified into three categories –
• Category 1 - Excessive wear with loss of vertical dimension.
• Category 2 - Excessive wear without loss of vertical dimension
of occlusion but with space available.
• Category 3 - Excessive wear without loss of vertical dimension
of occlusion but with limited space available
Turner KA, Missirlian DM. Restoration of the extremely worn dentition. Journal of Prosthetic Dentistry. 1984 Oct 1;52(4):467-74.
8

Restoring vertical dimension at occlusion
• loss of occlusal vertical dimension
due to unstable posterior occlusion or
congenital disease and exhibit
excessive wear of anterior teeth.
• method to confirm loss of vertical
dimension is with trial restorations
• A removable occlusal overlay splint or
a treatment partial denture that
restores the occlusal vertical dimension
is given for 6-8 weeks and the patient
is evaluated for comfort and function.
• teeth are prepared and provisional
fixed restoration are given 2-3 months.
• Then the final restorations can be
given
Category 1
J PROSTHET DENT 1984, vol 52, 467-474
9

• A long history of gradual tooth wear caused by bruxism or moderate oral habits
• Anterior slide is present from centric relation to centric occlusion.
• Equilibration or stability of posterior teeth for stability in centric relation, in
combination with enameloplasty of opposing teeth can provide sufficient space
for restorative materials.
• gingivoplasty and gingivectomy , 2-3mm of supporting bone can usually be
removed without jeopardizing periodontal support, dynamic recordings of
mandibular movement ,are recommended for this type of rehabilitation.
Category 2
10

•
• exhibit minimum posterior wear but excessive gradual wear of anterior teeth
over many years.
• Centric relation and centric occlusion are coincidental.
• Restoring this patient is most difficult because vertical space must be obtained
for restorative materials
• Increasing the occlusal vertical dimension to achieve space for restorative
materials where there has apparently been no loss of occlusal vertical
dimension is seldom advisable; but if deemed necessary , the increase should be
minimal and for restorative needs only.
• Trial restorations are crucial and must be evaluated for longer period of time
to ensure patient accommodation to the altered occlusal vertical dimension
Category 3
11

Classification by Brecker
• Group I
Class I – Patients with collapse of vertical dimension of occlusion because of shifting
of existing teeth caused by failure to replace missing teeth.
Class II – Patients with collapse of vertical dimension of occlusion because of loss
of all posterior teeth in one or both jaws with remaining teeth in unsatisfactory
occlusal relationship.
Class III – Patients with collapse of vertical dimension of occlusion because of
excessive attritional wear of occlusal surfaces.
Brecker SC. Clinical procedures in occlusal rehabilitation. WB Saunders; 1966.
12

Group II
• Class I – Patients with all or sufficient natural teeth present, with satisfactory
occlusal relationship.
• Class II – Patients with limited teeth present but in satisfactory occlusal relationship
requiring aid in the form of occlusal rims.
Group III – Patients requiring maxillofacial surgery or orthodontic treatment as an aid
in restoring the lost vertical dimension.
Group IV – Patients in whom sectional treatment is required over extended periods of
time because of status of health of the patient, age or economic factor.
Clinical procedures in occlusal rehabilitation .W.B Saunders,Philidelphia 1958
13

Etiology of extremely worn dentition
Congenital abnormalities Amelogenesis imperfecta
Dentinogenesis imperfecta
Parafunctional occlusal habit Chronic bruxism and other habits
Abrasion
Erosion
Loss of posterior support
Bernard smith :Tooth wear : Etiology and diagnosis Gerodontology Text Book 1994, 88-102 46/400
14

Attrition Abrasion Erosion Splayed teeth Advanced occlusal
disease
Anterior
guidance
attrition
Sensitive teeth Sore teeth Hypermobility Spilt teeth and
fractured cusps
Painful
musculature
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 21-26
15

Diagnosis
Ist appointment
• Listen to patient’s opinion and
expectations
• Make diagnostic casts
• Radiographs
• Bite records and facebow transfer
IInd appointment
• Individual tooth is meticulously
examined
• Extracted or restored
• Serve as abutments for RPDs or
fixed prosthesis
Tentative treatment plan done
EXAMINATION DIAGNOSIS AND TREATMENT PLANNING IN FMR
16

Diagnostic aids
• Medical history
• Dental history
• Behaviour evaluation
• Radiographs – Complete mouth periapical radiographs and orthopentamograph
• Photographs – to remind previous state of mouth prior to restorative therapy
• Clinical examination
• Diagnostic wax-up
• Computer imaging
• CBCT
Bowley JF, Stockstill JW, Attanasio R. A preliminary diagnostic and treatment protocol. Dental Clinics of North America. 1992 Jul;36(3):551-68.
17

DIAGNOSTIC WAX UP
• The process of converting the programmed
treatment plan into a three dimensional
visualisation
• Before diagnostic wax-up, the occlusal
discrepancies in centric and eccentric occlusion
should be eliminated
• Thus planning of subgingival margins or surgical
crown lengthening required can be done
• Then wax is used to appropriately shape all
crowns and final prosthesis is planned
can be used to prepare an elastomeric
putty mould and used for temporization
or sectioned through long axis of tooth to
act as reduction guide intra-orally.
18

Steps in the diagnostic wax up
• Step 1: Mount upper and lower casts with
centric relation bite record and facebow.
Duplicate the casts to preserve the original
conditions.
• Step 2: Verify the accuracy of the mounting.
• Step 3: Examine the occlusal relationship on
the casts.
19

• Step 4: Lock the centric latch when
observing the casts.
• Step 5: Determine the correct vertical
dimension.
• Step 6: Return the condyles to centric
relation and lock the centric lock.
Occlusal interferences should be eliminated by selective grinding on the casts until the incisal pin contacts the
guide plate. At that point, the original vertical dimension will have been re-established in centric relation. If a
change in VDO is needed to fulfil requirements for stability, it can be determined now.
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 368
20

• Step 7: Observe the teeth that were reshaped.
• Step 8: Remove unsavable teeth from the
casts. From the clinical exam, all teeth that
cannot be saved are marked with an X.
• Step 9: Mark decisions that have been made
to use certain types of restorations.
• For example, in the figure the two upper
molars have been predetermined to need
crowns (C).
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.page no. 368,369
21

• Step 10 : Equilibration is the first treatment
option to explore.
The jaw-to-jaw relationship at the first point of tooth
contact in centric relation.
Equilibration of the casts clearly shows that reshaping
the teeth is a good choice of treatment because contact
with the canines is achievable by selective grinding away of
the deflective interferences.
22

• Step 11: Examine the plane of occlusion.
• If the casts were mounted with a facebow
that was parallel with the eyes, the incisal
plane and the occlusal plane will relate to
the bench top.
• If the occlusal plane is slanted in the mouth
(yellow line), it will be slanted on the
articulator (red line)
23

• The occlusal plane established by the
simplified occlusal plane analyzer.
• Model is trimmed back to the
established new occlusal plane.
24

Note how the buccal surfaces have been
contoured to move the cusp
tip more in line with the upper teeth. The
wax-up has been started.
The completed wax-up. These corrected casts are now used
to form a putty matrix for fabrication of provisional
restorations. They are also the perfect visual aid when
presenting the treatment plan to the patient.
25

• Step 12: Establish stable holding contacts on
the anterior teeth.
• Step 13: Correct lower incisal edges if needed.
This refers to both position and contour.
Unmounted casts do not provide the
information needed to fulfill
this objective
26

• Step 14: Start with the lower anterior teeth.
• Step 15: Re-evaluate the total occlusion with
the upper cast to see it can be adapted to
occlude with the lower arch.
The range of change in
position of lower anterior
teeth is minimal compared
with the upper anterior
teeth.
Anteroposterior position
of lower anterior teeth has
very little flexibility, and
their position in the
narrow alveolar ridge is
quite limited.
The height of lower
incisors is also within a
limited range that is
consistent with the height
and contour of the
occlusal plane
simplifies the whole wax-up.
27

Step 16: Establish holding contacts on the upper anterior teeth
This
diagnostic
wax-up
positioned
the incisal
edges
forward
and
also made
the teeth
longer.
Casts of a
patient with
a tight
neutral zone
that
positioned
the upper
anterior
teeth with a
lingual
inclination.
28

A digital photograph of this patient shows
the incisal edges in line with the inner
vermillion border of the lower lip. It also
shows a lingual inclination of the upper
anterior teeth.
This photograph shows how the provisional
restorations made from the wax-up had to be
recontoured back to achieve a comfortable lip
closure path and phonetics.
29

Cast of poorly contoured
anterior restorations. Note
the contour
of the pontics where they
meet the ridge.
Cast showing defect of lost labial plate of
bone that makes it impossible to establish
gingival contours on pontics that are
esthetically pleasing.
Fill-in of area with pink wax
will be used to communicate
desired result to the surgeon. A
bone augmentation was
needed to achieve the planned
contour. All guesswork was
eliminated.
Recontouring of the anterior teeth on the
cast will be used to
form provisional restorations, as well as
explain the treatment
goal to the patient and the surgeon.
30

Treatment plan
• Comprehensive treatment plan
must be established prior to start
of the treatment .
• Communication and patient
education are essential in order to
match the dentist’s and patient’s
definition of success
1) Pre-
prosthetic
phase
2) Prosthetic
phase
3) Maintenance
phase
31

Preprosthetic phase
• To develop proficiency in diagnosing the need of occlusal rehabilitation,
periodontist , orthodontist , endodontist , oral surgeon and prosthodontist must
all be integrated in establishing an environment conducive to oral health.
Orthodontic
considerations
Periodontal
considerations
Endodontic
considerations
Oral surgical
considerations
Minor
orthodontic
tooth
movement-
tooth can be
uprighted,
rotated,
moved
laterally,
intruded or
extruded to
improve axial
alignment,
create
favorable
pontic space
and direct
occlusal forces
along the long
axis of teeth.
Scaling and root surface curettage bring back the gingival health.
Surgical crown lengthening - to improve esthetics and provide adequate
retention when clinical crown is short.
Free autogeneous gingival graft - increase width of inadequate attached gingiva
caries,
decalcification,
erosion,
attrition,
abrasion,
exposed root
surface or
fractures -
restore where
required.
Elective
endodontic
treatment may
be necessary for
supraerupted or
malaligned teeth
post and core
Infected root pieces, hopelessly mobile teeth and impacted or unerupted supernumerary
teeth are removed.
Block resection and movement of both maxillary and mandibular segments
Elective soft tissue surgery ,alteration of muscle attachments and alveoplasty
32

Prosthetic phase
Prosthetic full mouth rehabilitation is divided into-
• Immediate treatment
• Definitive treatment
33

Amelogenesis
Imperfecta in a child
impair correct
relationship between
maxillary and
mandibular teeth.
adverse psychological
effect
Postponing
treatment
until
adulthood
IMPORTANCE OF IMMEDIATE
TREATMENT
Ni-Cr crowns
are placed on
first permanent
molars and
second
deciduous
molars to
stabilize
occlusion and
halt attrition.
Vertical
dimension is
not altered.
As anterior
teeth and
premolars
erupt,
polycarbonate
resin crowns
are given
After all
permanent
teeth are
erupted, these
restorations
serve as
transitional
treatment
until
adulthood
34

Vertical Dimension: The distance between
two selected anatomic or marked points, one
on a fixed and the other on a movable
member.
Vertical Dimension of Rest: The postural
position of the mandible when an individual
is resting comfortably in an upright position
and the associated muscles are in a state of
minimal contractual activity.
Vertical Dimension of Occlusion: The
distance between two selected anatomic or
marked points when in maximal intercuspal
position.

Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-285. St Louis, MO: CV Mosby, 1989.
UNDERSTANDING VERTICAL
DIMENSION
• You cannot determine vertical dimension based on whether the patient is
comfortable.
• Measuring the freeway space is not an accurate way to determine the correct
vertical dimension of occlusion.
• Determining the rest position of the mandible is not a key to determining
vertical dimension.
• Lost vertical dimension is not a cause of temporomandibular disorders.

The mandible-to-maxilla relationship,
established by the repetitive contracted
length of the elevator muscles,
determines the VDO.
Dawson P E. Evaluation, diagnosis and treatment of occlusal problems. pp 280-285. St Louis, MO: CV Mosby, 1989 page number 115
The teeth continue
to erupt until they
meet an opposite
force of equal
intensity to the
eruptive force.
The jaw-to-jaw dimension is maintained with such consistent
muscle contraction length that even rapid abrasive wear does not
cause a loss of vertical dimension (A). The alveolar process lengthens in an
amount equal to the wear.

METHODS OF DETERMINING
VERTICAL RELATION
Abduo J, Lyons K. Clinical considerations for increasing occlusal vertical dimension: a review. Australian dental journal. 2012 Mar;57(1):2-10.

Calliper Method Willis gauge Boley gauge
Geerts GA, Stuhlinger ME, Nel DG. A comparison of the accuracy of two methods used by pre-doctoral students to measure vertical dimension. The Journal of prosthetic dentistry. 2004 Jan 1;91(1):59-66.

Phonetic methods
Silverman’s closest
speaking space
• Patient is encouraged to relax his jaws
so that it goes into physiologic rest
position .
• Swallowing and pronounciation of
‘M’ sounds have been used.
• Then the interocclusal distance should
be measured.
40
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.128

Facial appearance
• Diminished facial contours,
thin lips with narrow vermillion
borders and drooping of
commisure are associated with
overclosure where as increased
vertical dimension gives a
stretched out appearance
Neuromuscular perception
• Robert Lytle used centre bearing
device to permit the patient the
experience different comfort levels
during use of different vertical
relations for comparison.
41

Can vertical dimension be altered?
• As the teeth wear or become abraded, the teeth and alveolar bone elongate through growth to
maintain the original vertical dimension with the maintenance of the same closest speaking space.
However, occlusal wear may occur more rapidly than continuous eruption depending upon the
etiology of the wear.
Sicher(1949) and Silverman42(1952)
• Treatment of reduced vertical dimension is not designed to increase the vertical dimension beyond
the normal, but is intended to restore the amount of vertical dimension that has been lost. A young
person will tolerate a greater correction of vertical dimension and become adjusted more easily to
a reduction in the interocclusal distance
Harry Kazis and Albert Kazis
• Closest speaking space can range from 0 to 10mm in different patients and that there is no average
closest speaking space. But it is constant in an individual. Vertical dimension must not be increased
beyond the normal for each patient. . It is better to use a vertical dimension that is too small than
to use one that is too great
Silverman(1956)
42

• stated that increasing the vertical dimension places the muscles of
mastication and temperomandibular joint under strain. The crown to root
ratio is also affected and hence ‘bite raising’ is contraindicated
Landa(1955)
• even when the teeth have grown down to the gum line the vertical
dimension is not lost because of the eruption of the teeth along with the
alveolar bone.It is not practical to restore severely worn dentition without
restoring the vertical dimension to obtain space for the restorative material,
the dimension can be increased to 1-1.5 mm.The potential problems of
restoring the vertical dimension are clenching, muscle fatigue, soreness of
teeth, muscles and joints, headache,intrusion of teeth, fracture of porcelain ,
occlusal instability due to shifting of restored teeth and continual wear. In
such cases, checking and periodic occlusal adjustment must be done upto a
year before normal stability returns.
Dawson(1974)
43

• increased the vertical dimension in natural dentition by cementing acrylic resin
splints in lower canines, premolars and molars for 7 days. He found that subjects
experienced moderate symptoms of discomfort initially but symptoms decreased
later and no clinically demonstrable symptoms were found. He concluded that
moderate increase in vertical dimension of occlusion does not create problem
provided that occlusal stability is provided
Carlsson et al(1979)
• Experiments in animals proved that moderate changes in occlusal vertical
dimension does not cause hyperactivity of masticatoty muscles and symptoms of
temperomandibular dysfunction. Occlusal vertical dimension is a variable range
like other quantifiable aspects of a body.
Rivera-Morales(1991)
44

When Must The Vertical
Dimension Be Changed?
• Extremely worn dentition
• Crown lengthening vs. increasing
the VD
• Restoring severe arch mal-
relationships
• Extreme occlusal plane problems
• Anterior open bite
Why Not Increase The VD?
• Any disharmony in the system provokes
adaptive responses designed to return the
system to equilibrium.
• Adaptive process is not always predictable.
• No benefit over time to the patient whatsoever.
• The goal of occlusal therapy is to minimise the
requirements for adaptation.
• Segmental - instability of the entire occlusal
harmony.
45

Methods of
obtaining space
for restoring
worn teeth
Selective grinding
• Badly worn anterior teeth that have drifted into
anterior wear end to end relationship
• Posterior teeth that interfere, deflect the mandible
forward and cause excessive wear on upper anterior
lingual incline.
• Interferences should be eliminated by selective
grinding so that mandible can close at centric relation
46
Equilibrate Reposition Restore Osteotomy Orthognathics
Bloom DR, Padayachy JN. Increasing occlusal vertical dimension—Why, when and how. British dental journal. 2006 Mar;200(5):251-6.

Periodontal surgery
• Includes gingivoplasty, osteoectomy
to gain clinical crown length is
sometimes required for retention
and esthetics.
• 2-3mm of supporting bone can
usually be removed without
jeopardizing periodontal support.
47

• There are occasionally
situations where
restoration of a worn
dentition can be
accomplished only by
increasing occlusal
vertical dimension, even
though a loss of vertical
dimension is not
diagnosed
Splints and provisional restorations
Removable
occlusal splint
• Given for 6-8 weeks
Evaluated for
comfort and
function
Teeth preparation
and provisional
fixed restorations
• Evaluated for 2-3
months
If deemed absolutely necessary, modification of
vertical dimension should be accomplished through
cautious trials with removable occlusal splints
48

Occlusal splints
Permissive occlusal splints
• have a smooth surface on one side
that allows the muscles to move the
mandible without interference from
deflective tooth inclines into centric
relation.
Directive occlusal splints
• Direct the lower arch into a specific
occlusal relationship that in turn
directs the condyles to a
predetermined position.
• very limited use
• reserved for specific conditions
involving intracapsular TMDs.
49

When occlusal splints are not
necessary?
• No history of problems in the TMJs, including no history
of clicking, discomfort in the joints, restriction or deviation
of jaw movement,
• No intracapsular disorder.
• No sign of tenderness or tension on load testing
• Not necessary to fabricate an occlusal splint prior to
restorative dentistry orthodontics, or equilibration.
Occlusal splint is appropriate:
• If there is doubt about
complete seating of the TMJ
• Long-standing intracapsular
disorder that has been
resolved.
• To stabilize hypermobile teeth
and distribute the loading
forces over more teeth.
50

Fabrication of occlusal splints
• Three very common errors are:
The splint does not fit the teeth properly, so it is uncomfortable or loose, or it rocks
in place.
The occlusal contacts on the splint are not in harmony with centric relation.
An intracapsular structural disorder was not diagnosed, so centric relation was not
achievable.
51

ProcedureTake a verified centric relation
bite record.
Mount the casts in centric
relation with a facebow
Outline the
coverage area
of the base.
Fabricate a
Biostar vinyl
base on the
cast. (An
acrylic or
light-cured
composite
base will also
work.)
Remove the
excess from the
base, but do not
remove it from
the cast.
Place it back on the articulator.
Open the pin enough separate all
posterior teeth from any contact
with the base52

Mix resin and position it on
the base just behind the
upper anterior teeth to
contact and be slightly
indented by lower anterior
teeth in centric relation.
Remove the base and smooth the
edges. Remove undercuts into
interproximal areas.
The completed splint should fit
perfectly and require almost no
adjustment.
53

The splint in place may contact all of the anterior teeth in centric
relation, but there should be no contact on posterior teeth. Slight
adjustment is often needed on the anterior contact area.
It should be smooth and flat to permit the condyles to seat into
centric relation with no back teeth contact. This is an ideal
permissive anterior deprogramming device to use.
If all tension or tenderness disappears after placement of the
splint and there is verification that no posterior teeth are
contacting the splint, it is a good indication that the TMJs are in
either centric relation or adapted centric posture.
It also indicates that the TMJs are not the source of pain.
54

Principles of full occlusal splint design
The design must incorporate
four main principles:
 The splint should allow uniform, equal-intensity contacts of
all teeth against a smooth splint surface when the joints are
completely seated in centric relation.
 The splint should have an anterior guidance ramp angled as
shallow as possible for horizontal freedom of mandibular
movement.
 Occlusal splints for therapy must be worn 24 hours a day
except to eat and brush until the occlusion and the TMJs
become stable.
Stability is determined
by three verifications:
• Elimination of painful
symptoms
• Verification of centric
relation by load testing
• Stability of the bite on the
splint over the course of a
few days (or weeks if joint
damage has occurred)
55

If injury or inflammation has occurred within the
capsule of the TMJ, muscle will attempt to protect the
joint from compressing the edematous retrodiskal
tissue
Anterior deprogramming splint is contraindicated
increases
compressive
loading and also
activates lateral
pterygoid
activity to more
intense protective
contraction.
A full-coverage occlusal splint decreases
compressive loading of the joint, reduces loading
of the joint, and reduces compression of the
retrodiskal tissue
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31.389
56

Dahl appliance
• Partial coverage splint, 2-4 mm thick,
designed to depress the opposing teeth
against which it contacts and to allow
the unopposed teeth to overerupt.
• It contacts anterior teeth and allows
posterior teeth to erupt.
• Alveolar remodeling ensures that
anterior teeth are not intruded into the
bone, with a resulting loss of crown
height
Poyser, N., Porter, R., Briggs, P. et al. The Dahl Concept: past, present and future. Br Dent J 198, 669–676 (2005). https://doi.org/10.1038/sj.bdj.4812371
57

• Dahl described the use of
cobalt chromium appliance
but its modifications of acrylic
and bonded composite have
been used satisfactorily.
• Most space is created between
2-4 months of continuous
wear
58

Centric Relation
• It is defined as “ the maxillo-mandibular relationship in which the condyles
articulate with the thinnest avascular portion of their respective discs with the
complex in the anterior-superior position against the slopes of articular
eminences.
• This position is independent of tooth contact.”
59

Methods available to guide the mandible into
centric relation
1.Chinpoint Guidance method
or one handed technique
• Guichet
• It places the condyles in most posterior and
superior position which can result in trauma to
TMJ.
• not advocated.
2. Unguided method
Brill introduced a muscular position which allows
patient’s natural muscle functions to position the
mandible into centric relation position.
3. Bilateral manipulation method
• Dawson introduced this method in
which the condyles are in their most
superior position in the gleoid fossa.
• Firmness of upwardly directed
pressure at or near the angle of the
mandible to ensure that the condyles
are seated seated againt the eminence
Brit Dent J.1959, vol 106, pg 391-400
60

Method for taking centric bite records
1.the ability of the
operator to manipulate
the mandible
2.the ability of the
patient to co-operate
3.tooth mobility
4.edentulous area 5.condylectomy
6.Occlusal
interferences
Factors
considered
while making
interocclusal
records
Purpose:to capture ,in some stable material ,the relationship of the mandible to the maxilla when the
condyles are in their terminal axis position
61

4 basic techniques for making centric relation
interocclusal record:
1.Wax bite procedures
2.Anterior stop techniques
3.Use of preadapted bases
4.Central bearing point techniques
62

Wax bite procedure
• Most popular procedure (simple)
• Extra hard baseplate wax is an excellent bite
material
• When it is warm it becomes soft enough not
to cause movement of teeth.
• It should be brittle and not bend to mould
itself to fit the models as it will mask the
errors if not rigid.
• This method is not suitable for patients
having extremely mobile teeth or large
edentulous area.
63

Anterior stop technique
• Extremely accurate
• Allows the condyles to seat up without any possible deviation from
posterior teeth.
• When mandible is closed the lower incisors strike against a stop that
is precisely adapted to fit against the upper incisors
• thin enough so that the first point of posterior contact just barely
misses
• Anterior stop may be made from acrylic or hard compound
Very loose teeth
Posterior
edentulous ridges
Patients with
temporomandibular
joint problems
64

Mandibular deprogramming
Ask the patient to bite on these with anterior teeth for 5 -10 minutes.
• The memory position of teeth intercuspation is lost
1) Cotton role
2) Anterior Jig
3) Leaf Guage
65

Anterior bite stops/
Jig
• Anterior jig prevents posterior teeth from occluding and thus disrupts
the proprioceotive memory.
• As the anterior stop is rigid on contact with lower incisor teeth, anterior
resistance is created and a mandibular leverage is created with naturally
braced tripod effect along with two condyles.
• Jig breaks the patient’s habitual closure pattern and acts as the third leg
of the tripod by creating resistance while stopping the closure.
Principle
66

Fabrication of anterior jig
• Compound is softened and added to upper incisors so that their lingual surfaces
are completely covered
• The patient closes into the compound until the posterior teeth barely miss the
contact while in supine position the lower central incisors contact the smooth
lingual incline of the jig at only one point.
• The jig incline must stop the mandible before posterior tooth contact and should
be angled 45-60 degrees posteriorly and superiorly from the occlusal plane.
• The jig can also be made of autopolymerizing acrylic resin on mounted casts and
then adjusted intraorally.
• After the jig is made posterior bite record is taken
67

Leaf Gauge – Dr James.H.Long (1973)
• Previously they were made of
unexposed X- ray films after
developing to remove the emulsion
coating.
• Clear film was then cut into 1 cm X 5
cm sections.
• Recently, leaf gauges of uniform
0.1mm thickness which are sequentially
numbered are described
convenient and measure the exact
vertical opening between the incisors
• Centric relation interocclusal
records
• Occlusal equilibration
• Relieve painful spasms of lateral
pterygoid muscle.
Most useful and practical alternative to anterior jig
68

Procedure
• Arbitary number of leaves are placed at the maxillary anterior midline
parallel to the lingual plane of central incisors. Patient is instructed to
close on back teeth until lower incisors touch on back side of leaf guage.
• Leaves are added or subtracted until patient can barely feel a posterior
tooth touch while closing firmly on leaf guage.
• Often the patient can feel a posterior tooth contact in 15- 52 seconds
after the jaw is closed with a ‘half hard’ closing force.
• This procedure is repeated after adding a leaf guage until the patient can
close for 2-5 minutes without feeling a posterior tooth contact.
69

Power Bite
• Proper use requires precise location of centric relation before closing power from the elevator
muscles is applied.
• starts with a bite record made between the upper and lower anterior teeth.
• a softened compound that hardens after the indentations have been made between the upper
and lower anterior teeth.
• Closure of the jaw must stop short of any posterior tooth contact.
• patient is then instructed to clench tightly to seat the condyles up into centric relation.
• The problem is that if the anterior segment of the bite is made with the mandible displaced
from centric relation, the hardened material locks the jaw into that relationship and prevents
the condyles from moving back and up
70

Use of preadapted bases
• Indicated whenever there is
a danger that teeth will
move or soft tissues be
compressed by the bite
record
• Heated strip of dead soft
wax should be added over it
in edentulous region to
indent the lower teeth in
centric occlusion without
tooth to tooth contact
It is made with triple layer of extra hard
baseplate wax adapted on an accurate model,
usually of the upper arch to avoid
dislodgement by the tongue
71

Manipulated centric relation closure can bring the lower anterior
teeth into contact with the wax.
While holding the TMJs firmly on their centric relation axis, ask the patient
to lightly bite into the wax to form shallow indentations.
Then chill the wax to harden it and add the putty silicone to the preformed
wax base.
Manipulate a verified centric relation and close into the indentations.
The soft putty silicone will adapt to the opposing ridge
72

Central bearing point technique
• It enables free movement of the mandible without
influence of teeth proprioceptives.
• Drawback is that vertical dimension must be increased
considerably to accommodate the clutches and bearing
point apparatus.
• If the terminal axis is not recorded precisely it will
result in mounting error.
If a central bearing point
apparatus is adapted to well-fitted
upper and lower clutches, all
occlusal contact can be
disengaged.
The bite record is
made between
the clutches
rather than
directly between
opposing teeth.
73

Long centric / Freedom in centric
• Defined as ‘ freedom to close the mandible either
into centric relation or slightly anterior to it without
varying the vertical dimension of occlusion.
• When interference in centric relation is eliminated by
equilibration ‘long centric will usually be provided
automatically.
• The most important aspect is that the vertical
dimension of occlusion must be the same from back
to front of each long centric contact area.
74

Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.192,193,195
Contact in centric relation Clearance for long centric
75

Providing long centric by equilibration
• When Interferences to CR are eliminated by equilibration Long centric is
automatically acquired
• Equilibrated patient is free to move into centric or into his original convenience
position or any where in between
• Freedom to do so the mandible will close directly into centric or a few mm
anterior to it , depends on the anatomy and the musculature .
• Length of the long centric is determined by the anatomy of the condyle disk
relationship.
• Equilibration should not cause extensive flattening of the cusps and reduce the
efficiency of chewing for that careful use of small stones on the interfering
inclines only has to be used 76

• studied the positional difference between retruded contact position and
intercuspal positin and found 1.25+1 mm difference between them.
Posselt 1952
• found the initial contact from rest position to be 1 mm anterior to the border
path produced along the transverse horizontal axis.
Schuyler 1959
• advocated freedom in centric relation of occlusion of 0.2 mm which allows
space between condyle and fossa
Dawson 1974
77

Procedure
• To determine the patient’s long centric two different colours of marking
ribbon are used
• green or blue -centric relation points
• Red ribbon -closure from postural rest position
• knife edge inverted cone carborundum stone is used for accurate grinding
• There are no contraindications for providing the freedom.
78

79

Reading the marks
1.Red mark covered by Green
• Indicate that terminal hinge
closure and light closure
from rest are identical
• A Long Centric is not
essential in these cases
2.red mark extend forward from
green centric mark
• Shows a need for long centric
• Should not grind the green centric marks
equilibration complete when there are no red
marks on the inclines
• In perfected occlusion the red marks will still
extend forward from green but at the same
VD
• VD will slightly open posteriorly but very
minimally
Dawson PE. Functional occlusion-e-book: from TMJ to smile design. Elsevier Health Sciences; 2006 Jul 31. PAGE NO.196,197
80

3.Red mark extend forward
from green
• Only reason that the dentist has
not correctly manipulated the CR
4.Green centric marks missing
from red marks
• The equilibration is incomplete
• Teeth with some degree of mobility
are being move when patient taps
• To check mobility different color
ribbon should be used for
comparing light contacts from firm
contacts
81

82

Long centric when occlusion is to be restored
• By preparing all posterior teeth all possibilities of interferences are eliminated
then all that is needed is to correct any inclines on the anterior teeth that cause a
deviation from deviation from terminal hinge closure.
• Properly adjusted centric stops on anterior teeth should be stable enough that not
one of the teeth is jarred when the teeth are firmly tapped together in a terminal
hinge closure.
• If the patient requires the freedom of Long Centric red marks will extend from
the green marks.
• Occlusal inclines restricting mandibular movement are potential stress producers
83

Symptoms indicating
requirement of long centric
• Patient says they are
comfortable when lying down
but interfere while sitting up
• Patient says teeth fit fine when
dentist pushes the jaw back
but hit only on front teeth if
close it themselves
Advantage of long centric
• Freedom of movement in centric
occlusion provides patient
comfort and reduces the tendency
to bruxism and other
traumatogenic influence on the
supporting structures.
84

CUSTOMIZING THE
ANTERIOR GUIDANCE
85

86
The centric relation contacts
• The most critical tooth contour in
the entire occlusal scheme is also
the most universally mismanaged.

Upper half of labial surface
• second most important determination
is upper incisal edge position.
• will not be precise until the upper half
of the labial contour has been
determined.
• There is no bulge in nature from the
alveolus to upper labial surface ie the
upper half of the labial surface is
continuous with the labial surface of
the alveolar process
87

Lower half of labial surface
• two planes - for incisal position and to allow
the lip closure path to slide along the labial
surface hence the need to roll in the incisal tip.
• very important step in determining horizontal
position of the incisal edges
• lower lip can easily slide by the incisal third to
seal contact with the upper lip - lip-closure
path.
88

Incisal edge
• This should rest along the inner vermillion
border of the lower lip and is best determined
by observing the patient to counting from 50 to
55 ie 'F' sound. This needs to be in harmony
with the neutral zone, lip closure path,
phonetics, envelope of function and aesthetics.
89

Anterior guidance Contour of the lingual surface
from the centric stop to the
gingival margin:
• There should be no interferences
with the 'T', 'D' or 'S' sounds.
This is determined by the protrusive path
but should include a 'long centric' that allows
a little freedom before this path is engaged
and so the lower incisors are not bound in
90

Restoring lower anterior teeth
• Lower incisal edges are the
starting point for anterior
guidance and “the view”
when speaking.
• The arrangement of the
entire occlusal scheme starts
with the lower anterior teeth
5 important goals
1. Esthetics
2. Phonetics
3. Occlusal plane
4. Anterior guidance
5. Stability
91

92
The height of the incisal plane
In ideal instances, the lower
incisal edges form a continuous
gentle curve that is an extension
of the posterior occlusal
plane (
Lips sealed
The lower incisal edge is at the height of the
juncture of the upper and lower lips when the teeth are
together. On a lateral cephalometric radiograph, this usually
positions the incisal edge slightly above the functional occlusal
plane.

93
• Speaking • Smiling • Lips slightly parted
“The view” when speaking is of
the incisal
edges of the lower anterior teeth.
A varying amount of labial
contour may also be on display.
The upper teeth are usually
hidden during speech.
Only the upper anterior teeth
are typically on
display during smiling. The
lower incisors are usually
hidden during a big smile.
When the jaw is at rest and the lips
are slightly parted in a half smile, both
upper and lower
labial surfaces are about equally on
display.

94
Lower incisal edge contours
The most important contour on the
lower incisal edges is the
labio-incisal line angle.
The “leading edge”
is important for natural appearance
but also to achieve a stable
holding contact against the upper
lingual stop.
Use of the Esthetic Checklist reminds
the technician to do this on every
lower anterior restoration

95
The entire occlusion can be compromised
by instability if lower incisal edges are not
correct.
It is a critical point for analysis and
treatment of anterior teeth

Determining plane of
occlusion
2 basic requirement
• Permit anterior guidance to
disocclude posterior teeth
when mandible is protruded
• Permit disclusion of all the
teeth on balancing side when
mandible is moved laterally
Curvature of anterior teeth
determined by-
Establishing correct
• smile line
• proper phonetics
• Anterior guidance
96

CURVATURE OF POSTERIOR TEETH
97

Establishing plane of occlusion
3 practical methods
• Analysis on natural teeth through selective
grinding
• Analysis of models with fully adjustable
instrumentation
• Use of Pankey- Mann –Schuyler methods
of occlusal plane analysis.
98

SOPA-simplified occlusal plane analyzer
99

Broadrick occlusal plane analuser
• The Broadrick flag accomplishes the same occlusal analysis
on almost all types of semiadjustable articulators.
(1) Card Index 142-101, (1) Bow Compass
142-1001 with
graphite leads, an extra center point and a
needle point, (1)
Scribing Knife 142-3201 and (12) Plastic
Record Cards 142-
3401
Card index 142-101
Bow
compass 142-
1001 with
graphite leads
100

.
Maxillary cast mounted by
Facebow transfer
mandibular cast mounted in
centric relation
The accessory
Hanau-Mount Split-
Cast Mounting Plate-
This split cast allows
rapid cast removal
and accurate
replacement during
the survey. visual
guide for adjustment
of the Articulator to
protrusive or lateral
interocclusal relation
records
Place the Card Index onto the Upper
Member
with the open end around the incisal pin
and the slot on
the side around the mounting plate
thumbscrew.
Orbitale Indicator be mounted to the articulator, it
must me removed in order to mount the Card Index
Tighten the
thumbscrew to hold the Card
Index in place
Press a Plastic Record Card over the dowels on the
right
side of the Card Index.
The Cards are matte finished on both
sides and readily accept pencil or ink markings.
101

• An average of a 4" radius may be
used in the majority of surveyed
cases.
Variation is necessary only when
pronounced Curve of Spee - 3-3/4"
radius
flat Curve of Spee may require - 5"
radius.
The relatively small divergence between arcs of 3-3/4",
4" and 5" radii over the functional occlusal surfaces on
the lower posterior teeth
102

This point must be selected as the most desirable to “Beam” the line and
plane of occlusion posteriorly.
Once selected, it is marked on the cuspid and NOT CHANGED
Position the center point of the Bow Compass on the anterior survey point
(A.S.P.) which is usually the disto-incisal
of the cuspid,
If the cuspid is worn flat, the A.S.P.
may be at the incisal edge
With the center point of the Compass positioned on the
A.S.P., apply a long arc (about 3”) on the Plastic Record
Card.
The occlusal plane survey center (O.P.S.C.) will ultimately
be located on some point on this arc
103

.
Select the posterior survey point (P.S.P.) at the distobuccal cusp of
the last lower molar
replace the upper cast and place soft
modeling compound over the lower
ridge
Close articulator until the Incisal
Pin contacts the Incisal Guide in a
centric relation
Chill the compound and carve away
the excess, leaving only compound
contacting into the upper fossae
simulating the lower buccal cusp
No molars in
the
mandibular
arch
Remove the upper cast and select a P.S.P. on the modelling
compound in the same manner as the P.S.P. was selected on the last
molar
Position the center point of the Bow Compass
on the P.S.P.
and apply an arc to intersect the arc from the
A.S.P. as
illustrated.
104

Alternate to the molar P.S.P. is a position on the
Condylar
Element of the Articulator, at its anterior
intersection with
the Condylar Shaft
Position the center point of the Compass on this
condylar posterior survey point (C.P.S.P.) and apply
an arc to intersect the arc formed from the A.S.P
Continue with by substituting the needle point for the graphite lead.
105

Place the center point of the Bow Compass, still adjusted to the 4”
radius, at the intersection of arcs on the Plastic Record Card (initial
occlusal plane survey center).
Sweep the the needle point over the occlusal surfaces of the
lower posterior teeth to see how the arc conforms to the
existing occlusal plane.
Shift this occlusal plane survey center (O.P.S.C.) on the
long arc on Plastic Record Card, the A.S.P. line, until the
most acceptable line and plane of occlusion is found.
106

By trial and retrial, in ideal survey center forming the most
acceptable line and plane of occlusion will be located
• move the
center point
anterior to the
arc intersection
To raise the
line and
plane of
occlusion at
the distal end
• move the point
posterior of
the
intersection.
To lower the
line and
plane of
occlusion
The center point of the Bow Compass is now pierced into this
ideal O.P.S.C. on the Plastic Record Card and circled with pencil
or ink for subsequent relocation.
It may be advantageous to mark “R” (right) in the upper corner
of the Plastic Record Card for identification
A Plastic Record Card is then
place over the dowels on
the left side of the Card Index
and marked “L”. Repeat the
survey procedure
107

Measurement of difference between survey lines of
different radii of curvature
Various survey lines obtained from different radii
of curvature
108

Posterior occlusion
• Posterior teeth should have equal
intensity contacts that do not
interfere with either the
temporomandibular joints (TMJs)
in the back or the anterior guidance
in the front.
• The requirements for perfected
posterior occlusions start with the
lower posterior teeth.
Three key determinants
1. Plane of occlusion
2. Location of each lower buccal
cusp tip
3. Position and contour of each
lower fossa
109

Placement of Lower Buccal Cusps
• determined on the basis of providing the optimum effect for buccolingual stability,
mesiodistal stability, and noninterfering excursions.
• Upper central groove position is analyzed.
• On each upper occlusal surface, a line is drawn from mesial tdistal in the central groove.
• The ideal contact point for each lower buccal cusp tip is usually located somewhere on this
line.
• In some tilted teeth, it is advantageous to move the central groove to gain better direction of
forces through the long axis.
• If moving the central groove will enable the stresses to be directed more nearly through the
long axis of any upper tooth, the improved central groove position should be so noted on
the upper cast by drawing a new line.
110
Buccal cusp placement for buccolingual stability

111
• A mark is made on each lower tooth to
indicate the position of the buccal cusp
that would be optimum for buccolingual
stability and direction of force
• Alignment of the optimum lower buccal
cusp position against optimum upper
central groove position is evaluated.
The basic rule to follow regarding the buccolingual
position of the lower buccal cusp is: The lower buccal
cusp must be positioned so that its contact directs the
stresses through the long axis of both upper and lower
teeth.

Mesiodistal placement of lower buccal cusps
• The best mesiodistal stability is attained by
placement of the lower buccal cusps in
upper fossae.
• Placement in the fossae directs the stresses
properly through the long axis, eliminates
any possibility of plunger cusp food
impaction at contact, and is stable.
• There is no tendency for cusp tips to
migrate out of properly contoured fossae
112

Locating the lower buccal cusps
for noninterfering excursions
• Determining which fossa the lower
buccal cusp should contact depends on
where the cusp travels when it leaves
centric relation.
• The mesiodistal placement of each
lower buccal cusp is determined when
one locates it in the fossa that permits
excursions from centric relation
without interference
Contouring cusp tips
113

114
• Placement of lower lingual cusps
• In normal tooth-to-tooth relationships,
the tip of the lower lingual cusp never
comes in contact with the upper tooth.
• Even though the buccal incline of the
lower lingual cusp can be made to
contact in working excursions
• act as a gripper and a grinder by
passing close enough to the upper
lingual cusps to aid in tearing,
crushing, and shearing the food that is
caught between the opposing surfaces.
• The position of the tip should have
enough lingual overjet to hold the
tongue out of the way, but it should
always be located over the root, within
the long axis.
• The measurement between buccal cusp
tip and lingual cusp tip should not be
much greater than half of the total
buccolingual width of the tooth at its
widest part.
• lower lingual cusp height should be
about a millimeter shorter than the
buccal cusp.
• Cusp height can be lowered further in
the first premolar

115
Countouring the lower fossae
• As the mandible moves right or left
from centric relation, its front end
should be guided down the lingual
incline of the upper canine.
• When it serves as the lateral
anterior guidance, the lingual
incline of each upper canine
dictates the fossa contour of each
lower incline that faces it

If Only Lower Posterior Teeth
Are to Be Restored
• Cusp tip position and fossa contours
for lower posterior restorations are
aligned and contoured in relation to
the existing upper teeth on the
opposing cast.
• Lower fossa contours will be
established to conform to the upper
lingual cusps.
• Fossa walls can be carved to be
discluded by the anterior guidance
without complication.
If Both Upper and Lower
Posterior Teeth Are to Be
Restored
• If posterior disclusion is the goal, it is
easily achieved by making fossa walls
flatter than the lateral anterior guidance,
and establishing an acceptable occlusal
plane that permits the anterior guidance to
disclude the posterior teeth in all
excursions.
• After the anterior guidance has been
finalized, the simplest method for ensuring
that fossa walls will be discluded in lateral
excursions is through the use of a
fabricated fossa contour guide.
116

Determining and Carving
Lower Fossa Contours
Purpose
• to ensure a noninterfering
accommodation for the upper
lingual cusps.
• It will provide a fossa contour that
is compatible with the lateral
anterior guidance regardless of the
contour of the anterior guidance.
• It can be easily modified to provide
extra freedom.
Fossa contour guide
• can be used in any stage of wax-up or
even porcelain application.
• used only if both upper and lower
posterior teeth are to be restored
• The anterior guidance must be correct
before the guide is fabricated or before
occlusal contours can be determined
for lower posterior restorations
117

118
Making the fossa contour guide
• The anterior guidance may
be corrected in provisional
restorations, and a centrically
mounted cast of the
provisional restorations in
place may be used to
determine the allowable
fossa-wall angulation for the
posterior restorations.
• The guide is usually made
when the casts are mounted,
but it is not used until the
posterior wax-up is done or
the porcelain is being applied
and contoured.
• Step 1
The regular incisal guide pin is removed and replaced with
the special fossa-contour pin. The blade of the pin is indented into
a mound of wax on a flat plastic guide table

119
The upper bow is moved into left and right
excursions, allowing the contours of the lateral
anterior guidance to determine
the path that the guide pin cuts into the wax.
When the lateral guidance paths have been cut
sharply into the wax, the special pin is raised. It is then used to hold
a handle for the fossa guide. Make the handle by cutting off the tip
of a plastic protector for a disposable needle. The large end fits
snugly onto the raised special pin.

120
Resin is wiped into the hollow end of the handle, and
the pin is lowered so that the two portions flow
together. The resin is allowed to set hard. The guide
can then be removed. The wax on the guide table is
then no longer needed, and so it can be cleaned off
after the guide is removed.
A creamy mix of self-
curing acrylic resin is
flowed into the
indentation in the wax.
Because of the design of the special
wax-cutter pin, the lateral anterior
guidance angle will be evident as a
sharp line running
along the bottom edge of the acrylic
guide. The edge is marked with a
pencil, and any excess acrylic resin
may be ground off in front of the
line.

121
One may actually hollow-grind the front
surface down to
the line to make a scoop-shaped guide,
which is excellent for shaving
out wax from the fossae.
To ensure posterior disclusion, the
fossa walls
must be flatter than the lateral
anterior guidance, so the fossa guide
angle is flattened on the sides and
the tip is rounded to a more
opened-out fossa.
The fossa guide can be used to
contour the wax
patterns or as a guide for shaping
occlusal surfaces in porcelain.
The tip of the guide should be able
to touch the base of the fossa
without interference from the walls
of the fossa.

Carving the marginal ridges
• The ridges should be contoured to
reflect food away from the contact,
which means directing it into the
fossae.
• Sluiceways should provide an
escape route for the bolus out of
the fossae toward the lingual as the
stamp cusps crush the food against
the fossae walls.
Countouring ridges and grooves
• work out the fossae contours first and
then functionalize and beautify the
anatomy by placing the appropriate
grooves at the working, protrusive, and
balancing excursion.
• There can be no entanglement of cusps in
grooves that have been made into inclines
that are already out of reach.
• Other grooves may be added as desired to
improve esthetics or to provide more
ridges for better masticatory function
122

123
Upper posterior teeth
• last segment to be restored. It is the fixed posterior segment, and its cusps, inclines,
grooves, and ridges are placed and contoured to accommodate the many border
movements of the lower posterior teeth.
• If the upper contours are determined by the paths of the lower posterior teeth, both
the form and the paths of the lower teeth should be finalized before the upper teeth are
restored

LENGTH OF GROUP FUNCTION
CONTACT IN WORKING EXCURSION
• If we elect to provide group function on the working side, we should be aware that
all teeth do not stay in excursive contact for the same length of stroke.
• As the mandible starts its move to the working side, all of the posterior teeth may
contact in harmony with the anterior guidance and the condyle.
• As the mandible moves further to the side, the first teeth to disengage from contact
are the most posterior molars.
• The disengagement is progressive, starting with the back molar, which has the
shortest contact stroke, forward to the canine, which has the longest contact stroke
124
Balancing inclines must be relieved
on all natural teeth
regardless of the method used to
record the border
movements.

Types of posterior occlusal contours
There are three basic decisions to make regarding the design of posterior
occlusal contours:
1. Selection of the type of centric relation contacts
2. Determination of the type and distribution of contact in lateral excursions
3. Determination of how to provide stability to the occlusal form
125

Occlusal considerations in full mouth rehabilitation
• There is no one type of occlusion that is optimum for all patients.
• The starting point in designing occlusal contours is to shape and locate the centric
contacts so that the forces are directed parallel to the long axes of the teeth.
• Ideal occlusion can be defined as an occlusion compatible with the stomatognathic
system, providing efficient mastication and good esthetics without creating
physiologic abnormalities ( Hobo)
126

127
Types of centric holding contacts
• Centric relation contact is usually established on restorations in one of three ways:

Types of centric holding contacts
• It is stressful and produces lateral interferences and hence it should be avoided
Surface to surface contact/Mashed potato contact
• Contact is made on sides of the cusps that are convexly shaped.
• can be given in posterior disclusion cases where anterior teeth are strong enough.
• cannot be used when posterior teeth are in group function (convex cusps immediately disengage upon leaving
centric relation.)
• It is difficult with achieve with no actual indications and no advantage over cust tip to fossa contact.
Tripod contact
• It provides excellent function, stability, resistance to wear and aids easy to equilibrate by shaping the fossa
inclines without disturbing the centric holding contacts.
Cusp tip to fossa contact
128

Determinants of occlusal morphology
Posterior controlling factor
• The steeper the articular eminence,
the steeper path will the condyles
follow during protrusion. It is a
fixed factor.
Anterior controlling factor
• The steeper the lingual surfaces of
the maxillary anterior teeth, the
steeper and more vertical will be
the movement of the mandible.
• It is a variable factor and can be
altered by the dental procedures.
129

Vertical determinants of
occlusal morphology
• Anterior Guidance
• Condylar Guidance
• Distance of cusps from these controlling
factors
• Plane of occlusion
• Curve of Spee
• Bennett movement – Amount, Direction
and Timing
Horizontal determinants of
occlusal morphology
• It includes the relationship that influence the
direction of ridges and grooves on the occlusal
surface. Since the cusps pass between the ridges
over grooves, the horizontal determinants also
influence the placement of cusps
• Ridge and groove direction has the influence of
the following factors
• Distance of tooth from axis of rotation
• Distance from mid-sagittal plane
• Bennett movement
• Intercondylar distance
130

Occlusal scheme
Patient presents with Occlusal scheme
Natural canine protected Canine protected
Natural group function Group function
Canine missing or periodontally weak Group function
Opposing complete denture Balanced or monoplane
Where no posterior tooth remaining Canine protected
131

Variations of posterior
contact in lateral excursions
• Arch relationship does not allow the anterior guidance to do its job of discluding the
nonfunctioning side.
Group function
• allowing some of the posterior teeth to share the load in excursions, whereas others contact only
in centric relation.
Partial group function
• can be achieved by two different types of anterior guidance: anterior group function and canine-
protected occlusion.
Posterior disclusion
132
Class 1 occlusion with
extreme overjet
Class 3 occlusion with
all lower anterior teeth
outside of the upper
anterior teeth
Some end-to-end
bites
Anterior open bite
contacting inclines must be perfectly harmonized to border movements
of the condyles and the anterior guidance.
Convex-to-convex contacts cannot be used to accomplish this.

Anterior group function
1. It distributes wear over more teeth.
2. It distributes the stresses to more
teeth.
3. It distributes stress to teeth that are
progressively farther from the condyle
fulcrum.
convex lateral guidances make it
difficult to accomplish.
Canine-protected occlusion
• all lateral stresses must be resisted
solely by the canine.
• capability of the canine to withstand
the entire lateral stress load without
any help from other teeth.
• Exquisitely sensitive nerve endings
protect the canines against too much
lateral stress by redirecting the muscles
to more vertical function.
133

134
Selecting occlusal form for stability

Occlusal equilibration in natural dentition
The term ‘occlusal equilibtation’
• refers to the correction of stressful
occlusal contacts through selective
grinding.
• It is a phase of treatment that
eliminates only that part of tooth
structure that is in the way of
harmonious jaw function.
Objectives
• Centric relation occlusion
• Acceptable disclusion of anterior teeth
in harmony with condylar movement.
• Stability of occlusion
• Resolution of temperomandibular
joint symptoms.
135

Equilibration procedures
divided into four parts
Eliminating
interference to
terminal hinge
axis closure
Eliminating
interference to
lateral
excursions
Eliminating
posterior tooth
interferences
with protrusive
excursions.
Harmonization
of anterior
guidance
136

Interference to Centric Relation
Centric interference can be differentiated into two types-
Interference to arc of closure Interference to line of closure
137

Note the
freedom to close
either in centric
relation or
in maximal
intercuspation at
the most closed
vertical
Interferences to the arc of
closure
138

Interference to the line of closure
139

A balancing incline interference that would be easily
missed if the condyles are not held firmly up on the centric relation axis
during closure
When the condyles are
seated, the right molar is the
only contact during closure.
Squeezing the teeth together
shifts the jaw to
the right and causes the left
condyle to displace.
140

Grinding Rules
Rule 1: Narrow stamp cusps
before reshaping fossae
Rule 2: Don’t shorten a stamp
cusp
141

142

Tilted teeth
Tilted teeth or wide cusp tips can be
adjusted to improve stability
as well as to eliminate interferences. If
the mark on the
upper tooth is buccal to the central
fossa, the buccal surface
of the lower tooth is ground to move
the cusp tip lingually if
the shaping can be accomplished
without shortening the
cusp tip out of centric contact.
Grinding on the upper teeth
only may mutilate upper cusps
unnecessarily
143

Rule 3: Adjust centric
interferences first
1. By adjusting centric interferences first,
you have the option of improving cusp-
tip position.
2. When cusp-tip position is given first
priority, occlusal grinding is more evenly
distributed to both arches.
3. If cusp-tip contours and position are
improved first in centric relation,
eccentric interferences can be eliminated
with speed and simplicity.
Rule 4: Eliminate all posterior
incline contacts. Preserve cusp
tips only.
• If all eccentric contacts on
posterior teeth are to be eliminated,
any posterior incline that marks in
any excursion can be reduced.
• Centric stops must be preserved,
but all other contacts can be shaped
so that they are discluded by the
anterior guidance.
144

Lateral excursion interferences
• The path that is followed by the lower
posterior teeth as they leave centric
relation and travel laterally is dictated
by two determinants:
1. The border movements of the
condyles, which act as the posterior
determinant
2. The anterior guidance, which acts as
the anterior determinant
2 types
BALANCING
SIDE
BULL
WORKING
SIDE
LUBL
determine type of occlusion
Group Function - posterior disclusion
Cusp tips are centric holding stops hence adjustings to be done on fossa inclines
145

PROTRUSIVE
INTERFERENCES
Correction done in case of steep anterior guidance
Grinding rule-DUML
Materials for marking interference
• Ribbons
• Marking paper
• Joffe-marker
• waxes
146

• Works with Denar articulators
• It is preset to 4”
• line drawn on the cast represent an acceptable coclusal plane
• This process is used only if the posterior teeth are to be restored .
• It is never used to determine whether or not teeth must be prepared
147

Schuyler’s principles
1. A static co-ordinated occlusal contact of the maximum number of teeth when
the mandible is in centric relation.
2. An anterior guidance that is in harmony with function in lateral eccentric
position on the working side.
3. Disclusion by the anterior guidance of all posterior teeth in protrusion
4. Disclusion of all non-working inclines in lateral excursions.
5. Group function of the working side inclines in lateral excursions
148

149
Sequence is advocated by the PMS philosophy:
Examination, Diagnosis,Treatment planning and Prognosis
Harmonization of the anterior guidance for best possible esthetics,
function and comfort
Selection of an acceptable occlusal plane and restoration of the
lower posterior occlusion in harmony with the anterior guidance in a
manner that will not interfere with condylar guidance.
Restoration of the upper posterior occlusion in harmony with the
anterior guidance and condylar guidance
The functionally generated path technique is so closely allied with this part of the reconstruction.

Advantages of the Pankey Mann Schuyler
technique:
1. It is possible to diagnose and plan the treatment for entire rehabilitation
before preparing a single tooth.
2. It is a well- organized logical procedure
3. never a need for preparing or building more than 8 teeth at a time
4. It is neither necessary nor desirable to do the entire case at one time.
5. The operator always has an idea where he is at all times.
150

6. The functionally generated path and centric relation are taken on the occlusal
surface of the teeth to be rebuilt at the exact vertical dimension to which the case
will be reconstructed.
7. All posterior occlusal contours are programmed by and are in harmony with both
condylar border movements and a perfected anterior guidance.
8. no need for time consuming techniques and complicated equipment.
9. Laboratory procedures are simple
10. The PMS philosophy of occlusal rehabilitation can fulfill the most exacting and
sophisticated demands if the operator understands the goals of optimum occlusion.
151

Purpose of PM Instrument
1.to engineer the entire oral rehabilitation before a single tooth is prepared
2.Determine the occlusal plane on the lower cast
3.Study and plan the preparations of the lower and upper teeth
4.Orient both the relationship of both arches in centric position with maximum
esthetics and conservation of tooth structure
5.To establish and carve the occclusal plane and curvature in wax patterns
6. to check finished restoratons
152

P-M instrument ( Mann and Pankey)
6.Platform base
Mann AW, Pankey LD. Oral rehabilitation: Part I. Use of the PM instrument in treatment planning and in restoring the
lower posterior teeth. Journal of Prosthetic Dentistry. 1960 Jan 1;10(1):135-50.
1. Main base from which
extends an upright rod
2.upright rod
holding two
assemblies.
3.Horizontal rod
4.Facebow frame
5.Upper cast mounting
assembly
8 A and 8 B Diagnostic dividers and cutting dividers
9.Bite fork joined to a crossbar and two face-bow rods attached to the crossbar.
10. screwdriver wrench
11. Allen wrench
Auxiliary parts of the P-M instrument.
153

P-M face-bow (9) is seated in position
on the lower plaster cast (7) with the
ends of the face-bow rods (9)
approximating the pins in the ends of
the horizontal tube of the face-bow
frame (4).
jackscrews support the cast on the
platform base (6), enabling each
corner of the cast to be raised or
lowered to facilitate adjustment.
Moldine in the center of the
platform base to facilitate the
preliminary cast adjustment.
154

cast (7) is in the same position
Note that the booked end of
the
dividers (8A) is placed in
position in the divider seat on
the horizontal rod (3) and the
straight
end describes an arc of a
sphere, establishing the occlusal
plane (curvature).
155

The occlusal plane (OP.) is the plane passing through
the tips of all major cusps of the lower posterior
teeth.
In the mouth, the preparation plane (PP) guides are
used to facilitate tooth removal down to this plane.
After this, additional tooth substance is removed to
complete the occlusal preparations (F.P.)
Diagram
showing the
amount of
study cast and
tooth
substance to
be removed.
157

master cast is mounted in the same manner
as the study casts were mounted, except the
diagnostic dividers (8A), set at their original
settings, now sweep l/l6 inch above
tips of the cusps of the prepared teeth.
optimal functional
occlusal curvature has
been established, and the
deformity has been
eliminated. Note the
improved cusp-to-fossae
patterns providing
optimal functional
efilciency.
(The right third molar was
disregarded because it was
not in occlusion.)
Casts before and after complete lower posterior
rehabilitation
Before treatment there was
a “swayback” functional
occlusal curvature caused by
a premature loss of the
lower first molar and a
perpetuation of the
deformity in the original
fixed partial denture
158

Functionally generated path
It is a method of rehabilitating the upper posterior teeth using ‘
functionally generated path ’ record based on a modification of
the principles outlined by Meyer and Brenner in 1933
Functionally generated path relies on recording in a simple,
yet precise manner the pathways traveled by the cusps in the
border movements of the mandible.
Pankey LD, Mann AW. Oral rehabilitation: Part II. Reconstruction of the upper teeth using a functionally generated path technique. Journal of
Prosthetic Dentistry. 1960 Jan 1;10(1):151-62.
Meyer FS. The generated path technique in reconstruction dentistry: Part II. Fixed partial dentures. Journal of Prosthetic Dentistry. 1959 May 1;9(3):432-40.
Meyer FS. The generated path technique in reconstruction dentistry: Part I: Complete dentures. The Journal of Prosthetic Dentistry. 1959 May 1;9(3):354-66.
159

Tooth is ready for the
functional tracing when the
occlusal reduction is
completed
A square of tacky wax is positioned
over tooth being prepared
Tracing is begun
by having the
patient close in
the retruded
position
Paths of the cusps
in working
excursion are
recorded. The area
and direction of
these excursive
movements are
demonstrated by
fine lines in the inset
160

Path of cusps in non working
excursions are recorded next Protrusive paths are
recorded last
Paths of the cusps in
working excursion are
recorded.
161

Unneeded portion of the
functional index tray is
broken off
The functional core is
begun by brushing
mounting stone on the
functional tracing
The tray is held in position
while the stone sets
Excess mounting
stone is trimmed from
the functional core
The bite registration frame
is held while the bite
registration paste sets
Cast is placed in wet
stone in Dilok tray
Cast with prepared tooth
is mounted on the lower
member of the twin
stage occlude. Anatomic
cast is seen on upper left
member and functional
core on the upper right
member
162

Axial contours and proximal
contacts are checked before
preceding to the
occlusal surface.
The wax added technique
is used to form the
occlusal morphology.
Now the occlusal portion of
the wax pattern cab be
completed by waxing against
the functional core.
The functional core is painted
with white liquid shoe polish
To mark the wax pattern, the
freshly painted functional core
is closed against it
Restoration is adjusted to fit
against the functional core
Occlusal
contacts on
the wax
pattern for
mutually
protected
occlusion A,
and
unilaterally
balanced
occlusion B.
163

Hobo’s Philosophy
• They believed in posterior disclusion
in eccentric movements
• Posterior disclusion is dependent on
the angle of hinge rotation created by
the angular difference between
anterior guidance and condylar path,
and on inclination and shape of
posterior cusps, which helps in
controlling harmful lateral forces.
164

165
• In this case, during the protrusive
movement the mandible does not rotate
around the intercondylar axis but only
translates.
• Translation as defined means "parallel
displacement of a body" (the mandible).
• Since maxillary and mandibular molars
slide in contact during eccentric
movement, disocclusion does not occur

166
• In this case, the mandible translates and
rotates around the intercondylar axis; the
maxillary and mandibular molars
dlsocclude.
• McHorris (1979) Incisal path should be 5
degrees steeper than the condytar path.
• However, when setting the sagittal lncisal
path inclination 5 degrees steeper than the
condylar path, the amount of disocclusion
during protrusive movement is only 0.2
mm, about one-fifth the standard value
(1.0 mm).
• If the incisal path is steeper than 5
degrees, the patient will complain of
discomfort.
Anterior guide component

167
• In this case, the mandible does not
rotate around the intercondylar
axis, it only translates.
• However, since the cusp angle is
shallower than the condylar path,
the maxillary and mandibular
molars disocclude.
• Thus, the component influencing
the amount of disocclusion when
the cusp angle is shallower than the
condylar path is referred to as the
cusp shape component as a
mechanism of disocclusion.

168
• This shows the case when the
sagittal inclination of the condylar
path is 40 degrees, the incisal path
is steeper than the condylar path
and the cusp angle is shallower than
the condylar path.
• In this case, the mandible translates
and rotates simultaneously around
the intercondylar axis.
ANTERIOR
GUIDE
COMPONENT
CUSP SHAPE
COMPONENT
WIDE
DISOCCLUSION

169
Influence of the amount of disclusion
Cusp
angle
Incisal
path
Condylar
path
Dependent factors
NON WORKING
SIDE
WORKING ISDE

Twin-tables technique -Hobo (1991)
• Posterior teeth are restored using
two customized incisal tables:
without disclusion; and with
disclusion
• They did not include freedom in
centric.
Limitations
• The cusp angle was fabricated parallel
to the measured condylar path, and the
cusp angle became too steep
• To obtain a standard amount of
disclusion with steep cusp angle, the
incisal path has to be set at an angle
that is extremely steep
• The customized guide tables were
fabricated by means of resin molding.
• Was technique sensitive
170

Standard values of effective cusp angles on molars
• The cusp angle was then considered more reliable ( value of cusp angle at the time
of eruption was used as a reference for occlusion)
• The value of cusp angle was then found by trigonometry.
• The standard cusp values were summarized as standard values of effective cusp
angles on molars-
Cusp angle Cusp angle on molars
(deg)
Protrusive effective cusp angle 25
Working side effective cusp angle 15
Non working side effective cusp angle 20
171
a standard value for cusp angle
was determined such that it may
compensate for wear of natural
dentition due to caries, abrasion
and restorative works.
By using the standard cusp angle,
it was possible to establish the
standard amount of disclusion

Twin – Stage Procedure
Hobo and Takayama 1989
Advanced version of the Twin-Table
technique
A kinematic formula to calculate anterior
guidance from condylar path
Incorporated easily with commonly used
clinical techniques such as facebow
transfer, various centric recording
methods, and cusp-fossa waxing
INDICATIONS
• single crowns
• fixed prosthodontics
• Implants
• complete-mouth reconstructions,
• complete dentures
Contraindicated for malocclusion cases
172
Hobo S (1991) Twin-tables technique for occlusal rehabilitation.Part I: mechanism of anterior guidance. J Prosthet Dent 66:299–303

173
• In order to provide disocclusion, the cusp angle should be shallower than the condylar
path.
• Since anterior teeth help produce disocclusion, when waxing of the occlusal
morphology is done, to produce shallow cusp angle, the anterior portion of the
working cast becomes an obstacle - cast with a removable anterior segment is fabricated.
Different adjustment values of an articulator were determined for each occlusal scheme to reproduce the standard amount of disclusion

Condition 1
• The occlusal morphology of
the posterior teeth without
anterior segment is produced
so that the cusp angle is
coincident with the standard
value of effective cusp angle.
This is referred to as
‘condition 1’
Condition 2
• Secondly, the anterior
morphology of the anterior
segment is produced to
provide anterior guidance
with standard amount of
disocclusion. This is referred
to as ‘ condition 2’
The application of the two conditions described to fabricate the cusp angle and anterior guidance are termed as ‘
twin stage procedure
174

Factors that determine
disclusion
• Angle of hinge rotation
• Cusp shape factor
• Anterior guidance is steeper than condylar
guidance.
• The mandible rotates around the
intercondylar axis .
• The fact that compensates for the
difference in steepness is the angle of
hinge rotation
Cusp shape factor
• Posterior teeth disclude only when the
cusp inclination of the molar is parallel to
the condylar path and anterior guidance is
steeper than condylar path.
175

During protrusive movements,
condyle rotates
along horizontal axis if anterior
guidance (/?) is steeper than
condylar path ((Y). Angle of hinge
rotation compensates for
this angular difference.
During protrusive movement,
condyle translates
without rotation when anterior
guidance (~3) and condylar
path (fi) are parallel.
176

When cusp inclination of molars
is parallel to anterior guidance,
there is no posterior disclusion
despite
steeper anterior guidance (fi)
than condylar path ((Y).
Posterior disclusion is evident when
cusp inclination of molars is parallel
to condylar path and anterior
guidance (8) is steeper than condylar
path ((Y).
177

Contraindications
• In the above contraindicated cases, the
vertical axis of the posterior teeth may have
inclined abnormally.
• As a result, the effective cusp angle may vary
to some extent even though the cusp angle
of a n atural tooth varies minimally.
• In such condition The standard effective
cusp angle presented in the twin-stage
procedure may not be applicable - occlusion
of a restoration may be inaccurate
178
• Abnormal curve of Spee
• Abnormal curve of Wilson
• Abnormally rotated tooth
• Abnormally inclined tooth

Evaluation of twin stage procedures
The articulator test
• In the articulator test, after completion of
the posterior occlusal wax-up on casts
mounted on an articulator (under
Condition 1 ), and adjusting the articulator
(under Condition 2), the specific amount
of disocclusion occurring during various
eccentric movements was determined.
• This is an in vitro test.
The intra oral test
• In the intraoral test, when the results of
test 1 were completed and satisfactory, the
restoration made on the articulator was
cemented in the patient's mouth.
• Then it was tested to determine if the
amount of disocclusion was reproduced as
occurred in test 1 .
• This is an in vivo test.
179

Solving deep overbite
problems
• Care must be taken to maintain neutral zone relationship of upper anterior teeth.
• Deep overbites are almost always related to strong lip pressures and a tight neutral
zone.
• Phonetic relationship of incisal edges is critical for deep overbite patients.
• Supraeruption of lower incisors often requires correction.
• If lower incisors are shortened, stops must be provided.
• If stops cannot be provided, a removable substitution may be needed to prevent
supraeruption, or splinting may be considered.
183

Applying the principles
• A poorly made anterior fixed bridge with no holding contacts.
• The lower incisors erupted up to impinge on gingival tissues.
• The lower lip position is behind the upper incisors because the tight neutral zone
prevented the lip from fitting in front for a normal lip seal.
• The result was very unaesthetic as well as unstable.
184

The first treatment option:
Reshape
 It is often necessary to
reshape the lingual of upper
restorations to provide a
holding contour and
shorten the lower incisors if
they have erupted up too far
to make contact.
The second treatment option:
Reposition
• If the upper incisors have
been wedged forward,
they can be moved back so
lower incisor contact can
be achieved.
• Changes the neutral zone
as the lower lip will be able
to slide in front of the
labial surfaces to hold
them back as the lips seal.
The first goal of treatment is to achieve stable holding contacts on all anterior teeth.
185

• A simple but effective appliance for
moving the anterior teeth back into
a predetermined position against
contoured slots in the palatal part of
the appliance. A rubber band directs
the teeth into the slots.
The complete lack of holding
contacts on the straight lingual
contours of the original
restoration.
The anterior teeth are brought
lingually, their lingual contours
has to be recontoured to permit
anterior teeth contact into a stop.
186

• Teeth are prepared and
provisional restorations are
used refine the anterior
guidance and esthetic
concerns.
The third treatment option: Restore
• After the teeth have been brought
into an acceptable alignment by
reshaping and repositioning.
To achieve contact on all lower
anterior teeth, it is often necessary
to move one or more teeth
forward. Any tooth that is
not in contact will supraerupt.
187

After the teeth have been
repositioned for centric
relation contact, the final
details are worked out in
provisional
restorations. The patient may
wear the provisionals as long
as necessary to determine that
they are comfortable,
functional,
and esthetically acceptable.
After approval, the details must be communicated precisely to the technician via
casts of the approved provisional mounted in centric relation.
A putty silicone index communicates the exact incisal edge positions.
A customized anterior guide table communicates the lingual contours, leaving
nothing to chance for fabrication of the finished restorations.
188

Deep overbite with tissue contact
• Lower incisors erupt up into soft tissue
lingual to the upper anterior teeth. It is not
a problem if:
 The upper lingual tissue has been
unaffected by the contact.
 The contacted tissue is dense, firm, flat,
and shows no sign of inflammation.
• The lower incisor tissue contact is
simultaneous with contact against the lingual
surface of the cingulums of the upper
incisors.
• The incisal edges of the lower incisors are
smooth with no sharp edges.
• The incisal plane of the lower anterior teeth
is acceptable esthetically and must be in
conformity with the rest of the occlusal
plane.
189

190

191

192

Deep overbite problems associated with an
anterior slide
• Such a problem calls for a three-step solution:
1. We must equilibrate to permit the mandible to close without deflection from posterior
teeth.
2. We must shorten the lower incisors to position the incisal edges in an optimum
relationship to previsualized centric stops on the upper incisors.
3. We must restore the upper lingual contours to establish stable centric stops
193

Solving deep overbite problems
by splinting
• Teeth that have supraerupted into the
palatal tissue can be shortened to
relieve the pressure against the soft
tissues.
• Splinting is often the most practical
method of stabilizing such lower
anterior teeth.
Includes
• Full coverage
• Resin bonded lingual restorations
• Modifications in partial denture e.g.
continuous clasp splinting and
Swing-lock design.
194

Bite planes to solve deep overbite problems
• Discomfort from tissue impingement and if future problems are imminent.
• Least complicated way of preventing supraeruption of the lower anterior teeth.
• Fabrication is carried out on centrically mounted models.
• The appliance is most esthetically acceptable when it is made of clear acrylic resin. It must provide
stable centric contacts for all lower teeth, and it should be equilibrated so that there is no interference
to any excursive movement.
195

Partial dentures to solve deep
overbite problems
• When an upper partial denture is required, it can sometimes fulfill a double purpose by
serving as a contact for the lower anterior teeth.
• Palatal bar is designed to cover the tissues behind the upper anterior teeth, the lower anterior
teeth may be permitted to contact the palatal bar to prevent supraeruption.
• The contour of the palatal coverage may be designed to permit protrusive excursions of the
lower anterior teeth to slide smoothly from the palatal coverage onto the lingual inclines of
the upper anterior teeth.
196

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