FIXED PROSTHODONTICS .

OPERATIVE DENTISTRY
SECTION EDITORS

GORDON 1. CHRISTENSEN H. WILLIAM GILMORE

SAMUEL E. GUYER WILLIAM LEFKOWITZ WILLIAM F. I’. MALONE

An evaluation of 50 years of reconstructive dentistry.

Part I: Jaw relations and occlusion
Jerome M. Schweitzer, D.D.S.
New York, N.Y.

1 he past 50 years have witnessed the introduction difficult. The remaining natural teeth may be in
of many concepts intended to improve the quality of incorrect positions. The ability to create a harmoni-
dental care. Most innovations have been directed ous interocclusal relation may tax the ingenuity of
toward occlusion and have been promulgated to the most experienced and careful dentist.
maintain and/or improve periodontal health. The An experienced dentist may know when the man-
practice of reconstructive dentistry and the introduc- dible is correctly related to the maxillae. This is a
tion of occlusal theories have coincided for half a three-dimensional relation which involves lateral,
century. Reconstructive dentists have enjoyed the anteroposterior, and vertical placement. Many
rare opportunity to evaluate the proposed preventive methods have been described to attain a correct
and therapeutic values of the theories. centric relation.
This article represents a critical evaluation of the
theories of occlusion by a reconstructive dentist Interocclusal distance
based on 50 years of experiences. There is a space between the maxillary and
mandibular teeth when the mandible is in its physi-
OCCLUSION DEFINED ologic rest position. This is the interocclusal distance,
No subject has received more attention or created a basic requirement for successful prosthodontics. An
more controversy than the functional and nonfunc- overextended interocclusal distance prevents muscu-
tional movements of the mandible. Occlusion may lar relaxation; an overshortened interocclusal dis-
be defined as “contact of the maxillary and man- tance causes an overrelaxed musculature. In either
dibular teeth in closure, a static position.” Articula- instance, the neuromuscular tonus is disturbed. An
tion refers to “the mandible in motion, a kinematic incorrect interocclusal distance reflects itself in the
relation.” Both occlusion and articulation are essen- muscles of expression and, therefore, in esthetics.
tial to interocclusal relations. Mastication clarifies
the definitions. While chewing is in effect, the laws of Function
motion prevail. This is articulation. After the bolus In addition to comminution and deglutition, func-
has been adequately cornminuted, it is swallowed, tion of the stomatognathic system includes speech,
and the maxillary and mandibular teeth meet in full breathing, coughing, and sneezing. People should be
contact. This is occlusion. unaware of the oral cavity unless health factors
intervene. The sense of “oral comfort” includes
ESSENTIAL CONSIDERATIONS physical and psychologic sensations.
Centric relation
A correct centric relation is a major requirement Systemic factor
for successful prosthodontics. This exists when the Accumulated observations and records refute the
maxillary and mandibular teeth are in maximal concept that correct interocclusal relations alone
contact. Teeth occlude frequently, not only in mas- portend good dental health. Apparently the nebu-
tication, but throughout the day during the act of lous systemic factor influences results. Given a good
swallowing. For the edentulous patient, teeth may be systemic factor, the interoccclusal relations assume
arranged to provide maximal contact in centric secondary importance. On the other hand, patients
relation. For dentulous patients, this may be more with excellent occlusal relations but a subnormal

OOZ-3913/81/040383 + 06$00.60/00 1981 Tbe C. V. Mosby Co THE JOURNAL OF PROSTHETIC DENTISTRY 383
 adjusted with wax records, and they may be SUCCXS+
fully used for fixed and removable partial den-
tures.
A semiadjustable articulator should accommodate
the Bennett movement even though it may bc

compromised by using an arbitrar? formula or

similar device. The face-bow is an important adjunct
to the semiad.justahle articulator.

Temporomandibular joint
The temporomandibular joint (‘I‘MJ) exercises
control over rotational jaw movements when the
working condyle is braced superiorly and anteriorly
against the glenoid fossa. Only then are the indepen-
dent TMJ axes in control of the arc of closure. The
Fig. 1. Centric occlusion of a 5.5year-old patient with terminal functional movements of closure are con-
full complement of teeth. stant and repeatable. All others arc erratic and.
therefore, cannot be mechanically- reproduced.
Eccentric jaw movements are nonfunctional and
systemic factor experience deterioration regardless of have little value.
therapy. We have not yet discovered what consti- Cinefluorographic studies of the masticator);
tutes a good systemic factor, but we do know that it movements of the mandible demonstrated that the
is not the local environment. condyle paths are erratic as controls in articula-
tion.’ Burgess’ regarded condylar grtidancc as :A
Psychologic influences mvth.
Failure may be attributed to psychologic factors
when therapy cannot be completed or when the SECONDARY CONSIDERATIONS
treatment has been unsuccessful without a reason- Occlusion and periodontal pathosis
able explanation. Although dentists cannot be Faulty occlusion is presumed to be largely respon-
expected to serve as psychiatrists, the limit of their sible for periodontal disease. Correcting occlusal
obligation to such patients should be clearly defined. discrepancies has become the “major aim of dentist-
Permitting patients to fully express themselves q.“” Clinical observation denies this concept. The
before treatment often exposes emotional problems. etiology of periodontal disease is unknown. It is often
The dentist may decline to treat the patient, estab- related to the “systemic factor.” Only in selected
lish the possibility of withdrawal if an emotional patients has periodontal disease been eliminated by-
obstacle precluded proper treatment, or refer the correcting interocclusal variants. Despite this obser-
patient for psychiatric therapy in conjunction with vation: the concept that most periodontal problems
dental treatment. are created by occlusion persists.
The effect of occlusal trauma has been well
Articulators defined by Glickman’ who stated that the problem is
All articulators are subject to error in manipula- not occlusion but whether occlusion causes injury to
tion and transfer of records. The accuracy of creating the periodontium. Trauma may occur when the
an articulation depends upon a concept of occlusion. occlusion appears to be “normal.” A dentition may
Years of experience dictate caution in accepting a be anatomically and esthetically correct and still
specific theory. Good results have been attained be functionally injurious. Malocclusions are no1
using diverse techniques and articulators. necessarily injurious. If the periodontium can
By far, most patients are successfully treated by accommodate an increased occlusal force, it is 1101
well-established methods of conformative dentistry traumatic.
created on simple articulators. The semiadjustable The accusation that functional chewing is respon-
articulators, such as the Hanau H or similar instru- sible for injury cannot be supported by the experi-
ments, embody conventional ideas. They are simple ence of years of practice. Bruxism, defined as “grind-
to operate, compact, and durable. They may be ing, clenching, and gritting the teeth” during much

384 APRIL 1981 VOLUME 45 NUMBER J

JAW RELATIONS AND OCCLUSION

of the day and night seems to be the chief offender

where deterioration of the supporting tissues is
suspected of being caused by traumatic interocclusal
relations.
The dental literature is replete with occlusal
concepts and theories designed to improve and
maintain periodontal health. None of these enjoys
universal acceptance as each has defects. The follow-
ing comments resulted from dissents in the literature
and from personal experiences.

Pantographic tracings
These are pin-on-plate records of jaw movements.
The pins of the pantograph provide the direction of
mandibular movements.” The applied force over a
simple bearing point, a fulcrum, precludes normal
Fig. 2. Left working occlusion. There is no canine lift.
mandibular movements. To overcome lateral inter-
ferences, the increase in vertical dimension may
bring the condyles anterior to their rest position
and/or centric relation.

Axis orbital or cranial plane

Three points of reference are required to orient an
object in space. That requirement is served by the
hinge axes and any anterior point. Two theories of
occlusion refer to the axis orbital or cranial plane.”
Other theories fail to mention them. The Hanau H,
Kinescope, and Condylator make no provision for
the plane. However, the notch on the incisal pin
serves as the third point if the incisal edges of the
maxillary anterior teeth are on a level with the
notch.

Bennett movement Fig. 3. Right working occlusion. There is no canine

There are several descriptions of the Bennett lift.
movement.‘-” Every possible movement from lateral
to upward, downward, backward, or forward has produce a nontraumatic relation. Among the con-
been attributed to the Bennett movement. Sicher”’ cepts advanced to produce the desired relation are
proposed that its cause results from the time lag the following:
between contraction of the nonworking pterygoid 1. Segmental occlusions-functional contact of
muscle and the working temporal muscle. Schuyler* groups of teeth at one time
considered the Bennett movement unimportant 2. Bilateral balances-simultaneous contact of all
because of the small distance between the TMJ and teeth in function
the occlusal surfaces of the teeth. Obviously there is 3. Terminal functional orbit-contact of all teeth
disagreement on the Bennett movement and its only when they engage in the final 1 or 2 mm of
effect on occlusion. closure
4. Group functions-contact of the teeth from the
Nontraumatic relations canine posteriorly only on the working side
Patients with a traumatic interocclusal relation with the balancing side out of contact in lateral
require adjustment of occlusion and jaw position to excursion
5. Canine protections-maxillary canines acting
*Schuyler, (:. H.: Personal communication, March 9, 1977. to prevent attrition of the posterior teeth and in

THE JOURNAL OF PROSTHETIC DENTISTRY 385

 SCHWEITZEI?

teeth in lateral or bruxing excursions. In protrusion,

the articular eminences and vertical overlap of rhr
incisors determine the disclusion of the posterior
teeth. These concepts were apparently based on the,
work of D’Amico.” However, in a frame-by-framP
motion picture analysis made on 100 young people.
81% demonstrated working side contact (group fum-
tion).” Most of my patients over 54 years of age, who
presented with normal occlusion and good periodon-
tal health, also presented occlusal contact in lateral
excursion. Fig. 1 shows the dentition of a Xi-year-old
patient. She was first seen 22 years earlier. Her
periodontal health was good, and radiographic
examination showed no bone loss. Her oral healtil
remained static, and at 55 years of age the ratlio-
graphs confirmed that the peridontium remained
Fig. 4. Left view of dentition at start of reconstruction unchanged. Figs. 2 and 3 show the right and lef-t
lateral excursions. There was no canine lift. This was
the rule rather than the exception for patients this
age and older. Apparently. canine protection of
posterior teeth occurs in young people. As a result of
the canine protection concept, there is a trend
toward stressing the vertical aspect of chewing.
Nevertheless, contrary theories reject the concept of
canine protected occlusion.’ ’ ”
Recent investigation showed that most perfora-
tions are on the lateral aspect of the articular disk.’
This indicates that the TMJ is a stress-bearing joint.
Posterior cusps on the working side in group function
may provide protection for the TMJ during mastica-
tion.
The Pankey-Mann-Schuyler theory* differs on the
function of the canines. This concept indicates that
the role of the canines is to guide the posterior teeth
in lateral function and to provide contact of the
canines and posterior teeth. When possible, all ante-
Fig. 5. Right view of dentition at start of reconstruc-
rior and posterior teeth on the functioning side are in
tion.
simultaneous, even contact without contact on the
nonfunctioning side.
lateral movement, canines causing the posterior
Gnathologic concept
teeth to separate
6. Action of canines in forming posterior interoc- Comparing the gnathologic and neuromuscular
clusal relations, with canines guiding, and concepts of occlusion, SilvermanXh concluded that
directing formation of cusp carvings of the mandibular manipulation may alter normal occlu-
posterior teeth, and canines and posterior teeth sion to create a pathologic condition, since it tempo-
having simultaneous contact in lateral excur- rarily places the mandible in its most retruded
sions on the working side. position out of centric relation. He added thar
tap-tapping is the most effective method to pinpoint
Canines
Several theories relate to canine lift, or canine
guidance, which causes disclusion of the posterior *Schuyler, C. H.: Personal communication, March 9, 1977

386 APRIL 1981 VOLUME 45 NUMBER 4

JAW RELATIONS AND OCCLUSION

Fig. 6. Cutting edge of razor blades resting in central Fig. 7. Razor blades reinforced with dental stone in
grooves of casts of mandibular teeth. maxillary arm of articulator. Movement of maxillary arm
creates working and balancing occlusions.

horizontal relations between maxillary and mandib-

ular teeth. Standard and Lepley” also stated that the
first movement from rest position to occlusal contact
is upward and vertical.
Not all advocates of current theories support the
concept of cusped teeth. Some propose that with
time cusps become unnecessary. This differs from the
concept that interdigitation of cusps maintains sta-
bility of occlusion. Contrary opinons suggest that the
function of the cusps is to guide the teeth into their
occlusal relations.“. ‘$’ Wear of the cusps produces
the curves of Wilson and Monson and also eliminates
premature contacts.
In 1942, I reconstructed the dentition of a patient
using the blade method advocated by Schuyler.”
This technique uses razor blades to create the
working and balancing occlusions. Figs. 4 and 5
illustrate the oral health of the patient upon presen- Fig. 8. Completed mandibular restorations.
tation. The radiographs confirmed existing perio-
dontal pathosis. The original casts were mounted on the working and balancing occlusions (Fig. 7). The
a Hanau articulator. Fig. 6 shows the mandibular occlusal surfaces of the restorations conformed to the
cast in place and two razor blades, shaped to working and balancing occlusions. All cusps were
conform to the anteroposterior curvature, set in the eliminated. The masticatory effectiveness was
central grooves of the cast of the posterior mandibu- obtained by creating sluiceways, embrasures, and
lar teeth. The razor blades were secured with dental grooves. Figs. 8 and 9 illustrate the completed
stone so that moving the maxillary arm of the restorations, while Fig. 10 shows the reconstruction
articulator scraped the mandibular cast to establish in situ. The result has been excellent. It is now 37

THE JOURNAL OF PROSTHETIC DENTISTRY 387

 and wax interocclusal records as well-as provide f;)r
adjustable condyle paths, incisal table, and a form of
Bennett movement. Once ad.justed, it should re&rk
the position.
REFERENCES
1. Kowumaa, K. K.: Cinefluorographic analysis of the ma&
catory movements of the mandible. &omen Hammaelaak.
Torm 57:306, 1961.
2. Burgess. J. K: Discussion of Frahm, F. W.: lncisal gurd-
ante-Its influence in compensation and balance. J Am Dent
Assoc 13:782, 1926.
3. Lucia, V. 0.: The fundamentals of oral physiology and their
practical application in the securing and rqxoducing of
records to be used in restorative dentistry. ,J PKOSTI~T DI.\I
3:213, 1953.
4. Glickman, 1.: Clinical Periodontology. Philadelphia, lOi?
Fig. 9. Completed maxillary restorations
W. B. Saunders Co., pp 339-340.
5. Page, H. L.: Commentary no. 29, May 1966.
6. Schweitzer, Jerome M.: Concepts of occlusion: A discussion.
L>ent Clin North Am, Nov 1963, pp 649-671.
7. Granger, E. R.: Centric relation. ,I PROSOIE.I DENI 2~169.
1952.
8. Lucia, V. 0.: The fundamentals of oral physiology and their
practical application in the securing and reproduction of
records to be used in restorative dentistry / Prws-rtrrr I)I-~I
3:23@, 1953. p 230.
9. McCollum, B. B.: Fundamentals unsolwd in prescribing
restorative dental remedies. Dent Items Int 48, 1940.
10. Sicher, Harry: Position and movements of the mandible. j
Am Dent Assoc 48:625. 1954.
II. D’Amico, A.: The canine teeth. normal functional relation ol
the natural teeth of man. J South Calif State Dent .Awx
26:7, 1958.
12. Weinberg, L.: A cinematic study of centric and eccentric
occlusion. J PROSTWET DENT 14:290. 1964.
13. Stallard, H., and Stuart, C. E: Eliminatirlg tooth guidance
Fig. 10. Completed reconstruction in situ in natural dentition. J PROSTHFT DENI 11:474; 1961.
14. Schuyler. C. H.: The function and importance of incisai
guidance in oral habitation. ,J PROSNFT DLN.T 13:1011
years since treatment, and the reconstructed denti- 1963.
15. Agerberg, G., Carlsson, G. E., and I-lass&r. 0.: Vascular~-
tion continues to function well.
zation of the temporomandibular disk. A rrlirroarlgiographic
study of human autopsy material. Sartvrk Udontol Tidskr
SUMMARY AND CONCLUSIONS
77:5, 1969.
Many concepts and theories have been pro- 16. Silverman, M. M.: Comparative accuracy of the gnatholq-
pounded to enhance reconstruction of the dentition. ical and neuromuscular concepts. J Am Dent Assoc 96:5.59.
1978.
Some have been put to practice; others have been
17. Standard, S. J., and Lepley, J. B.: The free-way space and its
rejected. relation to the temporomandibular articulator. ,J PXOSTHE?
All reconstructive procedures must be acceptable DENT 5:20, 1955.
to the TMJ, the neuromuscular complex, and the 18. l’aylor, R. M. S.: The signiticance of tooth wear in Polyne-
periodontium. A correct centric relation and vertical sians. A review. Ann Dent 35:5, 1976.
19. Begg, P. R.: Stone age man’s dentition. .4m .J Orthod 40:298,
dimension are critical to success.
1954.
A major objective is to provide adequate function. 20. Schweitzer, J. M.: Oral Rehabilitarion. St. I,ouis. 1951, The
The concept of occlusion and related articulation C. V. Mosby Co.. pp 101 l-l 11.5
seems to play a secondary role. The best result occurs
Reprint requests to:
when the patient is unaware of the oral cavity and DR. JEROME M. SCHWEITZER
enjoys the esthetic result. 745 FIFTH AVE.
A usable articulator should accept the face-bow NEW YORK, NY 10022

388 APRIL 1951 VOLlJME 4.5 NUMBER 4