Fixed partial dentures and operative dentistry

Occlusal analysis and restorative dentistry

Benjamin V. Braly, D.D.S.* University of California School San Francisco, Calif.

treatment

planning

for

of Dentistry,

San Francisco

Medical

Center.,

ne of the most basic problems in restorative dentistry is that of analyzing interarch occlusal relationships. An adequate occlusal diagnosis begins with an accurate recording of existing restorations and an examination of centric occlusion and eccentric relationships of both anterior and posterior teeth. The type of occlusion or malocclusion is noted. and a determination of tooth contact in centric jaw relation made. Diagnostic casts which are anatomically related by means of a precisely located hinge axis and a centric jaw relation record are invaluable aids to accurate diagn0sis.l Unfortunately, economic factors have limited the routine use of this procedure to relatively few dentists. Experience has shown that a great deal of information can be obtained from a simple arbitrary means of relating casts.* The Quick-Mount face-bow3 provides dentists with a readily available, inexpensive means of relating the maxillary cast of a patient to the maxillary part of an articulator in a consistent anatomic relationship. The lower cast is related to the upper cast by means of a carefully made centric jaw relation record so a very valuable adjunct to accurate diagnosis and definitive treatment planning is available. Interocclusal records made with the mandible in protrusive and lateral positions may be used to determine approximate articulator settings. OCCLUSAL ANALYSIS

In order to derive maximum benefit from mounted diagnostic casts, the analysis should proceed in an organized manner. (1) Locate any differences between tooth contacts in centric jaw relation and centric occlusion. The nature and extent of such differences should be recorded. (2) Determine the type of occlusion according to Angles classification, realiz*Associate Clinical Professor.

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ing that a Class I classification covers a range, and it may be desirable to further describe a Class I situation as mesial, neutral, or distal. (3) Observe the cuspid relationship, and record pertinent information such as: the presence or absence of occlusal contact in centric occlusion, the amount of vertical and horizontal overlap of the maxillary cuspid, the extent to which cuspid contact prevents posterior tooth contact in eccentric function, and the extent of cuspal wear. (4) Observe the anterior tooth relationships, noting contact in centric occlusion, vertical and horizontal overlap of upper incisors, contacts in eccentric function, and the extent of incisal wear. (5) Observe and describe the relationship of posterior teeth in terms of missing teeth, rotation or tilting, cross-bites, curve of Spee, and excessive wear.

TREATMENT
Treatment planning. The accumulation and analysis of sufficient preliminary information make the next step, that of treatment planning, logical so it can be a well-thought-out procedure. Individual situations will vary, but a rational approach to treatment planning requires consideration of four areas: systemic treatment, preparatory treatment, restorative treatment, and finally the selected procedure and instrumentation. Systemic treatment. In addition to the more obvious situations requiring control of pain and infection, there will be times when treatment of a systemic nature must precede any other dental procedures. Preparatory treatment. The preparatory treatment should include anything necessary to enhance or insure the success of the prosthesis, and it might include surgical or endodontic treatment, caries control, periodontal therapy, orthodontic treatment, occlusal adjustment, and a preventive dentistry program. Restorative treatment. The restorative treatment of patients can be placed in one of three basic classes or categories, and this classification can be helpful in deciding on the instruments and procedures to be used. Class I situations usually involve single crowns or fixed partial dentures in which the occlusal position and tooth form existing in the patient are to be maintained. A prosthesis must be constructed which fits the existing situation of tooth form and guidance. The morphology and function of the restoration are limited by the form of the opposing teeth and the functional pattern of movement allowed by the existing teeth. In Class II situations, the diagnosis indicates the need for or desirability of modification of the arch form, tooth form, or occlusal position by repositioning, reshaping, or occlusal adjustment prior to construction of the prosthesis. A high percentage of patients have conditions in this category, and dentists must recognize the discrepancies or disharmonies which may exist and plan to eliminate them. The correction of occlusal disharmonies converts the problem into a Class I situation. The Class III restorative situation includes those in which breakdown is so great that no reliable guides of tooth form or occlusal position remain. These are the people for whom full mouth reconstruction procedures are indicated. This type

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of treatment should never be taken lightly and should be attempted only by dentists who are willing to obtain the necessary instruments and devote the necessary time to learn to use them to greatest advantage .4 Once the dentist has placed the problem at hand into proper perspective, he must decide what his clinical procedure will be and what instruments he will use to obtain the desired result.

SELECTION OF PROCEDURE AND INSTRUMENTATION

Class Z situations. When the problem is to construct the prosthesis which fits the existing tooth form and pattern of movement (Class I), there are three possibilities of instrumentation and procedure. (1) A wax pattern can be developed directly in the mouth with the help of an internal or external reinforcing coping. The procedure is not commonly used at present, but still is a valuable one. (2) Simple articulating devices can be used to hold opposing casts in a positive centric occlusion and to allow the dentist to follow wear facets on the teeth. These are used either with full mouth casts on a Johnson-Ogeleby correlator or a Hagman balancer type of instrument or with quadrant casts held in position by a Stephan articulator or similar device. The successful use of quadrant casts is dependent upon an accurate and consistently dependable means of relating the casts in centric occlusion. The Coe checkbite tray used with reversible hydrocolloid meets the requirements for making these records. (3) The functionally generated path technique is another means for building restoration to an existing situation. It is an excellent technique for use in problem situations. It is a rather demanding procedure and hazardous if the dentist does not understand its basic theory. Class ZZ situations. If the problem of restoration is one which is best handled by the use of an articulating device (Class II), a semiadjustable articulator which provides for adjustable condylar guidances and tooth guidances may be used. Such an articulator provides a good mechanical means of articulating casts and maintaining relationships, but its successful use is still largely dependent upon both tooth guidance and a clinical knowledge of the patients pattern of eccentric jaw movement. The important criteria for the selection of an articulator for this situation are as follows: ( 1) It must be able to accept and maintain an accurate hinge axis relationship as well as be adaptable for use with an arbitrary face-bow; (2) it must be able to maintain a definite interarch relationship; (3) it should accept interocclusal records or positional relation records for mounting casts and adjusting the instrument; (4) it should provide for variation in the side shift (Bennett movement) and condyle guidance angle; (5) it should have an incisal guide table to establish and maintain incisal guidance control. Class ZZZ situations. When occlusal breakdown has reached the point where no reliable tooth guidance remains (Class III), full mouth reconstruction is necessary. The patients condyle positions itself, and jaw movements must be determined and adjusted into an anatomic articulator. 0 The factors that must be recorded and reproduced are: ( 1) the jaw movement in the sagittal plane about a transverse axis; (2) the angle and character of the articular eminences; (3) the angle and character of the side shift of the mandible during lateral jaw movements; (4)

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the intercondylar distance or centers of rotation in the horizontal plane, and (5) the direction of movement of the rotating (balancing-side) condyle during eccentric jaw movement in a horizontal and a vertical direction. At the present time, dentists have only two reliable procedures for obtaining the required information : ( 1) a chew-in procedure of recording and fabrication of individual condylar elements based upon that chew-in record,7 and (2) a pantographic tracing device which records movement in the various planes by means of recording plates and styli and an articulator capable of individual adjustment to all of the jaw movement factors. There is clinical evidence that either of these procedures has the capability of producing the desired result and that inconsistencies and inaccuracy are largely variations in operating procedures and techniques. SUMMARY Successful restorative dentistry depends upon careful and systematic collection of information, analysis, and planning. Articulating devices can be of considerable help in achieving this goal if we remember that they are only tools and that they can function only as well as the trained hands and disciplined minds that use them. References
1. Lucia, V. 0.: Modern Gnathological Concepts, St. Louis, 1961, The C. V. Mosby Company, chapt. 3. 2. Teteruk, W. R., and Lundeen, H. C.: The Accuracy of an Ear Face-bow, J. PROSTHET. DENT. 16: 1039-1046, 1966. 3. Hickey, J. C., Lundeen, H. C., and Bohannan, H. M.: A New Articulator for Use in Teaching and General Dentistry, J. PROSTHET. DENT. 18: 425-437, 1967. 4. Stuart, C. E.: Good Occlusion for Natural Teeth, J. PROSTHET. DENT. 14: 716-724, 1964. 5. Bassett, R. W., Ingraham, R., and Koser, J. R.: An Atlas of Cast Gold Procedures, Buena Park, 1964, Uni-Trol College Press. 6. Stuart, C. E.: Accuracy in Measuring Functional Dimensions and Relations in Oral Prosthesis, J. PROSTHET. DENT. 9: 220-236, 1959. 7. Swanson, K. H.: A New Method of Recording Gnathological Movements, North-West Dent. 45: 99-101, 1966.
SCHOOL OF DENTISTRY

UNIVERSITY OF CALIFORNIA SAN FRANCISCO MEDICAL CENTER SAN FRANCISCO, CALIF. 94122