OCCLUSION IN RELATION TO REMOVABLE PARTIAL DENTURE.

Dentists are confronted with a rather vexing problem in restoring the dentition
of a partially edentulous patient with removable partial dentures. The problem
centers mainly around the differences in characteristics of the supporting
structures of the restorationthe relatively firmly attached natural teeth on the
one hand, and the displaceable soft tissues of the residual ridges on the other
hand. Additionally, occlusal and incisal relationships for removable partial
dentures involve both the natural and artificial teeth. Factors related to both of
these conditions must be observed and correlated in creating a harmonious
occlusion with removable partial dentures. All of us recognize that the vexing
problems of occlusal rehabilitation, including maintenance, are somewhat
reduced when treating patients with fully tooth-borne removable restorations as
opposed to the distal extension type of removable partial denture.

The fourth phase in the treatment of the patient with removable partial
dentures is the establishment of a functional and harmonious occlusion.
Balanced occlusion is desirable in complete denture but in removable partial
dentures, because of the attachments of the partial denture to the abutment teeth,
occlusal stresses can be transmitted directly to the abutment teeth and other
supporting structures, resulting in the sustained stresses that may be more
damaging than those of transient stresses found in complete dentures.
Failure to provide and maintain adequate occlusion on the partial denture
is primarily a result of
1. Lack of support for the denture base.
2. The fallacy of establishing occlusion to a single static jaw relationship record.

3. An unacceptable occlusal plane.

Occlusal form of teeth on partial denture must be made to conform to an
already established occlusal pattern (Only exception being opposing complete
denture and only when anterior teeth remain in both the arches).

The establishment of a satisfactory occlusion for partial denture patient includes

the following:
1. An analysis of existing occlusion
2. The correction of existing occlusal disharmony.
3. Recording of CR or an adjusted CO.
4. The recording of eccentric jaw relations or functional eccentric occlusion.
5. The correction of occlusal discrepancies created by the fit of the framework
and in processing of the denture.

DESIRABLE OCCLUSAL CONTACT RELATIONSHIPS FOR R.P.D.

1. Simultaneous bilateral contacts of opposing posterior teeth must occur in CO.

2. Occlusion for tooth-supported partial dentures may be arranged similar to the
occlusion seen in a harmonious natural dentition.
3. Balanced occlusion in the eccentric positions should be formulated when the
partial denture is opposed by a maxillary complete denture.
4. Working side contact should be obtained for mandibular distal extension
denture. These contacts should occur simultaneously with the working side

contacts of the natural teeth to distribute the stress over the greatest possible
area.
5. Simultaneous working and balancing contact should be formulated for the
maxillary bilateral distal extension partial denture whenever possible.
6. Only working contacts need to be formulated for either the maxillary or
mandibular unilateral distal extension partial denture. Balancing side contact
would not enhance the stability of the denture because it is entirely tooth
supported by the framework on the balancing side.
7. In class IV RPD, contact of opposing anterior teeth in the planned intercuspal
position is desirable to prevent a continuous eruption of the opposing natural
incisors, unless they are otherwise prevented from extrusion by means of a
lingual plate, auxillary bar or by splinting.
8. Balanced contact of opposing posterior teeth in a straight forward protrusive
relationship and functional excursive positions is desirable only when an
opposing CD or bilateral distal extension maxillary partial denture is placed.
9. Artificially posterior teeth should not be arranged farther distally than the
beginning of a sharp upward incline of the mandibular residual ridge or over the
retromolar pad.

A harmonious relationship of opposing occlusal and incisal surfaces alone

is not adequate to ensure the stability of the distal extension removable partial
denture. In addition, the relationship of the teeth to the residual ridges must be
considered.

METHODS OF ESTABLISHING OCCLUSION:

Two methods:
1. The functionally generated path technique
2. The articulator, or, static, technique.

THE FUNCTIONALLY GENERATED PATH TECHNIQUE:

Basis: when the pathways each tooth opposed to the edentulous space makes
throughout,

all functional movements of the mandible are recorded, the

artificial tooth may thus be positioned and formed so that it will remain in
harmonious contact with its antagonist at all times. The pathways are created by
the patient in a wax occlusal rim. The patient performs all the functional
excursions while the opposing teeth contact the surface of the occlusal rim. The
recording produced in the wax is actually a negative record of the movement of
each opposing tooth as the mandible executes the functional movements.

The pathways so generated are poured in hard improved stone to produce

a cast against which the artificial teeth are set. Each ridge or groove in the
resulting stone cast represents the path of a cusp- setting the teeth in contact
with the paths should result in a completely functional and harmonious
occlusion.

ADVANTAGES:
1. The greatest advantage it eliminates the need for adjusting an articulator with
the interocclusal records or a tracing device.

2. A far greater potential for error lies in attempting to adjust an articulator to

follow jaw movements precisely than in generating a functional pathway.
3. This method also eliminates the need to make a face-bow transfer, because all
the information derived from a face-bow transfer is contained in the pathway.

LIMITATIONS/DISADVANTAGES:

1. The occlusion in one of the arches must be complete before a generated

pathway can be developed.
2. If the opposing partial dentures are required, one of the partial dentures must
be completed before the other can be made.
3. This method also does not tend itself well to developing the occlusion for a
partial denture opposing a complete denture.
4. During the generation of the path in the hard inlay wax, movement of the
distal extension base carrying the occlusal rim is possible.
5. Verification of recording in mouth is difficult.
6. Masticatory cycle differs depending on the type and texture of the food being
chewed. The pattern therefore developed in the wax is accurate for the wax only
and food stuffs may fall inside or outside the particular chewing cycle.

THE ARTICULATOR OR STATIC TECHNIQUE:

If the denture base lack stability or if the patient is physically unable to form a
chew-in record, the articulator equilibration method is preferred. It is commonly
employed method. First upper cast is mounted to the articulator using face bow
with a orbitale pointer. The lower cast is related to the upper cast using a centric
interocclusal record at an acceptable vertical dimension.

The bucco-lingual relation of the lower teeth and their relation to the
upper arch are studied. A decision whether to articulate the central fossa of the
denture teeth to the lower buccal cusps or to the lower lingual cusps must be
made. Once the holding cusps have been selected, the inclines of the remaining
cusps are reduced. This allows for a cusp-to-fossa relationship. Therefore in
centric occlusion the only area of contact on the denture should be in the central
fossae.

At the time of the wax try in, eccentric records are made and the condylar
inclinations are set on the articulator. Once the centric holding cusps are
reestablished by selective grinding, eccentric balance is achieved. The end result
is a harmonious balanced occlusion that allows freedom in lateral excursion
while maintaining maximum bilateral contacts in functional and parafunctional
activities. Perfectly balanced occlusion in all eccentric positions may not be
possible in many cases when working with natural teeth in one arch.

OCCLUSAL

CONSIDERATION

FOR

IMPLANTSUPPORTED

PROSTHESIS:

The clinical success and longevity of the endosteal dental implants as loadbearing abutments are controlled largely by the mechanical setting in which
they function. The treatment plan is responsible for the design, number and
position of the implants. After achievement of rigid fixation, proper crestal bone
contour, gingival health, mechanical stress, and/or strain beyond the physical
limits of hard tissues have been suggested as the primary cause of initial bone
loss around implants.

The role of occlusion is important to osseointegration prosthesis. The

choice of an occlusal scheme for implant-supported prostheses is broad and
often controversial. Almost all concepts are based on those developed with
natural teeth and are transposed to implant support systems with almost no
modification. No clinical studies have been published comparing the various
implant occlusal theories.

The restoring dentist has specific responsibilities to minimize overload to

the bone to implant interface these include a proper diagnosis leading to a
treatment plan, providing adequate support based on the patients individual
force factors, a passive prosthesis of adequate retention and form, progressive
loading to improve loading to improve the amount and density of the adjacent
bone and further reduce the risk of stress beyond physiologic limits. The final
element is the development of occlusal schemes that minimizes risk factors and

allows the restoration of function in harmony with the rest of the stomatognathic
system.

IMPLANT PROTECTIVE OCCLUSION:

A proper occlusal scheme is a primary requisite for long term survival,

especially when parafunction or a marginal foundation is present. A poor
occlusal scheme both increases the magnitude of loads and intensifies
mechanical stresses (and strain) at the crest of the bone.

OCCLUSAL CONSIDERATIONS

Natural teeth versus implant mobility-CHARACTERISTICS UNDER LOAD

Criterion

Tooth

Implant

1. Impact force

decreased

increased

2. Mobility

variable

none

3. Diameter

large

small

4. Cross-section

not round

round

5. Modulus of elasticity +/- cortical bone

6. Hyperemia

5-10 times
_

7. Orthodontic movement
8. Fremitus

9. Radiographic changes PDL, cortical bone

10. Progressive loading since childhood

11. Wear

_
shorter period

enamel wear facets, localized

minimal

wear,

fatigue and stress # , cervical

&

abfraction, pitting on occlusal

components or

stress
#

of

prosthetic

cusps.

Implant body.

12. Occlusal awareness high detection of premature

(Proprioception)
13. Movement

low

contacts.
shock breaker effect of PDL

capture

intrude quickly 28m

no initial

stress at crest
Apical
movement
Lateral

50-108m

10-50m

OCCLUSION ON NATURAL TEETH AND IMPLANTS:

There has been ongoing controversy regarding whether a rigidly fixated implant
may remain successful when splinted to natural teeth. Because the implant has
no periodontal membrane, concerns centre around the potential for the nonmobile implant to bear the total load of the prosthesis when joined to the mobile
natural tooth. In the implant-tooth fixed prosthesis, four important components
may contribute movement of the system: the implant, bone, tooth and
prosthesis.

Tooth movement:
1. 8 to 28 m

initial movement in vertical direction with 3-5 lb of load

2. similar to implant secondary movement reflects surrounding bone property.

3. 3-5 m initial movement of implant in vertical direction
4. 56 m combined intrusive natural tooth movement - 28m + 28m
5. 33m combined intrusive movement natural tooth opposing implant - 28m
+ 5 m
6. 10m combined intrusive movement implant opposing implant - 5m + 5m

because the initial difference in the vertical movement of teeth and implants in
the same arch may be as much as 28m, the initial occlusal contacts should

account for this difference, or the implant will sustain greater loads than the
adjacent

teeth. The

existing

occlusion

is

evaluated

before

implant

reconstruction. Occlusal prematurities are ideally eliminated on teeth before

implant reconstruction. Thin articulating paper (less than 25m thickness) is
used for the initial implant occlusal adjustment in centric relation occlusion
under a light tapping force. The implant prosthesis should barely contact, and
the adjacent teeth should exhibit greater initial contacts. Only axial occlusal
contacts should be present on the implant crown, once the equilibration with a
light bite force is applied. The contacts should remain axial over the implant
body and may be of similar intensity on the implant crown and the adjacent
teeth under greater biting force to allow all elements to react similar to the
occlusal load. Hence to harmonize the occlusal forces between the implants and
the teeth, a heavy bite force occlusal adjustment is used because it depresses the
natural teeth, positioning them closer to the depressed implant position and
equally sharing the load.

In natural teeth anteriors (healthy incisors and canines) disclude posteriors in

lateral excursions. In natural teeth having implant replacements anteriorly,
during lateral excursion more forces are directed on the implant because initial
movement of implant is 10 - 50m laterally compared with natural teeth 68 108m .there fore either should be splinted together or occlusal adjustment
should be carried out.

Implants do not extrude, rotate or migrate under occlusal forces. The

proposed occlusal adjustment does not encourage additional tooth movement
because regular occlusal contacts occur. The teeth opposing implants are not
taken out of occlusion. Brief occlusal contacts on a daily basis maintain the

tooth in its original position (similar to the rest of the mouth). In addition,
because most teeth occlude with the 2 teeth (with the exception of mandibular
central incisor), the opposing teeth positions are more likely to remain the same.
On the other hand, no occlusal scheme will prevent mesial drift and minor tooth
movement from occurring. An integral part of the Implant Protective occlusion
philosophy is the regular evaluation and control of occlusal contacts at each
regularly scheduled hygiene appointment. This permits the correction of minor
variations occurring during long-term function and also helps to prevent
porcelain fractures and other stress related complications on the remainder of
the natural teeth.

IMPLANT PROTECTIVE OCCLUSION:

This concept establishment is credited to Carl Misch. It is also called medial

positioned lingualised occlusion. When teeth are present, the maxillary dentate
posterior ridge is positioned slightly more facial than its mandibular
counterpart. Once the maxillary teeth are lost , the edentulous ridge resorbs in a
medial direction as it evolves from division A to B to C to D. as a result the
maxillary permucosal implant site gradually shifts towards the midline as the
ridge resorbs. As a consequence, endosteal implants are also more lingual than
their natural tooth predecessors. Although many of the occlusal concepts are
similar in removable and fixed implant restorations, several aspects are unique
to the implant supported prosthesis and there fore constitutes implant protective
occlusion.

KEY FACTORS:

1. Occlusal table width:

In IPO the width of the occlusal table is directly related to the width of the
implant body. The wider the occlusal table, the grater the force developed by the
biologic system to penetrate the bolus of food. The restoration mimicking the
occlusal anatomy of natural teeth often result in offset load (increased stress),
complicated home care, and increased risk of porcelain fracture. As a result in
non-esthetic regions of the mouth , the occlusal table should be reduced in width
compared with the natural teeth.

2. Crown contour:

in mandibular division A bone, the implant is located under the central fossa
whereas in Division B it is located under the lingual cusp region of the preexisting natural tooth. As a result, mandibular endosteal implants are always
positioned more medial than the original buccal cusp. All occlusal contacts are
more medial than those on the natural mandibular teeth.

3. Influence of surface area:

An important parameter of the implant protective occlusion is the adequate

surface area to sustain the load transmitted to the prosthesis. Narrow diameter
implant receive greater forces therefore either they should be splinted or

increases the number of implants. Increased loads are compensated by increase

in implant width, reduced crown height, ridge augmentation if necessary, and
increasing the number of implants.

4. Design of the weakest arch:

Any complex engineering structure will typically fail at its weakest link, and
dental implant structures are no exception. Reduced occlusal forces with an
absence of lateral contacts in excursions are recommended on posterior
cantilevers or anterior offset pontics whenever possible. This minimizes the
moment forces on the abutments and decreases the load on the terminal implant
abutments.

5. Occlusal materials:

Occlusal materials play an important role in the transmission of forces and in

the maintenance of occlusal contacts. Commonly used materials are porcelain,
gold and acrylic resin.
Comparative characteristics:
Porcelain

Gold

Resin

1. Esthetics

2. Impact force

3. Static load

+/-

+/-

+/-

4. Chewing efficiency

5. Fracture

6. Wear

7. Interarch space

8. Accuracy

(Metal shrinkage is 10 times less in metal compared with porcelain or resin)