Comparison of occlusal contacts in maximum intercuspation for two impres-

sion techniques
Merle H. Parker, MS, DDS, a Stephen M. Cameron, DDS, b James C.
Hughbanks, DMD, c and David E. Reid, DDS d
U.S. Army Dental Activity, Fort Gordon, Ga.

Statement o f p r o b l e m . At the insertion of a fixed prosthesis, occlusal interferences in maximum

intercuspation are often present.
P u r p o s e . This study investigated and compared the accuracy of interocclusal relationships in maximum
intercuspation for mounted casts obtained from a quadrant dual-arch impression technique and conven-
tional full-arch impression techniques.
M a t e r i a l and methods. Comparisons were made between an intraoral interocclusal record and
interocclusal records made on mounted casts. Irreversible hydrocolloid, reversible hydrocolloid, polysul-
fide, polyether, and polyvinyl siloxane were used for the full-arch impression technique. For the quadrant
dual-arch impression technique, rigid polyvinyl siloxane and light-body polyvinyl siloxane injection
materials were used.
Results. Statistical analysis revealed a statistically significant difference (10 = 0.0017) in the median values
among treatment groups. All pairwise multiple comparison procedures (Student-Newman-Keuls) indicated
the average error of the quadrant dual-arch records was significantly different from the average error of
each group of records produced with the full-arch techniques (p < 0.05). Comparison of the records of the
full-arch impressions did not reveal any statistically significant differences. The average error of the full-
arch records was 72 +_33 }Jm and the quadrant dual-arch average error was 5 + 5 ]am.
Conclusion. The quadrant dual-arch impression technique produced mounted casts with significantly
more accurate maximal intercuspal relationships than mounted casts from full-arch impressions. (J Prosthet
Dent 1997;78:255-9.)

When casts are m o u n t e d on an articulator, an
accurate reproduction o f the interocclusal relationship
is necessary. Buchanan ~ suggested that accurate m o u n t -
ing of casts on an articulator is difficult if not impos-
sible. Causes o f inaccurate mountings include uneven
occlusal contacts, inaccuracies in the casts, inaccurate
interocclusal records, and mandibular flexure.
The views expressed herein are those of the authors and do not
necessarily reflect those of the United States Army or Depart-
ment of Defense.
Presented at the 1996 Annual Session of the American College of
Prosthodontics. Supported in part by a Cooperative Researchand
DevelopmentAgreement with Parkel[, Inc.
~Director, Prosthodontic Residency Program.
~'Chief, Maxi[Iofacial Prosthetics/Dental Oncology; Assistant Direc-
tor, Prosthodontic Residency Program, Eisenhower Army Medi-
cal Center and U.S. Army Dental Activity, Fort Gordon.
cCommander, Hanau Dental Clinic, Hanau, Germany.
dPrivate practice, Martinez, Ga.
Studies have focused on the quality of interocclusal
records used to m o u n t casts. 2-7 Muller et al. 3 reported
that the most accurate material still caused deviations o f
approximately 300 }~m. The accuracy o f the cast was
also found to have a major impact on the transferred
jaw relation records.
Techniques have been presented to make the mount-
ing of casts similar to the patient's occlusion by modify-
ing the occluding surfaces o f the casts. 18 A precise
interocclusal relationship o f the m o u n t e d casts is neces-
sary to ensure an accurate occlusal relationship for the
r e s t o r a t i o n . H o w e v e r , the d y n a m i c n a t u r e o f the
stomatognathic system complicates the process o f ob-
taining an accurate relationship o f the casts. U n d e r the
forces o f occlusion, teeth can move and the mandible
can flex. Tosa et al.8 reported that increasing the con-
traction o f the masseter muscles from 10% to 30% o f
maximal electromyographic activity caused a decrease
in all distances recorded in a silicone interocclusal record
made between the anterior teeth.

SEPTEMBER 1997 THE JOURNAL OF PROSTHETICDENTISTRY 255

THE JOURNAL OF PROSTHETIC DENTISTRY
The purpose of this study was to investigate and com-
pare the interocclusal accuracy of mounted casts made
from a complete arch impression technique and that from
a quadrant dual-arch technique.
MATERIAL AND METHODS
Nine patients were included in this study. Two of the
record sets were produced from a quadrant dual-arch
impression technique and the other five were from full-
arch conventional impression techniques with the use
of different impression materials.
The data for this study were obtained from an im-
pression exercise for a prosthodontic residency program.
Each resident had at least 5 years of clinical practice as a
general dentist before entering the postgraduate pro-
gram. Seven sets of impressions were made on and by
each of nine residents for a total of 63 sets. Of the 63
impression sets, 45 were full-arch and 18 quadrant dual-
arch impressions. An impression of the right and left
side was made for each patient to obtain the complete
arch for comparison.
Impressions were made with the following materials:
(1) rigid polyvinyl siloxane (Blu-Mousse, Parkell,
Farmingdale, N.Y.) and a light viscosity polyvinyl silox-
ane (Cinch-Platinum, Parkell) in a quadrant dual-arch
impression tray (Closed Mouth Impression Trays, Accu
Bite Dental Supply, East Lansing, Mich.); (2) irrevers-
ible hydrocolloid (Jeltrate Plus, L.D. Caulk Division,
Dentsply International Inc., Milford, Del.) pressed into
occlusal grooves by hand and the impression made in a
stock tray with an adhesive (Hold spray-on tray adhe-
sive, Teledyne Dental Products, Elk Grove Village, Ill.);
(3) reversible hydrocolloid, syringe and tray viscosities
(Acculoid, Van R Dental Products, Inc., Los Angeles,
Calif.) in a stock, water-cooled tray (L.D. Caulk Divi-
sion, Dentsply International Inc.); (4) polysulfide
(Permlastic, Kerr, Romulus, Mich.) light and medium
viscosities in a custom tray with adhesive; (5) polyether
(Imregum F, Premier Dental Products Co., Norristown,
Pa.) in a custom tray with adhesive; and (6) polyvinyl
siloxane, light and medium viscosities (Reprosil) in a
custom tray with an adhesive.
Custom impression trays were fabricated with poly-
methyl methacrylate (Fast-tray, Harry J. Bosworth Co.,
Skokie, Ill.) on preliminary casts made from irreversible
hydrocolloid. Custom trays were fabricated with one
layer of baseplate wax as a spacer. Occlusal stops were
placed on cusps that were not centric stops. After the
full-arch impressions were seated, the patients were in-
structed to relax and close, but not to the extent of oc-
cluding on the tray.
Quadrant dual-arch impressions were made of the left
and right side for each patient. The patient was rehearsed
in the proper closure into maximum intercuspation po-
sition (MIP) in an empty tray. An adhesive (V.RS. Tray
Adhesive, Kerr) was used on the solid plastic portion of
256
PARKER ET AL
the tray, a rigid polyvinyl siloxane material was used to
fill the two sides of the tray, and a light viscosity polyvi-
nyl siloxane was injected onto the occlusal and inter-
proximal surfaces of the teeth. The impressions were
recorded with the patient closed firmly in MIP. The oc-
duding position was visually confirmed on the contralat-
eral side. Each impression was inspected after removal
for light transmission through the areas ofocclusal con-
tact.
All casts were made with ADA type V dental stone
(Die-Keen, Modern Materials, Miles Inc., South Bend,
Ind.). A water-to-powder ratio of 21 ml/100 gm was
mechanically spatulated under vacuum for 15 seconds.
The hydrocolloid materials were poured within 10 min-
utes and all others were poured within i hour. The casts
were separated at 1 hour. The occlusal surface of each
cast was examined for defects and positive imperfections
were removed.
Each set of casts was mounted on an articulator (model
105-0095, Keystone Deluxe, Cherry Hill, N.J.) by us-
ing hand orientation to achieve MIP. Casts were luted
together with sticky wax and wooden dowels. For the
quadrant dual-arch technique, both sides of the impres-
sion were poured and mounted on the articulator be-
fore removing from the impression. Each cast was at-
tached to the articulators with type III stone (Labstone,
Modern Materials, Miles Inc.) at a ratio of 30 ml of
water to 100 gm of stone and mixed by hand. All
mounted casts were inspected by a staffprosthodontist
to ensure that there were no visible interferences such
as soft tissue contact to prevent complete closure of the
casts into MIP.
The interocclusal relationship of each set of mounted
casts was recorded by injecting the rigid polyvinyl silox-
ane on the occlusal surfaces of the casts. With the incisal
pin or holding screw moved out of contact, the casts
were closed and held together with hand pressure until
the material was set. The standard for comparing the
accuracy of an interocclusal relationship of a set of
mounted casts was a rigid polyvinyl siloxane interocclusal
record made intraorally with the patient's teeth in MIP.
Three intraoral records were made for each patient to
measure the consistency of the records. Ideally, the lo-
cation and thickness of all contact points of the
interocclusal record from the mounted casts would
match those of the intraoral record.
Multiple points for comparison were selected on the
intraoral record by transillumination (Fig. 1). The record
was placed over a view box, and points thin enough to
transmit light were identified. These points represented
areas of tooth contact or near contact between maxil-
lary and mandibular teeth. The location of each point
was recorded on a diagram of the ocdusal surfaces of
the maxillary arch. By using this diagram and compar-
ing the similarity of the records, it was possible to iden-
tify corresponding points for measurement. The total
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PARKER ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Table I. Average occ[usal error and standard deviation for the

dual-arch and full-arch impression technique in micrometers
(gin)
Impression N Mean SD

arch
Full 45 72 33
Dual arch 9 5 5

Table II. The average occlusal error and standard deviation

for each impression in micrometers (lam)
Impression material/technique N Mean SD

Dual arch 9 5 5
Irreversiblehydrocolloid 9 42 29
Poiyether 9 53 31 Fig. 1. Transilluminated interocclusal record illustrates how
Polyvinylsiloxane 9 62 49 points were selected for evaluation.
Reversiblehydrocolloid 9 80 68
Po[ysulfiderubber 9 92 125
Table III. The mean occlusal error and standard deviation for
each material by patient

number of contacts or near contacts in MIP varied among PT Material

Mean (SD) in pm
the patients, and the number o f points selected for evalu- DA IH PE PVS RH PR
ation ranged from 28 to 48.
The thickness o f each record at the selected points A 11(17) 45(35) 34(28) 45(46) 77(72) 52(39)
was measured with a digital caliper with a precision of B 5(19) 39(62) 57(53) 28(35) 41(41) 109(97)
+0.005 m m (No. 120M, L.S. Starrett Co., Athol, Mass.). C 13(51) 35(58) 25(61) 11(45) 32(69) 17(64)
D 6(20) 41(57) 72(61) 123(115) 236(168) 131(134)
The evaluators did not know the measurements o f the
E 3(13) 58(42) 101(70) 52(44) 64(37) 44(41)
intraoral record while measuring each articulator record;
F -3(29) 32(84) 85(130) 161(270) 77(169) 11(46)
therefore they were blinded to what value would be ex- G 0(32) -5(58) 38(87) 49(54) 59(90) 28(48)
pected. The difference in thickness between each point H 4(12) 103(89) 61(62) 57(71) 130(89) 407(374)
for the interocclusal record obtained from the m o u n t e d I 2(20) 24(25) 2(19) 30(40) 8(21) 32(67)
casts and the corresponding point on the intraoral record
was calculated and represented the error or distortion PT, Patient;DA, dual-arch;IH, irreversiblehydrocolioid;PE,polyether;PVS,poly-
vinyl siloxane;RH, reversiblehydrocoiloid;PR, polysulfiderubber.
for that point. The average o f these differences for all
the points on a record is the error for that type o f im-
pression for that patient. This error was calculated for significant differences when the average error o f the
each o f the five sets o f full-arch articulated casts and one quadrant dual-arch records were compared with the av-
for each pair o f quadrant dual-arch sets o f casts (a right erage error o f each group o f records produced with the
and left side combined to give a complete arch). The full-arch techniques (p < 0.05). The full-arch impres-
data were analyzed with a Friedman repeated measures sions were not significantly different from one another.
analysis o f variance on ranks. The level of significance The average error of the full-arch records (n = 45) was
was p = 0.05. 72 _+33 pm and the quadrant dual-arch (n = 9) average
error was 5 + 5 pm (Table I). The average error values
RESULTS
that correspond to each o f the six impression groups are
The three intraoral records made on each patient were presented in Tables II and III.
consistent. The largest average difference calculated for Visual comparison o f the transilluminated records
any o f the possible pairs o f similar records was 4 +_2 }am. (Fig. 2) revealed that the interocclusal records from the
This observation suggested that these records could be dual-arch impression technique more closely matched
used as a standard for comparing the full-arch and the the intraoral records than did the records from the full-
quadrant dual-arch impression techniques. arch impression technique.
The Friedman repeated measures analysis o f variance
DISCUSSION
on ranks revealed a statistically significant difference
(p = 0.0017) in the median values among the treatment The interocclusal discrepancy o f m o u n t e d casts was
groups. All pairwise multiple comparison procedures larger for the full-arch impression technique than the
(Studcnt-Newman-Keuls method) revealed statistically dual-arch technique. The error did not only appear vet-

SEPTEMBER 1997 257

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Comparison of three transilluminated interocclusal reg-
istrations. Dual-arch record (A) matched intraora[ record (B)
more closely than (C) record made from mounted complete
arch casts made with polysulfide.
tical in nature, but seemed to include a horizontal com-
ponent that was noted when the records were compared.
Some slopes appeared to be thinner and others thicker,
which is a subjective indication of a lateral shift in the
relationship.
The disadvantages of mounting casts from full-arch
impressions is that one error in the cast can affect the
entire interocclusal relationship. Errors such as stone
expansion, flexure of the mandible, bubbles in the cast,
defects in the impression, or shifting of teeth result in
two casts with occlusal surfaces that do not fit together
in the same manner as in the mouth. These errors ap-
pear to produce an average occlusal error that is approxi-
mately 12 times larger for the full-arch casts and a stan-
dard deviation that is six times larger than for the dual-
arch casts. The accuracy of the full-arch casts appears
more variable so results of mounting will also vary.
Distortion in the quadrant dual-arch impression does
not affect the entire interocclusal relationship because it
has been recorded as the three-dimensional record that
is an integral component of the impression. Even if the
impression is distorted by squeezing or twisting and the
resultant dies are distorted, the interocclusal distances
are still relatively accurate. The presence of the oppos-
ing teeth prevents impression material from distorting
into the intcrocclusal space. It is not possible to make
an impression with an air bubble error that can cause an
occlusal interference from a positive nodule on the cast.
An impression made with the teeth firmly in MIP elimi-
nates the problem of flexure of the mandible.
It is best ira rigid material is used as the tray material
to minimize distortion. One concern with a plastic, quad-
rant dual-arch impression tray is that distortion of the
tray during the impression procedure can cause rebound
that will result in a distorted impression and ultimately
a grossly ill-fitting crown. Nevertheless, ill-fitting crowns
258
PARKER ET AL
do not seem to occur with this technique. Presumably,
it is the rigid polyvinyl siloxane that prevents any re-
bound. With the rigidity of this material, caution is re-
quired to avoid locking the tray into undercuts. The use
of a thin layer of a light body polyvinyl siloxane on prepa-
rations, occlusal surfaces, and undercuts can ease tray
removal.
A possible objection to the use of the quadrant dual-
arch impression technique is the absence of contralat-
eral occlusal guidance. When guidance is absent on the
working side, the nonworking side inclines of the adja-
cent teeth become the guiding surfaces to determine
the cusp angle of the corresponding surfaces of the res-
toration. This lack of contralateral guidance usually pro-
duces a flatter nonworking cuspal angle and may reduce
the potential for nonworldng interference.
As with all casts mounted arbitrarily without a face-
bow, capricious ridge and groove directions are possible
and arbitrary ridge and groove direction may increase
the potential for nonworking interferences. 90cclusal
schemes that provide rapid disclusion of posterior teeth
as a result of anterior guidance may not be a problem;
clinically successful restorations can be fabricated with
arbitrarily mounted casts as long as there are sufficient
unprepared teeth to provide guidance. In situations
where accurate ridge and groove direction is required
such as group function occlusal contacts, the quadrant
dual-arch impression technique is contraindicated. As
currently used, it is also contraindicated for patients re-
quiring full-arch restoration, alterations in the vertical
dimension of occlusion, or having unstable MIP. A pro-
totype face-bow and a technique for a custom guide table
are under investigation and may expand the indications
for use in the future.
The accuracy of the relationship of the casts in MIP is
dependent on the patient closing completely into MIP.
With the trayin the mouth and mesh betwecn the teeth,
the patient's tactile sensation may be altered and inter-
fere with MIP. With residents as patients, closure into
MIP with mesh between the teeth was not a problem.
Nevertheless, from clinical experience, it is possible for
the patient to miss the MIR The dentist must therefore
rehearse the position with the patient, verify the rela-
tionship of the contralateral side after placement of the
impression, and evaluate the imprcssion by transillumi-
nation after removal to ensure desired closure.
Further study with a larger number of samples is
needed to determine whether there are statistically sig-
nificant differences among the full-arch impression ma-
terials and to detcrmine whether less time is required
for preinsertion occlusal adjustment with restorations
made from quadrant dual-arch impressions.
CONCLUSION
On the basis of the results of this study, the conclu-
sion was drawn that the quadrant dual-arch impression
VOLUME 78 NUMBER 3
PARKER ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

technique produced mounted casts with significantly
more accurate MIP with less variability than mounted
casts from full-arch impressions.
REFERENCES
1. Buchanan WT. Working cast verff[cation. J Prosthet Dent 1992;67:415-6,
2. Muller J, Gotz G, HorzW, Kraft E. Study of the accuracy of different record-
ing materials. J Prosthet Dent 1990;63:41-6.
3. Muller J, Gotz G, HorzW, Kraft E.An experimental study on the influence
of the derived casts on the accuracy of different recording materials. Part I:
Plaster, impression compound, and wax. J Prosthet Dent 1990;63:263-9.
4. Urstein M, Fitzig S, Moskona D, Cardash HS.A clinical evaluation of materi-
als used in registering interjaw relationships. J Prosthet Dent 1991 ;65:372-7.
5. Warren K, Capp N. A review of principles and techniques for making
interocdusa[ records for mounting working casts. Int J Prosthodont
1990;3:341-8.
6. Breeding LC, Dixon DL. Compression resistance of four interocclusal re-
cording materials, j Prosthet Dent 1992;68:876-8.
7. Richardson DW, Reynolds JM, Allen JD, Gardner LK. Elimination of poten-
tial ocdusal errors using an intraora[ index. J Prosthet Dent ] 991 ;65:457-8.
8. Tosa J,Takada H,Tanaka M, KawazoeT. Intraocclusal distance between the
anterior teeth in intercuspal position. J Osaka Dent Univ 1991 ;25:83-8.
9. Shi][ingburg HTJr, Hobo S, Whitsett LD, et al. Fundmentals of fixed prosth-
odontics. 3rd ed. Chicago: Quintessence; 1997. p. 25-7.
Reprint requests to:
DR. MERLEH. PARKER
5114 FA/RINGTONDR.
EVANS,GA 30809
10/1/83633

Noteworthy Abstracts Correlation between mucosal inflammation and marginal

of the bone loss around hydroxyapatite-coated implants: A 3-
Current Literature year cross-sectional study
Teixeira ER, Sato Y, Akagawa Y, Kimoto T. I n t f Oral
Maxillofac Implants 1997,'12:74-81.

Purpose. Plaque accumulation around osseointegrated implants leads to mucosal inflammation.

There appears to be no consensus regarding the ultimate bone response to this inflammation. This
cross-sectional study examined a possible correlation between soft tissue inflammation and mar-
ginal bone loss around hydroxyapatite-coated implants.
Material and Methods. A total of 110 two-stage hydroxyapatite-coated titanium alloy dental
implants (I(yoccera, Kyoto, Japan) were place in 42 patients. Clinical and radiographic success of
these implants at 1 year was 90.9%. Thirty-two implants from this patient group were selected for
assessment. Gingival index (GI), plaque index (PI), and Periotron (Harco Electronics, Winnipeg,
Manitoba, Canada) scores were used to evaluate the mucosal conditions. Marginal bone level was
assessed through periapical radiographic evaluation. Implants were divided into three groups: a
control group (CG), a borderline group (BG), and a gingivitis group (GG). Radiographs were
analyzed on three separate occasions. The first radiographic analysis occurred after implant place-
ment but before prosthetic connection. The second radiographic analysis occurred after pros-
thetic connection was achieved and the final radiographic analysis was performed an average of
35.6 months after implant placement. Radiographs were analyzed through the use of a magnify-
ing ocular lens with an accuracy of 0.1 mm. Nonparametric testing methods (Mann-Whimey U
test) were used for statistical analysis.
Results. All implants demonstrated a decline in marginal bone height from the first radiograph
made soon after implant placement to the second radiograph that was made just after prosthetic
insertion. The highest value of marginal bone loss at post-insertion radiographic assessment was
seen in the gingivitis group. Later radiographs, made after a period of prosthetic loading, con-
firmed this observation as being statistically significant (p > 0.05).
Discussion. This study provides preliminary data regarding progressive bone loss around hy-
droxyapatite-coated implants. The 3-year results suggest a correlation exists between mucosa in-
flammation and marginal bone loss. 18 references.--SE Eckert

SEPTEMBER 1997 259