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  1. 1. Philosophies of Occlusion for Implants
  2. 2. Implant Occlusion <ul><li>Single Crown </li></ul><ul><li>Fixed Partial Dentures </li></ul><ul><li>Full arch prostheses (screw retained) </li></ul><ul><li>Overdentures </li></ul>
  3. 3. M any Philosophies of Occlusion <ul><li>No definitive scientific studies to prove: </li></ul><ul><ul><li>one type of tooth form </li></ul></ul><ul><ul><li>one type of occlusal scheme </li></ul></ul><ul><ul><li>to be clearly preferred by patients </li></ul></ul><ul><ul><li>to be more efficient than another </li></ul></ul>
  4. 4. Tooth Forms Occlusal Schemes <ul><li>Anatomic </li></ul><ul><li>Non Anatomic </li></ul><ul><li>Canine Guidance (Mutually Protected) </li></ul><ul><li>Group Function </li></ul><ul><li>Lingualized (Balanced) </li></ul><ul><li>Monoplane </li></ul>
  5. 5. Denture Tooth Forms and Occlusal Forms
  6. 6. Occlusion & Implants <ul><li>Evidence Based Review </li></ul><ul><li>Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560 </li></ul><ul><li>No Preferred occlusal scheme </li></ul><ul><li>Clinicians advocate axial loading of implants, </li></ul><ul><li>but no evidence, at present, </li></ul><ul><li>demonstrating benefits </li></ul>
  7. 7. Occlusion & Implants <ul><li>Evidence Based Review </li></ul><ul><li>Taylor, Wiens et al. J Prosthet Dent 2005;94:555-560 </li></ul><ul><li>No evidence at present that </li></ul><ul><ul><li>progressive occlusal loading of implant is beneficial </li></ul></ul><ul><ul><li>occlusal overload is detrimental to implants </li></ul></ul>
  8. 8. Absence of Scientific Evidence Not proof against! Follow best available clinical principles Do not build in heavy non-axial loading or overloading
  9. 9. Clinical Principles for Occlusion Based on Clinical Experience Not Scientific Evidence
  10. 10. General Principles <ul><li>Improve denture stability or axial loading of single teeth </li></ul><ul><li>Centric contacts on flat surfaces, not inclines </li></ul>
  11. 11. General Principles Posterior Overjet to Avoid Cheek Biting
  12. 12. General Principles <ul><li>Improve denture stability or single tooth loading </li></ul><ul><li>Center occlusal contacts over ridge </li></ul><ul><li>Simultaneous posterior contacts in centric </li></ul>
  13. 13. General Occlusal Principles <ul><li>For overdentures or full arch prostheses opposing a CD: </li></ul><ul><li>No anterior contacts in centric </li></ul><ul><ul><li>Minimizes anterior resorption </li></ul></ul><ul><li>Grazing anterior contacts in excursions </li></ul><ul><ul><li>Incising </li></ul></ul>
  14. 14. Occlusal Schemes <ul><li>Canine Guidance </li></ul><ul><li>Group Function </li></ul><ul><li>Lingualized </li></ul><ul><li>Monoplane </li></ul>Dentures Single Teeth FPD’s
  15. 15. Crowns or FPD’s <ul><li>Either canine guidance or group function works - no preference </li></ul><ul><li>Use what the patient has </li></ul><ul><li>Use what would be easiest </li></ul>
  16. 16. Overdentures or Full Arch Prostheses ALL Occlusal Schemes Devised to Maximize Denture Stability
  17. 17. Lingualized Occlusion <ul><li>Maxillary cusped tooth </li></ul><ul><li>Mandibular cuspless or shallow cusped tooth </li></ul><ul><li>Maxillary lingual cusp balances like a mortar in a pestle </li></ul>
  18. 18. Lingualized Occlusion <ul><li>Lingual cusp contacts opposing central fossae </li></ul><ul><li>Mandibular cuspal inclines are shallow (0°, 10°) </li></ul><ul><li>Less lateral displacement </li></ul>
  19. 19. Lingualized Occlusion How Stability is Improved <ul><li>Simultaneous bilateral anterior and posterior in all excursions </li></ul><ul><li>Tilting forces theoretically neutralized </li></ul>
  20. 20. Enter Bolus Exit Balance? <ul><li>Many patients chew bilaterally </li></ul><ul><li>Biting forces maximum close to intercuspation (where balance most effective) </li></ul><ul><li>Non-functional aspects (swallow) </li></ul>
  21. 21. Point of Loading Affects Stability <ul><li>Browning, 1986 </li></ul><ul><ul><li>Loaded centrally, M, D, L, B </li></ul></ul><ul><ul><li>B caused unseating </li></ul></ul><ul><ul><li>Central loading better than distal loading </li></ul></ul>M D L B C
  22. 22. Lingualized Contacts <ul><li>Only buccal cusp contact is inner incline of mandibular teeth (balancing) </li></ul>Balancing Side Working Side
  23. 23. ‘IIF’ Rule <ul><li>IIF you have contacts on the I nner I nclines of F unctional cusps they are balancing contacts </li></ul>
  24. 24. Test!
  25. 25. Rules for Balancing Contacts <ul><li>Balancing contacts should be lines, not points </li></ul><ul><li>Balancing contacts should never be heavier than working contacts </li></ul>
  26. 26. Balanced Occlusion (Lingualized) <ul><li>Indirect evidence that balanced occlusion may: </li></ul><ul><ul><li>reduce ridge resorption ( Maeda & Wood , 1989) </li></ul></ul><ul><ul><li>allow for increased functional forces in excursions ( Miralles et al, 1989) </li></ul></ul>
  27. 27. Lingualized Cusp Angles <ul><li>Always use steep cusped maxillary tooth (33°) </li></ul><ul><li>When condylar guidance is steeper use more cusp angle in mandible (10°) </li></ul>
  28. 28. Lingualized Occlusion <ul><li>Balance cannot be set without an articulator </li></ul><ul><li>Clinical remount on an articulator - fewer adjustments </li></ul>
  29. 29. Condylar Inclination <ul><li>Posterior teeth separate as working condyle moves forward (and downward) </li></ul><ul><li>Anterior teeth contact </li></ul><ul><li>Closer to condyle, more separation </li></ul><ul><li>More anterior separation of Premolars if steep anterior guidance </li></ul>
  30. 30. Effect of Mandible Moving Downward During Excursions
  31. 31. Maintaining Balancing Contacts <ul><li>Change occlusal plane angle </li></ul><ul><li>Increase compensating curves </li></ul><ul><li>Increase cusp angles or effective cusp angles </li></ul>
  32. 32. Checking for Balance <ul><li>Feels Sm oo oo o o th in excursions </li></ul><ul><ul><ul><li>- Fingers on max. canines </li></ul></ul></ul><ul><ul><ul><li>- Check on articulator </li></ul></ul></ul>
  33. 33. Assess Contacts: <ul><li>Centric Stops </li></ul><ul><li>Excursions </li></ul>
  34. 34. Improving Denture Occlusion <ul><li>Most important cusp - maxillary lingual </li></ul><ul><li>Mandibular buccal cusps more lateral - more tipping </li></ul>
  35. 35. When Not to Balance <ul><li>Difficulty in obtaining repeatable centric record </li></ul><ul><ul><li>incoordination, </li></ul></ul><ul><ul><li>muscle splinting </li></ul></ul><ul><li>Dramatic malocclusions </li></ul><ul><li>Severe ridge resorption </li></ul><ul><ul><li>lateral forces displace the denture </li></ul></ul><ul><ul><li>Implants tend to negate this factor </li></ul></ul>
  36. 36. Monoplane Occlusion <ul><li>Cuspless teeth set on a flat plane with 1.5- 2 mm overjet </li></ul><ul><li>No cusp to fossa relationship </li></ul><ul><li>No anterior contacts present in centric position </li></ul><ul><li>No overbite </li></ul>
  37. 37. Monoplane Occlusion How Stability is Improved <ul><li>Elimination of cusps </li></ul><ul><ul><li>Lateral forces reduced, improving stability </li></ul></ul><ul><ul><li>Simplifies denture tooth arrangement </li></ul></ul>
  38. 38. Monoplane Occlusion With Condylar Inclination
  39. 39. Monoplane Occlusion With Condylar Inclination
  40. 40. Ensure Teeth Set Over Ridge <ul><li>Minimize tilting/tipping </li></ul><ul><li>Maximize stability </li></ul><ul><li>Minimize contacts on buccal of flat cusps </li></ul>
  41. 41. Monoplane Occlusion <ul><li>Functional, but unesthetic </li></ul><ul><li>Not balanced - flat </li></ul><ul><li>Zero degree teeth can be balanced if condylar inclinations are shallow </li></ul>
  42. 42. Monoplane Occlussion - When? <ul><li>Jaw size discrepancies, malocclusions </li></ul><ul><ul><li>cross-bite, Cl II, III </li></ul></ul><ul><li>Minimal ridge </li></ul><ul><ul><li>reduces horizontal forces </li></ul></ul><ul><ul><li>implants help </li></ul></ul><ul><li>Uncoordinated jaw movements </li></ul>
  43. 43. Summary <ul><li>No definitive studies to show one type of occlusion is best </li></ul><ul><li>Follow established clinical principles </li></ul><ul><li>Assess each case - adapt to clinical situation </li></ul><ul><li>Continue to read the literature </li></ul>