The five factors affecting occlusal balance are: 1. Condylar inclination 2. Incisal guidance 3. Occlusal plane orientation 4. Compensating curve 5. Cuspal inclination

3. Dr. Amal Fathy Kaddah
Prof. of Prosthodontics,
Faculty of Oral &Dental
Medicine, Cairo University

4. Advanced Removable
Prosthodontics

5. VS
–Natural dentition
–Partial lower denture
–Existing complete denture
Single Complete Maxillary
Dentures

6. Single Dentures Opposing
Natural Dentition

7. Problems of Single Denture
1- Difficulties – Maxillary Denture
Opposing Dentate Mandible

8. With single complete dentures, the
natural dentition opposing the
edentulated arch often exhibits an
uneven occlusal plane.
i.e. a “mutilated” dentition
Complete Dentures Opposing
Dentate Arch

9. Single maxillary edentulous cases

10. • Occlusal discrepancies*
• Excessive load
* These all predispose to tipping of the
denture and the generation of lateral
forces which can lead to compression of
the periosteum, disruption of the
vasculature and a resorptive remodeling
response of the maxilla.

11. Right working
Maxillary Denture Opposing Dentate Mandible
Centric occlusion •The patient wore this denture
for more than 10 years. Note
the resorption of the maxilla
and the wear associated with
the posterior mandibular
dentition.
•Note the patient in the right
working position. There are
no balancing contacts on the
opposite side.
Resorbed maxilla

12. The Subsequent problems with single
denture against natural teeth
1- Great force generated by the natural teeth.
Excessive pressure result in resorption of the
residual ridge & hyperplastic tissues.
2- Malposed, tipped, or super erupted teeth in the
lower arch make it difficult to achieve a
harmonious balanced occlusion.
3- The presence of the mandibular anterior teeth
makes the esthetic and phonetic placement
difficult.

13. 4- Increase the tendency of fracture of
maxillary denture due to occlusal
stresses exerted by natural teeth.
5- Abrasion of the artificial teeth if
acrylic is used or the abrasion of
natural teeth if porcelain is used.
6- Combination syndrome and
associated changes.
7- Mandibular single denture.

14. How To Overcome These Problems
-The primary consideration for a continued success of a
single complete denture is the preservation of that
which remains,
-Proper diagnosis and full use of every factor, which
favor success for this denture,
- Applying the principles of c. d construction
Reduction of the forces to which the denture is subject
Maximum base extension within functional anatomical
limits (distribution of forces
over the largest possible area of supporting structures
and the force per unit area kept at minimum.)

15. The polished surface: The creation of the
correct form of the polished surfaces.
The fitting surface: Good impressions that
yield an accurate fit spreading the bite load
out over the entire ridge.
The border Extension: Proper denture
border lengths that allow for free movement
of musculature and tissue attachments.

16. Occlusion:
 A balanced occlusion and
free articulation creating an
uniform application of bite
force down on to your ridge.

17. Steps for Single Denture construction
• Proper Diagnosis and mounting the diagnostic
casts.
• Occlusal Adjustment and Tooth Modification
• Final Impression.
• Jaw relation.
• Face bow transfer.
• Artificial teeth adjustment and Try-in of waxed
denture.
• Delivery.

18. Check Out the Opposition
• Ridge relationship
• Interdental space
• Occlusal plane
• Tooth position
• Cuspal inclination
• Rotations
• Tooth wear
Proper Diagnosis and mounting the diagnostic casts

20. Mutilated Dentition
• Extrusion, tipping, rotation
• Sharp, steep unworn cusps
• Spaces
• Cross-bite relationships
• Natural teeth inclines may prevent
development of balanced occlusion

21. Missing mandibular first molars,
or second premolars, or both

22. Strategies for prevention of resorption
• Correct occlusal discrepancies
a) Reshaping by grinding
b) Provide new restorations
c) Reshape with RPD framework
• Retain root tips particularly in the premaxilla
to facilitate support
• Place osseointegrated implants to facilitate
support
*Avoid excessive vertical overlap of
the anterior denture teeth.

23. Provide new restorations
• Treatment : Moderate RCT, Crown
Mild Recontour
Severe Extract

25. Tooth Reduction Protocol
• Confirm pulpal maturity (X-rays,
EPT)
• No anesthesia
• Begin with teeth requiring most
reduction

26. Tooth modifications and
occlusal adjustment
I- Swenson’s Technique
II- Bruce Technique
III- Yurkstas’ Technique
IV- Boucher’s Technique

27. Preparing Plane of Occlusion
Individual Tooth
Modifications
– Sharp Unworn
Cusps
• Reduce cuspal
inclination
– Heavily Abraded
Teeth
• Reduce Bu-Li width

28. Swenson’s Technique
 Casts mounted on articulator
using provisional CR at
acceptable vertical Dimension
 Maxillary record base made
and Denture teeth are set
 If lower teeth interfere with placement of denture teeth,
stone teeth are adjusted and marked on the cast with
pencil .
 The natural teeth are modified using the diagnostic cast
as a guide

29. Occlusal Plane Discrepancies
• The occlusal plane
discrepancy is
readily apparent
when the denture
teeth are properly
arranged.
• This discrepancy can
only be corrected by
restorative means.

31. Bruce Technique
The Modifications
are Made on the
Stone Cast. A Clear
Acrylic Resin
Template Is
Fabricated Over the
Modified Stone Cast.

33. Boucher Technique
The interferences are removed by
movement of the maxillary porcelain
teeth over the mandibular stone teeth.
Prematurities are identified and
removed by grinding the natural teeth.
The procedure is repeated for right and
lateral excursions until a harmonious
balanced occlusion is established.

34. Yurkstas Technique
The use of a metal U-shaped occlusal
template that is slightly convex on the
lower surface is placed on the occlusal
surfaces of the remaining teeth.
20° Template

35. Plane of Occlusion Evaluation

36. Impression

37. Impression Making
An ideal impression should provide: (Objectives of
impression making)
• Maximum extension without muscle impingement.
• Intimate contact with the tissue area covered.
• Proper form of the borders including the posterior border of
the maxillary denture.
• Proper relief of hard and sensitive areas.
• To equalize forces on the denture foundation
area.

38. Jaw relation

39. Recording Intermaxillary Relations
for Single Upper Denture
• Freely removing from the
upper rim whatever quantity
of wax is necessary to
achieve the required degree
of jaw closer. The incisal
level of the upper front teeth
and the occlusal plane can
be determined later by
reference to the lower
natural teeth.

40. (A) The artificial incisor has been set farther back and lower than
its natural predecessor, thereby providing a locked and potentially
traumatic occlusion. (B) The overbite has been reduced by raising
the tip of the lower incisor. The overjet has been increased by
moving the upper incisor forward to its correct position and by
grinding the labioincisal surface of the lower incisor.

41. Maxillo - Mandibular Relations
• Centric Registration
– CUD usually stable
– Extraoral hand
position if opposing
natural dentition (less
obtrusive)

42. Jaw relation, face bow transfer,
artificial teeth adjustment and check
waxed denture

43. Try in

44. Harmonious balanced occlusion in complete single
denture can be achieved either by
I - Statically equilibrated occlusion using a
programmed articulator to stimulate the
patient’s mandibular movements.
a- Articulator equilibrated technique.
b- Articulator generated path technique.
II - Dynamically equilibrated occlusion by the use
of functional generated path technique
(Functional chew-in techniques)
Methods Used To Achieve Balance Articulation:

45. Complete Dentures Opposing
Dentate Arch
• What is the principle challenge?
Designing a denture occlusion with bilateral
balanced occlusion.
•Why is bilateral balance so important?
Tipping of the denture and excessive lateral forces
lead to resorption of the edentulous arch
Ensure that the opposing dentition
can be made level

46. The simultaneous contact of the
maxillary and mandibular teeth on the
right and left and in the anterior and
posterior occlusal areas when the
jaws are in either centric or eccentric
relation, within the normal range of
mandibular function
? ? ? ? ? ?

47. Balanced sliding occlusion
(free articulation)
The even contacting of teeth as the
mandible moves to and from
eccentric to centric
maxillomandibular relations (any
mandibular movement made
without interference.)

48. Single Denture Occlusion
• “An occlusal scheme that
employs a multiplicity of point
contacts, rather than one that
utilizes broad-surfaced contacts
on inclined planes is advocated.”
John J. Shary

49. Anterior Tooth Arrangement
•Lip support
•Minimal vertical overlap
(Overbite)
•Protrusive balance

50. Posterior Tooth Arrangement
• Shary Concept
– No interdigitation (cusp to fossa)
– Cusp to cusp
• Maxillary Lingual VS mandibular Buccal
• c.f. “Lingualized”
– Avoid broad inclined planes

51. When the occlusal plane has been
levelled , what type of occlusion will
we have?
this
or
this

52. The second choice is more likely because:
• Natural tooth guidance would have a
tendency to dislodge the denture
• The natural teeth are seldom situated in
positions that allow the cusp to fossae,
cusp to embrasure relationship

53. The Golden Rule
for this type of case
Equal contacts in centric
occlusion and no interferences
in excursive movements
(commonly referred to as
functional occlusion)

54. CENTRIC
OCCLUSION
PROTRUSIVEWORKING

55. ? CONCEPT
b- Articulator generated path technique

56. b- Articulator generated path technique

57. MONOPLANE CONCEPT

58. Artificial Tooth Material
• Plastic
• Porcelain
• Metal
– Amalgam
– Cast

59. Metal Occlusal Surfaces
In patients with the financial resources, gold occlusals can be
used to minimize wear of the occlusal surfaces. In patients
with limited financial resources, amalgam stops can be
inserted into the cusp tips of the acrylic resin denture teeth.

60. 1- Porcelain teeth :
Wear very slowly and therefore the
occlusal vertical dimension is maintained.
cause rapid wear of opposing natural teeth
and may be exposed.
2. Acrylic resin teeth :
No wear of the opposing natural teeth,
they are the teeth of choice. The major
disadvantage of resin teeth is their wear,
which results in loss of vertical dimension.

61. 3- Acrylic resin with gold occlusal surfaces:
although gold occlusals are considered the best material to
oppose natural teeth, their expense and the time involved in
their fabrication.
4- Acrylic resin with amalgam stops:
reduce the occlusal wear, and the technique is simple less time
consuming and less expensive than with the gold occlusals.
5. IPN resin:
The wear resistance is higher than that of the conventional
acrylic resin teeth.

62. Artificial Tooth Material
PORCELAIN ABRASION

63. Five factors affecting occlusal balance
• Condylar inclination
• Incisal guidance
• Occlusal plane orientation
• Compensating curve
• Cuspal inclination

64. A- The Esthetic Factors Dictated A Steep Vertical
Overlap With Little Horizontal Overlap. Therefore
Steeper Posterior Cuspal Inclines Had To Be
selected
B- In eccentric movements the inclinations of the
posterior cusps are sufficient to prevent anterior
interference.

65. A- the esthetic factors allowed for an adequate
amount of horizontal overlap so that shallow cuspal
inclines were able to be selected.
B- In eccentric movements the shallow posterior
inclines are sufficient to prevent anterior
interference.

66. Arrangement of Denture Teeth
• Incisal angle
The flatter the angle the more
stable the denture.
Esthetics is often the driving issue. If you increase
the vertical overlap to an excessive degree to
satisfy the esthetic desires of the patient, you
loose balance, the denture is tipped anteriorly and
the long insidious process of resorption is set
motion.

67. Incisal Angle
This cast is being used to
fabricate an immediate
denture. Note the excessive
amount of vertical overlap of
the remaining anterior teeth.
If this amount of vertical overlap is incorporated into the denture the
occlusion will not be in balance, the denture will be tipped anteriorly
during function, and the premaxilla will resorb.
What are your options?
a) Reduce the amount of overlap by raising the incisal
edges of the denture teeth.
b) Reduce the length of the mandibular anteriors.
c) A combination of both (a) and (b).

68. Single denture insertion

69. 2- Edentulous Mandible
Opposing Dentate Maxilla

70. Contraindications Single CD
Edentulous Mandible
VS
Dentate Maxilla

71. Edentulous Mandible Opposing Dentate Maxilla
•Conventional dentures are
contraindicated because they
cause severe resorption as seen in
this patient. In past years many
prosthodontists recommended
extraction of the remaining
maxillary teeth. Today other options are
available.

72. Difficulties:
1. Excessive load
2. Occlusal problems
3. Minimal denture foundation area
4. Fracture
5. Tooth wear
6. Tissue abuse
7. Increased monitoring
Edentulous Mandible Opposing Dentate Maxilla

73. In the mandible, the limited denture bearing
area will lead to advanced residual ridge
resorption of the edentulous mandible.
For this reason, a lower complete denture
opposing upper natural teeth should be
avoided . A lower complete denture
opposing upper natural teeth is acceptable
for patients with class III jaw relation. and
for a patient with cleft palate
Edentulous Mandible Opposing Dentate Maxilla

74. • Avoid creating this situation if
possible
• If construction of this denture
is unavoidable ensure that the
opposing teeth are on a level
plane.
Edentulous Mandible Opposing Dentate Maxilla

75. A level plane may be established by
extraction, grinding of cusps,
crowns or occlusal build-ups
Edentulous Mandible Opposing Dentate Maxilla

76. • Maximize denture base coverage
• Minimized occlusal forces
• Preprosthetic surgery
• Retention of key roots
• Use of osseointegrated implants
• Temporary soft liners replaced on a regular
basis
• Permanent soft liners
Options other than extraction of maxillary dentition
For Preservation of the Residual Alveolar Ridge
Edentulous Mandible Opposing Dentate Maxilla

77. Ridge Augmentation
A variety of materials have been used for
this purpose:
 Autogenous bone from the iliac crest or rib.
 Non-autogenous bone.
 Hydroxyapatite, (in the granular or block form)
which is injected through one or more
subperiosteal tunnels to build up sufficient height
of the residual ridge.

78. Ridge augmentation
Edentulous Mandible Opposing Dentate Maxilla

79. Ridge Augmentation

81. Retained Roots
Retaining roots in key positions facilitate support and prevent
compression of the periosteum. In this patient a cuspid and a
premolar root have been retained. Support in the posterior
region, however, must still be provided by the retromolar pad,
the buccal shelf and the residual alveolar ridge.
The excessive loads delivered to these areas will result in
continued resorption of the mandibular body.

82. Osseointegrated Implants
• Implant assisted overlay dentures opposing
dentate maxilla
The implants are used to facilitate retention, stability, and provide
support in the anterior region. Posterior occlusal loads, however,
must be borne by the retromolar pad, the buccal shelf and the
residual alveolar process. A carefully made border molded
impression will make maximum use of these support areas.

83. Osseointegrated Implants Opposing Dentate Maxilla
• Implant supported prostheses – All the
occlusal forces are borne by the implants
This type of prosthesis stops the process of resorption of the
mandible and in many patients the volume of the body of the
mandible posterior to the mental foramen actually increases. It
is therefore the most desirable method for restoring the
edentulous mandible that opposes a fully dentate maxilla.

84. Implants to solve the problem
of mandibular single denture

85. Second case
( Fixed superstructure)

87. Questions for Review
1) Name the five factors affecting occlusal balance. (10 points)
2) Why is it difficult to achieve bilateral balance with a complete
denture that opposes an intact dentate arch? (6 points)
3) Define combination syndrome. (4 points)
4) In the past many prosthodontists recommended extracting the
remaining maxillary teeth when opposed by an edentulous
mandible. Why? What are the options available today? Which
option is preferred and why is this option preferred? (14 points)
5) Discuss in detail the strategies you would use when restoring an
edentulous arch that opposes a fully dentate arch to prevent or
minimize resorption of the edentulous arch. ( 10 points)
6) When fabricating a maxillary denture opposing a fully dentate
mandibular arch what are the consequences of arranging the
maxillary anterior denture teeth with excessive vertical overlap?
(4 points)

88. Typical examination questions
• In an organized summary, discuss the
problems of the single denture wearer
and possible solutions to specific
problems .
• Discuss the problems faced by the
patient wearing a specific type of
single denture and propose strategies
to cope with the problems.

89. REFERENCES
Carr AB. Single Dentures. In: Zarb GA, et al, editors. Prosthodontic Treatment
for Edentulous Patients. 12 th ed. St.Louis: Mosby; 2004. p. 427-436.
Heartwell CM, Rahn AO, editors. Textbook of Complete Dentures. 5th ed.
Canada: B.C. Decker; 2002. p. 481-492. .
Stephens AP. The Single Complete Denture. In: Sharry JJ, editor. Complete
Denture Prosthodontics. 3rd ed. New York: McGraw – Hill; 1962 p. 310-319.
Lauciello FR. The Single Complete Maxillary Denture. In: Winkler S, editor.
Essentials of Complete Denture Prosthodontics. 2nd ed. USA: Ishiyaku Euro
America Inc; 1996. p. 417-426.
Langer Y et al. Modalities of Treatment for the Combination Syndrome. JOP
1995: 4; 76 - 81.
Kelly E. Change caused by a mandibular removable partial denture opposing a
maxillary complete denture. J Prosthet Dent 1972: 27; 140 -150.
Vig RG. A Modified Chew - In and Functional Impression Technique. J
Prosthet Dent 1964: 14; 214 – 220.

90. Next lecture
Single denture opposing distal extension RPD
combination syndrome

92. Premolar Occlusion
• Indications
– Short
posterior
edentulous
span
– 2nd PMs
– Adequate
mastication
– Class II

93. Premolar Occlusion
• Exceptions
– Inadequate
mastication
– Class III

94. Complete Denture Opposing Fixed
• Use of 2nd molar as a balancing ramp
The incisal angle is manipulated to be compatible
with angle of the second molar to the occlusal plane.
Centric Occlusion Protrusive Position

95. Complete Denture Opposing Fixed
Note the occlusal plane
discrepancy (A,B). The plane
of the maxillary denture is
idealized (B) before the
preparation of the opposing
dental units is commenced.
The trial denture is shown
opposing a diagnostic waxup
(C).
A
C
B

96. Incisal Angle
This cast is being prepared for
an immediate denture. In this
patient the amount of vertical
overlap is being reduced
flattening the incisal angle and
making it compatible with
condylar guidance and the curve
of Spee.

97. Complete Denture Opposing Fixed
In this patient the
occlusal plane of the
mandibular arch was
idealized with fixed
restorations.
Note: The cuspal inclinations of the posterior maxillary
denture teeth are relatively flat and the compensating curve
is 15 to 20 degrees. The incisal angle is compatible with
the angle of the compensating curve. During function
tipping of the denture will be minimized and therefore
resorption minimized.