case reports on ligualised occlusion and comparative studies with other occlusal schemes a

1. Achieving Lingualized Balanced Occlusion
in a Fixed-Removable
Rehabilitation for a Maxillary Complete
and Mandibular Kennedy
Class II Case
IBRAHIM TULUNOGLU AND SAMUEL COHEN
CASE REPORTS IN DENTISTRY. 2019 OCT 30;2019.
JOURNAL CLUB PRESENTATION
PRESENTED BY ,
NAMITHA AP
3RD MDS
DEPT.OF PROSTHODONTICS

2. Contents
Introduction
Case report
Discussion
Conclusion
Related articles
References

3. INTRODUCTION

4. Definition
A form of denture occlusion that articulates the maxillary lingual cusps with the mandibular
occlusal surfaces in centric, working, and nonworking mandibular positions.
Good esthetics
Good bolus
penetration
Simple technique
Additional stability
in parafunction
Reduced lateral
forces directed
toward alveolar
ridges
Ease of adjustment
An area of closure
provided that better
accommodates
basal seat changes
More easily used in
Class II, Class III, and
cross-bite situations
Compatible with the
tenets of
neutrocentric
occlusion

6. Indications
1. High priority on esthetics but a nonanatomic occlusal scheme is indicated
2. Severe residual ridge resorption
3. Class II and class III jaw relationship
4. Flabby supporting tissue
5. When a complete denture opposes a removable partial denture.
6. Parafunctional habits

7. Gysi’s Cross-bite
Posterior Teeth
Dr. French’s
Modified Posterior
Teeth

9. RATIONALE
Methodology for fabrication of maxillary and mandibular complete dentures is well
documented, it has not been well established in cases involving a maxillary complete denture
(CD), opposing a mandibular removable partial denture (RPD) and fixed restorations to provide
harmonious lingualized occlusion.
This paper defines a method to achieve an adequate compensating curve and bilateral balanced
lingualized occlusion in a case requiring fixed and removable prosthodontics rehabilitation.

10. Case report
EXAMINATION
A 64-year-old Female
Ill-fitting maxillary acrylic-based removable partial
denture
to get “a new set of teeth,” seeking an
improvement in her esthetics and masticatory
function.
no major related medical conditions aside from
suffering from depression and anxiety.
Oral hygiene was fair and there was no periodontal
disease present.
.

11. Clinical and radiographic examination revealed edentulous spaces in both arches,
extensive presence of non restorable teeth, and active caries
Non harmonious plane
of occlusion
lack of a stable posterior
occlusion
moderate wear of
remaining anterior teeth
Collapse of VD!
not addressed with the previous fixed
partial restorations on teeth #14, 13, and
11
VDR – VDO = 9 mm
After removal of the restorations, teeth
#14, 13, and 11 revealed deep carious
lesions, and #5 vertical root fracture.
Teeth 17 and 27 showed furcation defects
on the distal aspects.

12. Treatment plan
The patient was given various treatment plans
Full arch-supported fixed prosthodontic rehabilitation with periodontal treatment on furcation
defects and crown lengthening for teeth #13, 11, 32, 31, 41, and 42 and placement of implants
to support the fixed partial denture restorations replacing the tooth loss at the edentulous spans
Crowning of teeth #35, 34, 43, 45, and 47 and the fabrication of a maxillary complete and
mandibular removable partial denture because of the patient’s avoidance from surgical
placement of implants and the cost of an implant-supported rehabilitation.

13. Treatment
After thorough oral hygiene instructions, the patient’s active
disease was stabilized with surgical, operative, and
prosthodontic intervention.
An interim maxillary complete denture and mandibular partial
denture was delivered immediately after the extraction of the
remaining maxillary teeth and mandibular incisors
In this provisional phase, the patient was rehabilitated at a
2mm increased VDO that allowed her to be monitored in
terms of any possible adverse reactions or changes in the
stomatognathic system.
After 6 months of osseous healing and observation period, the
definitive phase of prosthetic treatment began as no adverse
effect was observed in the stomatognathic system.

14. The maxillary wax occlusal rim was adjusted intraorally to provide the
correct location and position of the occlusal plane relative to the VDO
lip line and smile line of the patient.
Using a semiadjustable articulator (Stratos 100) the maxillary master
cast was mounted using the maxillary wax occlusal rim and the
Maxillary Mounting Table of the system.
The mandibular arch was mounted in centric relation (CR).
Maxillary anterior teeth were set using the Mounting Table that
represents the defined occlusal plane location, and the mandibular
teeth were set as to obtain 1mm of overbite and 1.5mm of overjet

15. .
Then, the maxillary cast was removed from the upper
member of the articulator, and the guide plane jig for
compensating curve (2.5D Setup Template, Ivoclar Vivadent,
Schaan, Liechtenstein) was inserted.
The simulation of tooth preparations was made on the
mandibular cast to ideal dimensions before the wax-up was
made.
An artificial tooth set-up for the maxillary posterior teeth
was made to fabricate the fixed restorations accordingly.
After preparations for abutment teeth for PFM crowns #35,
34, 43, 45, and 47, the final impression was made in PVS
impression material

16. A jig for proper VDO was made on the articulator against
the maxillary tooth arrangement.
This jig is used as a vertical stopper for the intermaxillary
relationship record to replicate the VDO.
Surveyed crown restorations with guide planes parallel to
the defined path of insertion and ledges were made, to
improve retention, stability, and support of the RPD and
tried intraorally.
A coping pick-up impression was made with the PVS
impression material and poured with stone
The guide planes and gingival ledges were refined and
milled once more, including the dovetail-shaped rests
between the splinted copings
Then, porcelain was built on the copings following the 2.5D
template and the maxillary tooth arrangement was also
made according to the same template

17. After the crowns were made, the RPD metal
framework was fabricated for the Kennedy Class
II mod II mandibular arch.
The metal framework and the crowns were
tried in together, and the final tooth
arrangement was made with the same
template

18. Trial and insertion appoinments
Final try-in of the maxillary CD, mandibular RPD, and fixed
prostheses allowed for minor adjustments in the tooth set-up.
The final tooth arrangement in wax shows the harmonious
occlusion between the fixed and removable elements of the
prostheses.
At delivery, minimal occlusal adjustments were done intraorally
to achieve lingualized occlusion with balanced centric and
eccentric contacts

19. Discussion
With such a dilapidated dentition and loss of vertical dimension, it was of utmost importance to
restore the patient’s occlusal plane so that proper function could be obtained.
Not only is having proper centric contacts on all teeth essential for function, but having those
contacts orientated in the correct occlusal plane and compensating curve was imperative.
Extractions, surveyed metal-ceramic restorations with parallel guide planes, a mandibular
removable partial denture (RPD), and maxillary complete denture (CD) were treatment avenues
used to rehabilitate this patient.
An approach utilizing the Stratos 100 Articulator and 2.5D guide plane was sought to harmonize
the occlusion between the fixed and removable elements of the mandibular prostheses

20. The system allowed to establish the desired occlusal plane location and position as well as the
contact patterns that are designed as part of the standards established with the Stratos system.
This included establishing the occlusal configurations as well as the positions and locations of
both fixed restorations and artificial teeth on removable dentures with minimal adjustment at
delivery.
Instead of maxillary and mandibular posterior teeth with steep cuspal angles, using artificial
teeth fabricated purposely for lingualized occlusion also contributed to the fact that fewer
adjustments overall necessitated.
The compensating curve is provided by the 2.5D template, and the cusp heights are also
provided by the artificial teeth set produced specifically for lingualized occlusion.

21. Influence of occlusal schemes on the stress
distribution in upper complete denture in
centric and eccentric relation
This study was aimed to identify the sites of maximum stresses in both balanced and lingualized
occlusion in centric and eccentric relation
Abdalbasit A. Fatihallah
Maxillary
complete
dentures
Group 1
Balanced
occlusal scheme
Group 2
lingualised
occlusal scheme
The model was drawn on a grid paper
after sectioning of the original upper
denture mesial and distal to the
upper first molar so that a section
was made crossing the palate to the
other side of the denture

22. 1. The mesial and distal area of the denture base were drawn on a grid paper with its exact
dimensions through super imposition of them on the grid paper, x and y coordinate system
obtained for a specific key points to both mesial and distal areas of the denture base.
2. The distance between the mesial and distal area of the denture base block section obtained
by the means of Vernier which represent the Z-value in space that change the model from two
dimensional to three dimensional model.
3. The mesial and distal areas were joined at their key points by lines then the lines converted to
areas and the areas converted to volumes which represent the denture base.

23. 4. Modeling of the tooth was made by the aid of Verniea through
obtaining the real dimension with the selection of specific key
points.
5. the mucosal thickness under the denture was supposed to be
1.5mm
6. The model "tooth, denture base and mucosa“ glued together in
order to act as one unit through ANSYS options when applying the
boundary conditions.

24. element used is a 3- dimensional brick shape element.
The Load was applied to the upper posterior teeth According to the site of contacts with the
opposing artificial lower posterior teeth in centric and eccentric relation, the load applied to
each set equal to 60 N
The maximum principle stresses obtained at a specific selected node, which located at the crest
of the ridge, buccal flange and the mid palatal suture.

26. Results
Comparing stresses generated at centric occlusion in balanced and lingualized occlusal
schemes:
Examination of the results obtained from the FEM through applying Von mises theory of
failure and obtains the stresses at specific selected nodes located at the crest of the ridge,
mid-palatal suture and buccal flange, results shows that the highest stress values at the crest
of the ridge “15.371 KPa, 0.961 KPa in balanced and lingualized occlusal schemes respectively”.

27. Discussion
Comparing stresses generated at eccentric occlusion in balanced and lingualized occlusal
schemes.
Generally speaking for both working and balancing side, the mean stress values in the
lingualized occlusal scheme much less than those generated in the balanced occlusal scheme.
While for mid-palatal suture no considerable changes takes place. (Table 2,3; Figure7, 8)
this may be due to number of occlusal contact reduced so that there is only a one centric
stopper between upper and lower antagonist teeth in case of lingualized occlusion
No changes take place at the mid-palatal suture when comparing the values of stresses in both
occlusal schemes

28. When comparing stresses in lingualized and balanced occlusal schemes generated at eccentric
occlusion:
Table 2 and 3 show that stresses generated at the mid-palatal suture reduced in fully balanced
occlusion than that in lingualized occlusal schemes due to the fact that
1.The position of the upper posterior teeth is rather tilted buccally than centered over the ridge
crest so that the buccolingual position of the posterior teeth will affect the stress distribution
and consequently the stress reaching the midline of the denture.
2.The site of occlusal contacts, in that only the palatal cusp of the upper posterior teeth contact
the fossa and central groove of the lower posterior teeth.
Stresses generated at the working side at the crest of the ridge and buccal flange for balancing
occlusion seems to be more than that for the lingualized occlusal scheme due to the number of
occlusal contact increased. For the balancing side at the crest of the ridge vice versa occur, while
at the buccal flange the same results take place this is may be due to the sites of occlusal
contacts differ.

31. Management of releasable full denture in
patient with pseudo jaw relation class III:
a case report
To give information about management
of releasable full denture in patient
with pseudo jaw relation class III
A 58 years old woman
she wanted a denture made because
she felt shy as she laughed and she
could not chew properly.
Last tooth withdrawal for tooth 26 was
done 3 months ago.
Elvi EM, Thalib B, Arafi A, Sulistiawaty I
Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci) April. 2017;2(1):58-60

33. DISCUSSION AND CONCLUSION
In this case the relation between patients jaw was abnormal relationship.
It was because the upper jaw experienced bigger reabsorption of tooth loss and irreplaceable
with denture compared to the lower jaw.
This appeared to become jaw relation of pseudo class III.
Then to gain natural look and stability, posterior teeth formation with lingualized occlusion was
conducted.

34. A double blind randomized clinical trial comparing
lingualized and fully bilateral balanced posterior
occlusion for conventional complete dentures
A lingualized occlusion (LO) for complete dentures reduces lateral inferences and
occlusal force contacts and direction; thus, LO is theorized to be more suitable for patients
with compromised ridges than fully bilateral balanced articulation (FBBA).
However, no studies have yet provided evidence to support LO in edentate patients with
compromised alveolar ridges.
The purpose of this study was to compare LO and FBBA in edentulous individuals with
compromised ridges
Kawai Y, Ikeguchi N, Suzuki A, Kuwashima A, Sakamoto R, Matsumaru Y, Kimoto S, Iijima M, Feine JS. journal of
prosthodontic research. 2017;61(2):113-22.

35. Materials and methods
The study setting, trial design and participants

36. Following delivery, several
denture-related
satisfaction
variables were measured
using 100 mm visual
analogue scales

37. At 6 months, participants
with severely atrophied
mandibles and FBBA rated
their
satisfaction with retention of
mandibular dentures
significantly lower than those
with LO
(median LO: 86, FBBA: 58.5, p
= 0.03). They also had
significantly lower OHRQoL
for the
domain of Pain (median LO:
4, FBBA: 5, p = 0.02). General
satisfaction and total OHIP
scores
significantly improved
between baseline and 6
months only for the LO
subjects with
severely atrophied mandibles
(satisfaction: p = 0.003, OHIP
total score: p = 0.0007).

38. Comparison of groups by patient
ratings of denture retention (100 mm
VAS) at 6 months, by severe and
moderate
mandibular ridge resorption.
Significantly lower denture retention
was observed with FBBA in the severe
resorption group

40. Conclusions
No significant differences were detected between LO and FBBA with the primary outcome at 3
and 6 month post-delivery.
Lingualized occlusion with hard resin artificial teeth is considered to be the first occlusal scheme
considered for subgroup patients, particularly those having less than 20 mm of mandibular
alveolar ridge height.

41. A comparison of lingualized occlusion and
monoplane occlusion in complete dentures
Harold E. Clough, Jack M. Knodle, Stephen H. Leeper, Myron L. Pudwill and David T. Taylor
In this present study two noninterfering occlusal schemes were compared:
(1) lingualized occlusion, using a combination of anatomic (30-degree) teeth fo the maxillary
denture and modified nonanatomic teeth for the mandibular denture
(2) nonanatomic or cuspless (O-degree) teeth for both the maxillary and mandibular dentures.
The comparison was made by constructing two sets of dentures for the same patient, allowing
the patient to wear both, and then asking the patient to report a preference and give reasons for
the choice.

42. Method
1. Primary casts of the maxillary and mandibular arches were obtained for the purpose of
constructing individual impression trays.
2. A single impression was developed for each arch with polysulfide impression material after
establishing the borders with modeling compound.
3. The maxillary and mandibular master casts were duplicated.
4. Both sets of casts were mounted with the same face-bow transfer record and centric relation
record, with the same denture bases, on two different articulators.
5. A second set of denture bases and occlusion rims (not used to transfer records) was placed on
one of the articulators and contoured to approximate the originals.
6. Maxillary and mandibular anterior teeth of the same mold and shade were arranged as
identically as possible on both articulators.

43. 7. The posterior occlusal scheme for the dentures
on one articulator was monoplane and the other
was lingualized.
8. Both sets of dentures were tried in the mouth in
wax and adjustments were made in the anterior
arrangements to make them as identical as
possible.
9. If a corrective centric relation record was
necessary at the time of the wax trial insertion,
both sets of casts were remounted with the same
interocclusal wax record obtained with one set of
bases.
10. Both sets of dentures were processed with the
same acrylic resin by the same procedures.

44. One of the two sets of dentures was inserted first in random fashion.
Thirteen of the patients received the lingualized occlusion first
17 patients received the monoplane dentures first.
The patients wore the first occlusal scheme for 3 weeks.
The patients were asked to observe the chewing efficiency, comfort, and appearance of the
dentures.
Adjustments were accomplished as necessary.
After the 3-week period was completed, the dentures were exchanged and the same procedures
followed.

45. Results
1. The number of adjustments required for each set of dentures
2. The chewing ability of each posterior scheme as observed by the patient
3. The dentures preferred by the patient and the reason for that preference
The 30 patients required a few more adjustments (95) while wearing the monoplane dentures
than they did with the lingualized teeth (90).
The average number of adjustments for the monoplane occlusion dentures was 3.17 and for the
lingualized occlusion dentures 3.
With the t-test used to compare the means, no significant difference was found in the two
occlusal patterns as measured by the number of adjustments required.

46. Sixteen patients previously had been wearing dentures with monoplane occlusion, or an
occlusal scheme
that was so worn as to be unidentifiable.
Only four of these (25%) preferred the monoplane occlusion.
One had never had dentures, a second was not wearing dentures, and a third already had
lingualized occlusion.
Of the remaining 11 who had previously used anatomic teeth (20- or 30-degree), all who had a
preference (8) chose the lingualised occlusion.
Eighteen patients had never worn dentures or had only one set.
Of these, 12 (66.67%) preferred lingualized occlusion, three liked the monoplane, and three had
no preference.
The others (12) had worn two, or more, sets of dentures previously. The same percent of this
group (66.67%) selected the lingualized occlusion.

47. There were 15 subjects 65 years of age and over, and the same number under 65. Of those 65
and over, 46.67% preferred lingualized occlusion, 33.33% preferred monoplane occlusion, and
20% had no preference.
In the younger age group, under 65 years of age, all who expressed a preference said that they
liked the lingualized occlusion (86.67%).
Of the 16 men, 10 chose the lingualized occlusion (62.50%), five (31.25%) the monoplane
occlusion, and one (6.25%) had no preference.
The 14 women either had no preference (28.57%) or chose the lingualized occlusion (71.43%).

48. Twenty of the 30 patients (66.67%) expressed a preference for the lingualized occlusion.
Only five patients (16.67%) preferred the monoplane occlusion, while the same number had no
preference. This
preference for the lingualized occlusion was significant at the 0.005 level according to chi-square
analysis.
The patients were asked to give reasons for their denture preferences.
Those selecting the lingualized occlusion mentioned that those dentures “chewed better” (13
times); that they “fit better”; were “more stable” or “more comfortable” (nine times); that they
“looked better” (seven times); and that “the speech was better” and “no cheek biting” occurred
(one time each).

49. Those preferring the monoplane occlusion, on the other hand, mentioned “more comfortable”
or “fit better” four times and “could eat better” once.
Most preferred the lingualized occlusion no matter what type of occlusion they had had
previously or how many different sets of teeth they had used over the years.
It could be assumed that improved esthetics helped influence both the younger age group and
the women to choose the lingualized occlusion exclusively when they expressed a preference.
The reason given for the preference of lingualized occlusion from those among this group of 30
patients who did so would seem to support the contention that lingualized occlusion improves
the masticatory abilities and the appearance of the dentures, as compared to a cuspless
scheme, while providing the same noninterfering freedom and bilaterally balanced occlusion

50. Summary
Two sets of dentures, one with lingualized occlusion and the other with monoplane occlusion,
were made for each of 30 edentulous patients.
Sixty-seven percent of those people preferred the lingualized occlusal scheme because of
improved masticatory ability, comfort, and esthetics

51. Lingualized occlusion revisited
Rodney D. Phoenix and Robert L. Engelmeier
Lingualized occlusion represents an established method for the development of functional and
esthetic complete denture articulation. Since its introduction, the lingualized technique has
undergone many changes. This article provides
an overview of the history and development of lingualized occlusion, and addresses common
misconceptions associated with the lingualized technique. In addition, a practical method for the
development of lingualized denture occlusion is presented

52. Dental technique
1. Program the articulator. Determine and set horizontal condylar guidance elements using a
protrusive jaw relation record. Horizontal condylar guidance settings should not differ by more
than 5 degrees. Establish and set lateral condylar guidance values using Hanau’s formula (L = H/8
+ 12).
Determine the incisal guidance by subtracting 20 degrees from the average horizontal condylar
guidance value.
Set lateral components of incisal guidance at 5 degrees on each side.
Establish appropriate soft tissue support, as well as acceptable esthetics and phonetics
2. Arrange the maxillary anterior teeth in accordance with rim contours.
3. Arrange mandibular anterior teeth to harmonize with maxillary anterior teeth. Ensure
appropriate contact of maxillary and mandibular incisal edges in eccentric positions

53. 4. Clearly identify the positions of the retromolar pads.
Identify the medial and lateral extensions of the pads with distinct lines on the posterior land
area of the mandibular cast.
Identify one half the height of each retromolar pad with a distinct line on the land area of the
mandibular cast.
5. Position a gently curved template (for example, 20-degree template; Dentsply Trubyte, York,
Pa) so that it rests on the mandibular canines anteriorly and bisects the height of the retromolar
pad posteriorly.
Use identifying lines described in step 4 above.

54. 6. Arrange the mandibular posterior teeth, allowing
the metal template to guide the vertical placement
and compensating curve (Fig. 7). Determine the
mediolateral placement of the mandibular posterior
teeth by ensuring that mandibular lingual cusps fall
within Pound’s triangle.
7. Modify the vertical dimension of the articulator to
accommodate corrective adjustment procedures.
To accomplish this, create a 0.5-mm increase in
occlusal vertical dimension at the incisal pin.
8. Arrange the maxillary posterior teeth, ensuring that
the maxillary lingual cusps are placed in the opposing
central grooves.
Position the maxillary buccal cusps 1 mm superior to
the maxillary lingual cusps (Fig. 8).

55. 9. Return the incisal pin to its neutral (zero) position.
10. Using articulating film and rotary instrumentation, perform corrective adjustment procedures.
Restrict adjustment to the mandibular teeth.
Stop the procedure when the incisal pin is in contact with the incisal table.
Do not perform corrective adjustment procedures in eccentric positions at this time.
11. Accomplish a clinical evaluation of the tooth arrangement at the trial insertion appointment.
Modify the anterior tooth arrangement as necessary.
12. Make centric relation records.
Verify the accuracy of the articulator mounting.
Remount if necessary.
13. Make required changes in proposed tooth positions.

56. 14. Perform corrective adjustment procedures to ensure appropriate contact in centric relation
position.
Be certain to reestablish contact between the incisal pin and the incisal table at the proposed
occlusal vertical
dimension.
15. Perform corrective adjustment to ensure appropriate contact in eccentric positions. Be
certain that bilateral posterior contact is present when anterior teeth are in an edge-toedge
relationship.
16. Accomplish corrective adjustment procedures for right lateral and left lateral excursions.
Ensure sustained, bilateral contact of the teeth as the articulator is moved into right lateral and
left lateral positions. Bilateral balance should be evident for 3 mm in each direction as measured
at the incisal pin (approximately one half the width of the incisal pin for many articulators).
17. Finalize the proposed denture base contours in wax.
18. Perform investment, wax elimination, packing, and processing procedures.

57. 19. Recover the processed dentures on their respective definitive casts.
Return the denture/cast assemblies to the articulator.
20. Perform corrective adjustment procedures.
Reestablish the desired occlusal vertical dimension by carefully adjusting the mandibular occlusal surfaces.
Carefully recontour the mandibular occlusal and incisal surfaces to achieve the desired centricand eccentric
contacts.
Refine the occlusal anatomy.
21. Perform a verified clinical remount and repeat the process outlined in step 20 above.

58. Summary
This article provides a brief overview of the development of lingualized occlusion and a
technique that results in an occlusal scheme as intended by the originators of this approach.

59. References
Tulunoglu I, Cohen S. Achieving Lingualized Balanced Occlusion in a Fixed-Removable Rehabilitation for a
Maxillary Complete and Mandibular Kennedy Class II Case. Case Reports in Dentistry. 2019 Oct 30;2019.
Elvi EM, Thalib B, Arafi A, Sulistiawaty I. Management of releasable full denture in patient with pseudo jaw
relation class III: a case report. Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci) April. 2017;2(1):58-
60.
Kawai Y, Ikeguchi N, Suzuki A, Kuwashima A, Sakamoto R, Matsumaru Y, Kimoto S, Iijima M, Feine JS. A double
blind randomized clinical trial comparing lingualized and fully bilateral balanced posterior occlusion for
conventional complete dentures. journal of prosthodontic research. 2017;61(2):113-22.
Phoenix RD, Engelmeier RL. Lingualized occlusion revisited. The Journal of Prosthetic Dentistry. 2010 Nov
1;104(5):342-6.
Clough HE, Knodle JM, Leeper SH, Pudwill ML, Taylor DT. A comparison of lingualized occlusion and monoplane
occlusion in complete dentures. The Journal of prosthetic dentistry. 1983 Aug 1;50(2):176-9.
Engelmeier RL, Phoenix RD. The development of lingualized occlusion. Journal of Prosthodontics. 2019
Jan;28(1):e118-31.