LINGUALISED OCCLUSION

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 1

2. Contents
Introduction
Case report
Discussion
Conclusion
Related articles
References
2

3. INTRODUCTION
3

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
4

5. 5

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
6

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

8. 8

9. Case report
EXAMINATION
A 64-year-old Female
Ill-fitting maxillary
acrylic-based removable
partial denture
a new set of teeth -
improvement in
esthetics and
masticatory function.
.
9

10. 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.
10

11. 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.
11

12. Treatment
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
Provisional phase - rehabilitated at a 2mm
increased VDO
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.
12

13. 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
13

14. .
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
14

15. 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
15

16. 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
16
Final try-in - minor adjustments in the tooth set-up.
At delivery - occlusal adjustments were done
intraorally to achieve lingualized occlusion

17. 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.
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
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.
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
17

18. 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.
18

19. Materials and methods
The study setting, trial design and participants
19

20. Following
delivery,
several
denture-
related
satisfaction
variables
were
measured
using 100
mm visual
analogue
scales
20

21. 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).
21

22. 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
22

23. 23

24. 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.
24

25. 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 non interfering occlusal schemes were compared:
(1) lingualized occlusion, using a combination of anatomic (30-degree) teeth for 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.
25

26. 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.
26

27. 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.
27

28. 28
Dentures exchanged
and same procedures
followed
patients wore the first
occlusal scheme for 3
weeks
One of the two sets of
dentures was inserted
first in random fashion 30 patients
17
MONOPLANE
17
LINGUALISED
13
LINGUALISED
13
MONOPLANE
The patients were
asked to observe
the chewing
efficiency,
comfort, and
appearance of
the dentures.
Adjustments
were
accomplished as
necessary.

29. 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
MONOPLANE
OCCLUSION
95
3.17
LINGUALISED
OCCLUSION
90
3
29
AVERAGE
NUMBER OF
ADJUSTMENTS

30. 30
30 SUBJECTS
15 > 65
YEARS
46.67% LO
33.33% MO
20% - NO
PREFERENCE
15<65 YEARS 86.67% - LO
30
16 MEN
62.50% LO
6.25% NO
PREFERENCE
31.25% MO
14 WOMEN
28.57 – NO
PREFERENCE
71.43% LO
30
66.67 - LO
16.67 -MO
16.67 – NO
PREFERENCE
13 • CHEWED BETTER
9 • MORE STABLE
7 • LOOKED BETTER
1 • BETTER SPEECH
1 • NO CHEEK BITING
4
1

31. 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
31

32. 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
32

33. 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
33

34. 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
34

35. 35
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

36. 36
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 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.

37. 6. Arrange the mandibular posterior teeth, allowing
the metal template to guide the vertical placement
and compensating curve.
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
37

38. 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.
38

39. 39
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.
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.

40. 40
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-to edge
relationship.

41. 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
17. Finalize the proposed denture base contours in wax.
18. Perform investment, wax elimination, packing, and processing procedures.
19. Recover the processed dentures on their respective definitive casts.
Return the denture/cast assemblies to the articulator.
41

42. 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 centric and eccentric
contacts.
Refine the occlusal anatomy.
21. Perform a verified clinical remount and repeat the process outlined in step 20 above.
42

43. 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.
43

44. A randomized clinical trial comparing anatomic, lingualized,
and zero-degree
posterior occlusal forms for complete dentures
A. F. Sutton and J. F. McCord
The purpose of this study was to compare
subject satisfaction with 3 types of
posterior occlusal forms for complete
dentures in a randomized cross-over
controlled trial
For each participant (n=45), 3 sets of
complete dentures were fabricated, each
of which had a different posterior occlusal
form (0-degree, anatomic, and
lingualized).
Each set was worn for 8 weeks in a
randomized order.
44

45. 45

46. 46
Lingualized posterior occlusal forms were significantly
superior in terms of reduced pain in the mouth,
reduced incidence of sore spots, ability to eat, and
meal interruptions, compared with 0-degree
posterior occlusal forms
Anatomic posterior occlusal forms
were significantly better in terms of masticatory
function compared with 0-degree posterior occlusal
forms
There were no significant differences when lingualized
posterior occlusal forms were compared with anatomic
posterior occlusal form

47. 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
47

48. 48

49. 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.
49

50. 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.
Sutton AF, McCord JF. A randomized clinical trial comparing anatomic, lingualized, and zero-degree posterior
occlusal forms for complete dentures. The Journal of prosthetic dentistry. 2007 May 1;97(5):292-8.
50

51. 51