A r a t i o n a l e for a simplified o c c l u s a l d e s i g n in r e s t o r a t i v e

dentistry: H i s t o r i c a l r e v i e w and clinical g u i d e l i n e s

H. W . A n s e l m Wiskott, DMD, M S , M S D , a a n d U r s C. B e l s e r , Prof. Dr Med
Dent b
School of Dentistry, University of Geneva, Geneva, Switzerland

A n o c c l u s a l c o n t a c t p a t t e r n in w h i c h t h e n u m b e r of o c c l u s a l c o n t a c t s h a s b e e n
s u b s t a n t i a l l y r e d u c e d a s c o m p a r e d w i t h t r a d i t i o n a l s c h e m e s is d e s c r i b e d . C o n c e p t s
t h a t m a y h a v e h a d a j u s t i f i c a t i o n in b a l a n c e d o c c l u s i o n s h a v e b e e n n e e d l e s s l y
t r a n s f e r r e d to a n t e r i o r d i s c l u s i o n m e c h a n i c s . N o n a t u r a l d e n t i t i o n p r e s e n t s o c c l u s a l
c o n t a c t s a s d e s c r i b e d in m a n y t e x t s a n d y e t s t a b i l i t y is e s t a b l i s h e d . T h e t e m p o r o -
m a n d i b u l a r joint d o e s p r e s e n t s t r u c t u r a l c h a n g e s t h a t s h o u l d b e a c c o u n t e d for
w h e n a n o c c l u s a l a n a t o m y is d e s i g n e d . T h e f o r c e v e c t o r s t h a t a r e a c t i v e on t e e t h
a r e not d i r e c t e d a l o n g t h e l o n g i t u d i n a l a x e s of t h e r o o t s only, a n d t h u s o c c l u s a l
contact locations will not determine the direction of functional forces. The stability
of t h e t e e t h on t h e a r c h d e p e n d s p r i m a r i l y on t h e f o r c e s o f e r u p t i o n f r o m t h e
p e r i o d o n t i u m a n d t h e b a l a n c e b e t w e e n t h e r e s t i n g p r e s s u r e s of t h e m u s c l e s of t h e
c h e e k s a n d t h e t o n g u e . T h e m e c h a n i c s of t h e s t o m a t o g n a t h i c s y s t e m a r e not a s
a c c u r a t e a s t h e i r c o u n t e r p a r t on a n a r t i c u l a t o r . T h e v a r i a b i l i t y o f t h e g u i d i n g
s u r f a c e s i n h e r e n t to t h e t e m p o r o m a n d i b u l a r j o i n t s s h o u l d be i n c o r p o r a t e d into a n
o c c l u s a l d e s i g n . O c c l u s a l c o n t a c t s t h a t do n o t fulfill a j u s t i f i a b l e p u r p o s e m a y b e
e l i m i n a t e d , a n d t h e n u m b e r o f c o n t a c t s m a y b e r e d u c e d to o n e p e r tooth. (J
PROSTHET DENT 1 9 9 5 ; 7 3 : 1 6 9 - 8 3 . )

HISTORICAL DEVELOPMENT
Much has been written about the location of In the 1950s, accepted philosophies of interarch dynamics
occlusal contacts (OCs) in maximum intercuspation (MI). evolved from "fully balanced ''5, 6 t o " m u t u a l l y p r o t e c t e d ''7, s
Many authors have described OC p a t t e r n s t h a t they occlusions. 9 During this transition, however, a number of
believed would promote optimal integration of the teeth features of the fully equilibrated contact p a t t e r n were need-
into the stomatognathic system. lessly transferred into the newer concept of anterior disclu-
Two types of contact p a t t e r n s have found acceptance for sion mechanics. There is still confusion today over at-
n a t u r a l dentitions and fixed prostheses: the "gnathologic" tributes t h a t m a y be suitable for complete dentures b u t are
and the "freedom-in-centric" types of occlusion. In gna- of questionable importance when applied to natural denti-
thologic (or organic) schemes, MI coincides with the tion or fixed prosthodontics. T h e main historical vestiges
r e t r u d e d contact position (RCP) (equivalent to centric re- pertain to the overall arrangement and the individual anat-
lation contact position). 1 T h e relationship between both omy of the occlusal surfaces. T h e y will be briefly reviewed.
dental arches and the t e m p o r o m a n d i b u l a r joints is set by
Occlusal curves
the occlusal anatomy, which is designed to determine a
unique position where M I can occur (Fig. 1, a). 2, 3 Classi- The earliest and most profound observation was by von
cally, this mechanical keying between the mandibular and Spee, 1~ who believed a continuum had to be established
maxillary arches is obtained by tripodized occlusal con- between the angle of the eminentia and the arrangement of
tacts. Conversely freedom-in-centric occlusion calls for a the occlusal surfaces of the teeth (Fig. 2). In his approach
contact range between RCP and a position 0.5 to i mm an- a steep condylar path required a profound "curve of Spee"
terior to it. 4 By necessity it relies on cusp-to-surface and conversely a fairly horizontal p a t h was best combined
mechanics (Fig. 1, b). with a flatter arrangement of the occlusal surfaces. This
relationship was later established in a more elaborate form
in " H a n a u ' s Quint ' ' u and "Thielemann's formula. ''12
Another i m p o r t a n t author was Monson, 1~ who described
a tooth arrangement in which the occlusal surfaces were
aHead of Scientific Clinic, Division of Fixed Prosthodontics. aligned along the outer surface of a sphere, which itself
bprofessor and Chairman, Division of Fixed Prosthodontics.
Copyright | 1995 by The Editorial Council of THE JOURNALOF centered on the crista galli. Besides still being an important
PROSTHETIC DENTISTRY. component of one philosophy of occlusal rehabilitation, 14
0022-3913/95/$3.00 + 0. 10/1/59534 this concept derived the curves of Wilson 15 and Monson 13

FEBRUARY 1995 THE JOURNAL OF PROSTHETIC DENTISTRY 169

 WISKOTT AND BELSER

O.
9 9
F i g . 1. a, Gnathologic contacts scheme; b, Freedom-in-
centric contact scheme.
F i g . 3. Occlusal concept of Monson. 13 Axes of teeth con-
verge toward common point and occlusal surfaces lie on
surface of sphere. Lower lateral segments are concave in
sagittal plane. As viewed from front, arrangement deter-
mines curve of Wilson in molar area and convexity on lower
front teeth (sometimes referred to as Monson curve).

Occlusal a n a t o m y
The other r e m n a n t of the fully balanced concept lies
in the emphasis still placed, by some clinicians, on oc-
clusal morphology as it relates to eccentric movements
of the m a n d i b l e J s In full balance the anatomy of cusps,
inclines, and fossae combined to refined registrations of
the condylar pathways have been considered an impor-
t a n t d e t e r m i n a n t of denture stability. However, in con-
temporary anterior disclusion mechanics, elaborate de-
signs of ridge and groove direction make little sense
F i g . 2. Spee's concept of relation between angle of emi- because by definition the teeth should disclude posteri-
nence and overall arrangement of occlusal surfaces. Condy- orly during excursive movements. The establishment of
lar p a t h and curve of Spee were located on outer surface of a "near miss" chewing p a t t e r n is inappropriate as well
cylinder.
because it does not provide for possible alterations of
the functional envelope of mandibular movements be-
yond what is shown on the articulator.
(Fig. 3). It appears t h a t Monson's sphere was a refinement Restorative procedures are taxing on both dentists
of Spee's cylinder if fully balanced occlusal schemes had to and laboratory technicians. Whenever an essential
be established. In contemporary complete denture pros- phase, such as the design of the occlusal surfaces, can be
thodontics, one may refer to analogous concepts as "com- simplified ("work smarter, not harder") this should be
pensating curves" in the sagittal and frontal planes. The done. It is our contention t h a t a sizable number of the
curvilinear arrangement of the teeth compensates for the OCs illustrated in Fig 1, a and b, are superfluous and do
inclination of the condylar path. not actually fulfill the purpose ascribed to them. There-
The Spee, Wilson, and Monson curves were designed to fore this work reviews some of the attributes of accepted
promote OCs on the entire arch during excursive mandib- occlusal schemes and presents the case for a substan-
ular movements. However, none of these curves has ever tially reduced number of OCs in MI. This is not to
been reported to be present in natural dentitions. ~6 Orth- imply t h a t the presence of a larger number of tooth
odontists actually t r e a t toward an occlusal plane. 17 A contacts is necessarily harmful, b u t t h a t they should not
residual or relapsing curve of Spee is often considered a be striven for, neither during occlusal adjustment nor
failure. during restorative procedures.

170 VOLUME 73 NUMBER 2

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INTERARCH TOOTH CONTACTS

of contact intensities 34 over a 24-hour period whereby the
Maximum intercuspation number of contacts and the total contacting surface de-
Maximum intercuspation is the jaw relationship t h a t es- crease toward the end of the day. 35 T h u s natural teeth have
tablishes the greatest number of tooth contacts between fewer and less ideally placed contacts than those described
opposing arches. 19 During function M I is the starting and in theoretic schemes, and the intensity of tooth contacts is
end point of the chewing cycle. This was first shown by not constant.
Hildebrand, 2~ who demonstrated the presence of tooth
contacts at the end of the masticatory cycle. M I is also the TEMPOROMANDIBULAR JOINT
favored and longest-lasting position during swallowing. 21 Traditional stomatognathologic views are based on the
Although a border position, RCP is a functional position as premise t h a t simultaneous contact of all posterior teeth
well. Clayton et al. 22 demonstrated t h a t patients will func- should occur in RCP only. Centric relation is the most im-
tion to the border tracings made by a p a n t o g r a p h if inter- p o r t a n t d e t e r m i n a n t of mandibular stability36; therefore
ferences are removed and do not restrict m a n d i b u l a r some restorative techniques rely heavily on a definitely re-
movements toward RCP. producible hinge axis location. For this to be true, the in-
Thus functional OCs occur preferentially in a manner ternal structures of the t e m p o r o m a n d i b u l a r joints (TMJs)
that best stabilizes the mandible. During chewing and as primary d e t e r m i n a n t s of hinge axis location should be
swallowing OCs cover a zone in the vicinity of RCP if func- absolutely stable themselves.
tion to RCP is unimpeded.
Structural changes
Location o f o c c l u s a l contacts On a 24-hour basis, some researchers report variations in
Present-day concepts of occlusal stability and function CR registrations. 37 The fluid content of the tissues sur-
are based on optimal intercuspation between maxillary and rounding the bony condyle fluctuates as it does in other soft
mandibular teeth. The m a n d i b u l a r buccal cusp should fit tissues of the body, 3s thereby creating shifts in hinge axis
into the central fossae and embrasures of the maxillary recordings. Over a longer time span, evidence exists as to
teeth and the maxillary palatal cusps into the central fos- remodeling phenomena in the glenoid fossa either natu-
sae and embrasures of the m a n d i b u l a r teeth. This arrange- rally or after artificial repositioning of the mandible. In a
ment of occlusal contacts (OCs) was first described by histologic study by Moffet et al., 39 bone remodeling (pro-
Frie123 in 1927 and has been carried to the present in gressive or regressive) has been demonstrated to varying
slightly modified versions. 3, 24, 25 degrees in the condyle and the glenoid fossa of each of 30
Reality, however, is different from those idealized anatomic cadavers. Experimental d a t a indicate t h a t in
schemes. Black 26 estimated the occlusal surfaces to cover younger animals the T M J can structurally a d a p t to artifi-
an area of 210 to 300 m m 2 of which an average of 48 mm 2 cial repositioning of the mandible, 4~ and the evidence of
were O C s Y A one-to-five variation between subjects in the adaptation is ultimately removed by normally occurring
ratio of the total occlusal surface relative to the OC area was remodeling processes. 4~
noted. Most OCs are located on a combination of flat and Clinically, a majority of patients have a 0.5 to 1.5 m m
inclined surfaces or on two or more inclined planes. 2s In anteroposterior discrepancy between M I and RCP. 42 Ce-
most situations, the lingual cusps of the maxillary molars lenza 43 described the recurrence of an inconsistency be-
were found to fit into a central fossa or on a marginal ridge tween M I and RCP after an M I - R C P coincidence was es-
of the opposing arch. This proportion decreased for second tablished: 30 out of 32 patients who were initially "gnatho-
and first premolars, which presented contacts on inclined logically t r e a t e d " to centric relation had a "deflective"
planes in 36 % and 67 % of the cases, respectively. 29 contact 2 to 12 years after completion of therapy. Whether
Plasmans et al. 3~ counted the number of OCs in three the T M J is capable of major adaptive changes in response
different clinical situations. Averages of three OCs for nat- to mandibular repositioning 44, 45 or occlusal alterations 46 in
ural teeth, 2.3 for crowns, and 1.6 for amalgam fillings were adult subjects is still controversial.
found. 3~ In a sample of 45 young adults, 80 % exhibited
some degree of dissymmetry in the n u m b e r of OCs. 31 Occlusal plane therapy
Occlusal planes have been recommended as conditioning
Intensity o f O C s devices to relax the neuromuscular apparatus and ensure
Teeth are not rigidly set in the maxillary bone b u t are optimal jaw relation recordings. Compared with other
merely suspended by the periodontal ligament to the effect techniques, a Hawley-type appliance worn for 24 hours led
that a tooth can actually be shown to "pulsate" inside its to the most "consistent" and the most "retrusive" record-
alveolus at each heartbeat. 32 As discovered by Riise and ings.47, 4s
Ericsson, 33 the number of tooth contacts increases roughly Investigations over longer periods demonstrated a shift
twofold on light versus hard pressure. Variations in masti- of the terminal hinge position over time, but no consistent
catory muscle activ!ty also alter the intensity of OCs. p a t t e r n emerged. Kovaleski and De Boever 49 treated pa-
Studies of diurnal variations indicate a random fluctuation tients who had a functional disturbance of the T M J and

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THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y W I S K O T T AND B E L S E R

Fig. 4. A, Rotational movement of mandible on closure. B, Detailed view o f A . Schematic

drawing of force vectors likely to appear on clenching. Resulting tilting movements of teeth
m a y vary according to point of application of load and location of center of rotation of tooth.
As drawn, resulting force on clenching causes maxillary teeth to tilt forward b u t actually
generates "posterior component of force" on m a n d i b u l a r teeth. C, Hypothetic angulation
of roots inside skull if loading was applied along longitudinal axes of roots.

they described a t r e n d toward an anterior and lateral dis- This range is a constant finding even though the conclu-
placement of the RCP. An anterosuperior shift after sions drawn may vary among authors. Inconsistencies in
occlusal plane t h e r a p y was also demonstrated in another the vicinity of 0.1 m m were found by Helkimo et al.5~ and
study on a group of normal subjects, in which the mean K a n t o r et al. 5t Larger values were reported by Smith 55
change was 1 m m with a range of 0.3 to 3.4 mm. 5~In another (0.22 mm) and Simon and Nicholls, 56 who used a fairly
investigation, 51 an initial anterior movement followed by a complex recording apparatus. In the latter study a spread
gradual retrusion was described; however, the amount of of up to + 0.5 m m in hinge axis recordings was reported. It
scattering relative to the small amount of variation (0.1 is therefore suggested that the T M J is not a precision-en-
mm) makes the d a t a somewhat questionable. Furthermore, gineered tool. Like any other living tissue it does present
the control group (no occlusal plane therapy) also demon- anatomic variations over time and will not allow absolute
strated a shift in the posterior direction. 51 duplication of repeated measurements.

Recordings FORCES
A number of studies have dealt with the consistency of A number of authors seem to support the notion of a
duplicate hinge-axis assessments. 52 It emerges t h a t RCPs control of the forces t h a t act on the teeth by way of specific
can usually be duplicated within a range of 0.1 to 0.4 mm. designs of the occlusal surfaces. 36, 57, 58 Such a premise re-

172 V O L U M E 73 NUMBER 2
W I S K O T T AND B E L S E R T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y

oral fom~ f~ for~

d
5Kp 4 3 2 1 0 1 2Kp

Fig. 5. Force vectors applied to molar on chewing. As depicted (difference in scaling on

x and y axes), loading of teeth is roughly equal in axial and buccolingual directions.
(Adopted from Graf and Geering, Oral Sci Rev 1977;10:1-10.)

quires closer scrutiny of the force systems that are active asked to chew various foods. Applied forces were recorded
in the mouth: the forces caused by mastication, those that in the vertical and horizontal planes. As illustrated in Fig.
are active over prolonged periods of time, and those that are 5, their intensity along the buccolingual axis was roughly
developed during parafunctional activity. equal to their magnitude along the longitudinal axes of the
teeth. The authors concluded that during function the
Functional forces teeth are actually "jiggled in several directions. ''64
It is accepted that the main force vectors should be di- Thus during clenching or chewing the teeth are not
rected along the longitudinal axes of the teeth. 59 An early loaded axially only; horizontal force vectors are also present.
study revealed the pain threshold to lateral force applica-
tion to be approximately one third of the force required to Long-term forces
elicit pain when the vector was applied along the longitu- Long-term forces have been discussed extensively in the
dinal axis. 6~This experiment, however, is only a partial re- orthodontic literature and can be subdivided into three
flection of reality. In 1923, a report by Stallard 61 diagram- groups: (1) the forces generated by the muscles of the
matically analyzed resulting forces during clenching. Ow- tongue (in a facial direction) and cheeks (in a lingual direc-
ing to the location of the roots in the skull relative to the tion), (2) the forces caused by the transseptal periodontal
rotational path of the mandible, he demonstrated the fiber system; and (3) the eruptive forces of the teeth.
presence of an anterior tilting movement of the teeth. The M u s c u l a r forces. In broad terms, the shape of the
resulting vectors were grouped into what was named "an- dental arch is determined by the reciprocal pressure of the
terior component of force" and supposedly explained the tongue and the cheeks. The teeth are stabilized at a loca-
anterior migration of the teeth in the human dental arch tion where the resultant force is zero. 65 This concept dates
(Fig. 4, A through C). The position of the maxillary incisors back to Tomes (1873) who stated that "the agency of the
relative to the closure path of the mandible forces these lips and tongue is that which determines the position of the
teeth labially during chewing. The magnitude of this teeth themselves. ''66 Indeed there is some circumstantial
movement has been reported to be in the 0.02 to 0.05 mm evidence to support this claim: children with congenital
range. 62 aglossia have extremely constricted dental arches. 67,6s
Masticatory movements, as projected on the frontal Also, the teeth are tipped lingually when the lips are
plane, nearly always show lateral displacement of the "hardened" by scarring66; conversely, they splay bucally
mandible. 63Therefore the force vectors applied to the teeth when the perioral musculature has been destroyed. 69
during mastication present a lateral component and are However, when the forces were actually measured, a
directed along the longitudinal axes of the roots. In an ex- preponderance of the lingual forces was consistently ap-
periment by Graf and Geering, 64 force transducers were parent. Whereas earlier studies focused on forces devel-
mounted in an edentulous space and the subjects were oped during function, 7~ the newer approach concen-

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THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y W I S K O T T AND B E L S E R

trates on resting forces. Efforts to explain this buccolingual moval of the overlay, rapid relapse to the original position
discrepancy by integrating the forces over longer periods 72 was observed.
or by correlating the forces with the shape of the dental
Parafunctional forces
arch 73 brought the force vectors closer to balance, but were
still unsatisfactory. One hypothesis calls for the periodon- Parafunctional forces are still incompletely understood
tal ligament to produce "active" and not j u s t "passive" b u t are thought to represent a combination of the previ-
stabilization, 6s in which the teeth are capable of resisting ously described forces. High-intensity forces of long dura-
pressures of up to 5 to 10 gm/cm. 2 This assumption differs tion (repeated phases of bruxism) lasting up to 5 minutes
from findings of earlier experiments by Harmon, 74 who have been reported ss and longer episodes are conceivable.
placed 2 m m thick plates on buccal or lingual tooth In a noninflamed periodontium, depending on the magni-
surfaces. It was established t h a t an additional force of only tude, the direction (unidirectional or back and forth) and
I to 2 gm was acting on these teeth, which after 90 clays had possibly genetically determined characteristics of the sup-
moved 0.25 mm in the direction opposite to the plate. Sev- porting structures, might cause either abrasion, mobility,
eral interarch tooth relationships (malocclusions) may be or migration of teeth.
stable 65 and thus "there can be no doubt t h a t there is an It appears t h a t two different force systems are active in
equilibrium. ''75 Its components, however, have yet to be the mouth. A high-intensity b u t short-acting system exists
established. t h a t might cause fractures of prosthodontic structures b u t
Transseptal forces. Transseptal force is clinically that is fully dissipated because of the shock-absorbing
proven by the tendency for teeth t h a t are adjacent to an function of the periodontal ligament, s9, 90 This system has
extraction socket to approximate after extraction. 76 In an no effect on an orthodontic-type tooth movement. Con-
experiment by Picton and Moss, 77 the periodic elimination versely, low-grade b u t long-lasting forces will determine a
of the transseptal fibers reduced the approximal drift to rearrangement of the supporting apparatus and cause mi-
nearly zero. It was thus concluded t h a t the transseptal fi- gration of the teeth until a new state of equilibrium is
ber system was responsible for space closure when inter- reached. For this system to be active, its duration must ex-
proximal tooth contacts were artificially opened. In an in- ceed 4 to 6 hours per day in humans. 91 The effects of
tact arch, the interproximal force has been determined as parafunctional forces must be evaluated along similar
averaging 36.7 gin. This pressure increases to 57.29 gm af- guidelines. Such forces will cause teeth to move if their du-
ter the chewing of food. 7s ration exceeds the threshold for movement.
Eruptive forces. T h e exact origin of the eruptive
CHEWING EFFICACY
forces of the teeth is still a topic of controversy, 79' so but
their existence is affirmed, sl In an experimental model on Anthropologists divide mastication into puncturing, cut-
tooth eruption in rabbits, Proffit and Sellers s2 were able to ting, tearing, compression crushing, and crushing by roll-
establish the growth rate of these teeth (50 ~m/hour ing 92 whereas in the dental literature trituration of food has
initially) and also the pressure/time ratio t h a t would cause been compared with the action of a pestle in a mortar. 3
them to stop erupting (3 gm pressure every other second). A number of publications have described the relation-
By extrapolating d a t a on the rate of "submersion" of ship between the number of occluding surfaces and chew-
ankylosed teeth, the speed of eruption can be quantified to ing efficacy. Some authors believe t h a t 20 occluding units
2 ~m per day in children, s3 W i t h the use of sophisticated in a continuous arch may be adequate for chewing, 93
video equipment, Proffit et al. s4 found eruption rates of 11 whereas others found t h a t masticatory function was sig-
to 14 # m / d a y when the teeth were close to occlusion. On a nificantly impaired in subjects with fewer than 20 remain-
24-hour basis, the teeth erupted relatively fast until meal- ing teeth. 94 Available clinical d a t a on the relationship be-
time when chewing food either halted their movement or tween occlusal anatomy and chewing, however, are limited
intruded them into their socket. Drifting, tipping, su- to an early review by Yurkstas. 27 For equal numbers of op-
praeruption, and segmental alveolar bone growth may oc- posing teeth, the total OC area had the strongest correla-
cur when intra-arch and interarch stabilization are lost tion with chewing efficacy (namely, degree of comminution
because of extractions, s5 Compagnon s6 investigated the of food relative to the number of chewing strokes). By ex-
behavior of periodontally sound unopposed molars and tension, opposing totally flat teeth would present the best
documented a continuous eruption of these teeth t h a t av- masticatory performance. Interestingly, the number of re-
eraged about 1 m m per decade. Clinically, wide variations maining teeth per se was reported to be a poor predictor of
exist as to the behavior of unopposed teeth. It might be chewing efficacy because of the individual adaptive capac-
hypothesized t h a t the pressure of the tongue at rest is the ity of the patients. More recent published data suggest the
p a r a m e t e r t h a t determines the stability of unopposed total surface of functional occlusal contacts has no bearing
dental arch segments. To some extent, eruption is a on the preferred chewing side. 6s
reversible phenomenon as shown in an experiment by It thus appears t h a t optimal masticatory efficacy is ob-
Anderson and Myers s7 in which 0.5 m m thick overlays were tained by flat occlusal surfaces. The "prophylactic reduc-
fitted to molars and caused intrusion of the teeth. After re- tion of cusps" to improve chewing has been discussed. 95

174 V O L U M E 73 NUMBER 2
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Fig. 6. Mechanical equivalent of tripodized occlusal contact. Device is stabilized by pins

A and B and pin C rests on plate. It can be repositioned to accuracy of + 3t~m.

Interestingly occlusal surfaces in primitive man wore along ing teeth, final tooth position depends on the overall state
a "helicoidal plane," which somewhat fits the lower portion of equilibrium between the teeth housed in their alveolar
of the Monson sphere (Fig. 3).96 Nevertheless, it seems dif- bone and the surrounding muscles of the tongue and the
ficult to accept Begg's "attritional occlusion" as anatomi- cheeks. As depicted in Fig. 7, despite optimized occlusal
cally correct. 97 Therefore flat occlusal surfaces cannot be relationships after active orthodontic treatment, a maloc-
considered a treatment objective. clusion is likely to recur if the muscular environment is not
in balance. 9s
MECHANICS
Tripods Joint v a r i a b i l i t y
Examination of the tripodizing principle proves it to be An "outward" translation of the working condyle was
a demanding exercise. Its mechanical equivalent is illus- presented by Bennett in 1908. 99 This movement will exist
trated in Fig. 6. Such a device can be repositioned to an ac- as soon as a Bennett angle is present. More important for
curacy of approximately 5 ttm (Wiskott, unpublished occlusal design is the amount of immediate side-shift be-
observation). This order of magnitude would appear to lie cause it has a bearing on the concavity of the occlusal sur-
far beyond the degree of reproducibility of hinge axis loca- faces in the posterior segments} ~176 Some treatment con-
tions. Further, if immediate disclusion is to be obtained on cepts rely heavily on refined registration techniques. The
lateral excursions, that is, the OCs should not glide the articulators that have been programmed by such means are
slightest on each other, an absolute point contact must be then used to create occlusal schemes in which the opposing
obtained for each tripod. In other words, the OC surface cusps glide in between each other (near-miss chewing con-
should tend toward zero. Such a requirement, however, is cept). 57 However, the dynamics of the mandible do not al-
at odds with the physical principle that specifies that pres- low absolute programming. The variations in OC intensity
sure is equal to the force divided by the surface of applica- have been described. Also, the mandible deforms on open-
tion. If the surface tends toward zero, pressure approaches ing 1~ and, most important, the amount of medial move-
infinity. Also, the slightest lack of contact or movement of ment of the working condyle (immediate side-shift) is sub-
the teeth acting as discluders (generally the canines) will ject to variation. When pantographic recordings were ob-
create a gliding contact on the posterior teeth. Therefore it tained while the balancing condyle was forced medially by
would be senseless to establish tripods in dentitions with- the operator, the amount of side-shift increased by up to 0.6
out immediate anterior disclusion. The mechanical princi- mm on average as compared with the amount found in
ple of tripodizing implies a degree of accuracy that conflicts nonassisted recordings. 1~ With a similar experimental
with available data on the stability of the joint, registration method, on unstrained movements, a balancing contact
methods, functional mobility of the teeth, and wear of the was present in about 30 % of the patients investigated.
discluding surfaces. This proportion increased to 90 % when operator-induced
mandibular excursions were performed} ~ From an ana-
Stabilization tomic standpoint, an inward movement can also be
A common conception holds that tooth intercuspation produced on contraction of the lateral pterygoid muscle,
would necessarily have a stabilizing effect. Although some an event that may occur during a bruxistic episode. It
bracing could be expected from profound keying of oppos- follows that unstrained registrations of lateral mandibu-

FEBRUARY 1995 175

THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y W I S K O T T AND B E L S E R

F i g . 7. Potential for relapse of malocclusion. A, Pretberapy cast. B, Orthodontic treat-

ment was completed at age 17 and resulted in optimal interarch relationships. C, Patient
at age 33 years. Despite adequate intercuspation of teeth, muscular environment was not
in balance and crossbite recurred. (Courtesy of Department of Orthodontics, University of
Washington, Seattle, with permission.)

lar movements as occur during classic pantograph trac-

ings will not record the full envelope of motion and
should be used with caution when one evaluates cusp
paths and clearances toward the opposing arch on an
articulator. Similarly it would seem appropriate not to
record a functionally, but a "dysfunctionally," generated
path. 104
The anatomic structures of the mouth are not as stable
as the plaster of Paris of the working cast and the
injection-molded aluminum of the articulator. The occlusal
anatomy of the teeth should incorporate a "safety leeway"
for alterations in cusp paths beyond what may be shown on
an articulator. Modifications in mandibular movements
caused by parafunction or slight structural changes in the
TMJ should be preplanned during design of the occlusal
surfaces. Indeed, no harm will occur to the mastieatory
system if clearance between the opposing arches is maxi-
F i g . 8. Proposed simplified pattern of OCs. Interarch mized within the boundaries of a functional anterior guid-
OCs are only present on buccal cusps of lower teeth. ance.

176 V O L U M E 73 NUMBER 2
WISKOTT AND BELSER THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y

Fig. 9. A, Schematic drawing of dentition reduced to its functional elements and with-
out respect for cosmetic attributes. In simplified occlusal pattern, at least one occlusal cusp
per tooth contacts opposing flat plane. B, Because of overlap and shape of palatal aspect
of upper anterior teeth, posterior teeth disclude during excursive movements of mandible.

Fig. 11. Effect of anteroposterior inconsistency of TMJ.

Locked tooth design as in a does not accommodate for
changes in position of condyle. Flexible, long centric design
as in b is recommended.

not ideally placed, (2) functional and parafunctional forces

are not directed along the longitudinal axes of the teeth
only, (3) the terminal hinge axis is neither absolutely sta-
ble nor absolutely reproducible, (4) unstrained lateral
movements have a smaller envelope of motion than strained
Fig. 10. Force vectors that stabilize tooth. Forces of movements, and (5) the position of the teeth depends on
eruption must be neutralized by plane on opposing tooth. forces of low intensity and long duration. Tooth stability is
As shown, this plane can lie in range of up to 20 degrees off mostly independent of occlusal relationships.
perpendicular to tooth eruption. Both teeth are stabilized Therefore the proposed simplified pattern of OCs should
buccolingually by reciprocal action of muscles of tongue
follow the preceding guidelines while satisfying the follow-
and cheeks.
ing criteria: allow adequate function, satisfy esthetic de-
mands, be applicable to small and extensive restorations,
and ensure occlusal stability.
A SIMPLIFIED OCCLUSAL SCHEME:
CLINICAL GUIDELINES Contact pattern
The following observations can be made for natural den- The considerations mentioned herein led to the pattern
tition: (1) relative to idealized schemes, the OCs are few and depicted in Fig. 8. As shown, all OCs that do not fulfill a

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T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y W I S K O T T AND B E L S E R

Fig. 12. Effect of mediolateral inconsistency of TMJ. Lateral shift of condyle combined
with progressive anterior disclusive angle will determine a flat area on occlusal surface of
posterior teeth.

justifiable purpose have been eliminated. The primary functionally nonsignificant occlusal anatomic features
characteristics of this scheme may be summarized as (nonoccluding cusps, fossae, ridges, and grooves) have to be
follows: placed on the occlusal surface. They must be arranged in
1. The buccal cusps of the mandibular posterior teeth a manner that eliminates any chance of interference on the
occlude in the central fossa of the maxillary posterior teeth. posterior segments of the dental arches.
There must be at least one occlusal contact per tooth to
ensure axial stability by neutralizing the eruptive forces of Occlusal contacts
the periodontium. From a mechanical standpoint, it is ir- Reduced in number, in the present occlusal design OCs
relevant whether the OC is established between the buccal must adhere to the following rules.
cusp of a mandibular tooth and the central fossa of a max- 1. T h e y m u s t effectively counteract the eruptive forces
illary tooth or the lingual cusp of a maxillary tooth and the of the teeth. The mechanics of the system would require
central fossa of a mandibular tooth. From an esthetic the opposing fiat plane to be at a right angle to the direc-
viewpoint, however, the former is desirable inasmuch as tion of tooth eruption. Clinically, however, this direction is
establishing contact on the lingual cusps of the maxillary difficult to assess and a range of up to 20 degrees off the
teeth generally leads to a "hanging cusp" effect. perpendicular has proved to be acceptable. Such a range
2. Proximal contacts stabilize the teeth mesiodistally by will considerably facilitate the design of a restoration or
antagonizing the effect of the transseptal fibers. occlusal adjustment procedures. There is a diffuse belief
3. An anterior guidance should provide for disclusion of among practitioners that one contact 0nly may not ade-
the posterior arch segments on excursive movements. quately stabilize the teeth, which could somehow "escape"
To demonstrate the fundamental principles of this in a buccal or lingual direction. Such a movement is highly
occlusal design, two arches were reduced to their functional unlikely because, as previously discussed, the teeth are in
elements and all nonpertinent anatomic features were a state of equilibrium between the tongue and the cheeks
eliminated (Fig. 9, A). Because of the anterior overlap, ex- (Fig. 10).
cursive movements will cause the posterior teeth to dis- 2. T h e y m u s t be so designed as to provide the room
clude (Fig. 9, B). The occluding cusps make contact on a flat necessary for the variability inherent to a biologic struc-
opposing surface. Again, whether this cusp-plane arrange- ture such as the T M J . Fig. 11 shows this effect in the sag-
ment is located on the upper, the lower, or a combination ittal plane. Given a functional anterior guidance, antero-
of both arches is of secondary importance. In essence, this posterior changes in condylar positions in a range of +-0.5
occlusal design is equivalent to the technique applied for mm will necessarily affect the dimensions of the contacting
occlusal plane therapy. 25 During restorative procedures surfaces on the teeth. Because the teeth are linked by a

178 V O L U M E 73 NUMBER 2
WISKOTT AND BELSER THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 13. Effect of alterations in ISS on occlusal anatomy of molar. In left row, cusp was
replaced by rotating bur that ground its way into internal slopes of opposing molar as ISS
was increased. Right row shows transverse views of sectioned teeth. Note resulting concave
anatomy of occlusal surface. (From Mani et al. Schweiz Monatsschr Zahn Med 1983;93:325-
34. Reprinted with permission.)

common bone (namely, the mandible) a similar argument pressure is equal to the force divided by the surface of ap-
can be made as to the room that is required in the trans- plication, the occluding cusp should p r e s e n t a definite
verse plane (Fig. 12). The occluding surface should further bearing surface so as to decrease the amount of force per
provide for possible alterations beyond what might have surface area and reduce wear.
been registered at one point in time. A possible slight pos-
terior displacement of the condyle should be planned for Occlusal anatomy
when the restoration is fabricated. The implications of an For the sake of clarity, the following definitions will be
increase in immediate side-shift are discussed in the used. A Bennett shift is the lateral movement of the work-
following section. ing condyle on excursive movements, and the medial
3. Because an elementary law of physics states that the movement of the balancing condyle is termed immediate

FEBRUARY 1995 179

THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y W I S K O T T AND B E L S E R

ing cusps and interproximal contacts) are essential for

function and occlusal stability and (2) occlusal surfaces
should be designed according to a"worst case scenario." No
harm will occur if occlusal surfaces are designed to provide
patients with more space between the arches during excur-
sive movements than the bare minimum shown on an ar-
ticulator. Expressed in clinical terms, an occlusal surface
should be designed as if the patient needed a larger amount
of anteroposterior freedom, had a rather flat condylar
P guidance, and a significant ISS.
During" the laboratory phase of extensive rehabilita-
tions, this can be achieved by setting the condylar guid-
ance to approximately 25 degrees 1~ and the ISS to 1.5
to 2 mm. 1~ In smaller restorations or single crowns, the
traveling path of the opposing cusps should be evaluated
and an appropriate leeway designed into the restoration.
As shown in Fig. 14, because of the physiologic confine-
ment of mandibular movements on working, balancing,
and protrusive excursions, the occlusal topography me-
Fig. 14. Principle of occlusal planning. Because of phys-
iologic confinement of mandibular movements on working sial to a maxillary bearing surface should be rendered
(W), balancing (B), and protrusive (P) excursions, occlusal concave and thus permit unimpeded movement of the
topography mesial to upper bearing surface should be ren- mandibular cusp. A similar topographic design should
dered concave and thus permit unimpeded movement of be created on the distal aspect if the bearing surface is
lower cusp. located on the lower arch.

CONCLUSIONS
When adequate anterior guidance is provided, benefits
result from the use of the system described. 1~
side-shift (ISS). A Bennett movement will exist when the 1. It satisfies functional requirements. The system main-
Bennett angle is nonzero and independent of the presence tains vertical dimension and allows chewing. It provides for
of an ISS. optimal clearance on the posterior arch segments during
Internal cusp slopes do bulge toward the central fos- eccentric movements.
sae of the teeth and the vast majority of the world 2. It will satisfy esthetic demands. The system requires
population accommodates itself to such an occlusal con- a slight adaptation of the occlusal topography. However,
figuration. However, this appears to be a prime example when contemporary ceramic layering techniques and in-
of the inadequacy of form and function because deep ternal staining are applied, the depth of the occlusal anat-
intercuspation of the teeth invites posterior interfer- omy can be built into the porcelain and the requirement for
ences. This has been graphically shown by Lundeen and concaveness respected (Fig. 15, A through C).
Wirth 105 and in a three-dimensional model by Mani et 3. It is applicable to small and extensive restorations.
al. 1~ In the latter experiment, a cusp was replaced by a The system can be applied on a tooth-by-tooth basis
rotating bur. While the anterior guidance remained un- because it can readily be adapted to the anterior guidance
altered, the ISS was increased up to 2.5 mm. As illus- at hand. When an entire arch is restored, the articulator
trated in Fig. 13, the bur ground its way into the inter- should be adjusted to worst-case settings. For smaller res-
nal surfaces of the cusps. Under similar conditions, pa- torations, that is, when tooth guidances are still present,
tients are likely to brux, wear away tooth substance, and the technician should provide the opposing cusps with
possibly fracture structural elements of the teeth. It more space during excursive movements by designing con-
follows that an occlusal anatomy designed to accommo- cave internal cusp slopes.
date larger amounts of ISS without interference should 4. It ensures occlusal stability. Forces exerted during
be concave and not convex. This occlusal topography is mastication will not influence tooth position. Only forces
a slight departure from commonly accepted schemes but caused by tooth eruption and by the resting pressures of
it will readily accommodate situations in which the an- the tongue and the cheeks will determine buccolingual
terior or posterior determinants of occlusion, or both stability (Fig. 10). One OC per tooth (to neutralize erup-
determinants, are not favorable. tive forces) and adequate interproximal contacts (that
A basic principle of work simplification states that (1) act against the transseptal fibers) will determine arch
only two structural elements of the teeth (that is, occlud- stability.

180 V O L U M E 73 NUMBER 2
WISKOTT AND BELSER THE JOURNAL OF PROSTHETIC DENTISTRY

F i g . 1 5. A through C, By use of contemporary ceramic layering techniques, overall anat-

omy of teeth can be designed as concave surface while optical depth of fossae and grooves
is maintained.

5. It is flexible. The system only requires one OC per cuspation will be created. A deepening of the opposing
tooth, which under ideal conditions should be located in a surface should be accompanied by appropriate reshaping of
central fossa. This will allow the design of an esthetically the adjacent internal slopes to maintain concaveness.
pleasing occlusal surface. F r o m the standpoint of mechan- 7. Fabrication is significantly less complex inasmuch as
ical stability, the location of the OC is not actually critical. the n u m b e r of contacts is reduced.
Further, the system can be a d a p t e d to most anterior guid-
We thank Mr. D. Vinci, CDT, for fabricating the restorations
ances and to varying degrees of group function if so desired.
shown.
6. A d j u s t m e n t is uncomplicated. At the trial stage, the
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