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Occlusion or more precisely the occlusodontology as a discipline is struggling to fi nd its place in the university curriculum. As part of the fundamental sciences, the teaching takes place before the commencement of clinical practice for students who do not fully appreciate the tangible outcomes.The few opportunities to put occlusion into practice in university dental care centers lead to graduates who consider the fi eld of occlusion as a complex discipline, beyond the reach of the general dentist and rather reserved in a panel specialists.The aim of this book is to demystify these a priori and demonstrate the essential place of the occlusion in daily practice from simple occlusal fi lling, to prosthetic treatments .In the same way that the music theory is the basis for the musician, few basic concepts are essential to understand the masticatory apparatus as a whole and the interactions of its various components. Co-written by clinicians and university teachers, the concepts outlined in this work are the synthesis of a long clinical practiceand pedagogy.We wanted to give a large place to the iconography in all chapters to enhance reading and facilitate comprehension.We will give in this book the answers to the questions thata large number of general dental practitioners and students may have, in order they can fi nally consider the occlusion... made easy.Gérard DuminilGérard Duminil with Olivier Laplanche Jean-Philippe Ré and Jean-François Carlier MADE EASYOcclusionOcclusion made easy
1 General notions 7 Foreword ..............................................3 I General notions .......................................8 2 Functional occlusion ..................................19 3 Centric relation .......................................37 4 Mandibular movements ...............................49 5 Clinical examination of the temporomandibular disorders (TMD) .......................................61 6 Examination of the occlusion ...........................85 7 Classification of the TMD .............................. 111 8 Mounting on the articulator ...........................131 9 Instrumental occlusal analysis .........................153 10 Occlusal splints ......................................167 11 Occlusal adjustment .................................185 12 Prosthodontic in daily practice ........................205 Afterword ............................................223Contents
11 Occlusal adjustmentOcclusion made easy - Chapter 11 - Publisher : Espace id - Paris 185 During the initial clinical examination, it is frequent to notice occlusal anomalies due to the coronal decay, to abrasion, dental migration, even to the presence of unsuitable prosthetic restorations which generated a pathogenic malocclusion (Fig. 1). Besides, the patient may or may not suer from changes in the mandibular kinematics, from articular disorders or from modications of the muscular activity, resulting from movements generated during the occlusal functions. In these clinical situations, the occlusal functions must be improved prior to any treatment, all the more if a prosthetic rehabilitation is envisaged.Occlusal adjustment is a therapeutic modication of occlusal tables by subtraction or by addition to restore the occlusal stability of the arches during the occlusion. Most of the time, it refers to adjustment techniques by selective grinding of the enamel structures which oppose each other during the occlusal functions, or during the access to the ICP.This chapter presents a technique of occlusal adjustment performed at rst on the casts mounted on articulator in centric relation, then transferred in the mouth following a timeline noted on a chart of modications. The occlusal adjustment is performed on a natural complete set of teeth, but the principles can be applied to cases of preprosthetic adjustment and their numerous indications.Occlusal adjustment 1 Pathogenic ICP.11
Occlusion made easy186Occlusion made easy - Chapter 11 - Publisher : Espace id - ParisFor the occlusal analysis on articulatorEquipment Use RefMiller tweezer Holding in place the marking ribbonsBK 132 Dr BauschShimstock® métal 12 μ Checking the existence of contactsBK 35 Dr BauschRed articulating paper 8 μ CR marking BK 21 Dr BauschGreen articulating paper 8 μGuidance marking BK 22 Dr BauschBlue articulating paper 8 μ Interferences marking BK 23 Dr BauschBistoury blades #15 Corrections on plaster -Hard toothbrush Erasing artefacts -Pencil 0,5 HB Marking out the corrected zones -LC Blockout Resin or wax Recreate guidance ridges -For the adjustment in the mouthEquipment Use RefMiller tweezer Holding in place the marking ribbonsBK 132 – 133 Dr BauschFix Clip Bite Frame Analyzing both sides simultaneously BK 143 Dr BauschRed articulating paper 40 μ CR marking BK 10 Dr BauschBlue articulating paper 40 μ Interferences marking BK 09 Dr BauschFG inverted cone bur Recreate an occlusal anatomy 805.314.01FG olive bur 8368-204.016 (023) 8368-204.016 (023)FG cylinder pointed bur Correction of external slopes (yellow ring or red ring)862EF.204.0128862.204.012Q tips Erasing marks between two measurements Silicone polisher Polishing corrections at the end of the sequenceCeramaster ShofuFluid composite resin / Recreate guidance ridges / -Polishing corrections at the end of the sequenceTransfer key Transparent silicone (shore 90)Memosyl 2 Block Out® BisicoNECESSARY EQUIPMENT
11 Occlusal adjustmentOcclusion made easy - Chapter 11 - Publisher : Espace id - Paris 187 Historically, we can list at least twenty techniques of occlusal adjustment, which dier according to the nature of the reference position, either articular or muscular, the sequence of correction, the concepts of lateral guidance or the type of stabilization.The rst authors, (Stuart, 1930; Schuyler, 1935; Lauritzen, 1965) followed by Ramord,Ash (1966), Dawson (1971) and Solnit (1988) suggested adjusting the defective alignment of cusps and fossae (generating a shift in ICP) by a widening of the fossa at the expense of the neighboring zones of contacts in centric relation. They thus made sure to follow the main rule: do not alter the primary cusps, while creating a coincidence between CR and ICP.Jankelson (1955), Glickman (1958), Wirth (1976), Jeanmonod (1988), Smuckler (1991) and Abjean (1997) developed their approach on a harmonious muscular functioning presenting synchronous and symmetric contractions of the masticatory muscles supposed to result in an optimal ICP. During the rst phase, a muscle reconditioning splint is prescribed. The adjustment is then performed by using the re-educated muscles to drive the mandible towards ICP.The current consensus recommends localizing the therapeutic articular reference position (CR) with the practitioner’s help such as it was described in the chapter on centric relation. A muscular reconditioning with a splint might be necessary rst (Okeson, 1998).A meticulous clinical examination associated with an occlusal analysis on articulator allows to put the indication of the occlusal adjustment.The adjustment of the models on articulator must be a systematic prerequisite which allows to verify the feasibility of the treatment by analyzing the anterior guidance. It allows to quantify the corrections and assess their incidence on the vertical dimension of occlusion. An anterior functional guidance in the VDICP authorizes the adjustment if there is a small number of alterations.Reminders of two important denitions often used in this chapter:Occlusal prematurity: occlusal contact decentering the closing movement when the mandible moves upward in centric relation. It does not aect the translation movements.Occlusal interference: dental obstacle limiting or deecting the mandibular movements of translation (diduction or protrusion). The interference can be posterior or anterior.
Occlusion made easy188Occlusion made easy - Chapter 11 - Publisher : Espace id - ParisAdjustment on the articulatorBefore taking impressions, it’s better to eliminate very egressed teeth, which are obvious prematurities, and thus an obstacle in excursions (Fig. 2).The occlusal analysis on articulator (described in a previous chapter) allows to observe dental arches from all angles as well as their simulated movements in all the directions. During the searching and the marking of contacts, the articulator can be locked either in centric, or on one side only, in order to obtain reproducible lateral positions. Using wedges (or protrusion screws when they exist) allows the preservation of the lateral or protrusion positions (Fig. 3). These elements easily enable to perform an occlusal instrumental analysis compared to what it is possible to make on the patient.Articulating paper of dierent colors is used to identify sequences more easily.According to the adjustment process, the successive corrections are noted in a grinding index form (Fig. 4), indicating the tooth number, the cusp, the involved slope and the corrected cusp slope, or marked on an occlusal diagram (Fig.5). Every corrected zone is marked with a pencil on the plaster model, in order to avoid noting several times the corrections on the same tooth (Fig. 6). The grinding chart allows to write down accurately 2 If the egressed tooth creates a major interference, it must be extracted before taking the impression.3 Activating the protrusion screw allows the preservation of the lateral position.
11 Occlusal adjustmentOcclusion made easy - Chapter 11 - Publisher : Espace id - Paris 189 the corrections to be made on the patient’s teeth in the order of their appearance.Casts are retouched with a bistoury blade #15All authors agree to carry out the following therapeutic gradient:Rule 1 : corrections preferentially concern restored teeth, rough llings, inadequate crowns, or misplaced teeth.Rule 2 : modications must only be made on the enamel part of the occlusal surface. When a bigger alteration is needed, it is necessary to reconstruct the tooth or prescribe an orthodontic treatment.Rule 3 : relief must be enhanced by deepening fossae and grooves rather than by reducing cusps.Rule 4 : alterations are equally distributed between both antagonist teeth.Rule 5 : To Okeson (1998 ), the location of contacts in CR, situated on the internal walls of the supporting cusps, directs the therapeutic attitude.5 The localization of the corrections is noted on the occlusal index form.4 The corrections are chronologically indicated on a grinding charter.6 The zone circled with a pencil indicates that the correction has been made.
Occlusion made easy190Occlusion made easy - Chapter 11 - Publisher : Espace id - ParisAdjustment chronology Sequence ObjectiveCorrection of CR//ICP discrepancy CenteringCreation of stable contacts StabilizationCorrection of translatory movements (diduction, protrusion, elimination of the interferences) GuidanceImprovement of stability in centricStabilizationCorrection of CR / ICP discrepancyDuring the closing of the articulator, the rst contact relates to a position of unstable occlusion. The contact on the prematurities pushes the mandible forwards and towards one side, right or left.When the mandible slides to the right, re-centering moves it backwards and to the left: the left side is cal-led “working” (W), and the right side is called “non working” (NW).The articulator is locked in CR and the incisal pin is set on the VDICP (it does not touch the table because of the contacts on the prematurities). Contacts may be found on zones indicated in Fig. 8-9.7 Corrections are rather made in fossae and grooves rather than on cuspal tips.8 Localization of zones to correct in the case of a right anterior shift.9 Localization of zones to correct in the case of a left anterior shift.