"Occlusal Remodeling" SELECTIVE REDUCTION/ADDITION

Pedro Paulo Feltrin Weber Adad Ricci

Occlusal Remodeling SELECTIVE REDUCTION/ADDITION

Chapter extracted from the book “Logical: A clinical approach to occlusion” Authors Henrique José Piccin Pedro Paulo Feltrin Weber Adad Ricci 1st Edition - 2020 Napoleão - Quintessence Publishing Brasil ISBN: 978-85-480-0086-7 All rights are reserved to Napoleão Publishing House.

Printed in Brazil.

Feltrin, Pedro Paulo P3208o Occlusal remodeling : selective Reduction / addition / Pedro Paulo Feltrin , Weber Adad Ricci. - Nova Odessa, SP: Napoleão, 2020.

50 p. : il. ; 23x31cm.

Offprint from Logical: a clinical approach to occlusion.

ISBN 978-85-480-0086-7

1. Temporomandibular Joint - abnormalities. 2. Dental Occlusion.

3. Malocclusion - physiopathology. I. Ricci, Weber Adad. II. Título.

CDD 617.522059 Maria Helena Ferreira Xavier da Silva / CRB7 - 5688

01 02 03 04 05

History of the Evolution of Occlusion Eurípedes Vedovato e Luiz A. S. Zeppini

Anatomy - Physiology of the stomatognathic system Laerte B. Schenkel e Rita de Cassia Schmitt

Occlusal References for Oral Rehabilitation 3.1 / 3.2 / 3.3 Henrique J. Piccin, Pedro P. Feltrin e Weber A. Ricci 3.4 Marcelo Calamita, Christian Coachman, Newton Sesma e John Kois

Pathological Occlusion João C. Palmieri Filho, Leandro Hilgert e Paulo V. Soares

Semi-Adjustable Articulators (ASA) Emílio C. Zanatta e Henrique J. Piccin

06 07 Rehabilitation Planning 08 09 10 Occlusal Remodeling

Pedro P. Feltrin e Weber A. Ricci

7.1 Felipe M. Saliba, Mateus Voigt e Victor Clavijo 7.2 Fernando A. Feitosa e Hilton Riquieri

Occlusion in Prosthodontics 8.1 Daniel Telles e José V. de Paula Eduardo 8.2 Paulo Vicente Rocha

Occlusal Splints

Alexandre Cardoso e Simone Oliveira

Technical Evolution (Digital)

Eduardo Miyashita, Guilherme Saavedra e Marcelo L.

06

Occlusal Remodeling Selective reduction/addition Pedro Paulo Feltrin | Weber Adad Ricci

Logical | A clinical approach to occlusion

The study of dental occlusion is a fascinating and

still very preliminary elucidated by contemporary

extremely important field for the clinician due to

science. After analyzing several schools of occlu-

the challenges presented by natural dentition in

sion, published studies and researches, books

the maturation and aging process, as well as in re-

and written handouts, there seem to be an agree-

habilitation procedures. Some authors even claim

ment that the way in which knowledge is interpret-

that this is the most important branch of Dentistry.

ed and applied clinically is more important than

This is due to the fact that, when analyzed in the

the data itself. They all converg that all concepts

light of the principles that rule the establishment

seek common objectives seeking to harmonize

of occlusion by the living organism, it is noted that

structures, in order to provide the means for a

the tooth gearing occurs at the end of a series

better functioning of the stomatognathic system.

of factors established before the appearance of

3

the teeth. The most crucial point of this process is

Historically, the study of occlusion gains strength

the stabilization of an adequate and comfortable

from reports of major tooth loss and the need for

position for the condyles associated with a defini-

prosthetic treatments. It appears that this branch

tion of functional muscle lengths. Thus, the infant,

of Dentistry was in its beginnings based on the

even toothless, swallows by means of a visceral

search for knowledge on how to introduce an

process where the tongue is interposed between

artificial apparatus in the replacement of missing

the gum rims, providing a stability of the condylar

teeth. However that, was mimetic to the living

positioning as well as an adequate length of the

being. Later, it was Periodontics that turned its

musculature to create a harmonious swallowing

attention to the study of the possibility that harm-

space. In this way, a healthy relationship between

ful forces could destroy dental support. With

muscles and joints is the first step towards a

this understanding, oral rehabilitators began to

healthy occlusion. As a linguistic definition, occlu-

pay more attention to the theme culminating in

sion means “closing”. However, it becomes explic-

the founding of the California Gnatological So-

it that in Dentistry the occlusion must be under-

ciety in 1926 by McCollum. The concepts that

stood much more than that. In a literature review,

emerged from these authors and their followers

there is a stir in relation to reliable guidelines.

became known as the Gnatological School. Two

When we analyze the term “ideal occlusion”, we

great contributions of this school are still in force

see that the concepts have changed since the

today: (1) the concept of occlusion protected by

1920s to the present. The agreement on defini-

the canine defended by D’Amico and (2) the sys-

tions related to the vertical dimension, centric re-

tematization of the occlusal adjustment defend-

lation, orientation plans and execution of occlusal

ed by Schuyler. In the area of mandibular move-

adjustments adjustments also evolved. In particu-

ments, the most notable contribution was made

lar, it is clear that in an area with major controver-

by Posselt, who, when examining natural teeth,

sies, two situations can be the driving forces: (a)

concluded that: (a) the maximum intercuspation

lack of a well-defined analysis methodology or (b)

was anterior and inferior to the retrusive contact

wide complexity and multiple contexts, which is

position; (b) that the maximum opening position

Occlusal Remodeling

required movements of rotation and translation

Changes in this dimension can affect the per-

of the condyles; (c) that the jaw could perform

formance of the muscle and disrupt the entire

opening and closing movements on an axis and

system in relation to its components. In the in-

(d) the jaw’s edging movements were reproduct-

terval between meals, it assumes a dimension

ible. However, the most interesting complement

of rest where the teeth are not in contact and

to the study of occlusion came with the contri-

the muscles remain with muscle tone in a low

bution of Jankelson on the following aspects: (a)

electromyographic activity. The distance ad-

during chewing, dental contacts rarely occur; (b)

opted by the mandible between this dimension

occlusion occurs during swallowing and (c) the

defined as the Vertical Dimension of Rest and

mandible, during swallowing, is brought to maxi-

the Vertical Dimension of Occlusion (situation

mum retrusion when there is no interference.

of occurrence of dental contact) is denominated as Free Way Space and presents an average

Concepts

value of 3mm (Figures 6.2A,B).

In order to have a safe approach during the occlu-

Achieving such “muscular rest� from where func-

sal adjustment process, it is extremely important

tional movements start is the initial objective of the

that the clinician masters concepts which are in-

process of verifying occlusal stability and harmony.

herent to the analysis of occlusion. The three-di-

The homeostasis of this musculature can be bro-

mensional positioning of the mandible in relation

ken by the occurrence of interference, especially

to the maxilla is defined by means of a vertical axis

immediately after an occlusal disarrangement (Eg.

called Vertical Dimension and by a horizontal axis

a recently performed restoration with a premature

defined as Centric Relation (Figures 6.1A,B).

contact without being adjusted) generating a pathology of muscular incoordination called protec-

The Vertical Dimension may be defined as the

tive co-contraction. This demonstrates how oc-

distance between two points being one above

clusal contacts have an intimate connection with

and one below the mouth. It is responsible for

muscle functionality.

the proper positioning of the jaw in space, favoring muscle action at an optimized length.

4

Logical | A clinical approach to occlusion B

A

5

Figures 6.1A,B - In the vertical plane, the mandibular positioning is established by the Vertical Dimension of Occlusion (A). In the horizontal plane, the mandibular positioning is established by the Centric Relation (B).

Occlusal Remodeling

A

0mm

DVO

6 B

1-3mm

DVR

Figures 6.2A,B - During the rest of the jaw, the teeth should have no contact at a distance of approximately 3mm, called Free Functional Space.

Logical | A clinical approach to occlusion

The Centric Relation (CR) designates the rela-

A

tionship between the mandible and the maxilla in the Temporomandibular Joint (TMJ) region.

For decades, the relationship between condylar processes and the glenoid fossa was discussed.

A range of different positions were presented and defended as ideals, and the anterosuperior positioning of the condyles in relation to the glenoid fossae is currently accepted. In fact, this seems to be the most logical position since the anterior inclination of the joint eminence, as well as its more robust anatomical constitution for the action of loads, differs from the thin bone plate and the shape of the glenoid fossa in its central region. (Figures 6.3A-C).

In the stage of oclusal maturation, the codyles

B

stability (CR) seems to be a primary factor. The organism, even in the absence of teeth, aims at the mandibular stability for swallowing, especial7

ly during breastfeeding. Several methods have been proposed for the manipulation of the mandible in order to position it to allow this harmonic joint integration. However, none of them showed a high level of reliability. Functional manipulations guiding the jaw can trigger muscle reflexes, which

C

Figures 6.3A-C - The harmonic positioning of the joint structures occurs when the condyle is located in the anterosuperior region, directed in the direction of the joint eminence, with the disc being correctly interposed (A). View of the glenoid fossa and its relation to the bone structures (B). Note by the intracranial transillumination that the middle of the glenoid fossa is not an area of structural reinforcement to receive loads. In the posterior region, there are noble structures such as auditory nerves and highly innervated retrodiscal tissues (C).

Occlusal Remodeling

A

severely hinders natural repositioning. In addition, when the related musculature is hyperactive, incoordination and subsequent difficulty in handling will be present. It is essential that the beginning of an occlusal analysis process takes place through neuromuscular deprogramming in order to release the mandible for a correct assessment position. What is practically unanimously postulated among authors is that this position is of mandibular retrusion when compared to the patient’s habitual occlusion (MHI). It is evident that mandibular positioning arrangements from intercurrences (premature contacts) in the maturation stage of maxillomandibular relations may occur,

B

promoting a displacement of the positioning of the mandible in relation to the most posterior posture, allowing for maximum tooh engagement in the so-called Maximum Habitual Intercuspation (MHI). However, when this maximum number of intercuspation happens and the relationship between the condyles and the joint eminence is in the so-called Centric Relation, we have an occlusal scheme called the Centric Occlusion Relation (COR) (Figures 6.4A-C). Naturally, this scheme occurs in only happens in 10% of the population.

C

Figures 6.4A-C - Ideally, during the mandibular closure, the condyles should have their final position defined by the Centric Relation right in the simultaneous interlocking of all functional dental contacts (COR). However, upon encountering premature contact, the mandibular closing path is deflected resulting in a more anterior gearing of the mandible and deranging the condylar Centric Relation (MHI).

8

Logical | A clinical approach to occlusion

However, we cannot classify an occlusion where such a condition is not present as pathological, as we would be stating a Public Health problem by simply finding that 90% of the population is in MHI. Thus, it seems obvious that there is a range of physiological tolerance in this position as seen in the rest interval of the Vertical Dimension. For horizontal positioning, some authors have defined this interval as “long centric�, where there is a slight 0.5 to 1.0 mm gap to anterior.

Finally, a very important concept is the orientation plans so that, once the three-dimensional positioning of the mandible in relation to the maxilla is defined, excursion movements can occur in harmony. Over the years, some authors have found that there are compensatory curves in the dental arches that allow for adequate movement dynamics. In the anteroposterior direction, the teeth have an upward 9

curve in relation to their occlusal surfaces. Lat-

A

erolateral, there is a slight buccal inclination in the axes of the posterior maxillary teeth, however, a lingual inclination occurs in the axis of the posterior mandibular teeth. These curves were called Spee and Wilson curves, respectively (Figures 6.5A,B).

Figures 6.5A,B - The Spee curve is characterized by its ascending and uniform path in the anteroposterior direction (A).

The Wilson curve is characterized by the convergence of the dental axes, generating a uniform inclination and an adequate distribution of loads on the bone base in the laterolateral direction (B).

B

Occlusal Remodeling

have the excursion that will be guidances by reference guides in a scheme defined as dynamic occlusion. In this process, the mandible is guided laterally by the canines and this scheme is known as a canine guidance. In fact, this tooth presents very peculiar situations in the arch. Its anatomical constitution has robustness in the contours of enamel and dentin, having a predominant convex shape, acting better in resisFigure 6.6 - Clear demonstration of a tooth outside the

tance to loads. Its root is the longest of the entire

alignment of the Spee curve (1st molar). This tooth was

dentition, thus having a large area of bone inser-

characterized as an occlusal interference.

tion. It is presented in a bone reinforcement pillar more favorable to the tolerance of mechanical efforts. This is the tooth prepared by means of

Knowledge of this principle is of paramount im-

an intelligent design so that it reigns in the con-

portance since teeth that escape these curves

duction of the jaw during its excursions. In the

can be potential contacts for occlusal interfer-

anterior movement, we have contact with teeth

ence (Figure 6.6).

of the upper arch that do not have these same characteristics as the canines. Unlike the canine

All these aspects presented with the teeth in

guidance, where a single tooth can support the

occlusal gearing, provide the analysis of the so-

entire load, the anterior dentition (incisors) must

called static occlusion. When the jaw opens to

be adjusted in a shared way without a single

perform masticatory rhythmic movements, we

tooth receiving all the load (Figures 6.7A-D).

A

B

C

D

Figures 6.7A-D - Ideal Class I occlusion. Harmonic gearing of the anterior and posterior teeth (A). Left and right lateral movement. Only the canines should make contact in this situation (B,C). Protrusion movement. Balanced contacts between the incisors without the disocclusion occurring in just one tooth (D).

10

Logical | A clinical approach to occlusion

Occlusal Contacts Knowledge When analyzing occlusion, the clinician must check the occlusal contacts location tooth by tooth. The shape of the dental crowns is different, as well as the location of the contact points so that they can dissipate the forces in

contacts must fall in a balanced way in the center of the groove or, when in slopes, they must have a balanced condition, as in a scale (Figures 6.8A-C).

Single contacts in slope direct the forces obliquely and not in the long axis of the pos-

an appropriate way to the supporting tissues.

terior teeth, generating coronal torques and

Teeth that have their shafts out of alignment

shearing which may have consequences on

in line with the compensation curves can be

dental tissues (abfraction lesions) or on the

severely affected by inappropriate contacts.

sustaining periodontium (bone remodeling

For the posterior dentition, in particular, the

and ligament injury) (Figures 6.9A,B).

A

B

11

C

Figures 6.8A-C - Groove contacts are more favorable for dissipating forces on the long tooth axis (A). Purely slope contacts are destabilizing as they result from tooth rotation (B). Bilateral contacts in strands of the same tooth generate balance, as in a scale, redirecting the force towards the long dental axis (C).

Occlusal Remodeling

A

The anterior dentition, in turn, allows the action of oblique forces, but only when it occurs as a guide to movement. When this process occurs during awake or sleeping bruxism, the anterior teeth may suffer injuries like severe wear of enamel and dentin, as well as migration of their positioning to the anterior one, favoring occlusal, periodontal and esthetic breakdown.

Objectives of Occlusal Adjustment After the conceptual understanding, the clinician must clearly define what the objectives of an occlusal adjustment should be. In a primary way, it would be the search for system homeostasis in front of the triad – teeth, muscles and joints harmoniously orchestrated by the central nervous system. Failure to respect this balance can trigger pathologies where one of these components of the stomatognathic system will be affected. Thus, a physiological occlusion provides uniform and functional stimulation to teeth and Masticatory force

periodontium, promoting conditions necessary

Final resulting vector

for the health of the muscular and joint system.

Vector of masticatory force on the slope Vector of masticatory force

Occlusal contacts are a factor of great importance for the balance of occlusion. The objective B

is the search for forces resulting in teeth with prevalence in the axial direction. Therefore, the posterior teeth must receive bilateral, simultaneous and equipotent loads so that there is no overload in one or the other region. Regarding the location of these contacts regionally on the occlusal surface of the posterior teeth, the clinician must analyze two situations: (1) the isolated cusp contact and (2) the contact of the tooth as a whole.

Figures 6.9A,B - The contact in exclusive slope generates an action of forces in an inclined plane. The final result is a force directed at the cervical region of the dental crown, producing deleterious effects on the tissues of this region (A). Exclusive contacts on the premolars during working movement. Note the occurrence of Non-Carious Cervical Lesions (B).

12

Logical | A clinical approach to occlusion

CUSP CONTACT: For stable occlusal engagement, the protagonist regions are the cutting slopes of the lower retaining cusp with the cutting slopes of the upper retaining cusp (Figure 6.10). Both regions are delimited by the tip of the cusp (C) and the bottom of the groove of each tooth (S). In this way, contacts can occur at the tip of the cusp and in the center of the groove, as well as contacts in the inclined portion of the slope within this path (V)

Figure 6.10 - Stable contact diagram of

(Figure 6.11).

occlusal gearing.

In these cases, the most destabilizing point and with the possibility of horizontal and oblique forces would be the contacts in the isolated in-

C

clined region (V). Ideally, simultaneous contacts

V S

between C and V, V and S or C, V and S would lead to balance (Figures 6.12A-C).

DENTAL CONTACT as a WHOLE: When analyzing the occlusal table, the regions where the contacts 13

Figure 6.11 - Illustration of the possible re-

predominate can influence the stability of a tooth

gions of contact with the teeth engaged

alone or the behavior of a force vector for the entire

in occlusion.

mandible. Thus, there may be contacts away from the dental axis promoting rotation of your individual position, as well as consequences for the entire jaw, causing an increase or decrease in the overjet.

These contacts are called “stoppers” or “equalizer”.

Stop contacts occur on the distal aspect of the cusp of the upper teeth and on the mesial aspect of the lower teeth (Figure 6.13).

A

C

B

C

V S

C

C

V S

V S

Figures 6.12A-C - The green combinations are favorable to the correct distribution of occlusal loads on the long-axis of the tooth.

Occlusal Remodeling

Balance contacts, on the other hand, occur in the mesial slopes of the upper teeth and in the distal slopes of the lower teeth (Figure 6.14).

Stop contacts result in increased overjet and possible compression of retrodiscal tissues (Figure 6.15). The balance contacts, on the other hand, decrease the overjet and overload Figure 6.13 - Contacts of “stop” or “stop-

the anterior teeth (Figure 6.16). Therefore, it is

pers” represented in the distal slopes of

evident that the cancellation of these harmful

the 1 molar.

forces occurs in the simultaneous presence of

st

both types of contacts, a factor that should be sought in the occlusal adjustment.

Figure 6.15 - Consequences on mandibular positioning and overjet, due to stop contacts.

Figure 6.14 - Contacts of “balance” or

14

“equalizers” represented in the mesial slopes of the upper 1st molar.

Figure 6.16 - Consequences on mandibular positioning and overjet, due to balance contacts.

Logical | A clinical approach to occlusion

A harmonic gear in an Angle Class I will be an occlusal scheme called cusp/fossa. The relationship between the maxilla and the mandible will be the perfect gear. In this model, the masticatory efficiency will come from the

Possible Remodeling Structures B.U.L.L .: Buccal Upper cusps and Lingual Lower cusps (Figures 6.18A,B).

L.U.B.L .: Lingual Upper cusps and Buccal Lower

crushing of food as in a pestle through the

cusps (Figures 6.19A,B).

lower buccal cusps, where the food escapes

U.M.R.L.I.: Upper Marginal Ridge and Lower Incisal

through the dental grooves. Below is the re-

(Figures 6.20A,B).

gional illustration of the contacts suitable for stable occlusion (Figure 6.17).

15

Figure 6.17 - Illustrative scheme of ideal contact points between the arches.

Occlusal Remodeling

A

B

Figures 6.18A,B - Illustration of occlusal contacts and BULL in the upper and lower arches.

A

B

Figures 6.19A,B - Illustration of occlusal contacts and LUBL in the upper and lower arches.

16

A

B

Figures 6.20A,B - Illustration of the anterior contact region: upper palates with lower incisals during the protrusion movement.

INDENTS ON THE WORKING SIDE BULL

INDENTS ON THE PROTRUSION PATHWAY UMRLI

INDENTS ON THE BALANCING SIDE LUBL

CONTACTS IN CENTRIC OCCLUSION

Logical | A clinical approach to occlusion

Occlusal Adjustment Indications The selective remodeling of the occlusion can

contacts) that result in trauma to this area leading to loose and fractured parts.

be performed by reductive (selective wear)

(c) Direct the forces in a longitudinal and bal-

or additive (strategic additions) methods. This

anced way in the face of interventions in peri-

second item became possible through the revolution led by Adhesive Dentistry, which allows for maximum conservation of dental tissues

odontal patients, thus eliminating possible occlusal trauma.

and should be the strategy of choice whenever

(d) As an adjunct in the treatment of muscular

possible. As a general rule, selective remodel-

and joint pathologies promoted by mechanical

ing is indicated in the following situations:

breakdown of the TMJs.

(a) Establish a stable and balanced occlusal pat-

As a contraindication, the clinician should never

tern at the end of interceptive treatments, such

perform this procedure as a prophylactic measure

as orthodontics and oral rehabilitation.

or in the face of sudden changes in the occlusion.

(b) Eliminate before the rehabilitation of the an-

It should also be avoided by inexperienced clini-

terior section (especially when increasing crown

cians without the correct occlusal diagnosis and

length) pathological interferences (premature

technical knowledge of the process.

17

Figure 6.21 - List of some materials suitable for occlusal remodeling. Articulation foils, burs and polishing tips (Kit Prof. Zachrysson_�CSAA das Brocas�).

Occlusal Remodeling

Materials Needed for Occlusal Adjustment Technically, the clinician will depend on the following materials to perform a correct selective reductive remodeling:

ducted with the attempt to position the condyles in CR. This therapeutic position is the starting point in the living organism when the jaw is in a swallowing position since the contacts are more effective at this time than in

– Oral mirror.

chewing. For this, the clinician must proceed

– Specific plier for holding carbon and occlu-

with neuroocclusal deprogramming. This does

sion verification paper (BK 133).

not seem to be an easily proven factor. Despite

– Baush Carbon BK 51.

the controversy about the possibility of this

– Bausch Carbon ArtFol BK28.

deprogramming procedure, as well as how

– Bausch Carbon ArtFol BK31.

– Shimstock (BK38).

– Nº8833 bur (Komet and “CSAA das Brocas”).

– Multiplier handpiece preferably in electric motor.

long it would take, the authors noticed that in cases of greater difficulty of coordination by the patient, even a short deprogramming (20-40minutes), has a beneficial effect. Immediate deprogrammers include Lucia’s JIG, MINI REG ZANATTA BAUSCH, Leaf Gauge, ROCCA

Methods for Occlusal Adjustment

wires and electrostimulation (MioTENS). For

For making the adjustment in the mouth, it

igan splint (myorelaxing splint), a front plateau,

must be preceded by a thorough occlusal analysis as well as by the evaluation of the signs and symptoms of temporomandibular disorders. Because occlusal adjustment is an irreversible therapy, it is completely contraindicated in the face of pathologies in the acute phase since occlusal derangements can be temporary in this situation. As a first step, good impression (silicones or siliconised alginates) must be taken. If the clinician chooses silicone, the two-stage impression is indicated, reducing changes in the impression. Pouring must be made with special stone, providing a smooth,

long-term deprogramming, one can use a Michas well as a Kois deprogrammer (see chapter 03.1, page 92). The principle of all these devices is increasing the VDO and the mandibular repositioning towards posterior, eliminating the contacts of the posterior teeth so that the proprioception is altered in the central level.

It is up to the clinician to master this process, which, to a great extent, is dependent on their practice and experience. Once the mandible is repositioned, the registration materials must be chosen according to their consistency during insertion into the mouth and after their

homogeneous and bubble-free surface (vac-

final reaction. Materials that are highly fluid

uum spatulation). With the stone models in

during registration and extremely rigid after

hand, facebow registration must be taken to

reaction should be the ideal. Polyvinilsyloxane

transpose the upper model to the articulator.

bite registration materials ideally should have

The assembly of the lower model must be con-

similar characteristics. Thus, the lower model

18

Logical | A clinical approach to occlusion

must be transferred to the articulator for the

verification of these contacts, as well as a definition

purpose of analyzing the occlusion.

of the power of this pressure performed, may depend on techniques where not only a paper with a

Once assembled in an articulator, details can be

thickness less than 40µm is used. In this sense, the

thoroughly analyzed through different positions

authors have clinically noted the importance of using

impossible to be assessed in the mouth.

a technique called “double paper” to obtain more accurate results. For this process, 200µm, 100µm and

At the end of this process, the clinician must use

12µm thickness carbon papers are combined with

common sense in the face of the reductions

the use of the following technology: the 200µm and

which were necessary to decide whether mini-

100µm carbon (Bausch BK01 and BK51 respective-

mal adjustments with ameloplasty or orthodontic,

ly) have a weft constitution where the paint is asso-

prosthetic or surgical corrections should be im-

ciated with a glue called transculase. Depending on

plemented, in this order of indication.

the pressure of the occlusal contact on the carbon, more ink and therefore more glue will be released in the marking. The clinician then uses a 12µm carbon

Equipment and New Technologies

19

(Bausch BK31) whose paint has a high affinity for

The most used method for checking occlusal con-

this transculase. Thus, double markings will appear

tacts is articulation papers. In this regard, there are

at the points of more pressure. These points should

important details regarding the ideal aspects of this

receive greater reduction than points where this

articulation paper as well as the aggregation of new

combination did not occur (Figures 6.22A,B). This

technologies. For an adequate location of the occlu-

favors the precise location of points to be adjusted

sal contacts, the paper must present a thickness that

as well as facilitating the equipotence process at the

is limited to the physiological movement of a tooth in

end of the occlusal adjustment. The process may still

its socket. This value is within approximately 40 µm

not be highly accurate as the markings are definite-

for a healthy ligament. Thus, this should be the maxi-

ly stamped on the final pressure of contact with the

mum thickness of articulation papers in adjustments

antagonist. In addition, the patient may be induced

to the natural dentition. However, a more accurate

to deviate the mandible to the side where the articu-

A

B

Figures 6.22A,B - Occlusal contacts checked by the double carbon paper technique. The first marking is made with the BK51 carbon paper from Bausch (A). Occlusal contacts checked by the double carbon paper technique. The second marking is made with carbon paper BK31 from Bausch. The points where the blue and red marks coincide are those of greatest power (B).

Occlusal Remodeling

A

20

B

Figures 6.23A,B - Bausch Occlusal Device. In this device, the contacts are marked by carbon paper and digitally registered through specific pressure sensors. This allows for a very refined occlusal analysis.

lation paper is. Recently, companies have been bet-

operational process more accurate. This is the case

ting on the use of sensors accessible to the clinician

of the equipment called OccluSense produced by

to further improve this process. Such devices use,

Bausch (Figures 6.23A,B). The authors clinically

in addition to the carbon sensors that capture the

verified that the conjoint use with the traditional

pressure and transmit this information dynamically

technique increases the precision of the treatment

to a screen of mobile devices. In this way, markings

as well as the speed of its execution. Probably, in the

that could go unnoticed by the clinician are faithfully

near future, sensors will be great allies of clinicians in

detected by the sensor, making the diagnostic and

the process of occlusal remodeling.

Logical | A clinical approach to occlusion

Rules for Occlusal Remodeling

(2) Supporting cusp vs. slope and distant from pit: perform single or complete prosthetic corrections.

When to Indicate The analyses of the predominant contacts defines how the occlusal remodeling should be.

There are three distinct methods:

(3) Supporting cusp vs supporting cusp: perform orthodontic correction.

This rule defined by Okeson is didactically illus-

– By wear or addition of direct materials.

trated below with minor modifications (Figures

– By performing prosthetic rehabilitation.

6.24A-C).

– By orthodontic treatment.

In Centric Thus, after checking the contacts through the use of a BK 28 carbon paper in the mouth or on stone models mounted on an articulator, the contacts should be checked for their predominant location in three different regions:

As for the rules for occlusal adjustment, it must be borne in mind that the supporting cusps (LUBL) are the primary support pillars of an occlusion, and their wear in height must be avoided at any cost, unless there is a need for correction oc-

(1) Supporting cusp vs close to the pit or the central

clusal plane if one of these cusps is outside this

groove: carry out the remodeling by wear or addition.

plane (Figures 6.25A-C).

21

OCCLUSAL ADJUSTMENT

DENTAL PROSTHESIS

A

ORTHODONTICS

B

C

Figures 6.24A-C - According to the location of the contact points, the clinician must guide the decision making regarding the adjustment, rehabilitation or use of orthodontics to reestablish occlusal balance.

Occlusal Remodeling

A

B

C

Figures 6.25A-C - Reduction of the supporting cusps (LUBL) should be avoided unless they are clearly outside the occlusal plane.

This check can be done through lateral movement of the mandible and persistence of contact at the tip of the cusp.

In severe disharmonies, the use of orthodontic

(c) great intensity in the posterior teeth;

appliances, such as mini-implants, should be pref-

(d) less intensity in the anterior teeth.

erable. In centric, the ultimate goals of occlusal adjustment should be: (a) multiple, simultaneous and bilateral contacts; (b) orientation of occlusal forces in the axial direction;

Figure 6.26 exemplifies the type of image that the clinician must view in relation to the contact points marked on the carbon paper at the end of an occlusion adjustment in this condition.

22

Figure 6.26 - Image of a clinical case at the end of the adjustment in centric showing the balance of the contacts according to the rules mentioned in this chapter.

Logical | A clinical approach to occlusion

2

3 1

2

Figure 6.27 - Contact points: A Lower smooth slope/upper cutting.

B

Lower/upper cutting slope.

C Lower cutting slope/upper smooth.

For the decision of where the clinician should

common sense, as already described above,

perform the reduction, it is necessary to have

throughout this process.

conceptual knowledge of specific points, as well

23

as which structures are more noble in relation to

Therefore, after adjusting the premature contacts,

others. This concept defined by points A, B and

one must seek the equipotence between the

C is illustrated in Figure 6.27.

teeth and the distribution of the contacts in relation to the stoppers and equalizer slopes tooth by

When the contact is of type A, start the adjust-

tooth according to the need of the case. In order

ment by region 1 because the smooth slope is a

that the mandible does not generate a force vec-

less noble region than the cutting slope. At this

tor on anterior, reducing the overjet and pressing

point, common sense should be used: if after ad-

the maxillary anterior teeth, the equalizer points

justment of region 1, a little extra reduction is still

must be eliminated. In reverse, the target is “stop-

necessary, due to the preservation of the enam-

per” points. For this, the occlusion is analyzed

el structure, reduce it sparingly in region 2.

through repetitive movements of opening and closing with the double carbon technique. The

When contact is of type B, the adjustment

color matching contacts should be the targets of

must be initiated on the tooth with the steep-

a finer adjustment as well as balanced contacts

est slope and continued in both regions 2

of the mesial and distal cutting slopes to maintain

and 3. To define which tooth has the steepest

the static mandible without an anterior or posteri-

slope, evaluate the occlusal tables separate-

or force vector. In order for the force vectors to be

ly. Occlusal tables with high cusps and deep

canceled without the mandible having a resulting

grooves are the initial ones when compared

position for anterior or posterior, “stoppers” and

to teeth with a flatter occlusal table (Figures

“equalizers”, must be evenly distributed in the

6.28 and 6.29).

same arch, which is the purpose of the adjustment. This avoids forward or backward mandib-

Finally, when the contact is of type C, the region

ular displacement vectors by defining a stopping

of beginning of the adjustment must be 4, using

point (Figures 6.30A-C).

4 3

Occlusal Remodeling

Figure 6.28 - Teeth with steep cusps have acutely inclined slopes.

Figure 6.29 - Teeth with flat cusps. Adjusted only after it is per-

These are the first to wear out in the need of adjustment.

formed on teeth with more inclined sides.

24 A

B

C

Figures 6.30A-C - Occlusal scheme with predominance of “equalizer” type contacts leading the mandible forward (A). Occlusal scheme with predominance of “stopper” type contacts, bringing the mandible backwards (B). Occlusal scheme with cancellation of the “equalizer” and “stopper” stabilizing the mandible position (C).

Logical | A clinical approach to occlusion

Working Side On the working side, interference can be eliminated by additive correction of the canine (composite or ceramic resins) or, in the reductive case, by remodeling the buccal cuttingslope of the upper arch or the cutting slope of the lower lingual cusp (BULL) (Figures 6.31 to 6.33A,B).

25

Figure 6.31 - During the lateral movement towards the working side, the lower lingual and upper buccal cusps can generate interference (BULL).

Occlusal Remodeling

A

B

C

Figures 6.32A-C - Adjustment of work interferences must be carried out in the cutting slopes of BULL.

A

B

Figures 6.33A,B - Clinical image showing interference on the working side in the crushing aspect of the upper buccal cusp with the smooth aspect of the lower buccal cusp. The adjustment must be made on the cutting side.

Logical | A clinical approach to occlusion

Balancing Side

the contact on the cusp furthest from the

In the lateral excursion, the balance side may

vertex. In case of doubt, give preference to re-

present interference between the contention

duce the upper palatal since the mandibular

cusps. Buccal cutting slopes with upper lin-

buccal cusp plays a more important role in the

gual cutting slopes (LUBL). As a rule, reduce

masticatory cycle (Figure 6.34).

Balancing Side

LUBL

27

Figure 6.34 - During the lateral movement on the balance side, the lower buccal cusps and the upper lingual cusps can generate interference (LUBL).

Supporting Cusp

Supporting Cusp

Figure 6.35 - Balance interference adjustment must be carried out on the cutting slopes of the LUBL without wearing out the tip of the cusp.

Occlusal Remodeling

A Working

B

C

Balancing

D

E

F

28 G

Figures 6.36A-G - Interference in LUBL slopes on the balance side (A-C). Working side in group function showing interference of the balance side clearly identified by the digital system OccluSense Bausch (D-F). Reduction of the cutting slope of the lower buccal cusp (balance side) (G).

Logical | A clinical approach to occlusion

contact occurs, reduce the incisal of the tooth

In Protrusion

that is outside the functional/esthetic plane

In the protrusive movement, balance must be

(incisal alignment) (Figures 6.37A-F). If, after

sought in the top position where single touches

adjusting the esthetic/functional plane, this an-

are avoided. Preferably, all incisors should par-

terior guidance path is still occurring over a sin-

ticipate in this movement, but it is accepted that

gle tooth, the adjustment in the maxillary palatal

in patterns where the edges of the central inci-

concavity must be made. At the beginning of

sors is more prominent than that of the lateral

the movement, simultaneous contacts should

ones, only the centrals receive contact. If single

be sought during the journey. In this way, check-

A

B

C

D

E

F

29

Figures 6.37A-F - Analysis of the protrusive movement with Bausch’s BK51 carbon in central incisors submitted to additive incisal remodeling with composite resins (A). Note interference contact only on tooth #8 (B). Tooth #25 and mesial tooth #26 outside the functional/esthetic alignment plane of the lower incisors (C). Adjustment with Exacerapol Edenta wheel of the lower incisors (D). Balanced protrusive movement after adjusting the plane (E). Multiple contacts on the lower incisors verified by the articulation paper BK51 (F).

Occlusal Remodeling

ing can be done by using finer carbon papers (BK 63 or BK 28) aided by shimstocks (BK38) (Figure 6.38).

Finally, if the protrusive interference occurs in the posterior teeth, the indication is to adjust the contacts that are not in the centric contour cusps: mesial slopes of the lower teeth with the distal Figure 6.38 - Use of Bausch’s Shimstock strip for analysis

slope of the upper teeth (DUML) (Figure 6.39).

of contact effectiveness.

30

Figure 6.39 - In case of interference with the posterior teeth during protrusive movement, the clinician must adjust the inferior mesial or distal superior slopes (DUML).

Logical | A clinical approach to occlusion

General Considerations on the Occlusal Remodeling Chronology The process of occlusal remodeling is closely related to the adaptive mechanisms of the stomatognathic system in the face of the changes made. Especially for patients after orthodontic therapy, the clinician must wait a period of six months before any irreversible occlusal therapy, since several adaptive changes will occur during this period. Even after this period, more complex adjustments must be made in more than one session. This is due to the fact that the exact condition obtained at the end of an adjustment appointment will not always

31

may gradually carry out the process in stages, allowing time for this rearrangement. This conduct is essential when the occlusal remodeling process will be performed by selective wear or by strategic additions. Thorough planning and execution with intervals of at least a week between appointments will be beneficial for the longevity and stability of the case. With regard to this stability, it is worth mentioning that the choice of materials for addition has a major role in the longitudinal orthopedic balance. Materials with abrasion similar to natural tissues are biomimetic and must be chosen to be placed in opposition to natural enamel. A highlight in this

be the same as that verified after a period of

regard is given to composite resins and hybrid

new neuromuscular reprogramming. Small ad-

CAD/CAM materials (Cerasmart by GC, Gran-

justments accomplished by the body itself can

dio Bloc by VOCO, and Lava ULTIMATE by 3M).

happen in an attempt to seek a refinement pat-

The abrasion rate of these materials is very sim-

tern. In this sense, it is of utmost importance

ilar to natural enamel, unlike ceramics, which

that the clinician be judicious in this process

can wear opposing teeth up to six times faster

as well as patient regarding the results. One

than the physiological one (Figure 6.40).

Figure 6.40 - Patient with esthetic rehabilitation of the upper anterior teeth made of feldspar ceramic. After two years, the wear facets on the lower incisors are evident.

Occlusal Remodeling

Clinical Case A (Occlusal remodeling of a young patient by reduction and direct addition) The illustrative clinical case demonstrates all the current potential of occlusal remodeling, using A B

both selective reduction and strategic additions to achieve a balanced occlusion favorable to the esthetic result required by the patient. The patient reported that she had morning headaches and a feeling of fatigue on one side of her face.

She also complained of asymmetry of facial contours and of her esthetic dissatisfaction with her

Figures 6.41A,B - Clinical case where the patient reported an unpleSAAnt appearance of her upper anterior teeth (A). In a

smile, since her smile did not seem pleSAAnt (Figures 6.41A,B).

close view, poor positioning and dental disproportions can be

During the clinical examination, the masseter

the cause of this negative perception (B).

muscle on the right side was hypertrophic (verified by the asymmetric perception of the A

face), this being the side with the greatest sensitivity to palpation with pain referred to the head (Figure 6.42A).

The patient stated that this was the side she felt the lighter occlusal contacts. On the other hand, she reported heavier contacts on the left side.

One of the most uncomfortable esthetic points was tooth #10, which had an atypical position (Figure 6.42B).

B

Figures 6.42A,B - Note the hypertrophy of the masseter on the patient’s right side when she is in mild occlusion (A). In an image with a black contrast background, it is possible to verify the lack of balance of the incisal edges as well as contour asymmetries in the incisors, especially the poor positioning of tooth #10 (B).

32

Logical | A clinical approach to occlusion

The patient reported lack of symmetry of the

A

centrals as something that also bothered her. The patient was emphatic in denying orthodontic treatment. The patient had a previous treatment plan the harmonization of the anterior teeth with ceramic veneers.

In view of such conduct, a comprehensive treatment plan was suggested to the patient where, in order for the correction of esthetic complaints, the functional balance of the system would be necessary, seeking answers to the pain complaints declared by

B

her. A first intraoral investigation showed the reasons for the breakdown of the esthetic area with functional deficiencies as well as a probable etiological factor for the patient’s pain. Through mounting in SAA and a record after the initial deprogramming of the musculature with ROCCA wires, the analysis demonstrated a difference of 2mm between 33

COR and MHI with premature contacts in the premolar #12 and in the molar region (Figures 6.43A-C to 6.44A-E).

C

Figures 6.43A-C - Transfer of the three-dimensional positioning of the maxilla to the articulator through the Elite Bioart facebow (A). Use of ROCCA wires for initial deprogramming favoring the occlusal registration (B). With Futar Kettenbach GmbH & Co. KG material, the position of the Centric relation (C) position was recorded.

Occlusal Remodeling

A

34 B

C

D

E

Figures 6.44A-E -Models correctly mounted on the A7fix Bioart articulator (A). With CR mounted models it is possible to slide to MHI and check the amplitude of this movement. In the images it is possible to verify this discrepancy, which was approximately 2.0mm (B,C). Checking the contacts with BK28 Baush carbon paper showed prematurity in teeth #12 and #2 (D,E).

Logical | A clinical approach to occlusion

Another important factor defined by the analysis was that in protrusion and left lateroprotrusion movements, tooth #10 presented a consistent touch (Figure 6.45) and in the final gearing, the left side had more contacts (also more powerful than the right side).

Figure 6.45 - In protrusion, the breakdown of the functional/esthetic plans generated serious occlusal interference.

In terms of esthetic analyses, the large asymmetry between the arches and the lack of dominance of the central incisors were noticeable (Figure 6.46).

The patient was then offered the following treatment aiming at homeostasis of the system as well as improving the es-

Figure 6.46 - In the picture of the smile, it is clear the non-dominance of the central incisors and the disproportionality of the height x width ratio of the lateral incisors.

thetic appearance: adjustment of the posterior occlusion and functional/esthetic remodeling with direct resins of the anterior teeth. After bein informed

A

35

about the minimal invasiveness of this process in relation to the treatment with ceramics, as well as understanding the optimal biomimetics of resins in the wear of antagonistic teeth, the patient opted for the treatment. A simulation of the adjustment was made in SAA to verify its predictability and minimal intervention (Figures 6.47A,B).

B

When major adjustments are made to the articulator, the clinician must convince the patient of longer, but less invasive treatments, such as orthodontics. Once it was determined that the

Figures 6.47A,B - After demarcating the contacts with the BK28 Bausch carbon paper, an adjustment simulation was performed on the articulator (dark colored areas), following the occlusal remodeling rules and writing down each step on a paper.

Occlusal Remodeling

adjustments would be small and restricted

The device must be installed from canine to ca-

to enamel, the patient was then called for the

nine and present simultaneous touches on all

first adjustment session for selective reduc-

anterior teeth. Once installed, the posterior teeth

tion. Aware of the great difficulty in relaxation

are without contact, thus decreasing the proprio-

and deprogramming of the muscles due to hy-

ception of the ligament to the central nervous

pertrophy of the masseter, a front plateau was

system, which is one of the probable effects of

delivered to the patient in the first session,

deprogramming. In the session after 24 hours of

which would only be used for 24 hours before

using the device, the front plateau is adjusted un-

the adjustment consultation. This device was

til it becomes a single central point and then re-

made with a 2mm crystal sheet (Bioart) in a P7

duced until the patient reports the first posterior

vaccum-former by Bioart (Figures 6.48A,B).

premature contact (Figures 6.48C-E).

A

B

C

D

E

Figures 6.48A-E - A front plateau was made using a 2.0 mm Bioart Crystal plate in a P7 Bioart Vaccum Former (A,B). This device must be adjusted to be positioned only in the region between the canines. The use will be for a period of 24 hours being withdrawn only for food. On the day of the adjustment, the device contacts are adjusted for a single anterior contact, which is then reduced until the patient reports the first posterior premature contact (C-E).

36

Logical | A clinical approach to occlusion

There was a coincidence of premature premolar contact (tooth #12) as well as the occurrence of contacts in molars (Figure 6.49).

The clinical perception was that the premolar contact was the most potent and, therefore, the most destabilizing. However, when submitted to the sensors of the OccluSense equipment (Bausch Co.), one of the apparently smaller contacts in the area and with little possibility of clinical perception proved to be the strongest (tooth #2) (Figure 6.50). This shows the greater precision and the technical sensitivity improved by the association of analog and digital methods

Figure 6.49 - After adjusting the front plateau and the occur-

in obtaining more agile and precise results. The

rence of the first posterior contacts, the results displayed on

double carbon technique was used to start the

the articulator coincided.

process (Figure 6.51).

Starting with the primary premature contact defined by the digital and analog method, a milling 37

cutter with specific contours for the maintenance of the occlusal anatomy was used (Figure 6.52) in an electric multiplier (iOptima, Bien Air) without water and at a speed of 25,000 RPM for full control of the process by the clinician (Figure 6.53).

Figure 6.50 - Through the OccluSense Bausch digital sen-sor, it was evident the power of disarrangement of the oc-clusion by the premature contact of the molars.

The analog-ical clinical perception was that the contact of the premolar was the most aggressive.

Figure 6.51 - The combined use of Bausch’s BK 51 and BK 31 carbon papers in the technique known as double carbon clearly demonstrates the demarcations of premature contacts.

Occlusal Remodeling

Figure 6.52 - Komet No. 8833 bur. This shape allows the maintenance of the convex anatomy of the slopes.

38

Figure 6.53 - Bien Air iOptima electric motor. The use of this type of motor allows high process control since low speeds can be used, but with torque maintenance.

Logical | A clinical approach to occlusion

At this point, the adjustment rules described

gressive increase in the number of contacts. This

above must be implemented, but always with

evolution is very evident in the digital analysis. At

good judgment to keep the process as conser-

the end of the first appointment, simultaneous po-

vative as possible. As this dynamic is being per-

terior bilateral contacts and slight contacts on the

formed, the clinician begins to observe the pro-

anterior teeth (Figures 6.54A-F).

A

B

C

D

E

F

39

Figures 6.54A-F - OccluSense Bausch charts at the end of the first consultation. In (A), note the total number of contacts. The circle on the left is divided into quadrants. As the four quadrants of the circle are green, this shows a balanced distribution throughout the arcade. In (B), the application of a filter to check the contacts of higher power. Note the maintenance of the green quadrants as well as the posterior bilateral points. In (C), right lateral excursion guided by the canine. In (D), left lateral excursion guided by the canine. In (E), balanced protrusion in simultaneous contacts of the central incisors. Result obtained in the assessment of double carbon in the first session. The patient reported a more pleSAAnt engagement of the arches at this time (F).

Occlusal Remodeling

Figure 6.55 - The use of electrocautery in the blend function and at low power can be used for minimal correction of gingival contours.

The patient’s comfort in this new position must be

A

taken into account. After the 10-day interval, a new session must be conducted. In the case in question, this session was that of remodeling by adding to the anterior teeth, correcting the dynamics of excursive movements. In order to meet the esthetic demands

40

of the case, an electrocautery gingivoplasty was performed on elements #8 and #7 (Figure 6.55).

Small ameloplasties were also performed strategically on the distal lateral incisors to improve their proportion (Figures 6.56A-C).

B

C

Figures 6.56A-C - Through the use of a Vision Flex Komet ultra-thin diamond disk, strategic enamel reduction was carried out to correct dental disproportions.

Logical | A clinical approach to occlusion

A

Under absolute isolation, the adhesive procedures were performed with the use of direct composite resins creating a convexity of incisal contours for the anterior teeth (Figures 6.57A-G).

B

C

D

E

F

G

41

Figures 6.57A-G - The reconstructive sequence must be started by a central incisor followed sequentially by its counterpart to then finish the remaining teeth. The resins of choice must be micro-hybrids or nano-hybrids of high tenacity in the first layers and a micro or nanoparticulate resin covering. In this case, the chosen resins were Estelite posterior (Tokuyama), Dentin Enamel HRi (Micerium) and final layer with Estelite Omega (Tokuyama).

Occlusal Remodeling

A

The immediate result demonstrated the functional and harmonic reconstruction of the disocclusion guidances, favoring the esthetic desired by the patient (Figures 6.58A-C).

A new refinement adjustment was performed after 10 days of this reconstruction consultation aiming at equipotence of the posterior contacts, with the predominance of “stopper”

B

contacts instead of “equalization” contacts (Figures 6.59A,B). This is due to the need to decrease the overload of forces of anterior displacement in the mandible, leading to pressure on the upper anterior teeth. At this time, the patient has already reported no pain and feeling of muscle fatigue on the face for the entire period, as well as describing greater comfort in chewing food bilaterally, something that did not

C

happen pre-treatment. After stabilization of the occlusion and dentogingival restorative therapy, a holistic conception of combining esthetics and function with the patient’s well-being could be verified (Figures 6.60A-G).

Figures 6.58A-C - Dynamic analysis of the occlusion.

Check the disocclusion guidances respected after occlusal remodeling.

A

B

Figures 6.59A,B - Result of contacts in the third session approximately 30 days after the first occlusal remodeling process. Note the predominance of “stoppers” type contacts, preventing masticatory force vectors to affect the upper incisors. Also check the balanced distribution of points throughout the arch.

42

A

43

B

C

Figures 6.60A-G - Final result presenting a holistic view where esthetic correction (the patient’s main complaint) was guided by functional and consequently biological correction as a priority. The facial harmony of the restorative process can also be assessed through the final artistic photos.

Occlusal Remodeling

D-G

44

Logical | A clinical approach to occlusion

A

Clinical Case B (Occlusal remodeling of an adult patient by indirect addition) The patient completed a treatment with aligners without the result having simultaneous posterior bilateral contacts. After the routine clinical examinations, a diagnosis and a plan for definitive resolution of the case in question were made. We opted for an indirect additive occlusal adjustment using lithium disilicate (table tops and crownlays). An analog and digital process was chosen to maximize the final result.

The complete sequence of the clinical case, as well as the execution details, are described in the legends of Figures 6.61A-E to 6.68.

B

C

45

D

E

Figures 6.61A-E - Frontal in maximum intercuspation (A). Left side (B). Right side (C). Both on the left and on the right side there is a lack of contact between the lower teeth articulating with the upper teeth. Lingual view of the scanned models showing lack of contacts in the posterior teeth (D,E).

A

46

B

C

D

Figures 6.62A-D - Assembly of printed models - via analog (A). Front, left and right side view, showing the diagnostic wax-up (addition of the dental structures detected in the diagnostic model). Essential procedure for planning execution (B-D).

Logical | A clinical approach to occlusion

A

B

C

47

D

Figures 6.63A-E - Scanned models showing lack of contacts on the posterior teeth (A,B). Post-makeup porcelain (C-E).

E

Occlusal Remodeling

A

B

C

D

E

48

F

Figures 6.64A-F - Model without canine guidance. Waxing reproducing the lateral canine guidance, and fragment of porcelain restoring the canine guidancee (A-C).

Clinical aspect of maximum intercuspation, showing engagement of the upper and lower teeth (D). Confirmation of contacts via OccluSense device (E,F).

Logical | A clinical approach to occlusion

A

B

Figures 6.65A,B - Protrusive movement with disocclusion of the posterior teeth by the anterior teeth, checked with OccluSense

A

B

49 Figures 6.66A,B - Right lateral movement via canine guidance checked with OccluSense.

A

Figures 6.67A,B - Left lateral excursion guided by the canine tooth and checked with OccluSense.

B

Occlusal Remodeling

Figure 6.68 - Front view of the restoration of the right and left anteroposterior curve.

References 1. Abduo J. Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int. 2012;43(5):369-80.

2. Alonso AA - Desoclusión- AlineaciónTridimensional y Oclusión-1 ed São paulo-Quintessence editora, 2019.

3. Alonso AA, Albertini JS, Bechelli AH. Oclusión y Diagnóstico en Rehabilitación Oral. Ed Panamericana 2004.

4. Ash MM, Ramfjord SP, Schmidseder. Oclusão. Ed Santos 1998.

5. Brill N, Tryde G. Physiology of mandibular positions. In: Physiology of mastication. Karger Publishers 1974.

6. Carlsson GE. Dental occlusion: modern concepts and their application in implant prosthodontics. Odontology 2009 Jan; 97(1):8-17.

7. Butler JA, Zander HA. Evaluation of two occlusal concepts.

Parodontol. Acad. Rev. 1968;2(1),5-19.

8. D’Amico A. Functional occlusion of the natural teeth in man. J Prosthet Dent. 1961;11:899-915.

9. Dawson P. Functional Occlusion-E-Book: From TMJ to Smile Design. Elsevier Health Sciences, 2006.

10. Duminil G et al. Occlusion made easy. Paris: Space ID ed, 2016.

11. Janson G, Martins DR, Henriques JFC, Freitas MR, Pinzam A, Almeida RR. Func-tional occlusion and occlusal adjustment.

In: Viazis AD, editor. Atlas of advanced or-thodontics: a guide to clinical efficiency. Philadelphia: Saunders 1998.

12. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporoman-dibular joint disorders. J Oral Rehabil 2004;31:287-92.

13. Lerman MD. The muscle engram: the reflex that limits conventional occlusal treatment. Cranio : the journal of craniomandibular practice. 2011;29(4):297-303.

14. Manns A, Chan C, Miralles R. Influence of group function and canine guidance on electromyographic activity of elevator muscles. The Journal of prosthetic dentistry. 1987;57(4):494-501.

15. McCollum BB, Evans RL. The gnathological concepts of Charles E. Stuart, Beverly B. McCollum and Harvey Stallard.

Georgetown Dent. J.1970;36(1):2-20.

16. McHorris WH. Occlusion with particular emphasis on the functional and parafunc-tional role of anterior teeth - Part 1. J. Clin. Orthod.1979;13(9):606-620.

17. McHorris WH. Occlusion with particular emphasis on the functional and parafunc-tional role of anterior teeth - Part 2. J. Clin. Orthod.,1979;13(10):684-701.

18. McNeill C. Ciência e Prática da Oclusão. Quintessence 2000.

19. Misch CE. Implantes Dentários Contemporâneos. 2a ed. 2a reimpressão. São Paulo: Santos 2006.

20. Okeson JP. Tratamento das desordens temporomandibulares e oclusão. 4. ed. São Paulo: Artes Médicas 2000.

21. Pankey LD, Mann AW. The philosophy of occlusal rehabilitation. Dent Clin North Am.1963;2:621-36.

22. Posselt U. Physiology of occlusion and rehabilitation. Oxford: Blackwell Scientific; 1969.

23. Razdolsky Y, Sadowsky C, BeGole EA. Occlusal contacts following orthodontic treatment: a follow-up study. Angle Orthod.1989;59(3);181-186.

24. Ruiz JL. Seven signs and symptoms of occlusal disease: the key to an easy diagnosis. Dentistry today. 2009;28(8):112-3.

25. Sadowsky C, Polson AM. Temporomandibular disorders and functional occlusion after orthodontic treatment: results of two long-term studies. Am. J. Orthod. Dentofa-cial Orthop.1984;86(5):386-390.

26. Schuyler CH. Freedom in Centric. Dent. Clin. North Am., 1969; 13 (3):681-686.

27. Swenson MD. Partial dentures. Mosby, 1955.

50

Printed in Brazil

ISBN 978-85-480-0086-7

9 788548 000867

www.editoranapoleao.com.br