Complete Denture Occlusion

Complete denture occlusion is a critical aspect of prosthodontics, as it affects the function, stability, and comfort of the dentures. There are three primary types of occlusion used in complete dentures: Balanced Occlusion, Monoplane Occlusion, and Lingualized Occlusion. Each type has its own characteristics and applications.

Types of Complete Denture Occlusion

1. Balanced Occlusion

• Definition: Balanced occlusion is characterized by simultaneous contact of all opposing teeth in centric occlusion, providing stability and even distribution of occlusal forces.
• Key Features:
  • Three-Point Contact: While a three-point contact (one anterior and two posterior) is a starting point, it is not sufficient for true balanced occlusion. Instead, there should be simultaneous contact of all teeth.
  • Minimal Occlusal Balance: For minimal occlusal balance, there should be at least three points of contact on the occlusal plane. The more points of contact, the better the balance.
  • Absence in Natural Dentition: Balanced occlusion is not typically found in natural dentition; it is a concept specifically applied to complete dentures to enhance stability during function.
• Importance: This type of occlusion is particularly important for patients with complete dentures, as it helps to minimize tipping and movement of the dentures during chewing and speaking.

2. Monoplane Occlusion

• Definition: Monoplane occlusion involves a flat occlusal plane where the occlusal surfaces of the teeth are arranged in a single plane.
• Key Features:
  • Flat Occlusal Plane: The occlusal surfaces are designed to be flat, which simplifies the occlusion and reduces the complexity of the denture design.
  • Limited Interference: This type of occlusion minimizes interferences during lateral and protrusive movements, making it easier for patients to adapt to their dentures.
• Applications: Monoplane occlusion is often used in cases where the residual ridge is severely resorbed or in patients with limited jaw movements.

3. Lingualized Occlusion

• Definition: Lingualized occlusion is characterized by the positioning of the maxillary posterior teeth in a way that they occlude with the mandibular posterior teeth, with the buccal cusps of the mandibular teeth being positioned more towards the buccal side.
• Key Features:
  • Maxillary Teeth Positioning: The maxillary posterior teeth are positioned more towards the center of the arch, while the mandibular posterior teeth are positioned buccally.
  • Functional Balance: This arrangement allows for better functional balance and stability during chewing, as the maxillary teeth provide support to the mandibular teeth.
• Advantages: Lingualized occlusion can enhance the esthetics and function of complete dentures, particularly in patients with a well-defined ridge.

Understanding the anatomical considerations for upper (maxillary) and lower (mandibular) dentures is crucial for successful denture fabrication and fitting. Proper knowledge of stress-bearing areas, retentive areas, and relief areas helps in achieving optimal retention, stability, and comfort for the patient.

Maxilla

Stress Bearing Areas

• Primary Stress Bearing Area:

  • Residual Alveolar Ridge: The primary area where the forces of mastication are transmitted.

• Secondary Stress Bearing Areas:

  • Rugae: The folds in the anterior hard palate that provide additional support.
  • Anterior Hard Palate: The bony part of the roof of the mouth.
  • Maxillary Tuberosity: The rounded area at the back of the maxilla that aids in support.

• Tertiary Stress Bearing Area and Secondary Retentive Area:

  • Posteriolateral Part of Hard Palate: Provides additional support and retention.

Relieving Areas

• Incisive Papilla: A small elevation located behind the maxillary central incisors; important to relieve pressure.
• Mid Palatine Raphe: The midline ridge of the hard palate; should be relieved to avoid discomfort.
• Cuspid Eminence: The bony prominence associated with the canine teeth; requires relief.
• Fovea Palatine: Small depressions located posterior to the hard palate; should be considered for relief.

Primary Retentive Area

• Posterior Palatal Seal Area: The area at the posterior border of the maxillary denture that aids in retention by creating a seal.

Mandible

Stress Bearing Areas

• Primary Stress Bearing Area:

  • Buccal Shelf Area: The area between the residual ridge and the buccal vestibule; provides significant support.

• Secondary Stress Bearing Area:

  • Slopes of Edentulous Ridge: The inclined surfaces of the residual ridge that can bear some stress.

Retentive Areas

• Primary Retentive and Primary Peripheral Seal Area:

  • Retromolar Pad: The area behind the last molar that provides retention and support.

• Secondary Peripheral Seal Area:

  • Anterior Lingual Border: The area along the anterior border of the lingual vestibule that aids in retention.

Relief Areas

• Crest of Residual Ridge: The top of the ridge should be relieved to prevent pressure sores.
• Mental Foramen: The opening for the mental nerve; should be avoided to prevent discomfort.
• Mylohyoid Ridge: The bony ridge along the mandible that may require relief.

Posterior Palatal Seal (PPS)

The posterior palatal seal is critical for ensuring a complete seal, which enhances the retention of the maxillary denture.

Functions of the Posterior Palatal Seal

• Displacement of Soft Tissues: Slightly displaces the soft tissues at the distal end of the denture to ensure a complete seal.
• Prevention of Food Ingress: Prevents food and saliva from entering beneath the denture base.
• Control of Impression Material: Prevents excess impression material from running down the patient's throat.

Vibrating Lines

• Vibrating Line: An imaginary line that passes from one pterygomaxillary notch to the other, located 2 mm in front of the fovea palatine, always on the soft palate. The distal end of the denture should be positioned 1-2 mm posterior to this line.

• Anterior Vibrating Line:

  • Located at the junction between the immovable tissues of the hard palate and the slightly movable tissues of the soft palate.
  • Identified by asking the patient to say "ah" in short vigorous bursts or performing the Valsalva maneuver.
  • The line has a cupid bow shape.

• Posterior Vibrating Line:

  • Located at the junction of the soft palate that shows limited movement and the soft palate that shows marked movement.

Kennedy's Classification is a system used in dentistry to categorize the edentulous spaces (areas without teeth) in the mouth of a patient who is fully or partially edentulous. This classification system helps in planning the treatment, designing the dentures, and predicting the outcomes of denture therapy. It was developed by Dr. Edward Kennedy in 1925 and is widely used by dental professionals.

The classification is based on the relationship between the remaining teeth, the residual alveolar ridge, and the movable tissues of the oral cavity. It is particularly useful for patients who are wearing or will be wearing complete or partial dentures.

There are four main classes of Kennedy's Classification:

1. Class I: In this class, the patient has a bilateral edentulous area with no remaining teeth on either side of the arch. This means that the patient has a full denture on the upper and lower jaws with no natural tooth support.

2. Class II: The patient has a unilateral edentulous area with natural teeth remaining only on one side of the arch. This could be either the upper or lower jaw. The edentulous side has a complete denture that is supported by the teeth on the opposite side and the buccal (cheek) and lingual (tongue) tissues.

3. Class III: There is a unilateral edentulous area with natural teeth remaining on both sides of the arch, but the edentulous area does not include the anterior (front) teeth. This means the patient has a partial denture on one side of the arch, with the rest of the teeth acting as support for the denture.

4. Class IV: The patient has a unilateral edentulous area with natural teeth remaining only on the anterior region of the edentulous side. The posterior (back) section of the same side is missing, and there may or may not be teeth on the opposite side. This situation requires careful consideration for the design of the partial denture to ensure stability and retention.

Each class is further divided into subcategories (A, B, and C) to account for variations in the amount of remaining bone support and the presence or absence of undercuts, which are areas where the bone curves inward and can affect the stability of the denture.

- Class I (A, B, C): Variations in the amount of bone support and presence of undercuts in the fully edentulous arches.
- Class II (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth on the opposite side.
- Class III (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth on the same side, but not in the anterior region.
- Class IV (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth remaining only in the anterior region of the edentulous side.

Understanding a patient's Kennedy's Classification helps dentists and dental technicians to create well-fitting and functional dentures, which are crucial for the patient's comfort, speech, chewing ability, and overall oral health.

Applegate's Classification is a system used to categorize edentulous (toothless) arches in preparation for denture construction. The classification is based on the amount and quality of the remaining alveolar ridge, the relationship of the ridge to the residual ridges, and the presence of undercuts. The system is primarily used in the context of complete denture prosthodontics to determine the best approach for achieving retention, stability, and support for the dentures.

Applegate's Classification for edentulous arches:

1. Class I: The alveolar ridge has a favorable arch form and sufficient height and width to provide adequate support for a complete denture without the need for extensive modifications. This is the ideal scenario for denture construction.

2. Class II: The alveolar ridge has a favorable arch form but lacks the necessary height or width to provide adequate support. This may require the use of denture modifications such as flanges to enhance retention and support.

3. Class III: The ridge lacks both height and width, and there may be undercuts or excessive resorption. In this case, additional procedures such as ridge augmentation or the use of implants might be necessary to improve the foundation for the denture.

4. Class IV: The ridge has an unfavorable arch form, often with significant resorption, and may require extensive surgical procedures or adjuncts like implants to achieve a functional and stable denture.

5. Class V: This is the most severe classification where the patient has no residual alveolar ridge, possibly due to severe resorption, trauma, or surgical removal. In such cases, the creation of a functional and stable denture may be highly challenging and might necessitate advanced surgical procedures and/or the use of alternative prosthetic options like over-dentures with implant support.

It's important to note that this classification is a guide, and individual patient cases may present with a combination of features from different classes or may require customized treatment plans based on unique anatomical and functional requirements.

Finish lines are the marginal configurations at the interface between a restoration and the tooth structure that are intended to be refined and polished to a smooth contour. In prosthodontics, they are crucial for the proper adaptation and seating of restorations, as well as for maintaining the health of the surrounding soft and hard tissues. Finish lines can be classified in several ways, such as by their location, purpose, and the burs used to create them. Here's an overview:

1. Classification by Width:
a. Narrow Finish Lines: These are typically 0.5mm wide or less and are often used in areas where the restoration margin is tight against the tooth structure, such as with metal-ceramic restorations or in cases with minimal tooth preparation.
b. Moderate Finish Lines: These are 0.5-1.5mm wide and are commonly used for most types of restorations, providing adequate space for a good margin and seal.
c. Wide Finish Lines: These are 1.5mm wide or more and are often used in areas with less than ideal tooth preparation or when a wider margin is necessary for material manipulation or when there is a concern about the stability of the restoration.

2. Classification by Location and Application:
a. Shoulder Finish Line: This finish line is at a 90-degree angle to the tooth structure and is often used for metal-ceramic and all-ceramic restorations. It provides good support and can be easily visualized and finished.
b. Knife-Edge Finish Line: This is a very thin finish line that is beveled at an approximately 45-degree angle to the tooth structure. It is typically used for all-ceramic restorations and is designed to mimic the natural tooth contour, providing excellent esthetics.
c. Feather Edge Finish Line: Also known as a chamfer, this finish line is beveled at approximately 90-degrees to the tooth structure. It is used in situations where the tooth structure is not ideal for a shoulder margin, and it helps to distribute the forces evenly and reduce the risk of tooth fracture.
d. Butt-Joint Finish Line: This is when the restoration margin is placed directly against the tooth structure without any bevel. It is often used in the lingual areas of anterior teeth and in situations where there is minimal space for a margin.

3. Classification by Function:
a. Functional Finish Lines: These are placed where the restoration will be subject to significant occlusal or functional stresses. They are designed to enhance the durability of the restoration and are usually placed at or slightly below the height of the free gingival margin.
b. Esthetic Finish Lines: These are placed to achieve a high level of cosmetic appeal and are often located in the facial or incisal areas of anterior teeth. They are typically knife-edge margins that are highly polished.

Advantages and Disadvantages:
- Narrow finish lines can be more challenging to clean and may be less visible, potentially leading to better esthetics and less irritation of the surrounding tissues. However, they may also increase the risk of recurrent decay and are more difficult to achieve a good margin seal with.
- Moderate finish lines are easier to clean and provide a better margin seal, but may be more visible and can potentially lead to increased tooth sensitivity.
- Wide finish lines are more forgiving for marginal adaptation and are easier to clean, but they can be less esthetic and may require more tooth reduction.

Burs Used:
- The choice of bur for creating finish lines depends on the restoration material and the desired margin design. For example:
a. Diamond Burs: Typically used for creating finish lines on natural tooth structures, especially for knife-edge margins on ceramic restorations, due to their ability to produce a smooth and precise finish.
b. Carbide Burs: Often used for metal-ceramic restorations, as they are less likely to chip the ceramic material.
c. Zirconia-Specific Burs: Used for zirconia restorations to prevent chipping or fracture of the zirconia material.

When creating finish lines, the dentist must consider the patient's oral health, the type of restoration, the location in the mouth, and the desired functional and esthetic outcomes. The correct selection and preparation of the finish line are essential for the longevity and success of the restoration.

The clinical implications of an edentulous stomatognathic system are considered under the following factors:

(1) modi?cations in areas of support .
(2) functional and parafunctional considerations.
(3) changes in morphologic face height, and temporomandibular joint (TMJ).
(4) cosmetic changes and adaptive responses

Support mechanism for complete dentures

Mucosal support and masticatory loads

- The area of mucosa available to receive the load from complete dentures is limited when compared with the corresponding areas of support available for natural dentitions.

- The mean denture bearing area to be 22.96 cm2 in the edentulous maxillae and approximately 12.25 cm2 in an edentulous mandible

- In fact, any disturbance of the normal metabolic processes may lower the upper limit of mucosal tolerance and initiate in?ammation

Residual ridge

The residual ridge consists of denture-bearing mucosa, the submucosa and periosteum, and the underlying residual alveolar bone.

The alveolar bone supporting natural teeth receives tensile loads through a large area of periodontal ligament, whereas the edentulous residual ridge receives vertical, diagonal, and horizontal loads applied by a denture with a surface area much smaller than the total area of the periodontal ligaments of all the natural teeth that had been present.

There are two physical factors involved in denture retention that are under the control of the dentist

- The maximal extension of the denture base
- maximal intimate contact of the denture base and its basal seat

 - The buccinator, the orbicularis oris, and the intrinsic and extrinsic muscles of the tongue are the key muscles that the dentist harnesses to achieve this objective by means of impression techniques.
 - The design of the labial buccal and lingual polished surface of the denture and the form of the dental arch are considered in balancing the forces generated by the tongue and perioral musculature.

Function: mastication and other mandibular movements

Mastication consists of a rhythmic separation and apposition of the jaws and involves biophysical and biochemical processes, including the use of the lips, teeth, cheeks, tongue, palate, and all the oral structures to prepare food for swallowing.

- The maximal bite force in denture wearers is ?ve to six times less than that in dentulous individuals.

- The pronounced differences between persons with natural teeth and patients with complete dentures are conspicuous in this functional context:

(1) the mucosal mechanism of support as opposed to support by the periodontium ;

(2) the movements of the dentures during mastication;

(3) the progressive changes in maxillomandibular relations and the eventual migration of dentures

(4) the different physical stimuli to the sensor motor systems.

Parafunctional considerations

- Parafunctional habits involving repeated or sustained occlusion of the teeth can be harmful to the teeth or other components of the masticatory system.

- Teeth clenching is common and is a frequent cause of the complaint of soreness of the denture-bearing mucosa.

- In the denture wearer, parafunctional habits can cause additional loading on the denture-bearing tissues

Force generated during mastication and parafunction

Functional (Mastication)

Direction -> Mainly vertical

Duration and magnitude -> Intermittent and light diurnal only

Parafunction

Direction -> Frequently horizontalas well as vertical

Duration and magnitude -> Prolonged, possibly excessive Both diurnal and nocturnal

Changes in morphology (face height), occlusion, and the TMJs

The reduction of the residual ridges under complete dentures and the accompanying reduction in vertical dimension of occlusion tend to cause a reduction in the total face height and a resultant mandibular prognathism.

In complete denture wearers, the mean reduction in height of the mandibular residual alveolar ridge measured in the anterior region may be approximately four times greater than the mean reduction occurring in the maxillary residual alveolar process

Occlusion

- In complete denture prosthodontics, the position of planned maximum intercuspation of teeth is established to coincide with the patient’s centric relation.

-The coincidence of centric relation and centric occlusion is consequently referred to as centric relation occlusion (CRG).

- Centric relation at the established vertical dimension has potential for change. This change is brought about by alterations indenture-supporting tissues and facial height, as well as by morphological changes in the TMJs.

TMJ changes

impaired dental ef?ciency resulting from partial tooth loss and absence of or incorrect prosthodontic treatment can in?uence the outcome of temporomandibular disorders.

Aesthetic, behavioral, and adaptive response

Aesthetic changes associated with the edentulous state.

- Deepening of nasolabial groove

- Loss of labiodentals angle

- Narrowing of lips

- Increase in columellae philtral angle

-  Prognathic appearance