PRACTICE

occlusion

Good occlusal practice in

3 simple restorative dentistry
S. J. Davies,1 R. M. J. Gray, 2 and P. W. Smith,3

Many theories and philosophies of occlusion have been

developed.1–12 The difficulty in scientifically validating the
various approaches to providing an occlusion is that an
In this part, we will ‘occlusion’ can only be judged against the reaction it may or may
discuss: not produce in a tissue system (eg dental, alveolar, periodontal
• The ‘conformative or articulatory). Because of this, the various theories and
approach’ to philosophies are essentially untested and so lack the scientific
restorative dentistry
validity necessary to make them ‘rules’. Often authors will
• Some techniques for
achieving this goal present their own firmly held opinions as ‘rules’. This does not
• Can and should the mean that these approaches are to be ignored; they are, after
occlusion be improved all, the distillation of the clinical experience of many different
within the conforma- operators over many years. But they are empirical.
tive approach? In developing these guidelines the authors have unashamedly
drawn on this body of perceived wisdom, but we would also like
to involve and challenge the reader by asking basic questions,
and by applying a common sense approach to a subject that can
be submerged under a sea of dictate and dogma.

Discussion school to examine and record the pre-existing

occlusion before providing a restoration.
Does occlusion matter in simple restorative Instead it has become customary to provide the
dentistry? restoration and then to ‘check’ the occlusion
It is easy to justify a chapter on restorative den- afterwards. If this is our habit, we should ask
tistry in a book on occlusion. Dentists are con- ourselves the question what are we checking the
stantly involved in the management of their occlusion of our restoration against? It cannot
patients’ occlusion during routine restorative be the pre-existing occlusion if we did not
dental procedures. This is because the occlusal examine it first. The principle of providing a
surfaces of the teeth are usually involved in the new restoration that does not alter the patient’s
provision of restorations. The significance of occlusion is described in restorative dentistry as
this obvious statement lies both in the relation- the ‘conformative approach’, and the vast
ship that the occlusion has within the articula- majority of restorations are provided following
tory system and the effect that trauma from the this principle.
occlusion may have on the tooth, and its peri-
1*GDP, 73 Buxton Rd, High Lane, odontal support. All dentists wish to avoid these The conformative approach
Stockport SK6 8DR; P/T Lecturer in problems; in reality dentists want predictable
Dental Practice, University Dental success for their patients and themselves. Explanation
Hospital of Manchester, Higher Successful occlusal management leads to: The conformative approach is defined as the
Cambridge Street, Manchester M15 6FH
2Honorary Fellow, University Dental predictable fitting of restorations and prosthe- provision of restorations ‘in harmony with the
Hospital of Manchester, Higher ses, longevity and absence of iatrogenic prob- existing jaw relationships’.13 In practice this
Cambridge Street, Manchester M15 6FH lems, patient comfort and occlusal stability. means that the occlusion of the new restoration
3Lecturer/Honorary Consultant in
is provided in such a way that the occlusal con-
Restorative Dentistry, University
Dental Hospital of Manchester The starting point: examination tacts of the other teeth remain unaltered.14
M15 6FH It is a general principle in medicine that before
*Correspondence to : Stephen Davies treatment is provided a careful clinical exami- Justification
email: [email protected]
REFEREED PAPER
nation is carried out. Dentistry generally holds The answer as to why dentists should wish to
© British Dental Journal to this principle, but with perhaps one exemp- adopt this approach is often given as being
2001; 191: 365–381 tion. Most dentists were not taught at dental ‘because it is the easiest’. In fact, this is not the

BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001 365

PRACTICE
occlusion

Fig. 1a Teeth touching in CO Fig. 1b Premature contact in CR

Fig. 2a Left lateral excursion Fig. 2b Non working side interference during left
lateral excursion

case; the easiest approach is undoubtedly not to not ‘interfere’. The danger in this approach
consider whether the new restoration changes is that the new occlusion may still not be an
the patient’s occlusion, maybe hoping not to ideal one, because of the existence of other
‘Fingers crossed’ change it too much. The reason why the confor- potential interferences. This new ‘less than
dentistry equals mative approach is favoured is not because it is ideal’ occlusion may be a less harmonious
stress the easiest but because it is the safest. It is less one which the patient will tolerate less well
likely to introduce problems for the tooth, the ie the possibility of iatrogenic problems
periodontium, the muscles, the temporo- may arise.
mandibular joints, the patient and the dentist. 3. Finally there should not be an existing tem-
poromandibular disorder (TMD). If there
When to use the conformative approach? is, the decision must be taken whether or
The short answer is to use it whenever you can. not to treat it first, since it is possible that
It is possible to provide a restoration to the con- the treatment of the TMD will result in a
formative approach when: change of the patient’s occlusion.

1. The patient has an ideal occlusion, ie centric Improving the occlusion within the restrictions of
Q: When do you occlusion (CO) is in centric relation (CR) the conformative approach
use the with anterior guidance free from posterior Although the principle of not changing the
interferences. This is unusual, it is much patient’s occlusion is paramount within the
conformative more likely that: conformative approach, this, of course, refers
approach? 2. The patient does not have an ideal occlu- to the occlusal contacts that the patient has
sion, but that the removal of the existing between their teeth that are not being
A: When ever occluding surface of the tooth to be restored presently restored. It does not mean that the
does not mean an inevitable change in the new restoration should slavishly reproduce
you can patient’s centric occlusion or anterior guid- the exact occlusion that the tooth in need of
ance. Examples of an occasion where this restoration has. One of the purposes of restor-
will not be possible is either if the tooth that ing it would probably be lost if that was the
is to be restored is a deflecting contact; ie it case. How the occlusion may be improved is
provides the principal guiding contact from best considered within the principles of ‘ideal
CR to CO, or if the tooth is providing a occlusion’.
heavy posterior interference. On the tooth level, ideal occlusion is
In both of cases shown in Figures 1 and 2 it described as an occlusal contact that is: ‘in line
is attractive to think that all that the dentist with the long axis of the tooth and simultane-
has to do is to provide restorations that do ous with all other occlusal contacts in the

366 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001

 PRACTICE
occlusion
mouth’. This means the elimination of incline
contacts. Incline contacts are considered to be
potentially harmful, because of the lateral force
Fig. 3 Possible consequences of an
that they may generate. A lateral force on a incline contract
tooth may have harmful sequelae, which are
illustrated in Figure 3.
So as long as the jaw relationship is the
same, it is still the conformative approach.
Within the conformative approach it is not
only possible, but advisable to improve the Tooth fracture
occlusion of the restored tooth by the elimi-
nation of incline contacts either by careful
design of the occlusal platform of the new
restoration or by judicial alteration of the
opposing tooth.
The acid test is whether or not the occlusal Tooth jiggling
contacts of the other teeth (those which are
not involved in the restoration) are changed.
If the occlusal relationships of these other
teeth are changed then the approach is not
the conformative but the reorganised
approach. This is not wrong, but requires a Mandibular deflection
different approach and is described later in
respect of both simple and complex restora-
tive dentistry.

Technique restoration. The only difference in this Fig. 4 The EDEC

sequence is that the suggestion is made that the principle
Sequence — the EDEC principle visualisation is better done after a simple
When considering the provision of simple occlusal examination (Fig. 6). The existing
restorative dentistry to the conformative occlusal marks will either be preserved by being E = Examine
approach, no matter what type of occlusal avoided in the preparation, or they will be D = Design
restoration is being provided the sequence is involved in the design. As established, they do
E = Execute
always the same. The ‘EDEC principle’ that is not have to be exactly duplicated as it may be
presented here (Fig. 4) is a system that the possible to improve them (from being ‘incline C = Check
authors have devised to give a logical progres- contacts’ to ‘cusp tip to fossa/marginal ridge’
sion through the sequence of producing a relationships), or it may be possible to add an
restoration, to the conformative approach. This occlusal contact if the restoration being
is capable of modification to other aspects of replaced was in infra occlusion.
clinical practice. Often it will be found that the previous
The EDEC principle is useful in relation to: restoration is in infra occlusion, as every dentist
is anxious to avoid the ‘high restoration’. But
• Direct restorations
the avoidance of a supra-occluding restoration
• Indirect restorations
by deliberately providing restorations that do
not contribute to the overall occlusion is not
The EDEC principle for direct restorations
good occlusal practice.
Examine
Firstly, examine the occlusion before picking up Execution
a handpiece. The examination is in two parts: The execution of the restoration to the design
the static and the dynamic occlusions. The implies that the dentist will have decided the
examination of the static occlusion in centric form of the preparation before starting to
occlusion (rather than in centric relation) is cut. It is our belief that this does not take any
done by asking the patient to tap onto thin artic- longer and that it is always easier to work to a
ulating paper or foil (Fig. 5). Next, ask the plan even in the simplest of restorations.
patient to slide from side-to-side using thin There will be an overall saving in time, espe-
paper or foil of a different colour; this marks the cially if the first two stages are carried out whilst
contacts of the dynamic occlusion . the local anaesthetic is working. The finishing
of the restoration is also facilitated if there is a
Design definite aim to the carving or shaping (Fig. 7). Visualise the
The clinician must visualise the design of the end before
cavity preparation. This may sound pedantic to Check
some, but it is in effect what every practising Finally, we check the occlusion of the restora- beginning
dentist does when preparing a tooth for tion does not prevent all the other teeth from

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PRACTICE
occlusion

Fig. 5 Shot of pre-existing Fig. 6 Close-up of tooth with Fig. 8a Initial check of finished Fig. 8b After adjustment
marks pre-existing marks restoration

touching in exactly the same way as they did to be accurately recorded and that record has
before. This is either done by referring to some to be transferred to the technician. This is the
diagrammatic record made, or by reversing the clinician’s responsibility. Secondly, the tech-
colour of the paper or foils used pre-opera- nician has the responsibility to preserve the
tively, or from memory. accuracy of that record during the laboratory
In the illustrated case it can be seen that the phase of treatment. Finally, because of the
occulsal contact against the mesial marginal interval in treatment to allow the restoration
ridge of the restored UL4 (24) is slightly too to be made, the clinician has the responsibil-
heavy (Fig. 8a); this has prevented the palatal ity to maintain the patient in the same occlu-
cusp of this tooth from occluding and has sion during that interval. Consequently it is
changed the occlusion of the canine. After min- imperative that the patient is dismissed from
imal adjustment, this has been rectified (Fig. the preparation appointment with a tempo-
8b). For simplicity of illustration, the dynamic rary restoration which will maintain the same
occlusion has not been shown in this series. relationship between the prepared tooth and
Fig. 7 Close-up of finished the adjacent and opposing teeth (Fig. 10).
restoration The EDEC principle for indirect restorations
The EDEC principle is still followed for indi- Examine
rect restorations (Fig. 9). The essential differ- The examination of the patient’s pre-existing
ence between a direct and an indirect occlusion is carried out in exactly the same way
restoration is that a second operator is as described for the direct restoration. There is a
involved, namely the laboratory technician. need for that information to be transferred
We believe that it is a more accurate represen- accurately to the laboratory technician: a record
tation of the working relationship to consider must be made.
the laboratory technician to be a second oper- The provision of an indirect restoration
There is no point ator rather than an assistant, as it makes it always involves the transfer of anatomical
in the technician clear that the technician also has expectations information in the form of the impressions. It is
and responsibilities the occlusal relationship of teeth which is the
designing the Two operators means there are several con- important record, because the technician can-
occlusal aspect of sequences to the treatment sequence (Fig. 10). not carry out his or her responsibilities without
the restoration The dentist not only has to examine the occlu- knowing how the upper and lower models
on models that sion but the results of that examination have relate to one another.
do not accurately
conform to the
Fig 9 The EDEC principle for indirect restoration
patient’s
occlusion
E = Examine and record the pre-existing occlusion
D = Design the restoration
E = Execute the restoration
C = Check the occlusion at the fit appointment

368 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001

 PRACTICE
occlusion
There are three ways in which this anatomical
information can be transferred: two dimen- Fig. 10 The sequence of events in a two
sional bite records, three dimensional bite operator situation (indirect restorations)
records, and a combination of both.

Two dimensional bite records

Photographs: It is entirely possible that as
instant intra-oral photography becomes more
available the clinician will be able to send the Patient’s
pre-treatment occlusion
technician a photograph of the patient’s pre-
existing occlusion marked by occlusal regis-
tration paper or foil; so that in making the
indirect restoration to the conformative Record at Check at fit
approach the technician can see what the preparation appointment
patient’s pre-existing occlusion was in the appointment
mouth (Fig. 11).
Written record: It is quick, simple but effec-
tive in some situations for the clinician to sim- Maintain in mouth
ply tell the technician what the occlusion by good temporary
restorations
should be when the restoration is finished
(Fig. 12).
Occlusal sketching: ‘Occlusal sketching’ is a
technique of recording onto an acetate sheet a Preserve at laboratory
by accurate model
sketch of the occlusal marks made in the
mounting
patient’s mouth, by articulating paper or foil, of
the static and dynamic occlusion. The acetate
strip is designed to be viewed in two different
ways: one is appropriate to the clinician treat-
ing the supine patient and the other is conve-
nient for the technician to use on the bench in
conjunction with the models. The occlusal
sketch is an easy way for the clinician and the
technician to check that the occlusion of the
restoration conforms to the pre-existing
occlusion (Fig. 13a–d).
Occlusal sketching is a user-friendly way of
recording the patient’s occlusion. It facilitates the
transfer of anatomical information between the Fig. 11 Intra-oral photograph
clinician and the technician. In addition, it offers of occlusal contacts on teeth
adjacent to a post crown
the clinician a convenient way of recording the preparation
patient’s occlusion as part of the dental records,
and this may have medico-legal considerations.
occlusal fissure or of an interdental embrasure
Three dimensional bite records could very likely result in a significant differ-
Bite registration materials: There are many ence between the occlusion of the patient’s
different materials and they all have their pros teeth and the models. As a consequence the
and cons.15 Their use is not a guarantee of suc- opposing model will not have a true relation-
cessful transfer of information; and it is easy to ship with the working model and it will keep
to be fooled that when one material fails to pro- the ‘other teeth’ apart.
duce a good result that a different material Even if the models are completely accurate
would have succeeded. In reality it is nearly and allow the bite registration material to
always a misunderstanding of the objective of adapt in exactly the same relationship to the
the exercise that has resulted in an inaccurate models as they had to the teeth, then there is
record. No particular bite registration material still the problem that in the mouth the
guarantees success. mucosal surfaces are soft and compressible,
The objective is to record only the correct spatial whereas on the models the mucosal surfaces
relationship of the prepared tooth to its antago- are replicated by hard incompressible material
nists. Other teeth should contact as before. which will probably hold the bite registration
The inadequacies of models as anatomical material away from its true relationship with
records of the teeth and mucosal surfaces give the models of the teeth. As a consequence the
rise to most of the problems. Impressions often opposing model will not have a true relation-
do produce models which are not completely ship with the working model: it will keep the
accurate.16 An incomplete impression of an ‘other teeth’ apart.

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PRACTICE
occlusion

Fig. 12 Examples of written record of patient

pre-existing occlusion

Patient: Mrs Jones Job: crown on tooth LR5 (45)

There are occlusal stops as follows:

Tip of LR3 (43) against cingulum of UR3 (13)
Palatal cusp of UR4 (14) against distal marginal ridge of LR4 (44)
Palatal cusp of UR6 (16) against central fossa of LR6 (46)
Mesio-buccal cusp of LR6 (46) against mesial marginal ridge of UR6 (16)

There is canine guidance on the right and left sides

Fig. 13a A sketch is made of the patient’s Fig. 13b This sketch is reconfigured at the
occlusion (before preparation of a bridge) by the laboratory as an aid to the technician to confirm
dentist at the chairside the correct mounting of the models

Fig. 13d At the fit stage, the dentist uses the

Fig. 13c The bridge is constructed in the sketch as an aid to check conformity between
laboratory to ‘conform’ with the occlusion the pre- and post-operative occlusions

For these reasons, three important guidelines • If a bite registration is going to be used to
emerge: record the relationship of other teeth it must
be carved so that no part of it touches the
• If possible the bite registration material models of the mucosal surfaces.
should only be used between the prepared • Before the technician starts to use the models
tooth and its antagonists; not used to take a to construct the occlusal part of the restora-
full arch record. tion, the occlusion of those models must be

372 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001

 PRACTICE
occlusion
confirmed against a second record of the bite; on that side. This carves grooves into the wax
and, if necessary, modifications to the models which represents the movement eg ‘pathway’ of
carried out (model grooming). the lower teeth relative to the upper teeth. This
impression is then cast in the mouth using a
The ‘second record’ may be a second bite reg- quick setting plaster applied with a brush. The
istration in a different material; for example if cast can then be mounted in the laboratory, and
an ‘easy’ material like an elastomer has been used, in conjunction with the ‘normal’ oppos-
used first, it may be wise to use a harder mater- ing model.
ial (in both senses) such as acrylic resin or hard Alternatively and probably more easily, the
wax. Alternatively the second record may be a patient is asked not only to bite together in cen-
two dimensional one, such as occlusal sketch- tric occlusion (Fig. 14a and b) but also to go
ing (Figure 13a–d). into excursive movements (Fig. 14c). A pattern
The process by which these small corrections acrylic (eg Duralay)17 can be built up on a
are made to the working models or ‘model preparation, and then the patient carves out a
grooming’ is discussed under the design stage pathway that the opposing tooth has taken rela-
of the EDEC principle. tive to the prepared tooth (Fig. 14d). This
record (Fig. 15a) can thus be mounted on to the
Functionally generated pathway working model at the laboratory and a cast is
The great advantage of this technique is that it produced of the movements of the opposing
produces a hard record of both the opposing teeth (Fig. 15b and c).18
static and dynamic occlusions in only three A functionally generated pathway indicates
stages, two of which are carried out in the not only where the cusp tips of the opposing
mouth. There is, therefore, much less room for teeth are in centric occlusion (Fig. 15d) but also
error. The construction of a functionally gener- where they move relative to the proposed
ated pathway is often considered to be very dif- crown (Fig. 15e). This is a static record of the
ficult and a ‘special’ procedure in much the patient’s dynamic movement.
same way as the use of a facebow or rubber
dam. In reality and in common with these other Dynamic occlusion bite registrations
techniques it becomes, with practice, simple, These are used to anticipate the movements of
logical and a time saver. the opposing teeth during excursive movements
Technique: A soft, plastic material (eg tacky of the mandible by enabling the condylar angle
wax) is applied to the teeth, and the patient is to be set in the articulator to the value compara-
asked to perform a lateral excursive movement ble with the patient’s TMJ (Figs 16 and 17).

Fig. 14a Patient in centric occlusion Fig. 14b Wax record of centric occlusion

Fig. 14c Patient goes into right lateral excursion Fig. 14d Duralay recording the pathway of the
LR 5 (45) relative to upper premolars during
right lateral excursion

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occlusion

Fig. 15a Set Duralay record of movement of Fig. 15b Twin stage articulator
LR5 (45) relative to upper premolars

Fig. 15c The Duralay record is used to cast an Fig. 15 d Centric occlusion (static occlusion)
opposing model opposing the inlay preparation of UR4 (14)

of the preparation and the opposing teeth

(Fig. 19).
If, because of clinical considerations (eg
nearness of the pulp) the clinician suspects that
the technician may not have sufficient room,
for say an adequate thickness of porcelain in a
metal ceramic crown, then it is much better to
give the technician permission to reduce the
height of the opposing tooth than to risk a high
crown. It is essential in this situation, to advise
the patient at the preparation appointment that
Fig. 15e The movement pathway (dynamic adjustment to the opposing tooth may be nec-
occlusion) of LR5 (45) cast in stone
essary next time, giving reasons. Alternatively,
after discussions between dentist and techni-
These records can be avoided, together with cian, it may be decided that the best course of
their inherent difficulties caused by the com- action would be to further reduce the height of
pressibility of even the hardest waxes, by the preparation. In this circumstance this can
either setting the condylar angle to a value be done simply by the use of a coloured separa-
that allows some cuspal morphology in the tor medium on the die, or very accurately by
restoration (say 25 degrees) or by setting the the use of a transfer coping with an open top
condylar angles by simple observation of the made to fit the adjusted height of the prepara-
space or lack of it between the patient’s molars tion (Figs 20a,b).
on the non working side (Figure 18a–e).
Model grooming: common sense or heresy?
Design Model grooming is the title given to the process
Clinically the cavity preparation is occlusally of adjusting the models so that they more accu-
designed in exactly the same way as for a rately reflect the occlusal contacts that the
direct restoration. The fundamental differ- patient has in their real dentition. Implicit in
ences are that firstly the technician is going to the use of the word ‘grooming’ is understand-
make the restoration and secondly that, ing that these are small not gross adjustments to
dependent on the material to be used, there the occlusal surfaces of the plaster models.
will be certain requirements especially with The critics of model grooming have two objec-
regard to sufficient clearance between the top tions, namely that it should not be necessary and

374 BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001

 PRACTICE
occlusion
that as soon as the technician or dentist scratches may be the only option; it will be inconvenient
those models, they are not a completely accurate to the technician, clinician and patient. How- There is a world
representation of patient’s teeth. ever, it will take less time than having to remake
the restoration.
of difference
Objection No. 1: It should not be necessary. If the error is small then model grooming is between
This objection is quite correct; if the impres- a good option. However, to deliberately deciding to
sion, casting and mounted processes have been ignore the inaccuracy is not a sin; it is simply ignore something
performed entirely without any error, then the an admission that the restoration delivered by
models will exactly duplicate the patient’s teeth the laboratory is not going to be as accurate as
and being
and the occlusal contacts that the teeth make. it could be. Some of the predictability, there- ignorant of it
Whereas everybody involved in this process of fore, has gone, so the expectation of adjust-
anatomical information transfer should strive ment at the fit stage has increased. In the ‘real
for this perfect replication, it is the authors’ world’, clinicians are constantly having to
view that nobody achieves this high goal every make compromises; in fact, the skill of a clini-
time. So it follows that whereas model groom- cian might be judged by their ability to choose
ing should not be necessary, model checking is and manage compromise.
always necessary. This means that, before the The clinician who decides to ignore an error
models and the relationship between them can at the verification stage, has made a conscious
be accepted as accurate then some process of decision to reduce the level of predictable suc-
verification should be employed (stage 4, Fig. cess and is committed to making the adjust-
21). This could even involve recalling the ments to the occlusal surface of the restoration
patient, but much more conveniently, some at the fit stage. The clinician who is ignorant of
form of second ‘check bite’ can be used. This an error is in uncharted waters and may not
may be either two or three dimensional as even care whether he gets the patient safely into
already described. port. It is emphasised that this model verifica-
If at this verification an error is detected, then tion stage only involves providing the techni-
the clinician has three choices: do all or part of cian with a second occlusal record; this can be a
the process again, engage in model grooming, two dimensional record (eg occlusal sketch).
or proceed with fabrication of the restoration
having decided to ignore the error. Objection No. 2: If models are ‘groomed’, then they
Which option is chosen should depend the are not accurate. Model grooming
circumstances of the case; the first and last have This is also true, but if the models are not accu-
definite drawbacks. Which is best depends rate, the process of grooming is designed to • Model grooming
upon many factors including the size of the reduce the inaccuracy. As far as the design of the shouldn’t be
error. If the error is gross, repeating the process occlusal surfaces of a laboratory-made restora-
necessary...
• Model verifica-
tion is always
necessary...
• Model grooming
makes sense

Fig. 16a Wax record is correctly seated... Fig. 16b ...indicating that the condylar angle is 45o
(scale FH) Frankfurt Horizontal (KaVo Articulator)

Fig. 17a Wax is incorrectly seated… Fig. 17b …because condylar angle is wrong

BRITISH DENTAL JOURNAL, VOLUME 191, NO. 7, OCTOBER 13 2001 377

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occlusion

Fig. 18a Gap between patient’s back teeth,

during a right lateral excursion

Fig. 18b Condylar angle is adjusted until... Fig. 18c ...gap on the NWS is the same as in the
mouth (see Fig. 18a)

Fig. 18d Too steep a condylar angle... Fig. 18e ...created too big a gap

tion are concerned the only parts of the models

that matter are the occlusal surfaces of the other
teeth. In fact the only parts that really matter are
the occlusal contacts that those teeth make in
static and dynamic occlusion. Anybody who
doubts this could try the experiment of taking
some totally accurate models and drilling holes
through the teeth to make them look like
Emmental cheese but avoiding the occlusal sur-
faces. The models would no longer be an accu-
rate three dimensional representation of the
patient’s teeth but you could still make an accu-
rate restoration on them: only the occlusal sur-
Fig. 19 Photograph of flexible thickness gauge
faces matter.

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occlusion

Fig. 20a Transfer coping on die after technician Fig. 20b Transfer coping ready to use in the
has reduced the height of the core mouth prior to fit of crown

Fig. 21 The stages before starting laboratory

fabrication of the restoration

1 2 3
Impression making Model casting Model mounting

5 4
Proceed with Model Technician’s
laboratory fabrication grooming verification of
of restoration (if necessary) occlusion of models
against occlusal sketch

Model grooming adjusts the occlusal surfaces

of the models so that they make the same con-
tacts as the patient’s teeth do. It is part of the
‘(relevant) anatomy replication’ process.

Execute: From an occlusal point of view one of

the most significant considerations is the provi-
sion of a temporary restoration which dupli-
cates the patient’s occlusion and is going to
maintain it for the duration of the laboratory
phase. For this the temporary restoration
should: be a good fit, so that it is not going to
Fig. 22a Prepared tooth with occlusal marks on
move on the tooth; provide the correct occlu- adjacent teeth
sion, so that the prepared tooth maintains its
relationships; be in the same spatial relationship
with adjacent and opposing teeth. By far the eas-
iest way of achieving these aims is to make a cus-
tom temporary crown. With a little preparation,
custom temporary crowns can be made quite
quickly. Figures 22a–d show the preservation of
the patient’s pre-existing occlusion (Fig. 22a)
through the temporisation, laboratory and
cementation phases.
Check: The occlusion of the restoration
should be as ideal as possible (preferably not on
an incline) and should not prevent all the other
teeth from touching in exactly the same way as
they did before. This needs to be checked before Fig. 22b Temporary crown in place with occlusal
marks on adjacent teeth
and after cementation. Cementation is the last

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PRACTICE
occlusion

Fig. 22c Final crown on articulator with static Fig. 22d Final crown in mouth with static
occlusion marked occlusion marked

Fig. 23 Ideal occlusion

Ideal occlusion at Ideal occlusion at Ideal occlusion at

tooth level system level patient level

• Cusp tip to flat fossa contact • CO in CR • Within the adaptive capabilities

ie no incline contacts • Freedom in CO of the rest of the articulatory
• Occlusal forces directed down • No posterior interferences system (muscles and TMJ)
long axis of root

chance we have to get it wrong! If it is a posterior relationship which that occlusion dictates. In
restoration then it is unlikely to be ideal if there is that scenario, because inevitably the patient is
any occlusal contact during lateral or protrusive going to have a different jaw relationship after
excursion. Ask the patient to slide their teeth dental treatment, it is the responsibility of the
using one colour of articulating paper or foil, clinician to ensure that the new occlusion is
and then tap their teeth using a different colour. more, rather than less, ideal in relation to the
rest of the articulatory system.
The reorganised approach in simple As stated earlier, an occlusal contact that
restorative dentistry guides the mandible into the jaw relationship
The rationale and procedure for restoring a is known as a deflecting contact. Some restora-
patient to the ‘reorganised approach’ will be, tive authorities advise that teeth that are not
more appropriately, given in the section: ‘Good directly involved in the restoration (tooth to
Occlusal Practice in Advanced Restorative be restored and its opposing tooth) can be
Dentistry’. altered to improve the occlusion, within the
In that section, we will be considering the ‘conformative approach’. We agree that is an
treatment of a patient when the treatment of attractive idea to try to improve the occlusion
their dental needs means that it will be impossi- of the surrounding teeth, by say removing the
ble to keep the same occlusion and so the jaw incline contacts. The difficulty is to be sure
that one is not changing deflecting contacts,
because if they are being altered then jaw rela-
tionships are being changed. This, then, is not
the conformative approach. The objective is
now the provision of an ideal occlusion (Fig.
23). For this to be successfully achieved,
detailed planning and usually multiple
changes in occlusal contacts are needed.
The important limitation of the conforma-
tive approach is that none of the teeth to be
prepared or adjusted can be deflecting con-
tacts, because if they are then as a conse-
quence of changing them the jaw relationship
will probably be changed. If modification to
Fig. 24a New restorations Fig. 24b After adjustment of new these deflecting contact teeth is envisaged,
are too high restorations, occlusion of adjacent this then becomes a reorganised approach no
teeth returns
matter how few teeth are being restored. This,

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 PRACTICE
occlusion
as will be seen in the next section, is a much nity to ‘improve’ the occlusal contact against 1 Beyron H. Optimal occlusion. Dent
Clin Amer 1969; 13: 537-554.
more complex procedure. the distal part of UL5 (25). This would involve 2 Celenza F V, Nasedkin J N. Occlusion.
It can thus be a difficult decision as to ‘when changing it from contacts on the cuspal inclines The state of the art. 1978 Chicago:
to stop’ adjustment of the teeth not directly either side of the marginal ridge to a more Quintessence Publishing Co.
3 Dawson P E. Evaluation, diagnosis,
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out under the conformative approach. ridge. Although a case could be made for doing Louis: C V Mosby, 1989.
The new restorations at UL6 and UL7 (26, so, there is no Figure 24c showing this com- 4 Gross M D, Mathews J D. Occlusion
27) were being provided within the ‘conforma- pleted because the clinician decided against it, in restorative dentistry. London:
Churchill Livingstone, 1982.
tive approach’. During the finishing, the preferring to leave the occlusal contact at the 5 Howatt A P, Capp N J, Barrett N V J.
occlusal contacts of these restorations are too UL5 (25) exactly as it was before treatment of A colour atlas of occlusion and
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UL4 and UL5 are not evident. After this has stronger case for adjustment if there had been a Publishing Ltd,1991.
6 Lucia V O. Modern gnathological
been achieved (Fig. 24b), there is an opportu- single incline contact. concepts. St Louis: C V Mosby Co,
1961.
7 Mann A W, Pankey L D. Oral
rehabilitation. Part 1. Use of the P-M
instrument in treatment planning
and restoring the lower posterior
Guidelines of good occlusal practice teeth. J Prosthet Dent 1960; 10: 135-
142.
8 Pameijet J H N. Periodontal and
1 The examination of the patient involves the teeth, periodontal tissues and occlusal factors in crowns and bridge
articulatory system. prosthetics. Dental Centre
2 There is no such thing as an intrinsically bad occlusal contact, only an Postgraduate Courses, 1985.
9 Schluger S, Yuodelis T, Page R C.
intolerable number of times to parafunction on it. Periodontal disease — basic
3 The patient’s occlusion shoul be recorded, before any treatment is started. phenomena. Clinical management
and occlusal and restorative
4 Compare the patient’s occlusion against interrelationships. Philadelphia: Lea
the benchmark of ideal occlusion. and Febiger, 1977, pp 392-400.
5 A simple, two dimensional means of recording the patient's occlusion 10 Schuyler C H. The function and
importance of incisal guidance in
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6 The conformative approach is the safest way of ensuring that the 1963; 13: 1011-1029.
11 Stewart C E. Good occlusion for
occlusion of a restoration does not have potentially harmful natural teeth. J Prosthet Dent 1964;
consequences. 14: 716-724.
12 Stuart C E, Stallard H. Principles
7 Ensuring that the occlusion conforms (to the patient’s involved in restoring occlusion to
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execution and checking (EDEC) 10: 304-313.
13 Celenza F V, Litvak H. Occlusal
management in conservative
dentistry. J Prosthet Dent 1976; 36:
164-170.
14 Foster L V. Clinical aspects of
occlusion:1. Occlusal terminology
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Update 1992; 19: 345-348.
15 Murray M C, Smith P W, Watts D C,
Wilson N F H. Occlusal registration:
science or art? Int Dent J 1999; 49:
41-46.
16 Wassell R W, Ibbetson R J. The
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reinforced stock trays. J Prosthet Dent
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