O CO

CCL C
U L
S U
I OS N
I O INN R E S T O R A T I V E D E N T I S T R Y

Conformative, Re-organized or
Unorganized?
STEPHEN DAVIES

often involved in restorative treatment.

Abstract: ‘Occlusion’ is presented within the concept of the articulatory system, and This therefore has the potential to
guidance is given on how to avoid unplanned occlusal changes. When and how to change the patient’s occlusion.
examine the occlusion is explained, and this is expanded to cover the needs of restoring
Often, the examination of the
a patient to the ‘re-organized approach’. In addition, the merits of the different types of
occlusion is left until after the treatment
occlusal records are discussed.
In order to avoid a lengthy explanation of the terminology in the text, a glossary is finished; when we ‘check the bite’.
is appended; any term that is defined in the glossary is marked by an *. This ‘final check’ will only show two
extremes: a restoration that is ‘too high’
Dent Update 2004; 31: 334–345 or one that has no occlusal contact at
all. If no examination of the pre-
Clinical Relevance: Most restorative procedures involve the occlusal surfaces of treatment occlusion was made, the post
teeth. Because dentists wish to avoid unplanned changes in the occlusion, it is
important that the occlusion is considered before, during and after treatment. This
treatment check alone could not confirm
paper aims to help dentists develop their own philosophy of avoiding the ‘unorganized that the new restoration added to, but
approach’ by providing techniques which follow a logical sequence. did not change, the patient’s overall
occlusion. If we do not know exactly
what the pre-treatment occlusion was, to
say that we have ‘checked that it is the
same’ may therefore be meaningless.

M ost restorative dentistry has the

potential to cause a change in the
patient’s occlusion*. Dentists should
be made when they are of practical help.
The aim of this paper is to explore some
of the decisions that practising dentists
How to Examine the Occlusion
avoid unplanned occlusal change, should make when they provide At its simplest, the examination of the
because it may lead to an iatrogenic restorations. It is a mistake to think that occlusion is performed in three steps:
problem or a restorative failure. an understanding of occlusion
Accordingly, most dentists develop a complicates common clinical procedures. l First, the teeth need to be dry and
strategy for planning their treatments This paper is an opportunity to describe one of the easiest ways of doing
within principles of ‘good occlusal some of the protocols and techniques this is to ask the patient to close
practice’. that have made life easier for the author, onto folded tissue paper held by
Despite the many excellent textbooks who is a general practitioner. For the Miller forceps* (Figure 1).
on occlusion,1-5 practitioners may feel dentist who is concerned about ‘getting
that the subject is daunting and even the bite right’, the process of thinking
confusing. Although an understanding about the occlusion before treatment
of ‘occlusion’ within the context of the makes clinical practice easier. More
articulatory system6 and of the factors importantly, it will also improve the
that influence mandibular movements7 outcome for the patient.
would be useful, it is not essential to the
reader of this paper. Reference to the
basic principles of occlusion8,9 will only EXAMINATION

Stephen Davies, BDS, MDSc, DGDP(UK), Figure 1. Folded tissue paper held in Miller
When to Examine? forceps to dry teeth prior to marking the
Dental Surgeon, Stockport, Cheshire.
The occlusal surfaces of the teeth are occlusion.

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the majority of restorative procedures. is the first stage of that approach.

There are two reasons why it is an
essential examination to carry out before The initial examination also helps with
every restorative procedure: the design of a restoration. For instance,
if a tooth to be filled has a good strong
l It enables the operator to make the ‘centric stop’*, it would be better if that
most important decision of all: can centric stop could be avoided in the
the restorations be provided within cavity preparation. If the occlusion is
the ‘conformative approach’?* That not marked, the design of the cavity
Figure 2. Red articulating paper held in Miller is to say: are there sufficient good cannot take this into consideration.
forceps to mark the dynamic occlusion. occlusal contacts on teeth that are Similarly, if the dynamic occlusion is
not going to be restored to ensure marked onto anterior teeth, then the
that the patient will occlude into the design of restoration can allow the
same jaw relationship? If this is the conformative approach to be used in the
case, and assuming that the patient provision of that restoration. (Figure 4a–
does not have a temporomandibular c).
disorder, the conformative approach This sequence is described by the
is the obvious decision. There E.D.E.C. principle:11
would be no reason to change the
occlusion. If there are not sufficient E– Examine the pre-operative
occlusal contacts on the adjacent occlusion;
Figure 3. Blue articulating paper held in Miller teeth, then, as soon as the occlusal D– Design the restoration;
forceps to mark the static occlusion.
surfaces are removed or altered on E– Execute that design;
the prepared teeth, it is already too C– Check the restoration adds to,
late to use the conformative but does not change, the
l It is best next to mark-up the approach! The patient’s pre- occlusion between the other
patient’s dynamic occlusion*, by treatment bite has been lost, and so teeth (i.e. the conformative
asking the patient to slide his/her the conformative approach is no approach).
teeth from side-to-side whilst longer an option. A good example of
holding articulating paper (Bausch this might be a posterior bridge However, if the pre-treatment occlusal
Articulating Paper – Red, Blue: 009 preparation without a standing examination indicates that a sufficient
010 – Bausch Articulating Papers tooth distal to it. number of the occlusal contacts are
Inc, Nashau, NH06062, USA) l If the conformative approach is going to be destroyed or changed, it
between them (Figure 2). Ideally, the going to be used, this examination may be impossible to keep the same
articulating paper©* will be no
more than 40 microns in thickness.
Thicker paper will give false marks.
a b
l The final stage requires changing
the colour of the paper and asking
the patient to tap his/her teeth
together into a normal bite (Figure
3). This will mark the static
occlusion*. This ‘dry-dynamic-
static’ order will produce a clear
representation of the occlusion. It is
much more reliable than the ‘static-
dynamic’ examination order, which
c
tends to rub off the static occlusion
marks during the excursive Figure 4. (a) Dynamic occlusion marked
movements. and prep done ‘E.D.E.’ of E.D.E.C.
(b) Adhesive bridge on models with dynamic
occlusion marked. (c) Adhesive bridge in
Examination of the contacts that the mouth with dynamic occlusion marked ‘C’ of
teeth make in the patient’s habitual bite* E.D.E.C.).
(synonym: centric occlusion*,
intercuspation position*) is quick and
reliable,10 and it is all that is needed for

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occlusion (the ‘unorganized approach’)

The Temporomandibular Joints is nil. The patient will adapt to it, maybe
The hinges of the system after a period of mild discomfort. Teeth
can move or wear in response to
occlusal load and this valuable
compensation can reduce occlusal
trauma. It is important to remember that
this adaptation is not possible in an
The Muscles implant. If, however, compensation does
The Occlusion
The motors of the The contacts of the not occur, then the resultant trauma may
system system have unwanted sequelae. There may be
damage to the dental and periodontal
Figure 5. The articulatory system. tissues, or the articulatory system may
be affected. The adaptive capability of
the TMJs, muscles, and periodontal
membrane, together with the strength of
occlusion; i.e. we cannot conform. In patient who is going to be restored to our restorations, are tested by a
this situation, the occlusion is going to the re-organized approach and one to be different and less than ideal occlusion.
be changed. If these changes are made restored to the conformative approach Damage is probably more likely if the
to a specific plan that: can be summed up in two words: ‘jaw restorations have occlusal surfaces in a
relationship’*. hardwearing material such as porcelain,
l Records the starting point (pre- In a dentate patient, the overriding or if the teeth are joined together by
treatment occlusion); guidance that determines the bridgework. In the author’s experience, a
l Defines the end point (final relationship between the mandible and significant number of
restoration); the maxilla is the occlusion of the teeth; Temporomandibular Disorder (TMD)
l Plans all the stages necessary to not the TMJs and associated muscles. If patients consider a course of treatment
take the patient successfully from the occlusal surfaces of a sufficient involving extensive restorations to be
the pre-treatment occlusion to the number of teeth are to be destroyed in the precipitating factor to their joint
occlusal prescription of the final the restorative procedure, then the problems.
treatment (treatment plan); patient’s original jaw relationship will Therefore, if dentists are going to
potentially be changed because, when change occlusions, it is safer to make
The treatment can justifiably be the occlusal surfaces of sufficient teeth them more ideal. The solution to not
described as having been carried out to are altered, so is the habitual jaw being able to use the ‘conformative
the ‘re-organized approach’’*. The relationship. approach’ is to follow the ‘re-organized
objective of the ‘re-organized approach’ It is possible that the patient’s approach’. The re-organized approach is
is to provide an occlusion that is more articulatory system will adapt to a new a system by which dentists can provide
ideal*. More ideal for the teeth, the occlusion and jaw relationship. a specific occlusal prescription that is
periodontal tissues (or osseointegrated However, as the dental defence much less likely to cause a disturbance
bone around an implant), and the organizations will testify, it is the case to the joints and muscles. It is used
tissues of the articulatory system (TMJs that this adaptation does not always when a significant change to the
and mandibular muscles). occur. The safest way of managing a patient’s existing occlusion is proposed.
If a patient’s occlusion is changed change in a patient’s occlusion, and
without following these criteria, it is an consequentially his/her jaw relationship,
‘unorganized approach’*. is to make the new occlusion more ideal. RESTORING A PATIENT TO
For, although the pre-treatment THE RE-ORGANIZED
occlusion was probably not an ideal APPROACH
THE EXAMINATION occlusion* either, the patient had
PROCEDURE PRIOR TO developed a longstanding tolerance of
RESTORING A PATIENT TO it. The danger of providing a new ‘less Examination
THE RE-ORGANIZED than ideal’ occlusion, in an The first step of a restoration to the re-
APPROACH ‘unorganized’ course of restorative organized approach is an examination of
The examination required to restore a treatment is that it is ‘revolution not all the elements of the articulatory
patient to the reorganized approach is evolution’. system (Figure 5).
more complex than that needed for the As stated, the most likely The first reason for carrying out this
conformative approach. The essential consequence of a patient being examination is to diagnose any pre-
difference between the examination of a provided with a new, and less than ideal existing TMD*. A TMD may be

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relationship if the patient feels the

a b same premature contact each time.
This is much easier than trying to
mark the premature contact with
articulating paper each time. It is
possible because of the
proprioceptive receptors in the
periodontal membrane. The patient’s
proprioception is the most sensitive
Figure 6. (a) and (b) Use of Duralay© to
piece of equipment that can be used
record an inter-arch record or ‘bite’. to confirm the consistency of centric
relation; if it is not a consistent
position, then it is not CR. It is worth
considering that this test does not
exacerbated by the treatment process patient into centric relation. The first or work if the teeth are anaesthetized or
and so may influence treatment premature contact is noted in this jaw the dentition is partially or
planning. Secondly, this examination has relationship2 (static occlusion), as are completely implant-supported.
the aim of determining the position of the contacts during mandibular
the centric relation* (CR) (retruded excursive movements (dynamic
contact position RCP), because CR is occlusion). Records
the starting point for the provision of an The ability to examine and record a There is a difference between an
ideal occlusion. patient’s centric relation is a examination and a record. Examining the
Examination of the TMJs12 and fundamental skill for a dentist whose occlusion is very nearly always
mandibular muscles13 is quick and patient cannot be restored to the necessary, whereas a record of that
simple. The TMJs should be examined conformative approach. It is difficult, if examination is necessary in order to
for sounds, tenderness to palpation and not impossible, to provide an ideal communicate or to refer back to the
range of motion. Three muscle groups occlusion without this first step. results of that examination.
are examined: the temporalis and The essential points of finding centric Therefore a record of the patient’s
masseter muscles are tested for relation are as follows: occlusion is essential if:
tenderness to palpation, whereas the
lateral pterygoid muscles are tested by l The patient should be relaxed in a l a technician is involved in the
the resisted movement test. supine position. treatment;
The examination of the patient’s static l The dentist, whilst holding the
and dynamic occlusion in and from patient’s mandible, can feel that the
centric occlusion (CO) (intercuspation lower jaw is loose and describes a
position ICP) is carried out in the same fairly perfect arch, i.e. the head of
manner as described for the the condyle is in the rotational
conformative approach. This is partly to phase of its movement. This means
confirm that the conformative approach that the mandible is in terminal
cannot be followed. Sometimes during hinge axis*.
this examination it will become apparent l Because centric relation is ‘the only
that, by preparing alternate teeth, the centric that is reproducible with or
conformative approach is possible. But without teeth present’,14 the best
the essential difference for an confirmation that centric relation Figure 7. Use of Hard Beauty Wax (Moyco,
examination prior to using the re- has been found is that the same USA) to record an inter-arch record or ‘bite’.
organized approach is the determination position is found at different times
of centric relation, because this is the and by different operators. Centric
starting point of the new restoration. In relation is a consistent position,
order to examine the occlusion in CR, which is one reason why it is so
the patient is not simply asked to close useful in the re-organized approach.
his/her teeth together. This would put l In order to confirm that it is the same
the mandible into the jaw relationship position, the procedure should be
determined by his/her habitual bite repeated several times and the
(centric occlusion). The first step of the patient is asked whether the same
occlusal examination for the re- teeth are touching. The clinician can
organized approach is to guide the be sure that it is the same jaw Figure 8. Schottlander Occlusal Sketch.

338 Dental Update – July/August 2004

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usually take the form of some type of occlusal examination can be recorded. It
bite registration and/or mounted models. can be configured both for the
The accuracy of these is very technique clinician’s and the technician’s
sensitive and there is evidence that they perspective. It is based upon the theory
may not be reliable.15,16 The author that dentists and dental technicians will
would wish to bring to the reader’s place a dot in the same place on an
attention the technique of Occlusal idealized diagram of a tooth to represent
Sketching© (Stephen Davies/the the mark left by articulating paper on a
Victoria University of Manchester 2002 tooth or model of a tooth.
– all rights reserved) which is a simple The Schottlander Occlusal Sketch©
Figure 9. Schottlander Occlusal Sketch being
used to check the accuracy of the occlusion and accurate means of communicating (Schottlander Ltd, Letchworth Garden
marked on articulated models, in the dental occlusal information.17,18 City, Herts) was initially configured for
laboratory. The occlusal record can be used as surgery use, i.e. the upper arch is
the only bite record or as a check of a viewed as a mirror image and the lower
conventional bite registration. by direct vision from above (Figure 8);
l a dentist is trying to conform either Additionally, it may be used as a means this facilitates the recording of the dots
with the patient’s pre-existing of keeping an archive of the occlusion of the static occlusion (in blue) and lines
occlusion or with the new occlusal for medico-legal purposes. The Occlusal of the dynamic occlusion (in red). This
prescription. Sketch© consists of a diagrammatic takes only a few minutes and is a
representation of idealized dental permanent record of the patient’s
Occlusal records (Figures 6a, b and 7) arches, on which the results of an occlusion at that time. It will either be

a c

d e f

Figure 10. (a) Mirror image of inlay preparation of 6|. (b) Articulated working models for construction of indirect composite inlay at 6|, ready to be
verified by occlusal sketch. (c) Close up of occlusal sketch, showing the record of the occlusal contacts of the teeth adjacent to 6| (d) Finished inlay at 6|
on model, showing the adjacent occlusal contacts. (e) Mirror image of finished inlay at 6| in mouth, showing the adjacent occlusal contacts. (f) Close up
of occlusal sketch, showing the record of the occlusal contacts of the teeth adjacent to 6|.

Dental Update – July/August 2004 339

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The re-organized approach is a

sequential process with a clearly defined
starting and end point.

Stage 1: Try to Avoid the Re-

organized Approach!

Reason
Figure 11. Marking of the patient’s occlusal The re-organized approach is much more Figure 12. Lower stabilization splint.
contacts during manipulation to centric relation. difficult and the consequences of failure
are more severe than in the conformative
approach
used as a record, against which reference
can be made during a patient’s treatment, Objective
or as a means of communicating To find a way by which the conformative
information that will enable the technician approach can be used, even in multiple
to check the accuracy of the mounting of restoration cases.
working models prior to the construction
of an indirect restoration. In the case of Technique
the latter, the sketch is sent with the Even in large cases, it is quite often Figure 13. Anterior Bite Plane or ‘Lucia Jig’.
impressions and any other records to the possible that, by using very careful
laboratory. In the laboratory, the sketch is records and splitting the restoration into
reconfigured for the technician to use stages, you can conform to the pre- To find the closing point of terminal
next to the mounted models in order to existing occlusion. The use of pattern hinge axis of the mandible.
check the accuracy of the occlusion as acrylic (Duralay©, Reliance Dental Mfg
marked on those models (Figure 9). If Co., Illinois, USA or GC Pattern Resin©, Technique
there is a difference between the GC UK, Newport Pagnell, UK) bite There are three levels of complexity:
occlusion as marked on the models and registrations in the alternative l In many cases, a careful
the sketch, then a few minor adjustments preparation technique19 are useful in this manipulation (Figure 11) of the
to the models may produce the same respect. patient’s mandible will be sufficient
occlusion as the occlusal sketch shows, to find centric relation.20 First, the
being that of the patient. This minor operator must feel that a
alteration to the models is known as Stage 2: To Find Centric neuromuscular release* has been
‘model grooming’.11 Figures 10 a–e show Relation achieved. The mandible should feel
the use of an occlusal sketch to confirm relaxed during a smooth arching
that the conformative approach has been Reason guided motion. Secondly, the
successfully followed. The inlay in 6| Centric relation is the starting point of patient must consistently feel
contributed to, but did not change, the any re-organized restoration, because: exactly the same premature contact
patient’s overall occlusion. in CR. This should be tested at
l Centric relation ‘is the only different times and, if there is
“centric” that is reproducible with uncertainty, by different operators.
RESTORATION TO THE RE- or without teeth present, and recent l In a significant number of cases, a
ORGANIZED APPROACH research has confirmed the great period of stabilization splint*
There is a sequence to this procedure. clinical significance of this position therapy (Figure 12) will be needed
Not every stage, as described below, is as the key to the solution of to be sure that the muscles have
necessary for every case; but it is occlusal problems. It is the only relaxed enough for the true position
essential that the objective of each reference position that assures of centric relation to have been
stage be considered. How that objective simultaneous harmonious alignment established. This extra stage is
is achieved is the clinician’s decision; it of both TMJs’.14 necessary in those patients for
will vary with the complexity of the case l Centric occlusion occurring in whom a degree of neuromuscular
and the experience of the operator. centric relation is the definition of release is possible, but it is
Irrespective of how it has been an ideal static occlusion* shortlived and so it is very difficult
achieved, a stage should not be started to maintain neuromuscular release
until the objective of the previous stage for long enough for the recording
has been realized. Objective procedure to be completed.

340 Dental Update – July/August 2004

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The overall objective of our ‘re-organized by careful and sequential removal of

treatment plan’ is to provide restorations the premature contacts in centric
in an occlusion that, although different relation until all of the posterior
from the patient’s pre-operative one, is teeth touch simultaneously in that
the most likely to be tolerated by the jaw position. It is done over at least
patient, i.e. an ideal occlusion*. The two visits and without local
objective of this stage is to establish one anaesthetic. Equilibration is not an
of the three important principles of easy procedure, as demonstrated by
‘idealized occlusion’: the coincidence of the fact that most dentists would
Figure 14. An example of a lower bridge that centric occlusion in centric relation or much prefer to prepare some teeth
has not been made to an ideal occlusion, which centric relation occlusion (CRO). The for crown and bridgework than do an
would have been the ‘re-organized approach’. other two principles (the establishment of equilibration! It is, however, a
This occlusion was also not the same as the
patient had pre-operatively, which would have a dynamic occlusion that is free from necessary skill for the dentist who
been the ‘conformative approach’. This patient, posterior interferences and cusp to fossa wishes to restore a case to the re-
who developed a TMD almost immediately after contacts between opposing teeth) are less organized approach.
this bridge was fitted was probably restored to achievable at this stage and so have to be
the ‘unorganized approach’! left until the provisional or definitive
restorations. Stage 4: The Diagnostic Wax-Up

Consequently, although the position Technique Reason

of centric relation is reliable enough There are two phases to this procedure. Once the patient is equilibrated to an
to make a splint, it is not truly The first is essential, in all but the occlusion in centric relation, the most
consistent because of the muscle simplest of cases, even in the hands of significant part of the ‘reorganization’ has
tension. Therefore it would be the most experienced of operators. been achieved; that is the establishment
dangerous to use it as the starting l Mock equilibration on accurately of an occlusion in the new jaw
point of the restoration of the patient mounted models. The first reason for relationship. Everything done now must
to a new occlusion. The splint will this stage is that it is undoubtedly ‘conform’ to that jaw relationship. So
need to be reviewed over a period of the best way of learning how to really the ‘re-organized approach’ is the
time, during which time it will require equilibrate. Secondly, it shows the conformative approach with a few extra
adjustment. Finally, a consistent and end point before commencing stages! However, during subsequent
muscle-free jaw relation will be treatment. In clinical practice, there stages and within the restriction of not
established. can be few things worse than moving away from the CRO, the
l In some cases, a stabilization splint starting to equilibrate a patient’s opportunity exists to improve the
cannot even be made because the teeth, only to realize, halfway occlusion further by providing:
mandible is so tight that the guiding through the procedure, that the
of the patient to centric relation is objective of providing an occlusion l Ideal anterior guidance (no posterior
made impossible. In these cases, an in centric relation is unachievable! A interferences);
anterior bite plane or ‘Lucia jig’ mock equilibration should answer l Enhanced tooth morphology;
(Figure 13) should be considered as the question whether provisional l Cusp to fossa occlusal contacts (no
an aid to trying to find CR.21 restorations are going to be incline contacts);
necessary in order to provide a l Better aesthetics.
patient with a CRO. Thirdly, it will
Stage 3: Equilibration of enable your patient to see the This does not happen by accident, it
Standing Teeth clinical objectives more clearly. This needs designing. A diagnostic wax-up is
facilitates their informed consent and the design stage of the mouth
Reason gives them confidence in your restoration.
By providing the patient with a centric approach to treatment planning.
relation occlusion in his/her existing Both are essential before Objective
dentition, a ‘reference point’ is encountering the difficulties that are The most important reason for designing
established for all of the future bound to lie ahead in the execution the future restorations in wax and on a
restorative work. If this stage is not done, of that plan. semi-adjustable articulator is that it
it becomes less likely that the definitive Finally, a mock equilibration gives a allows the two operators (technician and
restorations will occlude in the ideal jaw guide to the nature and sequence of clinician) to determine how the
relationship of CR. adjustments needed. It is a valuable restorations are going to interact with
rehearsal. opposing teeth, both in the static and
Objective l The equilibration of the teeth is done dynamic occlusion. Although some will

342 Dental Update – July/August 2004

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see this as an unnecessary stage it will, in Stage 5: Preparation of Teeth

most cases, save time. It is certainly and Construction of Provisional
preferable to performing multiple and Restorations
demoralizing adjustments at the fit stage.
Sometimes our ‘dental’ brain tells us Reason
that some crown and bridgework The function of the provisional
doesn’t look right. Figure 14 shows restorations is not only to protect the
such a case. The design stage in this prepared teeth and maintain gingival
case was missing. When it doesn’t health, but also to maintain the occlusion
look right, it usually doesn’t function Figure 15. Custom anterior bite table being
whilst the crowns are being made.
formed by simulating a left lateral mandibular
well from an occlusal point of view excursion against a cast of the upper anterior
either. ‘Form follows function’ in Objective provisional restorations.
dentistry. The unnatural looking One of the objectives for the clinician, at
occlusal plane, as seen in Figure 14, this stage, is to prepare the teeth in such
resulted in a significant non-working a way to allow the technician to construct
interference. And, although some the crowns to the agreed occlusal design.
patients may have adapted to it, the In particular, the preparations should
patient in this case didn’t. In fact, she have appropriate occlusal reduction. It is
developed a severe pain on the right important that the clinician keeps the final
side of her face within one month of occlusal prescription in mind during the
the fitting of the lower bridge. It would preparing of the teeth, otherwise the
have been much better if the design of technician may not be able to create the
the restoration of the right side of her desired result. Figure 16. Close up view of custom anterior
dentition had been ‘worked up’ in a bite table.
diagnostic wax-up. Technique
A transparent acetate template that has
Technique been made on a model of the diagnostic
At its simplest, all dentists and wax-up during the preparation of the
technicians can put some carving wax teeth is very useful, and almost justifies
(Ivory ‘Picowax’©, Skillbond Ltd, High the diagnostic wax-up stage by itself. It is
Wycombe, Bucks, UK) onto mounted not only used to form the temporary
models and carve some teeth that seem to crowns, but will help to gauge the
fit against the adjacent and opposing amount of tooth removal necessary. It
teeth. Although unsophisticated, this is can be either a vacuum-formed laboratory
still a valuable ‘design’ stage. made item, or can be formed on the model Figure 17. Custom anterior bite table guiding
At its most complex, there are a few at the chairside (Ellman Pressform Kit©, the upper working model through a simulated
‘masters’ who can do a diagnostic Ellman International UK Ltd, left lateral mandibular excursion.
carving using wax of different colours to Northampton, UK).
build up the detailed morphology of
each proposed restoration movements exactly. So final refinements
incrementally.22 Stage 6: Provisional to the new occlusion can only be made in
In addition, there is a largely ignored Restorations the patient’s mouth and this is best done
but very useful technique for on the provisional restorations, not the
establishing the ideal occlusal planes, Reason definite restorations.
called the Broadrick flag technique. This The fitting of provisional restorations In addition, the patient will have the
is based upon a concept developed by affords the clinician the opportunity to opportunity during a provisional
Monson in 1918, and has recently been refine the functional and aesthetic restoration phase to suggest
described again in the literature.23 aspects of the treatment. modifications to the appearance of any
Irrespective of the manner in which a The occlusion can be adjusted over a anterior crowns.
diagnostic wax-up is carried out, there period of time and the patient will have
are advantages that will help the patient, the opportunity to influence the Technique
technician and dentist to visualize the appearance of anterior crowns or Provisional restorations are usually made
final result. By designing the occlusal bridges. The reality is that, although the in heat-cured acrylic or composite, at the
planes at this stage, the final use of an articulator is essential in dental laboratory. They are made from
restorations will both look and function complex cases, no articulator is able to the same records as would be needed for
better. duplicate the patient’s mandibular the definitive crown or bridgework, and

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to the same high standard of marginal definitive restorations. The anterior phase becomes the foundation for the next
adaptation. They are cemented with a guidance table of a semi-adjustable stage. Success will be the result as long as
temporary cement to facilitate easy articulator is loaded with an accurate these phases are predetermined and the
removal. Over a number of review acrylic, such as pattern resin (Duralay© discipline is maintained of not starting a
appointments, the occluding surfaces of or GC©). The guidance pin of the phase until the aims of the previous one
the restorations are adjusted by articulator is transcribed through this have been achieved.
equilibration or addition. The objective is material whilst it is setting. This is done Sometimes, for a particular phase of
to fulfil the criteria of an ideal occlusion, by moving the upper member of the treatment, specialist help may be needed.
which are: articulator through lateral and protrusive This may be available from a consultant
excursions, whilst keeping the lower in restorative dentistry or an experienced
l Cusp to fossa tooth contacts (an anterior teeth of the models in contact colleague. In my experience, this sort of
avoidance of incline contacts); with the palatal surfaces of the upper second opinion is well received by the
l Multiple and simultaneous posterior cast. In this way, the movement of the pin patient. Because the patient is already
tooth contacts in ‘centric relation’; through the material is determined by the aware of the complexity of his/her case,
l Guidance for lateral and protrusive palatal surfaces of the upper anterior he/she will be reassured by the referral
mandibular movements of the teeth. Thus, when the upper working for a second opinion. It will be seen as an
mandible that is at the front of the model is fitted into the articulator, the example of a careful approach. Equally,
arch, and so free from posterior ‘custom anterior guidance table’ will act because the experienced colleague to
interferences, especially on the non- as a template for the ideal palatal contour whom the referral is made will be acutely
working side.24 of the upper anterior crowns (Figures 15, aware of the difficulty of this type of
16, and 17). case, he/she will not undermine the
The final act of this phase of treatment patient’s confidence in your approach by
is to articulate study casts made from suggesting that a second opinion is
impressions of the mouth with the Stage 8: The Post-operative anything other than prudent.
provisional crowns in place. These Stabilization Splint Increasingly, the public expect and
models will guide the technician during should have the opportunity for this type
the construction of the definitive Reason of clinical governance.
restorations. In very large cases, especially in patients The number of stages of the re-
who have a history of bruxism, it is sound organized approach will vary from case to
practice to protect the new restorations case, depending on the complexity and
Stage 7: The Definitive immediately from the effects of operator experience, but the essential
Restorations parafunction. steps can be summarized as follows:

Technique Objective l Attend to the needs of individual

By the time this stage has been reached If the patient might need a splint in the teeth first (e.g. endodontics, core
the exact form of the restorations and the future, it is much better to make it now, as placement) but without changing the
jaw relationship in which those the foreseen last stage of the treatment bite;
restorations will occlude has been plan, rather than in response to a failure l Diagnose and maybe treat any
organized. The challenge for both of the of a restoration. temporomandibular disorder;
operators (clinician and technician) is to l Determine ‘centric relation’ (retruded
execute that prescription (Examine, Technique contact position); the starting point
Design, Execute, Check). In effect this It is easy to record the ideal jaw of the re-organized occlusion;
last stage of the ‘re-organized approach’ relationship, because CO and CR l Design and develop an ideal
is to ‘conform’; conform to the new coincide. A facebow will be helpful. occlusion by some or all of the
design that has been worked up in the following:
previous stages. The techniques A diagnostic wax-up;
employed, including an accurate bite THE RE-ORGANIZED Equilibration of the natural dentition;
registration, are the same as would be APPROACH: A SUMMARY Provision of provisional
used in the ‘conformative approach’. A complex case involving multiple restorations.
One particularly useful technique, if the crowns provided to a different jaw
restoration of the upper anterior teeth is relationship, and maybe to an increased These stages are to ‘full mouth
involved, is ‘custom anterior guidance’. vertical height, may seem impossibly restoration’ what the ‘try in’ is to
This enables the ideal anterior guidance daunting. complete denture construction.
that has been developed in the In reality, it is a series of phased
provisional restorations or equilibrated treatments; each has a clearly defined aim, l Copy that design in the definitive
dentition to be duplicated in the and the successful completion of each crowns.

344 Dental Update – July/August 2004

 O C C L U S I O N

CONCLUSIONS 2: A Clinical Guide to Temporomandibular Disorders. centric relation (CR) – 1.A position of the mandible to
London: BDJ Books, 1995, 1997. the maxilla with the disc in place, when the head of
The restoration of teeth almost always 13. Davies SJ, Gray RJM. A clinical approach to the condyle is in its most superior position against
involves the occlusal surfaces of teeth, temporomandibular disorders: Examination of the distal facing incline of the glenoid fossa (an
and so has the potential to change the the articulatory system: the muscles. Br Dent J uppermost and foremost). This definition is purely
occlusion and possibly the jaw 1994; 177: 25–28 or Chapter 3: A Clinical Guide of academic interest because there is no way of
to Temporomandibular Disorders. London: BDJ establishing the position of the head of the condyle
relationship of the patient. Books, 1995, 1997. in the glenoid fossa.
Pre-treatment examination of the 14. Ash MM, Ramfjord S. Occlusion. 4th edition. 2. A position of the mandible to the maxilla
occlusion will answer the question Philadelphia: Saunders, 1995; p.76. with the disc in place, when the mandible is in
whether the treatment can be carried out 15. Murray MC, Smith PW, Watts DC, Wilson NFH. terminal hinge axis (see below).
Occlusal registration: science or art? Int Dent J 3. A position of the mandible to the maxilla
to the ‘conformative approach’ which is 1999; 49: 41–46. with the disc in place, when the muscles that
always the treatment of choice. If the 16. Walls AWG, Wassell RW, Steele JG. A comparison support the mandible are at their most stable and
complexity of the case precludes this, a of two methods for locating the intercuspal least strained.This is more a concept than a
position (ICP) whilst mounting casts on an definition.
planned and carefully staged re-
articulator. J Oral Rehab 1991; 18: 43–48. (Author’s Note: Again the Glossary of Prosthetic
organized approach to changing the 17. Davies SJ, Gray RJM, Al-Ani MZ, Sloan P, Terms is not especially helpful as it gives several
patient’s occlusion and jaw relationship Worthington H. Inter- and Intra-operator definitions, some of which (to this reader) appear
is indicated. reliability of the recording of occlusal contacts to contradict each other.)
using the ‘occlusal sketch’ acetate technique. Br centric stop – A static occlusal contact.
Unplanned changes may cause Dent J 2002; 193: 397–400. conformative approach – The process of restoring
iatrogenic change, which would be 18. Davies SJ., Al-Ani MZ, Richmond R, Worthington teeth with the intention of not changing the
difficult to justify in the light of these H. Is the ‘Occlusal Sketch’ technique a reliable occlusion between teeth that are not involved in
long established restorative guidelines. means for the dental technician to check that the the restoration
occlusion of working models is the same dynamic occlusion – see ideal occlusion
Avoiding a disorganized result in occlusion as the patient has? Eur J Prosthodont habitual bite – see centric occlusion
complex restorative cases is readily Rest Dent 2002; 11: 87 (Abstract – Paper ideal occlusion – 1. Static occlusion: centric occlusion (or
achievable, if the treatment is split up presented at the 50th British Society for the intercuspation position) occurs in centric relation
into phases with carefully considered Study of Prosthetic Dentistry Annual (or retruded contact position).
Conference, April 2003). 2. Dynamic occlusion: the anterior
objectives. 19. Davies SJ, Gray RJM, Whitehead SA. Good guidance (of the mandible) is provided by only
occlusal practice in advanced restorative dentistry. teeth at the front of the mouth; i.e. no posterior
Br Dent J 2001; 191: 421–434 or Chapter 4: A interferences.
Clinical Guide to Occlusion. London: BDJ Books, intercuspation position – see centric occlusion
R EFERENCES 2002. jaw relationship – The spatial relationship between the
1. Ash MM, Ramfjord S. Occlusion. Philadelphia: 20. Dawson PE. Evaluation, Diagnosis, and Treatment maxilla and mandible.
Saunders, 1995. of Occlusal Problems. St Louis: CV Mosby, 1974; Miller forceps – Paper holders.
2. Wise MD. Occlusion and the Restorative Dentistry for pp. 54–58. neuromuscular release – A description of the sensation
the General Practitioner. London: BDJ Books, 1986. 21. Lucia VO. Fixed partial dentures: A technique for that the patient and the operator can feel when,
3. Dawson PE. Evaluation, Diagnosis, and Treatment recording centric relation. J Prosthet Dent 1964; during bimanual manipulation of the mandible,
of Occlusal Problems. St Louis: CV Mosby, 1974. 14: 492–505. there appears to be a muscular release which
4. Howat A, Capp NJ, Barrett NV. A Colour Atlas of 22. Thomas PK, Tateno J. ‘Incremental waxing allows the mandible to arc freely in terminal hinge
Occlusion and Malocclusion. London: Wolfe technique’ in Gnathological Occlusion. Tokyo: axis (see above).
Publishing Ltd., 1991. Shorin Ltd., 1980. occlusion – The contacts between teeth.
5. Pameijer JHN. Periodontal and Occlusal Factors in 23. Lynch CD, McConnell RJ. Prosthodontic Pain Dysfunction Syndrome – see TMD
Crown and Bridge Procedures. Amsterdam: Dental management of the curve of Spee: Use of re-organized approach – The process of restoring teeth
Centre of Postgraduate Courses, 1985. Broadrick flag. J Prosthodont Dent 2002; 87: 593– with the intention of changing the occlusion to one
6. Davies SJ, Gray RJM. What is occlusion? Br Dent J 597. that is ideal.
2001; 191: 235–245 or Chapter 1: A Clinical 24. Ibbetson RJ, Setchell DJ. Treatment of the Worn retruded contact position (RCP) – see centric relation
Guide to Occlusion. London: BDJ Books, 2002. Dentition: 1. Dent Update 1989; 11: 247–253. stabilization splint – An occlusal splint designed and
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recording of the occlusion: why and how. Br Dent static occlusion – see ideal occlusion
J 2001; 191: 291–302 or Chapter 2: A Clinical temporomandibular disorder (TMD) – A generic term
Guide to Occlusion. London: BDJ Books, 2002. used to describe a group of disorders and
GLOSSARY
8. Smith BGN. Occlusion: 1. General Consideration. dysfunction of the articulatory system. Usefully
articulating paper – Paper impregnated with dye that will
Dent Update 1991; 18: 141–145. classified into common, uncommon and rare.
mark teeth when they are closed onto it. Ideally 40
9. Smith BGN. Occlusion: 2. Practical Techniques. Common disorders include Pain Dysfunction
microns or less.
Dent Update 1991; 18: 187–192. Syndrome (a myalgia), internal derangements (disc
centric occlusion – The occlusion between the teeth to
10. Anderson G, Schulte GC. Reliability of the displacements), and osteoarthrosis (a wear and tear
which the patient habitually closes (habitual bite/bite
evaluation of occlusal contacts in intercuspal of the articulatory surfaces of the bones of the
of convenience), or the occlusion between the
position J Prosthet Dent 1993; 70: 320–323. TMJ).
teeth when they fit together the best (maximal
11. Davies SJ, Gray RJM, Smith PW. Good occlusal terminal hinge axis – The head of the condyle is purely
intercuspation/intercuspation position).
practice in simple restorative dentistry. Br Dent J rotating (not started to translate forwards and
(Author’s Note:This is not the definition given in
2001; 191: 265–281 or Chapter 3: A Clinical Guide downwards), and so the mandible is rotating about
the current Glossary of Prosthetic Terms, which is
to Occlusion. London: BDJ Books, 2002. a relatively stationary centre of rotation.
the terminology ‘bible’ which is published by the
12. Davies SJ, Gray RJM. A clinical approach to Consequently, the point of the chin and lower
Journal of Prosthetic Dentistry.The definition of
temporomandibular disorders: Examination of anterior teeth are describing a relatively perfect
centric occlusion given now is what was in the
the articulatory system: the temporomandibular arch of opening and closure.
previous edition as the definition of centric
joints. Br Dent J 1994; 176: 473–477 or Chapter unorganized – Oxford English Dictionary: Not formed into
relation occlusion.They may change it again!)
an orderly whole.

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