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Occlusion In Fixed Partial Denture

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Occlusion In FPD

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Occlusion In Fixed Partial Denture

  1. 1. OCCLUSION IN FIXED PARTIAL DENTURES Guided By:- Dr. Dilip Dhamankar (HOD) Dr. Ravi Kumar C.M. (Prof.) Dr. Meenaksi (Prof.) Dr. DRV Kumar (Reader) Dr. Arun Gupta(Reader) Dr. Sonal Pamecha (Reader) Dr. Manish Chadha (Senior Lect.) Dr. Devendra Singh (Senior Lect.) Dr. Soham Prajapati 2nd Year PG, Dept. of Prosthodontics & Maxillofacial Prosthesis Including Oral Implantology 13-3-2015
  2. 2. CONTENTS • Introduction • Terminologies • Ideal occlusion • Evolution of occlusion • Concepts of Occlusion – Bilaterally Balanced Occlusion3° – Unilaterally Balanced Occlusion – Mutually protected Occlusion. – Organic occlusion – Beyron’s occlusal concepts – Biologic or physiologic occlusion • Patient’s Adaptablity OCCLUSION IN FIXED PARTIAL DENTURES 2/109
  3. 3. CONTENTS • Occlusal Interferences • Pathogenic Occlusion • Complete Occlusal Rehabilitation • Restoring Different Combinations • Review of Literature • Conclusion • References OCCLUSION IN FIXED PARTIAL DENTURES 3/109
  4. 4. INTRODUCTION • Peter E. Dawson stated, ”Patient lose their teeth in two ways: either the teeth break down, other supporting structures break down” OCCLUSION IN FIXED PARTIAL DENTURES 4/109
  5. 5. INTRODUCTION • Occlusion is such an important word in Prosthodontics, that in the bible of Prosthodontics, GLOSSARY OF PROSTHODONTICS TERMS, when searched in its soft copy version, it is repeated for no less than 60 times. • Occlusion – 1: the act or process of closure or of being closed or shut off – 2: the static relationship between the incising or masticating surfaces of the maxillary or mandibular teeth or tooth analogues The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 5/109
  6. 6. INTRODUCTION • Articulation – The static and dynamic contact relationship between the occlusal surfaces of the teeth during function. The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 6/109
  7. 7. INTRODUCTION • The contact of the maxillary and mandibular teeth in various functional (mandibular) movements is an important relationship that should NOT be traumatic to the supporting tissues and should allow an even load distribution throughout the dental arch. OCCLUSION IN FIXED PARTIAL DENTURES 7/109
  8. 8. Terminologies • CENTRIC RELATION – the maxillomandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anterior-superior position against the shapes of the articular eminencies. – This position is independent of tooth contact. – This position is clinically discernible when the mandible is directed superior and anteriorly. – It is restricted to a purely rotary movement about the transverse horizontal axis (GPT-5) The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 8/109
  9. 9. Terminologies • MAXIMUM INTERCUSPAL POSITION (MI) – The complete intercuspation of the opposing teeth independent of condylar position, sometimes referred to as the best fit of the teeth regardless of the condylar position—called also maximal intercuspation The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 9/109
  10. 10. Terminologies • Centric Occlusion – The occlusion of opposing teeth when the mandible is in centric relation. This may or may not coincide with the maximal intercuspal position. The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 10/109
  11. 11. Points To Clear – It is clear from the definitions that in natural dentition, MI position need not coincide with CR. – When fixed and removable prosthesis are fabricated with existing natural teeth, they may be made to coincide with the existing normal MI position, if sufficient natural teeth are present to guide the occlusion. OCCLUSION IN FIXED PARTIAL DENTURES 11/109
  12. 12. Points To Clear – MI position is made to coincide with CR only when there are insufficient occlusal contacts existing to guide the occlusion. – This is different from complete dentures where MI position is given at CR. OCCLUSION IN FIXED PARTIAL DENTURES 12/109
  13. 13. IDEAL OCCLUSION • Ideal occlusion can be defined as an occlusion which is compatible with stomatognathic system providing efficient mastication and good esthetics without creating physiologic abnormalities. Hobo(1978) OCCLUSION IN FIXED PARTIAL DENTURES 13/109
  14. 14. IDEAL OCCLUSION – Characteristics • Stable Posterior contact with vertically directed resultant forces. • MIP coincident with CR along with freedom in centric. • No posterior contact in ecentric mandibular movements. • Contact of anterior teeth in harmony with functional jaw movement. • Occlusion in Angle’s Class I OCCLUSION IN FIXED PARTIAL DENTURES 14/109
  15. 15. IDEAL OCCLUSION – Angle’s Class I – If the mesiobuccal cusp of the maxillary first molar is aligned with the buccal grove of the mandibular 1st molar. – Orthodontic textbooks have traditionally described an arbitrary 2 mm for horizontal overlap and vertical overlap as being ideal. OCCLUSION IN FIXED PARTIAL DENTURES 15/109
  16. 16. IDEAL OCCLUSION – For most patients, however, greater vertical over lap is desirable, to prevent undesirable posterior contact as a result of flexing of the mandible during mastication Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 16/109
  17. 17. IDEAL OCCLUSION – Importance of Ideal Occlusion • Use it as a benchmark for assessment of pre- treatment records and examination (diagnostic cast). • Correcting TMD and occlusal interferences (if they exist) before commencing restorative procedures. • For final prosthodontic rehabilitation - to accomplish this a confirmative approach (where patients pretreatment occlusion is retained for the prosthodontic rehabilitation), or a reorganized approach (where a change in occlusal scheme is planned) is utilizied. OCCLUSION IN FIXED PARTIAL DENTURES 17/109
  18. 18. OCCLUSION IN FIXED PARTIAL DENTURES 18/109
  19. 19. Concepts of Occlusion • These can be categorized as – Bilaterally Balanced Occlusion, 3° – Unilaterally Balanced Occlusion, and – Mutually protected Occlusion. • However, since restorative treatment requirements vary, the clinician should understand possible combinations of occlusal schemes and their advantages, disadvantages, and indications. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 19/109
  20. 20. Bilaterally Balanced Occlusion OCCLUSION IN FIXED PARTIAL DENTURES 20/109
  21. 21. Unilaterally Balanced Occlusion OCCLUSION IN FIXED PARTIAL DENTURES 21/109
  22. 22. Mutually protected Occlusion OCCLUSION IN FIXED PARTIAL DENTURES 22/109
  23. 23. Bilaterally Balanced Occlusion • FERDINAND GRAF SPEE was one of the earliest proposed theories -Bilateral Balanced Occlusion. Definition • The bilateral, simultaneous, anterior, and posterior occlusal contact of teeth in centric and eccentric positions The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 23/109
  24. 24. Bilaterally Balanced Occlusion • In complete denture fabrication, this tooth arrangement helps maintain denture stability because the nonworking contact prevents the denture from being dislodged. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 24/109
  25. 25. Bilaterally Balanced Occlusion • However, as the principles of bilateral balance were applied to the natural dentition and in fixed prosthodontics, it proved to be extremely difficult to accomplish, even with great attention to detail and sophisticated articulators. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 25/109
  26. 26. Bilaterally Balanced Occlusion • In addition, high rates of failure resulted. • An increased rate of occlusal wear, increased or accelerated periodontal breakdown, and neuromuscular disturbances were commonly observed. • The last were often relieved when posterior contacts on the mediotrusive (NON-WORKING) side were eliminated in an attempt to eliminate unfavorable loading. Thus the concept of a unilaterally balanced occlusion (group function) evolved. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 26/109
  27. 27. Unilaterally Balanced Occlusion (GROUP FUNCTION) • It is based on Schyler’s Concept Definition:- Multiple contact relations between maxillary and mandibular teeth, in lateral movements on the working side, whereby simultaneous contact of several teeth acts as a Group to distribute occlusal forces The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. OCCLUSION IN FIXED PARTIAL DENTURES 27/109
  28. 28. Unilaterally Balanced Occlusion (GROUP FUNCTION) • In a unilaterally balanced articulation, excursive contact occurs between all opposing posterior teeth on the laterotrusive (working) side only. On the mediotrusive (nonworking) side, no contact occurs until the mandible has reached centric relation. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 28/109
  29. 29. Unilaterally Balanced Occlusion OCCLUSION IN FIXED PARTIAL DENTURES 29/109
  30. 30. Unilaterally Balanced Occlusion (GROUP FUNCTION) • Thus, in this occlusal arrangement the load is distributed among the periodontal support of all posterior teeth on the working side. This can be advantageous if, for instance, the periodontal support of the canine is compromised. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 30/109
  31. 31. Unilaterally Balanced Occlusion (GROUP FUNCTION) • While on the working side, occlusal load is distributed during excursive movement, and the posterior teeth on the non- working side do not contact. • In the protrusive movement, no posterior tooth contact occurs. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 31/109
  32. 32. Unilaterally Balanced Occlusion (GROUP FUNCTION) • While on the working side, occlusal load is distributed during excursive movement, and the posterior teeth on the non- working side do not contact. • In the protrusive movement, no posterior tooth contact occurs. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 32/109
  33. 33. Unilaterally Balanced Occlusion (GROUP FUNCTION) • Long Centric (Freedom in centric) – As the concept of unilateral balance evolved, it was suggested that allowing some freedom of movement in an anteroposterior direction is advantageous. This concept is known as long centric. – Schuyler was one of the first to advocate such an occlusal arrangement. – He thought that it was important for the posterior teeth to be in harmonious gliding contact when the mandible translates from centric relation forward to make anterior tooth contact. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 33/109
  34. 34. Unilaterally Balanced Occlusion (GROUP FUNCTION) • Long Centric. – Others have advocated long centric because centric relation only rarely coincides with the maximum intercuspation position in healthy natural dentitions. – However, its length is arbitrary. At given vertical dimensions, long centric ranges from 0.5 to 1.5 mm in length have been advocated. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 34/109
  35. 35. Unilaterally Balanced Occlusion (GROUP FUNCTION) • Long Centric. – This theory presupposes that the condyles can translate horizontally in the fossae over a commensurate trajectory before beginning to move downward. – It also necessitates a greater horizontal space between the maxillary and mandibular anterior teeth (deeper lingual concavity), allowing horizontal movement before posterior disocclusion. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 35/109
  36. 36. Mutually Protected Occlusion • During the early 1960s, an occlusal scheme called mutually protected occlusion was advocated by Stuart and Stallard, based on earlier work by D'Amico. • In this arrangement, centric relation coincides with the maximum intercuspation position. • The six anterior maxillary teeth, together with the six anterior mandibular teeth, guide excursive movements of the mandible, and no posterior occlusal contacts occur during any lateral or protrusive excursions Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 36/109
  37. 37. Mutually protected Occlusion OCCLUSION IN FIXED PARTIAL DENTURES 37/109
  38. 38. Mutually Protected Occlusion • The relationship of the anterior teeth, or anterior guidance, is critical to the success of this occlusal scheme. • In a mutually protected occlusion, the posterior teeth come into contact only at the very end of each chewing stroke, minimizing horizontal loading on the teeth. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 38/109
  39. 39. Mutually Protected Occlusion • Concurrently, the posterior teeth act as stops for vertical closure when the mandible returns to its maximum intercuspation position. • Posterior cusps should be sharp and should pass each other closely without contacting to maximize occlusal function. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 39/109
  40. 40. Mutually Protected Occlusion • Investigations of the neuromuscular physiology of the masticatory apparatus indicate advantages associated with a mutually protected occlusal scheme. • However, in studies involving unrestored dentitions, relatively few occlusions can be classified as mutually protected Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 40/109
  41. 41. Mutually Protected Occlusion • Advantages – Patient’s tolerence – Ease of Construction • Disadvantages – Periodontally weak anterior teeth – Missing Canine – Class II and Class III situation – Cross-bite situation Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 41/109
  42. 42. Optimum Occlusion • In an ideal occlusal arrangement, the load exerted on the dentition should be distributed optimally. • Occlusal contact has been shown to influence muscle activity during mastication. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 42/109
  43. 43. Optimum Occlusion • Direct Effect – Any restorative procedures that adversely affect occlusal stability may affect the timing and intensity of elevator muscle activity. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 43/109
  44. 44. Optimum Occlusion • Horizontal forces on any teeth should be avoided or at least minimized, and loading should be predominantly parallel to the long axes of the teeth. • This is facilitated when the tips of the centric cusps are located centrally over the roots and when loading of the teeth occurs in the fossae of the occlusal surfaces rather than on the marginal ridges. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 44/109
  45. 45. Optimum Occlusion • Horizontal forces are also minimized if posterior tooth contact during excursive movements is avoided. Nevertheless, to enhance masticatory efficiency, the cusps of the posterior teeth should have adequate height. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 45/109
  46. 46. Optimum Occlusion • The chewing and grinding action of the teeth is enhanced if opposing cusps on the laterotrusive side interdigitate at the end of the chewing stroke. • The mutually protected occlusal scheme probably meets this criterion better than the other occlusal arrangements. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 46/109
  47. 47. Features of Mutually Protected Occlusion 1. Uniform contact of all teeth around the arch when the mandibular condylar processes are in their most superior position 2. Stable posterior tooth contacts with vertically directed resultant forces 3. Centric relation coincident with maximum in- tercuspation (intercuspal position) (CR = MI) Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 47/109
  48. 48. Features of Mutually Protected Occlusion 4. No contact of posterior teeth in lateral or protrusive movement 5. Anterior tooth contacts harmonizing with functional jaw movements Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 48/109
  49. 49. Features of Mutually Protected Occlusion • In achieving these criteria, it is assumed that (1) a full complement of teeth exists, (2) the supporting tissues are healthy, (3) there is no cross bite, and (4) the occlusion is Angle Class I. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 49/109
  50. 50. Rationale. • At first glance it might seem illogical to load the single-rooted anterior teeth as opposed to the multirooted posterior teeth during chewing. • However, the canines and incisors have a distinct mechanical advantage over the posterior teeth: the effectiveness of the force exerted by the muscles of mastication is notably less when the loading contact occurs farther anteriorly. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 50/109
  51. 51. Rationale. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 51/109
  52. 52. Dawson (1974) stated that, • “When canines cannot be used ,lateral movements have posterior dïsclusion guided by anterior teeth on the working side, instead of canine alone” • He called this “Anterior Group Function” OCCLUSION IN FIXED PARTIAL DENTURES 52/109
  53. 53. Rationale. (Dawson presented his Theory Of Nutcracker) • The canine-with its long root, significant amount of periodontal surface area, and strategic position in the dental arch-is well adapted to guiding excursive movements. • This function is governed by pressoreceptors in the periodontal ligament, receptors that are very sensitive to mechanical stimulation. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 53/109
  54. 54. Rationale. • The elimination of posterior contacts during excursions reduces the amount of lateral force to which posterior teeth are subjected. • Therefore, molars and premolars in group function are subjected to greater horizontal and potentially more pathologic force than the same teeth in a mutually protected occlusion. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 54/109
  55. 55. Organic occlusion features by THOMPSON (1967) • CRP and MIP are coincident • Posterior teeth are in a cusp fossa relation, one tooth to one tooth contact • Each functional cusp contacts the occlusal fossa at three points • In protrusion maxillary incisors guide the mandible and disocclude the posteriors • In lateral movements – lingual surface of maxillary canine glides along the distal inclines of mandibular canine and mesial ridge of 1st premolar cusp OCCLUSION IN FIXED PARTIAL DENTURES 55/109
  56. 56. BEYRON’S OCCLUSAL CONCEPTS • Based on functional convenience and avoidance of discomfort. • An optimal occlusion would be one that requires less muscular activity and is in harmony with the neuromuscular system and TMJ. • Beyron revealed that the majority of the subjects had anteroposterior slide, in the Centric Position , in the range of 0 to 2 mm. • Only 10% of them presented a coincidence of CO=CR. • He also advocated freedom in centric concept & canine guided occlusion OCCLUSION IN FIXED PARTIAL DENTURES 56/109
  57. 57. BIOLOGIC OR PHYSIOLOGIC OCCLUSION • It is defined as an occlusion in which a functional equilibrium or state of homeostasis exist between all tissues of masticatory system. • A physiologic occlusion implies a balance between occlusal stress and tissue resistance. • The biologic processes and local environmental factors are in balance. OCCLUSION IN FIXED PARTIAL DENTURES 57/109
  58. 58. Patient’s Adaptablity Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 58/109 58/109
  59. 59. Occlusal Intereferences • Interferences are undesirable occlusal contacts that may produce mandibualar deviation during closure to maximum intercuspation or may hinder smooth passage to and from the intercuspal position. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 59/109 59/109
  60. 60. Occlusal Interferences • Four types of interferences: – Centric Interference • Mandible is closed in centric relation until initial tooth contact occurs. • If increasing the the closing forces deflects the mandible, premature contact or interference exists. • Leads to deflection of the mandible, can be in a posterior, anterior and/or lateral directions. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 60/109
  61. 61. Occlusal Interferences • Four types of interferences: – Centric Interference OCCLUSION IN FIXED PARTIAL DENTURES 61/109
  62. 62. Occlusal Interferences • Four types of interferences: – Working Interference • Occurs when there is contact between the maxillary and mandibular posterior teeth on the working side and this causes anterior teeth to disocclude. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 62/109
  63. 63. Occlusal Interferences • Four types of interferences: – Working Interference • Occurs when there is contact between the maxillary and mandibular posterior teeth on the working side and this causes anterior teeth to disocclude. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 63/109
  64. 64. • Four types of interferences: – Working Interference Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. Occlusal Interferences OCCLUSION IN FIXED PARTIAL DENTURES 64/109
  65. 65. Occlusal Interferences • Four types of interferences: – Non-Working Interference • Occurs when there is contact between the maxillary and mandibular posterior teeth on the non- working side when the mandible moves in lateral excursions. • Destructive in nature because of non-axial nature of forces causing leverage of mandible Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 65/109
  66. 66. • Four types of interferences: – Non-Working Interference Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. Occlusal Interferences OCCLUSION IN FIXED PARTIAL DENTURES 66/109
  67. 67. Occlusal Interferences • Four types of interferences: – Protrusive Interference • Occurs when distal facing inclines of maxillary posterior teeth contacts the mesial facing inclines of mandibular posterior teeth during protrusive movement. • These are destructions forces due to closeness of teeth to the muscles, non-axial nature of forces and inability of patient to incise food. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. OCCLUSION IN FIXED PARTIAL DENTURES 67/109
  68. 68. • Four types of interferences: – Protrusive Interference Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. Occlusal Interferences 68/109
  69. 69. • Interferences may lead to pathologic occlusion and should be assessed and corrected if needed, with the aid of mounted diagnostic casts before prosthetic rehabilitation is commenced. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p.. Occlusal Interferences 69/109
  70. 70. PATHOGENIC OCCLUSION • A pathogenic occlusion is defined as an occlusal relationship capable of producing pathologic changes in the stomatognathic system. • In such occlusions sufficient disharmony exists between the teeth and the TMJs to result in symptoms that require intervention The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. 70/109
  71. 71. PATHOGENIC OCCLUSION • Signs & Symptoms – Teeth • Mobility • Open contacts • Abnormal wear like fracture or chipping of incisal edges – Periodontium • Chronic Periodontal disease • Widened PDL Space (Radiographically) • Tooth Movement and A compromised C:R Ratio. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 71/109
  72. 72. PATHOGENIC OCCLUSION • Trauma From Occlusion – There is no convincing evidence that chronic periodontal disease is caused directly by occlusal overload. – However, a widened periodontal ligament space (detected radiographically) may indicate premature occlusal contact and is often associated with tooth mobility Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 72/109
  73. 73. PATHOGENIC OCCLUSION Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 73/109
  74. 74. PATHOGENIC OCCLUSION • Trauma From Occlusion – Similarly, isolated or circumferential periodontal defects are often associated with occlusal trauma. In patients with advanced periodontal disease who have extensive bone loss, rapid tooth migration may occur with even minor occlusal discrepancies Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 74/109
  75. 75. PATHOGENIC OCCLUSION • Signs & Symptoms – Musculature • Chronic muscular fatigue leading to muscle spasm and pain • Restricted opening or trismus • Myositis. – TMJ • Pain, Clicking or popping in the TMJ Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 110-144 OCCLUSION IN FIXED PARTIAL DENTURES 75/109
  76. 76. PATHOGENIC OCCLUSION TREATMENT – This would include the following depending on the cause for occlusal interference:- – Short Term Treatment • Occlusal Splints/devices. – Used for short period and provide following benefits: » Serve to deprogram the occlusion such that future restoration in centric relation is easily accomplished V Rangarajan, Textbook Of Prosthodontics, Pg 500 OCCLUSION IN FIXED PARTIAL DENTURES 76/109
  77. 77. PATHOGENIC OCCLUSION TREATMENT – Short Term Treatment • Occlusal Splints/devices. – Used for short period and provide following benefits: » Act as a diagnostic tool in determining if a proposed change in occlusal scheme will be tolerated by the patient » Also been beneficial in relieving myofacial pain. V Rangarajan, Textbook Of Prosthodontics, Pg 500 OCCLUSION IN FIXED PARTIAL DENTURES 77/109
  78. 78. PATHOGENIC OCCLUSION TREATMENT – Definitive treatment • Compromising individually or in combination: – Orthodontic treatment to correct malalignment – Elimination of deflective occlusal cntacts through elective grinding of interfering inclines – Replacement of missing teeth to produce a more favorable distribution of force. V Rangarajan, Textbook Of Prosthodontics, Pg 500 OCCLUSION IN FIXED PARTIAL DENTURES 78/109
  79. 79. Complete Occlusal Rehabilitation • Occlusal rehabilitation is defined as the restoration of functional integrity of dental arch by the use of inlays, crowns, bridges and partial dentures. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 79/109
  80. 80. Complete Occlusal Rehabilitation • INDICATIONS FOR FULL MOUTH REHABILITATION – The restoration of multiple teeth which are missing, worn, broken down or decayed. – To replace improperly designed and executed crown and bridge framework. – Treatment of temporomandibular disorders is also advised, though caution is advised. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 80/109
  81. 81. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • One of the most practical philosophies is the rationale of treatment that was originally organized into a workable concept by Dr. L.D. Pankey utilizing the principles of occlusion espoused by Dr. Clyde Schuyler. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 81/109
  82. 82. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Schuyler’s principles were – A static co-ordinated occlusal contact of the maximum number of teeth when the mandible is in centric relation. – An anterior guidance that is in harmony with function in lateral eccentric position on the working side. – Disclusion by the anterior guidance of all posterior teeth in protrusion. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 82/109
  83. 83. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Schuyler’s principles were – Disclusion of all non-working inclines in lateral excursions. – Group function of the working side inclines in lateral excursions. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 83/109
  84. 84. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Sequence of Treatment – Part 1- examination, diagnosis, treatment planning – Part 2- harmonization of anterior guidance for best possible esthetics, function and comfort – Part 3- selection of occlusal plane and restoration of lower posterior occlusion in harmony with anterior guidance n a manner that will not interfere with condylar guidance. – Part 4- restoration of upper posterior occlusion in harmony with anterior and condylar guidance. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 84/109
  85. 85. Pankey-Mann- Schulyer Philosophy Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 85/109
  86. 86. Pankey-Mann- Schulyer Philosophy Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 86/109
  87. 87. Pankey-Mann- Schulyer Philosophy Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 87/109
  88. 88. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Advantages – It is possible to diagnose and plan the treatment for entire rehabilitation before preparing a single tooth. – It is a well- organized logical procedure that progresses smoothly with less wear and tear on the operator, patient and technician. There is never a need for preparing or building more than 8 teeth at a time. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 88/109
  89. 89. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Advantages – It divides the rehabilitation into separate series of appointments. It is neither necessary nor desirable to do the entire case at one time. – There is no danger of getting at sea and losing patient’s vertical dimension. The operator always has an idea where he is at all times. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 89/109
  90. 90. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Advantages – The functionally generated path and centric relation are taken on the occlusal surface of the teeth to be rebuilt at the exact vertical dimension to which the case will be reconstructed. – All posterior occlusal contours are programmed by and are in harmony with both condylar border move ments and a perfected anterior guidance. – There is no need for time consuming techniques and complicated equip ment. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 90/109
  91. 91. Pankey-Mann- Schulyer Philosophy Of Complete Occlusal Rehabilitation • Advantages – Laboratory procedures are simple and controlled to an extremely fine degree by the dentist. – The PMS philosophy of occlusal rehabilitation can fulfill the most exacting and sophisticated demands if the operator understands the goals of optimum occlusion Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 91/109
  92. 92. HOBO’ S TWIN STAGE PHILOSOPHY • In order to provide disocclusion, the cusp angle should be shallower than the condylar path. • To make a shallower cusp angle in a restoration, it is necessary to wax the occlusal morphology to produce balanced articulation so the cusp angle becomes parallel to the cusp path of opposing teeth during eccentric movement. • Since anterior teeth help produce disocclusion, when a dental technician waxes the occlusal morphology and tries to reproduce a shallower cusp angle, the anterior portion of the working cast becomes an obstacle. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 92/109
  93. 93. HOBO’ S TWIN STAGE PHILOSOPHY • Also, when fabricating the anterior teeth to produce disocclusion, some guidance should be incorporated. In this methodical approach described by Hobo, a cast with a removable anterior segment is fabricated. • Reproduce the occlusal morphology of the posterior teeth without the anterior segment and produce a cusp angle coincident with the standard values of effective cusp angle (Referred to as ‘Condition’). • Secondly, reproduce the anterior morphology with the anterior segment and provide anterior guidance which produces a standard amount of disocclusion (Referred to as ‘Condition 2’). Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 93/109
  94. 94. HOBO’ S TWIN STAGE PHILOSOPHY • Secondly, reproduce the anterior morphology with the anterior segment and provide anterior guidance which produces a standard amount of disocclusion (Referred to as ‘Condition 2’). Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 94/109
  95. 95. HOBO’ S TWIN STAGE PHILOSOPHY Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 95/109
  96. 96. HOBO’ S TWIN STAGE PHILOSOPHY Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 96/109
  97. 97. HOBO’ S TWIN STAGE PHILOSOPHY Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 OCCLUSION IN FIXED PARTIAL DENTURES 97/109
  98. 98. Difference • In the Twin Stage procedure, the cusp angle was considered as the most reliable determinant of occlusion. This was in accordance with the proven data from studies that cusp angle was 4 times more reliable than condylar and incisal paths. Pankey Mann Schyuler’s philosophy advocates that condylar guidance does not dictate anterior guidance. Thus it believes in harmonization of the anterior guidance for best possible esthetics, function and comfort and the determination of an occlusal plane based on anterior guidance. OCCLUSION IN FIXED PARTIAL DENTURES 98/109
  99. 99. RESTORING DIFFERENT COMBINATIONS PROSTHESIS POSITION ICP/CR ARTICULATOR AND RECORDS OCCLUSAL MORPHOLOGY Single crown ICP Simple hinge Conform to occlusal Morphology FPD- one quadrant ICP Semiadjustable /anterior guidance Conform to occlusal Morphology Several quadrants Long centric Fully Adjustable / anterior guidance and condylar guidance Group function is desired/cusp to fossa OCCLUSION IN FIXED PARTIAL DENTURES 99/109
  100. 100. Review of Literature • Pullinger in 1988 studied of occlusal variables associated with joint tenderness and dysfunction found ICP anterior to RCP in association with bilateral occlusal stability may be protective. Pullinger AG, Seligman DA, Solberg WK. Temporomandibular disorders. Part II: Oc- clusal factors associated with temporoman- dibular joint tenderness and dysfunction. J Prosthet Dent 1988;59:363-7. OCCLUSION IN FIXED PARTIAL DENTURES 100/109
  101. 101. Review of Literature • In 1988, Agerberg et al studied of occlusal interference frequency between centric relation and centric occlusion or nonworking contacts that prevented group function and observed that majority of individuals had deflective contacts that did not appear to interfere with mastication. Agerberg G, Sandstrom R. Frequency of occlusal interferences: a clinical study in teenagers and young adults. J Prosthet Dent 1988;59:212-7. OCCLUSION IN FIXED PARTIAL DENTURES 101/109
  102. 102. Review of Literature • In 2004, Occlusal wear studied and related to risk factors such as bruxism, gender, and social situations and it was found factors for high occlusal wear: bruxism, male gender, loss of molar contact, edge-to-edge incisor relations, unemployment. Bernhardt O, Gesch D, Splieth C, Schwahn C, Mack F, Kocher T, et al. Risk factors for high occlusal wear scores in a population-based sample: results of the Study of Health in Pomerania (SHIP). Int J Prosthodont 2004;17:333-9. OCCLUSION IN FIXED PARTIAL DENTURES 102/109
  103. 103. • The occlusal scheme can be classified by the location of the occlusal contact made by the functional cusp on the opposing tooth in centric relation • There are two types: – cusp-fossa – cusp-marginal ridge OCCLUSION IN FIXED PARTIAL DENTURES 103/109 Occlusal Scheme
  104. 104. • The cusp-marginal ridge relation is the type of occlusal scheme in which the functional cusp contacts the opposing occlusal surfaces on the marginal ridges of the opposing pair of teeth, or in a fossa. OCCLUSION IN FIXED PARTIAL DENTURES 104/109 Cusp-Marginal Ridge
  105. 105. • The cusp-fossa relation is an occlusal pattern in which each functional cusp is nestled into the occlusal fossa of the opposing tooth OCCLUSION IN FIXED PARTIAL DENTURES 105/109 Cusp-Fossa
  106. 106. • Although considered to be an ideal occlusal pattern, it is rarely found in its pure form in natural teeth. • Each centric cusp should make contact with the occlusal fossa of the opposing tooth at three points. OCCLUSION IN FIXED PARTIAL DENTURES 106/109 Cusp-Fossa
  107. 107. • The contact points are on the mesial and distal incline and the inner facing incline of the cusp, producing a tripod contact. Since the cusp tip itself never comes in contact with the opposing tooth, the cusp tip can be maintained for a long time with a minimum of wear OCCLUSION IN FIXED PARTIAL DENTURES 107/109 Cusp-Fossa
  108. 108. • The contact points are on the mesial and distal incline and the inner facing incline of the cusp, producing a tripod contact. OCCLUSION IN FIXED PARTIAL DENTURES 108/109 Cusp-Fossa
  109. 109. • Tripodization. It is logical to see but difficult to accomplish. It requires each cusp contacting an opposing fossae be developed such that it produces three contacts surrounding the actual tip. OCCLUSION IN FIXED PARTIAL DENTURES 109/109 TRIPOZIDATION
  110. 110. Cusp -fossa Cusp –marginal ridge Location of occlusal contact on opposing tooth Occlusal fossa Occlusal fossae and marginal ridges Relation with opposing teeth Tooth –to - tooth Tooth-to-two- teeth advantages Occlusal forces directed parallel to long axis of tooth- very little lateral stress Most natural type of occlusion -95% of adults. Can be used for single restorationswww.indiandentalacademy.com Classification of Occlusal Arrangements
  111. 111. Classification of Occlusal Arrangements Cusp -fossa Cusp –marginal ridge Disadvantages Rarely found in natural teeth – used only when restoring several contacting teeth Food impaction and displacement of teeth may arise if the functional cusps wedge into the lingual embrasure Applications Full mouth reconstruction Most cast restorations www.indiandentalacademy.com
  112. 112. Conclusion • Occlusion of FDP with the antagonist should be achieved favorably in order to fulfill the requirements of mastication, aesthetics, speech, and prevention of TMJ dysfunction. OCCLUSION IN FIXED PARTIAL DENTURES 112/109
  113. 113. References 1. The Glossary of Prosthodontic Terms, 8th Edition J Prosthet Dent 2005;81:63. 2. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3rd ed. St. Louis: Elsevier; 2000. p. 46-64. 3. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Quintessence; 1997.p. 85-103, 191-2. 4. V Rangarajan, Textbook Of Prosthodontics, pg 470 5. Joseph E. Ewing, Fixed Parial Prosthesis, 2nd Edition, 14-20. OCCLUSION IN FIXED PARTIAL DENTURES 113/109
  114. 114. References 6. Bernhardt O, Gesch D, Splieth C, Schwahn C, Mack F, Kocher T, et al. Risk factors for high occlusal wear scores in a population-based sample: results of the Study of Health in Pomerania (SHIP). Int J Prosthodont 2004;17:333-9. 7. Agerberg G, Sandstrom R. Frequency of occlusal interferences: a clinical study in teenagers and young adults. J Prosthet Dent 1988;59:212-7. 8. Pullinger AG, Seligman DA, Solberg WK. Temporomandibular disorders. Part II: Oc- clusal factors associated with temporoman- dibular joint tenderness and dysfunction. J Prosthet Dent 1988;59:363-7. 9. Shetty et al, PHILOSOPHIES IN FULL MOUTH REHABILITATION – A SYSTEMATIC REVIEW , Int J Dent Case Reports,Nov-Dec 2013, Vol.3, ,No. 3 10. Pokorny et al, Occlusion for fixed prosthodontics: A historical perspective of the gnathological influence , JPD, Volume 99 Issue 4, 299-306 OCCLUSION IN FIXED PARTIAL DENTURES 114/109
  115. 115. Thank You OCCLUSION IN FIXED PARTIAL DENTURES 115/109

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