11/16/2020 Choosing the denture occlusion - A Systematic review :Ritika Bhambhani, Shubha Joshi, Santanu Sen Roy, Aditi

, Aditi Shinghvi, The Jou…

REVIEW
Year : 2020 | Volume : 20 | Issue : 3 | Page : 269--277

Choosing the denture occlusion - A Systematic review

Ritika Bhambhani1, Shubha Joshi2, Santanu Sen Roy3, Aditi Shinghvi4,
1 Departments of Prosthodontics and Crown and Bridge, Gurunanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India
2 Department of Prosthodontics and Crown and Bridge, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be
University, Karad, Satara, Maharashtra, India
3 Public Health, Gurunanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India
4 Private Practitioner, BDS, AMRI Medical Centre, Kolkata, West Bengal, India

Correspondence Address:
Dr. Shubha Joshi
Department of Prosthodontics and Crown and Bridge, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed to be
University, Karad, Satara, Maharashtra
India

Abstract
Aim: The aim of the study is to acquire evidence for the choice of occlusion with anatomic/modified anatomic teeth in complete
denture prosthesis. Settings and Design: Systematic review following PRISMA guidelines. Materials and Methods: The study
reviewed original articles on various occlusal schemes bilateral balance occlusion (BBO), lingual occlusion (LO), Canine guided
occlusion (CG), posterior group function occlusion (PGFO) have been applied to the complete dentures and were analyzed for
the objective or subjective or both evaluations. The data were collected in standard format with the needed information such as
year of publication, type of study, occlusal schemes compared, test methodology used, sample size for experiment and control,
assessment of retention, stability, and other factors which determine the quality of life and period of follow-up. The risk of bias
was calculated using tools RoB2.0 and robvis. At all stages, the inclusion and exclusion of studies were discussed among the
reviewers. Statistical Analysis used: Due to the heterogeneity in the data of the included studies no statistical analysis was
used. Results: Of the 1896 articles screened only 17 studies were included in the systematic review. These were discussed
amongst the reviewers regarding the various occlusion schemes used. The subjective and objective criteria used in the studies
was tabulated separately. They were then analyzed for the risk of bias using the robvis 2 tool. Conclusion: No scheme is more
superior to the other with the anatomic tooth forms. The use of alternative unbalanced schemes produces a similar satisfactory
clinical outcome. The ridge classification also has a significant role to play in the preference for an occlusal scheme.

How to cite this article:

Bhambhani R, Joshi S, Roy SS, Shinghvi A. Choosing the denture occlusion - A Systematic review.J Indian Prosthodont Soc
2020;20:269-277

How to cite this URL:

Bhambhani R, Joshi S, Roy SS, Shinghvi A. Choosing the denture occlusion - A Systematic review. J Indian Prosthodont Soc
[serial online] 2020 [cited 2020 Nov 16 ];20:269-277
Available from: https://www.j-ips.org/text.asp?2020/20/3/269/289933

Full Text

Introduction

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11/16/2020 Choosing the denture occlusion - A Systematic review :Ritika Bhambhani, Shubha Joshi, Santanu Sen Roy, Aditi Shinghvi, The Jou…

The complete denture prosthesis is irreplaceable in the rehabilitation of edentulous patients. It restores oral function and
maintains esthetics and patients' psychological well-being. With better medical services and a greater life span, there is an equal
requirement of functional oral rehabilitation, where complete denture prosthesis too has an important role to play. This applies
greatly to our developing country where implant-supported prosthesis is still away from the reach of masses. Their fabrication
includes the right blend of art and science of stabilizing it against all odds of oral musculature, function, parafunction, and gravity.
The basic principles to be born in mind while fabricating a complete denture include retention, support, stability, and harmony
with stomatognathic system with preservation of the surrounding tissues to achieve good esthetics and function. Undesirable
denture movement may result during function by unfavorable masticatory forces, but these can be minimized by multiple
contacts on both working and nonworking sides during centric and all excursive mandibular movements.[1] Balanced articulation
means the simultaneous anterior and posterior occlusal contact of teeth in centric and eccentric positions.[2] This concept has
been applied clinically as it is assumed to dissipate the oblique forces and improve retention and stability.

However, alternatively, another approach called lingualized occlusion (LO)[2],[3],[4] has been advocated, where only the
maxillary palatal cusps articulate with the mandibular occlusal surfaces.[5],[6] There were reports of good acceptance of the
latter too in terms of patient comfort. This makes us question the significance of the complicated procedures or rather time-
consuming adjustments involved the balanced occlusion when speaking of clinical evidence. Moreover, here began a journey of
various studies of different occlusal schemes and tooth forms.[5],[6]

Various occlusal schemes other than the bilateral balanced occlusion and lingialized occlusion have also been used in denture
fabrication. Schemes like Linear (Monoplane occlusion), Canine-guided occlusion, Partial group function occlusion, Buccalized
occlusion have been researched upon.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] The earliest mention of CGO in complete denture
prosthesis was made by Gausch in 1986, where EMG (electromyographic) studies were done to explore the benefits. However,
there is a need of more scientific evidence to apply these schemes in appropriate situations.[16]

Complete denture occlusion and its prospective effects on the stomatognathic system along with the quality of life of the patient
hence is an area of interest. More evidence-based research is needed due to different biomechanics of conventional denture
prosthesis and the subjective factors involved in it. The role of occlusion is multifactorial toward the denture success–retention,
support, stability, preservation of the residual ridge and surrounding tissues/muscles, and undoubtedly the esthetics. The denture
behaves different than natural teeth as it acts as one unit, where the force applied to a single denture tooth gets passed on to the
whole denture. The muscle attachments and functional and parafunctional movements have their role to play in the denture
success.

The other factor which has to be born in mind is the adaptability of the denture patients and also the role of tissue resiliency
which is not objectively considered widely in literature. It is understood that an objective evaluation of the latter is clinically
difficult and so is its role in denture settling and associated occlusal changes. That is why the denture patients were rightly
termed as the denture acrobats.[17]

The balanced occlusion has been the preferred scheme for the stability of the denture, but yet questions have been raised and
existed since decades regarding the clinical significance of BBO for denture success. Enter Bolus and Exit Balance' was
mentioned in 1960's to emphasize the loss of occlusal balance during mastication. The deflective contacts may result in the
tipping of the denture bases. But as the mastication time is much smaller than the other activities swallowing the bilateral
balance would still be deisred. The aim being to minimise the deflective contacts. With use the balanced contacts originally
created might be altered in the mouth but even then denture wearers can have clinical acceptance. This balance is not only
dependent on the occlusal balance but also the lever balance created by the right tooth position (anteroposteriorly and
mediolaterally and the occlusal height).[18],[19] Various researches have concluded similar clinical results with other occlusal
schemes, the denture teeth do not always contact, and the absence of interruptive and deflective contacts is what has been
desired during function. The occlusal scheme pertaining to the above will fulfill the roles of retention and stability. Even if lost
during function, the BBO may be helpful during seating during terminal arc of closure. The time and effort while preparing
dentures with a balanced occlusion and the lateral forces which exist on working/nonworking sides are the areas which require
evidence for the preference of BBO. Considering the Muller Devan's principle as an important parameter of success, this attempt
has been made to look into more evidence related to the scheme which is clinically satisfactory and also maintains the integrity
of the residual ridge and the muscles of mastication. The angle/direction and amount of forces associated to various schemes
and its effect on lever balance, if known, can help choose the occlusal scheme not only by subjective preferences but also based
on biomechanical principles.[20],[21]

This systematic review has been taken up with an aim of acquiring evidence for the choice of occlusion in complete denture
prosthesis. The null hypothesis being balanced and nonbalanced occlusion schemes is similar in providing the denture-related
satisfaction, and no difference exists in resorption rates and long-term consequences. The authors tried to explore more of the
qualitative and objective studies done in association with complete denture prosthesis.

Methodology

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This review was done using the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Search policy

Literature that investigated into complete denture occlusion was searched using the predetermined search policy of PRISMA
guidelines. The search policy was based on a Population, Intervention, Comparison, Outcome, and Study Design framework,
and it is depicted in [Table 1]. The search keywords such as complete denture occlusion, balanced occlusion, bilateral balanced
occlusion, lingualised occlusion, occlusal schemes for complete dentures, canine guided occlusion, effect of tissue resilience,
and denture occlusion were used. It resulted in 215 articles for “balanced occlusion,” 713 for “occlusal schemes,” 59 for “CGO in
complete dentures,” 27 for “LO in CD,” 121 for “occlusal scheme in CD,” 1135 for “complete denture occlusion,” 158 for
comparison in CD occlusion, and 25 for the BO in CD making a total of 2448 studies.{Table 1}

An electronic search of studies published till September 2019 in PubMed, Science Direct, Google Scholar, Cochrane Central
Register of Controlled Trials, and EBSCOhost were included. The journals hand searched were the Journal of Prosthetic
dentistry and the Journal of Indian Prosthodontic Society; cross references and bibliography were also referred to.

Inclusion and exclusion criteria

Abstracts and full research manuscriptin vivo original studies related to occlusal schemes were read thoroughly, and the
following inclusion and exclusion criteria are depicted.

Inclusion criteria

Controlled clinical trial/randomized clinical trialCrossover trialsProspective and retrospective studiesObjective and subjective
testsArticles in English languagePresence of follow-up period after insertionUse of anatomic or modified anatomic teeth.

Exclusion criteria

Case report and case seriesReview articlesAnimal studiesIn vitro studiesUse of nonanatomic teeth for the denture
fabricationOther language articlesImplant-associated denture occlusion.

Quality assessment

Articles were read thoroughly to assess methodology, randomization, sample size, control group, blinding of participants and
personnel, quality of life, retention, and stability. The assessment was first done independently, and then, discussions were done
among the reviewers to include or exclude the studies and to elaborate on missing data. The Cochrane Collaboration tool was
used as an aid. Risk of bias was estimated as low, medium, or high based on the Cochrane risk of bias tool RoB2.0 and robvis
[Chart 3] shows the use of robvis).[22][INLINE:3]

Data extraction

The data information from published articles was collected in the needed format to include the information such as year of
publication, type of study, type of occlusal schemes compared, test methodology used, sample size, assessment of retention,
stability, and other factors of denture quality assessment and period of follow-up [15],[23],[24],[25],[26],[27],[28],[29],[30],[31],
[32],[33],[34],[35],[36] [Table 2].{Table 2}

Results

The steps of literature search were mainly identification, screening, eligibility, and inclusion or exclusion as suitable. Both
reviewers did an independent search, and conclusions were reached by mutual discussions on the selected articles [Table 3].
{Table 3}

Discussion

Most of the studies included have been crossover studies, and these trials decrease the intersubject response variations due to
reasons such as masticatory strength and unrealistic expectations. Most of the included crossover studies have used the same
denture base which would omit the duplication errors (Khamis and Hussein method). At the same time, there exists a carryover
effect with no washout period, which may result in reporting bias from the patients' response.[2],[24],[35] Some studies used
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single blinding when examiners were also involved in the denture construction whereas some studies were double blinded.[15],
[31]

The patient satisfaction was considered as the primary outcome to be tested, and the methods used have been subjective
questionnaire formats related to denture-related satisfaction variables, Visual Analog Scale, Likert scale, oral health-related
quality of life assessed using the Oral Health Impact Profile (OHIP), OHIP-edentulous adults, German Society for Dentistry and
Oral Medicine for Functional and Diagnostic Therapy, and other rating formats [Table 2]. Tests for retention and stability were
based on examiner skills [35] or Kapur index.[36]

Objective analyses have been performed for the masticatory forces, masticatory efficiency, and the stress and strain on the
ridge, and EMG studies for the muscle activity have been done. Masticatory function was assessed by food particle size
estimation using sieve method, colorimetric determination, optical scanning, biting force, or weight loss of viscoelastic food.
Dentures with CGO were preferred more for certain food products such as carrots and meat. BO and LO were found to reduce
selective food avoidance and physical disability aspects of patient satisfaction. More dislodging forces in BBO could cause
patients to avoid some foods causing an unpleasant eating experience.[25] No difference in the masticatory efficiency was
reported among various schemes,[17],[22],[25] and on the contrary, the efficiency is more ridge dependent.[24],[25] In poor
residual ridge conditions, LO was preferred by patients for acceptable stability and masticatory efficiency and retention. It allows
modifications to adapt to various ridge types, elimination of lateral interferences, and settling without cuspal interferences.[11],
[31] LO was also associated with a better lever balance and hence more controlled forces.[14]

MO has been reported for the requirement of more adjustment time and more chairside corrections; it compromises on esthetics
and masticatory efficiency with no special benefits. Anatomical tooth forms were found more efficient for chewing efficiency and
denture adaptation; hence, the present review explored the latter and schemes with modified anatomic teeth.[1],[11] Anin vitro
study on resilient edentulous jaw simulator was carried out for pressure analysis of various occlusal schemes to check for
pressure on nonworking side by unilateral chewing. Pressure sensors and multichannel electronic strain indicators were used to
check for pressure on the ridge under BBO, LO, and MO. The pressure in MO was found the least and almost similar in BO and
LO.[37] Results were found statistically equivalent for BBO and LO. Being anin vitro study, this was excluded.

Anterior tooth group function and CGO have been mentioned for the efficiency for chewing. The points to be explored further
are, the effects on denture retention and transfer of occlusal stresses. Some researchers have named these as 'Lateral occlusal
guidance studies' where canine or premolar guided occluion is preferred to bilateral balance.[38] CGO was preferred for
esthetics, phonetics, masticatory function, and retention in a crossover study with 50 subjects (10 dropouts) where all subjects
preferred CGO, but a greater adjustment time was involved.[31],[39] In another study,[11] similar results were concluded. Either
a separate denture was fabricated or only the occlusal scheme was modified by alteration of canines. The CGO is the preferred
scheme in dentulous patients for the well-known reason of discussion of posterior teeth during lateral movements, better
esthetics, and lesser and easier fabrication time. A reduced muscle activity was explored, with no negative influence on lateral
stability or higher resorption rates.

Little difference was found clinically among various occlusal schemes, so if the time taken for BBO is taken into consideration,
the application of the same on a regular clinical basis is questionable. LO has been proved equally accepted but has not been
taken as a control group in any of the comparisons. Scientific data for resorption patterns were not found in any of the studies,
and a trend of subject dropouts might exist in prospective studies. A trend toward studies for the CGO has been comparatively
more in the near past, and related literature was found only after the year 2000 [Chart 1]. The studies related to CGO are
crossover trials which make them more valued, but none of the comparisons have been made with LO dentures. LO can provide
the same freedom of movement as in neutrocentric or MO, even in cases of weak muscle engrams and with a better functional
efficiency. The discrepancies in studies' results might occur due to certain factors like- clinician's technique or interoperator
variability, tooth material and form selected, and various patient factors (ridge type, resilience and unrealistic or realistic
expectations.). More scientific evidence for preference of certain schemes in specific situations and their long-term effect on
ridge resorption would be beneficial. Studies based on finite element analysis for complete denture can be explored and have
scope for future.[40][INLINE:1]

Conclusions

Hypothesis was found partially correct that all schemes, if wisely used, can bring out good clinical results. No scheme is more
superior to the other when using the anatomic tooth forms [Chart 2]. The part of hypothesis regarding the resorptive rates is
difficult to be supported with enough evidence as there are no prospective studies with the different occlusal schemes. There is
scope for more evidence-based research for the preferred occlusal scheme in different ridge relations and comparative trials of
CGO with LO. Balanced occlusion is one of the preferred choices for occlusal schemes but not for all the ridges. Lingualized
occlusion can be helpful in resorbed ridges for the masticatory efficiency and even in providing bilateral balance. CGO is the
most preferred occlusion scheme for dentulous situations and needs more evidence-based research related to its effects on
denture stability.[INLINE:2]

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11/16/2020 Choosing the denture occlusion - A Systematic review :Ritika Bhambhani, Shubha Joshi, Santanu Sen Roy, Aditi Shinghvi, The Jou…

The complete denture prosthodontics is the most difficult and skill requiring area to bring out the best rehabilitation in an
edentulous patient. The wise choice of varied parameters is sure to result in clinical success.

Acknowledgment

We would like to thank all working toward an evidence-based dentistry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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