981528 PRD Primary Dental Journal

Key words Learning Objective Authors

Occlusal philosophies, full mouth •• To better appreciate the changes in Martin G. Kelleher BDS (Hons),
rehabilitation occlusal philosophies for full mouth M.Sc., FDSRCPS (Glasg), FDSRCS (Eng),
rehabilitation over the years FDSRCS (Edin)
Consultant & Specialist in Restorative Dentistry,
King’s College Hospital, London, UK

Hui Lynn Ooi BDS (Hons)

Staff Dentist in Acute Dental Care, King’s College
Hospital, London, UK

Igor R. Blum DDS (Hons), PhD, Dr Med

Dent, MSc, MFDS RCS (Eng), MFDS RCS
(Edin), FDS (Rest Dent)RCS (Eng),
FFGDP (UK), PGCHE, FCGDent, FHEA,
LLM (Medico-Legal)
Consultant & Specialist in Restorative Dentistry,
King’s College Hospital, London, UK; Reader in

Martin G.D. Kelleher, Hui Lynn Ooi, Igor R. Blum Primary Dental Care & Advanced General Dental
Practice, Faculty of Dentistry, Oral & Craniofacial
Prim Dent J. 2021;10(1):50-55 Sciences, King’s College London, London, UK

Changes in occlusal
philosophies for full mouth
rehabilitation
Abstract
This article reviews some of the main tenets of different occlusal philosophies
involved in ‘full mouth rehabilitation’ and evolved since the late 19th century. This
review is not intended as a comprehensive historical review of all the people
who wrote, researched, or taught on the topic, and it is certainly not intended to
disparage their well-meaning contributions. It is intended to highlight some of the
changes that occurred in relation to full mouth rehabilitation occlusal concepts
along with the dates when they were articulated.

Introduction premise was that the most posterior,

The main objective of ‘full mouth superior position of the condyles in the
rehabilitation’ is the restoration of the glenoid fossae was the optimal position
dentition by establishing new occlusal for setting up false teeth when making
forms at the correct vertical dimension in complete dentures.
order to improve function and
appearance, while maintaining the In their concept of bilateral balanced
health and harmony of the entire occlusion, balancing contacts needed
stomatognathic system.1,2 Since the late to be present during all mandibular
19th century, various occlusal concepts movements to keep the complete
and philosophies have been articulated dentures stable during chewing and
in relation to achieving a supposedly swallowing. However, those complete
‘optimal occlusion’. denture principles do not apply to
natural teeth, mainly because teeth
Occlusal philosophies from are held within their functioning and
the 1890s onwards adaptable periodontal ligaments
In the 1890s and early part of the which have exquisitely innervated
twentieth century, von Spee (1890)3 and mechanoreceptors to “programme” jaw
Gysi (1915)4 had done their work in movements and jaw positions. Many
relationship to occlusal schemes for enthusiastic ‘occlusionists’ seem blissfully
complete dentures. Their fundamental unaware that originally this bilaterally

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50 Pr i ma r y De n ta l J ou r n a l journals.sagepub.com/home/PRD
balanced occlusion concept was applied used to programme an arcon fully
to restoration of the natural dentition by adjustable articulator in order to make
means of what was termed ‘full mouth the multiple restorations that were
rehabilitation’. deemed to be required.6 The
gnathologists’ views were that the
Concepts in ‘gnathology’ condylar paths involved in jaw opening
and how these changed from and closing were a fixed entity in adults.
the 1920s ‘Anterior guidance’ describes the
In 1924, Dr Beverly B. McCollum contacts made between the labial and
described the first positive method of incisal aspects of the lower front teeth
locating the hinge axis, a milestone in contacting the palatal and incisal
dental research. He founded the anatomy of the upper front teeth during
Gnathological Society in 1926. protrusive movements of the mandible.
McCollum and the Gnathological Gnathologists believed that anterior
Society’s definition of ‘gnathology’ was guidance was independent of the
as follows: ‘Gnathology is the science Figure 1: The McCollum Gnathograph. condylar path movements.7
that treats the biologics of the masticating Copyright © American College of
mechanisms; that is, the morphology, Prosthodontists. Reproduced with Originally, the gnathologists’ beliefs
anatomy, histology, physiology, permission seemed to have been that the shapes or
pathology and the therapeutics of the positions of the teeth were ‘wrong’ and
oral organ, especially the jaws and Charlie Stuart (a prosthodontist) had that the occlusal surfaces of the natural
teeth and the vital relations of the become the leader of the McCollum teeth should be changed. More
organ to the rest of the body’.5 McCollum group. One of his devices was, in effect, appropriate restorations needed to be
is considered to be ‘the father’ of an early pantograph, which allowed made on an elaborate arcon articulator in
gnathology.5 Dr Harvey Stallard, an the tracing of various mandibular order to achieve their preferred goal at
orthodontist, proposed the word movements. In 1934, McCollum and that time, which was to have a bilaterally
‘gnathology’. It is derived from ‘gnathos,’ Stuart produced the first mandibular balanced occlusion. However, partly due
meaning jaw and ‘ology,’ meaning the movement recorder known as the to excessive occlusal wear that was noted
study of, or knowledge of something. ‘McCollum Gnathograph’ (Figure 1). subsequently on following up many of
those full mouth ‘reconstructions’, the
In 1927, Stallard articulated his view that In 1934, Dr Stuart demonstrated his bilaterally balanced occlusion philosophy
in assessing malocclusions, from an mandibular movement recorder at the began to be questioned by McCollum
orthodontic perspective, that the teeth University of Southern California Alumni and Schuyler as well as other
dictated the arc of closure and the meeting. It differed from today’s recorder clinicians.6,8 It was only when the fallacy
position of the mandible in maximum in that anteriorly it had a sagittal plate of applying the ‘bilaterally balanced
occlusion.5 If articulators were to be used with a horizontal stylus. It could record occlusion’ concept to natural teeth was
to reveal mal-positioned teeth, which at the entire capacity of mandibular exposed by the multiple clinical failures
that time were deemed to be causing the movements.5 These movements were (which was probably caused by frictional
problems, then inter-occlusal records were later described by Posselt, as the wear of their ‘occlusal rehabilitations’)
required to mount plaster casts, made ‘envelope of motion’. The night after his that Schuyler, Stuart9,10 and others quietly
from impressions of the teeth, in the presentation, Stuart realized, whilst abandoned their dogmatic approach and
centric relation position, i.e. before any of driving home, that he could make a developed new occlusal philosophies.
the teeth touched one another. recording apparatus, put it on a patient,
record the mandibular movements, 1960 onwards
The prevailing view at the time seemed transfer that information on to an Stuart and Stallard abandoned the
to have been that the feedback articulator and then set the articulator. bilaterally balanced occlusion concept
mechanisms from the teeth were He created this and demonstrated it at for natural teeth and espoused a new
fundamentally bad and had to be the Pacific Coast Dental Conference in set of principles.11 The main principles
avoided by using inter-occlusal 1935 at Long Beach, California. This included that the upper palatal cusps
registrations without the teeth being in resulted in a surge of interest in the new should make firm, even, contacts in the
contact. In other words, the interocclusal ‘science of gnathology’.5 fossae of the lower teeth when the
registrations were taken at a slightly patient bit into their intercuspal position
opened jaw position before any teeth The gnathology group put great store (ICP). The lower incisors and canines
met one another and before they could on the importance of recording the were to make firm contacts with their
cause the jaw to deviate into the transverse hinge axis in the condylar opposite numbers. The buccal cusps of
patient’s normal intercuspal position. regions. Mandibular movements were the lower premolars and molars were to
described in great detail by them. be designed to stamp themselves into
In 1930, Dr Charles Stuart and They emphasised the absolute necessity their opposing upper fossae.11
Dr McCollum developed the first for meticulous recording of maxillo-
semi-adjustable articulator called the mandibular relationships. Various inter- Their new belief was that this
McCollum Gnathoscope. By 1933, occlusal records (‘check bites’) were combination of occlusal contacts would

Vol. 1 0 No . 1 M a r c h 2021 51
 Changes in occlusal philosophies for full mouth rehabilitation

Following a comprehensive review of all

the evidence available in 2006, that
concept was discredited by Lindhe et al.18

In the 1960s, in places like Michigan,

non-working interferences were also
deemed to be causative of
temporomandibular joint TMJ problems
and of clenching and bruxism. Removing
those non-working interferences by
occlusal adjustments or by occlusal
reconstructions was deemed to be
important in alleviating TMJ pain
dysfunction syndrome (TMJPDS).19

Occlusal splint therapy involves making

devices that have no non-working
contacts as well as having even contacts
on the posterior parts of the device and
even contacts of the lower teeth on the
provide the ideal intercuspal position. Earlier history of the anterior part of the device during
In other words, all the teeth should meet importance of canines mandibular protrusion. Prolonged wear
together at the same time in ICP with the Various versions of ‘canine guidance’ had of such a device was deemed to be
mandible being in the ‘retruded axis’ been described in 1890 by von Spee required to make TMJ movements
position (Figure 2). who had referred to the vertical reproducible, as judged by pantographic
overlap/’overbite’ of the canine teeth.3 tracings, before then undertaking a ‘full
During lateral movements of the Gysi was probably the first to describe mouth rehabilitation’ to produce an ‘ideal
mandible from ICP, only the canines the concept of canine-protected occlusion occlusion’ as outlined above. That
were to contact. When the jaw moved, in greater detail.4 However, as often concept still survives in the concept of
e.g. to the left-hand side, the contacts happens in various areas of dentistry, a fabricating a ‘Michigan splint’ for patients
between canines should be sufficiently good idea falls out of fashion only for it to with TMJPDS, even though TMJPDS is
positive to disclude (i.e. stop any contact be allegedly ‘re-discovered’ a generation widely now regarded as having a
occurring) between all the other back or two later. In this instance, it took until multifactorial aetiology.
teeth on both the left and right hand 1958 for D’Amico to re-emphasise the
sides. concept of just the opposing canines In fact, the World Health Organization
contacting during lateral movements of (WHO) recognises tooth grinding (bruxism)
The side towards which jaw movement the mandible, which he presented, in its ICD-10 code as a somatoform
occurred was called the ‘working side’; fallaciously, as a new ‘concept of canine disorder under the ‘mental and behavioural
in this example that would be the left guidance’.12 In the canine guided disorders’ sub-classification. Bruxism is
side. The other side of the mandible in occlusal philosophy, the claimed benefits classified by the WHO as ‘being closely
that movement, i.e. the right side of the of this arrangement included preventing related to other psychogenic conditions
mandible, was then called the ‘non- any force being applied to the opposing such as pruritis (itching), neck stiffness,
working side’.11 Conversely, when the incisors, premolars and molars other than dysphagia and dysmenorrhea’.20 It is clear
jaw moved to the right, the right side of along their long axes.13 that the WHO define bruxism as a
the jaw would then be described as the
psychogenic condition and by inference
‘working side’ and the left side would
Avoiding non-working not particularly amenable to correction
then become the ‘non- working side’.
contacts on teeth through the sort of destructive dental
In the late 1950s and early 1960s, treatment that is involved in ‘full mouth
There was to be no contact on the teeth
avoiding non-axial loading of periodontal rehabilitation’.21
on the non-working sides during any
lateral movements of the mandible. ligaments was deemed to
be highly desirable. That was because Mutually protected occlusion
In other words, this arrangement of many dentists and many periodontists, at In a mutually protected occlusion,
restorations would produce canine that time, thought that non-working side the cusps of the back teeth should close
guided occlusion during lateral occlusal contacts were involved in helping together into centric occlusion (CO)
movements. That was very similar in to create infra bony defects on posterior with the mandible in the centric jaw
concept to the canine guidance concept teeth in those patients who were relation (CR).11
which had been described by D’Amico susceptible to periodontal disease.
in 1958 in a Californian dental journal12 Adjustments to the occlusion to remove In that occlusal scheme:
and again in 1961.13 D’Amico claimed non-working interferences were
that this was a ‘new concept’ but, in fact, deemed to be an important part of 1. The posterior teeth should protect
that was not correct. comprehensive periodontal therapy.14-17 the anterior teeth in maximal

52 Pr i ma r y De n ta l J ou r n a l
 intercuspation without any deflective
occlusal contacts occurring which
might cause an anterior slide in
to the intercuspal position (ICP).
2. The anterior teeth should be crowned
so that they would protect the
restored posterior teeth during
eccentric movements of the mandible.
3. The variation in philosophy here was
that crowned front teeth were to be
barely out of contact (25 microns)
when the back teeth were in maximum
intercuspation (ICP) (Figure 3).
4. In protrusive movements of the
mandible, only the anterior teeth
were to contact one another, without
any parts of the occlusal anatomy of
the posterior teeth meeting during
mandibular protrusion (Figure 4).
5. In lateral excursions of the mandible,
only the opposing canines should
contact one another with all the
other teeth not contacting when those
lateral jaw movements were occurring,
i.e. there should be canine guidance
during lateral jaw movements.

What does centric relation

mean to different
‘authorities’?
Recording the centric jaw relationship
correctly was deemed to be vitally
important if all of the remaining natural
teeth were to be grossly reduced in order
to provide a ‘full mouth rehabilitation’.
That is because there were no
recognisable pairs of sound natural
teeth left to articulate the working casts.
However, the fact is that this very real
the maxilla at an established vertical to a more anterior tooth position would
and difficult clinical problem was,
dimension which is repeatable and ‘lock-in’ the posterior occlusion.23
and is, created by the extensive tooth
recordable’.22
preparations which were involved in
the first place. Peter Dawson used the term ‘long
‘Freedom in centric’ centric’ to describe a roughly similar
In 2013, Palaskar and co-workers controversies and semantics concept to ‘freedom in centric’. Dawson
reviewed the extensive literature on Clyde Schuyler, recognising the taught that this was rarely to be more
centric jaw relation definitions and difficulties in providing very precise than half a millimetre (Figure 5).24
terminology from the 1920s onwards.22 occlusal contacts on restorations,
In their elegant review article they proposed his concept of ‘Freedom in The periodontist Ramfjord and the
noted that there had been decades of Centric’. He stated that ‘there is a flat prosthodontist Ash, who were working
controversy about what ‘centric relation’ area in the central fossae of teeth upon together at Michigan, also advocated
actually meant and how to determine it. which opposing cusps should contact, the idea of a horizontal ‘long centric’.25
which permits a degree of freedom Pullinger et al.26 suggested that an
In summary, confusion reigned about (0.5–1 mm) in eccentric movements intercuspal position anterior to the
where precisely centric relation was and which is uninfluenced by tooth retruded contact position, provided it
its alleged effects on the design of the inclines’.23 This meant that the cusps was delivered with bilateral occlusal
occlusal surfaces of the multiple should meet on a flat area rather than stability, would be desirable.
restorations that were involved. Palaskar immediately contacting other cusps.
and co-workers then proposed their own Schuyler’s view was that incisal To many interested observers these
definition as: ‘Centric jaw relation is the guidance without freedom for teeth to semantic changes in ideology and
most retruded position of the mandible to move from a centric relation occlusion terminology now sounded very much like

Vol. 1 0 No . 1 M a r c h 2021 53
 Changes in occlusal philosophies for full mouth rehabilitation

excurions, their view was there was to One occlusal contact per tooth–usually
be simultaneous contacts on a group of one which had a cusp-fossa relationship–
the canine and premolar and molar teeth was deemed to be sufficient, if coupled
on the side towards which the mandible with good anterior guidance. That
was moving. There was to be no approach could accommodate varying
occlusal contacts on the non-working degrees of group function with only minor
side. In summary, their method of occlusal adjustment being required.31
achieving this outcome involved the
following:
Some other philosophies
1. Multiple preparations were to be
proposed in different cultures
undertaken for full coverage crowns.
and countries
In Japan, Hobo and Takayama took
The incisal guidance was to be
a different view to the gnathologists.
developed intraorally with acrylic
Their belief was that anterior guidance
resin in temporary crowns to ‘satisfy
influenced the working condylar path and
the patient’s aesthetic and functional
that they were mutually dependent
requirements’. Those shapes were
factors.32 They offered their ‘twin-tables
then to be copied when making the
technique’. In this technique, molar
supposedly ‘permanent’ crowns.
disclusion was to be achieved using two
a quiet excuse. That was probably 2. Only anterior teeth were to contact
incisal tables. The first incisal guide table,
because the original waxing techniques during mandibular protrusive
which was labelled the incisal table
involved in the development of elaborate movements.27,28 The idea was that
without disclusion, was used to make
cuspal designs, which were done on this arrangement would spare the
the restorations for the posterior teeth.
rigid models mounted on elaborate crowned back teeth from contacting
The second incisal table termed the
articulators, proved not to deliver that one another during mandibular
incisal table with disclusion was used to
level of precision when placed in the protrusion.
achieve incisal guidance with posterior
mouth. That might well have been 3. Before beginning the reconstruction
disclusion.32-34
because the teeth had exquisitely of the posterior teeth, both maxillary
innervated periodontal ligament canines had to be in good functional
mechano receptors which were largely contact with the opposing lower Occlusal philosophies for
responsible for programming the patient’s canines in centric and in eccentric patients with reduced
new jaw movements with those positions. periodontal support for their
restorations. 4. The mandibular posterior teeth were remaining teeth
then to be restored in harmony with Youdelis et al.15 proposed an occlusal
Sadly, very little mention seems to have the anterior guidance in such a way scheme for patients with advanced, but
been made about the very many teeth that they did not interfere with the treated, periodontitis. The aim here was
that needed to be damaged electively to condylar guidance. to achieve simultaneous inter-occlusal
provide those semantic occlusal 5. The anatomy and shapes of the contact of posterior teeth in the centric
differences. In all probability, a patient’s maxillary posterior occlusal surfaces relation position, with the majority of the
ability to adapt to occlusal changes, were then to be developed after the biting forces being directed axially.
largely due to feedback from their completion of mandibular restorations
periodontal ligament mechanoreceptors, by the functionally generated path Anterior disclusion was to be provided
was probably as important then, as it is technique (FGP) which had been during protrusive excursions and canine
now, but that required adaptive capacity described by Meyer in 1938.30 disclusion was to be provided during
by patients scarcely got a mention. 6. The PMS philosophy advocated the lateral excursions. The cuspal anatomy
use of a non-arcon articulator. was to be so arranged in such a way
Pankey-Mann-Schuyler that if the canine disclusion were to be
rehabilitation principles Versions of this occlusal philosophy were lost through wear or by tooth movement,
In 1960, a different approach to oral further popularised by Peter Dawson,24 then the posterior teeth should drop into
rehabilitation was introduced by Pankey but, once again, little attention seems to group function.
and Mann27,28 utilizing some of the have been drawn to the long-term
principles of occlusion as advocated biologic consequences of these extensive Nyman and Lindhe35 described schemes
previously by Schuyler.8,9 That became tooth preparations being undertaken in for managing extremely advanced
known as the Pankey-Mann-Schuyler order to achieve those questionable periodontitis cases using extensive
(PMS) philosophy of oral rehabilitation.29 occlusal goals. bridgework which involved even contact
The principle change here was that the being provided in the intercuspal
PMS philosophy involved what they Simplifying the occlusal position. No great emphasis was placed
termed ‘group function’ during lateral scheme? upon the other types of contacts that
mandibular movements (as opposed to Wiskott and Belser proposed a simplified should occur. When there were long
canine guidance during those occlusal scheme which reduced the tooth-borne cantilevered restorations
movements). During mandibular overall number of occlusal contacts.31 being made, their aim was to achieve

54 Pr i ma r y De n ta l J ou r n a l
simultaneous working and non-working those attractions might have reinforced mutilations being undertaken just to clear
side contacts on the cantilevered those belief systems. the required area for the provision of the
sections, a sort of posterior balanced long-term unproven ‘all-on-4’ implant
occlusion, but with anterior disclusion Those same drivers are now back in system.
during mandibular protrusion.35 fashion in various aspects of destructive
allegedly ‘just cosmetic’ and also Biologically aware, responsible, ethical
Summary ‘digital dentistry’. These are often being dental professionals need to resist the
There was little proper science promoted with gushing enthusiasm by current attempts by some to try to justify
supporting the justification for many of some dentists with their stated objective the use of new ‘digital dentistry’
those full mouth rehabilitation/occlusal being to provide an allegedly ‘perfect technology, involving unnecessary
views in the past, or indeed at present. occlusion’ and/or a currently destruction of sound teeth, which is
However, many of the advocates for fashionable supposedly ‘perfect smile’. being promoted on new media to
those, seemingly ever-changing, achieve a supposed ‘ideal occlusion’.
occlusal philosophies were very Nauseatingly self-congratulatory Sadly, some of those nauseatingly
articulate, literate, strong characters websites and postings on platforms such destructive ‘full mouth rehabilitations’
with very persuasive skills about the as Facebook, Instagram etc. now show might be better described as being
supposed benefits of their occlusal wholesale destruction of reasonably a ‘full mouth mutilectomy’.
beliefs. healthy teeth in order to achieve some
spurious occlusal outcome, or to cure There is now copious evidence available
One needs to remember that undertaking patients of their alleged ‘cosmetic dental that patients adapt readily to changes in
extensive dentistry was interesting, disease’, usually by means of some their occlusion by additive, rather than
demanded high levels of clinical and ‘porcelain pornography’.36 Other subtractive, bonding techniques. That
technical precision as well as requiring ‘specialist’ publications and narcissistic, important and relevant information
lots of expensive gadgets. It was also self-promotional, commercially driven needs to be understood by any patient
lucrative to provide it. All, or some, of websites now show inappropriate dental for their consent to be valid.

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