Ivanhoe2004

Removable partial denture occlusion
John R. Ivanhoe, DDS* , Kevin D. Plummer, DDS
Department of Oral Rehabilitation, School of Dentistry, Medical College of Georgia,
Augusta, GA 30921, USA
When treating a patient with a removable partial denture, the natural
and artificial teeth, both functionally and esthetically, must coexist in
a harmonious relationship. To achieve this result, the clinician must have
a thorough understanding of the basic physiologic factors that affect the
patient’s occlusion. In reviewing the dental literature, it becomes readily
apparent that this area of dentistry has been discussed frequently and in
great detail, but confusion still exists.
Many differing occlusal schemes, morphologies, and materials have
become popular during the last few decades. Clinicians have become strong
advocates of a particular occlusal scheme, material, or articulator to the
point that they consider any other point of view heretical. Fox [1] perhaps
put it best when he stated, ‘‘The thinking of the dentist is frequently limited
and distorted by such things as the articulator he used, the scheme of
occlusion to which he subscribed, and the clinical experience that may not
have been properly evaluated. He has a tendency to get so deeply involved in
the detail of his work that he fails to maintain the perspective of the general
scene.’’
Clinicians must remember that there are multiple ways, both successful
and unsuccessful, to complete the restoration of a patient’s occlusion. The
goal is to meet the physiologic, functional, and esthetic needs of the
individual patient while applying knowledge, accurate diagnosis, experience,
sound clinical judgment, and meticulous attention to detail [2,3].
Because several terms are used throughout this article, their definition
is necessary [4]. Balanced articulation exists when there is bilateral,
simultaneous, anterior, and posterior occlusal contact of teeth in centric
and eccentric positions. Canine-protected articulation is a form of mutually
protected articulation in which the vertical and horizontal overlap of the
canine teeth disengage the posterior teeth in the excursive movements of the
* Corresponding author.
E-mail address: jivanhoe@mail.mcg.edu (J.R. Ivanhoe).
0011-8532/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.03.008
Dent Clin N Am 48 (2004) 667–683

mandible. Mutually protected articulation is an occlusal scheme in which the
posterior teeth prevent excessive contact of the anterior teeth in maximum
intercuspation, and the anterior teeth disengage the posterior teeth in all
mandibular excursive movements. Group function exists when there are
multiple contact relations between the 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. Lingualized
occlusion is a form of denture occlusion that articulates the maxillary lingual
cusps with the mandibular occlusal surfaces in centric, working, and
nonworking mandibular positions. Monoplane articulation is the arrange-
ment by which teeth are positioned in a single plane.
Diagnosis and treatment planning
There are many steps between the initiation of treatment and completion
of a physiologic occlusion for a patient. Decisions concerning many
treatment options must be made using best clinical judgment. Unless the
clinician begins the treatment with a properly completed diagnosis and
treatment plan, however, all the best decisions, materials, and techniques do
not assure satisfactory results. Information and material required to perfect
a diagnosis and treatment plan include a review of the patient’s medical and
dental history, a full-mouth series of radiographs, a complete clinical
examination, and well-made diagnostic casts that ideally have been aﬃxed
to a programmed semiadjustable articulator using a facebow and proper
interocclusal records.
If the patient exhibits the signs of an ongoing occlusal dysfunction,
preprosthetic treatment is required. Symptoms of occlusal trauma may
include temporomandibular joint dysfunction, pain in the head and neck
area or shoulders, pulpitis, fractured cusps, premature wear or bruxofacets,
mobile teeth, abfraction, or fremulus [5,6,7]. Treatment options may include
medications, physical therapy, occlusal stents, stress reduction or habit
elimination, restorative dentistry, endodontic therapy, periodontal surgery,
extractions, orthodontics, or orthognathic surgery [8].
Additionally, the plane of occlusion must be analyzed and altered as
necessary. Teeth may be rotated, infraerupted, or tipped. These teeth may
require selective occlusal adjustment to correct occlusal prematurities, a ﬁxed
partial denture, intentional devitalization, clinical crown lengthening using
periodontal surgery, orthodontic movement, orthognathic surgery, or
extractions.
A preconceived prejudice toward one particular type of occlusion is not
a valid reason for altering an existing occlusal scheme. An anterior slide of
less than 2 mm from the most retruded contact position to the maximum
intercuspal position is not necessarily a sign of a pathologic condition; both
group function and mutually protected articulations are commonly found in
668 J.R. Ivanhoe, K.D. Plummer / Dent Clin N Am 48 (2004) 667–683

natural physiologic dentitions and do not necessarily indicate a pathologic
condition in the partially edentulous patient [7,9]. The alteration of any
physiologic state may create a nonphysiologic or traumatic occlusion.
Because a classification of the edentulous arches is needed in any
discussion of removable partial dentures, Kennedy’s classifications are used
in this article [10]. A Kennedy class I patient has bilateral edentulous spaces
posterior to the remaining natural teeth; a class II patient exhibits
a unilateral edentulous space posterior to the natural teeth; a class III
patient has a unilateral edentulous space with remaining natural teeth both
anterior to and posterior to the space; and a class IV patient exhibits a single
edentulous space that crosses the midline and has remaining natural teeth
posterior to the space bilaterally. Other edentulous areas are classified as
modification spaces.
Articulator selection
The clinician must choose an appropriate instrument to perform the
pretreatment analysis and treatment planning as well as the actual treatment
phase for each patient. The selection depends on the clinician’s level of
experience with the instrument, the complexity of the treatment to be
performed, and the requirements dictated by the patient’s current condition
[11]. During the diagnostic phase, the articulator provides the information
required for occlusal analysis, aids in correct formulation of diagnostic wax-
ups and other aids, and assists in the final determination of a reasonable
treatment plan. As treatment commences, it permits the fabrication of
physiologic cusp and fossa morphology, correct artificial tooth placement,
and proper positioning, which help assure that the restoration will function
within the range of the patient’s dynamic movements.
The articulator may be used to relate casts in static positions to the
condyles and to simulate paths of mandibular movement in eccentric
positions. The accuracy of the methods used to record static positions or
actual mandibular movements within the envelope of motion dictates the
accuracy of the instrument in simulating mandibular movement. Although
the advantages and disadvantages of articulators and their uses have been
widely discussed [7], it is necessary to discuss briefly the use of these
instruments in removable partial denture occlusion. In this article the
authors use Celenza’s [11] classification of articulators as classes I, II, III,
and IV.
Simple articulator—class I and class II
Class I and class II instruments use a basic hinge opening with fixed
condylar pathways. This instrument may or may not be constructed with
average values to simulate a typical patient. This articulator is used for
limited restorations that will be constructed to follow the patient’s existing
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J.R. Ivanhoe, K.D. Plummer / Dent Clin N Am 48 (2004) 667–683

occlusal pattern. They also are used for monoplane occlusal schemes that do
not require eccentric positions. These simple instruments also are used when
generating an occlusal scheme by the functionally generated path technique,
in which the opposing template has been developed by an actual surface
recording of the patient’s functional movements.
Semiadjustable articulator—class III
Class III instruments are based on average size values and have adjustable
horizontal condylar guides that are set by using a protrusive interocclusal
record. The lateral condylar inclinations are set according to average value
formulas or lateral interocclusal records. These recordings are positional and
do not include information obtained from the patient about the actual
mandibular movement. Therefore more intraoral adjustments may be
expected because of the limited information provided by the positional
recordings. Restorations that may be fabricated using the semiadjustable
articulator include class I, class II, or class III/IV removable partial dentures
for patients whose remaining natural teeth dictate the occlusal movement
(group function or a canine protected articulation). This instrument also can
be used for restorations using monoplane articulation.
Fully adjustable articulator—class IV
This instrument is managed by multiple widely adjustable or customized
components to simulate accurately the actual movements of the mandible.
It can be programmed by tracings or records that capture movements rather
than static positions. It can be used with any theory of occlusion or occlusal
scheme, including balanced, group function, or mutually protected articu-
lations. The proper cusp/fossa/groove morphology can be established on this
instrument to function eﬃciently and harmoniously with the patient’s true
mandibular movements. The fully adjustable articulator allows the fabrica-
tion of the most complex occlusal patterns needed to create a physiologically
acceptable occlusion with the minimum intraoral adjustments.
Interocclusal records
Following attachment of the maxillary cast to the articulator using
a facebow recording, an interocclusal record or occlusal registration is
usually necessary to orient the maxillary and mandibular diagnostic or
master casts to each other properly.
Three widely separated tripod points of occlusal contact are necessary to
relate the two casts accurately. These contact points may be tooth-to-tooth
or tooth-to-interocclusal recording material. A stable orientation of the
opposing casts may exist if suﬃcient teeth remain, and in these patients no
interocclusal relation recording is necessary. It is suggested, however, that

orientation lines be drawn on the casts to guarantee proper cast alignment in
the future. An interocclusal recording will be necessary if insufficient teeth
remain to allow a stable cast-to-cast relationship.
It often is desirable to make the interocclusal relation record before the
fabrication of the removable partial denture framework. Doing so will allow
the laboratory technicians to fabricate and adjust the framework properly
before returning it to the clinician. This process should minimize clinical
adjustments to the framework and in many patients allow complete
fabrication of the removable partial denture without the intermediate trial
insertion appointment.
When a recording is necessary, a record base, occlusion rim, and occlusal
recording material are needed to make the recording accurately. It has been
suggested that the record base be fabricated using autopolymerizing acrylic
resin [12,13], although they often are fabricated of light polymerized resin.
Because a record base is not transferable from one cast to another, the
record base must be made on the cast to be attached to the articulator. The
occlusion rims most often are made using hard baseplate wax.
An interocclusal relation record must (1) be made in either the centric
occlusion position or the maximum intercuspation position, as desired by
the clinician; (2) be made at the correct vertical dimension of occlusion,
whenever possible; (3) allow the accurate and positive alignment of the casts;
(4) be dimensionally stable; (5) be made with a ‘‘dead soft’’ material to
minimize the displacement of displaceable tissues; and (6) be easily used by
both the clinician and the technician [13].
Excellent occlusal recording materials include zinc oxide eugenol impres-
sion material, plaster impression material, modeling compound, polyether,
and polyvinyl siloxane. Wax records made in edentulous areas with or without
the support of record bases may not be sufficiently stable to be acceptable.
The interocclusal recording is most often made after fabrication of
the removable partial denture framework. Following the fitting of the
framework and the making of a corrected cast impression (if indicated), the
record base is fabricated on the edentulous areas of the framework/master
cast. Occlusion rims are added, and an occlusal recording material is used to
make the record. The cast is oriented to the opposing cast with the
recording, and desired denture teeth are selected. This fabrication is
followed by a trial insertion appointment.
Selection of denture teeth
Choice of materials
Occlusal surfaces have been made of wood, ivory, porcelain, acrylic
resins, and gold [14,15]. In more recent years glass ceramics [16] and
composite materials [17] have been recommended.
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The factors that influence the choice of materials for occlusal surfaces for
removable partial dentures have been discussed in many articles [18–20].
Modern acrylic denture teeth, hardened by cross-linking agents, are
resilient, wear-resistant, natural-sounding in function, and possess excellent
esthetic properties. They are easy to adjust, can be recontoured when
necessary, and polish simply with little effort. Acrylic resin teeth can easily
be recontoured for limited space applications or when metal components of
the removable partial denture framework need to be closely approached.
The acrylic resin teeth bond chemically to the denture base resin; the
bonding prevents staining and leakage around that junction. Acrylic resin
has a low abrasion resistance, however, and can wear rapidly in some
patients. It is preferred that acrylic resin denture teeth oppose other acrylic
resin teeth; occlusal wear should be monitored more closely when they
function against natural teeth or restorations using porcelain or metal
occlusal surfaces. Proper function of the occlusal relationships must be
checked more frequently when acrylic resin teeth are used.
Porcelain denture teeth have a high abrasion resistance and exhibit
minimal wear. They are esthetic and match the porcelains used for fixed
restorations. They may sound unnatural to the patient; are brittle; may chip
or crack, and are difficult to adjust, recontour, and polish. Porcelain teeth
do not bond chemically with the denture base resin but are mechanically
retained with diatoric holes or pins. They may stain dramatically at the
tooth-to-base interface. They are not suited for patients with minimal
interocclusal space or those in whom extensive adjustment is needed to
approximate a minor connector or precision attachment. Porcelain may
cause severe wear of opposing natural teeth if the glaze is broken during
adjustment of the occlusal surface. To maintain a stable occlusion, it is
extremely important to smooth and polish highly any surface on which the
glaze has been broken [21].
Cast metal (eg, type III gold, type IV gold) is another material choice for
the occlusal surface of artificial posterior teeth. Although there are certain
disadvantages, such as additional technical procedures required for fabri-
cation, unacceptable esthetics for some patients, and the cost of the alloy,
there are some advantages. Because the technician waxes the occlusal
surfaces, they can be custom made to fit any occlusal scheme. Highly
polished metal surfaces cause minimal wear to opposing surfaces of natural
teeth, other metals, acrylic resins, or porcelain. Polished metal has high
abrasion resistance and can be used when the clinician might be concerned
about future loss of vertical dimension. They can be used in removable
partial dentures made for patients with reduced interocclusal space. Cast
surfaces also are easily adjusted and polished. In addition, patients state that
the cast surfaces feel and sound natural during function.
Another option similar to cast metal occlusal surfaces is using cast
ceramic surfaces to improve the esthetic results of the occlusal restorations.
The denture occlusal surfaces are reduced and prepared to accept an onlay

type restoration as with a metal occlusal surface. The wax patterns
generated are cast in ceramic material instead of metal. They are adjusted
and cemented to the acrylic resin denture teeth using a dual-curing
composite resin cement. This surface treatment may be useful when there
are opposing surfaces of existing ceramic materials [16].
Choice of occlusal schemes and morphologies
Occlusal schemes include balanced articulations [22], a neutrocentric
occlusion [23], a unilateral balanced articulation [24], a mutually protected
articulation [25], a canine-protected articulation [26], an occlusion in which
centric occlusion coincides with centric relation [25], or an occlusion with
a long centric [27]. Multiple occlusal morphologies that range from
mimicking the natural unworn dentitions to using metallic blades for
improved efficiency have also been advocated [28,29]. The occlusal
morphology of the artificial teeth must be capable of creating the type of
occlusal scheme desired.
Posterior denture teeth may be obtained with occlusal morphologies
varying from a monoplane form (0(), to a semianatomic form (10(–30(), to
a completely anatomic form (30(–45() [30]. Depending on the occlusal
morphology of the tooth selected, differing occlusal articulations have been
advocated ranging from multiple functional excursive contacts (balanced) to
minimal excursive contacts (monoplane). The form of articulation termed
lingualizedocclusionhasalsobeenadvocated[31]andisgrowinginpopularity.
DeVan [23] initially described a monoplane articulation that he termed
neutrocentric. With this type articulation, some recommend that all teeth be
set on a flat plane [23,32], whereas others recommend a stabilizing curve or
distal ramps to obtain some degree of balanced articulation [30,33,34].
Monoplane articulation consists of monoplane teeth set on a flat plane. It
offers less chance of prematurities during function and unrestricted freedom
of movement from the retruded contact position to the maximum
intercuspation position. Monoplane teeth are less esthetic than anatomic
teeth and do not permit balanced or group function. When there are no
cuspal inclines to contact during functional movements, some believe that
lateral destructive forces are decreased [23,32]. Others, however, argue that
there is an increased lateral component of jaw movement during function by
patients with monoplane teeth [35]. Nonanatomic teeth are seldom indicated
for use in removable partial dentures unless they oppose a complete
denture or removable partial dentures with monoplane articulation or if
a monoplane type lingualized occlusion is being developed.
Anatomic teeth can be placed to create a balanced, group function or
a mutually protected articulation. The cuspal angulation, fossae, and
working and idling grooves can be modified to permit any desired occlusal
scheme. These teeth are claimed to be more efficient in mastication [36],
although this claim has not been proved despite of numerous investigations
673

[37,38]. Anatomic teeth are indicated for partially edentulous patients for
whom esthetics is an important consideration, when a balanced or group
function articulation is desired, when anterior guidance from natural teeth is
present, or when artiﬁcial teeth must harmonize with existing natural cuspal
inclinations.
Semianatomic denture teeth are fabricated with numerous cuspal
morphologies. These teeth lie between monoplane and anatomic teeth as
far as advantages, disadvantages, indications, and contraindications are
concerned.
Lingualized occlusion is named because the functional elements of the
maxillary posterior teeth are the lingual cusps. Even in a balanced articulation
the buccal cusps of the maxillary teeth do not contact the mandibular teeth.
Generally anatomic or semianatomic maxillary and mandibular posterior
denture teeth are used to develop this occlusion. If a monoplane-type
lingualized occlusion is desired, monoplane mandibular teeth are used, and
anatomic maxillary teeth are used for esthetic and functional purposes.
Lingualized occlusion enjoys many of the advantages and few of the
disadvantages of both the balanced and neutrocentric articulations [5].
Position of natural teeth
Within reason it is desirable to place artiﬁcial denture teeth in close
proximity to the original position of the natural teeth. Therefore it is helpful
to know the average location of the natural dentition.
Landmarks for the anterior teeth
The incisive papilla is an important landmark for the maxillary anterior
teeth. With few exceptions the incisive papilla bisects the midline of the
natural dentition. In the authors’ experience, almost without exception, if
the incisive papilla does not coincide with the midline of the face, it also does
not indicate the midline of the natural dentition. Another potentially
important anatomic feature of the incisive papilla is the distance between
the most anterior border of the incisive papilla and the labial surface of the
central incisors. This distance varies from 5 to 7 mm.
Also the average distance from the depth of the labial vestibule,
immediately lateral to the labial frenulum to the incisal edge of the
maxillary central incisor is 22 mm. In extremely small individuals it may
be as small as 18 mm [39].
Landmarks for the occlusal plane
Guides in reestablishing the occlusal plane have included the retromolar
pad, the parotid papilla, and the commissures of the lips. The occlusal plane

(as established by projecting a line from the tip of the mandibular canine
through the tip to the distolingual cusp of the most distal mandibular molar)
almost always aligns with the middle to upper one third of the retromolar
pad. The occlusal plane also falls approximately 4 mm inferior to the
parotid papilla. The papilla also lies between the distobuccal cusp of the
maxillary first molar and the mesiobuccal cusp of the maxillary second
molar. The occlusal plane is located within 4 mm, either superiorly or
inferiorly, of the commissure of the lips when viewed frontally [40].
Landmarks for the posterior teeth
The maxillary tuberosity and retromolar pads are important landmarks
for the natural dentition in the posterior teeth. Roraff [39] demonstrated
that the maxillary tuberosity lies immediately posterior to the lingual cusp of
the maxillary second molar. This landmark is generally useful but becomes
less reliable as atrophy increases. The retromolar pad is the anatomic
landmark used most frequently as a guide for reestablishing maxillary
posterior tooth position. Pound [41] found that the triangle established by
lines drawn from the cusp tips of the mandibular canines to the lingual and
buccal aspects of the retromolar pad includes the lingual cusps of the
mandibular molars in the natural dentition.
Positioning the artificial teeth
Ideally the artificial teeth would occupy the same anatomic position as
the natural dentition. Because of phonetic and esthetic requirements,
changes in occlusal demands, altered alveolar ridge anatomy and relation-
ships, and decreased ability to withstand occlusal forces, such placement is
often not possible. Compromises, such as decreased vertical overlap of the
anterior teeth, bilateral reverse articulations, and decreased numbers of
artificial teeth, are often necessary. Natural tooth contacts that are present
without the removable partial denture inserted must be present with the
removable partial denture inserted. These contacts may be evaluated with
articulating paper or shim stock.
Anterior teeth
The position of the maxillary anterior teeth is dictated by the esthetic and
phonetic requirements of the patient but must function in harmony with the
remaining dentition. Many authors have offered guides for creating
outstanding esthetic results [42,43]. It has been recommended that 1 to 3 mm
of the incisal edge of the maxillary central incisors be visible when the
patient’s lips are in a relaxed position. During the ‘‘f’’ and ‘‘v’’ sounds the
incisal edge should contact the junction between the transitional epithelium
675

and the oral mucosa of the lower lip (wet/dry line). The incisal edges should
be positioned to support the lips and give the patient a natural profile.
Pound’s /S/ position is an excellent guide in positioning the mandibular
anterior teeth [44]. He details a technique that, using phonetics, relates the
mandibular teeth to the maxillary anterior teeth. He explains that ‘‘the /S/
sound is a subtle whistle which is created when air is forced through a 1 to
1.5 mm space between the incisal edges of the lower central incisors and the
coronal surfaces of the upper central incisors. It is the most forward, most
closed position of the mandible during speech.’’
Difficulty often is encountered when a tooth must be set between two
remaining natural teeth. The width of the edentulous space may be too
narrow for the denture tooth selected because of natural tooth migration,
requiring that the mesial and distal surfaces of the denture tooth be
narrowed by grinding and that the proximal surfaces of the natural teeth be
reduced slightly to increase the width of the embrasure.
Plane of occlusion
For patients with removable partial dentures, the plane of occlusion is
frequently established by the remaining natural dentition, especially in
Kennedy class III and class IV patients. For Kennedy class I and class II
patients, however, the plane must often be reestablished. When an occlusal
plane must be reestablished, a line may be drawn from the incisal edge of the
cusp tips of the most distal natural teeth to the middle to upper one third of
the retromolar pads. To provide acceptable room for positioning the
posterior artificial teeth or to favor the weaker arch, it may be necessary
to alter the position of the occlusal plane by either raising or lowering the
posterior determinates. Ideally, the plane of occlusion equally divides the
available interarch space.
Posterior teeth
For esthetic, phonetic, and functional reasons, the posterior teeth on
a removable partial denture should be positioned to harmonize with any
remaining natural dentition. Not every natural tooth that is lost must be
replaced with an artificial tooth. Only teeth required for esthetic, phonetic,
and functional purposes should be used. For class I and class II removable
partial dentures, any remaining opposing natural teeth dictate the placement
of the artificial teeth. The established plane of occlusion should be used to
position the artificial teeth vertically for patients with no remaining natural
posterior teeth [45]. To direct forces of occlusion in a favorable vertical
direction, the denture teeth should be centered over the residual ridge in
a medial lateral direction. The lingual cusps of the mandibular teeth are
positioned within the confines of a triangle established by drawing lines
from the buccal and lingual borders of the retromolar pads to the cusp tip of

the canines. Because of severe changes in the relationship of the ridges
caused by resorption, it is not always possible to obtain an acceptable
occlusion and still position the center of both the maxillary and mandibular
teeth over the residual ridges. The mandibular ridge should be favored when
a compromise becomes necessary.
Because of a limited choice of diﬀering tooth morphologies and the desire
for custom occlusal contacts to maximize function, it is often necessary to
position the teeth initially at an excessive vertical dimension of occlusion
(approximately 0.5 to 1 mm) and then to equilibrate the denture teeth until
the correct vertical dimension of occlusion is regained. This process creates
what often is referred to as a tight centric occlusion.
Another common problem encountered when positioning artiﬁcial teeth
for a removable partial denture is the need to position the tooth adjacent to
a clasp assembly. In these situations it is often necessary to custom grind the
tooth to encompass the clasp assembly partially. As much crown length and
facial surface as possible should be retained for esthetic reasons.
Functionally generated path
The functionally generated path is a method of developing occlusal
relationships on simple instrumentation without using a semi- or fully
adjustable articulator that has been programmed to match the patient’s
mandibular movements [46,47]. Using the removable partial denture frame-
work as a base, a dynamic recording of the occlusal patterns is generated in the
patient’s mouth under normal functional conditions. The patient’s own
functional jaw movements are used to form a three-dimensional opposing cast
or template. Although this record looks somewhat bizarre, it represents the
dynamics of mandibular movement and eliminates the need for an articulator
capable of eccentric movements. Using this type of opposing cast allows the
creation of any occlusal scheme and minimizes intraoral adjustments. Caution
must be exercised when using this technique to ensure that centric occlusal
contacts are not lost when denture teeth are adjusted or cast surfaces are
created to conform to the opposing template [48]. When both arches are being
restored, one arch must be completed before the opposing arch can be started.
To use this technique the removable partial denture framework is
adjusted, and an accurate and stable denture base is attached to the
framework. This work is completed using the master cast. After the denture
base is adjusted intraorally, an occlusal rim is added to support the
recording material that will be used to capture the occlusal patterns. The
occlusal surface is adjusted intraorally so that there is occlusal contact in
the centric occlusal position and during all excursive movements. The
patient wears the removable partial denture base, and functional recordings
are made over a 24-hour period with the exception of meals. The completed
functionally recorded surface will be shiny or burnished and somewhat
677

wider than the normal occlusal table. The final recording is reseated on the
master cast with the removable partial denture framework and secured in
the proper position. The record area is boxed, using clay or wax, to include
areas of the master cast that will serve as vertical stops. This step guarantees
maintenance of the vertical dimension of occlusion. Die stone is poured into
the boxed record to create an opposing template. The resulting working
template and master cast is attached to any type of articulator before the
newly poured template is separated from the master cast/framework record.
The record is removed, and the occlusal surface of the prosthesis is
fabricated on the denture base and adjusted to this template.
Cast gold occlusal surfaces
Although cast gold occlusal surfaces offer many advantages, they are
seldom used because of their cost, technical complexity, and esthetic results.
The authors have included this technique because they believe that it has
value. Because little has change in the last 20 years the following excerpt is
taken directly from a previous article by one of the authors [49].
It is possible to establish cast gold occlusal in various ways, including the
following [50–54]:
1. The surfaces may be purchased prefabricated and incorporated into the
occlusal portion of the denture teeth during fabrication of the removable
partial denture.
2. The occlusal surface of acrylic resin denture teeth can be replicated in
gold and incorporated into the partial denture either during initial
processing or after an adjustment period during which the patient wears
the removable partial denture for two to four weeks.
3. The surfaces can be custom fabricated, opposing a template by the
functionally generated path technique.
4. The surfaces can be custom fabricated by use of an opposing anatomical
cast and a fully adjustable articulator.
Although cast gold occlusal surfaces may be fabricated before delivery of
the removable partial denture, the following technique offers a more stable
occlusion. The partial denture is fabricated using acrylic resin artificial teeth,
delivered, and adjusted as necessary for several weeks. The partial denture is
then returned to the previously programmed articulator using remount casts,
and a new jaw relation record is made as closely to the vertical dimension of
occlusionaspossible.Theacrylicresinposteriorteetharereduced1.5to2mm,
and the individual occlusal surfaces are carved in wax or created via the fluid
or drop wax technique. Mechanical retention is created. The occlusal surface
is invested, cast, finished, and polished. The gold occlusal surface is then
attached to the reduced acrylic resin teeth with autopolymerizing acrylic
resin, assuring that the established occlusal relationships are retained. The
cast surfaces are refined on the articulator, and any necessary intraoral
adjustments are made to ensure the desired physiologic results.

With this technique, the occlusal table can be created to any desired
width. Occlusal morphology can have any desired cuspal angulation, cuspal
height or position, and groove placement. Occlusion can be created or
restored to any desired scheme.
Preliminary objectives for establishing an occlusal scheme
The following seven objectives should be met when establishing an
occlusal scheme:
1. If a physiologic state exists, maintain the patient’s maximum
intercuspal position. Maximum intercuspation also is an acceptable
position for treatment if the patient has no symptoms of dysfunction,
and the clinician is not in complete control of the occlusal position, as
with complete dentures or full-mouth rehabilitation. If centric occlusion
must be reestablished, it must be coincidental with centric relation.
2. Bilateral simultaneous contacts of the opposing anterior and posterior
teeth should be established in restored occlusion. Anterior points of
contact should be passive and should not assume any of the occlusal
load. Multiple points of posterior occlusal contact improve chewing
efﬁciency and decrease the potential for wear. If a complete denture is
part of the ﬁnal restoration, anterior occlusion must be controlled by the
complete denture occlusion scheme used by the clinician.
3. Do not alter a patient’s existing occlusal scheme in lateral movement
unless such alterations are needed to correct a nonphysiologic
condition. Both canine-protected and group function articulations are
commonly found in natural physiologic dentitions.
4. If the restoration must reestablish lateral guidance, canine-protected
articulation is preferable when the remaining natural canines are
present and not periodontally compromised or if implant replacement
of the canines is part of the restoration. Canine guidance reduces
horizontal forces on posterior teeth and promotes a more vertical
chewing cycle. This articulation scheme results in greatly diminished
lateral stresses on the posterior teeth and ridges and reduced occlusal
wear. With no posterior contacts in lateral movement, any posterior
occlusal morphology can be used, and the selection of the articulator is
less critical.
5. Establish group function or a unilateral balanced articulation for
patients with missing canines being replaced by a removable prosthesis
or periodontally compromised canines that will be maintained. Use
either a fully adjustable articulator programmed with a pantographic
tracing or with a simple articulator using the functionally generated
path technique to establish the occlusal scheme for these patients.
6. Do not establish nonworking contacts on remaining natural teeth
unless these teeth are opposed by a complete denture for which bilateral
balanced articulation is desirable.
679

7. When there are healthy remaining natural anterior teeth, posterior
tooth contact during the protrusive movement is not desirable. For
patients with an opposing complete denture, protrusive contacts may be
necessary to achieve a balanced articulation.
Determining the occlusal scheme
The number and positions of the remaining natural teeth in both the arch
in which a removable partial denture is being fabricated and the opposing
arch determine the necessary occlusal scheme. The following occlusal
schemes are recommended [20]:
1. Class III removable partial denture
a. The occlusal morphology of the artiﬁcial teeth is selected to match
that of the opposing teeth or surfaces.
b. If the existing occlusion is physiologically healthy, the patient is
restored to the existing occlusal scheme, which may be group
function or mutually protected.
c. A group function articulation is recommended if the patient’s
natural canine is missing or periodontally compromised.
d. A balanced articulation is recommended if the restoration is to
oppose a complete denture. Some clinicians believe that balanced
articulation is not desirable or clinically obtainable and select
a monoplane or lingualized occlusion.
2. Class II removable partial denture. The recommendations given for
class III are appropriate, with the following exceptions:
a. Group function articulation should be avoided when there are no
remaining premolars. A canine-protected articulation reduces the
destructive lateral forces that are generated on the distal extension
during function.
b. Except when opposing a complete denture, a balanced articula-
tion should be avoided to prevent nonworking contacts on
natural teeth.
3. Class I removable partial denture. The recommendations given for
classes II and III are appropriate with the following exception:
a. Balanced articulation is recommended for patients for whom
canine-protected articulation is not possible to provide bilateral
occlusal contacts for increased denture stability.
4. Class IV removable partial denture
a. During excursive movements the anterior artiﬁcial teeth should
either disocclude or have passive occlusal contact.

b. A balanced articulation is recommended if the restoration is to
oppose a complete denture. Some clinicians believe that balanced
articulation is not desirable or clinically obtainable and select
a monoplane or lingualized articulation with no anterior tooth
contact in function.
Summary
No single occlusal morphology, scheme, or material will successfully treat
all patients. Many patients have been treated, both successfully and unsuc-
cessfully, using widely varying theories of occlusion, choices of posterior tooth
form, and restorative materials. Therefore, experience has demonstrated
that there is no one right way to restore the occlusion of all patients.
Partially edentulous patients have many and varied needs. Clinicians
must understand the healthy physiologic gnathostomatic system and
properly diagnose what is or may become pathologic. Henderson [3] stated
that the occlusion of the successfully treated patient allows the masticating
mechanism to carry out its physiologic functions while the temporoman-
dibular joints, the neuromuscular mechanism, the teeth, and their support-
ing structures remain in a good state of health.
Skills in diagnosis and treatment planning are of utmost importance in
treating these patients, for whom the clinician’s goals are not only an
esthetic and functional restoration but also a lasting harmonious state.
Perhaps this was best stated by DeVan [55] more than 60 years ago in his
often-quoted objective, ‘‘The patient’s fundamental need is the continued
preservation of what remains of his chewing apparatus rather than the
meticulous restoration of what is missing, since what is lost is in a sense
irretrievably lost.’’
Because it is clear that there is no one method, no one occlusal scheme, or
one material that guarantees success for all patients, recommendations for
consideration when establishing or reestablishing occlusal schemes have
been presented. These recommendations must be used in conjunction with
other diagnostic and technical skills.
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