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Annali di stomatologia
 Control factors in removable complete dentures: from the articulation quintet to kinetic contact
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2010-06-01
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2010-06-01
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S. Di Carlo
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 Control factors in removable complete dentures: from the articulation quintet to kinetic contact
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               Control factors in removable complete dentures:
               from the articulation quintet to kinetic contact




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                                                                                                                 on
               Giorgio Pompa, MD, DDS                                             initial neural response to a stimulus is the sensory func-
               Agostino Giovannetti, DDS, PhD                                     tion (3).
               Tina Gentile, DDS                                                  The body responds to various peripheral sensory inputs
               Stefano Di Carlo, MD, DDS                                          by inhibiting certain signs and amplifying others. During
                                                                                  chewing cycles, an enormous amount of stimuli inform the




                                                                                                               zi
               “Sapienza” University of Rome, Rome, Italy                         various neural systems about the control and coordination
               Department of Ondonostomatological and Maxillofacial               of movement. The control system associated with the tex-
               Sciences, Prosthatic Rehabilitation Unit                           ture of the food adjusts the force developed by the eleva-




                                                                                              a
                                                                                  tor muscles of the mandible, and control system associ-
               Corresponding author:                                              ated with the location of food and language avoids trau-




                                                                                           rn
               Prof. Giorgio Pompa                                                matic contact, regardless of the amount of olfactory and
               Via Caserta, 6 - 00161 Rome, Italy                                 gustatory stimuli, the reflex control of saliva, and even the
               Tel: +390649976614 - Fax: +390644230811                            emotional component that creates the need for adaptation.
               E-mail: giorgio.pompa@uniroma1.it                                  The movement of chewing requires a learning period dur-




                                                                                  te
                                                                                  ing the various stages of eruption of the deciduous teeth
                                                                                  and changes therein, after which the subject begins to
                                                                                  make the first masticatory movements.
                                                                                  The masticatory function contributes to the proper devel-
               Summary
                                                                        In        opment of the jaw and significantly affects the positions of
               Control factors in removable complete dentures:                    the structures in the arch. The coordination of motor ac-
               from the articulation quintet to kinetic contact.                  tivity occurs at different times during masticatory move-
                                                                                  ments, and in particular during the final stage of such move-
               Hanau’s laws and the so-called articulation quintet                ments when the arches come into contact during the an-
                                                          ni
               have contributed greatly to the evolution of the pros-             tagonistic phase, maintaining contact until its return to nor-
               thetic dentistry and have been further elaborated by               mal occlusion; this process is called “contact kinetics” (4-
               various authors. The main aim of this study was to                 9).
                                                io


               establish the stability of prosthetic plates by attaining          The learning of the motor pattern that characterizes
               balanced occlusion. Several authors have addressed                 chewing is structured based on the morphology of the oc-
               the problem of removable and fixed prostheses by                   clusal plane (5, 10) - every change brings a new motor pat-
                                      iz



               classifying mandibular movements into functional                   tern to a new phase of adaptation and learning. An opti-
               and parafunctional movements which extends the                     mal prosthesis will ensure that the patient applies the low-
               classical occlusal mechanics for the modern occlusal               est adaptation effort. The occlusal morphology of the pros-
                      Ed




               feedback model. Moreover, they suggest the use of                  thesis should be integrated as far as possible with the con-
               the angle of convergence as a reference plane when                 tact kinetics of the existing occlusion, with studies of the
               manufacturing prosthetic.                                          neuromuscular factors needing to assess the occlusal mor-
                                                                                  phology (4, 5, 10).
               Key words: bruxism, occlusal guidance, occlusal                    One of the greatest contributions to understanding the
               plane, cuspal guidances.                                           anatomical factors that determine the characteristics of the
                                                                                  behavior of the occlusal surfaces during contact was from
         IC




                                                                                  the kinetics analysis of Hanau (1). Hanau’s laws concerning
                                                                                  articulation and Hanau’s quintet have contributed greatly
                                                                                  to dental prosthetics (2, 11), clarifying this heretofore con-
               Introduction                                                       fused area of dentistry by simplifying the construction of
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                                                                                  dentures (Fig. 1). Although Hanau was interested in
               The adaptive capabilities of the patient are critical to the       gnathologic mechanics related to dentures, he considered
               success of prosthetic therapy. Anochin and Agafonow in-            that the articulator of artificial teeth was related to nine fac-
               terpreted the process of adaptation as a series of psy-            tors: (1) horizontal condylar inclination, (2) sagittal condy-
©




               chophysical events triggered by a stimulus that induces a          lar path, (3) plane of orientation, (4) compensating curve,
               behavioral response that serves the dual purpose of restor-        (5) buccolingual inclination of the tooth axis, (6) protrusive
               ing the homeostatic conditions before the stimulus and             incisal guidance, (7) sagittal incisal guidance, (8) alignment
               maintaining them thereafter (8).                                   of the teeth, and (9) cusp height.
               For the adaptive learning process, without which no be-            Hanau mathematically traced the above 9 factors and list-
               havior can be structured, it is essential to establish - through   ed the “laws of balanced articulation” as a series of 44 state-
               the maintenance of a neural engram - a “Gestalt” coordi-           ments. He then reduced the original nine factors to five,
               nation of the various factors underlying the behavior. The         showing how they affect one another using a clearer dia-

               14                                                                                         Annali di Stomatologia 2010; I (2): 14-19
0373 5 Control_Pompa:-     30-11-2010        18:58         Pagina 15




               Control factors in removable complete dentures: from the articulation quintet to kinetic contact




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                                                                        In
               Fig. 1 - The Hanau quintet.
                                                             ni
               gram called the articulation quintet: (1) condylar guidance,       be used to restore the occlusal kinetics relationship; that
               (2) plane of orientation, (3) compensating curve, (4) incisal      is, the way in which the mechanical occlusion acts in move-
               guidance, and (5) cusp height.                                     ments where there is contact between opposing arches
                                                                                  (11). The articulator registrations serve to reproduce the
                                                 io


                                                                                  protrusion and lateral movements such that the dental tech-
               Hanau’s laws of articulation and the quintet                       nician would only fit teeth and compensate for spaces re-
                                                                                  sulting from malocclusion (as in the phenomenon of Chris-
                                       iz



               The articulation quintet diagram illustrates the relationship      tensen) and organize the elements of the quintet (plane
               between the above five factors, and it constituted the first       of orientation, anterior guidance, cusp heights, and com-
               step toward organizing occlusal factors when producing             pensating curve) by Hanau’s scheme.
                      Ed




               dentures.
               The purpose of the present study was to achieve a bal-
               anced occlusion in which the occlusal relationships be-            Boucher concept
               tween antagonist arches are characterized by “balanced”
               contacts, which might contribute to the stability of inferi-       Boucher developed his own concepts and ideas following
               or dentures during chewing.                                        an analysis of the work of Trapozzano and Winter (15, 16,
               The design and realization of a prosthesis with such char-         17). Boucher disagreed with the concept introduced by
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               acteristics required a tool that could restore the lost mo-        those authors that the occlusal plane could be located at
               tion of chewing by ensuring contact between the antago-            various heights to facilitate a weaker ridge, instead rec-
               nistic factors in the centric occlusion (a critical time for the   ommending that the occlusal plane could “be oriented ex-
               stability of the prosthesis) due to the registration of some       actly as it was when there were natural teeth”. He con-
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               anatomical values (Eminence and Bennett-angle inclina-             sidered this approach to be essential to complying with the
               tion) (12).                                                        anatomical and functional requirements.
               To this end, Hanau designed and constructed three ar-              Boucher, unlike Trapozzano and Winter, was convinced of
               ticulators: “Hanau H2-’R”, “Hanau 130-7” no-arcon type,            the need for a compensation curve and declared: “The val-
©




               and “Hanau XP-51” arcon type (Fig. 2). Contact balancing           ue of the compensation curve is that it allows an alteration
               (B) on the nonworking side was needed to improve the sta-          of cusp height without changing the shape of the manu-
               bility of the lower dentures by mounting the teeth according       factured teeth…If the teeth themselves do not have
               to the Monson curve perpendicular to the crestal axe (A).          cusps, the equivalence of cusps can be produced using
               It is possible for cusp inclination to affect the mastication,     a compensation curve”. The concept of Boucher was based
               with the highest inclination inducing lower prosthesis mal-        on the following fixed factors: the orientation of the occlusal
               occlusion on the nonworking side (13-14).                          plane, anterior guidance, condylar guidance, the angula-
               Hanau and De Pietro showed that these articulators could           tion of the cusps, and the compensation curve; which can

               Annali di Stomatologia 2010; I (2): 14-19                                                                                      15
0373 5 Control_Pompa:-    30-11-2010       18:58     Pagina 16




               G. Pompa et al.




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               Fig. 2 - Geometric equivalence of the intercondylar distance on the XP-51 articulator for the registration of the Bennett corner.
                                                         ni
               allow the effective heights of the cusps to increase with-         Occlusal mechanics and parafunctional movements
               out changing the shape of the teeth (15).
                                                                                  Federici and collagues (4, 5, 6) interpreted the quintet and
                                                                                  laws of Hanau based on both the construction and usage
                                               io


               Further evaluations of Hanau’s work                                of removable prostheses, particular in parafunctional pa-
                                                                                  tients. Classifying mandibular movements into functional
               The theory postulated by Hanau has been revised by many            and parafunctional movements, these authors criticized
                                      iz



               authors, each of whom has interpreted the five elements            those who applied only the laws of occlusal mechanics to
               and their relationship with the aim of achieving a balanced        functional movements, pointing out that kinetic contacts
               occlusion in order to stabilize dentures during mastication.       need to be included in a new occlusal feedback model.
                      Ed




               During the 1960s some authors attempted to simplify the            Only in parafunctional movements does kinetic contact oc-
               theory by reducing the number of the occlusal elements.            cur between antagonist arches. The contact is traumatic
               The “triad of occlusion” proposed by Trapozzano and Laz-           because the elevator muscles are activated and exerting
               zari considering only three elements: protrusive incisal guid-     forces. Federici argued that eliminating the reflex inhibi-
               ance, cusp height, and condylar guidance (18, 19, 20, 21)          tion is the first feature of parafunctional movements, and
               (Fig. 3). Levin proposed a diagram similar to that of Hanau        the muscular activity can generate forces greater than those
               that described relations between four of the five original         produced when functioning. In contrast, any barrier (an-
         IC




               elements that dominate the plane of orientation (7). Both          terior guidance, cusp heights, compensation curve or Spee
               Trapozzano and Levin realized the importance of a bal-             curve, or the Monson or Wilson curve) is capped by the
               anced occlusion, and their proposal was similar to that of         action of the horizontal component of parafunctional
               Hanau (Tab. 4).                                                    loads.
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               Lott (22) retained all the elements in the laws of Hanau but       Weinberg suggested using removable and fixed prosthe-
               clarified the posterior separation and unbalanced occlu-           ses that distribute parafunctional loads between the in-
               sion, stating that increased inclination of the condylar guid-     volved elements (23, 24). During lateral movements they
               ance is associated with increased posterior malocclusion           suggested using the group function instead of canine guid-
©




               (Fig 5).                                                           ance in order to avoid contact on the nonworking side, and
               Lauritzen used mounted the artificial teeth using a tech-          placing cusps of the lateroposterior areas in an “anti-Mon-
               nique that differed from that used by Hanau (1). Dorier de-        son” configuration to increase the relation between the oc-
               bated the registration technique of the individual values in       clusal plane and the condylar path (which they referred to
               an edentulous patient through the vallum of wax on the             as the “angle of convergence”) in order to increase the mal-
               “Hanau H2-XPR” articulator, such as the phases of the              occlusion in posterior areas and thereby avoid interference.
               mounting teeth according to the quintet of Hanau to achieve        Tsao solved the problem of balanced occlusion by sug-
               balance according to Lauritzen (10).                               gesting the use of a plane rather than a spherical surface

               16                                                                                        Annali di Stomatologia 2010; I (2): 14-19
0373 5 Control_Pompa:-     30-11-2010        18:58         Pagina 17




               Control factors in removable complete dentures: from the articulation quintet to kinetic contact




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               Fig. 3 - Trapozzano’s triad of occlusion. IG: incisal guidance; CH: cusp height; CP: condylar path.
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                      Ed
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               Fig. 4 - Balanced occlusion laws in the protrusive and lateral positions according to Levin.


               Annali di Stomatologia 2010; I (2): 14-19                                                             17
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               G. Pompa et al.




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               Table 5 - Lott’s intuition about the importance of the malocclusion in posterior sectors.
                                                                      In
               for mounting the teeth in the lower denture (25). The frontal      that the space formed in the posterior areas depends on
               orientation plane of tooth cusps mounted by this method            this angle during protrusive and sagittal movements, when
               is perpendicular to the chewing forces rather than to the          the antagonist arches are in contact.
                                                         ni
               crestal axis according to the theory of classical balancing.       The results of this study can be summarized as follows:
               Chewing then exerts forces predominantly on the lower              1. During the individual value registration on the articu-
               denture, promoting stability, and away from the top den-                lator, the Frankfort plane is replaced by the occlusal
               ture whose stability is guaranteed by a thin layer of sali-             plane.
                                               io


               va.                                                                2. The condylar inclination is recorded on the occlusal
               Federici considered that balancing the contact on the non-              plane rather than on the Frankfurt plane, via the an-
               working side would improve the stability of the lower den-              gle of convergence of the patient.
                                      iz



               ture, since the presence of food during chewing prevents           3. In a total or partial denture, the occlusal plane must
               contact during the nonworking phase.                                    be inclined so as to increase the malocclusion in pos-
                                                                                       terior areas, without considering the occlusal plane ori-
                      Ed




                                                                                       ented parallel to the Camper plane.
               The convergence angle                                              4. Since parafunctional movements can involve totally or
                                                                                       partially edentulous subjects, ensuring the correct con-
               The existence of a kinetic contact between opposing arch-               nection between the occlusal plane and the condyle
               es necessitates a study of the mechanical occlusion in or-              is also important in orthodontic treatment (Fig. 6).
               der to produce a model that would allow the operation of
               the neuromuscular system to be predicted in particular sit-
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               uations (26). Without parafunctional movements, this               Conclusion
               study would be superfluous and the use of articulator would
               be unnecessary.                                                    Separating mandibular movements into functional and para-
               The actions of the top and inferior planes during protru-          functional movements represented a turning point in
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               sive sliding is determined by the total denture, primarily in      gnathologic studies from both theoretical and practical view-
               the sagittal plane (without considering anterior guidance,         points. Considering only kinetic contacts during para-
               the heights of the cusps, or the curve of compensation),           functional movements is justified by the removal of the in-
               according to Christensen’s phenomenon (27, 28). Dorier             hibitory reflex.
©




               described it as follows: “When the mandible is in protru-          Practically all dental prostheses must be functionally and
               sive position, while maintaining contact between the               parafunctionally corrected on the articulator (the elimina-
               bases of the joint, forming a space between occlusal wax-          tion of occlusal interferences). Therefore, the concept of
               es in the posterior area while anterior area is continuous         applying gnathologic mechanics to the function (research
               in contact. This space and the distance of protrusion are          of balanced occlusion and the terminal condylar axis) is
               necessary to measure the angle formed by the condylar              obsolete. With their theory of occlusal feedback, Federi-
               path inclination with respect to the occlusal plane” (10).         ci and colleagues have aligned dentistry with the under-
               Federici mentioned the “convergence angle”, and argued             lying neurophysiology.

               18                                                                                          Annali di Stomatologia 2010; I (2): 14-19
0373 5 Control_Pompa:-      30-11-2010        18:58        Pagina 19




               Control factors in removable complete dentures: from the articulation quintet to kinetic contact




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               Fig. 6 - The use of Federici’s articulator demonstrate the value of convergence angle necessary for Cristensen phenomenon.




                                                                                                rn
                                                                                      14. Xiaojun C, Rubo L, Eryi L, Chengtao W. A mathematical mod-
                                                                                           el of mandibular movement on the Hanau articulator and com-
               References                                                                  puterized simulation system of dynamic occlusion for com-




                                                                                      te
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                   ulation system of mandibular movement on Hanau articulator.             Crristensen’s phenomenon: a geometric-mathematical
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               Annali di Stomatologia 2010; I (2): 14-19                                                                                                19
