Understanding occlusion and factoring it into treatment early on is a fundamental aspect of providing the best care for your patients, improving your clinical success and strengthening your practice as a going concern. This applies to all aspects of dentistry, since there are very few dental treatments that do not involve the occlusal surfaces of the teeth.
Restorative dentistry
Where treatment involves the occlusal surfaces of the teeth, occlusion is relevant.
Put succinctly by Davies and colleagues in 2001, “Successful occlusal management leads to: predictable fitting of restorations and prostheses, longevity and absence of iatrogenic problems, patient comfort and occlusal stability.”
Examination is the prudent place to start, a process that should include examining and recording the occlusion prior to any treatment taking place. Recognising that such methods are best practice, most clinicians use the conformative approach, which is defined as providing restorations that are “… in harmony with the existing jaw relationships.”
Practically speaking, this means providing a restoration that does not interfere with the occlusion of the untreated teeth in the mouth. You may ask why this is best practice. The answer is simply because “… it is the safest [approach]. It is less likely to introduce problems for the tooth, the periodontium, the muscles, the temporomandibular joints, the patient and the dentist.”
For more complex cases, the clinician will have to take a decision whether to adopt a conformative or reorganised approach. To be able to make this decision, an in-depth knowledge and understanding of occlusion is required.
Implant dentistry
In 2006, Handelsman wrote about implant dentistry: “… parafunctional habits will greatly affect the outcome and longevity of the type of reconstruction planned. The opposing occlusion along with the type of restorative materials selected for the final prosthesis will affect the ability of the bone-implant interface to withstand the occlusal load. In the periodontally compromised patient, loss of teeth without replacement leads to lack of posterior support. This often causes an unstable occlusal scheme with mesial drifting of posterior teeth and flaring of anterior teeth with a loss of vertical dimension.”
Then in 2010, Jambhekar et al wrote: “The objectives of implant occlusion are to minimise overload on the bone-implant interface and implant prosthesis, to maintain implant load within the physiological limits of individualised occlusion, and finally to provide long-term stability of implants and implant prostheses. To accomplish these objectives, increased support area, improved force direction, and reduced force magnification are indispensable factors in implant occlusion.”
These two papers, alongside many others, make it clear that consideration of a patient’s occlusion must play an integral part in any treatment plan involving dental implants in order to achieve a successful outcome. In essence, scant regard as to how the occlusal surfaces come together can only lead to a troubled future for such fixed prostheses.
Orthodontics
Peter Dawson, in his book Functional Occlusion – from TMJ to smile design, writes about ‘occlusal disease’, describing it as the number one factor in instability of orthodontic treatment.
Edward Angle, widely recognised as the founding father of orthodontics, defined not only functional occlusion but also malocclusions. His description of the former led to the creation of the specialty of orthodontics as a way of correcting bites that deviated from the ideal. Now, of course, knowledge of further categorisation such as the British Standard Classification of Incisor Malocclusion and Katz’s quantitative modification of Angle’s groupings are significant in practice, while modern day orthodontics embraces not only function (optimal occlusion) but also form (aesthetics).
Writing on the subject of occlusal examination, Davies and colleagues (2001) state: “It is important to emphasise that it is necessary to carry out a full occlusal examination for all orthodontic patients. It is essential to record not only the patient’s habitual bite… but also to record the patient’s ideal jaw relationship. This is done against the benchmark of ideal occlusion.
“Without doing this the dentist or orthodontist cannot fully assess a malocclusion or avoid a potential mistake in treatment planning.”
There is no doubt that "excellent functional occlusion" is central to successful orthodontics and must be considered alongside achieving "stable tooth position, periodontal health, and a beautiful smile with balanced facial features". However, too often, orthodontic cases are completed where the condyles are not properly seated in the fossae.
Understanding occlusion and factoring it into orthodontic treatment from the very beginning should be considered best practice. After all, if you get occlusion right, you’ve eliminated one of the major reasons for failure.
References available on request.