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Anterior-canine guidance for complete dentures

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Introduction

The most important change in thinking regarding anterior-canine guidance has been the abandonment of the concept of completely balanced occlusion. The completely balanced occlusion advocatedby Lauritzen has been partially replaced in modern full dentures by anterior-canine guidance, which was proposed by Swap, Stuart and later by Gausch. However, it is still controversial.

Anterior-canine guidance was introduced in Germany by Gutowski. Long-term studies (according to Gutowski) showed that occlusion and, in particular, centric condyle position (CCP) are more stable compared with other occlusion concepts.
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The problem

Since Gysi, setting up the teeth on the alveolar ridges is still often taught and practiced quite dogmatically in universities.

If the teeth are set up over the alveolar ridges, this often leads to far oral positioning of the teeth with narrowing of the tongue space and a poor aesthetic appearance (Grunert 2000).

Muscle equilibrium and muscle freedom are most important for the functional and aesthetic result.

Certain conditions must be met:
  • Correct positioning of the incisal edges of the lower incisors in the gap between the lips. This allows the vertical dimension to be determined correctly.
  • The axial inclination of the lower incisors must be noted. To ensure muscular support, the tongue space must not be narrowed.
  • The inclination of the condyles and occlusal plane must be noted. This is essential for adjusting the anterior-canine guidance. In edentulous patients, the condylar inclination is determined by axiography so that the anterior-canine guidance can then be matched optimally.
  • Correct occlusion must be maintained for denture retention, protection of the denture-bearing area and denture adaptation.

Concept

This occlusion concept, promoted by Gutowski, is based on the assumption that
  • When the vertical dimension is correct, the closing bite position of both jaws is in a functional condylar axis position.
  • The teeth touch each other at the same time.
  • The distance between the anterior teeth is 50 µm.
  • Disocclusion of the posterior teeth is produced when there are eccentric movements over much shallower guidance elements in the anterior-canine region.
  • The anterior guidance should not be 10° steeper than the slope of the condylar path.
  • The canine guidance, on the other hand, should not be steeper than 35 degrees compared with the slope of the condylar path.
  • Anterior-canine guidance is much easier to achieve and functions very well in the patient.
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Advantages of anterior-canine guidance

(after Grunert I)

  • Simple and fast tooth set-up
  • Faster grinding in of the dentures is possible for reassembly
  • During excursive movements such as pro- and laterotrusion there is agreement between the articulator and the oral situation provided the articulator is programmed following previous axiography. This minimizes traumatic shear forces on the denture-bearing area, ultimately reducing bone atrophy.
  • Anterior-canine guided dentures lead to a switch to a more vertical chewing pattern. This also diminishes traumatic horizontal shear forces on the denture-bearing area (Grubwieser, Flatz, Grunert et al. 1999).
  • In addition, the denture-bearing area is protected by the reduction in the activity of the muscles of mastication, which is important especially in the event of bruxism (Grunert et al. 1994).
  • The denture can also be worn at night because of the reduced loading of the denture-bearing area and soft tissue.
  • Usually better and more natural appearance
  • Smaller number of relinings required
  • The survival rate of anterior-canine guided dentures, at 90% after a mean time in situ of 7.1 years (Grunert 1999, 2000, Grunert and Bösch 2001), is better than that of dentures with balanced occlusion, only about 50% of which were still worn after 6.7 years.
  • Patient acceptance is higher than with the conventional procedure (Peroz et al. 2003).

Summary

Whether complete dentures fulfil their function or not does not depend only on the occlusion concept, but it is an important aspect.

There has been no scientific evidence in the recent literature that bilateral balanced occlusion is the ideal occlusion concept for complete dentures so it not essential for successful denture treatment.
Despite the good results achieved with canine-guided complete dentures, this does not mean that bilateral balanced occlusion has lost its reasons for use. Rather, the dentist should select the occlusion concept that appears most suitable for the patient.


The number of traditional and modern occlusion concepts is large. The concepts differ and are sometimes contradictory, and most of them are controversial.
In 2009 Carlsson referred to the tried and tested concept of bilateral balanced occlusion for complete dentures, which he regarded as essential for successful treatment. The concept of bilateral balanced occlusion is not, however, based on strictly scientific evidence but rather on decades of clinical observation. The prevailing view was that canine-guided dentures must be avoided as they are associated with functional instability and reduced masticatory force.
The attitude that is encountered more and more often at present is that the conventional ways of tooth set-up with balanced occlusion concepts should be abandoned as more recent studies show that dentures can function very well without bilateral balanced occlusion.

Study results

It was said of bilateral balanced occlusion that it has more effective masticatory force (due to a greater number of masticatory surface contacts with every movement), but no study has been able to confirm this effect.

As regards patient satisfaction, no differences were found between bilateral balanced and canine-guided occlusion.



The occlusion concept has only slight influence overall on mastication and patient satisfaction.

According to Pound, bilateral balanced occlusion produces a good concentration of masticatory forces, which is believed to protect alveolar bone from resorption. No study has confirmed this thesis.

Patients with parafunctions may possibly benefit from bilateral balanced occlusion. However, this assumption has yet to be investigated and confirmed scientifically.

Prospects

Further studies on this very complex topic are required before a final and comprehensive conclusion can be drawn and a recommendation made regarding the choice of occlusion concept for complete dentures. Studies conducted to date focused on the factors masticatory force, aesthetics and phonetics. Other important influencing factors that should be investigated scientifically include:

→ Mucosal resilience
→ Structure of the alveolar ridge
→ Degree of ridge atrophy
→ Parafunctional activities

Randomized controlled studies: comparison of bilateral balance occlusion and canine guidance in total prosthetics (Farias-Neto et al. Am J Prosthodont 2012)
  1. Trapozzano, 1960, USA
    Masticatory capacity and patient assessment of own mastication
    No differences
  2. Motwani and Sidhaya, 1990, India
    Masticatory capacity
    No differences
  3. Compagnoni et al., 2002, Brazil
    Patient survey regarding subjective mastication
    No differences
  4. Peroz et al., 2003, Germany
    Patient survey regarding the aesthetic appearance, denture fit, mastication and phonetics
    Better result with canine-guided dentures
  5. Heydecke et al., 2007, Germany
    Patient survey of subjective mastication
    Better result with canine-guided dentures
  6. Rehmann et al., 2008, Germany
    Patient satisfaction
    Better results with bilateral balanced occlusion
  7. Farias-Neto et al., 2010, Brazil
    Effectiveness of mastication and patient satisfaction
    No differences


sources

  • Carlsson GE (2009) Critical review of some dogmas in prosthodontics. J Prosthodont Res 53:3-10 PMID:19318064
  • Compagnoni MA, Leles CR, Barbosa DB (2002) Changes in occlusal vertical dimension in microwave processing of complete dentures. Braz Dent J 13:197-200 PMID:12428596
  • Dapprich J (2004)Totalprothetik – die weiterentwickelte Lauritzen-Methode, ZMK online Ausgabe 10
  • Farias Neto A, Mestriner Junior W, Carreiro Ada F (2010) Masticatory efficiency in denture wearers with bilateral balanced occlusion and canine guidance. Braz Dent J 21:165-169
  • Farias-Neto (2013) Complete Denture Occlusion: an evidence-based approach. J Prosthodont 22:94-97 PMID: 22984917
  • Grubwieser G, Flatz A, Grunert I (1999) Quantitative analysis of masseter and temporalis EMGs: a comparison of anterior guided versus balanced occlusal concepts in patients wearing full dentures; J Oral Rehabil
  • Grunert I, Kofler M, Gausch K (1994) Masseter and temporalis surface elektromyography in patients wearing full dentures comparing anterior and posterior occlusal concepts; J Oral Rehabil 1994
  • Grunert I (1999) Wissenschaft und Praxis von Front-/Eckzahnkontrollierten Totalprothesen, Zahnarzt Prax Intern 1999
  • Grunert I (2000) Fortschritte in der Rehabilitation des Zahnlosen; Mag Zahnheilk Manag Kult, 2000
  • Grunert I, Bösch H (2001) Front-Eckzahngeführte Totalprothesen – ein praxisnahes Konzept. Quintessenz Zahntech 6:632-640
  • Grunert I (2008) Eckzahngeführte Zahnaufstellung in der Totalprothetik, Quintessenz Zahntech 8:966-975
  • Grunert I (2011) Front-Eckzahngeführte Totalprothesen – was sonst ?. Quintessenz Zahntech 11:1460-1465
  • Gysi A (1948) Das Aufstellen der Zähne für Vollprothesen, Zürich: Schweizerische Techniker Vereinigung
  • Hofmann M, Knauer G (1990) Studies on canine guidance in complete dentures. Dtsch Zahnarztl Z 45:566-570
  • Motwani BK, Sidhaye AB (1990) The need of eccentric balance during mastication. J Prosthet Dent 64:689-690
  • Peroz I, Leuenberg A, Haustein I (2003) Comparison between balanced occlusion and canine guidance in complete denture wearers – a clinical randomized trial. Quintessenz Int PMID: 14620212
  • Peroz I, Leuenberg A, Haustein I (2003) Comparison between balanced occlusion and canine guidance in complete denture wearers – a clinical randomized trial. Quintessenz Int PMID: 14620212
  • Pound E (1954) Lost-fine arts in the fallacy of the ridges. J Prosthet Dent 4:6-16
  • Rehmann P, Balkenhol M, Ferger P (2008) Influence of the occlusal concept of complete dentures on patient satisfaction in the initial phase after fitting: bilateral balanced occlusion vs canine guidance. Int J Prosthodont 21:60-61
  • Sutton AF, McCord JF (2007) A randomized clinical trial comparing anatomic, lingualized, and zero-degree posterior occlusal forms for complete dentures, J Prosthet Dent 5:292-298 PMID 17547948
  • Söhnel S (2012) Qualität rationeller Methoden zur Anfertigung von Zahnersatz bei völliger Zahnlosigkeit, Dissertationsschrift Uni Greifswald 2012
  • Trapozzano VR (1960) Tests of balanced and nonbalanced occlusions J Prosthet Dent 10:476-487
  • Utz KH (1997) Studies of changes in occlusion after the insertion of complete dentures (Part II). J Oral Rehabil 24:376-384 PMID:9183032