Indications
Indications
Indications
Occlusion simply means the contact between teeth. In routine daily dentistry, clinical
analysis of occlusion occurs within two major parameters, static and dynamic occlusion
(Davies & Gray, 2001).
Static occlusion refers to contacts between the teeth when the mandible is not
moving whilst dynamic occlusion refers to contacts between teeth whilst the mandible is
moving.
With respect to this discussion, there are two major types of dynamic occlusal
schemes which are reported in literature, canine guidance and group function (Jemt et al.,
2004).
There is no mention of how many teeth constitutes “several teeth” as per the
definition, however, Abduo and Tennant described in a systematic review that 2 or more
simultaneous contact of the posterior teeth within the working side as being group function
(Abduo & Tennant, 2015).
Advocates of lateral occlusal schemes
Both occlusal schemes classically had their distinct advocates, although previously,
authors were more keen to adopt canine guidance as the more “ideal” occlusal scheme
(Abduo & Tennant, 2015; Thornton, 1990) . Several factors were quoted, amongst them, that
canine guidance prevented future periodontal disease, that canines were acting as natural
“stressbreakers” that protected the rest of the dentition from lateral stresses during eccentric
movements, and that canine protected occlusion was the only way that prevented
traumatogenic occlusion and halted the rate of wear of posterior teeth (D’Amico, 1961;
SIEBERT & Siebert, 1981; Thornton, 1990).
Proponents (such as Beyron and others) of group function lateral occlusal scheme
stated that group function occlusal pattern is an eventuality caused by a “well developed and
well sustained dentitions” (Beyron, 1964). In addition, others stated that group function led
to an even distribution of stress of on teeth, leaving them in a balanced state (BEYRON,
1954). Schuyler who was the main proponent and advocate of group function, questioned
the rationale of “stressing” the canines (Schuyler, 1953). Some even questioned the
biological, histological and functional basis of canine protected occlusion (Alexander,
1963).
Modern studies have disproved both lateral occlusal scheme proponents and let
clinical considerations such as parafunctional habits, restorative materials that is going to be
used as well as the presence of implant prostheses be the determinant. Practical
considerations such as delivering a restorative solution that is practical, simple, esthetic yet
conservative should be the determinant when choosing which lateral occlusal scheme is to
be chosen (Abduo et al., 2013).
The reasoning behind this is because in real life dentition, one is never truly canine guided
or group function only, rather that, both schemes of dynamic occlusion can occur
simultaneously and may fluctuate itself due to various factors. The main 3 factors as
described by Abduo and Tennant which contributes itself to the presence of both lateral
occlusal schemes are degree or magnitude of excursion, age and static occlusal relationship
(Abduo et al., 2013).
With regards to magnitude of excursion, authors have pointed out that a “progressive
occlusion” phenomenon occurs whereby the initial lateral excursion (including during
mastication) is dictated by a group of posterior teeth (DiPietro, 1977). Once greater lateral
movement commences, the canine plays a primary role. This has been substantiated by
multiple studies (Al-Nimri et al., 2010; Ogawa et al., 1998a).
During partial lateral excursion, group function occlusion ranges from 45 – 74% (compared
to 6 – 26% canine guidance). By contrast, when the jaw fully excurses, the canine takes a
higher role (17 – 74% , as compared to 26 - 68% for group function) (Abduo et al., 2013).
Secondly, age also factors in to the variancy of lateral occlusal patterns. In general, the
development of group function comes with age, as a result of tooth wear. Loss of enamel per
annum from physiological tooth wear ranges have been reported to be 20 - 38 um annually
(Lambrechts et al., 2016) . This (relegating pathological tooth wear factors) explains the
higher prevalence of group function within a more aging population (>50% of 40 year old
population have group function occlusion and the percentage increases thereon) (Abduo et
al., 2013). Having said that, studies have not enumerated of any transition period whereby
both occlusal schemes may as well be present as progressive physiological tooth wear
proceeds.
Thirdly, existing static occlusal relationships can also heavily predetermine the lateral
occlusal scheme. Findings from multiple studies determined that Class II molar and incisal
relationships were most associated with having a canine guided lateral occlusion, followed
by Class I relationship. Class III incisal relationship was most associated with group
function (Al-Hiyasat & Abu-Alhaija, 2004; Scaife & Holt, 1969).
Recently, Wiechens et al have also pointed out variances in the static and dynamic occlusal
profile based on time of day. The study detected significant differences in the registered
occlusal patterns on both right and left laterocclusal movements on both traditional
(shimstock) as well as digital detection methods (static sensor registration) on different
times of the day (Wiechens et al., 2022). The sample cohort of the study were also Class I
patients with healthy dentition and no significant tooth wear. Having said that, this
variability of occlusal pattern, whilst challenging, should not overconfuse the clinician on
choosing which occlusal philosophy that should be undertaken during rehabilitation (Berry &
Singh, 1983; Wiechens et al., 2022).
All these factors combined have led to some authors advocating that true group
function and canine guidance may not exist intraorally and that a more representative
occlusal scheme should be proposed (Ogawa et al., 1998b). Especially when both cohorts of
patients can cross adapt successfully, nor does selection of either lateral occlusal schemes
give significant differences in restoration longevity or in the development of
temporomandibular disorders (Abduo et al., 2013; al Marzooq et al., 1999).
Whilst debatable, some authors have described that the canine guidance lateral
occlusal scheme is more desirable due to its ease and practicality (Thornton, 1990). The
maxillary canine does have a stabilizing effect in the stomatognatic system because of
robustness of the canine and its strategic location in the arch (Bueno et al., 2022).
Having said, there are certainly clinical situations whereby the canine should be
protected from lateral guidance and instead a group function scheme should be employed:
1. Compromised canines: This can include situations whereby the canines maybe
endodontically treated or heavily restored. It can also occur if the canine is periodontally
compromised (Yoon et al., 2022). The effect of endodontic treatment on root rigidity is
significant (up to 3x increase in root deformity), especially when access cavity and post
preparations are done (Lang et al., 2006).
2. Implant restorations: Some implant retained restorations are indicated for group function. The
cases include:
a. Single implant restored canine
This is in line with an occlusal scheme that is specific with implant retained restorations
termed “Implant-Protected” occlusion (Abichandani et al., 2013). This is where light
occlusal contact only occurs with the antagonistic teeth during heavy loading with no
guidance on excursion for single implant restorations (Gross, 2008).
This is substantiated in a study done by Lo and Abduo, whereby they noted that stress
concentration on an implant retained canine crown was the lowest when a group function
lateral occlusal scheme (ie; no contact on the canine implant crown) was employed (Lo et
al., 2017).
b. Full arch implant restorations (metal acrylic vs metal acrylic, ceramic vs ceramic, ceramic
vs metal acrylic and ceramic/metal acrylic vs natural dentition).
The rationale for choosing group function in these scenarios is because group function
allows for a reduction of occlusal load on the canine denture teeth as well as a more even
distribution of forces amongst the prosthetic components (Türker et al., 2021; Yoon et al.,
2022).
A finite element analysis study conducted by Turker et al also found that for all on 4
restorations, group function produced a lower prosthetic deformation on the maxillary
components. This led to them concluding that group function occlusion is advantageous in
maintaining the stability of prosthetic component due to a more even distribution of forces
within group function occlusion (Türker et al., 2021).
All on 4 prosthetic component structure deformation (in mm) during various occlusal
movements. Reproduced from Turker et al (2021). Journal of Oral Implantology.
In addition, they also deduced that screw loosening and screw fracturing are more likely to
occur in all on 4 restorations applying canine guidance due to the presence of cyclic stresses
that are more prominent in canine guided models (Türker et al., 2021).
*However, it should be noted that, the group function occlusal scheme has not been shown
to be conducive on a canine implant retained fixed partial denture. Finite element analysis
studies have found that there is considerably higher forces on implant retained fixed partial
dentures where group function is employed as compared to canine guidance (up to 3-5x
higher in Gore and Evioglu, 2x higher in Anaraki et al) (Anaraki et al., 2019; Göre & Evlioǧlu,
2014).
3. Class III incisal or skeletal relationships: In these situations, it is beyond practical to design a
canine guided relationship unless orthodontic/surgical optimization is done (Furquim et al.,
2014; Moullas et al., 2006).
4. Anterior open bite: Similarly, it may be unpractical or even unesthetic to design a canine
guided occlusion in this scenario, since orthodontic itself aims to return canine guidance
occlusion (Janson et al., 2008).
1. Confirmative approach
If the existing lateral excursion pattern is of group function, and due to various indications
as provided above, the patient is indicated for a group function scheme of restorative
scheme, then there are multiple techniques to record the existing occlusion, some more self-
explanatory than others:
a. Indexing/bite registration
b. Alternate preparation of teeth
This involves taking preparing teeth in an alternate fashion, taking an impression and
registering the bite and then proceeding with the other set of teeth and taking another
impression.
In this case report by Re and Orthlieb, a deciduous retained maxillary canine is indicated for
a crown and the decision was to employ a group function occlusal scheme. After
conservative preparation of the crown, bite registration was done using soft wax supported
by pattern resin. Eccentric mandibular movements were recorded into the soft wax and then
a quick setting plaster was adapted to the teeth and transferred in to the master model (Ré &
Orthlieb, 2019).
Reproduced from Duvall and Rogers (2013). J Prosthodont. 22(3) 226-232
In the above sequence, clinical and laboratory steps are described for recording functionally
generated pathway to achieve group function in cases were there is a lack of distal stop. In
this case, a stone crib is preformed in the diagnostic cast and relined intraorally with
polyvinyl siloxane. At the same time, a bis-acryl recording table is fabricated to support
sticky wax on top of tooth 36 and 37 that will be used to record eccentric movement.
Subsequently, all of the structures are then “saved” into position with fast -setting plaster
and placed into the mounted cast(Duvall & Rogers, 2013).
d. Youdelis scheme
e. Pankey-Mann-Schuyler scheme
f. Digitally recorded dynamic occlusion