The most basic tool used in occlusion is articulating paper; it has remained unchanged for over a century and is used in dentistry around the world. The word ‘occlude’ means ‘to come together’. As a mandible engages into a position against a maxillary arch, dentists use color in various forms to enhance what they think they know about occlusion based on their previous experience.
Occlusion is the study of the relationship between the maxillary and mandibular arches. Sounds simple, doesn’t it? However, the reality is that occlusion is often confusion and, more often than not, dentists are left to reinvent the wheel, using a trial and error approach based on their own clinical experience.
Experience is what you get when you don’t get what you want. A negative result is often the best way to learn what not to do in the future. Occlusion may mean something different to every dentist, but all dentists use ‘colored paper’ to find how a mandible is directed into a maxillary arch.
The study of any procedure is only as good as the tools used to measure and verify its results. The knowledge accumulated from research, textbooks, and teachers grows with each generation of dentists because each generation invents better tools, acquires more experience, and develops a greater understanding of the functioning of human anatomy. Could it be that the reason dentists cannot ‘come together’ on how the stomatognathic puzzle works is because their basic tool of communication between the arches is still . . . crayons?
A transfer of energy, defined as conduction, occurs when two objects touch. Colored marks, wax imprints, mylar strips, or any tool that illustrates contact energy transfer are valuable or we would have stopped using them. Why are ink marks valuable and what do they mean? Finding conduction balance may be the goal but retrofitting is the most common reality. Never leave it ‘high’ is what experience teaches, so most procedures are ‘tattooed’ (inked up and adjusted out of occlusion) to decrease conduction that may result in inflammation and translate into possible future pain.
When a mandible does engage into a maxilla, either with teeth or prosthetics, what does the transfer of energy mean to the dentition, joints, ligaments, and muscles? How does the brain use neurovascular and biochemical information to maximize physiology and minimize pathology? This is the science of occlusion.
Dentists repair or build occlusions, make splints or adjust ‘something’ during treatment. Every procedure on every patient has the potential to affect how the mandible will engage the maxilla. Some dentists believe that they know where that ‘magical’ position is because of previous experience using their technique. However, our profession has not found, nor does it have the ability to find, ‘the’ perfect position with analog tools only. Why? Because, without objective measurement, occlusion is a trial-and-error, subjective procedure performed by humans on humans.
Chemical energy in food is converted to mechanical energy in muscles that creates kinetic energy in motion, the transfer of which is conduction. Conduction is unique to every closure and can create an infinite number of force variations. Pin points can hit hard, large areas can land soft, and hit-slides are unique to muscle physiology factors. In any given arch, materials may vary from enamel and dentin to gold, alloys, silver, many generations of ceramics, porcelain, plastic, titanium, or space. Materials are placed by different dentists, at different times, for different reasons, and they function and wear differently.
Basically, every dental procedure (that includes contact) we perform is ‘colored’ and adjusted according to our past experience and to what we think we know about occlusion. Bottom line is: we guess! The most amazing factor in the equation is that it works most of the time, especially in subtractive, single-tooth dentistry. Dentists can retrofit almost anything with any number of materials. The answer as to why it works is probably somewhere between our ability to improve balancing within the system and the ability of the human body to adapt and repair.
Subtractive dentistry, which has been the standard of care for a century, is no longer the only ‘game in town’ since the advent of new materials and new technology. Ceramic adhesion, titanium implants, tissue augmentation, and comprehensive occlusal philosophies have made additive dentistry an alternate treatment choice. Additive dentistry brings a new set of rules to the world of occlusion. An unbalanced occlusion can turn the most beautiful cosmetic reconstruction into a pathologic envelope of destruction. Expensive treatments that fail are definitely not good for business and they do undermine credibility. Experience with failed cases is only valuable if we do not continue to make the same mistakes . . . with the same old tools.
Oral health and quality-of-life issues are stretching the scope of our profession. As soon as dentists in the United States were allowed to treat sleep disorders, anti-snoring splints showed up on TV infomercials. Splints are better understood and are helpful in the treatment of patients suffering from headaches and/or migraines. Orthodontics is about early treatment for airway development and once the bones are in a better position, the teeth tend to drop in straight. Our role as doctors in the field of human wellness is growing fast. As occlusion involves the study of mandibular positioning, there will be many more questions that dental professionals will have to answer. What is the ideal jaw position during sleep, during long hours in front of a computer, to alleviate headaches, neck aches, TMDs, and earaches?
How are we going to expand the field of occlusion when we can’t agree on how the teeth should fit? Physiologic occlusion is a balance of hard and soft tissue in a neurovascular bundle in a 24/7 world. Today, mandibular position is a theoretical guess in every discipline of dentistry because the modern age of occlusion has yet to come about. Digital occlusion, digital imaging, and the study of human wellness from an oral perspective are the future. 3D imaging opens a new window on hard and soft tissue anatomy and reveals the significance of articulating paper marks.
Sensors, scans, and digital imaging within the operatory will produce a ‘Star Wars’ effect which can be magical for the patient. However, what good is technology if the profession does not have the ability to make it work in a predictable and efficient manner in the oral cavity?
Computerized occlusal analysis, or Digital Occlusion for short, is changing the subjective experience of occlusion into an objective science. The new occlusal paradigm celebrates and integrates everything that we already know about occlusion.