A cross-over randomised clinical trial of eccentric occlusion

in complete dentures

A. G. PALEARI* , J . MARRA†, L. S. RODRIGUEZ* , R. F. DE SOUZA‡, A. C. PERO*,

F. DE A. MOLLO JR.* & M. A. COMPAGNONI* *Department of Dental Materials and Prosthodontics,

Araraquara Dental School, UNESP, Univ Estadual Paulista, Araraquara, SP, †Department of Prosthodontics, Paulista University, UNIP-

Goiania, GO and ‡Department of Dental Materials and Prosthodontics, Ribeirao Preto Dental School, USP, University of Sao Paulo, Ribeirao

Preto, SP, Brazil

SUMMARY The objective of this study is to compare

the effects of canine guidance (CG) and bilateral

balanced occlusion (BBO) on denture satisfaction

and kinesiographic parameters of complete denture

wearers, by means of a cross-over trial. Fifty eden-

tulous patients received new maxillary and man-

dibular complete dentures. After the intra-oral

adjustments and adaptation period, 44 participants

were enrolled in the trial and randomly received a

sequence of occlusal schemes: BBO followed by CG,

or CG followed by BBO. Outcomes were assessed

after 30 days of each occlusal scheme. Participants

answered a denture satisfaction questionnaire and a

kinesiograph instrument recorded mandibular

physiologic movements and pattern of maxillary

denture movement during chewing. Wilcoxon test

and paired sample t-test were used to compare

satisfaction levels and kinesiographic data for each

occlusal scheme, respectively (a = 0Æ05). The results

showed no differences between occlusal schemes on

participant’s satisfaction and in any of the kinesio-

graphic parameters studied, except for the vertical

intrusion of the maxillary complete denture during

chewing, which was lower with CG. It can be

concluded that the occlusal scheme did not influ-

ence on satisfaction and kinesiographic parameters

evaluated, as long as volume and resilience of

residual edentulous ridges of the participants

were normal. Clinical Trial Registration Identifier:

NC.T01420536.

KEYWORDS: complete denture, dental occlusion,

cross-over studies, randomised controlled trial

Accepted for publication 4 February 2012

Introduction

There is no agreement regarding the eccentric occlusal

relationship for complete denture treatment, because

the benefit of balanced occlusion remains unknown.

Bilateral balanced occlusion (BBO) is one of the earliest

occlusal scheme for complete dentures and purports the

balance of artificial teeth in laterotrusive and protrusive

movements (1, 2). Some authors have reported that

BBO facilitates patients’ adaptation to new complete

dentures (3, 4), whereas other studies suggest that it

does not improve masticatory efficiency of complete

denture wearers (5).

Canine guidance (CG), on the other hand, disengages

the posterior teeth during excursive mandible move-

ments by vertically and horizontally overlapping the

canines (2). Grubwieser et al. (6) observed lower

muscle activity in patients wearing dentures providing

CG compared to those with BBO. Peroz et al. (2)

affirmed that CG can be used successfully in complete

dentures as it provides better mandibular denture

retention, esthetic appearance and masticatory ability.

Despite these disagreements, experimental clinical

studies could assist practitioners to choose the most

favourable occlusal scheme. However, there is still a

lack of evidence concerning complete denture occlusion

ª 2012 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2012.02299.x

Journal of Oral Rehabilitation 2012

J o u r n a l o f Oral Rehabilitation

schemes based on previous studies (7). It could be

minimised by means of simple approaches such as

randomisation, allocation concealment, blinding and

management of lost or dropouts participants (8, 9).

Analysis of patient-reported outcomes such as patient

satisfaction is recommended in studies of denture

occlusion. The success of any treatment with complete

dentures is often related to the degree of patient

satisfaction (10). Moreover, the study of physiological

variables, such as the extension of masticatory man-

dibular movements, could disclose how the masticatory

system reacts to different disocclusion schemes. Study-

ing complete denture movement during chewing could

demonstrate how occlusion schemes influence denture

stability. Within restricted movement ranges, the use of

a kinesiograph could provide accurate graphic records

of mandibular movements, such as, chewing cycles and

interocclusal rest space (11). Such equipment is also

capable of detecting the pattern of maxillary complete

denture movement during chewing (12).

Therefore, the objective of this study is to compare

CG and BBO with regards to denture satisfaction and

kinesiographic parameters of edentulous patients using

complete dentures, by means of a randomised cross-over

trial. The null hypothesis was that the occlusal scheme

does not influence denture satisfaction or kinesiograph-

ic parameters of complete denture wearers.

Materials and methods

Participants

A group composed of 50 completely edentulous

patients (34 women; mean age: 65Æ5 � 10Æ1 years

old), who had volunteered to receive new complete

dentures at Araraquara Dental School, was assessed for

possible inclusion in this study. A sample size calcula-

tion was done after previous evaluation of the results

from the first 27 participants. It was found that at least

40 participants were necessary to detect significant

difference between CG and BBO (a = 0Æ05; b = 0Æ20).

Considering possible losses and withdraws, an amount

of approximately 20% more participants were evalu-

ated. Thus, according to this sample size calculation, a

group of 50 participants was estimated.

The inclusion criteria were as follows: (a) adult

patients who needed new complete dentures, (b)

mentally receptive individuals and (c) normal volume

and resilience of residual edentulous ridges. Residual

ridge volume was considered normal when the contour

of a cross-sectional portion of the edentulous ridges

displayed a grossly triangular shape, with the base

ranging between labial ⁄ buccal vestibules and the sides

corresponding to the bilateral linear projection of both

ridge slopes (12). We excluded participants who had

dysfunctional disorders of the masticatory system,

debilitating systemic diseases or a cardiac pacemaker

to avoid possible interferences from kinesiograph

instrument. This study was approved by the Institu-

tional Ethics Committee (Protocol Number 43 ⁄ 08) and

registered in the clinicaltrials.org database (Identifier:

NCT01420536).

Fabrication of new complete dentures

Participants received one set of new complete dentures

fabricated according to the standardised protocol used

in Araraquara Dental School (13). The fabrication of

new complete dentures was performed by three

researchers [Marco Antonio Compagnoni (MA), Fran-

cisco de Assis Molo Junior (FA) and Ana Carolina Pero

(AC)] and a dental technician, who were previously

trained. A methacrylate-based resin* and 33 � acrylic

resin teeth† were used. Denture base resin was mixed

and packed according to the manufacturer’s recom-

mendations and polymerised in an automatic polymer-

isation water tank‡. Temperature and time were 73 �Cfor 90 min, followed by 30 min at 100 �C. All complete

dentures were fabricated according to the BBO concept.

After the insertion of the new complete dentures,

patients were invited to participate in this clinical trial

and written consent was obtained prior to enrollment.

We waited 30 days before starting the experimental

procedures as this was deemed necessary for functional

adaptation (14). Denture bases and occlusion were

adjusted during this period and it was also possible to

determine which participants could be excluded

because of low compliance.

Experimental design

After the adaptation period, six participants declined to

participate. Forty-four participants were enrolled and

randomised in one of the occlusal scheme sequences

*Lucitone 550; Dentsply Ind. e Com. Ltda, Petropolis, RJ, Brazil.†Trubyte Biotone; Dentsply Ind. e Com. Ltd, Rio Janeiro, RJ, Brazil.‡Solab Equipamentos para Laboratorios Ltd, Piracicaba, SP, Brazil.

A . G . P A L E A R I et al.2

ª 2012 Blackwell Publishing Ltd

(CG or BBO). Twenty-two participants received CG

initially, and the other 22 continued with BBO until the

1st outcome assessment (14 women for each sub-

sample, mean age: 65Æ5 � 10Æ6 and 66Æ4 � 10Æ3 years

old, respectively).

The occlusal scheme was determined randomly using

computer-generated numbers§. The numbers were

stratified by gender and age and secured by another

researcher [Julie Marra (JM)] until the conclusion of

the study. This researcher assigned each participant to

the sequences of occlusal schemes immediately after

enrollment, without involvement in other parts of the

trial. After a period of 30 days, we performed the first

evaluation (denture satisfaction and kinesiographic

assessment) and the occlusal schemes were changed.

A second evaluation was performed after another

30-day period.

Canine guidance establishment was performed by

another researcher (MA) using composite resin¶ on the

palatal surface of the maxillary canines. After photo-

polymerisation** for 40 s, it was observed if the resin

was large enough to promote canine disocclusion

without causing interference to centric occlusion. In

the group where BBO was maintained, a sham proce-

dure was performed by the same researcher (MA). This

was done by adding composite resin to the cervical

region of the maxillary canines’ palatal surface, without

changing centric and excursive contacts. The researcher

responsible for this phase was informed about the type

of procedure (active or sham procedure) only after the

patient had been seated in the dental chair. All

procedures were performed out of the patient’s sight.

Denture satisfaction

Participants answered a denture satisfaction question-

naire (Table 1) based on the criteria used by Celebic and

Knezovic-Zlataric, (10) also described by Souza et al.

(15). Possible answers for each question and respective

scores were: (A) unsatisfactory (‘0’); (B) regular (‘1’);

(C) good (‘2’). The questionnaire was applied by

another researcher [Larissa Santana Rodriguez (LS)],

who was unaware of all other procedures performed in

this research.

Kinesiographic assessment

The kinesiographic evaluation was performed by

another researcher [Andre Gustavo Paleari (AG)],

who was unaware of the occlusal schemes used during

assessment. A kinesiograph instrument†† was used for

this evaluation. This instrument is connected to a

computerised system that records and displays spatial

coordinates of vertical and anteroposterior axes to the

nearest 0Æ1 mm. Participants sat upright in a dental

chair with the Frankfort plane parallel to the horizontal

plane.

According to the purposes of this research, three

tracing modes (scans) were selected for recordings:

Scan1 – opening and closure movement limits, Scan 3 –

Three-dimensional mandible movement from rest

position to maximal occlusion and the pattern of

maxillary complete denture movement during chew-

ing, Scan 8 – Three-dimensional mandible movement

during chewing.

The sensor array was positioned according to the

manufacturer’s instructions and the magnet was

attached to the labial midline surface of the mandibular

(Scans 1, 3 and 8) or maxillary complete denture (scan

3 – pattern of maxillary complete denture movement

during chewing) (13, 14, 16). To study mandible

movement during chewing and the pattern of maxillary

Table 1. Denture satisfaction questionnaire

Questions Original criteria

How do you rate the comfort of

your mandibular denture?

Comfort of wearing

mandibular denture

How do you rate the retention of

your mandibular denture?

Retention of mandibular

denture

How do you rate the general

quality of your dentures?

General satisfaction

How do you rate the ability to

chew with your dentures?

Chewing

How do you rate the ability to

speak with your dentures?

Speech

How do you rate the

appearance ⁄ aesthetics of

your dentures?

Aesthetics

How do you rate the comfort of

your maxillary denture?

Comfort of wearing

maxillary denture

How do you rate the retention of

your maxillary denture?

Retention of maxillary

denture

§BioEstat 5.0; Universidade Federal do Para, Belem, PA, Brazil.¶Restorative Z100; 3M Brazil, Sumare, SP, Brazil.**Ultralux; Dabi Atlante, Ribeirao Preto, SP, Brazil.

††K6-I Diagnostic System; Myotronics Research Inc., Seattle, WA,

USA.

E C C E N T R I C O C C L U S I O N I N C O M P L E T E D E N T U R E S 3

ª 2012 Blackwell Publishing Ltd

complete denture movement during chewing, volun-

teers deliberately chewed a 5 · 10 · 15 mm of bread.

Procedures were carried out according to the man-

ufacturer’s instructions and three reproducible mea-

surements were recorded for each scan mode.

Statistical analysis

Statistical analysis was performed by another researcher

[Raphael Freitas de Souza (RF)], who was also unaware

of all procedures performed in this research. The results

of each question about denture satisfaction were

evaluated separately and described by counting fre-

quencies. The results originate a general score that did

not have symmetrical distribution and were described

by non-parametric methods. Data from each question

were compared using the Wilcoxon test.

For the kinesiographic assessment, the Kolmogorov–

Smirnov test was used to evaluate whether the

variables had normal distribution, which was positive

in the majority of cases. A comparison between the

values obtained for both groups was performed by

means of the paired sample t-test.

Regardless of the test, significance was set at a = 0Æ05.

All data were analysed using PASW Statistics§§.

Results

Figure 1 presents a diagram of participants throughout

the research. Results of the denture satisfaction ques-

tionnaire according to the occlusal scheme are shown

in Table 2. The sum of the scores of each question

generated a summary measure, with a possible range

from 0 to 16, which was the primary outcome variable

of this study. Summary denture satisfaction scores did

not show an important variation with regards to

occlusal schemes (Fig. 2). The comparison between

the two occlusal schemes showed no statistically

significant differences (Wilcoxon test, P = 0Æ569).

The results of the kinesiographic recordings are listed

in Table 3 according to scan tracings. The analysis

shows no significant differences between the occlusal

schemes for mandibular movements of opening and

closing, mandible movement from rest position to

maximal occlusion or mandible movement during

chewing. The results also demonstrated no significant

differences for occlusal schemes on maxillary denture

movement during chewing, except for the maximum

vertical intrusion of the denture (P = 0Æ044), which was

on average 0Æ1 mm lower with the canine guidance.

Discussion

This study aimed to compare CG and BBO from two

distinct viewpoints, namely the patients’ perceptions

and kinesiographic parameters. Regarding the first

aspect, the occlusal schemes used in this study were

not important in terms of patient satisfaction. Other

aspects are more important in the final judgment of the

treatment by patients, such as their attitude towards

dentures, the number of previous dentures, personality

and expectations, patient–dentist relationship and a

judgment of the dentist’s qualifications (17–19).

Although the objective evaluation has demonstrated

that CG promotes lower maxillary complete denture

movement than BBO, this effect did not interfere with

participant’s satisfaction with the new complete den-

tures concerning disocclusion guidance. No differences

to any answer regarding denture satisfaction were

found in the questionnaire applied in this study. The

answers were predominantly favourable, particularly

concerning aspects associated with the maxillary den-

ture, aesthetics and speech. Regardless of the question,

the occlusal scheme showed no influence on specific

aspects of denture satisfaction. High values were

observed for most of the participants, which means

that they confirmed high satisfaction levels. Half of

them scored ‘regular’ for a maximum of one criterion

and ‘good’ for others, resulting in a score of 15 points or

the maximum of 16 points. Nearly a quarter of the

sample, independent of the occlusal scheme tested had

scores below 13.

Rehmann et al., (4) found that participants were

more satisfied with BBO dentures than CG dentures

during the adaptation period. Furthermore, these

authors also supposed that BBO minimises rocking

movements during protrusion and consequently, pro-

duces fewer neuronal stimuli compared with CG.

According to these authors, it helps patients adapt to

their new oral situation. On the other hand, a clinical

trial conducted by Peroz et al. (2) showed that patients

with CG dentures seemed to be more satisfied than

those with BBO dentures. Our results are in agreement

with Farias Neto et al. (5) who found no significant

difference between patient satisfaction with BBO den-

tures or CG dentures. From the results of these previous§§version 18; SPSS Inc., Chicago, IL, USA.

A . G . P A L E A R I et al.4

ª 2012 Blackwell Publishing Ltd

reports, it could be hypothesised that favourable effects

for BBO might appear during the adaptation period

because the patients are still adapting to a different

centric occlusion and may intercuspate in eccentric

relations (20). However, this difference tends to disap-

pear following patient adaptation and possibly inverts

itself, as shown by Peroz et al. (2).

To our knowledge, this is the first randomised trial to

compare BBO and CG by means of kinesiographic

assessment. The majority of kinesiographic parameters

evaluated in this study (opening and closure move-

ment, three-dimensional mandible movement from

rest position to maximal occlusion and during chew-

ing), indicate that the occlusal scheme does not alter

the pattern or limits of these movements. Although it is

argued that edentulous patients display the same

Table 2. Satisfaction with complete dentures related to occlusal scheme

Original Criteria

BBO CG Differences

P (Wilcoxon test)U R G U R G BBO > CG BBO < CG BBO = CG

Comfort while wearing

mandibular denture

5 7 29 6 6 29 4 2 35 0Æ739

Retention of mandibular

denture

2 13 26 3 12 26 4 3 34 0Æ705

General satisfaction 1 7 33 1 6 34 4 5 32 0Æ739

Chewing 6 13 22 4 16 21 3 4 34 0Æ705

Speech 1 5 35 1 8 32 4 1 36 0Æ180

Aesthetics 1 4 36 0 3 38 1 4 36 0Æ180

Comfort while wearing

maxillary denture

0 3 38 0 2 39 1 2 38 0Æ564

Retention of maxillary denture 0 6 35 0 1 40 1 6 34 0Æ059

Frequency of answer for each question.

U, unsatisfactory; R, regular; G, good; BBO, bilateral balanced occlusion; CG, canine guidance.

Fig. 1. Flow diagram of participants. E1, evaluation 1; E2, evaluation 2.

4

Bilateral balanced occlusion Canine guidance

6

8

10

12

14

16

Fig. 2. Box plot graph comparing the occlusal schemes.

E C C E N T R I C O C C L U S I O N I N C O M P L E T E D E N T U R E S 5

ª 2012 Blackwell Publishing Ltd

gnathological principles found in persons with natural

dentition (6), according to our results, both BBO and

GC appear to provide similar conditions for complete

denture wearers.

This research reveals that changing the occlusal

scheme does not alter the pattern and limits of

functional movements during the chewing cycle. It

should be noted that test food (bread) used in this trial

can be classified as ‘soft’ and is characterised by the

occurrence of occlusal contact during chewing (12).

Bread can provide interaction between antagonist

occlusal surfaces, thus resulting in a lesser amount of

anteroposterior movement compared with ‘hard’ food

(bovine meat, for example), which is first crushed by

the teeth without contact until a soft consistency is

attained (12). Thus, it was assumed that the test food

did not interfere in the evaluation.

The results obtained reinforce the concept that the

temporomandibular joint receptors play an important

role in controlling mandibular movements and, even if

periodontal proprioception is absent, as in the edentu-

lous patients, masticatory dynamics remain unchanged

because chewing is a rhythmic activity modulated by a

central neural generator (14, 21, 22). It is possible that

the masticatory system may work well regardless of the

occlusal scheme chosen. Our results related to func-

tional movements during the chewing cycle reinforce

the idea that BBO and CG provides similar masticatory

efficiency for complete denture wearers (5, 23, 24). In

relation to the pattern of maxillary complete denture

movement during chewing, CG was supposedly associ-

ated with a higher incidence of oblique forces capable of

dislodging dentures during mastication (5). However,

we found a lower intrusion of maxillary denture base

during mastication for this occlusal scheme. It is

possible that CG has provided a situation where patients

felt it was easier to keep their dentures stable. Grub-

wieser et al. (6) observed that CG reduced muscle

activity during laterality and protrusion when com-

pared with BBO. In agreement with a previous study

(12), denture movement was predominantly vertical

during chewing. The differences between occlusal

schemes, albeit statistically significant, probably have

no clinical relevance because of their magnitude.

A cross-over design was used in this research to

eliminate the intersubject response variation to the

same treatment and to reduce the influence of con-

founding covariates, as each participant serves as

his ⁄ her own control, which increases statistical efficacy

(5, 9). Additionally, blinding participants and research-

ers may have decreased the chance of bias which can

occur if one treatment intervention (BBO or CG) is

Table 3. Mean values (and standard deviations) for the two occlusal schemes tested [bilateral balanced occlusion (BBO) and canine

guidance (CG)] and a comparison between them

Criteria BBO CG (BBO-CG)

t-test

t P

Scan 1 – Opening and closure movement limits VO 30Æ9 � 4Æ6 30Æ3 � 4,5 0Æ6 � 4Æ2 0Æ97 0Æ339

HO 25Æ8 � 8Æ8 25Æ1 � 9,4 0Æ7 � 7Æ3 0Æ66 0Æ515

RO 1Æ7 � 2Æ4 1Æ4 � 1Æ3 0Æ3 � 2Æ3 0Æ71 0Æ485

LO 6Æ2 � 4Æ7 5Æ4 � 4Æ3 0Æ9 � 5Æ2 1Æ06 0Æ297

Scan 3 – Movement of the mandible from rest

position to maximal occlusion

VER 2Æ3 � 1Æ1 2Æ1 � 1Æ2 0Æ2 � 0Æ8 1Æ63 0Æ111

AP 1Æ9 � 0Æ9 1Æ9 � 1Æ0 0Æ1 � 0Æ7 )0Æ85 0Æ399

LAT 0Æ4 � 0Æ3 0Æ5 � 0Æ5 )0Æ1 � 0Æ6 )0Æ60 0Æ550

Scan 8 – Movement of the mandible during chewing VER 12Æ1 � 2Æ7 12 � 2Æ7 0Æ2 � 2Æ0 0Æ52 0Æ609

AP 4Æ3 � 2Æ0 4Æ2 � 2Æ1 0Æ2 � 1Æ9 0Æ53 0Æ600

LAT 1Æ3 � 1Æ4 1Æ2 � 2Æ1 0Æ1 � 1Æ8 0Æ51 0Æ611

Scan 3 – Maxillary denture movement during chewing VER )0Æ6 � 0Æ3 )0Æ5 � 0Æ4 )0Æ1 � 0Æ3 )2Æ08 0Æ044*

AP )0Æ4 � 0Æ4 )0Æ4 � 0Æ7 0Æ0 � 0Æ7 0Æ42 0Æ677

Maximum LAT )0Æ1 � 0Æ3 )0Æ1 � 0Æ5 0Æ0 � 0Æ5 )0Æ15 0Æ885

Scan 3 – Maxillary denture movement during chewing VER 0Æ0 � 0Æ3 0Æ1 � 0,3 )0Æ1 � 0Æ3 )1Æ82 0Æ077

AP 0Æ1 � 0Æ4 0Æ0 � 0,6 0Æ0 � 0Æ6 0Æ45 0Æ654

Residual LAT )0Æ1 � 0Æ3 )0Æ1 � 0,4 0Æ0 � 0Æ4 )0Æ15 0Æ878

*Significant differences (P < 0Æ05).

VO, vertical opening; HO, horizontal opening; RO, right opening; LO, left opening; VER, vertical; AP, anteroposterior; LAT, lateral.

A . G . P A L E A R I et al.6

ª 2012 Blackwell Publishing Ltd

provided preferentially to one group and detrimentally

to another. All procedures were performed to safeguard

the internal validity of this research.

One limitation of this research was the losses during

the follow-up, although only three participants

declined to continue the research. In addition, it is

necessary to consider the possibility of errors in the

kinesiographic assessment. Such errors, however, were

low in this study and equally distributed between the

assessment periods. As related by Balkhi et al. (11) and

advocated by Souza et al. 2009 (12), a mandibular

kinesiograph is accurate for a vertical range of motion

lower than 40 mm provided that the magnet is

correctly positioned.

These results could be valid for edentulous individ-

uals of both genders and all ages who underwent the

treatment with complete dentures. Extrapolation for

wearers with bruxism or other dysfunctional disorders

of the masticatory system, severe residual ridge resorp-

tion and debilitating systemic diseases should be eval-

uated in future studies. Furthermore, the long-term

influence of the eccentric occlusion on alveolar ridge

bone reabsorption and mucosal resiliency must be

investigated as soon as possible, because it cannot be

answered by this research.

With the limitations of this study, the null hypoth-

eses were confirmed for all variables considered, indi-

cating that the occlusal scheme did not influence on

participants satisfaction and kinesiographic parameters

evaluated, as long as volume and resilience of residual

edentulous ridges of the participants were normal.

Acknowledgments

The authors gratefully acknowledge the financial sup-

port of FAPESP (Grant Numbers 2008 ⁄ 07183-5 and

2009 ⁄ 11185-6). We also thank Mr. Joao Monti Junior

(dental technician) for his assistance in the fabrication

of complete dentures. The authors declare no potential

conflicts of interest with respect to the authorship

and ⁄ or publication of this article.

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Correspondence: Marco Antonio Compagnoni, Araraquara Dental

School, Rua Humaita 1680, CEP 14801-903 Araraquara-SP, Brazil.

E-mail: compagno@foar.unesp.br

A . G . P A L E A R I et al.8

ª 2012 Blackwell Publishing Ltd