The influence of the accuracy of the intermaxillary relations on the use of complete dentures: a clinical evaluation, By Tatiana Araya

E. DERVIS Department of Prosthodontics, Faculty of Dentistry, University of Istanbul, Istanbul, Turkey

SUMMARY The aim of this study was to investigate
possible associations between the accuracy of intermaxillary
relations and complete denture usage
3 months and 3 years after their insertion. A total
of 600 patients were provided with new complete
dentures. Willis gauge and Woelfel’s method were
used to assess the quality of the existing complete
dentures and the use of these dentures. Three years
after insertion the remaining 250 patients took part
in a follow-up examination. Three months postinsertion,
significant relationships were found
between adequate interocclusal rest space or quality
of registration of centric relation and daily wearing
of complete dentures and between quality of registration
of centric relation and use of dentures for
eating. Three years after insertion the adaptation
to denture wearing was generally satisfactory.
However, no significant relationship was observed
between the accuracy of intermaxillary relations
and complete denture usage.
KEYWORDS: intermaxillary relations, complete denture
usage, denture satisfaction
Introduction
There have been many studies of patient satisfaction
with new dentures rather than patients’ use of dentures.
However, the results of these investigations are
contradictory. No association between the quality of
occlusal relationships and patient acceptance of complete
dentures were reported by Carlsson et al. (1),
Smith (2), Berg (3), Diehl et al. (4) and Bergman &
Carlsson (5). Manne & Mehra (6) found a negative
relationship between denture quality and denture
satisfaction. Yoshizumi (7) observed a highly significant
association between denture quality including intermaxillary
relations and satisfaction. Van Waas (8, 9)
recorded a positive association between denture quality
and patient satisfaction 3 months after the insertion of
complete dentures. In the same investigations, he
reported a negative association between the quality of
centric relationship and patient satisfaction. Fenlon
et al. (10) found a statistically significant relationship
between the accuracy of intermaxillary relation and
complete denture usage 3 months after insertion.
Clinical evaluation of complete dentures is mostly
subjective. Moreover, it is important to observe
dentures critically and periodically over an extended
period. However, the professionally assessed quality of
complete dentures does not agree always with the
subjective judgement of the patients. Bergman &
Carlsson (11) examined 32 patients who had dentures
in the maxilla or mandible after 21 years and found a
discrepancy of the patient’s satisfaction and the dentist’s
assessment of their quality. Magnusson (12) found
no statistical significance between the subjective and
objective evaluation of the 39 patients with complete
dentures 5 years after receiving dentures. Kalk et al.
(13) revealed that patients and dentists agree on
assessments of denture retention, but do not agree on
assessment of denture appearance 5 years after complete
denture treatment. Mojon & MacEntee (14) as
well as De Baat et al. (15) observed no relation between
clinical treatment and denture satisfaction.
The aim of this study was to evaluate the relationship
between the accuracy of establishing intermaxillary
relations and denture usage for daily wearing of
complete dentures and eating. In addition, an objective
was to investigate the patient’s opinions of their
dentures and dentists’ technical evaluations 3 years
after insertion of complete dentures.
ª 2004 Blackwell Publishing Ltd 35
Journal of Oral Rehabilitation 2004 31; 35–41
Materials and methods
A total of 971 patients who had attended the Dental
Clinic of the Haydarpasa Hospital were examined. Most
patients had been referred to the hospital dental clinic
for specialist assessment and treatment because of a
history of failure of previous dentures or were selfreferrals
by patients interested in the possibility of
having dentures made in a specialist treatment centre.
A total of 371 patients were excluded from this study:
42 patients did not attend for treatment, 161 patients
did not keep their follow-up appointments, 168 patients
did not complete the questionnaires. The remaining
600 patients (373 women and 227 men) were included.
Their ages ranged from 32 to 87 with a mean of 58Æ2.
Patients were examined by the same specialist prosthodontist
at the beginning of treatment, at the first
post-insertion and 3 months after denture insertion.
Centric occlusion and centric relation were evaluated
by Woelfel’s (16) method. Woelfel’s classification is
shown in Table 1.
Coincidence of centric relation position and position
of maximum intercuspation was examined by repeated
closure of the mandible relative to the maxilla in the
retruded contact position. Interocclusal rest space was
calculated from the difference between the vertical
dimension at rest and the vertical dimension of occlusion.
Two measuring points for the measurement of the
vertical dimension at rest were chosen in the midline
face – one related to the nose and one to the chin. These
points were selected on sites of minimal influence from
the muscles of facial expression to avoid skin movement.
Measurements were made at the relaxed and
comfortable position, unsupported by the back of the
dental chair, with the Frankfurt plane horizontal, while
wearing only the complete maxillary denture under
consideration. A Willis gauge was used for this measurements.
The vertical dimension of occlusion was
measured with the same instrumentation while sitting
in similar position with the complete maxillary and
mandibular dentures in situ and in contact in the
maximal intercuspal position.
Three years after denture insertion all patients were
invited to come for an examination. Of the 600 patients
in the initial investigation, 47 patients had died;
181 patients were not to be found at the addresses
given in the register, 37 patients were living outside the
country; 85 patients said they did not wish to participate.
The remaining 250 patients were invited for
reexamination, which consisted of a questionnaire
(Fig. 1) and clinical examinations. Their ages ranged
from 35 to 78 with a mean of 54Æ7. Again, quality of the
complete dentures was evaluated according to Woelfel’s
method and the interocclusal freeway space recorded
with a Willis gauge.
Data from this study were analysed with the Pearson
chi-square test. The level of statistical significance
chosen was 0Æ05. Patients’ judgement of complete
dentures was assessed with Cronbach’s a.
Results
Classes 3 and 4 of Woelfel’s Index include only those
with either no as only minor occlusal errors, while
classes 1 and 2 are titled as including major occlusal
errors. A chi-square test was applied to determine
whether there was a relationship between the accuracy
of maxillomandibular relationships and complete denture
usage 3 months after insertion. Statistically significant
relationships were found between quality of
centric relation registration and wearing of dentures
(v2 ¼ 18Æ07, P ¼ 0Æ007), between quality of centric
relation registration and denture use for eating
(v2 ¼ 35Æ52, P ¼ 0Æ002), between adequacy of interocclusal
rest space and wearing of denture (v2 ¼ 9Æ23,
P ¼ 0Æ009) (Tables 2–4).
Three years after complete denture treatment, the
remaining 250 patients answered questions concerning
the satisfaction or dissatisfaction with their appliances
(Fig. 1). All answers were analysed according to one
specific satisfaction or dissatisfaction. Internal consistency
of these variables assessed with Cronbach’s a was
0Æ82. A total of 198 (79Æ2%) patients responded that
Table 1. Woelfel’s classification
Woelfel’s
classification Clinical findings
Class 1 Gross error (>1Æ5 mm) between centric relation
and position of maximum intercuspation
Class 2 Substantial variation (0Æ5–1Æ5 mm) between
centric relation and position of maximum
intercuspation
Class 3 Slight variation (<0Æ5 mm) between centric
relation and position of maximum
intercuspation
Class 4 Centric relation and position of maximum
intercuspation coincide
36 E . DER V I S
ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 35–41
they adapted well to their dentures, but 21 patients
reported that they had not adapted and 31 patients that
they regretted the transition to the edentulous state.
When retention was assessed by the patients, 78%
(195 patients) of maxillary dentures and 39% (98
patients) of mandibular dentures had satisfactory
retention. A total of 201 (80Æ4%) patients stated that
they were satisfied with the aesthetic outcome.
Fig. 1. Questionnaire given to
patients to assess adaptation,
satisfaction or dissatisfaction relating
to dentures 3 months and 3 years
after insertion of new dentures.
THE ACCURACY OF INTERMAXILLARY RE L A T I O N S 37
ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 35–41
Forty-seven (18Æ8%) patients complained of difficulties
relating to function; 16 (6Æ4%) patients pain from
maxillary dentures and 52 (20Æ8%) patients from
mandibular dentures; 78 (31Æ2%) patients mentioned
other difficulties with their appliances.
Table 5 presents the observations of denture quality
and tissue health assessed by the specialist prosthodontist
3 years after insertion. In 121 (48Æ4%) of
250 patients the occlusion of the dentures was not
satisfactory according to the professional quality assessment.
According to the examiner’ s opinion, 59 of the
250 patients needed new dentures and 96 patients
needed relining, occlusal adjustment or repair. No
correlation was found between variables of denture
quality or the quality of the residual alveolar ridges as
assessed by the prosthodontist and by the subjects
themselves.
No statistically significant relationships were observed
between quality of centric relation registration and
wearing of denture (v2 ¼ 0Æ763, P ¼ 0Æ531), between
quality of centric relation registration and denture use
for eating (v2 ¼ 1Æ254, P ¼ 0Æ214), between adequacy
of interocclusal rest space and wearing of denture
(v2 ¼ 0Æ321, P ¼ 0Æ593) 3 years after complete denture
treatment (Tables 6–8).
Discussion
In the study the major errors in intermaxillary relationship
appeared to have influenced the denture
usage. This result would tend to challenge the reports
of Carlsson et al. (1), Bergman & Carlsson (5), Berg (3)
and Van Waas (8, 9). The reason for the difference
could be based on the fact that the sample size in
previous studies was smaller than in this study. Some
of the previous studies also have been unable to
demonstrate a link between patient assessment of, or
satisfaction with complete dentures and clinical quality
Table 2. Distribution of wearing of complete dentures of 600
patients (%) according to quality of denture occlusion 3 months
after insertion
Major occlusal
errors*
No/minor
occlusal errors† Total
Dentures not worn 48 (8) 47 (7Æ8) 95 (15Æ8)
Dentures worn 159 (26Æ5) 346 (57Æ6) 505 (84Æ1)
Total 207 (34Æ5) 393 (65Æ5) 600 (100)
v2 ¼ 18Æ07, P ¼ 0Æ007.
*Woelfel score of 1 or 2 for quality of centric relation.
†Woelfel score of 3 or 4 for quality of centric relation.
Table 3. Distribution of use of complete dentures for eating by
600 patients (%) according to quality of denture occlusion
3 months after insertion
Major occlusal
errors*
No/minor occlusal
errors† Total
Dentures not used
for eating
75 (12Æ5) 88 (14Æ6) 163 (27Æ1)
Dentures used
for eating
132 (22) 305 (50Æ8) 437 (72Æ8)
Total 207 (34Æ5) 393 (65Æ5) 600 (100)
v2 ¼ 35Æ52, P ¼ 0Æ002.
*Woelfel score of 1 or 2 for quality of centric relation.
†Woelfel score of 3 or 4 for quality of centric relation.
Table 4. Distribution of wearing of complete dentures by 600
patients (%) according to adequacy of interocclusal rest space
3 months after insertion
Interocclusal
rest space
<2 mm
Interocclusal
rest space
Table 5. Observations on the quality of the dentures and tissue
conditions assessed by the prosthodontist 3 years after insertion of
complete dentures (percentage distribution in 250 denture wearers)
and Yoshizumi (7), who used the next largest sample size.
The fact that the overall denture satisfaction was derived
only from one question is open to concern. Therefore,
in this study, data was obtained from clinical examinations
by one specialist prosthodontist according to
Woelfel’s Index and interocclusal rest space measurement
with a Willis gauge 3 months after insertion of
the complete denture. This is in contrast to Fenlon et al.
(10) who assessed by a postal questionnaire the quality
of the dentures 3 months after insertion.
The vertical dimension of rest has been considered to
remain constant throughout regardless of the presence
or absence of the teeth by Thompson (17) and McGee
(18). Atwood (19) reported instability of the rest
position and a decrease in rest face height after removal
of occlusal contacts. Sheppard & Sheppard (20) using
cephalometric examination found that the rest position
of the edentulous mandible tended to vary even over a
short span of time. It is now generally accepted that the
vertical dimension at rest is not a stable position
through life for a given individual.
Several studies have reported that the vertical relation
of rest is affected by the presence or absence of dentures
in the edentulous mouth. Tallgren (21) recorded that it
was less without dentures than with them. However,
Atwood (22) evaluated carefully the raw data of three
cephalometric studies (19, 23, 24). He reported a
variation in measurements between sittings and within
the same sitting, and between readings with and
without dentures. Kleinman & Sheppard (25) and
Gattozzi et al. (26) also affirmed that the resting vertical
dimension was affected the same way. However, they
considered that this difference was not predictable.
Tallgren (27) and Sheppard & Sheppard (20) found
that those subjects whose vertical dimension at rest
decreased with insertion of dentures had older dentures
and more years of denture wearing experience than
subjects whose it increased with insertion of dentures.
This may be because of impaired retention and stability
of the lower denture.
Ramstad et al. (28) and Cabot (29) reported that the
validity and reliability of recordings of the quality of
complete dentures are often doubtful. This problem
could be one cause of the discrepancy between the professionally
assessed denture quality and the subjective
judgement of the patients. This study revealed no
statistically significant correlation between professional
quality assessment of dentures and subjective
judgement of the patients. This result supports the
findings of De Baat et al. (15).
Three years after insertion of the complete dentures
the adaptation to denture wearing was excellent for
79Æ2% of patients, only 10% assessed the complete
denture function as less than good. Fifty-nine (23Æ6%)
patients needed new dentures and 96 (38Æ4%) substantial
adjustment to their present dentures. This study
found no relation between clinical treatment need and
Table 6. Distribution of wearing of complete dentures by 250
patients (%) according to quality of denture occlusion 3 years
after insertion
Major occlusal
errors*
No/minor
occlusal errors† Total
Dentures not worn 17 (6Æ8) 22 (8Æ8) 39 (15Æ6)
Dentures worn 104 (41Æ6) 107 (42Æ8) 211 (84Æ4)
Total 121 (48Æ4) 129 (51Æ6) 250 (100)
v2 ¼ 0Æ763, P ¼ 0Æ531.
*Woelfel score of 1 or 2 for quality of centric relation.
†Woelfel score of 3 or 4 for quality of centric relation.
Table 7. Distribution of use of complete dentures for eating by
250 patients (%) according to quality of denture occlusion 3 years
after insertion
Major occlusal
errors*
No/minor occlusal
errors† Total
Dentures not used
for eating
33 (13Æ2) 32 (12Æ8) 65 (26)
Dentures used
for eating
88 (35Æ2) 97 (38Æ8) 185 (74)
Total 121 (48Æ4) 129 (51Æ6) 250 (100)
v2 ¼ 1Æ254, P ¼ 0Æ214.
*Woelfel score of 1 or 2 for quality of centric relation.
†Woelfel score of 3 or 4 for quality of centric relation.
Table 8. Distribution of wearing of complete dentures by 250
patients (%) according to adequacy of interocclusal rest space
3 years after insertion
Interocclusal rest
space <2 mm
Inteocclusal rest
space ‡2 mm Total
Dentures not worn 17 (6Æ8) 22 (8Æ8) 39 (15Æ6)
Dentures worn 82 (32Æ8) 129 (51Æ6) 211 (84Æ4)
Total 99 (39Æ6) 151 (60Æ4) 250 (100)
v2 ¼ 0Æ321, P ¼ 0Æ593.
THE ACCURACY OF INTERMAXILLARY RE L A T I O N S 39
ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 35–41
denture satisfaction. This discrepancy between the
patients’ and examiner’s opinion has been demonstrated
in previous studies (14, 15). Thirty-nine patients
who said that they had been unable adapt to wearing
dentures even after 3 years.
The results of this study revealed a causal relationship
between accuracy of intermaxillary relations and
patient use of complete dentures at the first postinsertion
and 3 months after insertion of new complete
dentures. However, 3 years after insertion there was no
correlation between denture usage and occlusal relationships.
Major errors in intermaxillary relations
3 years after insertion were found in 48Æ4% of the
remaining 250 patients. Of the remaining 250 patients
66Æ8% had no/minor occlusal errors 3 months after
insertion and 22Æ7% of these patients were observed
major occlusal errors 3 years after insertion. Therefore,
it is most likely that during the subsequent wearing
period, the denture-bearing tissues of edentulous
patients had changed shape because of individually
varying resorption of the alveolar bone. This process
can lead to a certain shift of the dentures on the
tissues due to altered position on the jaw bone. It may
be expected, therefore, that the occlusion of complete
denture wearers may not remain stable during the
wearing period. These observations are in accordance
with those of Brigante (30), Tallgren (31, 32), Tallgren
et al. (33), Tuncay et al. (34) and Utz (35, 36) who
observed that complete dentures move further anteriorly
during the wearing period because of alveolar bone
resorption.
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Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 35–41 2004