Reconstructing Occlusion in Complex Cases: Why I Start with the Maxillary Anterior Teeth
One challenge I sometimes face in complex rehabilitation is having no reliable reference for the patient's original dentition. The teeth may be severely worn, displaced, or repeatedly restored. In these circumstances, I do not even know what the patient's occlusion used to be like, so I cannot simply return to it.
I remember learning an approach to occlusal reconstruction during my specialty training that began with the mandibular canine. We first determined its appropriate position using lip references, then reconstructed the occlusal plane with techniques such as the Broadrick Flag.
This approach has its own principles and rationale, but the truth is that I have never used it in clinical practice since completing my specialty training.
I have always been drawn to simplifying complex work. To me, however precise a treatment method may be, its clinical usefulness is limited if it is difficult to perform and cannot be reproduced across patients. Simplicity does not mean sacrificing accuracy; I look for a method that combines high accuracy with practicality and reproducibility.
I was also familiar with John Kois's perspective and the concept of Facially Generated Treatment Planning. Years ago, I read Global Diagnosis and discussed it in DentCast's five-part series, episodes 116–120.
This perspective made more sense to me, and I use it in complex rehabilitation.
I first try to establish an appropriate position for the maxillary anterior teeth, particularly the central incisal edges, using the patient's face, lips, smile, and phonetics. I then proceed with designing the rest of the occlusion.
What makes this approach particularly appealing to me is its similarity to complete denture principles.
In complete denture treatment, we do not necessarily know the previous tooth positions either. We use facial and lip references, phonetics, and jaw relationships to determine tooth position and gradually establish an appropriate occlusion.
In my view, understanding complete denture principles allows us to apply the same logic to complex rehabilitation.
More importantly, we do not have to consider every decision final from the outset. We design the proposed tooth positions, fabricate provisional restorations, and evaluate them under actual intraoral conditions. We assess esthetics, phonetics, and function, and modify the design wherever necessary.
For me, the main advantages are this simplicity, flexibility, and reproducibility: turning a complex treatment into a series of decisions that can be evaluated and revised.
Reviewing the article
To revisit the support for this approach, I turned to a 1999 article by Frank Spear, entitled The Maxillary Central Incisal Edge: A Key to Esthetic and Functional Treatment Planning.
Spear opens with a simple point: when planning tooth position, just as in complete denture treatment, it is better to begin with the maxillary central incisors.
But why the maxillary central incisors?
The position of this incisal edge influences more than smile esthetics; it also plays an important functional role. For example, together with the mandibular anterior teeth, its position influences the path of mandibular movement during protrusion and, consequently, protrusive guidance.
So how do we determine where the maxillary central incisal edge should be?
Spear presents three references:
- The other teeth and the occlusal plane: We assess the position of the maxillary central incisal edge relative to the other maxillary teeth and the occlusal plane.
- Phonetics: During sounds such as F and V, the relationship between the maxillary anterior incisal edges and the lower lip can help us determine an appropriate position.
- The patient's lips and face: We assess how much of the maxillary anterior teeth is visible at rest and during smiling, and how their position harmonizes with the patient's facial features.
(These are the familiar references we have used repeatedly when making complete dentures. For a dentist who understands complete denture principles, the logic of determining tooth position in this approach is therefore not particularly unfamiliar.)
Importantly, these references are not always equally reliable.
For example, we may wish to position the central incisors according to the existing occlusal plane, but the patient's posterior teeth may be missing, severely worn, overerupted, or restored inappropriately. In such circumstances, we clearly cannot use their current position as a basis for design without evaluating it, and we need other references.
Establishing an incisal-edge position does not mean that the treatment plan is finalized. We can test the proposed position intraorally with provisional restorations and modify it if necessary.
Spear also reminds us that changing the position of the central incisors should not be driven solely by improving esthetics. We must consider why the tooth came to occupy its previous position and how repositioning it will affect function and occlusal relationships.
What I take from this article is that the maxillary central incisor position is an important starting point for treatment design: one that considers esthetics while also prompting us to think about function from the outset.
My conclusion
I am not suggesting that the mandibular-canine approach is wrong, or that starting with the maxillary anterior teeth always produces better results. Both approaches have their own rationale.
Nor does an esthetically appropriate restoration position, by itself, guarantee appropriate function. We still need to assess VDO, jaw relationships, anterior guidance, the occlusal plane, and the other components of occlusion.
For me, however, starting with the maxillary anterior teeth fits better with the way I think and work. I begin with references from the patient, draw on the principles I learned in complete denture treatment, and use provisionals to test and modify the result before fabricating the definitive restorations.
Reviewing Spear's article showed that my chosen starting point is consistent with a recognized approach to prosthodontic treatment planning. The simplicity and reproducibility I experience with this method are, however, my own clinical impressions, not the result of a scientific comparison between the two approaches.
When I do not know where the patient's teeth used to be, I prefer to design an appropriate position for them rather than attempt to reconstruct an unknown one: a position that is esthetically acceptable and allows me to establish desirable function.
Reference
Spear FM. The maxillary central incisal edge: A key to esthetic and functional treatment planning. Compend Contin Educ Dent. 1999;20(6):512–516. PMID: 10650364.