Biomimetic Occlusion in Restorative Dentistry

Biomimetic dentistry aims to mimic a natural tooth throughout the restorative process. The last four decades of research has shown that mimicking and conserving a tooth’s natural connection to itself, its natural bond and resilience to occlusal forces and its natural defense mechanisms for infection benefits the tooth’s long-term health. This is also true for occlusion.

In this episode, Dr. David Alleman discusses what all dentists can learn from a body’s natural occlusion, lost research from the last few decades and approaches for daily occlusal techniques that can be applied to cases doctors regularly see in their office.

Articles referenced in this episode:

• Michael C. Alpern. The Ortho Evolution: The Science and Principles Behind Fixed/Functional/Splint Orthodontics. editor GAC International, Inc; 2003.

2025 training programs:
Biomimetic Mastership - class starts May 12. Learn more and register at allemancenter.com/mastership

In-Person SLA Workshop Dates:

• August 8-9
• October 24-25
• December 12-13

Learn more and register at allemancenter.com/training

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Transcript

0:33

Well welcome to season two, episode nine. Today's topic is occlusion. In the six lessons approach we have a hierarchy of importance. And we've talked about caries detection. We've talked about crack dissection. We've talked about immediate didn't sealing resin coating Lesson four is c factor one of the most difficult concepts to to put into practice. And then last time we talked about enamel replacement and those different options. The sixth most important thing in restoring a tooth and having it function like a tooth is to have it operate under function occlusion. when I was a dental student, 1975 to 1978, we had two experts in occlusion Larry Luce was the main expert. And then he had a, companion on the faculty named Doctor Beck, who was a part time. But Larry Luce was there every day as a dental school, and he had been traded occlusion through the traditional gnathology leaders in the prosthodontic world. And Larry Luce was a prosthodontist, very precise clinician. If you really wanted to have the highest level of critique, some people like criticism. Other people would like to have a little less criticism, but Larry Luce was the person that would be the most stickler for every item of any crown and bridge restoration. And of course, a single crown has something in common with a quadrant of crowns or an arch of crowns, or a full mouth reconstruction where you're changing vertical dimension and all of those concepts. As undergraduate dental students, you realize that's a specialty, and that's something that you wouldn't want to tackle your first day after graduation. But Doctor Luce and Doctor Beck, they were quite a team. They put on quite a show, and one of their, great demonstration was called a fully adjustable articulator and a pantograph tracing. Now, many of you have never heard of these concepts. They're not something that you need to master to, fix a tooth or a quadrant or even an arch. When you start talking about opening vertical dimension, then you're talking about the joint being usually in a different position. Then it has adapted to as the dentition has, has deteriorated. And so the leaders, were, a pair of prosthodontists L.D. Pankey actually was not a prosthodontist because there were no prosthodontists in the 30s. Everybody just learned how to make dentures and dentures were, using a technique of rearward centric relation. And that centric relation for dentures was the only point of contact that you really had to to deal with when you're trying to relate the movement of two jaws or movement of one jaw. The mandible reminds me of a joke that John Kois used to tell. He would say, would you move your jaw to the right? And the patient, if they said, should I move my upper jaw or my lower jaw? John Kois would diplomatically say, well, for today, let's just move your lower jaw. Move. Of course, that's the joke, because maybe only dentists know that only one part of the apparatus for chewing moves. But this idea of having a fully adjustable articulator that would mimic the, mastery system, the relationship of the jaws, this was the ideal. Unfortunately, when Peter a huge the he made a huge mistake. And the mistake is that on the articulator the upper jaw moved and not the lower jaw, the lower jaw was fixed. I mean, I'm laughing about it. But. There actually was one fully adjustable articulator developed that I've used, but it wasn't developed by a prosthodontist because he was not in that community that had certain dogmas about central relation, and he wasn't in that community. There had certain dogmas about, the way the mandible moved. He was able to think outside the box. His name was Mike Alpern and Mike Alpern was an orthodontist. And as an orthodontist, obviously you're mainly moving teeth, but teeth are connected to jaws. And so he was focused on jaws, particularly of a jaw. And a patient had pain in the orthodontic treatment. But interestingly enough, he was within, 30 miles of the, inheritors of the tradition of Pankey-Mann gnathology. And that was, Pete Dawson and his group in, Saint Petersburg, Florida. And so in Port Charlotte, close to Saint Petersburg, Florida. He would get patients who had jaw pain. And this jaw pain had developed after they had had a complete nasal logical reconstruction. So the change vertical dimension, they change jaw position. They had beautiful crowns. Only one problem. They could chew on the crowns. Why? Because the joint was painful. And so he. Because he had this patient base that were, coming from. Supposedly ideal process, idiotic treatment. He could see that there were problems and the problem actually had been identified. The decade before he made his innovations in Sweden and the, the Swedish school of mythology had a much more under un-American approach. And the Swedish, prosthodontiss were putting their jaw position down and forward until instead of an upward rearward position that, allowed the joint to be guided by the fossa. And so you've got a fossa, you got a head of the fossa on your mandible. That should be a free flowing, poly centric or poly movement. Option. And the brain is able to find the teeth that connect best. And so the brain is able to say, okay, chew here because you have teeth here or chew here because you have teeth here. So the Swedes started to question the dogma of a centric relation or an ideal position of the mandible in relation to the maxilla. Well, that information was out there, but it wasn't pioneered by Americans. So the Americans kind of dug their heels in and tried to find this ideal centric relation that the, kings of gnathology BB McCullum, Niles Guichet. P.K. Thomas, these are some of the West Coast gnathologists that, pioneered this idea of finding an ideal rotary opening and closing, the mandible. Well, people have started looking at the salt, envelope, which was documented in Scandinavia years before. Saw that there was not only a rotary position of the mandible but actually a translational position where as it rotates, then it slides down and forward to find these contacts between cusps and forces of existing teeth. And so Mike Alpern using this idea, was kind of fighting a war against people in the 80s when I was a young dentist who were fixated on the capsule and the disc on top of the condyle. And so the TMJ Decade of education in the 80s was trying to understand why clicking and popping was happening, and they had come to a conclusion. Pete Dawson was a leader in this. He had illustrations in his book, but illustrations are what, you know, they're symbols. They're just guesses of what's actually happening. And so this disc displacement or the disc could go forward off of the head of the condyle was the rage. And so you're trying to recapture the disc with a night guard that had a programed occlusal bite on the bottom was called a Tanner device. Henry Tanner actually was from Salt Lake City. I've talked to him when he was older, and I was younger, and this Tanner device was all the rage with the Dawson and the Pankey-Mann. Gnathologists But there was problem. Nobody actually had ever seen a clicking and a popping related to the position of the disc and the head of the condyle. you know, if you're a scientist, you try to see things. You know, Galileo saw some things, and he got put under house arrest and, you know, punished by his religious establishment for seeing the moons of Saturn and from the moons of Saturn and the movements of the of the moon, of the Earth. He was able to confirm Copernicus, conclusions of 80 years previous that the Earth was moving around the sun and not the sun moving around the earth. I digress, because it's a long time ago. It's not dentistry, but it is science. And so observational science gives better information than deductive science. And so you have to collect information. That's called inductive reasoning. That's what Aristotle was, pushing in, not trying to just use deductions of ideals or ideas that had come from the Plato school of philosophy. But as we started looking and seen, Alfred realized that nobody had ever seen this. No. At that time there had been some what are called fresh cadaver dissections of the joint and the prosthodontist who pioneered this and named Terry Tanaka and Terry Tanaka lived in Chula Vista, California, where my parents retired. And so I had a little interaction with Terry Tanaka. He was a major speaker at dental conventions, wrote a book, he had these dissections on a tape. And the dissections and the videotaping were actually done by one of, my UoP, not classmates. he graduated the year before I graduated, but Jeff Moss became an oral surgeon as part of his training in Los Angeles, he connected with Terry Tanaka in these, fresh cadavers, people who had just freshly died. And then, they cut open the joint and they simulated by moving the mandible into the different positions the joint could go and how the capsule was related to that. And this tape that Tanaka produced, but it's a VHS tape. I don't even have a VHS player now, but I do have one at the office. We don't have it at home, but the VHS tape, it's, priceless. I wouldn't sell it for any amount of money right now, but Jeff Moss, who was valedictorian of his class before us, we graduated, became the oral surgeon. And this tape showed that there are many different positions that the head of the condyle can take in relation to the disc. And that disc condyle relationship to the glenoid fossa, can take many positions. Well. This information was not well diffused around the world. So you got the Scandinavians getting some information. We got some information from, Tanaka and Jeff Moss and the main thing, though, you have to talk to patients. If you talk to patients, where are you most comfortable when you have this painful jaw? This is when my jaw is open. And when it opens, it always opens down and forward. This down forward position, once opened, understood that as an orthodontist, he was putting people down and forward all the time. He wasn't trying to get them into a retracted position, although there was one school of orthodontics that the push that unfortunately. But he decided to try to see what a clicking and popping joint looked like in real time. Now, as an orthodontist dentist with the specialty, you don't have permission to, make a surgical incision into a joint. Oral surgeons had that some of the oral surgeons were trying to do disc replacements turned out to be a disaster. This procedure failed 100% of the time. the older oral surgeons that we spoke to in Palm Springs a year ago. Boy, they had stories that were really sad. The patients were subjected this. But this pain, mostly from muscles that couldn't comfortably get to a position so their teeth could close. This pain drives people to distraction. And that was called TMJ. Now it's called TMD temporomandibular disorder in the gnathologists And the pain specialists like to focus on wrote books, lots of books. We had a specialist here in Salt Lake that was classmate of mine, undergraduate named Jim Gwin, and he made his whole living his whole life trying to get people into this position where they could be comfortable, and often required 28 crowns to do that. I'm just like, oh, man, what a Overtreatment. But Jim, Gwen's retired. You know, I'm not retired. So I get the last word on this. But these nephrologists and pain specialists and TMJ, these specialists, they would be having arguments all the time about small, aspects of which is the best articulator, which is the best way to program an articulator. That got us back to this story that I started with, with Luce and Beck. They had a fully adjustable pornographic tracing that showed exactly the jaw movement. Based on the condyle and the lower teeth. But they would make tracings, and then these tracings would be transferred on to an articulator that would have many movements. But again, the movements were on the upper part of the articulator, the exact reverse of a natural, masseter system. Well. Mike Alpern decided he wanted to see inside of a joint. And instead of choosing an oral surgeon, he chose an actual expert on arthroscopic visualization. In other words, putting a camera into a knee and doing a minimally invasive arthroscopic revision in torn cartilage. For example, in the knee that was pioneered by the orthopedic surgeons. And so the orthopedic surgeon that he partnered with, was named Doug Nuelle. And Doug Nuelle and Mike Alpern had patients with clicking and popping under anesthetic. Doctor Nuelle would insert the camera and Mike would manipulate the jaw. Mike Alpern was finding the position where there was no click and pop, and then he found the click, and then he found the pop. The click was forward. The pop was backwards. Now, the dogmas of the prosthodontic community were that this was going on to a disc when it came forward with the click, and then it came off the disc when it had the pop and went back. So this was diagnosed as a disc replacement, and they would try to recapture this disc by taking a orthotic, usually a Tanner appliance. Take it forward and then try to hold that position. And you could chew with a Tanner appliance. So you could actually, get some, some repetitions into this new position where there was no click and no pop, and they were trying to recapture the disc. Well, when they actually visualized this, they found out that over 80, 80% of the time the disc was doing just fine. It was encapsulated and attached to the head of the condyle. There was no problem with the disc position. The pop was coming because there was a little speed bump. It's actually scar tissue on the medial wall of the glenoid fossa. So that medial wall of the glenoid fossa had been rubbing against the capsule. There'd been some stickiness from the glycoproteins that lubricates this apparatus and that sticky. Eventually, particularly if there was a change in occlusion, could be rubbing more and more, and eventually there gets to be a little speed bump. And so when the condyle surrounded by the disc and the disc capsule went forward, it's stuck against this adhesion. So this little bump, this sticky bump would resist the movement, but then it would click. And then when it came back over the adhesion, it would pop. And that was the source of over 80% of the patients clicking and popping, which caused the muscles pain, the pain in the muscles, from trying to avoid these little speed bumps, these adhesions on the medial wall of the glenoid fossa. This was like, big deal. In other words, you change the diagnosis in 80% of the situations from a displaced disc into an adhesion that needs to be avoided. It was not received well from the dogmatic for US erotic community and the pain oral facial pain community. What can you say? Human beings are not that bright, but we're all human beings. We all have to learn from our mistakes. Mike Alpern wasn't going to make the same mistakes. And so his solution was repositioning the jaw, past these little adhesions, it would be always down forward and you'd open the vertical dimension. Usually in these cases you'd find a places they'd click and you would restore them there before it popped back. Because if you let the jaw after you'd had a Tanner appliance for a while and it was comfortable, then you take it off, then all of a sudden you're reactivating the adhesion and it doesn't solve the the problem that was causing the, clicking and popping and the pain. Mike, used adhesive dentistry to get his patients into a position that they were comfortable and they could function. And what he did do is he did adhesive on inlays without properly preparing the teeth. So he use bonding to enamel. These on les and the on les were like little snow caps on mountains, you know, just little tops, no tooth reduction. And the patients were great. Well, this information came, eventually to my first mentor, Ray Bertolotti and Ray Bertolotti brought Mike Alpern out to Yosemite, a yearly course in Yosemite, a three day course or two and a half day course in Yosemite. And I would go there for 20 years and, Mike Alpern presented this information. Totally made sense. At that time, I was teaching six lessons, so I took 12 of the doctors that I trained to Florida, trained in these new concepts for Mike Alpern. Now, his final treatment of, a full arch to get this down a four position, obviously, that's a great option, but usually patients aren't ready for 28 onlays or 24 onlays, 20 olays. You know, if they're $1,000 apiece, $20,000 to get out of pain. I mean, it's a little much, but the evolution came when I took a principle that I learned from John Kois in 1998 and 1999 called the Dahl appliance and Dahl. Was a prosthodontist was from Scandinavia. I believe Norway might be wrong, but one of the Scandinavian countries. In 1975, he was trying to treat patients. That had where of the lower anterior teeth and they needed to create some space, for the restoration. And so he came upon the treatment that he said he's going to put a platform. So the patient is only chewing on these lower teeth. In other words, the lower teeth were worn, significantly, they were restored, with composite, very famous, English dentist name Angus Walz restored composite on these lower teeth. And then use the dahl appliance on the top. And then Dahl said that if you do that and you just are touching on these 60s on the front, you can still chew pretty good. Not great, but a little bit. And then over time, the posterior teeth. It didn't need restoration would erupt and that eruption would be normal eruption with a attached periodontal apparatus. There would be no period problems, no problem. Just took about 18 months, sometimes two years to get all the teeth in occlusion. But that was, a concept that was adhesive. Dentistry became, much easier. Dahl appliance originally was made out of metal cast, lab supported, you know, work just fine. You had 60s, that you could chew on the front for a while. But with adhesive composite, we would just make little platforms on the back. And so 1975, to get this position of down and forward, John Kois was using a deprogrammer that did that same thing. But the problem was a deprogram. You couldn't chew with it. And so when you take it out, if you're trying to treat a TMD problem, not just a where problem, then you would still aggravate this, this condition in the joint. But the doll appliance that I started to use in 1998, 1999, 2000, when I received the information from from Mike Alpern and was trained by him, he also showed us a fully adjustable articulator that he designed. Peter Silver in Chicago was a manufacturer. They were manufacturer for about two decades. And unfortunately, there wasn't enough interest in the groups that he was training. Mike Alpern as an orthodontist didn't get a lot of stage time with state conventions with general dentists. And his technique for mounting his fully just vertically, were the lower mandible moved in any position, it was called a poly articulator because it's a poly centric, there's no one correct centric relation, which is the main dogma of the gnathologist prosthodontist So this poly articulator, based on the book that Michael Alpern and Doug Nuelle had written, Really has been lost to the profession. We we cover that in the six lessons approach. Our lesson six on occlusion talks about vertical ization of occlusion and opening vertical dimension, and use of a doll appliance to achieve these new, vertical dimensions. Anyway, that's it's it's important information. Not that difficult if you're restoring one tooth or a quadrant or even a full arch, but you're changing vertical dimension, then you have to have some principles of, guidance, either anterior guidance or posterior guidance. All of these, concepts, if you choose to do very complex cases, then you need more mentoring. We can provide that. But most dentists are not, you know, routinely, using these, Prosthodontic exclusion principles. But that being said, the success that I've had with down and forward using dollar appliance, and avoiding the clicking and popping by going past them and then reconstructing the patient at that new down, forward position that's past the adhesion. It's been basically 100% successful. you know, fortunately, the vast majority of patients don't have temporal mandibular disorder. But with adhesive dentistry, it's so easy to vertical eyes occlusion, for example, if we have patients that don't really have good cusp fossa relationships, and they have a little movement too much, they have their main complaint is usually biting their cheek or biting their tongue, or they don't like to chew gum. All of those indicates that you don't have a solid home position. The centric relation, or I should say the the position that the mandible has the best intercostal position. ICP or IPC. This ideal cusp fossa relationship is guiding the position of the joint. In other words, traditional theology says the joint is king. The condyle is king. In reality, the teeth are king. So the teeth tell the jaw where to go and the brain picks up that position of the teeth that are in the jaw. Those neural signals, gives the ability to program the cerebellum. So you have subconscious cueing in maximum inner castration. So this maximum inner conservation, if you slam your teeth together and it makes that sound, that means you have normal occlusion and you have enough intercourse based on maximum motor castration so that the brain doesn't you have to think, you know, you can be like this and go, or you can be like this. It overcomes gravity. You're like this. You actually have a little bit different muscle firing. If your head is like this, if your head's like this or if your head's like this, I'm not thinking about that. I can just do it like riding a bike. I don't think about riding a bike now, but when you first get these teeth coming into intercostal relationships about, you know, age eight, then, you know, a lot of kids when they're like 3 or 4 years old, they don't know where that jaw's going. They just mash their teeth and the food comes out on the side. these ideas of, destruction of the dogma of an ideal centric relation being back and up, which was based on denture technology that got modified. And then Pete Dawson started talking about a long centric, which is like, not, you know, what they were talking about. And then all of a sudden John Kois was saying, no, we never want to go up and back that that's the old school. So John Kois taught me occlusion would always put the mandible down forward in these, in these large cases in a dollar place is one way to stabilize that for the period of time while the restorations are being made. can be phased. You can do to by cusps on one on each side. You can do four by cosmos, two on each side. You know, the order, isn't that important. You just need three points of contact. One on the front and one on each side to really give the brain the cusp fossa relationship they need to to program. And so the idea is that occlusion has generated some had to be thrown out, others have been invented, but unfortunately been lost. And I don't know anybody that's teaching, Mike Alpern's concepts except the six lessons. But that's because we trained 12 doctors to come back to Florida, got trained, got some poly, articulators. But you don't actually need the poly articulator. What you do need is an actual patient, but you can test out the new down forward position that has no click new popping test the new down or forward position. If it's too open, the muscles can get a little sore. Sometimes you have to close it down, but with composite bonding on your facials over your lower cost and the lingual of your upper bicuspid, you can vertical as the occlusion and keep that sideways movement to a minimum. So that vertical ization of of occlusion is a great prosody principle. It still is true. Vertical ization of occlusion, stresses the tooth less because we're not doing talking on the tooth. You getting it? Compression teeth and paddles like to be compressed. You don't like to be talked. And so to avoid talking contacts usually in a non-working position, that's something that's very important to understand. We teach a technique that I learned from my second mentor, Gary Unterbrink The three paper technique, which is, genius. I've made some posts on that on my Instagram. Maybe we can talk about that another time, but that as always, glad you're listening. Glad you're interested. Get bonded. Stay, bond. See you next time.