JAW RELATION

MAXILLOMANDIBULAR RELATIONSHIP

Jaw Relation
refers

to any relation or position of the mandible to the maxilla

According to the Glossary of Prosthodontic terms, the term JAW RELATION is objectionable, MAXILLOMANDIBULAR RELATIONSHIP is recommended

Jaw Relation Classification

Vertical VDR VDO Horizontal
VD at other position

Orientation

Centric Relation

Eccentric Relations Lateral Excursion

Protrusion

1. Orientation Relation

establish references in the cranium relationship of the jaw to the TMJ or opening axis of the jaw opening axis can be located by using a FACE BOW

FACE BOW
a

U-shape frame caliper-like device that is used to

record the relationship of the jaws to the opening axis of the TMJ to orient the casts in this same relationship to the opening axis of the articulator

Indications for Face Bow Use

When

balanced occlusion is desired When cusp form teeth are used When interocclusal check records are used When occlusal vertical dimension is to be changed during teeth setting For diagnostic mounting and treatment planning For making occlusal corrections after denture processing

Classification Of Face Bow

Arbitrary Gives approximate values Condylar rods placed approx over the condyle Fork attached to maxillary occlusal rim Approx determines the terminal hinge axis used for CD procedures Kinematic fixed values Condylar rods placed accurately over the condyles Fork attached to mandibular rim Accurately determines the terminal hinge axis Used commonly for fixed or RPD

2. Vertical Relation / Vertical Dimension

It is the vertical measurement of the face between any two arbitrarily selected points conveniently located one above and one below the mouth usually in the midline

Types of Vertical Relation / Dimension 1. Vertical Dimension at Rest (VDR) 2. Vertical Dimension at Occlusion (VDO) 3. Vertical Dimension at other position

A. Vertical Dimension at Rest (VDR)

vertical dimension when the mandible is in the physiologic rest position established by muscle and gravity used as a guide to the lost vertical dimension at occlusion (VDO) measured when the head is upright in position and not supported by the headrest

Physiologic rest position

position of the mandible when all muscles that closes and opens the jaws are in a state of minimal tonic contraction sufficient only to maintain posture

Interocclusal Distance / Freeway Space / FWS

space

or gap between the upper and lower teeth when the mandible is in physiologic rest position usually 2-4mm when observed at the position of the first premolars essential because it maintains health of periodontal tissue when teeth are present

B. Vertical Dimension at Occlusion (VDO)

established by the natural teeth when present and in occlusion established by the vertical height of 2 dentures/OCR in contact computed by the formula VDO = VDR - FWS

C. Vertical Dimension at Other Position

no significance in CD construction vertical dimension when mouth is half open or wide open

Consequences of Increase Vertical Dimension

trauma

teeth possibility of pain in the TMJ more awkward to manipulate due to longer leverage clicking of dentures more easily displaced face appears long patient could hardly closes his mouth rapid destruction of residual ridges facial muscles appears strained

on the tissue due premature striking of

Consequences of Decrease Vertical Dimension

reduces function of the muscles with resultant loss of muscle tone cause creases at the corners of the mouth cause loss of space in the oral cavity with an adverse effect on the eustachian tube may affect hearing may produce trauma in the TMJ chin appears to far forward shrunk appearance of the face vermillion borders of the lips reduced approximately to a line lips lose their fullness face is flabby instead of being firm corners of the mouth turn down or droop

Methods of Determining Vertical Dimension

PHYSIOLOGIC METHODS

1. Physiologic Rest Position

Swallow and relax

presence of interocclusal distance of 2-4 mm at the premolar area

Niswongers method
Two marking are made, one on the upper lip below the nasal septum, the other on the chin. Patient is told to swallow and relax. The distance between the two marks are measured a difference of 2-4mm when VDO is subtracted from VDR if less than 2mm, VD is probably too great
if greater than 4mm, VD is considered too small

2. Phonetics

consist of listening to speech sounds Using m sound, presence of 2-4mm space observing the relationships of teeth during the production of ch, s, and j sounds ( bring anterior teeth close together but no contact)

Using thirty-three, enough space for tip of the tongue to protrude between the anteriors Using f or v sounds, maxillary incisal edge, lightly contact the lower lip Silvermans closest speaking space (1mm), presence of space during the function of speech
if speaking space is too large VD is considered too small if speaking space is too small VD is probably too great

presence of speaking space of not more than 1mm at the anteriors

3. Esthetics

Facial Esthetics
tone of skin throughout the face should be the same

Willis Method
Distance between the outer canthus of the eye and corner of the mouth should be equal to the distance between the lower border of the septum of the nose and lower border of the chin

4. Swallowing

presence of a very light contact at the beginning of the swallowing cycle if denture occlusion is missing VD maybe too small if there is difficulty VD is probably too great

5. Tactile Sense

Patient tactile sense

Boos Bimeter

Patient is asked if the rims appear to touch too soon, or if the jaw closes too much or if it feels just right
A device the measures the biting force Maximum biting force ocurs at VDO Using a central bearing plate and pin

Lytles method

Electromyography

Rest position determined by recording minimal activity of muscles of mastication

6. Patient Perceived Comfort

Mechanical Methods

Mechanical Methods

Ridge relation Incisive papilla to mandibular incisors

- approximately 4mm in natural dentition

Parallelism of ridges Measurement of former denture Preextraction records

Profile radiographs
have

been used but cannot be considered adequate an indication of the amount of space required between the ridges for the teeth of this size of Willis gauge

Cast of teeth in occlusion

give

Facial measurement
use

HORIZONTAL JAW RELATION

Horizontal Jaw Relation

refers to the front to back, side to side relation of the mandible to the maxilla Classifications of Horizontal Jaw Relation 1.Centric relation the basic horizontal jaw relation 2. Eccentric relation A. protrusion B. right and left lateral excursion C. all intermediate position

Centric relation

A maxillo-mandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anteriorsuperior position against the slopes of the articular eminence the most retruded position of the mandible against the maxilla at the established vertical dimension

Centric Relation vs Centric Occlusion

Centric Relation vs Centric Occlusion

Centric

Relation

This position is independent of tooth contact and is repeatable position

Centric

Occlusion

The occlusion of opposing teeth when the mandible is in centric relation. In natural dentition this may or may not coincide with maximum inter-cuspal position In complete denture CR=CO=MIP

Significance of Centric relation

if

centric relation and centric occlusion do not coincide, it will result to denture instability and pain or discomfort

METHODS OF RETRUDING THE MANDIBLE

1.

Passive Method

dentist guide mandible in terminal hinge axis movement

2.

Active Method

patient responds to instruction by actively retruding the mandible

Techniques to retrude the mandible

finger

guidance central bearing point stretch-relax exercises tongue curling backward swallowing reclining the patient palpation of temporal muscle

METHODS OF RECORDING CENTRIC RELATION

1. Static Method
placing

the mandible in centric relation, then making a record of the 2 rims to each other. advantage
minimal displacement of recording bases in relation to the supporting bone

2. Functional Method
involve

functional activity or movement of the mandible at the time the record is made includes: A. chew-in technique by Needles, House, Essig, Paterson B. swallowing disadvantage causes lateral and anteroposterior displacement of the record base

3. Graphic Method

involve the used of intraoral or extraoral tracing devices, with a central bearing point secured to the record base

Gothic Arch Tracing

Recording Medium /Materials Used in Recording CR

plaster

wax
ZOE

paste cold cure acrylic resin warm staple wires pins

Complications in Recording CR
Biologic
- Realeff - Neuromuscular problems - TMJ abnormalities

Mechanical
- Ill fitting bases - Excessive pressure

Psychological
- Patient factors
- Operators abilities

Mandibular Movements

Mandibular Movements
Mandibular

Movements occur during mastication speech swallowing respiration facial expression parafunctional habits like clenching and bruxism

a ginglymoarthrodial joint (sliding, hinge joint) Structures 1. Bony Structures

TMJ

- condyle - glenoid fossa - articular tubercle

2. Articular disc 3. Articular capsule 4. Ligaments A. temporomandibular ligaments B. sphenomandibular ligaments C. stylomandibular ligaments

Mandibular Movements
1.Hinge movement 2. Translatory movement - forward or protrusive - direct lateral side shift (Bennett movement) - translatory movement that occurs when the mouth is opened wide

Envelope of Motion
Border

movements of the mandible Types 1. Envelope of motion in sagittal plane 2. Envelope of motion in the frontal plane 3. Envelope of motion in the horizontal plane

ARTICULATORS

ARTICULATORS
a

mechanical device that represents the TMJ and jaw members to which maxillary and mandibular casts can be attached

Parts of an Articulator

Upper & lower arm/member Mounting plates

Represents the maxilla & mandible where casts are atached Connects the casts to the articular arm Represents the condyle Represents the slope of the articular eminence which guides the movement of the condyle Can be fixed or adjustable or customized

Condylar analogues Condylar guidance

Incisal guide pin

Incisal guide table

Represents the vertical dimension at occlusion

Represents the lingual slopes of the maxillary anterior teeth along which the lower incisor move Can be fixed or adjustable or customized

Classification of Articulators

1. Simple Hinge

accept only centric relation record can be opened and closed only also called onedimensional instrument because only one interocclusal record is necessary for its adjustment and use

2. Mean value
allows

lateral and protrusive movements based on average determinations condylar guidance angle and incisive guidance are fixed, 30 and 10 degrees respectively

3. Semi- adjustable
with

individually adjustable condylar guidances in both the vertical and horizontal planes accepts face-bow transfer interocclusal records can be used to record the condylar guidance

4. Fully Adjustable
a 3-dimensional articulator that requires a CR record, at least 2 lateral records, and some means for controlling the height and inclination of the cusps capable of reproducing jaw movements with great accuracy Pantograph (consist of six styli and tracing tables) use to produce tracings called pantogram

ARCON Articulator
a

contraction of the words articulator and condyle means that the condylar guidance is located in the upper member on the articulator and the ball (condylar analogue) is located in the lower member Better visualization and understanding of mandibular movements

Programming The Articulator

Programming the condylar guidance

Horizontal condylar guidance
Use

protrusive record (protrude mandible 6mm)

Lateral condylar guidance

Use

lateral record or Hanaus Formula (H/8 +12)

Programing the incisal guidance

Horizontal guidance

controls the anteroposterior movement of the lower jaw

influence lateral movement of the jaw (canine guidance)

Lateral guidance

Occlusion

Definition of Terms

Occlusion
a static state used when opposing teeth are in contact without movement

Articulation
is a dynamic state used when opposing teeth are in contact during movements of the mandible

Centric Occlusion

Eccentric Occlusion

Occlusion of opposing teeth when mandible is in centric relation Occlusion other than centric occlusion that includes lateral and protrusive occlusion

Balanced Occlusion (discussed later) Working Side Balancing Side

The side opposite the working side

The side towards which the mandible moves in a lateral excursion

Natural Vs Artificial Occlusion

Natural Occlusion
1. Supported by roots which are firmly anchored to the bone 2. Moves independently in their socket 3. Malocclusion may remain uneventful for years 4. Occlusal forces affect only the concerned teeth 5. Nonvertical forces are tolerated much better 6. Mastication is usually done in the second molar region 7. Bilateral bvalance is not naturally found and is considered detrimental 8. The proprioceptive mechanism enables the patient to avoid prematurities and gives him better control

Artificial Occlusion

1. Supported by denture base placed on slippery mucosa 2. Move as unit on their base 3. Malocclusion evokes immediate instability and pain 4. Forces acting on a complete denture affect the whole base 5. Nonvertical forces are usually not well tolerated 6. The second premolar area is preferred for mastication; mastication in the second molar region can cause shifting of the base 7. Bilateral balance is usually considred necessary for denture stability 8. Poor feed back mechanism, so neuromuscular control is compromised

Functions of Complete Denture Occlusion

1. Improve masticatory function 2. Minimized harmful nonvertical or lateral forces 3. Contribute to the stability of the denture bases 4. Contribute to the health and preservation of the alveolar bone and soft tissues 5. Maintenance of the comfort and well-being of the patient

Complete Denture Occlusion

Balanced

occlusion Nonbalanced occlusion Lingualized occlusion Functionally generated occlusion

BALANCED OCCLUSION

The bilateral simultaneous, anterior & posterior occlusal contact of teeth in centric & eccentric Advantages
Denture stability Enhanced retention Enhanced patient comfort Maintenance of the integrity of supporting tissue

Occlusion

Factors Affecting Balanced Occlusion (Hanaus Quint)

1. Condylar Guidance
- slope along which the condyles travels when the mandible protrudes - Patient related factor - Horizontal condylar guidance (protrusive record) - Lateral condylar guidance (L = H/8 + 12)

2. Incisal Guidance
- the influence of the contacting max & mand anteriors on the mandibular movement

Factors Affecting Balanced Occlusion

3. Occlusal plane established by the cuspids (commisures) in the anterior and ht of retromolar pad in the posterior 4. Cuspal inclination cuspal height

Factors Affecting Balanced Occlusion

5. Compensating curve artificial curves in CD to achieved a balanced occlusion Types Anteroposterior Compensating Curve
Lateral Curve (molar curve, first premolar curve)

Christensens Phenomenon
is

the development of spaces between the upper and lower occlusal surfaces at the distal of the occlusal rims or dentures with the downward and forward movement of the mandible

Bennett Movement
Mandibular

lateral translation Also known as Bennetts shift, direct lateral side shift, side shift, laterotrusion Cause separation during lateral movement Determines cusp height and morphology

INTER-RELATIONSHIP OF THE FACTORS INFLUENCING BALANCED OCCLUSION

Cusps

Condylar Guidance

Incisal Guidance

Occlusal Plane

Compensating Curve

 Nonbalanced

occlusion

Nonanatomic teeth are used Plane of occlusion parallel to residual ridge No compensating curve
Lingualized

occlusion

Upper lingual cusps are set into the lower central fossa; buccal cusps out of contact
Functionally

generated occlusion

Maxillary teeth carve out a path in the wax placed on the lower occlusal table, then wax is replaced with cast gold or metal alloys

SELECTING ARTIFICIAL TEETH

Anterior Teeth Selection

color

or shade form or shape size material

*Pre-extraction Guides - photograph - diagnostic cast - radiograph - teeth of close relative - extracted teeth

1. Color or Shade
Qualities of Shade Hue specific color eg. Blue, green, grey, brown, reddish yellow Saturation or chroma amount of color per unit area Brilliance or value the lightness or darkness of a tooth Translucency permits light to pass through but cast no image Aids in Determining the Shade shade is correlated with the color of skin, hair, eyes should not contrast with the surrounding structures should be examined both under artificial and natural light possible to make minor variations to create a more natural appearance

Shade Selection
should be examined in 3 positions outside of mouth, side of nose gives hue, chroma, value under the lip, incisal edge exposed give effect of color when mouth is relaxed under the lip, covers only the cervical simulate smiling do the squint test

2. Form or Shape of Anterior Teeth

Outline

of the face Square Tapering Ovoid Square tapering Facial profile - convex - straight - concave

Form or Shape of Anterior Teeth

curvature of labial surface (incisal view) convexity or flatness of the face

Sex of the Patient Female - More pronounced curvatures - rounded point angles - more delicate appearance - Lateral incisors are smaller

Male - Squareness of teeth

3. Size of Anterior Teeth

length of max central incisors is 1/16 of the length of the face from patients hairline to the chin or is equal to the distance from high lip line to incisal plane

width of max central incisors is usually 1/16 of the bizygomatic distance width of six anterior teeth is equal to the bizygomatic distance divided by 3.3 or distance between the 2 cuspid lines

4. Materials Used
A. Plastic or Acrylic Advantages: - Economical - easily adjusted - bond to denture base - can be stained to esthetic mprovement - dont abrade gold or teeth Disadvantage: - poor abrasion resistance

B. Porcelain

Advantages: - Hard and wear resistant - mastication is more efficient Disadvantages: - mechanical bonding by holes or pins - much lower thermal expansion thus can produce stress in denture base - very hard to adjust, glaze lost with grinding - may cause clicking noise on eating or in patient with hearing aids - teeth may chip in used

C. Composite Resin -harder than acrylic but tends to collect stains

D. Hard Acrylic - more wear resistant than acrylic but dont have staining problem of composite

Posterior Teeth Selection

tooth

form buccolingual width mesiodistal width length cuspal inclines materials ( porcelain, resin, metal insert, teeth with metal occlusals) shade

1. Tooth Form (Classification of Posterior Teeth)

Anatomic
A. Provide a more natural look to the dentures B. more efficient in mastication C. definite cusp to fossa relation D. cuspal inclination facilitate the development of bilateral balance in eccentric occlusal position

Non-anatomic

A. use in Class II and Class III jaw relationship B. closure of the jaws over a broad contact area C. creation of minimal horizontal pressures

2. Buccolingual Width of the Posterior Teeth

should

be greatly reduced - to enhance the development of the correct form of the polished surface - to reduce the amount of stress to the supporting tissues

3. Mesiodistal Width of the Posterior Teeth

should

be measured from the distal of canine to the beginning of the retromolar pad

4. Length of the Buccal Surface of the Posterior Teeth

length

of max. first premolars should be comparable to the max. canines

5. Cuspal Inclinations

angle form by the MB cusp of the lower first molar with the horizontal plane Types: A. 33 degrees - maximum opportunity for a fully balanced occlusion B. 20 degrees - develop balancing contacts in eccentric jaw position C. 0 degree - no cross-arch balanced occlusion - effective only when it is difficult to record centric jaw relation precisely - there are abnormal jaw relation

Materials Used
Acrylic

Porcelain

Inexpensive, easily available, easy to grind, absorbs stresses, does not wear opposing natural teeth and gold crowns Use in sufficient interridge space, well formed ridges, superior esthetics, can cause wear of natural teeth and gold crowns and bridges To reduce the wear of resin when oppose by porcelain teeth

or Plastic

Acrylic

or Plastic with amalgam inserts

Acrylic

or Plastic with gold occlusal surfaces

When oppose by natural teeth, gold occlusal surfaces

* Porcelain anteriors and resin posteriors dangerous combination