Jaw movement maxillo/mandibular relations and face bows and articulators

The face bows and articulators, we will talk just a little bit about them today and they will be covered in the next lectures. This lecture will focus on jaw movements and maxilla/mandibular relations. It is a very important clinical lecture, what you will see in this lecture you will do in the patients mouth 4th and 5th year and in your life as a future dentist. If anyone of you (dentate or not) bites down and closes his mouth, he can move his mandible forward, right side, left side a little bit backward and in any area between (rotation). Any rotation that you do when the teeth are in contact is composed of protrusion, right lateral excursion, left lateral excursion, and retrusion. Now when the teeth are in contact, the mandibular movement is affected by the teeth, so the determinants of occlusion when the teeth are in contact are 1) How does the movement happen? Nerve impulses and muscles so.. Neuromuscular 2) TMJ joint: we have the glenoid fossa and articular eminence. When I ask you to do protrusion, you will notice that your mandible will slide forward and downward, until the head of the condyle is below the articular eminence. At this time your teeth are almost edge to edge. If you continue, the condyle will become anterior to the articular eminence. So I want you to know that the determinants of mandibular movements when the teeth are in contact are affected by neuromuscular control, affected by teeth which are supported by PDL in the bone. So bone and PDL play a role, plus the anatomy of the TMJ and related structures, like the ligaments and muscles related. All of these will determine the pattern of movement you do when your teeth are in contact. *Now when teeth are not in contact you can open your mandible. Opening the mandible, is not affected by teeth, but only effected by the TMJ and neuromuscular control. So the first few cms like 2.5 cm or 25 mm are pure rotation for the condyle in the glenoid fosse. If you continue to open, it becomes rotation and sliding or gliding, due to the anatomy of the TMJ. The maximum opening is pure rotational then rotation and sliding together. When opening your mouth, u can achieve a position for the condyle which is similar to when u do protrusion, the condyle will be in front of the eminence. Also u can move to the right and left without teeth coming in contact. *When the teeth are in contact, it becomes more complex for mandibular movements, why? Because the posterior teeth with their anatomy cusps and anterior teeth with their anatomy will overlap, which we call overbite and overjet. We will discuss them in setting of teeth, they will affect the movement. This is the reason that mandibular motions are very complex. The envelopes that I am going to show u in the slides are just the average, but every person is different than the other, even the same patient might chew in a cycle today that will be different than tomorrow.

We have what we call border movement, which means the maximum or extremes that the mandible can move to. U cant move the mandible beyond these limits or borders. You have border movements and within these borders the mandible moves during function. So you have extremes in which the mandible can move. So the function or the chewing cycle is within these borders of movement of the mandible. (This part talks about the envelop of motion, it is very confusing, but I wrote exactly what Dr.saleh said. He referred and pointed at the diagrams a lot, and acted out many movements (like this like that).. It was hard to interpret these movements into words). There was a scholar his name was Posselt, who was interested in mandibular movements. He examined a group of patients, using a graphite pen and paper sort of device, to trace mandibular movements in the sagittal plane. The pen was put between the incisors and the paper in some position pg 271book...this will draw the movement in the sagittal plane, giving us the envelope of motion in the sagittal plan (maximum border movements).

So the first point he started from, in a dentate patient, was maximum intercuspation, the teeth are in contact. Its the highest point on the envelope. Then he asked the patients to retrude, and the retrusion movement was downward backward, (not for every person because not all patients can do retrusion), 80 to 90% can retrude and this retrusion is just for a short distance 1 to 2 mm. The point which is downward and backward to the maximum intercuspation, and the teeth are still in contact is called centric occlusion. Then back again to the maximum intercuspation, he asked the patient to protrude, this is edge to edge. You will have complete downward forward movement. The protrusion is affected by the condyle, glenoid fossa and articular eminence plus the guidance from the anterior teeth. After this upward movement which is maximum protrusion So we have M.I maximum intercuspation, CO centric occlusion, edge to edge, and maximum protrusion. These are the movements in the sagittal plane when teeth are in contact. *Now back again to MI, he asked the patient to move to the right side, which we call right excursion. The side to which the patient moves his mandible is called the working side and, the side against the working side is called the nonworking side. If I tell you to move your jaw laterally to the right, the right side becomes the working side and the left side is called the nonworking side or the balancing side. So from the MI he asked the patients to move their mandible laterally to the right. The arc of rotation of the mandible will be on the condyle of the working side and most of the movement happens in the nonworking side. The movement in the nonworking side will be downward 2

forward and medially. On the other hand the working side, even though it moves just a short distance, it moves in the opposite direction, upward backward and medially, because the mandible is one piece. There is one characteristic that is specific to the mandible: it is the only bone in the body, that when movement happens in one joint the other joint must move. No movement can happen in one TMJ without moving the contralateral TMJ. The movements are different, but it should move. From MI, there is extreme right lateral excursion and extreme lateral left excursion, the last point is the right excursion. These same movements can be carried out from centric occlusion. You can do maximum protrusion first, and then the lateral. So from all these points you can start lateral movements. But this motion you cant draw it on a sagittal plane, you should draw it in the horizontal plane because these lateral movements you look on top of the patient so it is on the horizontal plane. So now we have an envelope in the sagittal plane and an envelope in the horizontal plane. *Now these were movements with teeth in contact. But if you take any point, the patient can open the mandible and do the same movement, so movement without teeth. So this movement without teeth, if you come to CO, move the mandible backwards, and open, the first opening cycle is pure rotation, then when you keep opening, you will have another cycle which is rotation and sliding. From CO, this pattern of movement ends. * Now if you go to MI and you open your mouth, the same thing but almost one motion, you dont have a curve that is as steep as the previous example, but it is 2 movements basically. Now if you go to maximum protrusion, already the condyle is in front of the articular eminence, and if you open, it's just one movement. So if you put these movements in the sagittal plane either with teeth in contact or not, and if you put the lateral movements in the horizontal plane and then put them together you will end up with a 3D envelope. This envelope gives you the border movements, so the mandible can't move beyond this envelope. All the movements you do are within this envelope, because these are the extremes of your movements, whether in the sagittal or horizontal plane, and therefore you do this 3d model, posselts envelope. However posselt's envelope is mainly for the sagittal movements but we add the lateral excursions as well. Now we have CO, MI, MP, LE, and MO =Maximum opening with pure hinge axis, which is rotational movement. The posselts envelope is very important you have to know what each point indicates. I gave you the mandibular movements to understand that when the patient becomes edentulous, the effects of teeth on these movements will be gone. You will replace the teeth so you need to understand the effects of teeth on mandibular movements so that you can provide the patient with dentures that are functional to them. You dont want the patient to come back telling you he can't chew because of improper movements affected by teeth interferences, you should understand the way the mandible moves.

Now we are done with the theory part and move to the clinical part. So we have a patient who has lost all his teeth, most of the relationships like the vertical, horizontal, lip support and cheek support, are all gone and we will restore them back to the patient. How? We construct a device called record block, so we will have upper and lower record block. Every record block is composed of the base plate and wax rim. The base plate is customized on the secondary impression, so we cant do changes to it. Sometimes you can thin the base plate in some areas if you need, but most of the time we depend on adjusting the wax rim. We have upper and lower wax rims or occlusion rims. The 4 main functions of occlusions rims:1) Establishes the neutral zone or the arch form based on the resorption that happened to the patient. 2) Level and orientation of occlusal plane. 3) Vertical and horizontal arch jaw relationships. 4) Estimate of the interocclusal distance. Neutral zone or arch zone: In the patient, resorption happened, lips are collapsed the cheeks are collapsed, there are wrinkles why? Because of resorption pattern. First thing you do when u receive the record blocks from the lab, you start with the upper record block. You place the upper record block in the patient's mouth. Remember that we've constructed the record blocks with average dimensions; you dont expect it to be perfect when you insert it the first time. So sometimes if the lip is protruded, the angle between the nose and the lip is acute, this means that the labial support is more than needed. You need to take off wax labially. If the labial support is less than should be, you add wax to make the angle almost 90. So the wax rim brings back support or stability to the lip so that you end up with good labial support or labial fullness, in which you find the angle almost 90. But this is not a rule, because some people have a longer nose than average or the angle between their nose and lip is not 90 to begin with. So this is not a rule, the rule is to check the labial support. How can u know if the labial is supported in an esthetic way? We have a vertical depression on our upper lip called the philtrum. If the lip was overstretched the philtrum will be lost. If the lip was less supported than needed the philtrum will be narrowed and you will see wrinkles in the lip. Plus you can also use the nasolabial angle as an indicator for the labial support. This is the neutral zone. When you achieve the labial support, you think this is the preextraction position of the teeth that Im going to set the artificial teeth in the complete denture in this position, to end up with labial support, because natural teeth give labial support.

This is anteriorly, now posteriorly you have to do the same thing, u need to support the cheeks. So when you support the lips and cheeks you end up with the arch form for the denture. So the teeth for the wax rim will be in what you think is the suitable neutral zone for the patient. This is the first step you do in the patient's mouth. Labial fullness and cheek support.

2) Level of occlusal plane and orientation of occlusal plane. Suppose you have good lip support but when the patient smiles or speaks the teeth dont show or only show a little bit of their length, so its not esthetic. Most of the people show 1/3 of their incisors, but some have short lips (gum smiles) they show the whole length of the teeth plus part of the gum. The average shows 1/3 incisors. If your patient has short lips, you can't follow this guide line. But most of the patients we provide them with wax rim 2 mm below the level of the upper lip. I told u zero to 2 most of the time we make it 2mm for old patient's maybe we provide them with 1mm sometimes for some patients 3mm, but the average is 1 to 2mm, so this is the level of the occlusal plane. Sometimes for this level of the occlusal plane, it might be posteriorly (like this or like that) .so what's another function of the wax rim? Its orientation of the occlusal plane. The device we use for this is called Foxs plane device. We insert the upper record rim in the mouth. This device has a fork, that fits the upper wax rim, and it has horizontal arc and anterio/posterior arcs. So when you place it into the patient's mouth, the patient must be in an upright position. That horizontal arc should be parallel to the interpapillary line. The lateral arc should be parallel to the arac tragus line, which we call campers plane, not to the Frankfort plane, because the average of the patients is like this. We use a ruler. The wax rim in the patients mouth gave us level of occlusal plane and orientation of occlusal plane. 3) Whats lost? The vertical dimension and anterio/posterior relationship. There are many ways we can determine the patients VDO, we have mechanical and functional methods. Mechanical methods: sometimes you have pre-extraction records or models from the past if the person was an old patient of yours. He had teeth, and he became edentulous over the years, so you might have his pre-extraction records such as an x-ray for the profile (like a lateral cephalogram) so you see the distance from bone to bone. Then you can take another xray while he is edentulous, and make the distance close, but that wont be accurate because there are accommodations for edentualism, but it can help. Sometimes you might have old casts when they bite so u can measure the distance form one fixed point to another fixed point, and refer it to the patient and you can open or close the vertical dimensions according to cast. Sometimes you might have facial measurements that you have taken of the patient,

and have it recorded in the patients file, so you can use this toonone of these methods is very accurate, you can use all of them to just help you. Also we can use the ridge relations. In anatomy there are some studies found that there are some landmarks that can help us. They found that the incisive papilla. If we ask anyone of you to bite, the lower incisal edge of most of the patients is below the incisive papilla by 4mm. So this can help in determining the vertical. So when you place the upper and lower record block together on the cast (or in the phantom head) you can measure the distance from the lower rim to the incisive papilla. If it is not 4mm, its not an issue because this is just average, but it can help. Also parallelism of ridges, most of the time, even if you show me your registration, I will be able to tell you if it is good. If the upper and lower ridges are parallel, most of the time your registration is correct. Because the upper and lower occlusal plane are parallel due resorption that happens when the teeth are lost. But again I told you there are accommodations to edentualism or adaptation, the mandible might move forward, so its also not accurate but it can help. Most of the time, if you have good VDO, the upper and lower ridge are almost parallel. If the patient has old dentures and wants new dentures for some reason, you can also use them. Most of the time the teeth are worn, so you can measure the distance and add 1 or 2mm just to give them nice teeth. So the old denture can also help. Since mechanical methods are not fixed we have physiological methods that we rely on most of the time. In the physiological method we have the rest position, the patient is upright, and u ask him to relax, leave him for 5 minutes, ask him to do some massage for the muscles, ask him to say M, because the m sound relaxes the muscles. After this leave him for 5 minutes, and place two dots (one dot here one dot there), on the tip of the nose and chin? Then measure this distance, we call this distance from one point to another point, vertical dimension at rest. So VDR, there is separation between teeth usually which is in average 2 to 4mm, we call it the freeway space. So if I measure the VDR and its 70 for example, and I say ok the freeway space is 4mm, 70-4 = 66, so the VDO is 66. I place the record block in the patients mouth and measure between the dots. If it is 66mm fine, if its 64 I add wax, if its 68 I take off wax from the lower record block only. But freeway space also is not fixed, so how do we make sure that our relation is good? At the end no one will measure this distance for the patient, because people look at the way the patient speaks and the appearance. So I want the phonetics and esthetics to be good. Some letters are important for vertical dimensions. The most important one is the S sound, which we call the closest speaking space. When u say ssss your teeth come in close proximity but they dont touch, because in speech we dont have clicking of teeth. So the S sound they are almost in contact, so it's like VDO plus 0.5mm. if the patient says S and u notice that laterally the upper wax rim touches the lower wax rim this means that u have to remove wax from the lower rim. Most of the time if the wax is more than needed, the patients will say esshh you remove wax and the it becomess. Now if you ask the patient to say s and he says ethh this means you have to add wax because there is more space than should be, so the S sound is important also the letter H and word edge, the teeth come in close proximity. 6

Swallowing threshold: a technique some prosthodontics and dentists, I dont think we use it anymore. They place the upper record block and wax and ask the patient to swallow. Anyone who swallows you will see that at the beginning of the swallowing cycle, which is the end of the chewing cycle, the teeth will come in contact. When they place these wax .in the mandible and ask the patient to swallow, the wax gauze are made longer than needed, they will be until the patient is in proper VDO. Again the wax can distort in the mouth and it's not an accurate method. What we do is the measurements first, phonetics and esthetics, plus patients comfort. If the patient is happy, if he can count from 1to 10, his lips and cheeks are relaxed Sometimes we have certain instruments that we place in the upper and we call them placing instruments. We keep increasing until the patient says Im not comfortable then we stop and start decreasing until the patient says Im not comfortable so you stop and say this is the VDO. But as we said what we use in the clinic and have been successful for almost every patient, measurement #1, phonetics, esthetics and patient comfort without the tracing device, plus if we have old photos and old records can help us. But if we dont have old photos and records, the above should be enough. The way u measure the 2 dots, most of the times we place one on the nose and one on the chin. We have a special ruler (u can use a normal ruler) but this special ruler or measuring device is called Willis Gage, it gives you the distance. *Now, how can I use esthetics to determine the VDO? Most patients if you measure from the lateral canthus of the eye to the commeasure of the lips which is the junction of the upper and lower lips, it will be almost the same as the distance from the nose to the chin. When you put the lower record block in the patients mouth, u measure this distance, if it is similar, this means you are on the right track, if too much or too little, this means there is something wrong. Again we cant rely on anyone of them to give us proper VDO; we have to join most of them, measurement with esthetics and phonetics, so that at the end we achieve suitable VDO for the patient.

*Now after you get the VDO, and we already have VDR, indirectly the wax rims will have given you the free way space, which is VDR VDO. Now suppose that you made a mistake in the clinic, instead of making the VDO 50mm for a certain patient for example, u did it 54, so u reduced the free way space, from the actual measurement. The dentures are longer than needed vertically. This will lead to Discomfort, 7

Trauma to the ridge due to resorption because there are high forces on the bone, Clicking of teeth (cant says) Appearance, it will look long lower face height. Most patients cant tolerate their dentures in this case, because muscle fatigability is painful. *Now what if you give less VDO than needed and more freeway space, which is a very common error? The problem is that patients can sometimes tolerate this. But some consequences are: Difficulty in chewing, Cheek biting, Old appearance, which is chin to nose approximation, Soreness of the corners of the mouth.fungal infection called anuglitis because of the saliva, Long-term TMJ dysfunction, Now the free way space is affected by short and long term factors, it is not fixed, thats why you cant rely on it alone. You should rely on phonetics and esthetics. Short term factors: The patient is not in an upright position. If the patient is positioned a little backward, the mandible tends to open, resulting in a larger free way space, when indeed it's shorter when the patient is seated in an upward position. Long term: Muscle spasm Aging process, The last thing we do after we finish the vertical dimensions, we have lines we should draw, like the midline, to determine the midline of the teeth. DONE BY: Lema Sbeih