COMPLETE

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VICTOR H.

SEARS,

D.D.S.

Vallejo, Calif.
THE MUSCLES, THE TEETH, or both may force the condyles into distorted positions and make it impossible to find and record unstrained jaw relations. The many distressing conditions associated with muscles in trismus and temporomandibular joints under stress may be brought on or perpetuated by the dentist who proceeds at once to register the vertical and horizontal jaw relations and fails to restore and maintain mandibular equilibrium.ls2

ITHER

MUSCLE TONUS AND SPASM

A muscle functions best in a given range of length. Any overstretching of the muscle generally leads to continuous muscle contraction and discomfort, if not actual pain. Such contraction of the elevator muscles of the mandible leads to overloading and destruction of the supporting structures. On the other hand, too little jaw separation when the teeth are in occlusion causes the elevator muscles of the mandible to be too short and leads to attendant undesirable facial changes and sometimesdiscomfort as well. Muscles may go into spasm in groups, singly, or even in parts. Spasm in any of the muscles which govern the position of the mandible will pull it out of normal position. Although the facial and hyoid groups of muscles and those of the neck in general influence the jaw position, our chief concern is with the temporal, masseter, and pterygoid muscles. When these muscles which connect the mandible to the cranium are in spasm, they cause overclosure and horizontal distortions of the position of the mandible, making it difficult for the dentist to register jaw relations. Muscle spasm may be slight or severe, but even slight spasm pulls the mandible out of its normal rest position. The lateral (external) pterygoid muscles carry the mandible into protrusion
*Present address: Commission for Educational Pasea de Calvo Sotelo 20, Madrid, Spain. 1014 Exchange Between the U.S.A. and Spain,

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when they are in spasm. When only the right external pterygoid muscle is in spasm, it becomes difficult to register any position other than left lateral relation. Spasm of the upper fibers of the external pterygoid muscle may pull the interarticular disc anteriorly to its normal position on the condyle. Contraction of these fibers also pulls the condyle forward. The horizontal and vertical jaw relation records should be made only after normal muscle tonus has been restored and the mandible is returned to a state of equilibrium.
TEMPOROMANDIBULAR JOINT

The condyles should lie in their sockets without stress of any kind when the mandible is in the resting position. Muscle spasm distorts the position of the mandible and puts the temporomandibular joint under stress. However, even in the absence of muscle spasm, distortion of the mandibular position with resultant stress in the joint can be caused by the inclined planes of cusp teeth as well as by excessive loading on the anterior teeth.3
INCLINED PLANES

When a cusp moves exactly between opposing cusps, no horizontal force that causes horizontal displacement is developed. However, for example, if under closing force the mesial incline of a lower cusp glides on the distal incline of an upper cusp, the closing action causes a backward thrust on the lower teeth. Such a backward thrust is transmitted to the lower tooth-supporting structures and also to the condyle. This backward thrust of great force, or of small persistent force, may put the temporomandibular joint under sufficient stress to bring on pain, vertigo, nausea, and other symptoms. While backward displacement of the condyle is perhaps the most distressing of the horizontal distortions, displacement in any direction may bring on the symptoms. Since most persons press the teeth together 1,000 to 2,000 times a day and since even slight force becomes traumatic in time, horizontal displacement of the condyle should be looked for whenever cusp inclines are present. Horizontal displacement of the condyles, which is caused by cusp inclines, can be treated successfully by removing the inclines. Condyles which have not been displaced horizontally can be protected against such displacement by the use of flat plane or cuspless teeth.
OCCLUSAL PIVOTS

Although flat plane teeth protect against horizontal displacement of the condyles, no tooth form protects against vertical displacement. Protection against vertical displacement of the condyles is achieved by maintaining the occlusal load on the molar teeth. When vertical displacement of the condyles has already occurred, it can be reversed by pivoting the mandible at the molars.4 The condyles are displaced upward when there are excessive pressures from occlusion on the anterior teeth (Figs. 1 to 3). Condyles displaced upward in this way are caused to descend by the

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Fig. 1.

Fig. 2.

Fig. 3. Fig. 1.-A schematic representation shows the normal space between condyle and articular surface of the temporal bone. The shaded areas indicate upper and lower complete dentures. Fig. P.-The jaws come closer together with resorption of alveolar bone. Closure occurs around the condyle so that the incisor region closes farther than the molar region. This places the occlusal load at the front of the mouth and causes a separation of the teeth in the molar region. The dotted outline indicates the position of the mandible before resorption of the ridges and attendant jaw closure. Fig. 3.-The incisor region acts as a stop, and the muscle pull raises the posterior part of the mandible and closes the space in the molar region. The condyle is carried upward in its fossa, placing the temporomandibular joint under stress. The upward displacement of the condyle in its socket displaces some of the soft tissues between condyle and temporal bone. The dotted line shows the position of the mandible before the upward displacement of the condyle. Actually, the changes shown separately in Figs. 2 and 3 ocaur simultaneously.

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Fig. 4.

Fig. 5. Fig. I.-The former degree of jaw separation, as shown in Fig. 1, is accomplished by building an occlusal pivot on the first molar. Transferring the stop from the incisor to the molar region reduees the upward force at the condyle. With sufficient reduction of the upward force at the condyle, the condyle descends toward its original position. Fig. 5.-The downward movement of the condyle is approximately equal to the upward movement of the lower incisors when the pivot is in the region of the lower first molar. Therefore, when the lower incisors discontinue upward movement around the pivot, it can be assumed that there will be no further downward movement of the condyle. The jaw relation registrations can be completed for the making of new dentures with the condyle thus restored to its normal position.

action of occlusal pivots (Figs. 4 and 5). When the stop is transferred from the incisor to the molar region, the mandible returns toward a condition of equilibrium. The occlusal pivots may be placed on either the upper or lower occlusal surface. For complete dentures, the pivot is located as far posteriorly on the lower teeth as possible without causing the denture bases to slide or teter. Since the residual alveolar ridge in the second and third molar regions is often either too sloping or too yielding for good support of dentures, the pivots are usually placed on the lower first molar teeth.
TECHNIQUE

The pivots are built on the lower artificial teeth with self-curing acrylic resin. The cusps on the teeth of the upper denture must be flattened and smoothed so that the pivots can move horizontally on them without any interference. This free

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horizontal gliding is necessary to allow the condyles to move into their unstrained horizontal positions. The buccal surfaces of the denture base are roughened so that the acrylic resin of the pivots will adhere well. Then, the resin is built onto the lower first molar teeth, and a part of the mix is extended down onto the roughened buccal surfaces of the denture base. The height of the resin on the lower first molar teeth should be slightly greater than that needed to maintain the estimated jaw separation so that the patient can tap down the excess resin and at the same time equalize the height of the pivots on the right and left sides. When the acrylic resin has set enough to offer some resistance, the dentures are placed in the mouth, and the patient is instructed to tap the teeth together lightly to bring the mandible just up to the predetermined vertical relation of occlusion. The lower denture is then removed, the resin is allowed to cure, and it is smoothed and polished. The lingual surfaces should be well polished to prevent irritation of the tongue. The occlusion of the occlusal pivots is tested for freedom of movements with carbon paper and corrected if necessary. The patient wears the dentures with the pivots on the teeth continuously for several days. The amount of separation between the opposing incisors is noted at the time of the addition of the pivots and observed until there is no more upward migration of the lower incisors. This migration usually requires at least 3 days, although the dentures can be worn with the pivots in position for several weeks if there is any uncertainty as to the complete equilibration of the mandible. If the muscles are not entirely comfortable after the pivots have been worn, it is probably because the vertical relation of occlusion has been increased or decreased too much. The muscles may ache particularly when the vertical relation of occlusion has been excessively increased. Clicking of the joints may be the result of a vertical relation of occlusion that is too far closed. The pivots are reduced or increased in height as indicated. The vertical relation of occlusion is found tentatively by the usual means.6 Ordinarily, an acceptable degree of jaw separation can be found immediately. However, when the mandible is out of equilibrium, the most acceptable degree of jaw separation changes as muscle spasms and temporomandibular joint strains are relieved. Therefore, the dentist must be prepared to raise or lower the pivots as the dentures are worn over a period of several days. When the desired vertical relation of occlusion has been established, jaw relation records may be made at this opening for the construction of new dentures. However, after muscle spasms have subsided and after stress in the temporomandibular joint has been eliminated, it is sometimes advisable to increase the height of the pivots. The desired vertical relation of occlusion is usually the one of greatest comfort to the patient. For most patients, the exact degree of jaw separation at the vertical relation of occlusion is not critical. There is a latitude of 2 mm. or more. However, some patients need to have this relationship determined with great accuracy. Adjustable pivots are useful when such accuracy is needed.

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PIVOTS

The adjustable pivot consists of a threaded housing that carries a fitted screw. To mount adjustable pivots, the lower first molar teeth are removed from the denture to make space for the housings. Each housing and threaded screw is attached to the denture base with self-curing acrylic resin in the space created by the removal of the molar tooth. The housing must be set low enough so that the screw can be raised or lowered until the exact desired degree of jaw separation is found.* The chief advantage of an adjustable pivot over the one built up with resin is that the increase or decrease in vertical height can be made quickly and easily. Sometimes, the patient is instructed to make the adjustments between visits with the dentist. After the mandible has been equilibrated, the dentures should be constructed with teeth so designed and arranged that the major occlusal load will be carried in the molar regions. This posterior loading should be maintained continuously. Periodic observation of the patient should constitute part of the denture service to discover and correct shortening of the elevator muscles, stress in the temporomandibular joints, or occlusal interference. Whenever the load has become too heavy on the anterior teeth, they should be shortened by grinding, or the molar teeth should be built up in height.
CONCLUSION

Equilibration of the mandible should be established and maintained, especially for all patients with temporomandibular joint symptoms. However, even in the absence of symptoms, the equilibration of the mandible should be considered because it is a prophylactic measure and constitutes an important service to which the patient is entitled.
REFERENCES

1. Bell, W. E.: Temporomandibular Joint Disease; a Teaching Manual for Students and Practitioners of Dentistry, Dallas, 1960, J. A. Majors Co. 2. Lipke, D., and Posselt, U.: Panel Discussion, Compendium of the American Equilibration Society, 1960,.pp. 73-85. 3. Sears, V. H.: Mandibular Condyle Migrations as Influenced by Tooth Occlusions, J.A.D.A. 45:179-192, 1952. 1. Sears, V. H.: Occlusal Pivots, J. PROS. DEN. 6:332-338: 1956. 5. Nagle, R. J., and Sears, V. H. : Dental Prosthetics; Complete Dentures, St. Louis, 1958, The C. V. Mosby Company.
646 WASHINGTON VALLEJO, CALIF. ST.

*A. A. Nelson:

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