Horizontal Jaw Relation, Methods Of Recording In Prosthodontics

Date: 23rd Feb,07

Presented by:- Gautam Adhikari

Horizontal jaw relation

It is the relationship of the mandible to the maxilla in a horizontal plane. It can also be described as the relationship of the mandible to the maxilla in the antero-posterior direction. Horizontal jaw relation can be centric or eccentric jaw relations.

To maintain stability of complete dentures, the opposing teeth must meet evenly on both sides of the dental arch when the teeth contact anywhere within the normal functional range of mandibular movement. An occlusion of complete dentures that provides these even contacts can be developed only when centric occlusion is in harmony with centric relation.

Centric Occlusion (CO):

Def. - The occlusion of opposing teeth when the mandible is in centric relation. This may or may not coincide with the maximal intercuspal position. (GPT 8th ed.)

Centric Relation (CR):

The maxillo-mandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anterior-superior position against the slopes of the articular eminences. This position is independent of tooth contact. This position is clinically discernible when the mandible is directed superior and anteriorly. It is restricted to a purely rotary movement about the transverse horizontal axis (GPT 5th ed.).

The most retruded physiological relation of the mandible to the maxillae to and from which the individual can make lateral movement. It is a condition that can exit at various degrees of jaw separation. It occurs around the terminal hinge axis.
(GPT-3)

The most retruded relation of the mandible to the maxillae when the condyles are in the most posterior unstrained position in the glenoid fossae from which lateral movement can be made at any given degree of jaw separation.
(GPT-1)

Centric relation is the most posterior relation of the mandible relative to the maxillae from which lateral movements can be made at a given vertical dimension.
(Boucher)

A maxilla to mandible relationship in which the condyles and disks are thought to be in the midmost, uppermost position. The position has been difficult to define anatomically but is determined clinically by assessing when the jaw can hinge on a fixed terminal axis (upto 25mm). It is a clinically determined relationship of the mandible to the maxilla when the condyle disk assemblies are positioned in their most superior position in the mandibular fossae and against the distal slope of the articular eminence. (Ash)

The relation of the mandible to the maxillae when the condyles are in the uppermost and rear most position in the glenoid fossae. This position may not be able to be recorded in the presence of dysfunction of the masticatory function. (Lang)
A clinically-determined position of the mandible placing both condyles into their anterior uppermost position. This can be determined in patients without pain or derangement in the TMJ
(Ramsfjord 1993)

The centric relation has the following features:

It is learnable, repeatable and recordable position which remains constant throughout life. It is a definite learned position from which the mandible can move to any eccentric position and return back involuntarily. It acts as a centre from which all movements can be made. If the mandible has to move from one eccentric position to another it should go to the centric relation before advancing to the target eccentric position.

Functional movements like chewing and swallowing are performed in this position, because it is the most unstrained position. The muscles that act on the temporomandibular joint are arranged in such a way that it is easy to move the mandible to the centric position from where all movements can be made. The casts should be mounted in centric relation because it is the point from which all the movements can be made or simulated in the articulator.

It is helpful in adjusting condylar guidance in an articulator to produce balanced occlusion. It is definite entity, so it is used as a reference point in establishing centric occlusion.

Harmony Between Centric Relation And Centric Occlusion:

Centric is an adjective and must be used with either relation or occlusion to be specific and meaningful. Centric relation is a bone-to-bone relationship whereas centric occlusion is a relationship of upper and lower teeth to each other.

In many people, CO of the natural teeth does not coincide CR of the jaws. In natural dentition CO is usually located 0.5 to 1 mm anterior to CR. Natural tooth interferences in CR initiated impulses and responses that direct the mandible into CO.

When natural teeth are removed many receptors that initiated impulses resulting in positioning of the mandible are lost or destroyed. Therefore, the edentulous patient cannot control mandibular movements.

Deflective occlusal contacts in CR cause movement of the denture bases and displacement of the supporting tissues or direct the mandible away from the relation. Therefore, CR must be recorded for edentulous patients to enable CO to be established in harmony with it.

Form and function of TMJ structures:

Normal functional movement of TMJ entails apposition of the articular surfaces of the condyle and eminence, with consideration of the anatomy and position of the interposed intra-articular tissues. A description of centric relation must include the functional relationship of the inter articular tissues to be clinically significant.

Components of TMJ:
It consists of cranial base, the mandible and the muscles of mastication with their innervation and vascular supply. An articular disc separates the mandibular fosse and the articular tubercle of the temporal bone from the condylar process of the mandible.

This soft tissue structure has 4 definable zones, the thinner central bearing area and the thicker anterior and posterior bands (disk) and bilaminar zone (as it consists of 2 layers : elastic superior layer and a collagenous inelastic inferior layer).

Failure of the central bearing area of the intra-articular tissue to remain in apposition to the articular surfaces of the condyle is associated with joint abnormalities, including displacement, clicking or locking and perforation of the disk.

The central bearing area is composed of densely woven collagen fibrils having no vascularity or innervation, while indicates that this zone is adapted to accept pressure. The posterior limit of movement of the condyle on the eminence has been attributed to wedging of the thickened posterior band of the disk between the distal surface of the condyle and the roof of the articular fossa.

The innervated posterior band possibly protects by sensory feed back, the thin roof of the articular fossa from heavy pressure and provides a bio-mechanically stable relationship.

Muscle involvement in centric relation:

Centric relation is not a resting or postural position of mandible Contraction and relaxation of muscles is necessary to move and fix the mandible in it.

Retrusion:
Middle and posterior temporal fibres. Suprehyoid muscles genio-hyoid and digastric

Elevation:
Anterior temporal fibres

Masseter
Medial pterygoid

Lateral and protrusive:

Lateral pterygoid

Williamson studied the pattern of muscle contraction in centric. He found that the contraction of the superior head of external pterygoid placed the disk in a braced position against the posterior slope of articular eminence and the contraction of temporalis positioned the condyle superiorly in closed approximation to the articular disc.

This condyle disc assembly was then finally seated against the posterior slope of the articular eminence by the contraction of masseter and temporalis.

Retruding the mandible to CR:

The mandible should be in its most posterior position while recording centric relation. Some patients may show difficulties in retruding the mandible due to certain biologic, psychologic, and mechanical condition.

Method of retruding the mandible

Relaxing the patient. Making him feel comfortable. The patient is asked to try to bring his upper jaw forward while occlusing on the posterior teeth. The patient should be instructed to touch the posterior border of the upper record base with his tongue.

The mandible occlusal rim should be tapped gently with a finger. This would automatically make the patient to retrude his mandible. The temporalis and the masseter are palpated to relax them.

Difficulties in retruding mandible:

Difficulties in retruding the mandible can be classified as:

Biological Physiological Mechanical

Biological causes Lack of coordination between groups of opposing muscles when the patient is requested to close in the retruded position. Habitual eccentric jaw relation. Physiological causes Inability of the patient to follow the dentists instructions is one of the major psychophysiological factors, which produce difficulty in retruding the mandible.

This is overcome by instituting stretch relax exercises, training the patient to open and close his mouth. Central bearing devices can also be used to retrude the mandible in these patients. Mechanical causes Poorly fitting base plates produce difficulty in retruding the mandible. The base plates should be checked using a mouth mirror for proper adaptation.

Methods Of Recording The Centric Jaw Relation:

According to Smith in 1941, Moylar in 1955, and Kapur in 1957 following are the methods for recording the centric relation: Direct recording, Graphic recording, Functional recording and, Cephalometrics recording

Direct recording:
Oldest technique CR recording can be recorded by following: Inter-occlusal check record method Pressure-less method Pressure method Tripodal method (Akerly WB in 1979)

Inter-occlusal check record method:

Tentative jaw relation The maxillary occlusal rim is inserted into the patients mouth. A tentative centric relation is recorded by using one of the methods to retrude the mandible. The occlusal rims are articulated using the tentative jaw relations and the artificial teeth are arranged. Now the trial dentures are ready for making the inter-occlusal check record.

Making the inter-occlusal check record The upper and lower trial dentures are inserted into the patients mouth. The artificial teeth are prevented from contacting the opposing members by keeping a piece of cotton inter-occlusally. Alu-wax is loaded on to the occlusal surface of teeth in the mandibular occlusal rim. The patient is asked to slowly retrude the mandible and close on the wax till tooth contact occurs.

The trial dentures are removed and the wax is allowed to cool. Both the maxillary and mandibular trial dentures are placed on their articulated casts. Before placing the trial dentures, the horizontal condylar guide locks in the articulator are unlocked to allow free horizontal movement of the casts. The Aluwax on the buccal aspect of mandibular teeth is scraped off and the articulated casts (which are free to move horizontally) are adjusted to fit into the Aluwax check record.

If the tentative relation record is accurate and is the same as the check record then both the condylar elements of the articulator will contact against the centric stops i.e. the articulated casts need not move to fit into the check records. If anyone of the condylar elements (condylar element represents the condyle in the articulator) do not contact on the centric stops (centric stop represents the centric position of the condyle in the glenoid fossa) it indicates that the tentative recording is inaccurate. Occlusal indicator wax can be used instead of Aluwax for recording trial dentures with nonanatomical (cuspless) teeth.

If the tentative CR is accurate and same as the check record then both the condylar elements of the articulator will contact against the centric stops If any of the condylar elements do not contact on the centric stops, it indicates that the tentative record is inaccurate.

Pressure-less method:
Occlusal rims are inserted. Patient is trained to close the mouth at centric relation position After attaining the centric relation, rims are sealed. Nick and notch method or stapler pin can be used to seal the rims.

Nick and notch method:

Patient is seated in a upright position, as it is easier to retrude the mandible in CR. Upto 3 mm wax is removed from the mandibular rims, known as tough (from premolar region till the distal end) v shaped notches are cut from the maxillary rim, running totally across the width of the occlusal rim

V shaped nick from the maxillary rims is cut anterior to the notch, but do not extend throughout the width of the rims Nick and notch on the upper rim lubricated. Both he rims are inserted in the mouth and patient is taught to close his mouth at the maximum retruded position.

Mandibular rim is removed from the mouth. Alu wax is placed on the troughs, 1.5 mm of wax is projected above the rim. Then the rim is placed in the mouth and ask patient to close the mouth in CR.

Pressure method:
Here, after establishing the vertical dimension, the upper occlusal rim is inserted into the patients mouth. The lower occlusal rim if fabricated to be of excess height. The entire lower occlusal rim is softened in a water bath and inserted carefully into the patients mouth. The patient is guided to close his mouth in centric relation.

The dentist should gently guide the mandible. The patient is asked to close on the soft wax. After the patient closes his mouth till the predetermined vertical dimension, both the occlusal rims are removed, cooled and articulated.

Tripodal method:
Tripodal is a direct method of recording centric relation. The advantages are: It offers a stable relationship with minimum contact and maximum visibility Registration is made with minimum pressure Registration is instantaneous

Registration can be quickly and accurately verified Patients habitual pattern of occlusion can be recorded and compared with centric relation before posterior teeth are selected or arranged

Method:Fabricate rigid and stabilized record bases Construct maxillary rim to average dimension Construct the mandibular rim in 3 widely separated segments, 1 anterior and 2 posterior segments Contour the maxillary occlusal rim for esthetics and locate the occlusal plane Establish the V.D of occlusion

Determine intra orally the most desirable location for the registration tacks. The tacks should be widely separated to provide stability. They should be directed toward the maxillary rim. Mark the wax to indicate the optimum linguo-facial and antero-posterior positions for the tacks Make the face bow registration and mount the maxillary cast on the articulator.

Trim the mandibular rim according to the marks to provide the best visibility and remove excess wax to facilitate placement of the tacks Pick up a metal tack with a forceps and heat it on flame. Press the hot tack into the wax. Locate the apex of the point 0.5 mm above the wax rim to allow for a 0.5 mm depression into the maxillary rim at the vertical dimension of occlusion.

Trim the wax away from each tack to provide better visibility. Recline the dental chair approx. 450 Stabilize the record base lightly on the mandibular residual ridge with the index fingers on the record base and thumbs on the inferior border of the mandible. Guide the closure of the patients jaw in centric relation to the 1st contact of one or more tacks

Trim or add wax to provide simultaneous contact of the 3 tracks at the desired vertical dimension of occlusion. The depth of acceptable registrations should be 0.5 mm at the apex of the indentation. Soften the hard wax with a hot spatula in the 3 registration areas.

While the wax is congealing, seat the maxillary record base with firm pressure and guide the mandible into centric relation closure Chill the wax rim, color the indentation with a fine tipped marker. Trim the wax until only the apex of indentation is visible Confirm the accuracy of the C.R record by observing the relationship of tacks to the marks when the jaw is closed just short of contact in C.R. a registration is inaccurate if a vertical or horizontal discrepancy is observed between the apex of any tack and the colored indentation.

Detach the maxillary cast and mounting from the articulator and place the record bases on the casts. Chill the hard wax in cold water Relate the casts by seating the apices of the tacks into the marked indentation without pressure. The posterior part of the casts may need to be trimmed to prevent interference. Repeat the registration procedure to confirm the accuracy of the registration and mounting.

Invert the articulator and note discrepancies between the tacks and indentations. If 2 or more identical discrepancies are noted the mandibular cast is separated and remounted. Make additional registrations as necessary to verify the accuracy of the mounting or registration

Graphic technique:
Hesse (1897) first needle point tracing done and introduced the graphic method of recording centric relation. Gysi (1910) improved and popularized this method. These methods are called so because they use graphs or tracings to record the centric jaw relation.

Graphic methods are of two types namely: Arrow point tracing and Pantograph.

Arrow point tracing:

One dimensional graphic tracing made using gothic arch tracers. General concept of this technique is that a pen like pointer is attached to one occlusal rim and a recording plate is placed on the other rim. When the mandible moves, the pointer draws characteristic patterns on the recording plate. The pointer is known as the central bearing point and the recording plate is known as the central bearing plate.

Functions of central bearing device:

Maintains VD Equalizes the pressure by distributing the forces throughout the supporting tissues. Allows the mandibular movement to be dictated by the condyles.

Indications of graphic method:

Well healed broad edentulous sides. Adequate inter arch space In patients with habitual centric; the use of the graphic method, allow the patient to record his true centric.

Contraindications:
Severely resorbed ridges. Excessively flabby ridges. Decreased arch space difficult to place central bearing device without raising the VD. In patient with temporomandibular joint arthropathy. In patient with abnormal jaw relations.

Technique:
Make a accurate stable maxillary and mandibular record base, with contoured wax occlusal rims. Establish the vertical dimension of jaw separation, with mandible at physiologic rest Reduce the mandibular occlusal rim to provide excessive interocclusal distance

Make a facebow transfer and mount the maxillary cast. Make a tentative CR record at a predetermined vertical dimension of occlusion Adjust the articulator with condylar elements secured against the centric stops Relate the maxillary occlusal rim in the soft wax record and attached the mandibular cast to the articulator with plaster

Mount the central bearing device. Care has to be taken to centre the central bearing point in relation to the plate both antero-posteriorly and laterally Mount the tracing device. The stylus is attached to the maxillary rim and recording plate to the mandibular rim This arrangement develops an arrow point tracing with apex anteriorly. The reverse placement develops arrow point tracing with apex posteriorly.

Seat the record bases with the recording device in the patients mouth. The record base should be checked for stability and also any interferences between the occlusal rims when mandible is moved The stylus should maintain contact with the recording plate during mandibular movement Retract the stylus and the patient is conducted for training exercise to move the mandible right left, forward and backward. A Ney excursion guide can be used to aid in training the patient.

Home is the most retruded Comfortable position position.

NEY excursion guide

When patient learns the mandibular movements, the tracing is made by droping the stylus on the record plate. Before this the tracing plate is prepared for tracing by the thin coat of chalk in denatured alcohol. When a definite arrow point tracing with a sharp apex is made, have the patient retrude the mandible to centric relation. The point of the stylus should be at the point of the apex of the arrow point tracing. Inject quick setting dental plaster between the occlusion rims and allow the plaster to harden.

Remove the assembly and mount the mandibular cast with the new record. This record is a tentative record and will be checked with an inter-occlusal check record when the teeth are arranged and the wax is countoured.

Based on the location of the tracers, arrow point tracers can be classified as: intra oral extra oral

Intra-oral 1. Tracing not visible when being made. Tracings are small as they are located close to the centre of rotation. Therefore difficult to locate the apex. More accurate than extra oral as it is made closer to the center of rotation of the condyle. Plate and styles not hindered by the position of lips and cheeks.

Extra-oral Visible when the tracing is being made Larger tracings easier to locate the apex.

2.

3.

Less accurate than intra oral as made further away from the center of rotation. The lips and cheek interfere with the position of the plate and the styles.

4.

5.

Lips and cheeks in passive relation. Accuracy of the record cannot be assessed as the record bases may shift during the recording.

Does not keep the lips and cheek in passive relation.

6.

Accuracy can be assessed virtually.

7.

Example: Seidal tracer Ballard tracer Messermar tracer Cobble tracer

Example: Hight tracing device Stansberry tracers Philips extra-oral tracer Sears trivet

Pantographic tracing:
It is defined as, A graphic record of mandibular movement usually recorded in the horizontal, sagittal and frontal planes as registered by the styli on the recording tables of a pantograph or by means of electronic sensors
(GPT- 8th ed)

Pantographic tracer

It is a three-dimensional graphic tracer. It is the most accurate method available to record centric jaw relation. Even eccentric jaw relation can be recorded using these instruments. These equipments are very sophisticated and are generally used in for full-mouth rehabilitation of dentulous patients.

A pantographic tracer has six flags:

Two flags located perpendicular to one another near the condyles. Totally there are four flags adjacent to the right and left condylar guidances. They locate the true hinge axis. Two flags are placed in the anterior region. They record the anteroposterior movements.

Functional technique:
The records in the functional class include the various chew-in techniques suggested by Needles, House, and Essig and Paterson. They also include methods that make use of swallowing for positioning and recording the relative position of the jaws. The patient produces a pattern of mandibular movements by moving the mandible to protrusion, retrusion, and right and left lateral.

The following factors are common to all functional methods: In a functional method, a tentative centric relation and vertical dimension are measured for determining an accurate centric relation. The occlusal rims for these methods are reduced in excess than that required for the tentative vertical dimension. The exact vertical dimension of occlusion is determined only when the patient closes on the occlusal rims and their attachments (tracers etc).

The record bases should be very stable while recording centric jaw relation. If the record base gets displaced, the mandible will tend to move into an eccentric position. Lack of equalized pressure exerted on the record base can result in inaccuracies in recording centric jaw relation. A good neuromuscular coordination is required form the patient.

Needles-House method:
In 1918 Needle and House gave this method. In this method, compound occlusion rims with four metal styli placed in the maxillary rim. When the mandible moves with the styli contacting the mandibular rim, the styli cut four diamond shaped tracings.

Maxillary rims with metal styli

Mandibular rims with diamond shaped markings

Patterson method:
In 1923, Patterson uses wax occlusion rims. A trench is made in the mandibular rim and a mixture of half plaster and half carborundum paste is placed in the trench. The mandibular movements generate compensating curves in the plaster and carborundum.

When the plaster and carborundum are reduced to the predetermined vertical dimension of occlusion, the patient is instructed to retrude the mandible and the occlusion rims are joined together with metal staples.

Trench

Carborundum and dental plaster mixture

Lateral and retruding mandibular movement

Cephalometrics technique:
Pyott and Schoeffer in 1952 describes the use of cephalometrics to record centric relation. Cephalometrics radiographs determined the proper centric relation and vertical dimension of occlusion.

Other methods of recording:

M Bissasu in 1999 describes a simple procedure that enables the edentulous patient to put the tip of the tongue in the most superior posterior position in the mouth.

Procedure:
A strip of rectangular shaped baseplate wax (50mm long and 17mm wide) adapted to the palatal surface of the maxillary record base.

Cut 4 holes (10mm diameter) Then holding the record base in the hand demonstrate the patient where they should place their tongue by placing an index finger into the holes. Then place the record base in the mouth and assist the patient to put the tip of the tongue into the first hole, then move it into the second and so on, until it reaches the desired posterior position.

Complications In Recording Centric Relation:

Yurkstas and kapur (1964) concluded following

factors influencing centric relation record:

Resiliency of the supporting tissues Stability of the recording bases TMJ and its associated neuromuscular mechanisms Character of the pressure applied in making the recording Technique used in making the recording and the associated recording devices used Skill of the dentist

Health and cooperation of the patient Posture of the patient Character or size of the residual alveolar arch Amount and character of the saliva Size and position of the tongue

Significance of centric relation:

The correct registration of C.R is essential in construction of complete dentures: C.R serve as reference relation for establishing an occlusion. If C.R and C.O does not coincide in artificial teeth the stability of denture bases is jeopardized and the edentulous patients are subjected to unnecessary pain or discomfort. So, C.R and C.O should coincide

C.R is used in edentulous patients for closures during mastication and swallowing. C.R must be accurately recorded and transferred to the articulator to permit proper adjustment of the condylar guidance for the control of eccentric movements of the instrument An accurate C.R record properly orients the lower cast to the opening axis of the articulator and orients the C.R to the hinge axis of the articulator and the mandible.