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Jaw relationship record Notes:

The Dr. started the lecture by revising a few steps in making complete denture which we talked about it many times ! The dr. announced that he'll ask us in the exam about advantages and disadvantages of materials used for making primary and secondary impressions in the lab, I summarized them in the last page. This lecture and the coming one, we'll cover chapters 15 & 16 in the book . the Dr. repeated some points many many times so I mentioned them in a simple way. Now we'll begin our lecture . Jaw relationship record has a lot of steps, it's not a simply taking an impression or border molding or wax impression, it essentially need establishing the measurement of patient's face. Now we know from studies that usually there are certain things present in patient's mouth before and after extracting teeth. Example: we know that after we extracted teeth, the residual ridge resorb , and when we want to set teeth back to their normal position, how can I do that if I have lost teeth and I don't have a record for the patient's original ones ?! .. there are a number of guidelines that will help us along away. For example : I told you that there are some things in the mouth remain the same such as the incisive papilla, we said that the center of the incisive papilla is 8-10 mm behind the labial incisal edge of the central incisor.

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So we have a guideline that presents before and after extraction in order to find the ideal position of the teeth.

I know for instance that the teeth in the upper arch toward labial (facial) to the ridge, so when the ridge resorbed I have to put the teeth labially. Just to each residual ridge, this is relatively simple but when we talk about upper and lower jaw and the 3D relationship between them, it becomes a little bit complicated.

Maxillo- mandibular relationship :

In jaw relationship record, there are three basic steps : 1- Adjusting the maxillary and mandibular rims forming vertical relationship.
So firstly, I find the distance between two arches; it's important and different between patients .

2- Hinge axis location , I need to find the relationship between the upper jaw and the patient head. The relationship between the upper jaw and the axis of rotation of the lower jaw, because I'm taking these relationships to transfer them the patient's face to an instrument called " Dental Articulator " which is used to simulate the patient's head. 3- Horizontal relationship between upper and lower jaws. To find the relationship between two objects; I have to find the x,y and z axis. Occlusal Vertical Dimension: is the relationship between upper and lower jaws when the teeth are in occlusion. Horizontal relationship: also called the "centric relation". It is the reference position of the mandible that can be routinely assumed by edentulous patients under the direction of the dentist [ from the book].
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In this lecture we'll concentrating on the vertical dimension of occlusion . When the patient comes without teeth, how can I find the relationship between the upper and lower jaw. Remember always we use a guideline that presents before and after extraction because the patients comes to me after extraction so I don't know what he like before. In some rare cases patients come with some teeth so I can do some measurements. BUT usually the patient comes without teeth so the normal relationship is almost lost.
A student asked : do we have an average that we can rely on it to all patients ? - unfortunately no ! it doesn't work so the best thing is to use a guideline which is present before and after extraction.

You know from physiology that muscles always and for certain degrees are contracted, the mandible is hanged; attached to the upper jaw not only through the TMJ but with muscles. We have the massester outside, medial pterygoid inside.. we have muscles of mastication and muscles in floor of the mouth attached to the hyoid bone. When I'm not required to chew, speak or swallow then the mandible is relaxing (hanging). If the patient setting upright, muscles that tends to hold the mandible up by some degree of extension and the gravity will leave the mandible from a specific distance from the upper jaw. Why this is significant ? Because we're dealing with edentulous patients so I need a measurement that present before and after extraction. The objective in making complete denture is the distance between upper and lower jaws with teeth inside them not to make a denture at the rest position all the time. If I draw a point on the tip of the nose and the tip of the chin then I get a ruler and measured the distance between them; I call it " the vertical dimension of occlusion (VDO)" represented by A in the picture below.
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This is important because I'll set the teeth according to it. After the teeth are lost, VDO is lost but we still have the vertical dimension of rest (VDR) so it's the same before and after extraction. So now, I know VDR but still the VDO is unknown .. here we use the average , they took many normal people and measure VDO and VDR to them and found that the distance between these two measurements is approximately 3 1 mm ( range 2-4 mm ) in 95 % of population. This distance is called the" interocclusal distance (IOD)" or commonly known as "Freeway space" . So for my edentulous patient; I know IOD (constant) and VDR but I don't know VDO .. look at this simple equation :

VDR= VDO + IOD ( FWS) VDO= VDR IOD (FWS)

Assume that VDR = 8 cm ( 80 mm) then I can find my objective which is VDO :

VDO = 80mm 3mm = 77mm

We made a record block in the lab which has a wax rim on it; wax rims made according to the average measurements, when I put the wax rim in the patient mouth and measure from tip to tip (it's not VDO nor VDR it's vertical dimension of wax rims) , assume that we found it 85 mm
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then we have to remove wax to reach 77mm ( according to the example ) , if we found it 75mm then we have to add 2mm of wax in order to reach 77mm which is the VDO. Why we have FWS ? Teeth were designed to chew and even in chewing they'll not become in touch because if we they do we'll end up with what's called clenching and bruxism. So it's a natural protection in order not to hurt the muscles and joints so they become in touch only 15-20 minutes daily ! The teeth only touch in chewing and swallowing, the average of swallowing is about 1000 daily but they actually become in touch for less than a second so it's a count for almost nothing. If we give the patient a longer teeth, let's say 80 mm .. then when they become in contact there will be tension on TMJ, muscles and inflamed gum. So the reasons for having FWS are : 1- phonetic. 2-relaxing jaw.
We measure VDO and VDR when the patient in upright not in lying position because the tension on muscles will be different and the equation also will be .

While measuring, try to use tissues that don't move a lot like the tip of the chin and the tip of the nose, or the base of the nose and the base of the chin. (( the Dr. showed us a picture for instruments used for measuring VDO but unfortunately I couldn't understand their names )) but in the clinic we usually use a ruler.

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Now, how can I know the correct plane for the wax rim in the patient mouth ? We have what's called "Frankfurt Horizontal plane ".
It is the anatomical position of the human skull. It was decided that a plane passing through the inferior margin of the left orbit (the point called the left orbital) and the upper margin of each ear canal or external auditory meatus, a point called the porion, was most nearly parallel to the surface of the earth, and also close to the position the head is normally carried in the living subject. [ wikipedia]

But it's not our reference because the teeth aren't at the same level; they are short in the front than in the back so if you look to the patient mouth when sitting upright you'll see that the front teeth will be lower than the back teeth. That's mean that right and left will be at the same level but in the back it'll be higher; so it's not parallel to Frankfurt horizontal plane. In the clinic we use what's called " Camper's plane "; camper is the name of a dentist.
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We need anterior and posterior lines, the anterior one pass from pupil to pupil ; this is the anterior reference to the wax. The posterior one is called " Ala- tragus line " from the lower border of the ala of the nose to the tragus of the ear ( variable between patients) . The angle between the Ala- tragus line and Frankfurt plane is 5 -15 . How long the wax rim should be ? The patient should show 1-2 mm of the incisal edges ( the wax rim in edentulous ). So now we know the length and axis of the wax rim, we remove wax until it becomes parallel to the Ala-tragus line and at the same time shows 1-2 mm of the wax rim interiorly. After we knew the length of the wax rim , we need to support the lip so the angle between the columella of the nose and the philtrum of the lip is 90 . So I adjust the upper wax rim to be parallel to the Ala-tragus line , inter-pupillary line showing 1-2 mm below the crest of the upper lip. Now after finishing with the upper, we put the lower one and start adjusting it by adding or removing wax as in the upper.

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Usually we adjusting the upper rim for esthetic, phonetic and occlusal plane then we put the lower rim and start adding or removing wax according to our VDO.

** The next two pages contain classification of impression materials and tables for materials used in both primary and secondary impressions .. hope they'll be useful

Done by: Eman Tawalbeh.

" It is amazing how a person can make your life very special "

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Materials for taking primary impressions

Material Advantages
1- elastic. 2- cheap. 3- good for deep undercuts. 4- used for dentate and edentulous patients. 5- accurate.

Disadvantages
1- poor dimensional stability. 2-syneresis (loss of water) and imbibitions (sorption of water).

Alginate

Impression 1- reusable. compound 2- Non-irritant and non-toxic.

1- accurate. 2- dimensional stability. 3- non irritant or toxic.

Rubber

1. Poor dimensional stability. 2. Easy to distort when withdrawn from the Mouth. 1- hydrophobic. 2- expensive.

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Materials for taking secondary impressions

Material Zink oxide eugenol (ZOE) Advantages
1. Low viscosity no compression of soft tissues. 2. Dimensional stability (shrinkage less than 0.1 %). 3. Good surface detail reproduction. 4. cheap. 1- accurate. 2- dimensional stability. 3- non irritant or toxic.

Disadvantages
1. Cannot be used in deep undercuts. 2. Eugenol allergy in some patients.

Rubber

1- hydrophobic. 2- expensive.

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