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Maxillo-Mandibular Relation (MMR)

& occlusion in complete dentures

Dr Mandakini Mohan
Dr.Omar H. Bayati

International Medical University (IMU)


Learning objectives:
to understand what is the component parts of the maxillo-mandibular
relation and it is role in the success of the complete denture treatment.

to understand the clinical steps of maxillo-mandibular relation in


complete denture treatment.

to uderstand the theory of the face-bow transfer , it‘s indication & clinical
application procedure.

To undertand the difference of occlusal concept in dentate & edentulous


patients & appreciate the role of occlusion in the success of complete
denture treatment.

to understand the theoretical principles & concepts of occlusion in


complete denture treatment.
Maxillo-Mandibular Relation (MMR) in
complete dentures

Part 1
MMR is The clinical stage following the visit where
Definitive (final impressions) are recorded.

Occlusal rims should be


ready to accomplish the
MMR record.
MMR stage is composed of three
component parts:
Creating and outlining the form of the
dentures
Recording of intermaxillary relations
Selection of teeth.
Creating and outlining the form of
the dentures:
Objective:
• to design and orient the polished surface of the denture to be in
harmony with the physiological function of the Tongue, lips and
cheeks.
• the polished surface should occupy a position of equilibrium
among these groups of muscles and it is frequently referred to as
the neutral zone.
Clinical steps in Creating and outlining the form of the
maxillary denture:

prior to inserting the


rim into the mouth,
ensure that the rim is
well adapted to the
master cast

Remember that the technician constructed the occlusal rims based on


average values and it is the role of the dentist to create & outline the
form of the denture by adding or removing wax for each individual
patient.
Clinical steps in Creating and outlining the form of
the maxillary denture:

First clinical step is to ensure


that the infra-nasal tissues
are harmonious with the soft
tissues of the middle third of
the face.
Failure to do this may affect
the form and length of the
upper lip, by raising the lip
inappropriately.
Clinical steps in Creating and outlining the form of the
maxillary denture:

Confirm that the upper lip is adequately supported.


This should result in restoration of the
- vermilion border
- the philtrum
Vertical Naso-labial angle is 90º

Horizontal labial angle


varies from 90º to 120º
determine the position of the
incisal point relative to the
resting lip:
the incisal level of the upper rim
is 2 mm inferior to the resting
upper lip.

Younger patients may reasonably be


expected to show 4–5 mm of tooth
beneath the resting lip.

In contrast, a 70-year-old patient


might be best suited by having the
incisal point level with the resting lip
Antero-posterior verification of the placement of the
incisal point may be achieved by asking the patient to
say a word containing a labiodental sound eg ‗fish‘ .

in general terms, the incisal point should correspond to


the vermilion border of the lower lip
Determine the upper
anterior plane.
‗Fox Plane‘ device placed against the
maxillary occlusion rim. This should
be parallel to the interpupillary line.

Determine the posterior occlusal


plane.
Fox‘s plane device used
The posterior occlusal plane
should be parallel to the ala-
tragus line (Camper‘s Plane).
Determine the position of the mid points of
the upper canine teeth using one of 2 methods:

extend dental floss from the inner canthus of the eye, via
the lateral border of the alar cartilage (with the patient
smiling) onto the incisal edge of the upper rim
use a photograph of the patient
when the patient was dentate.
Using the pupils as stable
reference points, the clinician
may determine the relative
position of the upper canine
teeth using the ratio
Using the canine tips as a
reference point, the buccal
form of the upper rim may
be moulded by reducing the
inferior borders of the
posterior rims by 3° to 5°.

This procedure creates what


are known as the buccal
corridors and creates a
more natural smile
the following should be
scribed clearly on the
anterior aspect of the
rim:

High smile line

Canine points.
Centre line
Recording of intermaxillary relations:

JAW RELATIONSHIPS:
Vertical Relationships
Horizontal Relationships
Orientation of the occlusal plane in
relation to the condyler axis.
Vertical Relation
Important terms
Vertical dimension of rest: (RVD)
also known as Physiologic rest
position

Vertical Dimension of Occlusion:


(OVD)

Interocclusal Distance
Formerly known as ― freeway
space‖
Vertical Dimension of Occlusion:
The position of the jaws when
the natural teeth are in maximum
intercuspation.
May become ―less‖ (nose closer to
chin) if posterior support is lost or
natural teeth wear quickly.
With complete dentures
VDO ―lost‖ as denture teeth wear
and ridges resorbs.
Vertical Dimension of Rest Position
of jaws when ―All muscles that open and close the jaw are in a state
of minimal tonic contraction‖.
• VDO is usually about 2-4mm less than VDR
• Difference (VDR-VDO) is the interocclusal distance (free way
space)
• This space between the teeth is necessary for comfort
• This is the best starting point in establishing the correct VDO for
a new set of dentures
Vertical Relation

RVD OVD
Increase in OVD
―patient mouth is opened excessively‖
Loss of interocclusal distance
Denture teeth in contact at rest
Soreness of mucosa over ridges
Potential for accelerated resorption
Soreness of facial muscles : ―Tired face‖
Soreness of TMJ
Difficulty with eating and speech
Clicking dentures, no room to chew
Decrease in OVD
―patient‘s mouth has over closure‖
Collapsed Appearance - chin too close to
the nose or protruding jaw
Fatigue when chewing
Sore muscles or joints
Establishing
Occlusal Vertical Dimension
1. Measure difference between RVD & OVD
2. Tactile sense and patient-perceived comfort.
3. Phonetics tests “Closest Speaking Space”

Patient sitting upright


Patient sitting upright
Soft tissue position affected by posture
Measure difference between RVD &
OVD:
Tactile sense and patient-perceived
comfort:
Phonetics tests ―Closest Speaking Space‖:

Closest Speaking Space confirms OVD


Sibilant sounds ("s", "z", sh", ch")
Rims should be at least 1 mm apart.
Don‘t worry about sounds quality yet.
Horizontal Relationships
The generally agreed position for recording
the antero-posterior position of the mandible
relative to the maxilla is that of the retruded
contact position (RCP).
RCP=CR (centric relation).
Centric relation:

The most posterior


relation of the lower to the
upper jaw from which
lateral movements can be
made at a given vertical
dimension.
Centric relation:
the maxillomandibular
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
eminencies.
Why centric relation ...?
it is the only repeatable , recordable & reproducible
position in the edentulous patient.
abnormal contact between opposing dentures when
set up in other than the retruded relationship results
in denture instability.
the apparatus used for reproducing relevant jaw
movements (the articulator) operates from the
retruded position.
Registration of the centric relation:
Guiding the patient into retruded contact
position:
Ask the patient to relax
and guide the mandible
into the centric relation.
Guiding the patient into retruded contact position:

Ask patient to curl back


the tongue to touch the
posterior border of the
palatal baseplate and then
close together (swallow).
Guiding the patient into retruded contact position:

Ask the patient to push


the mandible forward
while applying gentle
counter resistance to the
chin.

Train the patient to bite into retruded contact position prior to registration.
Draw a check marks on the occlusal rims to ensure reproducibility of the
mandibular closure pattern.
Registration of the centric relation:

Make a 3mm notches into the


maxillary occlusal rims at
about the 2nd premolar region
bilaterally .

2 mm of wax are removed


from the mandibular occlusal
rims at the opposing region.
Register the centric relation
using a bite registration
material.
Registration of the centric relation:
Gothic arch tracing :
This trace is made on a ‗central bearing
apparatus‘.
This comprises upper and lower acrylic
plates onto which is mounted centrally,
a stylus and a platform.
Gothic arch tracing :
These will record a ‗map‘ of the patient‘s
range of movements, by asking
the patient to go into:
• Protrusive
• Right lateral
• Left lateral excursions.
Orientation of the occlusal plane:
The use of a face bow registration
fixes the maxillary cast in the
same three-dimensional plane in
relation to the condyles as exists
in the patient and thereby
reproduces the patient's arc of
closure.
Capturing the correct mandibular
arc of closure is probably the
most compelling rationale for the
use of a semi-adjustable
articulator.
A facebow relates the maxillary arch to the axis
of the condylar hinge using tripod localisation:
1. Two posterior references approximating each of the TMJ
(external auditary meatus)
2. An anterior reference point to relate the maxilllary cast
vertically to the selected horizontal reference plane.
What is the hinge axis ?
The frame of reference common to
the articulator and patient. It is
determined :
i) Mechanically with a device called a
(Kinematic facebow).
ii) Arbitrarily or automatic measurement 12
to 13 mm anterior to the tragus
(Arbitrary Facebow).

• When facebow is not used to relate the maxillary cast to the


approximated starting positions of the condyles, the resulting arcs
of movement may differ from the patient to the articulator.
• This may cause restorations fabricated on the articulators to have
potential occlusal errors.
Facebow Transfer Record
using arbitrary facebow:
Edentulous Bite Fork:
Allows patient to close
against the opposing rim to
stabilize the record bases
Heat bite fork and imbed it centered
and parallel the occlusal plane
Finger cots can be used over
ear pieces for infection
control

Patient can assist with


placement and orientation
in external auditory
meatus
Orient in external auditory
meatus
Slide facebow onto bitefork

Extend nasion support&


tighten
Tighten all facebow wrenches
Loosen these tighteners.
Release the recordbase by
breaking the seal, and
removing the facebow.
Loosen and remove the
transfer jig from the earbow
Place facebow support on
transfer jig and attach to
indirect mount.
Don’t use direct method with
indirect mount.
Remove incisal pin and set the
centric latch
Transfer jig with record base on articulator
Place cast support and
maxillary mounting plate
Attach cast with mounting
plaster
TEETH SELECTION
Selection of upper anterior
teeth.
Selection of lower anterior
teeth.
Selection of posterior teeth
types and moulds.
Selection of shade(s) of the
anterior and posterior teeth.
Selection of upper anterior teeth:
Pre-extraction record:
Photograph.
Relate canine points to pupils.
Relate canine points to inter-alar width.
Relate six anterior teeth to smile line.
Radiograph
Cast of arch
Relative of similar facial appearance.
Pre-extraction record:
Photograph
Radiograph
Cast of arch
Relative of similar
facial appearance.
Pre-extraction record:
Photograph
Radiograph
Cast of arch
Relative of similar
facial appearance.
Pre-extraction record:
Photograph
Radiograph
Cast of arch
Relative of similar
facial appearance.
Post-extraction record:
Central Incisor restore philtrum
Central incisor restore
vermillion Border
Incisal point and smile line
determine height of tooth
Position of canine points.
Relate to inner canthus of the
eyes and inter-alar width (smiling).
Selection of lower anterior teeth
Lower anterior teeth selected to be
harmonious with upper teeth.
Selection of posterior teeth
types and moulds.
Posterior tooth moulds are of three types:
a) Posterior teeth which have
cusps.
b) Posterior teeth which have
no cusps.
c) Hybrid mould ie teeth
which are modified to obtain
the benefits of a) and b)
Selection of teeth shade(s)

Remember that patient acceptance is the


main factor.
Complete dentures‘ occlusion
Part 2
The design of an occlusion in complete
dentures is different from that of the dentate
patient…?

The absence of direct attachment between


the dentures and the patient‘s musculo-
skeletal system requires a different set of
guidelines of good occlusal practice.

occlusion is considered a major factor governing


stability…?
The minimal level of occlusion that
should be achieved in complete dentures..?
Balanced occlusion:
is ‗even, harmonious bilateral
contact between teeth or
tooth analogues in retruded
contact position (RCP)‘.
This is a ‗static occlusion‘
concept
Balanced articulation:
In which the teeth of the
maxillary denture must maintain
harmonious sliding contacts
with the teeth of the
mandibular denture in all
excursive (Protrusive & lateral)
movements.
‗Dynamic occlusal‘ concept.
If balanced articulation is
required :

Use a facebow transfer.


Accurately determining condylar angles.
Harmonise the occlusion to match
mandibular movements.
The biomechanics of functional occlusal contacts
Two determinants of
Protrusive movement:

The incisal guidance angle


(IGA).

The sagittal condylar


guidance angle (SCGA).
―Christensen phenomenon‖
in which the mandibular path in a forwards direction
produces a downward displacement of the mandible.
This means that record blocks, for instance, set on a flat
plane will separate when the mandible moves forwards.
Setting of 20º teeth in flat occlusal plane:
The mandible's path is an arc which
is steeper posteriorly than anteriorly.
The only teeth that will remain in
contact are those mid-way between
the 30° movement posteriorly and
the 10° movement anteriorly,
i.e. whose cusp angles are 20° at
the midpoint of the arc (30+10=40;
half of 40=20).
Setting of 20º teeth in a compensating
curve (curve of Spee):
The steepness of the
compensating curve
(curve of Spee)varies
according to the
condylar guidance
angle as the incisal
guidance angle remains
the same.
The biomechanics of functional occlusal contacts

Two determinants of Lateral


movement:
The Canine guidance angle
(CGA).

The Medial condylar guidance


angle (MCGA).
Setting of 20º teeth in a compensating
curve (curve of Monson):
Lingualized articulation:
this form of denture occlusion articulates the
maxillary palatal cusps with the mandibular
occlusal surfaces in centric, working and
nonworking mandibular positions.
Centric occlusion in a lingualised
articulation.
The upper palatal cusps contact the central fossae
of their opposing mandibular teeth, and the buccal
cusps have been adjusted to just raise them
sufficiently so that they do not take part in the
articulation.
The teeth set in
(curve of Spee) in a
same way as in
balanced articulation.

The teeth set in (curve of


Monson).
Excluding the buccal cusps
(simplified the setting by
eliminating it‘s influence on
the working side contact).
References:
Davies SJ, Gray RM, McCord JF. Good occlusal practice in
removable prosthodontics (2001).Br Dent J.10;191(9):491-4, 497-502.

Grant A. A., Heath J. R. & McCord J. F. (1994). Complete prosthodontics problems


diagnosis and management. Mosby.

Mc Cord J F, Grant AA(2000).Registration: stage I--creating and outlining the form


of the upper denture. Br Dent J. 27;188(10):529-36.

Mc Cord J F, Grant AA(2000). Registration: stage II--intermaxillary relations.

Mc Cord J F, Grant AA(2000). Registration: stage III—selection of teeth.

The glossary of prosthodontic terms (2005) J Prosthet Dent ;94(1):10-92.

Zarb Bolender (2004) Prosthodontic treatment for edentulous patients.


Complete dentures and implant-supported prostheses. Mosby. Twelfth Edition.
Br Dent J. 24;188(12):660-6.