1

Prosthodontics lab 6 part 1. Done by : Enas Y. Salameh

Jaw Relation Record

After we fabricated the Record Block in the previous lab, today we are going to learn how to make Jaw Relation Record (JRR) / Jaw Registration / Bite Registration (informal term), which represents the relation between the maxilla to the mandible, and the maxilla to the rest of the head, the colour/shade of teeth and so on. This step will be in the CLINIC which will be the last clinic to register the jaws relations, then we will attach them to the articulator after that we will start to do setting of teeth. The Process of attaching the casts to the Articulator is called Mounting using Plaster. ** The next process after setting of teeth will be wax trying, if everything is ok we do processing to the dentures (flasking, dewaxing, curing, deflasking polishing) finally we will do the dental Insertion.

Steps of Jaw Relation record :

1) The Vertical Relationship
** Starts first with the maxillary rim THEN the mandibular rim.

A) Maxillary rim:
1) Labial Fullness:
You have to check if the lip has enough support from the opposing teeth (wax rim till this point).

In right situations the angle between the lip and the columella of the nose equals to 90 degrees ,if this angle is less than 90 (acute angle ) this means that it's too prominent ,but if it's greater than 90 this means there is not enough support (the patient will look older). If it is too prominent I use my wax knife ,heat it then I reduce the anterior angulations, but if it's position is backward I add more wax to it until I have adequate prominence .

2) Buccal Corridor:
(check the contours posteriorly) when the patient smiles there is a space between the occlusal rims and the cheek (at the corner of the mouth) at both sides. If the wax rim is too prominent the teeth will look as they continue endlessly and the smile will look like a wall which is not aesthetic. In Normal smile we see the anterior teeth and the most prominent surfaces of the premolars and barely you see the first molars, but if the teeth are too prominent we will see the whole teeth specially if you choose small teeth, therefore we will remove the excess wax from the side and if the corridor is small we add wax.

3) Length:
It depends on aesthetic (which we will concentrate on it), phonetics and functions. At rest position where the mouth is a little bit open normally you will see about 1-2 mm of the incisal edges of the teeth (occlusal rim) below the upper lip. In Old patient the upper lip will look longer because of the change of the muscle tone with time, and the gravity will bring it down, so less teeth will be seen, and the lower lip will go down too and more teeth will be visible. "The smile line will go down".However, in younger patients you will see more of teeth.

The natural length of the lip, if the patient has a long lip we expect to see less of teeth. So, you have to use your artistic sense to see if the smile looks nice or not.

4) Orientation:
The occlusal rim should be parallel to the patient's natural occlusal plane. All my measurements depends on where the teeth should be, but the problem is that the patient has No teeth, so I need references or guides that was and still present in the patient face before and after teeth extraction which are: - One anterior reference and two posterior references to make the occlusal plane which are imaginary references. 1- ** The anterior reference is called Interpupillary line. **The posterior references are called Ala tragus lines. Camper'sPlane

Anteriorly: use a ruler and put it in front of the patient's face and keep moving it until you find the interpupillary line ,then I put the wax rim in the patient's mouth and mark the excess points then remove the wax rim and remove these excesses by a hot plate ,and if it's not enough add wax until you find the right orientation (parallel to interpupillary line) . In some cases the eyes are not levelled due to trauma so we use other references like lower lobes of the ears, but in worst cases where you can't find any references ask the patient to stand up and look forward , if the wax rim is parallel to the floor then it's levelled . Posterior References: Alatragus line, from the lower border of the ala of the nose to anywhere in the tragus of the ear (tip/middle/lower border). But as you can't see the wax rim orientation through the patient's head, you have to use an instrument to find campre's plane (interpupillary +Alatragus 4

lines) which is called Fox's Plane. Put this instruments inside the patient's imouth and put the ruler in front of the eyes, if it's not well oriented I start to remove the excess from that side .

This is the foxs plane instrument

Foxs plane used inside the patient mouth

5) Check:
To see if everything is okay * aesthetically (see if he/she smiles well) we dont need a gummy smile. *Phonetically (check the sounds of some letters like (S), (F and V) . The wax rim should have the same dimension of teeth. *Functionally

6) Mark the midline:

Which represents the middle of the face not the lips or nose, because people often have asymmetrical faces, so we use a floss or a ruler to mark it, and we mark the midline on the occlussal rim where we will start to put teeth on the right and the left of this line. Then I have to mark the width of the teeth by marking the distal surfaces of canines by a line that extends from the intercampus of the eye to the outer edge of the ala of the nose to the occlussal rim on the right and left and the canines will be determined there. After that ,measure this distance by a flexible ruler which will help in determining the size of the teeth .Sometimes we take a straight line from 5

the side of the nose to the occlussal rim which will give me the tip of the canine ,this distance is smaller than what I want, so I use a specific equation to find the right value. Or you can use the corners of the mouth; when the patients lips are at rest place a lecron carver in the corner of his mouth which will mark the distal surface of the canine. The canines is called eye tooth because its located below the pupil of the eye . Then I need low and high smile lines, when the patient relaxes draw a curve line with a lecron carver that represents the position of the lips at rest (low smile line), then let the patient smile and I draw another line curve (high smile line) which is important in selecting the length of teeth.

~END OF PART ONE ~

Prosthodontics lab 6 part 2. Done by: Osama Yusuf

Now that we have finished the vertical relation of the maxillary occlussal rim, we are going to make the same for the mandible.

B) THE MANDIBULAR RIM

There is a reference called Vertical Dimension of Occlusion (VDO). It is a measure I take, which start from the tip of the nose to the chin. This measure will help me to select how tall the mandibular rim should be. Unfortunately this reference is gone when there are no teeth present, meaning this reference is not found on edentulous patients. Luckily, I have another reference I could use which is not affected by the presence or absence of teeth. It is called Vertical Dimension at Rest; (VDR). This reference is always constant before or after teeth extraction. Most of us when resting (watching TV, listing to a lecture ...etc) our teeth are not touching each other; the mandible is hinging a specific distance below the maxilla with a space between the teeth (Freeway space). The hinging of the mandible at rest depends on A) Gravity B) the muscles. Please take into consideration that VDR measures the space between the jaws, but Freeway space is between the arches (teeth).

Asking the patient to sit upright, the lower jaw will relax in a specific distance between the upper and lower arches. Measuring this distance will result in a reference that is stable; VDR. You dont need VDR, you need VDO. You measure VDR because the patient has no teeth, and then you calculate VDO = VDR 3. The number 3 came from many studies which have concluded that the freeway space in a huge numbers of patients to be 3-4 mm. Take in mind in some rear cases this might reach to 9mm.
Now we got the VDO, we have to do a check to make sure that it is correct. We will do a visual check and a Phonetic check

In the patient mouth I should see that the lower wax rim should be leveled with the vermilion border (the red border which is between the mucosa and the skin ) Wax rim should be leveled with the corner of the mouth by the sides.

 The height of the wax rim should be 2/3 of the height of the retromolar pad
The occlussal rim plane must divide the tongue into an upper half and a lower half when the tongue at rest; in other words the occlussal rim plane must be in the equatorial of the tongue.

We said that there is a natural space between teeth when at rest; we said it is called freeway space. This space is good, teeth touching each other always are not good for many things (TMJ, muscles ... etc) even when talking you dont hear yourself clicking your teeth, and you talk smoothly without your teeth touching. I have to make a check to make sure that when applying the wax rims to the patient mouth that when he is talking he is not touching his teeth together. How to do this? There are some specific sounds, when pronounced the teeth will be as close as possible (try to say Faaa , and try to say Saaah , in Faa they are not close as in Saaah ). Saah , Chaah are some examples when the teeth are very close to each other but they dont touch. Asking the patient to count from 60-70 fast, we observe if the wax rims are touching or not. This is one example for this; there are too many other tests you can do on your patient. Anything with Shaa and Chaah is good. If there is 2 mm between his teeth when he says these words, fantastic. Even if there is 1 mm this is still good, there must not be a contact between teeth when speaking.

This space is included within the freeway space, it is called the Closets speaking Space and it is less than the free space (1 mm while freeway is 3 mm). Now that we have finished the vertical occlussal relationship, logically we have to do the 2nd step which is the Horizontal relationship

What relates the upper jaw and the lower jaw together? It is the TMJ. From this I know that my reference for the horizontal relation is the TMJ, but still the lower jaw can move lots of movement, we need something accurate which is Centric Relation reference. We use it to bring the rims together in the horizontal plane, if you didnt do the horizontal relationship and just inserted the rims in the patients mouth he could close them many directions each time he close. This is certainly not good and more importantly not natural. Centric Relation means the zero point or the middle point. I want the mandible to be at the most posterior position (which is the natural position of the mandible). If the lower jaw is in the most posterior position, the condoyle will be actually on the most Anterior Superior position in the genloyid fossa. Keep in mind that the condoyle is bone to bone relationship not tooth to tooth, because of its bone to bone relation it saves repeatable positions this is why I use the condoyle as my reference, because it is repeatable or habitual position. This means when I put the teeth on, the patient will close and open in the same position. Keep in mind that this will only be correct if the vertical relation is correct.
10

From all the information above I can say that, the centric position is when:
The mandible is at the most posterior position There is bone to bone relationship in the TMJ The condoyle is at the most superior anterior position in the genlyoid fossa It is a repeatable/Habitual position as long as the vertical relation is correct. Now that we have talked about the vertical and horizontal, the third step is facebow record.

This step came from the need to know where exactly I put the upper and lower rims on the articulator. In this step we use another instrument called Facebow. Its function is to measure the relation between the upper jaw and the rest of the skull or between the upper jaw and the hinge axis that go through the TMJ. Keep in mind it is unlink the Foxs plane instrument which locate (not measure) the occlussal plane. While the facebow relates the occlussal plane to the base of the skull.

This is the facebow instrument 11

100 years ago anatomists gathered in Frankfort-Germany and agreed that the zero reference is called Frankfort Horizontal Plane; it is present on the patients head as follows: from the inferior margin of the orbit we mark a point to the external auditory meatus we mark a point. If I drew a line between them while the patient is standing this will give me two lines. (4 points, 2 for the orbit and 2 auditory meatus = 2 lines). So my reference for this step is the Frankfort plane. Keep in mind 3 points are enough to draw this plane (2 auditory meatus /TMJ and one infraorbtial will make a line).

FH = Frankfort plane

12

Although we will not use the Facebow instrument, it is wise to show you how to use this instrument. It will become handy to learn this now and be ready to use it in the upcoming years nshallah.

13

14

15

This step includes choosing the proper teeth, teeth color and other properties; we will talk about this more in later lectures. With this we have finished the theory part for this lab. The only thing left now is the practical part, but before that we will show you the different parts of the articulator.

You have three types of Articulators, Non-adjustable, Semi-adjustable and Fully adjustable. And you also have average value and nonaverage value.
If you look at your Articulator box there is a phrase says AS 5000 which means your articulator doesnt accept facebow record. But if it were AS 5010 it can accept facebow record but costs more.

16

A very important note you should note, is that the condylar in nature is attached to the mandible. But in the articulator it is attached to the maxilla ( not like nature ). A new classification rises with this note, we have Articulator Condylar or ARCON. Which they have their condylar attached to the maxilla. We have Non-Articulator Condylar or Non-ARCON, Which have it on mandible. 17

The articulators are not always centered by default by the manufacture. So I need you every time you use yours to make a check on the following things: - Open the incisal pen screw, allowing the incisal pen to move freely. Look at the incisal pen you will see we have three lines above and then a heavy line and then a three line below. The heavy line should be leveled with the top of the articulator, after you adjust it tighten the screw to hold it in the correct place.
- Some of you when opening the condylar screw you will hear a

click. This click is because it is tripped in a wrong position, what you have to do is using the condylar screws; adjust them by pushing them in the correct way and then hold them in that place by tighten the screw.

Angles :
In (1) which is the angle of the incisal table laterally which is 10. And the angle of the incisal table (2) which is 15. You also have the angle of the condylar assembly which is 30.

18

Keep in mind that each one of you has a different length of wax rims. We wanted you to be all equal so we didnt do the facebow technique, instead we made a maxillary jug and a mandibular jug (not sure of the word but it is something jug), Attached them to the rim while working. So you all had the same method of constricting it. So you are not going to do any of what we disscuesd , but you must remember it. Before doing anything we have to bring the cast and make a three retention notches one labillay and two behind. If you are not sure where to trim the cast using the bur draw three triangles and then cut it like the pictures on the right. After that we will use the jigs (or whatever their name is look at the last right picture) for the upper and lower. Remember we dont do this at the clinic it is just a method to make us all have equal results. Then we will pour the plaster and we will remove the excess using the plaster knife until we have a nice clean looking plaster attached to the cast. We can polish the surface of the plaster with sandpaper. We soak the cast for 3-5 min, do you know why? Because the plaster will not sick to the cast when it is dry (the thin layer between the cast and the plaster will become dry because the water moved from the plaster to the cast). While if we soaked the cast in water we can start the mounting without any problems.

Done by : Osaka Yusf (yes Ali it is Osaka )

19