Jaw Relations

Definition
Any spatial relationship of the maxilla to the mandible or any one of the finite relationships of the mandible to the maxilla

Types
1. Orientation relation 2. Vertical relation 3. Horizontal relation a. Centric relation b. Eccentric relation

Clinical Significance
1. 2. 3. 4. 5. 6. To re-establish the functional position of the mandible. Comfort. Esthetics. Phonetics. Functional efficiency. Structural balance

Vertical Jaw Relation

Definition
1. Vertical Jaw Relation: The distance between two selected points, one on a fixed and one on a movable member 2. Occlusal Vertical Dimension: The distance measured between two points when the occluding members are in contact 3. Rest Vertical Dimension: The distance between two selected points measured when the mandible is in the physiologic rest position

Classification
1. Vertical jaw relation at occlusion 2. Vertical jaw relation at rest 3. Vertical jaw relation in other positions

Interocclusal Rest Space / Freeway Space

difference between the vertical dimension of rest and the vertical dimension while in occlusion 2-4mm Verticentric: o Involves the simultaneous recording of vertical dimension of occlusion with the jaws in centric relation. Vertical dimension of speech: o distance measured b/w two selected points when occluding members are in their closest proximity during speech

Physiologic Rest Position

1. Definition: The mandibular position assumed when the head is in an upright position and the involved muscles, particularly the elevator and depressor groups, are in equilibrium in tonic contraction, and the condyles are in a neutral, unstrained position

Vertical Dimension at Rest

1. Features: a. Bone-to-bone relation b. Position of mandible is influenced by gravity c. Relaxed position d. May not be easy to record in patients with neuromuscular disturbances e. Position in space cannot be maintained for definite time 2. Concepts: a. Constancy concept: i. position of the mandible in relation to the face and head is as unchangeable as is the form of the mandible, and "the proportions of any face, as far a vertical height is concerned, are constant throughout life b. Variability concept: i. Readily affected by age, disease and emotion 3. Hypothesis: a. Active

i. Muscles exhibits minimal contracture to maintain posture of mandible called tonus b. Passive i. Elastic elements of jaw musculature (and not any muscle activity), balance the influence of gravity 4. Factors: a. Accuracy and validity of rest position: i. Measurement on soft tissues ii. Manipulation of face iii. Concentration on measuring device iv. Lack of permanent record and permanent reference points at subsequent examinations b. Variability of rest position: Physiologic Factors Function Postural reflexes Fatigue and sleep Psychic factors Voluntary control Heat, cold / pain Pathologic Factors Diseases of muscles Diseases of nerves Diseases of bone and joints Diseases causing fatiguability Anaesthesia and sedation Mental disease Malfunction External factors (Prosthesis)

c. Number and timing of measurements i. Factors: 1. Head position 2. Loss of teeth 3. Intraoral appliances 4. Emotional tension 5. Exercise 6. Tongue posture 7. Respiratory requirement 8. Weight of lower denture 9. Lip posture, occlusal characteristics

Methods of Determining Vertical Relation

1. Vertical Dimension at Rest a. Facial measurement after swallow and relaxation b. Fatigue c. Phonetics using M sound d. EMG e. Myomonitor f. TENS 2. Vertical dimension at occlusion a. Mechanical i. Ridge relation 1. Distance of incisive papilla from mandibular incisors / crest of lower ridge 2. Parallelism of ridges 3. Distance from hamular notch to retromolar pad ii. Measurement from former Dentures iii. Pre-extraction records: 1. Profile radiographs 2. Profile photographs 3. Profile tracing 4. Facial measurements a. Sorenson profile scale b. Dakometer c. Willis gauge d. Swensons method 5. Casts of teeth in occlusion b. Physiological i. Physiologic rest position / Niswongers method ii. Open rest method iii. Phonetics and esthetics as guide iv. Swallowing threshold v. Tactile sense c. Others

Ridge Relations
Distance of incisive papilla from mandibular Incisors / crest of lower ridge

Parallelism of Ridges Correct vertical relation is at a point where jaws are parallel, with 5 degree opening in posterior region Disadvantages: o Not reliable in cases of marked resorption o When teeth are lost at irregular intervals the residual ridges are not parallel

Measurement of Former Dentures

Boleys Gauge is used to measure the distance between the border of the maxillary & the mandibular denture when both these dentures are in occlusion

Pre-extraction Records
Profile Radiographs Made with teeth in occlusion Compared with those made with occlusion rims in position Disadvantages: o Enlarging image cause some inaccuracies o Image may be distorted o Time-consuming o Radiation hazards Profile Photographs Made before extraction and taken in maximum occlusion Wrights formula: o Interpupillary distance on photograph:Patients interpupillary distance = Brow-chin distance of photograph:Patients brow-chin distance Disadvantage:

o o o

Profile angles can change with changes in patients posture Enlargement inaccuracies Tissues movable inaccuracies

Profile Silhouettes / Profile Tracing Types: o Cardboard profile record (Ballard) o Lead wire adaptation Used to record pre-extraction profiles and served as a guide for determining vertical dimension Disadvantage: o Lots of errors

Facial Measurements
Dakometer The instrument is positioned on the bridge of the nose with compound. The chin piece is screwed till it touches the front of the chin. A spring pressure gauge controls the pressure. An incisor attachment records position of the central incisors. Records are noted & the compound nose piece is preserved for reassembly after extraction.

Willis Gauge One arm contacts base of nose The other arm is moved along the slide till it touches base of the chin Disadvantage: o Not accurate as there may be variations in applying pressure

Sorensons Profile Scale The nasion locator of this instrument was placed in the depression at the bridge of the nose and the chin seat was raised until it lightly contacted the most inferior, as well as the most anterior part of the chin.

Swensons Method Acrylic face mask made before extraction using facial impression and cast Plaster face mask (Oslen) Not practical

Casts of Teeth in Occlusion

Advantages: o Simple o The size & shape of the teeth can be noted o It gives an indication of the amount of space required between the ridges for the teeth of this size Contraindicated: o In long waiting period o Severe resorption

Physiologic Rest Position

Swallow and Relax Insert occlusal rims swallow jaw relax part the lips interocclusal distance at the rest position should be 2-4mm when viewed in premolar region Niswongers method The pt. is asked to sit upright with his head unsupported & ala-tragal line parallel to floor 2 markings made: o One on upper lip below nasal septum o One on chin Patient told to swallow and relax distance between marks measured Disadvantage: o Marks move with skin

Open Rest Method

Unstrained mouth breathing position & only slightly opened from physiologic rest position of mandible. Relatively practical & constant position Upper plane 3mm above the commissure of lip. Lower plane 2mm below the commissure of lip

Phonetics
M sound When lip touches, all jaw movements stopped Occlusal rims adjusted so that they are 2- 4mm short of this position

Ch, s and j sounds (Bouchers) Brings anterior teeth close together Lower incisors should move forward to a position nearly directly under and almost touching upper central incisors Thirty-three There should be enough space for the tip of the tongue to protrude between the anterior teeth

F or v sounds Maxillary incisal edge lightly contact lower lip at vermillion border Silvermans Closest Speaking Space The closest relationship of the occlusal surfaces & incisal edges of the mandibular teeth to the maxillary teeth during function & rapid speech Dynamic / functional measurement 0-10mm Space is measured before loss of the remaining natural teeth to give the patients natural vertical dimension which can be recorded & used at time of denture construction. Both rims are placed in mouth & height of mandibular rim is adjusted until minimum of 2mm space exist when patient pronounces letter S The closest speaking space can be determined more accurately with artificial teeth set up in wax & is rechecked at that time Earl Pound Let S be your guide: o Condyles are usually anterior to terminal hinge position. o Centric relation can be recorded by simply retruding mandible to hinge position & then closing jaw

Esthetics
Facial Esthetics Tone of the skin same throughout Normal relaxed position, lips are even anteroposteriorly and in slight contact Nares and skin around eyes and chin are relaxed Willis method (Facial proportions) Distance between outer canthus of eye and corner of mouth = distance between lower border of septum of nose and lower border of chin

Swallowing Threshold
Theory: o Swallows teeth come together very light contact Method: o Cones of soft wax having excessive height placed on lower base o Salivation stimulated o Patient instructed to swallow o Repeated swallowing reduces height of wax to occlusal vertical dimension Disadvantage: o Results obtained not consistent o Results affected by length of time swallowing motion is performed

Tactile Sense
Patients Tactile Sense Patient is asked if rims appear to touch too soon or if the jaw closes too much, or it feels just right Neuromuscular Perception Central bearing device is attached to record bases which permit the patient to experience through neuromuscular perception the different vertical relations. Boos bimeter (Power point) Stated that maximum biting force occurs at OVD Bimeter (measures biting force) attached to mandibular record base and metal plate (central bearing point) to maxillary Screw is turned to adjust vertical relation Maximum power point is determined on spring gauge Boucher stated: o Vertical dimension obtained by the Bimeter was greater than that determined clinically and by the electromyographic method. o The use of the Bimeter is also limited because of the psychic influences of pain and apprehension

Other Methods
Use of posterior teeth in determining OVD silicon impressions posterior region of mouth from dentate patient in maximum intercuspation mean distance as guide construction of occlusion rims Use of lingual frenum Distance b/w anterior attachment of lingual frenum - incisal edges of mandibular incisors

Fatigue
Stand / sit erect open jaws wide close slowly

Electromyography
Electrodes placed on muscles of mastication to demonstrate activation potential Rest position coincides with the EMG silence in the digastric, masseter, & temporalis muscles Discrepancy between clinical rest position & EMG rest position ranges 4.5 12.5mm Disadvantages: o expensive equipment o skill, knowledge & experience o pt should correlate visual signs to correct mandibular positioning

Myomonitor
Relax the musculature by light myopulse induced electronically & accordingly rest position is adjusted

TENS (Transcutaneous Electric Nerve Stimulation)

Induce relaxation of the masticatory musculature by repetitive physiologic depolarization devoid of tooth contact. Mandibular movement induced by TENS without tooth contact will allow the physiologic rest position of mandible

Effect of Increased Vertical Dimension

1. Clenching of teeth Increased risk of trauma. 2. Discomfort to patient. Painful mucosa, muscle soreness. 3. Teeth are liable to contact causing clicking during speech. 4. Speech problems - p,b,m sounds 5. Trauma & pain basal seat areas of denture 6. Loss of freeway space muscular fatigue 7. Elongated appearance of face. 8. Clicking sound. 9. Bone resorption 10. Loss of retention & stability of dentures. 11. Generalized hyperemia

Effect of Decreased Vertical Dimension

1. Pain in TMJ. 2. Reduced masticatory efficiency.

3. 4. 5. 6. 7.

Poor esthetics (Lack of lip & chin support, chin protrusion). Cheek / tongue / lip biting due to loss of muscle tone & VD. Facial muscles loose tonicity & face appears flabby instead of firm & full. Denture look. Angular chelitis. Costons syndrome (mild cathedral deafness)

Reduced VD

Tongue displaced towards throat along with adjacent tissues.

Occlusion of Eustachian tube.

Interfere with function of ear

Ear discomfort & impaired hearing

a. Tinnitus or snapping noises in joint. b. Tenderness to palpation over T.M.J. c. Dryness of mouth. d. Neurological symptoms e.g. burning sensation of tongue. 8. Prognathism : Lower jaw over closes in forward & upward direction