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Khalid Al-Hamad
27-10-2013
Occlusion
- Occlusion is Relation of the of the maxillary and mandibular teeth when in functional contact during activity of the mandible. - Terminal Hinge Axis is an imaginary line goes horizontally between the condyles during rotation . Another definition for the occlusion from the slide : - An integral part within the stemato-gnathic system (SGS) (SGS: Teeth, TMJ, muscles, Periodontium. ) that relates teeth, not only to other teeth, but the other components of the SGS during normal function, Para function and Dysfunction.
- Centric Relation: The Maxillomandibular relationship in which the condyles articulate with thinnest avascular portion of their respective disks ( in centric relation you are talking about the maxilla and the mandible and the condition of the condyle )
- While the retruded contact position you are referring to the contact of the teeth (from the the slide : the initial tooth contact upon closure when the condyles have purely rotated whilst in their most superior unrestrained position in the glenoid fossae.) - and inter-cuspal position is the complete intercuspation of teeth regardless of the condyle position (Centric Occlusion) -the inter-cuspal position is the habitual position that the patient will come with with his natural teeth when patient come to you need a restoration , crown or etc you must plan in what position your future restoration will be in (in its existing occlusion which is the inter-cuspal position or you want to change the position to the centric relation or to the retruded contact position ) - In 90% of the population, ICP is 1-2mm anterior to RCP
Here in this picture you can see the maximum interdigitation in the inter-cuspal position while if the mandible moves backward a little bit you can see that there
is a contact ( cusp to cusp contact ) which is not comfortable to the patient so that is why the patient will move forward for maximum interdigitation So the mandible will go a little bit backward but because the way the teeth are matching the patient will not occlude in this position he will use the habitual position which is the inter-cuspal position **So what will happen when the teeth are lost ? the inter-cuspul position is not exist now , because the inter-cuspal position is only exist because of teeth and now the only existing position is the centric relation because it is a boundary position it is not controlled by the way the teeth meet -You don`t want to lose your all teeth to lose your inter-cuspal position . Sometimes when there is a key contact between two teeth ( usually between the second molars ) we call it holding contact that hold your current intercuspal position , if you lose that contact the patient will get into a new inter-cuspal position
- FOR EXAMPLE : When patient occlude in RCP it will be uncomfortable to him , (we will call it the holding contact deserving the inter-cuspul position ) but every time he occlude in this contact he will avoid it and go to the ICP and develop a memory for that . So usually patient know where to close and go directly into ICP Slide 10
-If you are preparing a tooth ( a single crown ) , the contact in the ICP position will be lost and the patient will develop a new ICP so you prepare the tooth and the patient come back again, you remove your temporary crown the patient will come occluding in that tooth because the mandible moved to a new ICP Slide 11
From the examples You must know that to lose the ICP you don`t need to lose all the teeth , you can only lose a contact which is a holding contact and you will lose the existing intercuspal position
TO SUMMARIZE : -The inter-cuspal position is the easy position for you the patient come with it and it is for every day practice -You always use the inter-cuspal position unless you cant use it any more ( in increasing vertical dimension , when losing all teeth ,when cutting all the teeth ) you switch to the RCP .
Mandibular movement :
When the mandible moves, teeth slide over each other. This partly determined by: - the Shape of the teeth( anterior guidance) - Anatomical constraints of the TMJ (Posterior guidance). - Both ( the teeth and TMJ) should be in harmony.
Anterior guidance
When patient pushes his mandible forward the movement will be controlled by different factors the factors are - the shape of the lower - the way the upper and the lower anterior teeth contact - its the effect of the contact between the incisal edges of the lower teeth against the palatal surfaces of the upper teeth on mandibular movement. -If you have steep incisal guidance you will have increase separation of the posterior teeth like in class 2 division 2 -Also the anterior guidance will be controlled by condyle guidance which is the way the condyle moves on the fossa but this is some thing you cant change , The anterior guidance will affect directly your work ( you might be doing a crown on anterior teeth or you have to develop an anterior guidance in natural teeth to separate the posterior teeth ) when the mandible is moving forward posterior teeth should be out of occlusion ( in complete denture you shouldnt do that ,when edentulous patient is moving his mandible forward the posterior teeth should be in contact ) there is a difference between occlusion in dentate patient and in edentulous patient . -The anterior guidance is protective , is protecting the posterior teeth , the mandible moves forward and downward so posterior teeth upper and lower will be out of contact ( in dentate patient ) -The anterior guidance should be comfortable to the patient - Smooth guidance, that is , there are no mandibular deflection. -Acceptable aesthetics & in term of phonetics. -Minimal movement of guidance teeth ( we don`t want over load on anterior teeth so you have to select the proper teeth and avoid weakened or periodontally involved teeth or teeth with post or crown ) Because the anterior teeth are guiding the movement of the mandible the best thing is that this teeth should be strong enough to carry the load so if there are teeth weakened periodontally or restorative you have to avoid them and select another teeth to carry the load . - they should provide posterior disocclusion ( posterior teeth should be out of occlusion )
-And if you are placing crowns and the anterior teeth , if they keep fracturing then there is something wrong in the load with these anterior teeth.
starting with the upper rim ,because it is wax you can simply add or decrease it changing it's dimensions. determine incisal show : how much you want your patient to show teeth (0mm, 1mm or 2mm). using the fox plane device: it gives the direction of the wax inclination . make the level of the wax parallel to the inter pupillary line anteriorly, and to the camper's line posteriorly. Camper's line : imaginary line between the inferior border of the ala of the nose to the tragus of the ear, usually the tip of the tragus. ** fox's plane IS NOT a face bow , one of the common mistakes made by students in exams. It should give good support to the upper lip , we build it up esthetically. place the midline, canine line, smile line and reassure the occlusal plane conformance with the inter pupillary line and camper's line. by that your wax rim which representing the upper denture is DONE :D
IMPORTANT NOTE: These three pictures are for the same patient, they are different from each other by the orientation of the occlusal plane. viewed from the dead center give a straight line , from above curved down and from below curved up. so you have to be aware about your position because it will affect your work. You have to look from dead center don't look from the side or from above you have to be straight ahead to make sure that your occlosal rim is parallel to the inter pupillary line. How much we show from the teeth below the lip, it differ between males and females, females tend to show more from the teeth. female : maxillary central incisors 3.40 mm and mandibular central incisors 0.49 mm. while males : max. central incisors: 1.91 mm and mand. central incisors : 1.23 mm. and with increasing age we tend to show less from the upper teeth and more of the lower teeth. how can i use that; if my patient is about 60 year old i make my incisal rims up to the level of the lip. also you have to discuss it with the patient. when you want to determine the Vertical dimension use non mobile dots .
Methods for determining occlusal vertical dimension: preextraction records using old casts of the patient's mouth when he was edentulous. preextraction measurements in his file. Ridge relations usually a good vertical dimension can be achieved when the ridges are almost parallel to each other. measurements of old dentures Niswonger technique: we determine the interocclusal rest space ( the free way space) the commonest technique when the patient comes to our clinic without anything to help us, we have to create that vertical dimension then we use the rest of stuff here. the space between the ridges at occlusion and at rest. then place the upper and lower wax rim to meet to gather in the patient's mouth, and measure the Vertical dimension (e.g. it is 40 mm) then get the mandible into resting position (relaxing position) the mandible should drop a little bit to get (e.ge 44mm) new vertical dimension. by this we get the difference between those two readings which is 44 mm at rest - 40 mm at occlusion = 4 mm is the inter occlusal space. which means when the patient is relaxing there is around 4 mm of space between the upper and lower rims of the complete denture. if that space is around 3 mm then your vertical dimension at occlusion is correct. phonetics : asking the patient to pronounce certain letters
esthatics : bring the upper and lower rims to the standers, the lower rim does not be higher than the corners of the mouth, that usually conforms for good occlusion. Tactile perciption Bite force to be honest the is no one technique that gives you dead right vertical dimension, you have to use combinations of these things. How to get the Rest vertical dimension? ask the patient to pronounce the litter M and relax , or drink some water and relax again, or open wide and tap on the cheek and ask him to close until the lips parley touch. these will help to get the patient into resting position. Resting position means that : the mandible is resting there with minimal contractual activity, the muscles are not contracting, by this we will get the bigger vertical dimension at rest which we just said an ex. 44 mm. then when we place the wax rims in ask the patient to close and measure the vertical dimension at occlusion, which should be less than the VDR (vertical dimension at rest) by around 3 mm , which is the Niswonger technique. you can use instruments and place dots to check the difference. Mistake : in some cases during practice in DTC you may end up with wax rims dimensions that their VDO bigger than VDR! which means you have to reduce from the wax rims. until the VDO is smaller than VDR by around 3 mm.
Video 1: how to get the patient's mandible into resting position. to check that ur vertical dimensions are correct.
Video 2 : Adjusting vertical dimension to obtain the required free way space. a patient putting the wax rims with increased VD and he is trying to talk saying Mississippi, because there is no space the patient can't talk. then the dentist adjusted the lower rim to increase the space between the rims to the proper space and then patient could talk again. so u can use the measurements and check again with phonetics and go to tactile sensation with the general esthetics to the patient and you can come to the conclusion that : yes my vertical dimension is correct or I have to adjust it , increasing or decreasing it.
But if it is too much increased or decreased then your patent will be affected , that's why no one technique will give you an exact VD wanted it gives you an indication. also it is not very accurate because: - tissues are mobile. - esthetics perceptions of esthetics differ from one dentist to another - the general comfort of the patient himself -phonetics usually the patient is a new edentulous when you just put the rims in , a lot of saliva is secreted it is not comfortable normally he will not pronounce some words properly even if your VD is correct. so each technique has a divorce by itself but if you use combination of these techniques you will end up by providing the patient an acceptable VD. this is a good video to take a look at:
https://www.youtube.com/watch?v=Q1xoWm0Ts_A&feature=youtube_gdata_player