Jaw Relation

PRINCIPLES OF REGESTERING
MAXILLO MANDIBULAR RELATION SHIP

Definition:
positional relationship which mandible bears to maxilla and is considered in terms of
vertical and horizontal component . These two component are interdependent and cant be
changed without changing the other.
Establishing correct maxillomandibular relationship is very important in prosthodontics
especially when treating complete denture patient to restore function, facial appearance and
patient health .

Classification of various component of maxillomandibular relation ship :

 Orientation relation:

a- Check Denture Foundations.

Extension:
• Extend to the functional depth
• Checked visually or by palpation eg. Tuberosity flange
• Mirror is used to palpate the hamular notches
• Maximum coverage eg. Using indelible pencil to check the posterior palatal seal and the
trial base is inserted in place
• Check the lingual extension: patient is asked to open his mouth slightly and protrude the
tongue and move it gently from side to side while the operator’s index finger is placed in
the region of first molar
Stability
• By applying vertical pressure on each side of the denture bases  idea about the relief
whether it is sufficient or not or the position of the wax rim
Retention
 Gives information regarding the retention of the finished denture
 Overextension: Tension in the tissues cause displacement of the trial bases
 Underextension: Lack of peripheral seal or post-dam
 Warpage of the base

Maxillary arch
Posterior palatal seal: upward and forward pressure on the lingual surface of the occlusion rim
Posteriorly: forces on the lingual surface of one side gives the degree of border seal on the
opposite side
Anterior region: Vertical downward force on the anterior part of the occlusion rim
Mandibular
Posterior region: anterior forces on the lingual surface of the occlusion rim
Anterior region: Vertical upward forces on the anterior part of the occlusion rim
 Unsatisfactory extension, support and stability due to bad impression  repeat the
impression
b)Contouring the occlusion rim:
* Anteriorly ( labial): according to patient esthetics
• Upper jaw:
 The lip is normally supported by the alveolar process and teeth which, at this stage, are
represented by the base and rim of the record block.
 Bone loss occur in ridge-...-so no support
 Therefore, the labial surface must be cut back or added to until a natural and
pleasing position of the upper lip is obtained.
 To overcome this-...-slight labial wax to make contour and to make lip support &
philtrum & naso-labial sulcus & to make naso-labial angle 90
 Avoid over-contouring (protruded lip, acute angle of naso-labial) & also to avoid
obliteration of orbicularis oris muscle
 under-contouring (retruded lip, obtuse angle)
 labial inclination till 15 degree

• Lower jaw:
• Bone loss in lower ridge
• Adding of slight wax in labial surface
• To adjust lip support & labio-mental sulcus
• If over contoured wax --- acute angle of labio- mental sulcus
• If under waxing --...- flat or 180 degree labio- mental sucus
### adjust upper & lower to give proper over jet (2mm )|

* Posteriorly (buccally):
• Make upper occlusal rim over lower occlusal rim by 2mm (over jet )
• Occlusion rim must be centered on ridge (in lower ) slight palatal in upper to create space
between the cheek and the rim
• Avoid obliteration of buccal corridor by over contour of wax to prevent cheek biting &
instability of denture.
[buccal corridor-.....-the space (black triangular) between occlusal rim & check in
posterior area

c) Establish the occlusal plane:

i. Maxillary occlusal plane:
* The anterior occlusal plane: the primary concern is esthetic
• Esthetic (lip line) method : (functional or physiologic)
• Ideally 2mm of wax should appear under the lip line v
• According to lip length.-
1. long lip "excessive ridge resorption" _-increase height--ever imbalance - ..--vertical
cantilever ---instability of denture.
The teeth may be invisible when the lip is relaxed
 2. Short lip (well developed ridge) -_..decrease height...-short teeth
The teeth 2-4 mm visible.
* Phonetic method: (functional or physiologic method)

• Proper occlusal plane should be achieved for proper phonetic in case of (V) or
(F) the incisal edge of upper incisor touch the lower lip (labio-dental sound)
• If low height-.......improper phonetic
* The posterior occlusal plane: (anatomical)

 Level of occlusal plane posteriorly should be at the same level with or 1/4 inch
below stenson's duct of parotid papilla. (opposite to second molar)
ii. Mandibular occlusal plane: the primary concern is stability
o The anterior occlusal plane:(anatomical)
The tip of canine should be at same level of tip of corner of the mouth when slight
opening
o The posterior occlusal plane: (V.I.)
1) Functional relation to the tongue:
* During chewing: (functional or physiologic method)

 During chewing, coordination between tongue & buccinator muscle keep the food on the
occlusal surface of teeth. So, stop or prevent escape of food to the floor of mouth
 The occlusal plane should be just below the greatest or maximum convexity of the
tongue-....-- improve stability of lower denture by preventing cramping of tongue &
prevent escape of food to floor of the mouth
 During speech, the tongue pushes against the sides of the teeth to produce a seal for better
pronunciation of wards.
2) Principle of the physics and mechanics: (static)
a) Leverage action:

 The occlusal plane in lower denture should be near the lower ridge as possible--
to give more support & stability
 Teeth on crest of ridge and arranged in the neutral zone
 Should not exceed 2/3 of the retro-molar pad
b) Parallelism:
The occlusal plane should be parallel to the ridge & midway from maxillary & mandibular.
 Force should be directed vertically to ridge.
 Must have no tendency for horizontal displacement.

Methods of determining the occlusal plane:

1- Anatomical method:
a) Anterior occlusal plane:

 Parallel to inter-pupillary line (Inter-pupillary line--.-

--- line between two pupil of the eye)
b) Posterior occlusal plane:

 Parallel to ala-tragus line (camper line) (Ala-tragus line--..--line between inferior border
of ala of nose & superior border of tragus of ear) (maxillary)(higher in anterior than
posterior)
 Occlusal plane in lower not exceed 2/3 of retro-molar pad (mandibular)(higher in
posterior than anterior)
 Use fox plane
2-Functional method:
1. Buccinator groove: parallel to posterior occlusal plane
2. The lateral border of tongue:

3- Biomechanical method: The occlusal plane must be parallel and midway between ridges

d-Cranio-maxillary orientation

Aim:
* Transfer the relation of established occlusal plane to fixed anatomical landmark of the cranium
(horizontal axis between condyle & infra-orbital foramen) "by using face bow" to achieve
balanced occlusion

 Hinge axis----- imaginary horizontal axis passes through the center of both condyle
around which mandible rotate during opening and closing
 Face bow---...--A calliper like instrument used to record the spatial relationship of the
maxillary arch to some anatomic reference points, and then transfer this relationship to an
articulator
 It orients the dental cast in same relationship to the opening axis of articulator.
 Customarily the anatomic references are the mandibular condyles transverse horizontal
axis and one other selected anterior point.

• Type of face bow:

Maxillary (arbitrary) face bow:
 U-shape bow, have condylar rod & clamp carries a bite fork & infra orbital pointer
(3 reference point)
##called arbitrary because position of condyle recorder arbitary by Frankfort plane from outer
canthus of eye & tragus of ear (11---13mm infront of tragus of ear) (bavron point)

A. Maxillary face bow:(arbitrary)

1) The facia face bow:

 Condyler position determined by 11---13mm anterior to superior border of tragus on

Frankfort plane (line extended from the outer canthus of the eye to the upper margin of
the external auditory meatus).
  Anterior reference is infra-orbital foramen (touch without pressure)

1. The ear piece of face bow: (webmix articulator)

 Ear piece in external audiotary meatus
 Anterior reference point (nasal bridge) (nasion)

2. The orbitale:
 A notch located in the inferior margin of the orbit or infra-orbital margin and is used
as a third reference point. This anterior point togother with the two posterior points
produce a three dimensional location of the occlusal plane in relation to the

B. Mandibular face bow: (kinematic)

 Attached to lower record block

 Rod initially inserted arbitrary
 Then adjusted by opening & closing in hinge movement (actual hinge axis
of patient)

Mounting upper cast on articulator:

 Bite fork is heated and inserted to maxillary wax rim parallel to the occlusal plane
 Condylar rod located 11----13mm anterior to the tragus on the Frankfort plane and
moved from side to side until equal reading then tightened
 Lock the condylar rod to the condylar shaft of articulator

Correct centric occlusion can be developed on an articulator without a face-bow transfer

record, provided it is developed at the exact vertical dimension used to mount the casts.
Any increase or decrease of the vertical dimension will cause a difference between the centric
occlusion of the articulator and that in the mouth when the dentures are inserted.

Vertical component of jaw relation :

Vertical dimension :
Vertical measurement of the face between two arbitary selected points located one above and one
below the mouth usually in the mid line

Vertical dimension of the rest :

Vertical dimension of the face at the rest position .

Physiological rest position :

-The habitual postural position of the mandible when the patient is setting comfortably in upright
position and the condyles are in neutral unstrained position in the glenoid fossa.
-the mandible is considered to be in physiological rest position when all the muscles that open or
close the jaw are in state of minimal tonic contracture sufficient only to maintain posture .
-Gravity must be considered ang the head is in upright position when observation of vertical
physiological rest position is made .
-all mandibular functions (mastication ,swallowing , speech ) and parafunctions start and end at
this position.
-at this position teeth are separated by an average distance 2-4 mm which is called interocclusal
distance or free air space .
-The main objective of vertical dimension of rest to establish vertical dimension of occlusion .
-Vertical dimension of rest – free way space = Vertical dimension of Occlusion.

Summary of the short and the long term intraoral and general factors that
influence the postural rest position :

A-Short term factors :

1-Head posture : tilting head backward will increase the vertical dimension of rest while
inclining head forward will decrease the value .
2-Stress: tends to decrease the vertical dimension of rest as a result of increased activity of the
elevator muscles attached to the mandible .
extraction of teeth or after insertion of lower denture .
4-Pain in the muscle supporting the mandible : affect the vertical dimension of rest as a
protective posture may assume .
5-Respiration : produce minimal variation of vertical dimension of rest .

B- Long term factors :

1- Age and health status : when natural teeth or the denture are worn down or prolonged
period edentulous has occurred leads to decrease in vertical dimension of rest and chronic
neuromuscular disorder produce changes in jaw rest position .
2- Bruxism : and habits of abnormal occlusion often associated with muscle hypertonicity
leads to decrease in vertical relation . patient should be seated in upright position with out
any tension and relaxed and mandible can be clinically guided this requires clinical skill
can be achieved by practice and experience
Interocclusal distance (freeway space )
Definition :
The distance between the occluding surfaces the mandibular and the maxillary teeth at the
physiological rest position . can be determined by calculating the difference between the vertical
dimension of rest and vertical dimension of occlusion at the incisor region .
- It vary class1 (2-4) mm
- Class2,3 more than 4mm
Significance of inter occlusal distance :
-allow relaxation of masticatory muscles
-when mandible at rest position teeth are out of contact so tissues that support the denture are not
loaded and no strain at temporomandibular joint capsules.
-elimination or reduction of inter occlusal distance or free air way space will result in excessive
loading of denture bearing tissues and muscles cant return to rest position leads to continuous
muscular activity result in accumulation of metabolites and fatigue and pain in affected muscles.
- reduction in masticatory activity and affect the appearance .

Vertical dimension of occlusion :

Def: is the vertical dimension of the face when the teeth or occlusion rims are in contact in
centric occlusion .

Effects of excessively increasing vertical dimension :

-Pain : and discomfort of tissues owing to bruising of mucosa by the sudden and frequent contact
caused by increased vertical dimension .
-Increased bone resorption :increase vertical dimension beyond physiological limits leads to
accelerate bone resorption of the residual alveolar bone .
-Muscle pain: and in some instances spasm and facial pain.
-Clicking of teeth : clicking sound of teeth during speech.
-Poor appearance : elongation of the face , at rest lips are parted and closing them together give
the appearance of strain .
-Pathological condition at the temporomandibular joints .

Effects of excessively reducing vertical dimension :

- Poor esthetics: the general effect of over closure on facial appearance Give the
appearance of having his chin too close to his nose (old age appearance) , the muscles of
facial expressions lose their tonicity the face appears flabby and the mandible becomes
protruded and prognathic appearance results .
- Reduced masticatory efficiency: because muscles of mastication are acting from
attachment which have been brought closer together.
- Cheek biting : due to loss of muscle tonicity and reduced vertical dimension of
occlusion.
- Angular cheilitis : due to lack of support of the angle of the mouth and dribbling of
saliva .
- The patient take the characteristic denture look caused by sagging of the lower face .
- Pain in temporomandibular joints : symptoms of temporomandibular joints
dysfunction syndrome due to stress in tissue related to the joint .
Methods of determining vertical dimension:

Mechanical methods:
1- Parallelism of posterior residual ridges :
-some clinicians consider the correct vertical relation when the posterior ridges parallel to
each other, this paralleling is natural cause natural teeth in normal occlusion leave posterior
region of residual ridge parallel to each other .
- excessive divergence from the parallel seen in master casts that have been mounted to
articulator indicate vertical dimension is probably wrong and should be rechecked .
 - because ridge loss would not be even if natural teeth are lost in different time it would not
be a reliable method in many instances .
2-Measurement of former dentures :
-the patient existing denture can be a valuable aid stablishing the vertical dimension of
occlusion .
- aid in accurate assessment of the patient esthetics , phonetics and vertical relation .
- the first thing to study the lip support (denture look) in adequate lip support result in loss of
vermillion and flat upper lip and loss of dominance of maxillary lip over mandibular lip ….
Lip support should be restored before studying the vertical relation .
-over the years denture settle result in ride resorption ,abrasion of teeth leads to loss of
vertical relation .
-when vertical relation is lost lower anterior teeth move forward and upward leads to crossed
occlusal relation .
-this lead to trauma from occlusion , habits like clinching , excessive bone resorption .
- thin strips of soft wax can be added to the labial surface of existing denture to retore lip
support .
-like wise wax can be added to posterior teeth to restore vertical occlusal relation , the
patient appearance is improved as a result .
- A measurement of inter ridge distance by a caliper and it id the distance between incisive
papilla and mandibular ridge crest it is measured with calipers located at the fitting surfaces
of the dentures while held in occlusion without wax inter occlusal record .
- the actual inter ridge distance is note measurement minus 20 mm.
-next hold upper and lower denture in occlusion with the wax inter occlusal record . measure
the record this is interridge space .
- the difference is the increase in vertical relation that is desired after adjusting the record
blocks prior to recording the centric relation .

…(Mechanical methods)…
3. Pre-extraction records
We see the patient before extraction of his or her teeth.. the dentist has the opportunity to record
the vertical dimension and the position and shape of the teeth.
Various methods have been used to make pre-extraction records which include:
a. Profile radiographs
A cephalometric profile radiograph with the teeth in occlusion is made for the patient before
teeth extractions.
After extraction, record blocks are adjusted to an apparently correct vertical dimension. They are
inserted in the patient's, the patient is allowed to close on them, and another film is taken. The
two films are compared, and any necessary adjustment is made in the occlusion rims to match
the position in the initial film.
Disadvantages
1. The method requires considerable time.
2. It may result in too-frequent exposure to irradiation.

b. Profile photographs
Since the teeth and their relationship with the oral tissues do not change dramatically,
photographs, especially those showing the shape and size of the teeth and the smile line, are
especially valuable.
Profile views showing the support of the lips and giving an indication of facial height are an aid
to tooth position.
Profile photographs are made with teeth in maximum occlusion, as this position can be
maintained accurately for photographic procedures.
These photographs are enlarged to life size.
Measurements of anatomic landmarks on the photograph are compared with similar ones on the
patient's face. These measurements can be compared during the recording of maxillomandibular
relationship and again at the try-in stage. As an example.
Wright's relative measurement
Interpupillary distance on a photograph:
Interpupillary distance of the patient= brow-chin distance on a photograph: X
(X is the brow-chin distance before the teeth were extracted)
Measurements are not exact due to variation in sharpness and size of the photographs and
inability to establish exact points of measurements.

c. Articulated study casts

Casts of upper and lower natural teeth in maximum occlusion can serve the following functions:
Measurements between certain relatively stable anatomic landmarks can be made such as the
incisive papilla and the crest of the lower ridge, the extended height of upper and lower buccal
frena or the hamular notch and the retromolar pad.
ii Indicate the amount of vertical and horizontal overlap as well as assisting in the selection of
size, shape and position of the teeth to be used for the denture.

d. Facial measurements
There is a proportional measurement which is taught in art schools, and while it is true that a
drawing made to these dimensions will be pleasing in its proportions, there are many individuals
whose faces, although not appearing in any way distorted, do not conform to these somewhat
ideal limits.
The theory of this proportional facial measurement is that "the distance from the lower border of
the septum of the nose to the lower border of the chin, is equal to the distance from the outer
canthus of the eye to the corner of the relaxed lips with the teeth in occlusion" (Fig. 9.6).

Another general proportion of the face which may be used in assessment of vertical dimension is
to divide the face into three equal parts:
(a) Hairline to nasion.
(b Nasion to philtrum - columella junction.
(c) Piltrum - Columella junction to below the chin.

These and other concepts based on facial measurement have been shown to be of little practical
value for a variety of reasons:
i. The points of measurement are too vague.
ii. The individual variation in facial features.

Methods of determining the vertical dimension

Various devices for making measurements have been used in different forms:
facial many different forms:

i. Willis gauge
When (this device is used for recording the vertical dimension before extraction),
the fixed arm is placed in contact with the base of the nose and the sliding arm is moved along
the slide until it is lightly but firmly touching the lower border of the chin, when it is locked in
position by a screw (Fig. 9.7). The distance on the scale is recorded on the patient's chart for
future reference.
The Willis gauge does not provide an accurate measurement because it depends on the vertical
orientation of the gauge as well as on the operator always applying exactly the same degree of
pressure when the instrument is making contact with the base of the nose and with the
undersurface of the chin.
For achieving good results with the Willis gauge, three points require attention.
1. The vertical orientation of the gauge.
2. The position of the fixed arm under the nose.
3. The position of the sliding arm under the chin.

The vertical orientation of the gauge

The gauge should be positioned so that the handle is just contacting the skin of the chin
in the mental region and that its long axis is in line with the long axis of the face so that the
variation in vertical orientation of the gauge can be kept to a minimum during successive
measurements (Fig. 9.8).
This is difficult to achieve with facial profiles produced by very full lips or a severe skeletal class
II jaw relationship.

The position of the fixed arm under the nose

If the patient has a well-defined nasolabial angle, the fixed arm can be positioned with
reasonable accuracy. If the nasolabial angle is obtuse, a small mark may be made on the skin of
the upper lip and the fixed arm placed in relation to it (Fig. 9.9).

The position of the sliding arm under the chin

The sliding arm should be moved so that it is just touching the undersurface of the chin.
If undue pressure is applied to the skin the position of the mandible will alter. Further inaccuracy
arises as it will not be possible to achieve the same degree of compression on subsequent
measurements. Inaccuracies may be introduced if the shape of the chin prevents positive location
of the sliding arm.This is less likely if the gauge has been previously modified by reducing the
length of the arm and modifying its angle (Fig. 9.10).

ii. Profile silhouette

Lead wires may be adapted carefully to preextraction profiles starting on the brow, following
down the nose and lips and ending just below the chin. It is then carefully laid on a piece of stent
cardboard. The cardboard cutout is then placed on the face to check its accuracy and to mark the
position of the upper central incisors (Fig. 9.11). Later, when the patient is edentulous, it is
repositioned to the face after the vertical dimension has been established at the recording of the
maxillomandibular relationship and/or the try-in stage to see whether the proper facial contour
has been reestablished.

This method is fraught with too many errors and is not in common use today
ili. Face mask
Swenson (1959) suggests the use of an acrylic face mask made before teeth extractions and later,
when the patient is edentulous, fitted on the face to see whether the vertical dimension has been
restored properly.
Disadvantages
1. It requires time and extensive experience with the use of facial impressions and casts for
the fabrication of artificial facial appliance.
2. The face assumes a different topography in the stress position from that in the rest
position.
3. It does not give good results when compared to other preextraction methods.
It must be emphasized that all pre extraction records cited are approximations. Many dentists
with a good deal of clinical experience can look at the profile of the patient and be rather sure
that the vertical dimension is either closed or opened too much.
In this matter, we must admit, sadly, that experience offers the best results.
However, a combination of several methods can be used to achieve a satisfactory vertical
dimension of occlusion.

iv. Tattoo
Before the teeth are extracted, make a tattoo on the anterior labial of the maxilla and on the
mandible. Have the patient close into centric occlusion and make a measurement between
tattoos. This measurement can be compared after the teeth are extracted.

Physiologic Methods
Many methods have been proposed for the determination of the vertical dimension of rest
position.
Unfortunately, for the prosthetic educator, no practical and accurate means are presently
available for the determination of vertical dimension. Instead, the student must learn that the
registration of vertical dimension is still a matter of clinical judgement - an art rather than a
science.

Some of the methods that offer helpful aids to good clinical judgement include:
1. Physiologic rest position
Niswonger suggested a method for determining the vertical dimension that is rather commonly
used today (the two-dot technique).
However, before making a recording of the rest face height, the dentist must be satisfied that the
patient is truly relaxed. Visual assessment of facial features assists the dentist in judging . The
patient is seated so that the ala-tragal line is parallel with the floor. Two marks are placed on the
face in the midline - one on the tip of the nose and the other on the chin. The patient is instructed
to swallow and relax and the distance between the marks measured. The distance represents the
rest vertical dimension.
This method has the disadvantage that the marks move with the skin, and sometimes it is
difficult to obtain two constant measurements of the rest position.

2. Phonetics
Phonetic methods are widely used to determine the proper vertical dimension of occlusion. The
use of phonetics in the assessment of the vertical dimension depends on a correlation during
speech of the interocclusal distance, the position of the occlusal plane, and the position of the
tongue relative to the occlusion rims or teeth. The most popular sound used as an aid in
determining rest position is the labial "m" sound which can be said without the use of teeth.
However, the (m) sound often leaves the lips in contact.
As soon as they are parted by the dentist to observe the space between the occlusion rims, the
mandible is depressed and the rest position is lost. To overcome this difficulty the sound m is
often extended to the word emma or followed by the labial p sound which leaves the lips apart;
hence, the popularity of the word Mississippi. Some patients depress the mandible when
pronouncing p. Observing a patient talking of helps in judging the occlusal face height. If the
occlusion rims make frequent contact, then the height is obviously excessive. On the other hand,
if the patient can talk without making such contacts, the dentist has obtained a further piece of
evidence to indicate that the occlusal face height is acceptable.

Speaking Method of Determining Vertical Dimension

This phonetic method is based on the physiologic movement and position of the mandible during
speech.
the position of the tongue and the relation of the teeth are important (Fig. 9.12).
During pronunciation of the "S" sound, the anterior teeth come very close to touching end to
end. By observation of the patient's teeth during pronunciation of such words as "Mississippi" or
during counting upward from 60, the dentist can arrive at the proper vertical relation.
Silverman (1955) described the "closest-speaking space" which is the space between the
occlusal surfaces and incisal edges of the teeth when the mandible is elevated to the maximum
extent during speech and advocated a space of 1 to 2 mm space between the upper and lower
teeth. in all complete dentures.

The closest speaking space

After adjustment of the vertical dimension of occlusion using various aids, the patient is asked to
make;
1. the "S" sound, a minimum of 1 mm. space between the upper and lower occlusion rims is
acceptable.
2. in pronouncing words with the letters "th" such as the, three, thirty-three, the tongue
protrudes slightly to occupy the interocclusal distance between the occlusion rims.
3. in pronouncing the letter "M", the mandible may or may not rise and fall …
The proper interocclusal distance is maintained while the lips contact one another in making the
sound.
With the use of this letter(M), we determine the vertical dimension of rest position as the
mandible returns to rest position after the letter "M" is pronounced.
4. in pronouncing the letters "F" or "V" the lower lip seals slightly against the incisal edges of
the upper incisors, the teeth contacting just inside of the maximum contour of the lip at the wet-
dry line (Fig.9.13).
These sounds provide an excellent guide for placement of the maxillary anterior teeth both
vertically and Anteroposteriorly (likewise determining the labioincisal edge of upper occlusion
rim). These facts can be used as guides in determining the proper position of the occlusal plane
and adequacy of the interocclusal distance and the bulk and contour of the wax occlusion rims.

3. Esthetics
The estimation of vertical dimension by appearance is based upon the esthetic harmony of the
lower third of the face, upon the contour of the lips and the appearance of the skin from the
margin of the lower lip to the lower border of the chin, and upon the labiomental angle.
… With the record blocks in the patient's mouth.

Check the facial profile with the lips at rest the occlusion rim should support the lips so that there
is a normal amount of vermilion border visible and the face has a relaxed appearance.

Many dentists with a considerable amount of clinical experience are able to tell simply by
looking at the profile of the patient whether the occlusal face height (vertical dimension of
occlusion) is too great or too small. Here they are using the evidence of the appearance of the
facial tissues; such an approach is very subjective.

The labiomental angle

This angle or depression found between the lower lip and the chin is always present, but varies in
degree from patient to patient. The amount of jaw separation by the record blocks in the mouth
affects this angle. If the separation is too great, the angle is flattened as the patient strains the
lower lip to make contact with the upper. On the other hand, if the separation is not enough, the
lower lip bulges forward as it contacts the upper, causing a deepening of the labiomental groove.
It is however, important to point out that a deep labiomental depression is not always indicative
of a reduced occlusal face height and the operator should be aware that the angle is pronounced
in skeletal class Il cases when the vertical jaw separation is perfectly normal.
 (a) The labio-mental angle (between Li-B’ and B’-Pg’) gives a measure of lower lip curvature. It is reduced in the short-faced patient
shown in (b), and increased in the long-faced patient shown in (c).
Ref. https://pocketdentistry.com/2-dentofacial-assessment-2/

The lips
At the correct degree of jaw separation the lips should be able to come into a relaxed and easy
contact. If the vertical dimension is too great, the patient will have difficulty in making the lips
touch. If the vertical dimension is insufficient (overclosed), the lower lip becomes everted with
the normally hidden, inner aspect, which is moist and shiny, becoming visible.

The angle of the mouth

The appearance of angular folds at the corners of the mouth will normally change to become
more deep as the patient grows older.
The really deep folds which are liable to be bathed in saliva and become infected, can usually be
solved or avoided by:
1. slight opening of the vertical height to help restore the corners of the mouth to their
normal position,
2. correct positioning of the anterior teeth, and,
3. providing sufficient support for the angles of the mouth by the denture flanges. The
dentist should be wary of the middle aged female who is anxious to have the multiple fine
lines radiating from the corners of the mouth and the vertical lines in the lips eliminated
by an increase in the vertical dimension of occlusion. Such patient must by advised that
denture comfort and esthetics of youth become more incompatible with increasing age;
the use of cosmetics should be suggested.
The esthetic guide in estimation of the vertical dimension of occlusion generally applies to
normal young patients or middle-aged patients with good tonus of the skin.

4. Swallowing
When constructing complete dentures, the users of the swallowing technique believed that soft
wax on the occlusion rim is reduced during deglutition to give the correct vertical dimension of
occlusion.
In adopting this observation, occlusion rims are constructed which are shorter than the vertical
dimension of occlusion is thought to be, soft wax cones are added to the lower occlusion rim to a
distance above what the vertical dimension of occlusion is thought to be. The patient is then
given a piece of candy or sips of water.
Since the teeth come into contact slightly during swallowing, the wax cones are flattened as the
patient swallows.
When the wax cones contact but do not flatten, the correct vertical dimension of occlusion can be
assumed. The length of time the swallowing action is carried out and the relative softness of the
wax cones will affect the results.

5. Patient's tactile sense

The patient's tactile sense is used as a guide to the determination of the correct occlusal vertical
dimension. This method depends totally on the sensation ability of the patient, as it has been
theorized that the patient can innately sense when the jaws are in the position they assumed
during occlusion of the natural teeth.
Mc Gee (1947) stated that methods which depend on the patient's muscular perception
transferred the responsibility of registering the occlusal vertical dimension from the dentist to the
patient. He found patients tended to register a reduced vertical dimension of occlusion because
they felt more comfortable in that position.

6. Boos bimeter
Measurement of closing forces to establish vertical dimension has been suggested by Boos
(1952). His theory says that the maximum closing force developed at a degree of jaw separation
equal to this vertical relation of rest position.
Smith (1958) said that Boos a bimeter; is a device that registers the biting force is the best device
for determining the vertical dimension of rest position.
The bimeter is attached to an accurately adapted mandibular record base.
A metal plate is attached in the vault of an accurately adapted maxillary record base to provide a
central bearing point.
Adjust the vertical distance by turning the cap.
The gauge indicates the pressure generated during closure at different degrees of jaw separation.
When the maximum power point is determined, lock the set nut.
Make plaster registration and transfer the master cast to an articulator.
The accuracy of this method is affected by the fit of the denture bases and the comfort of the
supporting tissues under the masticatory force.

Disadvantages
1. The bimeter is bulky and not practical for routine clinical practice.
2. It cannot be used in close interridge space.
3. The closing power of the patient is affected by pain and fearne's.
4. In some cases, a maximum biting range rather than a definite point is exhibited.
5. The use of the bimeter does not offer more accuracy than other conventional methods
used for determination of the vertical dimension.

A correlation of results obtained with the bimeter and those registered by clinical methods
Showed that the use of the bimeter produced increased vertical dimensions.

7. Electromyography
A further approach for the establishment of the vertical dimension utilizes electro-myographic
recordings on the basis that minimal muscular activity occurs when the mandible is in the resting
.Hickey and coworkers (1957) content that the vertical relation of the rest position can be
determined by the electromyograph which would record the minimal activities of the muscles
and they stated that "all muscles showed greater activity (in other positions) than when the jaws
are at rest".
The use of electromyograph for determining the vertical dimension in the dental office may not
be practical because the equipment is too expensive, the technique is too involved, besides that it
requires considerable experience in the field of muscle physiology before one can attempt to
interpret the tracings.

C. Horizontal jaw relation:

1- Centric relation record
2- Eccentric relation record

1-Centric relation:
* Def:
Most retruded physiologic (unstrained) relation of the condyle (mandible) to the maxilla from
which individual can make eccentric movement (lateral, protrusive) at established V.D.O.
When the condvle make contact with the thinnest avascular position of the disc
3D Bone to bone relation ...--not affected by loss of teeth
Occur around the terminal hinge axis (rotation of condyle without translation)
This position is independent of tooth contact.
• This position is clinically discernible when the mandible is directed superiorly and anteriorly
and restricted to a purely rotary movement about a transverse horizontal axis.
Mandibular centric position (horizontal position)
1. Tooth position (centric occlusion):
Maximum intercuspation position can be estimated 1mm anterior to the muscular
position (centric relation)
Maximum intercuspation between upper & lower teeth when condyle is in articular fossa
Tooth to tooth position
2. Ligamentous position:
Extreme posterior strained position of the mandible in relation to maxilla
Limited by ligament of the joint 1mm posterior to the centric relation
Obtained only in case of muscle relaxant or muscle block

3. The muscular position:

Teeth contact position of the mandible determined by the reflex muscle pattern acting as
the mandible close from rest position (concide with centric occlusion) in normal
dentulous patient
Muscular position = centric position (concide with each other)
In case of edentulous patient muscular position is in protrusion position called habitual
position or muscular position of edentulous patient
 During fabrication of denture centric occlusion must concide with centric relation to avoid cusp
interference (centric occluding relation) freedom in centric)
Significance of centric relation
1) Repeatable & reproducible (bone to bone relation) (learnable) (riable)
2)Reference point of jaw relation
Reference point of mandibular movement

iii.Reference point for starting developing occlusion

ten sipoloizvnA("
1. Centric relation closure used in mastication & swallowing
2. Coordinated center around which muscle, bone , ligament , teeth and all related structure
grows into activity
Methods used to retrude mandible to centric relation
1) Patient instruction:
Close not bite -
-when ask patient to patient--
-he will make protrusion
movement
2) Tongue retrusion: (most common)
Ask patient to retrude the tip of the tongue as far as possible on the palate & close occlusa; rim
(activation of genio-glossal muscle -retrude mandible)
3) Control of the mandible:
/ Index finger on lower buccal flange area
• Thumb on chin
/ Ask patient to close posteriorly while index move buccally & thumb guide the mandible (no
pressure to avoid reflex)
Some time used with the tongue retrusion method
4) Relaxation:
General body relaxation enhance jaw muscle relaxation which automatically
assume a retruted position
Swallowing:
* As patient swallow saliva...
--teeth come in C.R.
1. Fatigue:
‹ Patient muscle habitually make mandible protruded So make fatigue to retraction
muscle (temporalis.... by repeated protrusion & retrusion
2. Head position:
Lower or backward head rest --mandible is backward so make mandible in retruded
position (centric relation)
3. Temporalis muscle check:
• Temporalis muscle responsible for retraction of mandible
~ So palate temporalis muscle--. if contracted - the mandible in centric relation
Method recording C.R.
1) Physiologic method; the static recording method or interocclusal check bite:
This is a simple and convenient method.
• The maxillary and mandibular wax occlusal rims were adjusted according to the patient's
anatomical landmarks for the accepted orientation relation.
/ Make V-shape notch in upper occlusion rim
‹ Add some wax in lower and heated
* When patient close soft wax enter V-shape notch to record relation (centric relation)
This method is called centric inter-occlusal record
‹ After finish take upper & lower closed in centric relation and put it on articulator to set teeth
r Setting teeth (centric occlusion) on established or recorded centric relation on
articulator is called "centric - occluding relation)
r Should make long centric or slide in centric by wide the fossa
• Vertical dimension
/ The final centric relation established by guiding mandible to close into centric position
• Indications:
1. Abnormally related jaws
2. Excessively displaceable supporting tissues
1. Large tongue
2. Abnormal mandibular movements
3. Verify occlusion in existing dentures

> Bite registration/recording materials

1. Waxes
2. Quick setting plaster
3. Impression compound
4. Bite registration paste (ZnO-E)
5. Bite registration silicone
2)Graphic method (Gothic arch tracing):
The general concept of this technique is that a pen-like pointer is attached to one occlusal rim
and a recording plate is placed on the other rim, the plate coated with carbon or wax on which
the needle point can make the tracing, when the mandible moves in horizontal plane, the pointer
draws characteristic patterns on the plate.
The characteristic patterns created on the recording plate is called arrow point tracing, also
known as Gothic arch tracing.
• The apex of the arrow point tracing gives the centric relation, with the two sides of the tracing
originating at that point being the limits of the lateral movements.
The apex of the arrowhead should be sharp else the tracing is incorrect
Record centric & eccentric relation
Record dynamic relation
Made in well developed ridge and well attached and retentive record block
The graphic methods are either intraoral or extraoral depending upon the placement of
the recording device.
o The extraoral is preferable to the intraoral tracing, because the extraoral is more accurate,
more visible, and larger in comparing with the intraoral tracing.
o Indications
1. Well healed broad edentulous ridges.
2. Adequate interarch space
• Contraindications
1. Severely resorbed ridges
2. Excessively flabby ridges
3. Instability of denture bases due to:
4. Decreased arch space
5. In patients with temporomandibular joint disorders
6. In patients with abnormal jaw relation

Types of tracer
A. Intra oral tracer:
" Tracing plate in the upper wax rim & stylus in the lower wax rim controlled by a locking nut to
be adjusted for patient vertical dimension
Ask patient to move lateral & protrusive movement while stylus contact to plate which carry thin
layer of cording wax
Drill hole at the apex of arrow (result shape from movement) Centric relation)
Seal the block together by hot wire staple
If stylus fixed to lower --
- arrow pointed posteriorly
* If stylus fixed to upper--
--arrow pointed anteriorly
• Disadv-.
--small & invisible during tracing
B. Extra oral tracer:
/ Stylus & plate are outside patient mouth and attached to the rim by metal rod
Adv. :
i. Visible
ii. Can guide patient
iii. Magnified Gothic arch tracing
Disadv. :
i. High weight —----cause tipping (lever)
So should use with well formed ridge

3)Functional generated path (chew-in technique):

• Can make balanced occlusion & record all movement (centric & eccentric) in simple hinge
articulator by using of plaster & pumice record block "only in Essig and Patterson"
A. Needle house technique:
/ Upper & lower block made up from compound at correct V.D.
4 triangular studs of 2mm height are fixed to upper occlusion rim
* Ask patient to move mandible in all directions
4 diamond shape tracing-- The anterior most point of this diamond pattern indicates the centric
jaw relation.
In semi —adjustable articulator
B. Essig & Patterson: (plaster & pumice)
• Upper & lower compound occlusion rim at corrected V.D.
/ Furrow are cut in the center of the upper and lower rim leaving the cuter margin of the
compound (undercut)
r Undercut filled with mixture of plaster & pumice (carborondom) exceeding 1mm
height over occlusal plane
* Ask patient to move in all directions
‹ Patient move mandible till this 1mm over occlusal plane abraded & functional movement
recorded in the portion of plaster & pumice which found in undercut these movements till a
predetermined vertical dimension is obtained.
• The advantage is to record compensating curve:
i. Curve of spee
iii. Curve of wilson
ii. Curve of monsoon
After this----mounting on simple hinge articulator
This only case make balanced occlusion on simple hinge articulator

• All functional methods require:

1. A stable record base. If this record base is dislodged, the record will be inaccurate.
2. Patients must have good neuromuscular coordination to participate in such a recording
procedure
3. Patients must also be capable of following instructions

4) Terminal hinge position by using kinematic (mandibular) face bow:

The terminal hinge axis is the most retruded physiologic hinge position.
The kinematic face-bow is used to locate the center of rotation at the hinge axis and transfer the
mandibular cast to the articulator in accurate relation.
It is generally not used for complete denture construction due to:
Resiliency of the recording base in relation to the bone; making the determination
of the precise location of the rotational centers quite difficult.
o Terminal hinge axis concide with centric relation r Consists of:
o Clutch of the hinge face-bow is attached to the lower occlusion rim.
o Condylar rods adjusted over the skin just adjacent to the palpated condyles
o The patient is instructed to open and close to perform hinge movements till no concentric
arc develops but a true rotation of the rods occur. The point at which the condylar rod is
only rotate (still steady point). It represents the center of rotation of the hinge axis.

> Sources of errors associated with the use of check records

o Early contact in the third molar region displaces the lower block forward and a gap can
be seen between the base plate and the mucosa in the incisor region.
o When a contact of record blocks occurs on one side,
o The compressibility of the tissues provides another source of error.
Any attempt by the operator to push the mandible back into position.
Displacement of the lower block during the registration procedure.
Contact of the heels of the casts.
urate. recording
ce bow:
1ge axis rmination
2-Eccentric relation: (protrusive - lateral)
Condylar path & angle Protrusive record:
Instruct patient to protrude the lower jaw for 4-6mm to record condylar path at midline
‹ Make midline marking on upper & lower to avoid deviation
When protrusion of mandible till edge to edge...
-space will occur between upper
& lower posterior teeth (Christenson's phenomena)
• Soft wax inserted in this space
After hardening of wax--
--measure the protrusive condylar angle & path from
‹ Then give lateral condylar angle from Hanau equation (L= "H/8" + 12 )|
Adjust articulator (semi - adjustable) by this 2 angle by adjusting condylar
guidance
Then setting of teeth with no interference.