Operative dentistry

nln n n _ _ - - - . _ _ _

A diagnostic wax-up technique

Don W. Morgan, D.D.S.,* Martin C. Cornelia, D.D.S.,** and

Robert S. Staffanou, D.D.S., M.S.***
Letterman Army Medical Center, San Francisco, Gaff/.

T h e diagnostic, or preliminary, wax-up has been heralded by many as a mandatory

prerequisite to any extensive restoration of the oral cavity. Many, if not all, remov-
able prosthodontists use the diagnostic wax-up in the form of the wax try-in. Oral
surgeons, with their "plaster surgery," and orthodontists, with their diagnostic casts,
are using the diagnostic wax-up when they section the diagnostic casts and reposition
the segments to determine the optimum position of the anatomic components of the
oral cavity. Proponents of the various gnathologic techniques routinely employ the
diagnostic wax-up in the diagnosis and treatment planning phase of their complete
oral rehabilitation treatment. 1-5
This article is an attempt to bring this valuable and relatively simple procedure
out of the gnathologic archives and into the hands of today's dentist. There will be
no attempt to detail extensively all of the concomitant knowledge and abilities
required for this procedure. It is assumed that all practicing dentists, whether in
genera} or other practice, will possess either the skills or the desire to develop them.
The steps of technique will be amplified with explanations of the goals they are
intended to accomplish. The steps are supplemented by appendices which give
additional details about some of the more intricate parts of the procedure.
PROCEDURE
1. Select the articulator. Select the articulator which is to be used for the final
waxing of the planned restoration. The selection of an instrument should be based
upon the type of restoration contemplated, the patient's mandibular movements, and
the method which is to be used to develop the final occlusal design. The instrumenta-
tion should be limited to an articulator which is fully adjustable, within the

Written in partial fulfillment of the requirements for Residency in Fixed Prosthodontics,

Letterman Army Medical Center.
~Senior Resident, Fixed Prosthodontics, Department of Dentistry.
~¢*Junior Resident, Fixed Prosthodontics, Department of Dentistry.
~¢~Chief, Fixed Prosthodontics Service, Department of Dentistry.
169
 170 Morgan, Comella, and Staff anou j. Vrosthet.
February;Dent.
1975

Fig. 1. (A) A stone diagnostic cast of the maxillary arch. (B) A stone diagnostic cast of the
mandibular arch.

Fig. 2. Casts mounted on the articulator.

capabilities and understanding of the operator, and which will accept the movement
capability of the patient. The articulator selected must be adjusted to the cor-
responding equivalents of the patient's mandibular movements in order to simulate,
as nearly as mechanically possible, those movements. Thus, an occlusal morphology
which will be functional and harmonious with the patient's neuromuscular system
can be developed.
2. Construct and orient the diagnostic casts. Make two sets of accurate diagnostic
casts (Fig. 1, A and B), and mount both sets of casts on the selected articulator
(Fig. 2). One of.the sets may be made of plaster or a plaster-stone mixture to
facilitate the preliminary preparations which will be done on the mounted casts.
Use these casts for the preliminary preparations and diagnostic wax-up. (Note: The
procedure may be more accurate, although slightly more difficult, if both sets of
casts are made of stone.) Use the mounted diagnostic casts (the stone casts) for
 vol,m~ :~3 A diagnostic wax-up technique | 71
Number 2

Fig. 3. (A) Preliminary preparations made on the maxillary stone cast. (B) Preliminary
preparations made on the mandibular stone cast.

pretreatment reference throughout the diagnostic wax-up procedure as well as dur-

ing the actual preparation and final waxing phases of the treatment.
3. Diagnostic occlu'sal adjustment of the mounted casts. Adjust the occlusion of
both sets of mounted casts to provide maximum intercuspation at the recorded and
verified centric relation position:, ~ Perform the occlusal adjustment carefully, and
record these reductions, in order, on a "Grinding List." This list will be used as a
guide to facilitate an equilibration procedure in the mouth, if it is indicated, before
the oral preparation phase (Appendix 1). This diagnostic occlusaI adjustment is
used as an aid to: (1) determine the amount of tooth structure which must be
removed in order to establish maximum intercuspation in centric relation, (2)
establish the positional relationship of the teeth and the dental arches, (g) determine
the desirable occluding vertical dimension, (4) diagnose the requirement for ortho-
donti,z movement to improve the positional relationship of the teeth, (5) determine
the necessity for removing teeth which could endanger optimum prognosis, (6)
evaluate the position and relation of the incisal guidance and its effect on the
distribution of horizontal forces, and (7) establish a "preparation prescription" by
plotting the position of the planned cusps, fossae, and grooves on the teeth which
will serve as an aid in not only the preliminary but also in the final preparation, as
well as in the diagnostic and final wax-up phases (Appendices 2 and 3).
4. Complete the diagnostic preparations. Prepare the stone teeth on one set of
mounted diagnostic casts (preliminary preparations, Step 2, see Fig. 3, A and B).
Plan for sufficient clearance for the travel of opposing cusp tips through their cor-
responding grooves to eccentric positions so as to establish: (1) the proper proximal
and occlusal forms of the final restorations and (2) a harmonious occlusal plane and
compensating curve.
5. Duplicate the diagnostic preparations. Duplicate the casts with the completed
preliminary preparations (Step 4). Use the casts for reference during the intraoral
preparation phase.
6. Gomplete the diagnostic wax-up. Complete the diagnostic wax-up on the
mounted casts (Step 4) using the drop-wax technique as advocated by Dis. Everett
 172 Morgan, Comella, and StaI]anou j. Pfosthct.rebruary,Dcnt.197S

Fig. 4. (A) Completed diagnostic wax-up on the maxillary cast. (B) Completed diagnostic
wax-up of the mandibular cast.

Payne and Peter K. Thomas (Fig. 4). The desired occlusal morphology and proximal
contours of the planned restoration are developed at this point. This is the occlusal
prescription.
7. Duplicate the diagnostic wax-up. Duplicate the completed diagnostic wax-up
in stone (Fig. 5, A and B). Use this cast of the completed occlusal prescription as
an aid during discussions of the treatment plan with the patient. Use it for construc-
tion of an interim restoration (Fig. 6, A to H ) , in conjunction with the preliminary
preparations as a guide during actual preparation, and as a reference during wax-up
of the final restoration.

SUMMARY
A procedural outline has been presented for the accomplishment of a diagnostic
wax-up as a preliminary step to actual preparation of the teeth as suggested by the
proponents of gnathologic techniques. 8, 9 The use of this technique will decrease
the possibility of error in the construction of any extensive fixed partial denture
prosthesis. The success of any procedure requires the willingness of general dentists
and specialists to, "Spend more time planning than doing. ''1°

APPENDIX 1--.PRINCIPLES OF OCCLUSAL CORRECTION 9

1. Protrusive position. Test incisors in edge-to-edge relation. If any bicuspids or
molars contact, remove tooth structure from the buccal cusps of the upper teeth
a n d the lingual cusps of the lower teeth until no contact remains except at the
edge-to-edge position of the anterior teeth. If a lower tipped molar interferes, make
a groove in the distal marginal ridge of this molar for the upper cusp to pass
through. This occurs when the lower tipped molar is distal to the upper molars.
2. Lateral position. Test the cuspid relations in a lateral excursion in tip-to-tip
contact. "Balancing" and "working" are used to denote the respective sides of the
arch.
BALANCING SIDE. If any posterior cusps interfere with or make simultaneous
contact on the balancing side, make a groove in the upper teeth for the lower cusps
 volume:~,'~
Number 2
A diagnostic wax-up technique 173

Fig. 5. (A) The maxillary diagnostic wax-up duplicated in stone. (B) The mandibular
diagnostic wax-up duplicated in stone.

to pass through, and make a groove in the lower teeth for the upper cusps to pass
through. These grooves are sloped mesially from the markings on the upper teeth
and distally from the markings on the lower teeth.
Woar~iNo SLOE. If there is interference or simultaneous contact between the
bicuspids or between molars on the working side in the tip-to-tip relation, remove
tooth structure from the buccal cusps of the upper teeth and lingual cusps of the
lower teeth.
After molar and bicuspid interferences have been eliminated on the balancing
and working sides in the tip-to-tip cuspid relation, the occlusion is tested nearer
the centric relation position. That is, the occlusion is tested just a little inside the
tip-to-tip cuspid relation. At this station, the posterior cusp contacts are eliminated
on the balancing and working sides as dictated by the cuspid tip-to-tip relation.
Successive recordings are taken nearer and nearer to centric relation, and the inter-
ferences are eliminated with each test until the centric relation closure is reached for
one lateral movement.
3. Opposite-side lateral position. Repeat the procedure for the opposite lateral
movement, beginning with the tip-to-tip cuspid relation and gradually working
toward centric relation. T h e eccentric clearances on the posterior teeth should be
sufficient so that no carbon-paper marks are obtainable and the patient cannot feel
contact.
4. Centric relation position. The "centric relation" is adjusted last by having the
patient's head tipped back and by lightly closing the jaw in its rearmost position.
Carbon paper is placed between the teeth, and the patient is instructed to close
from the first contact to full intercuspation. The interferences are removed from
the mesial slopes of the upper teeth and the distal slopes of the lower teeth. After
the sloping contacts are removed, the fossae ark deepened to give the centric-related
intercusping slightly more closure than found in the, former forward intercusping.
Make certain that the patient's intercusping has even presstlre on both sides and
that the bicuspids close simultaneously with the molars. It is necessary to have equal
closure mesiodistally as well as bilaterally. The finished occlusion should have the
maximum intercusping with the jaw in the rearmost, midmost, and uppermost posi-
tion, and any other contact between the upper and lower teeth is r~legated to the
 174 Morgan, Comella, and Staffanou J. Prosthet. Dent.
Februaryi 1975

Fig. 6. Construction of interim restorations. (A) The stone diagnostic east. (B) Preliminary
preparations. (C) The completed diagnostic wax-up. (D) The 0.020 template vacuum formed
over the east of the diagnostic wax-up.

anterior teeth outside the chewing cycle or to ordinary uses of the mandible. After
the bicuspids and molars are relieved of eccentric contacts, the centric relation inter-
cusping can be accomplished because the eccentric relations have been considered.
In waxing or any occ!usal adjustment, test the eccentric relations first to make sure
that centric relation contacts are not destroyed in the eccentric excursions.

APPENDIX 2---REQUIREMENTS OF AN OPTIMUM OCCLUSION

There are many different terms "which have been used to achieve some semblance
of originality to the words "optimum occlusion." These include (but are not limited
to) "ideal," "harmonious," "physiologic," and "organic." We prefer the term
"optimum occlusion" probably for the same reason that Guichet 11 chose it. Optimtim,
by definition, implies the maximum goal achievable under any set of circumstances.
An optimum occlusion must not induce harm (pathogenicity) to any structures
in the gnathostomatic system, to include teeth, supporting and adjacent bone, soft
tissue, and the neuromuscular system.
The establishment of an optimum occlusion includes the reduction or elimina-
tion of any forces acting upon the teeth which are not within physiologic limits.
This is achieved through "planar-point contact" in centric relation. Planar-point
contact connotes a simultaneous, even contact throughout the occlusal plane during
maximum intercuspation (in centric relation). Planar-point contact should exist
on sharp transverse and oblique triangular ridges, with supplemental grooves
(sluiceways) and wide embrasure.space angles to allow food escape. Planar-point
contact should also exist in cross-tooth contacts in order to establish a tripod effect
 Volu.~.~3
Number 2
A diagnostic wax-up technique 175

Fig. 6. (E) The template is filled with temporary resin (see Fig. 6, D). (F) The template
removal and finishing are begun. (G) The completed interim restorations on the stone cast.
(H) The completed and polished temporary restorations.

of each cuspal unit of the restoration. This tripodism is ideally est~iblished with each
functional (stamp) cusp. Where this is not possible, it is mandatory to have at least
one tripod contact on each individual tooth unit for centric stability and optimum
force direction. The criteria for an optimum occlusion are as f011ows-~Z:
1. Everything done must aim toward maximum efficiency with a m i n i m u m of
muscle tension or exertion.
2. The stresses or forces should be directed in line with the long axes of the
teeth. Adverse or lateral forces must be eliminated.
3. The end result should be comfortable to the patient who should be as un-
aware as possible of the actual presence of teeth in his mouth.
4. The teeth should be stable in the dental arches. The teeth should not become
loose nor should they migrate or otherwise change position adversely following
treatment.
5. All of the component elements involved in occlusion should be in harmony.
No single component should dictate or become master over the other components
in any jaw position.
6. A minimum of wear or degeneration and a maximum of health of all
of the elements involved should follow completion of the treatment.
7. Proper contact, contour, and external tooth form should be achieved to main-
tain periodontal health in addition to occlusion per se.
8. A narrow occlusal table should be attempted to better direct the forces over
the long axes of the teeth to improve efficiency in function.
9. The teeth should not be locked into any position; freedom of all excursive
movements is essential.
10. The skeletal arc of closure and the adaptive arc of closure should harmonize.
 176 Mqrgan, Gomella, and Staff cinou j. Vrosthet. Dent.
February, 1975

11. The initial points contact, of:the posterior

teeth, should b e u n i f o r m i n charac-
ter andshould Occur exactly at thee-same-time. No tooth contact should'elther direct
or deflect such'clos~ire.
12: All centric holding cusps should contact their counterparts evenly. Ideally,
the~ buccai cusps of t h e mandibuIffr t e e t h a n d the. lingual cusps of the maxillary
teeth are referred to as the "centric h01dingcusps."
13. This init]al contact should)be :/t multiplicity of small points rather than
large areas: of tooth contact.
141 This initial contact~should occur at the most closed vertical dimension, which
is the established vertical dimension for any pdtient.
15. The teeth should ~be '~free' tO functi0n as 'groups without interference from
another group: ( a ) T h e incisoi, s should be permitted to cut 0r incise very thin
foods, such as lettuc e, without posteiior t o o t h interference;.:(b) the cuspids should
be free to hold or tear foods efficiently: Without posterior o r incisor interference;
and (c) the posterior teeth should shred and grind food efficiently without anterior
interference from either incisors or cuspids.
16. Vertical dimension ~must' permit a physiologic rest position with available
intei'occlusal distance.
17. The anteri0i" teeth must be given consideration to harmonize the occlusion.
The proper lingual concavitF - of the maxillary anterior teeth is an essential in-
gredient along with the interrelationship of tl~e mandibular anterior teeth.
APPENDIX 3---COMPONENTS OF OCCLUSAL SURFACE MORPHOLOGY ~3
The articulating surfaces of posterior teethare composed of occlusal elements.
These elements combine to forrn the. surface morphology fan~iliar, at least empiri-
cally, to every student of dental anatomy.
The elements of occlusal surfaces of molars and premolars are cusps. The cusps
are composed of occlusal elements: These are (1) the cusp tips, (2) occlusal
marginal ridges, (3) triangular ridges, (4) developmental grooves, (5) supplemental
grooves, and (6) the fossae.
The occlusal surfaces of the teeth which come into function during mastication
must also include the buccal, lingual, and interproximal contours. These peripheral
contours are important not only for efficiency in chewing but also for health of
the adjacent soft tissues.
There are two types of triangular ridges. The transverse triangular ridges trav6rse
the surface of the tooth in a generally buccolingual direction. The oblique triangular
ridges lie in a more mesiodistal direction. Components of occlusal surface mor-
phology are: (1) cusps tips, (2) marginal ridges, (3) transverse triangular ridges,
(4) oblique triangular ridges, (5) developmental grooves, (6) Supplemental grooves
(sluiceways for food escapement), (7) fossae, and (8) peripheral contours.

References
1. Mann, A. W., and Panky, L. D.: Oral Rehabilitation. Part I. Use of the Panky-Mann
Instrument in Treatment Planning and in Restoring the Lower Posterior Teeth, J.
PROSTHET. DENT. I0: 135-150, 1960.
2. Stuart, C. E., and Stallard, H.: Principles Involved in Restoring Occlusion to Natural
Volume 33 A diagnostw wax-up technique ]77
Number 2

Teeth, a Syllabus on Oral Rehabilitation, vol. I, San Francisco, University of California,

San Francisco Medical Center.
3. Stallard, I-I., and Stuart, C. E.: Eliminating Tooth Guidance in Natural Dentitions, J.
PROSTnE'r. DENT. 11: 474-479, 1961.
4. Stuart, C. E.: Why Dental Restorations Should Have Cusps, J. PROSTHrT. DENT. 10:
553-555, 1960.
5. Brayley, B. V.: A Preliminary Wax-up as a Diagnostic Aid in Occlusal Rehabilitation,
J. PROSTrIET. DENT. 16: 728-730, 1966.
6. Needles, J. W.: Mandibular Movements and Articulator Design, J. Am. Dent. Assoc. 10:
927-935, I923.
7..Lucia, V. O.: A Technique for Recording Centric Relation, J. PROSTrtET. DENT. 14: 492-
505, 1964.
8. Mann, A. W.: Examination, Diagnosis, and Treatment Planning in Occlusal Rehabilita-
tion, J. PROSTHET. DENT. 17: 73-78, 1967.
9. Stuart, C. E.: Occlusal Acljustment. Unpublished paper.
10. Thomas, P. K.: Personal communication, March 23, 1974.
I1. Guichet, N.: Occlusionma Collection of Monographs, Anaheim, Calif., 1970, The Denar
Corporation, p. 23.
12. Huffman, R. W., Regenos, J. W., and Taylor, R. R.: Principles of Occlusion, Laboratory
and Clinical Teaching Manual, Columbus, Ohio, 1969, The Ohio State University,
p. l-A-15.
13. Stuart, C. E., and Stallard, H.: Good Occlusion for Natural Teeth, Oral Rehabilitation
and Occlusion Syllabus, vol. II, San Francisco, University of California, San Francisco
Medical Center.

DR. M O R G A N
DENTAL C O M P A N Y M E D D A C
FORT LEONARD WOOD, Mo. 65473

DRS. COMELLA AND STAFFANOU

LETTF~RMAN A R M Y MEDICAL CENTER
PRESIDIO OF SAN FRANCISCO, CALIF. 94129