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Establishing jaw relation and occlusal relationships for removable partial denture

BY DR SALAH HEGAZY

: :

 The desired occlusal scheme of the removable partial denture may vary from that of a complete denture( bilateral balanced occlusion) to that of a fixed bridge. The decision is made upon: A) The number and distribution of remaining teeth. B ) The existing periodontal conditions C) The type of occlusion in the opposing arch.

 Establishing the jaw relation is necessary if the opposing casts cannot be accurately hand articulated or if the denture is being constructed at the centric jaw relation position. It must be needed following the corrected cast impression procedure because the lack of posterior occlusion in class I & II partial edentulous arches.
When occlusal relationships are established to position the artificial teeth correctly, the vertical and horizontal components of the jaw relation are equally important.

Components: V.R.& H.R . Methods of Establishing occlusal relationship: 1.Function generating path tech. 2.Articulator or static Tech.; a. Direct opposition of casts( hand articulation) b. Occlusal relations using occlusal rims c. Jaw relation record by using frame work d. Complete upper and class I lower RPD

 Adequate tooth number vs. Inadequate tooth number Interocclusal Record to support the bite registration materials

[C] Establishing vertical dimension of

occlusion:
Indications:

1- complete denture opposed RPD.

2- lost all posterior teeth in one or both arches. Procedure: by measuring V.D of rest and then subtracting 3 mm (amount of free-way space).

I - Vertical jaw relation:

[A]

Vertical dimension:

Two vertical dimensions are recognized for each patient:

-Vertical dimension of rest is taken when the patient is in an upright position and is completely at rest. -Vertical dimension of occlusion V.D is measured when the teeth contact in maximum intercuspal relationship.

- Free-way space the space between the teeth when the mandible is in its resting stated, it's about 2-4 mm.

[B] Altering the existing vertical dimension of occlusion:

- The

prosthesis should be constructed at vertical dimension of occlusion, if the natural teeth in opposing arch contact in centric occlusion.

-Changing the V.D of occlusion should be considered only if the vertical dimension of occlusion has been diminished.

Signs and symptoms of diminished V.D of occlusion:

Symptoms such as: 1- Severe tooth wear 2- Tired aching muscle. 3-Unexplained pain in the head and neck. 4-Appearance of premature aging caused by a shortened nose-chin distance. Objective sign indicates loss of V.D in excessive free-way space (i.e. more than 4 mm).

 Signs:
1- If the occlusal surfaces of the teeth have been worn excessively, it will not indicate that the V.D of occlusion is lessened because a compensating eruption of the teeth usually maintains the proper V.D. 2- Also extreme anterior vertical overlap in which the mandibular teeth strike the soft tissue of the palate. In these cases, no treatment needed to correct the V.D of occlusion without more definite proof that the loss of V.D has occurred. Cephalometric examination confirming migration of condyles and greater than 4 mm free-way space indicate loss of V.D.

Prosthetic management for increase the existing V.D:

-Increase in interocclusal height must be accomplished with a temporary removable appliance (occlusal overlay). It's normally more convenient to construct the appliance to cover the maxillary teeth (to avoid interference with the tongue movement if cover mandibular teeth). -All remaining teeth in both arches must be contacted by the prosthesis otherwise: 1- Teeth which do not contact by appliance tend to erupt. 2- If sufficient number of remaining teeth do not contact, the appliance, the supporting teeth will be submerged to an infraocclusal position .

 -Encroaching (obliteration) the free-way space by prosthesis the person may refuse to wear the appliance.
Or if he wears the appliance either depressing the supporting teeth to reestablish the free-way space.

or destruction of supporting alveolar bone with loss of teeth.

 -Temporary appliance is used several months (usually 3 months) followed by permanent RPD. -When permanent treatment is begun, it must be planned so that all occlusal-dimension restoring prosthesis, fixed and removable are inserted at the same time. Crown and fixed partial denture should never be inserted before the construction of RPD to avoid destruction of the supporting tissue of teeth that maintain the V.D by crown or fixed restoration.

II - Horizontal jaw relation:

Two horizontal relationships of the mandible to maxilla are important in the occlusion of partial denture. Centric relation bone to bone relation. It's repeatable, reliable position. Centric occlusion tooth-to-tooth relation. It's learned habitual closure. In more than 90% of all persons, centric relation and centric occlusion do not coincide. Centric occlusion was always be anterior 1 to 2 mm to centric relation.

Factors influencing development of occlusion:

Several factors influence the occlusal scheme for RPD purposed by Hanau known as Hanau quint: Condylar guidance X incisal guidance= Compensatory curves X Inclination of occlusal plane X Cusp Height

 In complete denture, compensating curve, plane of orientation, incisal guidance and height of cusp may be changed. The only factor that cannot be altered is the condylar guidance; therefore development of occlusal scheme for C.D is easily developed (i.e. anatomic or non-anatomic teeth may be used).

 In partial denture, prominence of compensating curve, plane of orientation and incisal guidance and height of cusp are determined by the presence of natural teeth; therefore the form of artificial teeth is detected by the natural one.

Methods of establishing occlusion:

There are basically two methods of establishing the occlusion of RPD: Functionally generated path technique. The articulator or static technique.

A ] Functionally generated path technique:

.All functional movements of the mandible are recorded

on hard wax occlusion rim. The record represents the pathways of each tooth opposed to edentulous space. The artificial tooth is positioned and formed to make harmonious contact with its antagonist at all times 1. Acrylic record base is attached to framework then construct hard inlay wax (purple) occlusion rim.

2. If occlusal contact between opposing natural teeth fail to maintain the vertical dimension of occlusion record this V.D (V.D of rest 3 mm).

3. Occlusion rim is constructed so it's slightly higher (keep the remaining teeth apart about 0.5 mm) and wider than the width of opposing tooth to record full range of functional motion. 4. Patient continuously wear the framework and occlusion rim for 24 hours except during eating and drinking. 5. The framework with function generating path occlusion rim (wax pattern) reset in master cast. 6. The wax pattern is poured in hard stone to produce stone record.

7. The stone record and master cast with function generating path occlusion rim is mounted on the articulator, the incisal guide pin is opened 1 mm before the artificial teeth are positioned. The increase in V.D will return to normal by selecting grinding the artificial teeth. Using water-soluble Prussian blue dye paint the surface of stone record. 8. Selective grinding is made on articulator in open and close movement only (i.e. articulator is locked in centric relation). The articulator is not moved into protrusive and lateral because these positions are incorporated in the pathway.

Limitations to use the generating path:

The occlusion in one of the arches must be completed before the generated path can be developed (one PD constructed before the other can be made).

PD against complete denture Here complete the partial denture by articulator method and functional generating path for CD.

 Disadvantages: Movement of distal extension base carrying the occlusion rim is possible produce inaccurate pattern of path. The pattern (path) developed in the wax is accurate for wax only but not for food stuffs (as masticatory cycle depend on the type and texture of food). Advantages: Elimination of the use of tracing device. Elimination of the use of face-bow transfer

B ] Articulator technique:
a.Direct apposition of casts [Hand articulation]: When hand articulation is used, tooth position can be determined by occluding the model together (i.e. when sufficient opposing teeth remain in contact to make the existing jaw relationship. It should be used when only a few teeth are to be replaced. The occluded casts are secured together with wooden sticks and sticky wax and mounted arbitrarily on an articulator. No face bow is used.

b. Occlusal relation using Occlusion rim:

The mandibular distal extension occlusion rim may be constructed so that the height will be even with cusps of the adjacent abutment tooth anteriorly and posteriorly to the height of the retromolar pad.

 Clinical procedure:
[A] When the vertical dimension is maintained by occlusal contact of several standing teeth in both jaws and the tooth position cannot be determined by occluding the models together centric occlusion has been selected as the proper jaw relation. 1. The height of the occlusion rims must be adjusted so that no contact takes place between opposing occlusion rims or between rim and opposing teeth. A space of approximately 1 mm is desired.

2- If opposing occlusion rim is to be used one of these, usually mandibular rim is adjusted to establish an ideal occlusal plane [because the landmarks that are normally present. The posterior height at of retromolar pad and anterior height to the height of remaining teeth] and the opposing maxillary rim adjusted to short of contact.

3. If opposing occlusion are to be used. The recording medium is placed on the mandibular rim. The maxillary rim should be indexed with several v-shaped notches. 4. The surface of occlusion rim that support the recording medium should be roughened to ensure that the record will remain attached to it. 5. If any portion of the wax occlusion rim shows through the recording medium indicates that incorrect jaw relation as any force occur in the occlusion rim, the distal extension base will depress the soft tissue beneath the base relief the portion of the occlusion rim and the

Project 1: Record Bases & Wax Rim

Clinical Implications: To evaluate and record the proper VDO and CR position when the remaining dentition is not adequate enough to support the bite registration material

Model #1

Model #3*

Use your eyes to estimate the correct path of insertion. Then use small amount of wax to block out the undercut.

Minimum Wax Block Out

Where?
Teeth: marginal gingiva, proximal surfaces, and embrasures Soft tissue: gross undercut

Why? To obtain a stable and retentive record base and yet avoid the damage on the cast

Apply the separating medium Wait for the first coat air dry, then apply the second coat.

Round, smooth, and polish the record base

Before adding the wax rim, roughen the acrylic surface for mechanical retention

Record base extension: 2-3 mm short of vestibule

Record base extension: 2-3 mm short of vestibule

Record base extension next to the teeth: R Avoid the extend toward to e the tooth

Record base: 2-3 mm thick Do not overextend

Extend the record base onto the proximal, palatal/lingual surfaces of the teeth to enhance the retention, stability, and support of the record base

Keep the space for the bite registration material

Bite registration materials:

ZOE bite registration paste Wax Compound Silicone

Selectively adding the wire clasps can improve the retention & stability of the record base for accurate jaw record

Record base & wax rim Stable Good support Rigid Comfort

Accurate interocclusal record

c. Jaw relation record made by using the framework: It's used if tooth position cannot be determined by hand articulation. If jaw relation appointment follow the construction of an altered cast. 1. It's advisable before removing the framework to examine the relationship of the framework to teeth on the cast. Be sure that the occlusal rests and other components of the framework did not move during pouring the cast. If any change in position of the framework was evident repeat the alter impression.

2. Acrylic tray should be removed from the framework by heating the tray material over a burner until it starts to smoke and then pulling it by pliers. Making the record base: 1. If the edentulous space is not too long hard base plate wax may be used as a record base [it should be formed over the acrylic resin retention metal in contact with edentulous ridge]
Autopolymerized acrylic resin should be used to construct the record base if the edentulous ridge is long or if the interarch space is restricted.

2. Soft tissue undercuts on the edentulous ridge must be blocked with baseplate wax to avoid damaging of the master cast when the acrylic record base is used.
2. Tissue stop under acrylic resin retention minor connector will not contact cast following making of altered cast to prevent framework from being moved during record base construction or prevent the framework from being disturbed during packing of denture base, bead of auto polymerizing resin is placed between tissue stop and stone ridge and allowed to set before the record base is adapted.

Complete upper and class I lower RPD:

The vertical dimension of occlusion is determined by rest V.D 3mm. Establishing the centric relation. Centric recording medium for seating the occlusion rims together.

The upper cast mount of the articulator using face-bow and the lower are using centric interocclusal record.

 Protrusive interocclusal record is used to adjust horizontal condylar guidance.

Lateral condylar guidance is adjusted by the following Hanau equation: L= H/8 +12
The teeth are set in balancing occlusion.