Determining an Accurate Starting Point for Restorative Dentistry Thomas R. McDonald D.M.D.

To achieve long-lasting, predictable, restorative treatment, clinicians must start with accurate and repeatable diagnostic records. Complex restorative cases often involve missing teeth, severe wear, mobility, fractured teeth, periodontal problems, TMJ problems, and unstable occlusions. Accurately mounted diagnostic casts can often enable the clinician to quickly unlock the mysteries of these complex problems and simplify the treatment planning process. Additionally, todays modern occlusal instruments can facilitate esthetic analysis and provide templates for anterior restorative-periodontal treatment. Joint Position In recent years there has been considerable discussion over the correct joint position for restorative dentistry. A thorough study of TMJ anatomy will reveal the only repeatable, physiologic position of the joint. Anatomically, when all of the muscles are stripped off of the mandible, the bones fit together in centric relation. Functionally, the large closing muscles contract in a precise direction that seats the joint into centric relation. Physiologically, the positional muscles are inactive during closure, allowing the large muscles to seat the joint into centric relation.1 Tooth contact can have a profound effect on muscle contraction. Studies have shown that removal of posterior tooth contact will cause a tremendous decrease in masticatory muscle activity. 2 Therefore, diagnostic occlusal records must be taken in the absence of posterior tooth contact. Occlusal records Following a thorough TMJ evaluation, recording an accurate centric relation occlusal registration is the most important step in our goal to acquire the proper diagnostic and treatment information. Dawsons bimanual manipulation is the most accurate method to achieve this record.3 Bimanual manipulation allows the clinician to load test the joint and allow the joint to seat into its anatomic position. Due to technique sensitivity, patient cooperation, and experience required, many clinicians have chosen other methods to achieve an occlusal record. The use of the leaf gauge or anterior bite plane in conjunction with bimanual manipulation can provide an acceptable and accurate record. Anterior Bite Plane 1. Place the patient in a supine position. Try in an anterior bite plane (Best-Bite Discluder*). Load the device with silicone putty and place over the upper anterior teeth. Allow the patient to rest the lower teeth against the bite plane for several minutes.

2. Prepare a Delar wax wafer to allow for the anterior bite plane. Register the occlusal record with bimanual manipulation and anterior contact against the bite plane.

Facebow Record The facebow is the most important bridge between the occlusion and esthetic worlds. A properly registered and mounted facebow record will establish the relationship of the upper teeth to the planes of the face as well as the relationship of the teeth to the temporomandibular joint. The Kois Dento-Facial Analyzer (Panadent **) is a simplified facebow device that records the upper teeth at a fixed distance from the axis of rotation (according to established anatomic norms). Its design allows for a precise registration of the facial midline and the horizontal and vertical facial planes. The Dento-Facial Analyzer uses a removable index tray with compound stops to record the position of the upper teeth. The index tray has an anterior stop which places the upper central incisors 100mm from the axis of rotation. The clinician can easily index the teeth while recording the horizontal and vertical planes of the face as well as the position and angle of the facial midline.

Following this recording, the index tray is removed from the Analyzer and placed onto a mounting platform on the articulator (Panadent PCH ). The upper cast is placed onto the tray-platform and mounted. The lower cast is then mounted using the occlusal record.

Now that the casts are mounted accurately, occlusal analysis can be accomplished, wear patterns determined and vertical dimension evaluated. Esthetic analysis can be facilitated by the mounting platform and Analyzer Trays including Golden Proportion Guides.

. The modern restorative practice will include the use of many unforgiving materials including immovable objects (implants) and fragile items (porcelain restorations). Therefore, it is especially important to provide a precise, stable, atraumatic occlusion to ensure longevity of the dentition. An accurate starting point is the key to proper diagnosis and treatment. *bestbite.com **panadent.com Dr. McDonald is a graduate of the Medical College of Georgia in private practice in Athens Georgia. He is a Clinical Instructor of Oral Rehabilitation at MCG and lectures around the country in the areas of occlusion, restorative dentistry, esthetics, and provisional restorations. A Featured Clinician at Hinman 2006, Dr. McDonald will present a full day Occlusion-Esthetics Participation course and a lecture entitled Functional Considerations in Esthetic Dentistry.

Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd edition, St. Louis: The C.V. Mosby Co. 2 Becker I, Tarantola G, Zambrano J, Spitzer S, Oquendo D. Effect of a prefabricated anterior bite stop on electromyographic activity of masticatory muscles. J Prosthetic Dent 1999; 82(1):22-26 3 McKee JR. Comparing condylar position repeatability for standardized versus nonstandardized methods of achieving centric relation. J Prosthetic Dent 1997; 77:280-4
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