Functional Occlusion Online Manual

FUNCTIONAL
OCCLUSION
ONLINE
“Whatever You Vividly Imagine, Ardently Desire, Sincerely Believe, And

Enthusiastically Act Upon... Must Inevitably Come To Pass!”
Paul J. Meyer

No part of this handout may be reproduced without written permission from
Dr. Stephen Phelan

www.phelandentalseminars.com
drsphelan@me.com
1-800-964-1619
FUNCTIONAL OCCLUSION
ONLINE
DAY 1

Paul J. Meyer

Dr. Stephen Phelan

drsphelan@me.com
1-800-964-1619

Copyright © Phelan Dental Seminars - All Rights Reserved 2
Functional Occlusion Online
Day 1

This seminar could be called Practical Occlusion Online.

SPEED OF IMPLEMENTATION

"The difference between an ordinary business and a extraordinary business is
implementation."
Bill Glazer

If you implement what you learn in this seminar and start in the next month it will
change your practice permanently!

I believe you need systems for treating complex cases.

The primary goal of this program is to teach you Foundational Occlusion Systems
that you can implement right away in your dental practice.

PEOPLE WHO HAVE INFLUENCED MY OCCLUSAL
PHILOSOPHY

Dr. Peter Dawson
Dr. John Kois
Dr. Frank Spear
Dr. Jimmy Eubank
Dr. Jeff Morley

Steve Jobs said something that I think is brilliant:

He said that you have to go out and expose yourself to the best of what others have
done, and then bring some of it back and add it to what you’re doing.

Mastery takes time and effort to develop skill.

There is no short cut for hard work.


Anterior Determinants of Occlusion

The two anterior determinants of occlusion are overbite and overjet and their
interaction produces the anterior guidance.

Overbite: The vertical relationship of the incisal edges of the maxillary incisors to
the mandibular incisors when the teeth are in maximum intercuspation.

Overjet: The projection of the teeth beyond their antagonist in the horizontal plane.

Anterior Guidance: The influence of the contacting surfaces of the anterior teeth on
mandibular movements.

Protrusive Guidance: Disclusion of the posterior teeth in the anterior excursive
direction by the cuspids and incisors, often referred to as incisal guidance.

Canine Guidance: Disclusion of the posterior teeth in the lateral excursive direction
by the cuspids.

Designing Anterior Guidance Patterns

Guidance Pattern Designs

1. Balanced Occlusion
2. Group Function
3. Cuspid Guidance
4. Anterior Group Function

Balanced Occlusion

The fully balanced occlusion design is very difficult to achieve in a reconstruction. It
is a little easier to achieve in a TMJ splint because the surfaces can be made really
flat. This can help support the joint in a patient with TMJ problems.

Group Function

The group function occlusion design is not intentionally used in a reconstruction if
you are trying to achieve force management.
It has been shown to increase the muscle activity and bite force, especially if you
have non-working or balancing side contacts.


Cuspid Guidance

The cuspid guidance occlusion design is the easiest and most common design for a
reconstruction if you are trying to achieve force management.
It has been shown to decrease the muscle activity and bite force and it is the easiest
to design and create on a semi-adjustable articulator with a facebow.

The problem with the cuspid guidance occlusion design is all the forces are placed
on the cuspids. This can be an issue if the patient has a high risk profile with large
muscles, high bite force and bruxism.

I would NOT USE cuspid guidance for the following cases:

1. High risk profile; large muscles, high bite force, deep overbite, bruxism
2. Structurally compromised cuspids
3. Mobile or periodontally compromised canines
4. Cuspid implants
5. Cuspid pontics

The ideal occlusion design will have the shallowest angle of anterior guidance
capable of discluding the posterior teeth in all mandibular movements.

Anterior guidance has an inhibitory effect on the elevator muscles and posterior
interferences or guidance can generate higher elevator contraction forces and
uncoordinated muscle activity.

Dental Literature

It has been shown that cuspid guidance has an inhibitory effect on the temporalis
and masseter muscle contraction. Posterior tooth contacts in lateral excursions
override this inhibition.

The problem is that with bruxers you can decrease the number of bruxing episodes
but you will not eliminate them.

Anterior Group Function

The anterior group function occlusion design is a great option for a reconstruction
when traditional cuspid guidance is not ideal.

I will typically distribute the guidance on the six anterior teeth if they are all healthy
and solid. In some cases I avoid building the guidance on the lateral incisors. In
some cases we build the guidance on the first bicuspids as well.

What is the angle of the guidance?

As the angle of guidance rises, the degree of force placed on the teeth also rises.
Ideally you would like to use the anterior guidance that is the shallowest one
capable of clearly discluding the posterior teeth.

J Prosthet Dent. 1983 Jun;49(6):816-23.
Anterior guidance: its effect on electromyographic activity of the temporal and
masseter muscles.
Williamson EH, Lundquist DO

The flatter the angle of guidance the lower the muscular activity.

Dental Literature

For every 10 degrees the angle of guidance increases, You place 32% more force or
stress on the head of the implant fixture.

The ideal occlusion design will have the shallowest angle of anterior guidance
capable of discluding the posterior teeth in all mandibular movements.

Anterior guidance has an inhibitory effect on the elevator muscles and posterior
interferences or guidance can generate higher elevator contraction forces and
uncoordinated muscle activity.

Posterior Determinants of Occlusion

There are six posterior determinants of occlusion and the first three cannot be
modified and the last three can be modified.

Intercondylar Distance: This does not have a significant impact on the occlusion
and most articulators are fixed with an average value of 110 mm.

Condylar Guidance: The path and angle developed by the condyle moving
anteriorly. Anatomical studies show this angle is always greater than 25 degrees
which influences the set-up of the articulator.

Bennett Angle: The angle at which the NWS condyle moves away from the sagittal
reference plane when viewed horizontally.

Curve Of Spee: The anatomic curvature of the occlusal alignment of the teeth,
beginning at the tip of the lower canine, following the buccal cusps of the natural
premolars and molars and continuing to the anterior border of the ramus.


Curve Of Wilson: The curvature of the cusps of the teeth as projected on the frontal
plane. That of the mandibular dental arch is concave and that of the maxillary dental
arch is convex.

Occlusal Plane: The plane passing through the occlusal or biting surfaces of the
teeth. It represents the mean of the curvature of the occlusal surface.

The Occlusal Plane from the frontal perspective should be parallel to the inter
pupillary line or the horizon. This perspective has important aesthetic implications.

The Occlusal Plane from the sagital perspective should rise posteriorly but not be as
steep as the condylar plane. This perspective has important functional implications.

If you design the Occlusal Plane too flat relative to the guidance, you have the
potential to develop posterior interferences.

In cases with a flat occlusal plane and guidance you will need to build a flatter
posterior tooth anatomy and shorter cusps.

KEY CONCEPT FOR OCCLUSAL THERAPY

Not every patient that has what looks like an unstable occlusion needs to be treated.
Some patients with a poor looking occlusion are in fact stable and do not have any
signs of instability because of the way they use their teeth. These patients often have
a more vertical chewing pattern with no parafunction and frequently sleep with
their mouth open.

ONLY THE PATIENT LACKING STABILITY NEEDS TREATMENT!

TRIAD OF STABILITY


REQUIREMENTS FOR EQUILIBRIUM OF THE MASTICATORY
SYSTEM

1. Stable, comfortable TMJ’s that can be loaded.
2. Anterior guidance is in harmony with the functional movements of the

mandible (the envelope of function) and the way the patient wants to chew.
3. Non-interfering posterior teeth with an equal distribution of contacts.
4. The patient has the ability to locate a comfortable and repetitive chewing
position .
5. The teeth are firm with no mobility, no excessive wear relative to age and have
healthy periodontal and pulpal supporting structures.
6. All the teeth are in harmony with the neutral zone and the masticatory
muscles.
7. Coordinated and pain free masticatory muscle function.

KEY CONCEPT

If your patient has firm teeth with no mobility, no excessive wear, and they stay in
the correct position with no joint or muscle pathology with a negative load test, the
occlusion is stable.

KEY CONCEPT

You need to find a functional equilibrium for your patient to work within their
individual adaptive range.

What is the starting point for patient treatment when you
are planning an occlusal change?

We always start with comprehensive diagnostic records!

COMPREHENSIVE DIAGNOSTIC RECORDS

The quality of your diagnostic records will influence every step that you take going
forward with the case.


"Be a yardstick of quality. Some people aren't used to an environment where
excellence is expected."

Steve Jobs

In my practice the case cannot be started without these records.

The objective of the comprehensive diagnostic records appointment is to determine
which patients are safe to treat and which patients you should delay treatment or
refer.

“I am going to examine 4 areas of your mouth today.”
Your Bite
Your Gums
Your Tooth Structure
Your Smile

COMPREHENSIVE DIAGNOSTIC RECORDS

1. Digital Photo Series
2. Complete Exam
3. Functional Analysis
DIGITAL PHOTO SERIES

There are a total of 20 images in my digital photo series.
Remember that after you start the preparations you will never have another chance
to take the before images!

COMPLETE EXAM

Periodontal Probing and Charting, Oral Cancer Screening, etc

Functional Analysis System

The second objective of the functional analysis is to create accurate mounted
study models for your patient.

THE FUNCTIONAL ANALYSIS PROTOCOL

This is the list of procedures that will need to be completed while the patient
is in the office.

1. Facial Pain and TMJ Questionnaire
2. Muscle Examination
3. Range Of Motion Testing
4. Doppler Examination
5. Joint Examination
6. Bite Records, Study Models and Facebow
7. Dental Examination
8. Periodontal Examination
9. Esthetic Examination
10. Radiographic Examination

After the patient has completed these procedures in the office you will then need to
mount the case on the articulator and complete the model analysis on the mounted
models. You will then gather all of your records to complete the risk assessment and
treatment plan for your patient.

FACIAL PAIN AND TMJ QUESTIONNAIRE

You need to be able to evaluate the jaw joint and determine if it is stable and safe to
finish complex dentistry for this patient. This questionnaire will help you start your
evaluation.

FUNCTIONAL ANALYSIS

The bottom line is that you want to evaluate what needs to be done to make the
occlusion work for the desired esthetic treatment plan.

MUSCLE EXAMINATION

Muscle can be an important source of pain in patients with occlusal dysfunction and
complex dental needs. In most of these patients I feel it can be managed with
occlusal therapy and will not prevent me from treating them.

Coordinated muscle function requires the correct timing of the contraction of the
pulling muscle with release of the opposing muscle. The goal of our treatment is a
peaceful neuromusculature, which is only possible with coordinated muscle
function.

There is often a relationship between premature occlusal contacts and elevator
muscle hyperactivity.

The lateral pterygoid muscle cannot be palpated so you need to test it by provoking
it. The best method to provoke this muscle is with the leaf gauge.

RANGE OF MOTION TESTING

Two factors limit normal R.O.M
a) Muscle Contraction
b) Joint Problems

Look for smooth, symmetrical, non-limited movement with opening, left, right, and
protrusive.

RANGE OF MOTION SHOULD BE TESTED IN 4 WAYS

1. Maximum Opening Before Discomfort Occurs
Have patient open as wide as possible until discomfort occurs. When discomfort
before a normal maximum opening is completed it is usually indicative of muscle
incoordination. Discomfort at minimal opening may be either muscle incoordination
or an intra-capsular problem.

2. Maximum Opening
Normal range of opening is 40 mm or more. A wider opening does not indicate a
problem. Opening range varies with the size of the patient and the mandible.
Conversely, a reduced range in opening, the more likely the problem is intra-
capsular, but extremely restricted openings of less than 10 mm can be observed in
trismus patients with no intra-capsular problems.

You will likely need an MRI of the joint to determine if a patient with a significant
limitation of opening is a disk or a muscle problem. You could try and prescribe to
them a muscle relaxant and see if the limited ROM improves but you will not be
doing any dentistry until a diagnosis is made.

3. Protrusive Range
Normal protrusive range is approximately 10 mm.

4. Range Of Lateral Movement
Measure the maximum distance that the jaw can move to the right or to the left
starting at the position of the lower incisor midline. Normal range is approximately
10 mm.

DEVIATION FROM NORMAL PATHS

1. A sharp deviation at the beginning of opening indicates probable disk
derangement on the side toward which the jaw shifts.
2. A gradual shift to the side on opening indicates probable muscle incoordination.

You will likely need an MRI of the joint to determine if a patient with a significant
limitation of opening is a disk or a muscle problem. You could try and prescribe to
them a muscle relaxant and see if the limited ROM improves but you will not be
doing any dentistry until a diagnosis is made.


PATIENTS WITH MUSCLE SYMPTOMS

Most patients that have muscle palpation tenderness and/or range of motion issues
and muscle incoordination have occlusal dysfunction and will have some form of
occlusal treatment with appliance therapy and/or a bite adjustment.

DOPPLER EXAMINATION

Doppler auscultation is an excellent non-invasive method for analysis of the joint.
Healthy joints with no displacement of the disk elicit very little to mild sounds of
crepitation when tested with the Doppler.

If the patient is load testing positive you can listen to their joint with the Doppler to
see where the medial pole of the disk is and if it is place. If the Doppler indicates the
disk is in place the load testing result is likely the lateral pterygoid muscle and you
can try and deprogram them with the lucia jig.

To check the medial pole you will want to see if the Doppler is quiet on rotation. To
check the lateral pole you will need to listen to the Doppler in a translational
movement.

We will also listen for a click and the timing of the click and note if the patient is
having pain with any of these movements. If you hear a click the joint is reducing
and recapturing the disk.

JOINT EXAMINATION

If the patient is at all difficult to manipulate you likely need a leaf gauge to make the
CR bite records and you may want to use an appliance to deprogram them prior to
final restorative treatment.

IF LOAD TESTING with THE leaf gauge IS POSITIVE

1. Anterior disk displacement or another form of intercapsular or TMJ disorder.
2. Lateral pterygoid muscle tension or spasm.

Bite Records: Foundation and Literature Review

The first objective of the functional analysis is to determine which patients are safe
to treat and which patients you should delay treatment or refer.

The second objective of the functional analysis is to create accurate mounted study
models for your patient.

WHEN TO USE CENTRIC RELATION

I use CR when I am treating patients with muscle pain and an unstable bite. I use it
as a position to equilibrate the occlusion to that is reproducible and comfortable.

I also use CR when I am treating patients with complex dentistry and large
rehabilitations as a consistent position to create the bite records that is also
reproducible and comfortable.

I also use CR for veneer cases when the functional analysis reveals an interference
with a slide that would be detrimental to the new porcelain restorations.

Oper Dent. 2000 May-Jun;25(3):234-6.
Techniques in recording centric relation.
Hartzell DH, Maskeroni AJ, Certosimo FC.

Muscle seated centric registration is a reproducible method of obtaining centric
relation (Wood, 1994). The muscle-seated CR record provides a consistent, accurate,
less technique-sensitive CR record of condylar position.

LEAF GAUGE

I like the Leaf Gauge because it is very simple and easy to use, easy to find the initial
point of contact, and easy to construct reproducible bite records with this appliance.

CENTRIC RELATION

Wikipedia Definition

In dentistry, centric relation is the mandibular jaw position in which the head of the
condyle is situated as far anterior and superior as it possibly can within the
mandibular fossa/glenoid fossa.

It is a physiologic position that is used for reproducibility. The Temporomandibular
Joint is not restricted to Centric Relation in function. At the most superior position,
the condyle-disc assemblies are braced medially, thus centric relation is also the
midmost position.

A properly aligned condyle-disc assembly in centric relation can resist maximum
loading by the elevator muscles with no sign of discomfort. It also allows for the
most repeatable and recordable position and therefore should be used when
designing an appropriate occlusion.

J Prosthet Dent 2004 Feb;91(2):171-9.
The effect of clenching on condylar position: A vector analysis model.
Radu M, Marandici M, Hottel TL.

The stable equilibrium was found in the anterior-superior position in the fossa.
CONCLUSION: Within the limitation of this study, vector analysis suggested that the
anterior-superior position of the condyle-disk assembly on the eminence was the
most stable equilibrium position. All other tested positions of the condyle were less
stable and maintained at the expense of other structures.

Dent Clin North Am.1979 Apr;23(2):169-80.
Centric relation. Its effect on occluso-muscle harmony.
Dawson PE.

If centric relation is not properly located, occlusal interferences will remain
regardless of what procedures are used to record or adjust excursive movements.

KEY CONCEPT

Centric relation is the only condylar position that you can build an interference free
occlusion in all head posture positions for the patient.

CENTRIC RELATION

The mandible will change its position depending on the patients head posture.
When the head is reclined the mandible will posture back and the condyle will seat.
When the head is upright the mandible postures slightly forward and when the head
is tipped forward, the mandible will posture down and forward.

Centric relation is not about putting the patient into this position; it is about
eliminating the interferences that keep the condyle from going into it and allowing
the patients own muscles to seat the condyle in CR.

With the anterior only contact (like the leaf gauge, lucia jig or anterior
deprogrammer) the posterior teeth cannot keep the condyle out of centric relation.
The only muscle keeping the condyle from centric relation is the lateral pterygiod
and it is fighting all of the elevator muscles, which want to seat the condyle into
centric relation.

J Prosthet Dent. 2005 Oct;94(4):389-93.
Comparing condylar positions achieved through bimanual manipulation to condylar
positions achieved through masticatory muscle contraction against an anterior
deprogrammer: a pilot study.
McKee JR.

The results of this pilot study indicate that, without influence from occluding teeth,
the contraction of the masticatory muscles places the condyles into the same
position as centric relation.
The key is to allow the lateral pterygiod muscle to relax.

HOW TO VERIFY THAT YOU ARE IN CENTRIC RELATION

1. Load test with no tension or tenderness.
2. Repeatable 1st point of contact.
3. Repeatable bite records.

When you place the leaf gauge, have the patient move forward, back and squeeze
and if they have no tension or tenderness (load test negative) they are in centric
relation. This patient is safe to treat and you can take your diagnostic bite records.

If the patient has significant joint pain with the leaf gauge, refer the patient for joint
films and an evaluation with an oral surgeon or joint specialist.

The patient may have an internal derangement of the TMJ or some other form of
joint condition that should be evaluated. These patients should not be treated with
restorative dentistry until the TMJ is stable and can accept a load (load test
negative).

If the patient has tension with the leaf gauge you can have the patient squeeze on
cotton rolls between the molars to have the elevator muscles break the lateral
pterygoid muscle spasm.

If the patient still has some level of tension in the jaw muscles after 15 to 20 minutes
of deprogramming they will need a longer period of deprogramming with the Lucia
jig, a Kois deprogrammer, an Anterior bite plane or another type of deprogrammer
such as the NTI.


Fenlon MR, Woelfel JB.

Condylar position recorded using leaf gauges and specific closure forces.
Leaf gauges resulted in displacement of the condyles in a superior direction with
little anteroposterior movement

Anterior Deprogrammers

J Prosthodont.1999 Mar;8(1):59-61.
Centric relation registration using an anterior deprogrammer in dentate patients.
Hunter BD 2nd, Toth RW.

A technique is described for registering centric relation in dentate patients using an
anterior deprogrammer to prevent muscle splinting. Properly executed, the patient
is able to close into centric relation unassisted, eliminating the possibility of
operator-induced error associated with commonly accepted manipulative
techniques.

I would recommend that you use an anterior deprogrammer if the tension or
tenderness persists and you want to deprogram the lateral pterygoid muscle.

I would also recommend you use an anterior deprogrammer when you take 2
different centric relation bite records and they DO NOT MATCH.

The concept of how these appliances work is that by keeping the posterior teeth out
of occlusion you have decreased muscle activity and you allow the lateral pterygoid
muscle to relax and the condyle seats in the fossa.


Option #1
Chairside Lucia Jig

I like to use the Lucia jig when the patient is having some lateral pterygoid tension
with the leaf gauge.

Some patients will develop a slight lateral pterygoid tension in the leaf gauge that
will go away if you switch them to a lucia jig. This seems to be due to the flat
platform of the lucia jig that is parallel to the upper occlusal plane. You cannot easily
locate the point of initial contact with the lucia jig.

OPTION #2
Kois Deprogrammer
TWO TYPES OF PATIENTS I WOULD AVOID TREATING

1. Patients that have a positive load test even after an attempt to deprogram them
with a lucia jig, or a Kois or anterior deprogrammer.
2. Patients who have an occlusion that is changing. For example an anterior or

posterior open bite is developing.
At this point with the history, examination, bite records, and load testing, you
should be able to identify these patients.

FACEBOW TRANSFER

Preparing and Placing the Axioquick Facebow Using the
Axiomatic® Transfer Fork Assembly

1. Attach blue disposable earpiece caps to black earpieces with flat surface
positioned anterior.
2. Attaching the transfer fork assembly to facebow: At the top of the transfer fork
assembly, there is a black portion with a dovetail slot. On the underside of the
facebow, there is a black dovetail slide. The transfer fork assembly is attached
to the facebow by guiding the dovetail slot onto the dovetail slide. The assembly
will be securedonce it contacts the small silver pin at the end of the slide.
Tighten screw.
3. Attach the nasion relator (with interpupillary line leveling rod) to the facebow,
making sure it is fully retracted. Use the guide pins to ensure that the nasion
relator is centered.
4. Prepare the bitefork with compound bite tabs:
a) Place tabs on bitefork (as shown in photo).

b) Immerse the bitefork with tabs in water heated to 58ºC (135ºF) for 2
minutes.
5. Place the bitefork on the maxillary arch to obtain imprints.
* Note: Make sure the bitefork is centered.
6. Remove bitefork and chill tabs in cool water. Confirm that teeth fit imprints and
fork is stable.
Seating the Facebow

The SAM Axioquick Facebow can be positioned automatically parallel to
the interpupillary line when you follow these instructions:

1. Hold the facebow with the thumb and index finger opposite the covered
earpiece. Position the earpiece into both ear canals equally blocking hearing.
Move the earpieces superiorly and firmly inward into the small boney
depression. The patient’s hearing should now beunobstructed.
2. With the patient holding the facebow opposite the earpieces, gently position the
Nasion Relator AX into light contact with nasion to establish a horizontal plane.
Use the interpupillary line leveling rod to verify that the facebow is parallel to
the interpupillary line. Tighten nasion screw.
3. Holding the clamp assembly in one hand, use the other hand to tighten the
single toggle lock to secure the bitefork assembly in place.

4. Confirm that the facebow is parallel to the interpupillary line and that the
nasion relator is properly positioned. Loosen toggle and adjust as necessary.

Removing the Facebow

1. Check the single toggle lock for tightness.
2. Remove earpieces from the patient’s ears and remove facebow assembly.
3. Loosen silver screw at the top of the transfer jig and slide the transfer fork
assembly off the facebow. Set aside until ready for upper cast mounting.

ACCURATE STUDY MODELS

You want the most accurate impression material available for your study models.
Some of the newer alginate substitutes are excellent like Position Penta and
Counterfit.

You will need to insert the tray in a vertical pathway to eliminate pulls and
distortion with these materials.

Another excellent option is to use a regular PVS material like Aquasil Ultra.

I have my study models poured out of vacuum mixed die stone and I will take 2 sets
for any patient with complex dentistry that will be having a diagnostic wax-up.

You need to clean off all the little defects on the models.

DENTAL EXAMINATION

PERIODONTAL EXAMINATION

The goal of treatment is to have all the supporting tissues healthy and free of
inflammation and infection.

ESTHETIC EXAMINATION

The main area I want to assess with the patient in the office is the incisal edge
position, lip dynamics and lip mobility. This will allow me to determine if the incisal
edge position and gingival tissue will need to be altered as part of the treatment
plan.

LIP IN REPOSE EVALUATION

Ask the patient to lick their lips and then breathe continuously through their mouth
to separate the lips.

RADIOGRAPHIC EXAMINATION

An extensive digital radiographic examination is recommended before starting any
complex dentistry.

RECOMMENDED ARTICULATOR AND SETTINGS

SIMPLIFYING YOUR INSTRUMENTATION

It is more important to have an accurate set of casts and accurate CR bite records
than a full adjustable articulator for most cases. The best articulator will not
compensate for poor casts or inaccurate CR bite records.

The semi-adjustable articulator will provide you with an accurate simulation of
mandibular movements for most patients without being excessively complex and
time consuming to program.

A simple hinge articulator is not acceptable to treatment plan any occlusal changes
for your cases. The geometry of the arc of closure with a hinge articulator will
produce significant error if you mount your case in CR with a bite record with any
thickness.

You cannot accurately wax up cases at a different vertical dimension with these
hinge articulators.

Your articulator needs to be able to relate your upper and lower casts to one
another in centric relation. For the relationship of the two casts to be maintained at
different levels of vertical dimension, both casts must also be related to the correct
condylar axis.

My recommendation is a semi-adjustable articulator like the
Sam 3.

I prefer the Sam 3 system because the articulators are created with
precision engineering and exacting tolerances making the
instruments interchangeable.


ARTICULATOR SETTINGS

These articulators use average values for the intercondylar distance, guiding
surfaces of the fossa elements, and allow you to set the condylar guidance and
Bennett angles.

Condylar Angle

Any condylar path that is flatter on the articulator than it is on the patient will result
in posterior restorations that disclude the moment the condyle starts down a
steeper eminence on the patient.

A number of anatomical studies have show that the minimum horizontal condylar
path is 25 degrees. This means that occlusal restorations fabricated on an
articulator with a 25 degree condylar path, would automatically separate if placed in
a mouth with steeper condylar paths.

I don’t use a protrusive or lateral check bite to set my articulator.

I set the Condylar angle to 25 degrees.

Bennett Angle: The angle at which the NWS condyle moves away from the
sagittal reference plane when viewed horizontally.

I set the Bennett angle or progressive side shift to 10 degrees.


Average value articulator settings

One case where average values is not a great idea is the class 3 patient with no
anterior guidance. With this patient if the guidance is going to be set up in group
function on the molars there is more need to have an accurate simulation of
condylar movement, especially if immediate side shift id present.
That is a case where you would want to customize the fossa elements and tailor it to
the individual patient using a pantographic tracing.

MOUNTING THE CASE: MOUNTING PROTOCOL

1. Clean models free of any occlusal defects and imperfections.
2. Upper model is mounted with the facebow transfer assembly with the incisal
pin set at zero.
3. Trim the bite records.
4. Seat the models into the bite record, make sure there is no rocking and no voids
between the models and the bite record (you want to see stone/bite
record/stone).
5. Mount the lower model on the articulator with the incisal pin open to account
for the thickness of the bite record.

HOW TO ACCURATELY TRIM THE BITE RECORD

I will trim the bite records with a 12b surgical blade and remove all the detail from
the bite record until I have just the cusp tips and basic anatomy left. You want to
remove all the fine detail from the bite record so the models will accurately seat into
it.


HOW TO VERIFY THE ACCURACY OF YOUR MOUNTING

1. Evaluate for the same point of initial contact (PIC) on the models as you found in
the mouth.
2. Evaluate that both sets of mounted models match each other.
3. Evaluate both sets of bite records with the MPI.

THE SAM MPI

This instrument can be used with SAM articulators to measure the three
dimensional positional change of the condylar elements of the articulator.

The Sam MPI is an excellent tool to compare the two centric bite records and to
compare the movement of the condylar position of the patient from CR to CO.

WHAT IF THE POINT OF INITIAL CONTACT DOES NOT
MATCH?

This can be caused by a number of potential factors:

1. The mounting is incorrect.
2. The models are distorted.
3. The bite record is incorrect.

4. The point of initial contact in the mouth is incorrect and your mounting is
correct.
One problem could be that you recorded the wrong point of initial contact in the
mouth. If you ask the patient where they are first contacting in some cases they can
tell you the wrong location. I always verify the contact they are telling me about
with 8 micron shimstock.

If the point of initial contact with your mounting is distal to the point of initial
contact you recorded in the mouth you can consider the mounting correct. The
patient’s condyle was seated more with the bite record then when you recorded the
point of initial contact.

If the point of initial contact with your mounting is mesial to the point of initial
contact you recorded in the mouth you can consider the mounting and or the bite
record wrong.

The patient’s condyle was not seated with the bite record. The patient should have a
deprogramming appliance created before the next attempt to create the bite
records.

MODEL ANALYSIS

Once you have confirmed that the mounting is correct you can evaluate the mounted
models and develop your treatment plan based on the overall goals you have for the
case.
The bottom line is that you want to evaluate what needs to be done to make the
occlusion work for the desired esthetic treatment plan.

Review the Model Analysis form with the mounted models and the digital photo
series to formulate your overall occlusal and aesthetic treatment plan.

EVALUATION OF MOUNTED MODELS

Take a look at the tooth anatomy. Are the teeth flat or do they have fairly steep and
long cusps.

As a general rule patients with really flat anatomy are harder to equilibrate and
patients with steep anatomy are easier to equilibrate.
Review the Model Analysis form with the mounted models and formulate your
overall occlusal and esthetic treatment plan.

USING THE SAM MPI

Attach the upper model onto the MPI and then place the bite record used for the
mounting into the lower model, which is already attached to the lower portion of
the articulator.

Mark the CR location with Accufilm on the graph paper attached to the condylar
block of the MPI.

Remove the bite record and hand articulate the models. Then mark the condylar
position with the condylar blocks of the MPI with accufilm. These marks represent
the condylar position in CO.



The horizontal and vertical distance between the dots will tell us how easy or
difficult the restorative treatment will be.

If you have a patient with a large vertical change the MPI will help you evaluate the
amount you will need to reduce the molars to equilibrate that patient.

The vertical change also helps you if you need to open the vertical dimension, which
we will see in Day 2 of this seminar.

You can also use the MPI to evaluate if both sets of CR records are the same.

Risk Assessment For Complex Cases


I believe the Patient has the dominant influence on our treatment outcomes!

High Expectations

These patients are considered high risk and you need to be very careful if you agree
to treat them.

It is beneficial to meet the patient a couple of times before you agree to treat them
or even provide them with an estimate so you can have a feel for weather they have
low, medium or high esthetic expectations from your treatment.

I would recommend that you develop a form to have the patient provide you with
written approval of the provisional restorations and written approval of the final
restorations before you proceed with the case. I think this is the only way to protect
yourself with complex cases.

I would also recommend you collect the fee before you cement the
final restorations.


What about a Smile Line that changes?

Be careful when you evaluate the smile line and the amount of gingival tissue
display. With some patients you will see them as having a low smile line before
treatment but after you have placed the new restorations and the patient likes their
smile more they will start to smile with more lip movement!

In a case like this you may have thought you did not need to alter the tissue levels
but after completion you find out that you should have.


RED, BLEEDING GUMS AROUND YOUR DENTISTRY IS BAD FOR THE LONG
TERM DENTAL HEALTH OF YOUR PATIENT!

RED, BLEEDING GUMS AROUND YOUR DENTISTRY IS BAD FOR THE LONG
TERM SYSTEMIC HEALTH OF YOUR PATIENT AS WELL.

I will refer you to perio.org for more information on periodontal disease.


High Risk

There are many patients with high risk for biomechanics. My two biggest concerns
are recurrent decay and fractures.
I feel a caries management program is an excellent idea for patients that have had a
large amount of dentistry completed.


Bite force is a very large issue for the long-term success of
our cases.

An Attempt To Quantify Tooth Wear

Tooth Wear from normal function should not exceed 0.11 microns per year. With
normal function and diet a patient would take 100 years to achieve 1.0 mm of tooth
wear!

TREATMENT PLANNING TOOTH WEAR

Patients with significant tooth wear are generally lacking stability and require some
form of treatment.
One of the biggest challenges when we are treating the worn dentition is the tooth
position that develops as a result of the tooth wear.

Pathological Tooth Wear

These patients will exhibit a degree of wear that is advanced in rate and severity to
the amount expected relative to their age. The wear has also advanced to the point
that the patient will require restorations

The term “pathologic tooth wear” has been used to describe the state when the
destruction of the teeth has reached a level at which restorations are indicated.

Physiologic Tooth Wear

These patients will exhibit a degree of wear that is within the normal limits
expected relative to their age.

WHAT ARE THE MOST COMMON FORMS OF TOOTH WEAR?

1. Attrition
2. Erosion
3. Abrasion
4. Abfraction
5. Combinations of the above

Int Dent J. 2005;55:268-76.
The worn dentition--pathognomonic patterns of abrasion and erosion.
Abrahamsen TC.

The categories of tooth wear encountered most commonly in dental practice are
abrasion and erosion. The major causes of wear from erosion are regurgitation,
coke-swishing and fruit-mulling.

ATTRITION

Attrition is the most commonly thought of form of tooth wear and is caused by tooth
to tooth grinding. Attrition is easily diagnosed because the wear facets will line up
on the teeth and they will have a shiny appearance with the enamel and dentin even.
Attrition is only found in areas of occlusal contact.

Key Question:
Is the attrition normal relative to their age?


HEAVY ATTRITION

These patients are High Risk

EROSION

Erosion is the loss of dental hard tissue through chemical etching and dissolution by
acids of non-bacterial origin.
Erosion is characterized by seeing the wear facets cupped out with the dentin being
worn more than the enamel. With erosion the wear facets can be on non-occlusal
surfaces.
It is generally considered that patient’s with erosion are at a lower risk to treat
because the bite forces are usually less than with severe attrition. The acid that
causes erosion is generally extrinsic or intrinsic in nature. The classic extrinsic
sources of acid can include carbonated beverages, citrus fruits, sports drinks, etc.

This would include Colas but drinks like Red Bull and Gatorade can be even worse.
The pH of these drinks is usually between 1.5 and 3.0.

Swishers and poolers of carbonated beverages can compound the problem. These
people can develop pot holes on the occlusal surfaces of mandibular molars and can
be at risk for an increased level of caries.

Gen Dent. 2004 Jul-Aug;52(4):308-12.
Dissolution Of Dental Enamel In Soft Drinks.
von Fraunhofer JA, Rogers MM.

A high percentage of the population consumes a variety of soft drinks on a daily
basis. Many of these soft drinks contain sugar and various additives and have a low
pH. This study compares enamel dissolution from both regular and diet beverages.

J Dent. 2005 Mar;33(3):243-52. Epub 2004 Nov 26.
Dental Erosion: Possible Approaches To Prevention And Control.
Amaechi BT, Higham SM.

Optibond solo has been shown to offer protection against erosion and reduce the
rate of tooth wear in vitro and in situ. without adverse effect on pulpal circulation
(in rat studies). This can be applied to protect erosively exposed dentinal tissues.

J Dent. 2005 Mar;33(3):243-52. Epub 2004 Nov 26.
Dental Erosion: Possible Approaches To Prevention And Control.
Amaechi BT, Higham SM.

Porcelain veneers may be used to improve appearance as well as provide protection
against further damage.


The classic Intrinsic sources of erosion are related to stomach acid and present
themselves as GERD and Bulimia.

Patients with GERD have erosion on the lingual of the maxillary teeth and the
occlusal surfaces of the mandibular molars. In some patient’s the teeth could be the
first sign of GERD and may need to be diagnosed by the dentist and referred to their
MD.

"Mr Brown, I am concerned that you have worn down right through one of the
hardest substances in the body and now you are into dentin, which is a much softer
surface. "
"Mr Brown, I am concerned that your teeth are not going to make it!"

Instead of letting the patient know that they have tooth wear you can call it damage.
"You have damage to your enamel."
"You have destruction to your enamel."
"You have deterioration of your enamel."

Patients with Bulimia have severe wear on the lingual surfaces of the maxillary
incisors.

Treatment Recommendations For Early Erosion

1. Do not brush for 30 minutes after the acid attack.
2. Rinse with water after the acid attack.
3. Use additional fluoride and fluoride varnish.
4. Seal and restore the exposed dentin with a filled dental adhesive like Optibond
Solo.

ABRASION

Abrasion is usually located on the cervical and facial areas of teeth.
The Abrasion lesions can be very wide.

ABFRACTION

Abfraction is said to be caused by tooth flexure but it is a controversial subject.

COMBINATIONS OF THE DIFFERENT FORMS OF TOOTH WEAR

A combination of erosion and abnormal attrition will led to an increased level of
destruction and tooth wear.


Lets look at some of the Chewing Research

MASTICATION

Normal opening path is vertical and the closing path is more variable.

Patients with unworn teeth close in a more vertical chewing pattern with a
definitive stop and no lateral slide.

Patients with severely worn occlusions tend to exhibit wider lateral chewing
movements with longer glide lengths than people with normal amounts of tooth
wear.

If the patient can be diagnosed with Bruxism you SHOULD follow their chewing
pattern with their restorations

When you are restoring these patient’s you need to avoid providing them with a
steeper anterior guidance, a deeper overbite and a tighter overjet.

You need to make sure the teeth do not interfere with the way the patient wants to
chew.

You want to provide them with a little more freedom in the envelope of function and
a little more horizontal overjet.


Medium Risk
Class 3

I would classify these patients as medium risk. If they are end to end on their
incisors they are at an increased risk to fracture or wear these teeth.

It is harder to lengthen their teeth even if they are not end to end but they usually
chew in a vertical chewing pattern because they are locked in so that actually
decreases their risk level.

This is different than a patient that has developed an end to end incisor relationship
due to wear. These patients are high risk.

High Risk
Class 2

I would classify these patients as high risk. It is more difficult to create anterior
contacts and they often have inadequate anterior guidance. If you open their vertical
dimension you increase their overjet and often loose anterior contacts.

Anterior Open Bite
I would classify these patients as high risk as well due to the lack of anterior
guidance and anterior tooth contact.

Deep Overbite
I would classify these patients as high risk as well due to the forces placed on the
anterior teeth.


Another Risk Factor for Occlusal Design is when the patient has current restorative
treatment with a poorly designed occlusion.
This is compounded when the pretreatment records are not available!

Occlusal Disease

Restricted Chewing Pattern

Typically these patients will exhibit more wear on the anterior teeth and less wear
on the posterior teeth. When attempting to locate CR the initial point of contact will
usually appear on an anterior tooth.
To treat these patients you need to create room for the restorative material either
by changing the tooth position (using orthodontics or restorative therapy) or
altering the vertical dimension.

Occlusal Dysfunction/ Parafunction

THE GLOSSARY OF PROSTHODONTIC TERMS
Parafunction:
Disordered or perverted function.

Wikipedia
Parafunction:
A parafunctional habit is the habitual exercise of a body part in a way that is other
than the most common use of that body part.

Dysfunction:
The presence of functional disharmony between the morphologic form (teeth,
occlusion, bones, joints) and function (muscles, nerves) that may result in
pathologic changes in the tissues or produce a functional disturbance.

Parafunction can be defined as a patient that is grinding their teeth due to a
know etiology. An occlusal etiology such as an occlusal interference or a high
restoration, a medication based etiology like antidepressants, or a stress induced
etiology.

KEY CONCEPT:
Many of these patients can be treated with occlusal therapy if you remove the
etiology.

KEY CONCEPT:
For these patients if you can eliminate the etiology you can reduce the tooth
grinding frequency and force levels.

Nocturnal Bruxism

Nocturnal Bruxism is defined as a neurologic disorder with a central nervous
system based etiology. It occurs in 8 to 10 percent of the population or 1 in 10
adults.

There is evidence from sleep studies that patients who have been diagnosed with
sleep bruxism will ALWAYS display bruxism.


There is little evidence that occlusion has anything to do with the etiology of sleep
bruxism.

Bruxism seems to be related to a sleep related micro-arousal and has been classified
in the medical literature as a sleep-related movement disorder. It is not a dental
disorder but a sympathetic nervous system disorder.

With the sleep related micro-arousal, the brainstem puts out a discharge of
sympathetic nervous activity and that discharge starts to raise the patients heart
rate, respiratory rate, brain activity and at the end of this event the patient starts to
grind their teeth. The tooth grinding is the end of the event and the sympathetic
discharge starts the event. None of this is caused by occlusion, the teeth are not even
together until the end of the event. This is not like occlusal dysfunction.

RMMA, rhythmic masticatory muscle activity is the start of the tooth grinding. The
interesting fact is that 60% of all adults have sympathetic micro-arousals but only
8% to 10% do the people actually bring their teeth together and grind their teeth
and exhibit nocturnal bruxism.

It is believed that these people have an amplified elevator muscle activity and the
elevator muscles are strong enough to get the teeth together and grind on them. In
severe nocturnal bruxers this can occur 20 times an hour or once every 3 minutes.
The bite force and intensity varies with the elevator muscle size and strength.

Awake or Daytime Bruxism

Awake or Daytime Bruxism occurs in 1 in 5 adults and the physiology is not known
but the frequency seems to be highly related to stress and anxiety

J Oral Rehabil. 2008 Jul;35(7):476-94.
Bruxism physiology and pathology: an overview for clinicians.
Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K.

Awake bruxism is defined as the awareness of jaw clenching. Its prevalence is
reported to be 20% among the adult population. Awake bruxism is mainly
associated with nervous tic and reactions to stress. The physiology and pathology of
awake bruxism is unknown, although stress and anxiety are considered to be risk
factors. During sleep, awareness of tooth grinding (as noted by sleep partner or
family members) is reported by 8% of the population. Sleep bruxism is a behaviour
that was recently classified as a 'sleep-related movement disorder'. There is limited
evidence to support the role of occlusal factors in the aetiology of sleep bruxism.

Bruxism Conclusion

Many people with significant occlusal problems do not exhibit bruxism! There is
little evidence to support the theory that nocturnal bruxism is a reaction to occlusal
imperfections. Altering the occlusion will not stop bruxism!
Occlusal design is very important in determining how forces of bruxism or
parafunction or occlusal dysfunction are distributed when you are completing a
reconstruction.

You should look at the patients masseter muscle size when you are evaluating the
risk involved with treating a Bruxism patient. The muscle size will provide you with
an idea about the patients bite force

KEY CONCEPT
You need to assume that a patient that displays Bruxism will continue to grind their
teeth even after your treatment. You should also plan for them to grind their teeth
in the same chewing or wear pattern that they displayed before treatment.

KEY CONCEPT
The Bruxism patient should have an appliance made to protect their investment and
reduce the potential for failure of either the restorative material or the tooth.


FUNCTIONAL OCCLUSION
ONLINE
DAY 2

Paul J. Meyer

Dr. Stephen Phelan

drsphelan@me.com
1-800-964-1619


Functional Occlusion Online
Day 2

“To me, the function and duty of a quality human being is
the sincere and honest development of one’s potential.”

Bruce Lee
Legendary Martial Artist

TREATMENT PLANNING THE HIGH RISK WEAR PATIENT

WHAT IS THE KEY CONSIDERATION WHEN TREATMENT PLANNING
TOOTH WEAR

• What are the risk factors?
• How much risk are you taking by treating this patient?
• How much risk are you willing to assume to provide treatment?
• How much risk is the patient willing to assume to have treatment?
• When you are considering treating these people you need to think about the
risks involved.

The worst-case scenario is generally fractured porcelain.

Some Key Questions To Ask The Patient To Help With The
Diagnosis Of Bite Related Problems

1. Can you chew gum or hard and sticky foods?
2. Have your teeth changed in the past five years?
3. Do your teeth feel loose?
4. Do you have more then one bite?
5. Do you wake up with stiff and sore jaw muscles?
6. Do you get clicking, locking or pain in your TM joint area?


What is the patient risk factor that will wreck your cases
and what can you do about it!

High Forces in both magnitude and direction will wreck our cases.


The Key for treatment planning the high risk wear patient is to establish their Risk
Profile first and then use Force Management to engineer their new occlusion.

Key Concept
The safest way to manage these patients is to alter the occlusion with the
provisional restorations and see what the patient will do to them.

Always keep an original set of models in case you need to return to an occlusal
design closer to the starting position.

Force Management

Force Management Checklist

1. What is the chewing and wear pattern?
2. What is the condylar position?
3. When and where the tooth contacts will occur?
4. What is the overbite?
5. What is the overjet?
6. What is the vertical dimension?
7. Which teeth will touch in the guidance?
8. What is the angle of the guidance?
9. What is the envelope of function?
10. What is the terminal position of the guidance?

These ten questions are a key blueprint for the Occlusion Design

The system I use for force management is to apply the answers to the ten
questions to the occlusion design and the diagnostic wax-up. I then take the
results of the diagnostic wax-up to the mouth.

1. What is the chewing and wear pattern?

The patient’s pattern of wear will show you their individual chewing and
grinding envelope.

Determining this envelope will help you determine which restorations will be
at risk if the patient continues to chew and grind their teeth in that envelope.

You can look at the patient in the chair to get a feel for how all of the wear
facets will line up and then verify what you observed with the mounted study
models.


2. What is the condylar position?

For occlusion design and force management purposes I would recommend
using centric relation as the condylar position.

This creates a condylar position that is reproducible and is a boarder position.
This means that any mandibular movements will result in the condyle moving
inferiorly down the glenoid fossa and discluding the posterior teeth and allowing
only anterior tooth contact.

3. When and where the tooth contacts will occur?

Ideally you would like to design the occlusion with equal intensity contacts of all the
teeth in the reconstruction coming into contact at the same time.

This is very difficult to achieve in the reality of everyday patient care.

If you look at a Tscan reading of a well adjusted reconstruction, you will see that it is
practical to achieve an even distribution of contacts but it is difficult to make them
hit at the same time or at the same intensity.

What I have found is that I can create a nice equal distribution of contacts. Ideally I
would like all of the teeth from the cuspid back to hold the shimstock tight.

I would like the incisors to hold shimstock if we are designing an anterior group
function.

If I am designing a cuspid guidance I may have the incisors just drag the shimstock
but not hold it firm.

4. What is the overbite?

The main issue with overbite is creating an overbite that is too deep.

You want to avoid locking in the patient and causing a restricted envelope of
function.

5. What is the overjet?

The main issue with overjet is creating an overjet that is too tight.

When you are restoring these patient’s you need to avoid providing them with a
steeper anterior guidance, a deeper overbite and a tighter overjet.


You need to make sure the teeth do not interfere with the way the patient wants to
chew. You want to provide them with a little more freedom in the envelope of
function and a little more horizontal overjet. You don’t want these patients to feel
really locked into their new occlusion.

6. What is the vertical dimension?

7. Which teeth will touch in the guidance?

Guidance Pattern Designs

1. Balanced Occlusion
2. Group Function
3. Cuspid Guidance
4. Anterior Group Function
8. What is the angle of the guidance?

As the angle of guidance rises, the degree of force placed on the teeth also rises.
Ideally you would like to use the anterior guidance that is the shallowest
capable of clearly discluding the posterior teeth.

J Prosthet Dent. 1983 Jun;49(6):816-23.
Anterior guidance: its effect on electromyographic activity of the temporal and
masseter muscles.
Williamson EH, Lundquist DO

The flatter the angle of guidance the lower the muscular activity.

9. What is the envelope of function?

KEY CONCEPT

You need to build your restorations in harmony with the envelope of function and
how the patient would like to chew.

You need to make sure you don't restrict the envelope of function with either the
final tooth position or the thickness of restorative materials that you use.


10. What is the terminal position of the guidance?

For the high risk profile wear patient I would recommend having the terminal
position of guidance on broad, flat surfaces.
The patient will often have a direction and end point that they like to move their
teeth in that has caused their wear. It is rare that you can change this direction so
you need to engineer the case so that the new restorations will survive the way the
patient will want to move their teeth and the terminal position of guidance.

Clinical Pearls
Leaf Gauge Equilibration Technique

I call this procedure balancing the bite when I talk to patients about it. I compare the
need to balance the bite to the need to balance the tires on your car to achieve
proper alignment for driving.

Patients seem to relate well to this analogy and they also seem to understand that it
needs to be done periodically like you would with your car.

TRIAL EQUILIBRATON

The trial equilibration is useful to provide us with information regarding whether
we can successfully complete the equilibration alone or if we require a combination
of additive restorative treatment and equilibration.

Step 1
Unlock the condylar lock and slide the cast together into maximum intercuspation
or centric occlusion. Drop the anterior guide pin down to contact the table on the
front of the articulator and secure that in position. Now place the casts back into
centric relation and lock the condylar lock into place.

Step 2
Close the articulator and the casts together to contact the point of initial contact.
Observe the amount of separation between the pin and table in the anterior of the
articulator. This is the amount of vertical room available for the equilibration before
you would close the vertical dimension of occlusion.

Step 3
Equilibrate all premature interfering contacts between teeth to return the pin to
contact with the anterior table. If you are missing a contact you can now evaluate if
that contact can be added with restorative material like composite resin or
porcelain.

Step 4
Once you have the cuspids into contact and/or the pin back on the table, use the red
articulating paper to mark and eliminate all working and non-working posterior
interferences.

Step 5
Now harmonize the anterior guidance to establish a smooth gliding movement of
the cast, both left, right and protrusive. It is desirable to share this movement with
as many teeth as possible in the anterior.

Step 6
Once the anterior guidance has been harmonized, re-check for any posterior
working or non-working interferences and eliminate those.


HOW TO PERFORM A SIMPLE AND EFFICIENT EQUILIBRATION
USING THE LEAF GAUGE

1. Place the Leaf Gauge and have the patient move forward, back and squeeze.
2. Take out leaves until the patient feels the initial contact.
3. Add one more leaf.
4. Mark the initial contact with the black Accufilm articulating paper.
5. Remove the mark (grind the contact that does the least damage, upper or
lower tooth).
6. Take out another Leaf and remark the contacts.
7. Remove the marks.
8. Continue removing Leafs until the cuspids contact and all the Leafs are out.
9. Evaluate the cuspid and incisor contact.
10. When the cuspids are in contact and all the Leafs are gone you are in Centric
Relation.
11. Evaluate the size and location of all the contacts.
12. Place the red Accufilm, have the patient move right, left and forward and
firmly grind all around.
13. Place the black Accufilm and have the patient tap, tap, tap.
14. Evaluate the anterior guidance.
15. Any red spots on the back teeth are interferences that need to be removed
unless you build up the anterior guidance with composite resin.
16. After the equilibration is completed check the patient in the supine position,
replace the black Accufilm and tap, tap, tap.
17. Sit the patient up and have them tap, tap, tap on the red Accufilm.
18. If the patient feels a little locked in by the anterior teeth, you can decrease
the red marks on the incisors to provide them with more freedom in centric.
Many patients do not need this adjustment.

Occlusal stability is rarely accomplished with a single appointment equilibration.
Overloaded teeth will often rebound and some remodeling of the intracapsular
structures can occur following the equilibration.

Most patients’ require 2 to 3 appointments to achieve a stable occlusion and will
require some monitoring to maintain the equilibration over the years.

Equilibration For The Porcelain Veneer Patient

PATIENTS WITH ANTERIOR ONLY TOOTH WEAR

The reasons that the patient may grind only on the anterior teeth:

The patient grinds in an end-to-end protrusive position. Which is often due to a
posterior interference on the second or third molars. This could also be due to some
form of parafunctional habit that you would want to eliminate.

The patient has a very steep eminence on the TM joint that separates the back teeth
as the mandible moves.

The patient has a restricted envelope of function and grinds in a more vertical
chewing pattern behind the front teeth.


Altering The Vertical Dimension

One of the number one questions that I am asked when I am teaching is how to alter
the Vertical Dimension!


Key Concept

Vertical Dimension is a highly adaptable position and there is no one vertical
dimension that you need to build your cases to but a range of vertical dimensions
that will work for most patients.

Options when you are altering the vertical dimension.

Several techniques have been traditionally used to determine the
VDO.

1. Freeway Space.
2. 2.Trial Appliances, like splints, RPDs, and orthotics.
3. 3.Transcutaneous Electrical Neural Stimulation (TENS).
4. 4.Measurements Using the CEJ.
5. The Method of Facial Proportion.

I don’t use those techniques. I use what I would refer to as Restorative
Generated Occlusal Vertical Dimension.

This is a modification of a technique that is referred to in the text by
Dr. Peter Dawson.

I am using the geometry of the jaw and the space created by seating the condyle into
CR to my advantage to determine the vertical dimension for my cases.

Key Concept

The vertical seating of the condyle into centric relation can be helpful to increase the
vertical dimension for the anterior teeth without increasing the contracted length of
the elevator muscles.

Due to the geometry of the jaw, if you open the vertical 1 mm in the posterior you
will open the vertical 3 mm in the anterior.

Overjet is also altered significantly: for each 3 mm vertical change in the anterior
teeth, there is approximately a 2 mm horizontal change in an anteroposterior
dimension.

Option #1

Build the new vertical dimension AT THE point of initial contact with the joint in
centric relation.

This will provide you with the extra space you need without increasing the
contracted length of the elevator muscles.


Option #2

Build the new vertical dimension LESS THAN the point of initial contact with the
joint in centric relation.


Option #3

Build the new vertical dimension MORE THAN the point of initial contact with the
This will provide you with the extra space you need BUT YOU WILL INCREASE the

Case 1

Option #1

Build the new vertical dimension AT THE point of initial contact with the joint in
centric relation.


Case 2

Option #2

Build the new vertical dimension LESS THAN the point of initial contact with the


A nice technique for us to control the vertical dimension for the diagnostic wax-up is
to complete a trial equilibration on the mounted models to decrease the vertical
dimension from the PIC.

With this technique you can equilibrate the mounted models from CR until the
vertical dimension creates an overjet and overbite that will be acceptable for the
diagnostic wax-up to be completed.

Test the new Occlusion Design with the provisional restorations.
Replicate the Angle of Guidance.

Create The Guidance On Broad Contact Areas.

Create the final restorations based on the provisional restorations.


Case 3

Option #1

Build the vertical dimension at the point of initial contact!

In patients like Paul that have really flattened out their posterior occlusion you will
often need more anterior space either to lengthen their teeth or for restorative
material?

Option #3

Build the new vertical dimension MORE THAN the point of initial contact with the

This will provide you with the extra space you need BUT YOU WILL INCREASE the

The technique that we use to determine the VDO is to create the ideal maxillary
anterior tooth position for the patient with the diagnostic wax-up on the mounted
study models in centric relation.


The custom incisal guide table will allow you to create the same angle of guidance
and anterior envelope at the increased OVD.

We then determine the ideal mandibular anterior tooth position using the custom
incisal guide table to wax in the guidance and refine the maxillary palatal contours.

Close the articulator and set the incisal pin to this new position. That is now your
New Occlusal Vertical Dimension!

You then finish waxing the posterior teeth to complete the diagnostic wax-up.

Technique Refinement

Wax-up the ideal esthetics on the facial of the upper anterior teeth and then look at
the overbite and overjet to determine the vertical dimension.

After creating the ideal facial esthetics on the anterior teeth, I asked Harald to drop
the incisal pin of the articulator to the guide table with the models in protrusive at
the new incisal edge position. When the models are moved forward into centric
relation the incisal pin creates an overbite the same as the pretreatment models but
for the new incisal edge position and this will set the new vertical dimension.

I recommend to equilibrate the provisional restorations into CR. I use the leaf gauge
to guide the equilibration. I then typically give the patient 3 to 6 months to test out
the new occlusion with option # 3.

After the testing phase, I will complete the rehabilitation one arch
at a time basing the final restorations on the refined provisional
restorations.

Precision Bite Records

New Protocol For Restorative Cases!

First Review The Old Protocol For Restorative Cases!

Restorative Records Protocol For Complex Cases

1. Take a new facebow of the upper provisional.
2. Mount the upper provisional model on the articulator in the correct three
dimensional position.
3. Cross mount the remaining models to the mounted upper provisional model
using the various bite records.

Specific Bite Records For A Full Mouth Case

1. Upper provisional to lower preparation bite record.
2. Lower preparation to upper preparation bite record.
3. Upper provisional to lower provisional bite.

New Protocol Precision Restorative Records For Complex Cases

The new protocol is based around completing the full mouth case one arch at a time
and verifying the precision of the CR bite records and the final case mounting with
the MPI.

Additional precision is achieved by taking 2 final CR bite records and a PVS or PE
impression of the opposing completed arch to build the final arch of porcelain
restorations against.

NEW Restorative Records Protocol For Complex Cases

1. Take a new facebow of the upper provisional.
2. Mount the upper provisional model on the articulator in the correct three
dimensional position.
3. Cross mount the lower provisional model to the mounted upper provisional
model.
4. Take 2 CR bite records (upper preps to lower provisional bite record) and
mount the upper preparation model to the lower provisional model.
5. Verify the mounting with the MPI.
6. Complete the upper porcelain restorations.
7. After verifying the results of upper porcelain restorations, take two new CR Bite
records. (Upper final porcelain restorations to lower preparations)
8. Take a PVS or PE impression of final upper porcelain restorations and lower

provisional and mount to the previous lower provisional model.
9. Mount the lower preparation model to the final upper porcelain restorations
model with the CR bite record. (Upper final porcelain restorations to lower
preparations)
10. Verify the mounting with the MPI.

Case Example

Opposing Arch PolyEther Impression Adds To The Precision!

Case 4: Applied Occlusion Design


APPLIANCE THERAPY

If the Patient grinds or clenches with no joint problems and you can load test the
joint but they have muscle tension.

Use an E Splint or an anterior bite plane or Kois Deprogramer.

If the Patient grinds or clenches with no joint problems and no muscle tension and
you can load test the joint.

Use a Vivera retainer, or Essix retainer.

If the Patient has joint problems, or load tests positive.

Use a Full coverage splint, upper or lower with a fairly flat anterior ramp.

6 Steps For Treating The Complex Wear Patient

1. Complete the diagnostic records including digital photo series, functional
analysis and complete exam.
2. Develop a Treatment plan that is designed to decrease risk factors.
3. In these higher risk patients create trial restorations from the diagnostic wax-up
and wait three months to see the results of the occlusal change.
4. If the occlusal change is successful proceed to final restorations and use the
prototypes to guide the creation of the final bite records and restorations and
complete the case one arch at a time.
5. If the occlusal change is not successful modify the occlusion and retest until the
new occlusion is successful. Once the occlusal change is successful use the
provisional restorations to guide the creation of the final bite records and
restorations and complete the case one arch at a time.
6. Deliver the final restorations.

1. Complete the diagnostic records including digital photo series, functional
analysis and complete exam.

The functional analysis is completed with the study models mounted using the CR
leaf gauge bite records and facebow. These records are mounted on a Sam 3
articulator and then analyzed for wear facets, guidance pattern, envelope of
function, overbite and overjet. The overall diagnosis and risk assessment can be
completed with the aid of the mounted study models, radiographs, digital
photographs, and the results of the clinical exam.

CASE EXAMPLE

This patient presented with severe erosion and tooth wear. He was concerned with
sensitivity and the wear getting worse and he was not happy with his smile.

Risk Assessment

7 out of 15 are high risk.

2. Develop a Treatment plan that is designed to decrease risk factors.

The treatment plan is designed to create an occlusion that can withstand the forces
that caused the tooth wear in the first place. The vertical dimension, condylar
position, angle of guidance, envelope of function, overbite, overjet, and force
management all need to be considered when developing a treatment plan that will
decrease risk factors.

My Treatment Plan For This Case Included:

1. Stop the extrinsic acid associated with Coke intake.
2. Endodontic referral to assess the compromised teeth.
3. Rebuild all compromised teeth with core build- ups and posts as required.
4. Equilibration of the lower incisors and crown lengthening of 21 and 11.
5. Partial mouth rehabilitation with an extended provisional phase to test out

the new Occlusion Design including vertical dimension, overbite, overjet and
guidance.
6. Partial Rehabilitation will include PJC crowns for 16 to 26 and 35,36,45,46.
7. Final Equilibration of the unrestored teeth to match the porcelain restorations.

3. In these higher risk patients create trial restorations from the diagnostic
wax-up and wait three months to see the results of the occlusal change.

Use the force management checklist to plan the diagnostic wax-up based on the
treatment plan designed to decrease the risk factors. Transfer this Occlusion Design
to the provisional restorations. Test out the provisional restorations for three to six
months and see if the patient is comfortable and there is no breakage or loosening of
the provisional restorations.

Clinical Pearls For Rebuilding Structurally Compromised Teeth

CORE BUILD-UPS

I place a core build-up 99% of the time when I prepare a tooth for a crown.


BENEFITS OF CORE BUILD-UPS

1. Decreased post operative sensitivity.
2. Decreased cement failure due to inadequate retention.
3. Decrease in undercuts with the preparations, both crowns and onlays.
4. Decrease in microleakage around provisional and final restorations.
5. Improve smoothness of the preparation.
6. Allow for a more uniform thickness of the restoration.
7. Improve the ability to take the impression.
8. Allow cementation of the final restoration without local anesthesia.

CORE BUILD-UP PROTOCOL

1. Etch and rinse.
2. Apply the Gluma or G5 desensitizer, evaporate excess with the high volume
suction.
3. Apply 5 coats of the dentin primer (Optibond Fl Primer), evaporate with the air
only syringe.
4. Evaluate the surface and re-apply the dentin primer

(Optibond Fl Primer) as needed until dentin surface glistens.
5. Apply the bonding resin (Optibond Fl Adhesive), light cure.
6. Mix the Core-Paste for 40 seconds, load into the Centrix tube.
7. Apply to the preparation and let cure for 5 minutes.

CREATING THE PROVISIONAL

My technique for the Direct veneer provisional is to make a Hardcast shell of the
Diagnostic wax-up and load it with the provisional material directly onto the
prepared teeth. I will let the provisional material set on the prepared teeth and after
the material has started to set my assistant starts to cool down the shell/provisional
complex with the air/water syringe.


I will then remove the provisional from the mouth and start to remove the excess
material using the Soflex XT discs and Ultra thin diamond discs.

I will pick up any deficient or open margins directly in the mouth and finalize the
provisional contours. Extra attention needs to be paid to the gingival embrasure
form to ensure there is room for the papilla to rebound from the gingival retraction
and impression procedures. The provisional is coated with Glistin and cured in the
Triad oven.


4. If the occlusal change is successful proceed to final restorations and use the
prototypes to guide the creation of the final bite records and restorations.

Build the bite record at the same vertical dimension as the provisional restorations.
Have the ceramist create a custom incisal guide table of the provisional restorations
and use this as the guide when building the final restorations.

5. If the occlusal change is not successful modify the occlusion and retest until
the new occlusion is successful.

If there are problems with the provisional restorations try and modify them and
retest for another 3 months. (shorten the incisal edges, flatten guidance angles,
decrease overbite, hollow the palatal contours a little to provide more room for the
envelope of function, etc.) If none of these changes work you may need to create
another diagnostic wax-up and another set of provisional restorations. In this case
go back to the original study models and use them for a guide. This is why we create
2 sets of original mounted study models. Once the occlusal change is successful use
the provisional restorations to guide the creation of the final bite records and
porcelain restorations.



5. If the occlusal change is not successful modify the occlusion and retest until
the new occlusion is successful.

Once the occlusal and esthetic changes are successful use the provisional
restorations to guide the creation of the final bite records and porcelain
restorations.

6. Deliver the final restorations.


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FUNCTIONAL

“Whatever You Vividly Imagine, Ardently Desire, Sincerely Believe, And

“Whatever You Vividly Imagine, Ardently Desire, Sincerely Believe, And

2. Anterior guidance is in harmony with the functional movements of the

3. Non-interfering posterior teeth with an equal distribution of contacts.

7. Coordinated and pain free masticatory muscle function.

DIGITAL PHOTO SERIES

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2. A gradual shift to the side on opening indicates probable muscle incoordination.

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TWO TYPES OF PATIENTS I WOULD AVOID TREATING

2. Patients who have an occlusion that is changing. For example an anterior or

4. Prepare the bitefork with compound bite tabs:

a) Place tabs on bitefork (as shown in photo).

Seating the Facebow

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2. Evaluate that both sets of mounted models match each other.

3. Evaluate both sets of bite records with the MPI.

2. The models are distorted.

3. The bite record is incorrect.

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2. Rinse with water after the acid attack.

3. Use additional fluoride and fluoride varnish.

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“Whatever You Vividly Imagine, Ardently Desire, Sincerely Believe, And

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4. Anterior Group Function

8. What is the angle of the guidance?

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3. Add one more leaf.

6. Take out another Leaf and remark the contacts.

7. Remove the marks.

9. Evaluate the cuspid and incisor contact.

11. Evaluate the size and location of all the contacts.

14. Evaluate the anterior guidance.

Many patients do not need this adjustment.

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2. 2.Trial Appliances, like splints, RPDs, and orthotics.

3. 3.Transcutaneous Electrical Neural Stimulation (TENS).

4. 4.Measurements Using the CEJ.

5. The Method of Facial Proportion.

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2. Lower preparation to upper preparation bite record.

3. Upper provisional to lower provisional bite.

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5. Verify the mounting with the MPI.

6. Complete the upper porcelain restorations.

8. Take a PVS or PE impression of final upper porcelain restorations and lower