-=,-' ,-=,-' =' ~

1aw Relationship Record

- In the previous lecture we talked about the vertical dimension, and we said there
were several steps during recording oI the jaw relationship record. And these steps
require us to go in a sequential so we can make a measurement in the actual
patient mouth. These measurement involves 4 basic things :
i. Vertical dimension
ii. Horizontal dimension
iii. Hinge axis relation
iv. Teeth selection

So who can tell me what we did during the vertical dimension of
occlusion measurement in the lab??!!
- We placed 2 points on the patient's Iace we said we can use more than one
reIerence as alternatives because we only need two points To make a
measurement we need a reIerence in the upper part oI the patient Iace & in the
lower part oI the patient Iace. In order to make these measurements we need this
kind oI reIerence.
- Today we'll be talking more about horizontal relationship & face bow
record transfer.
" which has been Dental Articulator You will have an instrument called a " -
designed & based on the measurements & reIerences which Iound in the patient's
head.
- The main reference is :
Ala tragus line from ala of the nose to tragus of the ear the ala tragus line
makes an angle of 15 degrees with the ala tragus line.
- On the patient's head &in the articulator we have an axis which naturally
presents & you don't have to measure it which called the "terminal hinge
axis". This axis is very close to the IrankIurt plane . It's essentially the axis
which goes through the condyles oI the mandibular jaw .
--~-' 4--' ,',;- ,;=-

- It's the reIerence which we relate the maxillary arch beIore we relate
the mandibular to the maxillary .meaning we relate maxillary arch to the
head by measuring how Iar the maxilla is Irom terminal hinge axis
II you were in lab or last week, we repeated many oI these steps

RELA1IOASHIP JER1ICAL

- The Iirst thing that we do in recording vertical relationship is contour the
wax rim (add or remove wax to the rim`s width not length).
We said the patient is 50-60 years old & we want visibility approximately
1-2 mm. we want this visibility to be appropriate Ior the patient it should
be Age related, iI the patient is too young we see more oI his teeth when
upper lip is at rest, or iI the patient is too old we see less. It is also related to
the anatomy oI the patient's lip iI he has long or short lip.
- The lip should be unstrained & we're looking also Ior the naso-labial angle
which approximately is 90 - this angle is between the philtrum oI upper
lip & the columella oI the nose.

- We decided the contour not only Ior labial Iullness, we look Ior the space
around the sides oII wax rim 'the space between lateral boarder oI wax rim
", Buccal Corridor which is called " and the inner surIace oI the check
when the patient smiles normally we see a space between upper wax rim &
the cheek .

- Then we need to orient the wax rim in relation to our reIerence in the
patient head beIore teeth extraction which is the "Camper's Plane" made
up essentially Irom three lines: interpupilary line & Ala-tragus lines(right
the doctor referred to campers plane as n the previous lecture i . and left)
the ala tragus line fust to simplify things because you didnt know
interpupilary line but now he gave you details.
We want the wax rim anteriorly to be parallel to the line which runs Irom
one pupil oI the eye to the other !!!
Posteriorly in right & leIt we want the plane to be parallel to the line Irom
the lower border oI the Ala oI the nose to the tragus oI the ear (tragus either
in the middle or lower border oI it)

- The occlusal plane isn't the same as IrankIurt horizontal plane, there may
be about 5 - 20 between the 2 planes.

- In order to do these measurement you should use an instrument ( because
U can't see the wax rim plane through the patient's cheek) this instrument is
called "ox's Plane", this instrument usually has 2 Ilat arches: on inside the
patient's mouth, one outside.
Once this plane is inside the patient's mouth it will indicate the angulation oI
the wax rim inside the patient's mouth .

- Once we make the ( inter pupilary line & the camper's plane & the
occlusal plane) once they are parallel to each other and we are satisIied that
the upper rim is in the right position. There are certain checks that we can
do : the phonetic check & the anatomic check. The phonetic check such
as the "S" sound , "F" & "V" sounds.
They will be discussed in details in the lab.

-Once we Iinish the maxillary rim we need to mark certain lines which are
the midline oI the patient's Iace & the canine lines. In order to know where
to put the teeth & the size oI the teeth that we should use.

a. idline: be careIul not the midline oI the nose or the lip but the midline
oI the FACE , we place a ruler in the midline oI the patient's Iace & we
try to Iind the centre oI the Iace because the patient's face is
asymmetrical; the nose is asymmetric, the lip & the Irenum asymmetric.
So we try to Iind the centre oI the Iace to set our teeth according to it.

b. Canine lines: which suppose to mark the distal of the canine:


1- while the lips are relaxed we use a relatively sharp instrument and we
mark the canine lines at the angle oI the mouth ( distal oI the canine is
located at the angle oI the mouth).
ose take a line Irom the inner canthus oI the eye to the outer ala oI the n - 2
and hopeIully should coincides with the angle oI the mouth

age take a line straight down Irom the pupil oI the eye. In English langu - 3
the canine is known as EYE tooth.
take a line straight down Irom the side ala oI the nose & you will notice - 4
that this line is Iurther in Irom the other reIerences. This method gives us the
you need to add 3 mm to our not the distal oI it so tip of the canine
measurement.
", we want to see how much High Smile Line We also need to mark the " -
oI the patient's teeth appear when he smiles not when lip is relaxed because
we don't want to see the gums when the patient smiles. We only want to see
two third to three quarters oI the patient's teeth .
- Now aIter completing these measurement we want to know the orientation
or the distance between the upper & the lower arches. So we need a
reIerence: we can use the columella oI the nose to the lower oI the chin, we
can use the upper lip. But we are looking Ior a point which doesn't move.
We mark these point and then we do our measurement.
- We want to measure the distance between the lower & upper jaw when the
person closes his teeth. But the patient doesn't have a teeth so how to make
this measurement??
We take advantage oI a measurement which it's close to it which is called "
the physiological rest position" or "vertical dimension at rest". All oI us
when we're relaxed the lower jaw is hanging and away Irom the upper jaw
by muscle tension & the Iorce oI gravity. So there is a space between the
teeth we call it " interocclusal distance" , "interocclusal clearance" "
freeway space". It's usually 2-4 mm or 1-9 mm in rare cases. We give it an
avarage oI 3 mm.
NOW: we end up with this relationship :
VDR VDO + S
- Since I know that this equation is correct beIore & aIter extraction because
VDR stays the same beIore & aIter . so all I do is measure VDR and
subtract FWS Irom it & it will give me VDO.

- So what I do is to mark a point at the tip on the nose and the tip oI the chin
and measure the VDR and I place a ruler and mark a second point and call
it VDO.
- AIter this I put the lower wax rim in the patient's mouth and I measure
VDW (vertical dimension oI the wax rim). Sometimes the patient's mouth
will be larger than VDW so the wax height is reduced, sometimes the mouth
is smaller meaning the wax is high, because the measurement is made
according to an average. So I have to modiIy the wax to make VDW the
same as VDO.
ow how to make the patient rest ( how to measure the VDR) ?? -
You can use one or two of these
t on the chair. And then we make the comIortably up righ Make the patient sit - 1
patient relax and measure VDR. This is one oI the best technique
You can also ask the patient to tell you his most comIortable position when he - 2
closes but this is less accurate.
" sound gives us the correct VDR. Make the Using the phonetic technique, " - 3
patient say "mmmmmmm..". it's helpIul but not the best.
4- Facial expression, iI the muscles oI the Iace are stretched or too tight. Then I
know the wax rim is too high. One muscle which is nice to look at & has not too
much Iacial hair is the entalis . this muscle is active when the vertical
dimension oI wax rims is too high. So iI U see it contracted then the vertical
dimension is too much.
se the angle oI the mouth & two third oI the Anatomic land marks, we can u - 5
retromolar pad to determine that the lower wax rim height is correct. 'the right
lower wax rim height usually coincides with the line running Irom angle oI the
mouth to thr level oI two thirds oI the retromolar pad
Electromyography, measures the elctric movement in the muscles. The correct - 6
vertical dimension will give us the best amount oI muscular activity at this point.
It's very accurate but not practical.
starting point Ior the mandible Make the patient wet their lips and swallow. The - 7
which brings it back to the right position is the "Swallowing"

- We usually use two or three technique to measure the VDR

- Make sure that the patient is in the right posture, lying down or supporting his
head by the chair will give us an incorrect measurement.
- in measuring the points, you can use a calipers, dividers, piece oI wax, tongue
(blade) depressor, and willis gauge which composed oI two parts one goes under
the nose the other goes under the chin which is the mobile part oI the instrument.
ow how to know that VDR VDO are correct ?? -
There are many check that we do the first one is: -
is about 3 mm so we give the pace S ay W ree : we said that the F Phonetic check -
patient 3 mm. when he talks & the teeth hit each other I know they don't have
enough FWS . You should know that there are speciIic sounds make the teeth very
close to each other but they don't touch. These sounds are "S" , "Ch" , "1" and
sometimes "Z". usually what we do is to tell the patient to say 66 or count Irom 60
to 70 and iI the wax rims touch, so that 3mm isn't enough so I have to remove
more wax Irom the lower rim. Sometimes I need to add more wax iI the space is
more than 3 or 4 mm.
ideal occlusal plane in the e have when w : we know that the Anatomic check -
lower arch that is adjusted correctly, the wax rim will be:
parallel to the residual ridge.
Also posteriorly the wax rim will be at a level oI the line running Irom the point
between halI to two third the height oI retromolar pad on the cast to Anteriorly
we expect that the side oI the wax rim to be at the level with the angle oI the
mouth or level with the lower lip.
Also iI we ask the patient to open his mouth, the tongue should be divided into
upper halI ( dorsum) and lower halI (ventral) by the wax rim. So iI the tongue
doesn't appear too much or they are at the same level the wax rim is too high. But
iI the tongue is showing too much the wax rim is too short.
hat happens if we change the vertical dimension or we didn't give the
high vertical patient the right vertical dimension and give him too
dimension??

- It will cause changes in the patient's Iace. It might cause pain in the TMJ,
instability in the dentures, more and Iaster Atrophy (bone resorbtion) to the
residual ridge, pain underneath the dentures. So it's not acceptable.
a small vertical hat will happen if we do the opposite ( give the patient
dimension) ??
- This causes similar problems, the TMJ won`t be able to support the muscles
correctly so the muscles cannot contract enough Ior the patient to chew in a
comIortable position.
Facially Aesthetically- the patient isn't in a good state because he'll look older
when the distance between the two jaws is less than it should be then the nose and
chin will approximate each other and this will give me the old look, so what's the
point in making denture without restoring Iunctional & aesthetic & phonetic.
- A student asked: if the patient was having a class 2 or class 3 before teeth
extraction like having retraced mandible or protruded mandible do I have to
make the denture the same as the teeth??
- Answer: I try my best to get them to class 1 but sometimes because the
bone is far away I can't do this so I try to get it back to where it was.

HORIZOTAL DISIO

- The relationship between the upper & lower jaw when the teeth are present
aximum " or " Centric Occlusion is called " and are in occlusion
". Researchers Iound out that "centric occlusion " & "centric Intercuspation
relation" are very close to each other.
***remember Irom the previous lecture that centric relation is a bone to
bone relation ship that is independent oI tooth position.

- All oI you iI you close your teeth together now.. You will be in the
centric occlusion or maximum intercuspation. II you push your mandible
Iurther backward, in most people the mandible can go 1 to 2 mm backwards
this position of mandible now when it`s 1-2mm further behind is called
are condyles osition is in most posterior p mandible "Centric Relation"
in most superior anterior position.

- This centric relation is important Ior you as a dentist because the patient
comes to you without teeth so when you ask him to close down, the teeth
can't come together, you don't know where to put his mandible.

- In centric relation the Mandible will be in the most retracted or posterior
position. This means that the Condyle will be in the most superior-
anterior position in the glenoid fossa. This position is reproducible
because it's a bone to bone position not tooth to tooth. That means I'm
not on the teeth. And it's correct iI the vertical oint depending on the
then I vertical dimension I have to adjust the first dimension is correct. So
try to Iind the horizontal relationship.

the patient to close in the right position ( centric How do I get -
relation)??

- II I try push the patient`s mandible backward the protective mechanism oI
the patient is to bring it Iorward so the mscles will resist my Iorce and
prevent me Irom going to the right position. We should make the patient
relax and trust us, this is called "euromuscular release". The thing I do is
bimanual palpation, I put a thumb on each side oI the base plate in the
posterior part oI buccal vestibule in the mandible and the rest oI my Iingers
will be outside the patient`s mouth holding the mandible so only my thumb
inside patient`s mouth, then I ask the patient to open and close gently when I
Ieel that that the jaw is loose no muscle tension, I ask him to open and close
on a soIt material that I placed between the two record blocks and he'll close
in the relaxed hinging position. centric relation is a hinge position~~.

- When the patient opens and closes about 5 mm the condyles will only
rotate, iI the patient opens a lot more than 5mm the condyles will slope
down on the articular eminence and when this happens have lost centric
relation position. So I ask him to open only about 0.5 cm and make him Ieel
relaxed . When you will Ieel the jaw is loose or relaxed you put the material
and ask the patient to close.

which centric relation Ior putting the mandible into The other technique -
is more complicated is using a special type oI marker called " Gothic arch
tracing ". you will learn about it later on.

- ow how to record the jaw relation in the patient's mouth(bite
registration)??

- First I ask the patient to close in centric relation and I put a material
between the upper and lower rims, I use a bite registration material or
centric relation registration material. These materials are similar with
. Because with impression material I faster but they set s impression material
want to register the patient mouth and do border molding. But in centric
relation patient without teeth they don't have one position and this gives us
inaccurate record, so I want it to set Iast.

**bite registration materials:

- we can use special type oI wax called " Alu wax" which include Iine
aluminum metal powder in it. This allows us to heat it very quickly and cool
down very quickly because wax isn't a good thermal conductor but when
you use metal in it it'll transmit heat in and out very quickly. The wax has a
green metallic color because oI the aluminum powder in it. In order Ior the
wax rim. upper in the notches top oI the wax rims to meet we have to put
one and ask the patient to close. The lower on the soft wax Then we put the
soIt wax will go inside the notches and when it cools down I'll have
something like Lego or lock and key, the two pieces will Iit together.

- We can use impression material like silicon material but they are more
rigid and should set very Iast usually 1 or 1.5 min. Here I put the silicon
between the upper and the lower then it will go inside the notches, I can also
make notches in the lower rim.

- We can use special type of ZO paste which sets Iast (1- 1.5 mins).


AC BO RCORD

culator to the arti TransIers the relationship between maxilla and the skull -
. in the same speciIic measurements oI my patiet

- I need some land marks that gives us the relation between the upper jaw
and the rest oI the skull. These things are:
Terminal hinge axis which runs through the condyles,
FrankIurt horizontal plane.
- The Iace bow is a device which records the relationship between the
or the base of the skull , terminal hinge axis maxillary arch and either the
. frankfurt horizontal plane the

-To understand how s Iace bow works you need to understand how an
articulator works. In the articulator the upper part opens and the lower stays
stable, this is the reverse oI the normal in the patient the mandible is the part
that moves or opens.
We want to put the casts in the articulator the same way that the teeth were
in the patient's mouth.

ARTICULATORS

- Articulators come in diIIerent types, we have classiIication; some we can
change the angulation on some we can't:

1- on-adjustable articulator
2- Semi-adjustable articulator
3- ully-adjustable articulator

- The articulator that you use is called " average value non -
. This means that the articulator looks like adjustable articulator"
the patient's head but you can't change the angle oI the condyles. You
can't change the angle oI the over jet and overbite. It's set according
to average values.

- Some other types oI articulators allow us to change these settings,
fully they are more expensive and more complicated. We have
which helps us to recreate the shape oI the ator adjustable articul
we can distance between the condyles condyles perIectly even the
adjust it which is the main advantage oI the Iully adjustable
articulator.

- in semi-adjustable articulator we can modiIy every thing but the
we can`t change it. fixed is distance between condyles

-In your articulator we can't use the Iace bow to transIer the records,
you have to use an average measurement.

***so average value articulator doesn`t accept Iace bow
Back to the ace Bow:

- The Iace bow is used to transIer the relationship between the
maxilla and the base oI the skull. It comes in two basic types:
1- Arbitrary face bow
2- Kinematic face bow

- The aim oI the Iace bow is to Iind the three points which represent the
FrankIurt horizontal plane.


the TMJ on both side. Or or are: terminal hinge axis, posterior points The -
two close points which are : external auditory meatus or the ear.

is usually the inIerior margin oI the orbit. anterior reference The -

oI terminal hinge axis are exact position ich can locate the wh face bows -
". This ( kinematic) is Kinematic or actual hinge axis ace Bow called "
used Ior Iully-adjustable articulators.

ace Arbitrary the exact position are called " can't locate which face bows -
bow".
- These Iace bows locate by estimation based on accurate scientiIic
inIormation. So I try to locate TMJ and when I Iind it`s estimated position
then I am within 1cm radius oI where it is, which is good enough. This is
le articulators. adjustab - semi usually Ior

- Arbitrary face bow, there are two types: one oI them uses the TMJ the
other uses the ear.
1- acia bow : the one which uses the skin or the T1.
2- ar bow : the one which uses the ear.

- So we place the Iace bow, we have a pointer that points on the eye, a
pointer on the TMJ Ior (Iacia Iace bow) or a pointer that goes in the ear
(Ior ear Iace bow) and a Iork inside the patient's mouth. The Iork will
relate the teeth to the joints, the joints will relate teeth to the bow and the
bow will relate teeth to the FrankIurt horizontal plane and by this we have
related the maxilla to the skull.

we maxilla to skull ***notice that when we are trying to relate ***important:
as our reIerence but when we are adjusting the rankfurt plane use
. camper`s plane we use maxilla oI the clusal plane oc



TTH SLCTIO

We will be talking about it when we start
setting oI teeth
We will talk about it in terms oI shade , shape and size.

The end