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Deprogramer leaf gauge, cotton role, etc; discludes ant teeth

By Curtis Gonzales,2014-05-08 21:36
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Deprogramer leaf gauge, cotton role, etc; discludes ant teeth

Deprogramer: leaf gauge, cotton role, etc; discludes ant teeth; disable brain engrams (“MI/muscle memory” oppose dentist when

    manipulating into CR); Bi-manual (dawson), 1 handed, or leaf gauge technique;

Transferbow Assembly: 1) position earpieces into proper frame recess (inclined surface faces forward); 2) adjust earpiece to

    compensate for non-parallel ear canals; 3) insert nosepiece rod into nosepiece holder & position nosepad (rotating nosepiece gives additional 10 mm); 4) secure nosepiece holder into frame of TB; 5) position reference indicator (offset surface facing upward); 6)

    select bite fork; 7) make bite fork registration (not connected to facebow yet) in silicone registration material; 8) position TB to pt (pt

    places earpieces into ears canals) & secure set-screw; 9) position nosepiece into depression above pt’s nose (glabella) & secure set-

    screw (Dr’s hands free now); 10) position reference indicator to widest part of nose (ala); 11) frontally view pt & adjust earpieces if

    necessary to parallel the front member of TB to pt’s esthetic horizontal plane (inter-pupillary) & secure the earpiece set-screws; 12) attach bite fork to 3D registration joint; 13) replace bite fork registration into pt’s mouth & attach registration joint to TB (universal

    set-screw must be on pt’s left side, or it may interfere w/ registration joint holder when mounting to articulator); 14) remove TB from

    pt by releasing nosepiece & earpiece set-crews; 15) disconnect 3D registration joint from TB & transfer to articulator; 16) remove

    incisal pin & replace w/ plane indicator; 17) remove incisal guide table & replace w/ registration joint holder; 18) position magnetic

    bite fork support; 19) attach 3D registration joint to registration joint holder; 20) close articulator & position plane indicator to contact upper flange of registration joint holder; 21) elevate magnetic bite fork support until it contacts bite fork; 22) position Max cast into

    bite registration & mount;

     oooStratos 300 setting: condylar inclination at 30 or customize w/ right & left lateral bites; Bennett angel 15; Ant/Post shift at 0;

     Axis pin: on TB is used for direct mounting procedure only;

     oS100 Arcon: average intercondylar distance (value) 110mm (90-130); top wall= 19mm radius curvature; medial wall= 8-15; facebow; ocondylar guidance= 20-30; adjustable or custom;

    Mandibular movements: horizontal axis- condyle to condyle; elevate (close) & depress (open); vertical axis- through each condyle; lateral movements; sagittal axis- condyle to coronoid process; abduction & adduction

    Determinants of Mandibular movement: Condylar guidance- articular eminence slope (condylar inclination= top wall of articulator) is oo20-30 steeper than O plane (steepness determines degree of post teeth separation); condylar path is curved (19mm radius); CAN’T change; tooth guidance- post teeth provide vertical stop & Ant teeth disclude Post teeth in excursions (protrusive & lateral)= mutually

    protected occlusion (k9 protected occlusion); dentist can change; neuromuscular system- proprioceptors & mechanoreceptors in periodontium, muscles & joints; Man position & movement (voluntary control or involuntary reflexes)

Bennett movement: AKA (early) immediate lateral translation/side shift; ~86% of pts; working side condyle moves? laterotrusion,

    lateroprotrusion, lateroretrusion (articulator rear wall or alternative centric NM position), laterodetrusion, laterosurtrusion; due to slack

    ligaments on working side, shape of non-working condlye, or shape/position of non-working side medial fossa; L&W= 0-3 mm (1 mm); H&M= 0-2.6 (0.4mm);

    Bennett Angle: angle of mediotrusive path of nonworking condyle in horizontal plane; angle difference btw orbiting condyle path & sagittal plane as viewed in horizontal plane; AKA progressive side shift/lateral translation (toward working side as condlye moves ooooooforward); L&W= 6-8 (~7.5); H&M= 1.5-36 (~12.8);

    CR: musculoskeletally stable position of mandible; condyles superoanterior position in glenoid fossa; post slopes of articular eminence contact articular discs; ~10% of pts have same initial contact as MI; records should be stable of pt’s casts, reproducible on pt,

    & simultaneously align both joints on hinge axis; tooth depressions in interocclusal CR record should be shallow enough to visualize

    fit of cusp tips

    Semi & fully Adjustable Articulators: kinematic facebow= mount Max cast; CR record= mount Man cast; Pantographic or Stereographic tracing = set condylar top, medial, & back wall & set intercondylar distance & fabricate condylar inserts; *semi-

    protrusive record= condylar top wall; lateral record= condylar medial wall*

Protrusion: involves a little rotation as well

    Lateral movement: downward, forward, & inward movement in non-working condyle; non-working side= orbiting= mediotrusive; working side= rotating= laterotrusive;

    TMJ ligaments: temporomandibular (lax at CR/no role in determining CR), sphenomandibular, & stylomandibular; attach body of mandible to skull

    Articular Disc: dense collagen CT; avascular & no nerves in area of articulation (Ant displaced NV tissue will cause pain upon opening); posteriorly attached to loose vascularized CT? retrodiscal pad or bilaminar zone (superior elastic & inferior collagenous

    layer); collateral ligaments hold disc in place at medial & lateral poles so that the disc may rotate backwards & forwards on condyle; anteriorly fused w/ capsule & superior lateral pterygoid muscle (moves disc forward); follows condyle during hinging & translation

    Synovial cavities: above and below disc; capsule and synovial membrane border; filled w/ synovial fluid;

Articulating Surface: surface of condylar processes & fossae are covered w/ avascular fibrous tissue

Ginglymoarthrodial: both joints can be described as capable of hinging & gliding articulation

Lateral Pterygoid muscle: inserts on lateral surface of TMJ joint capsule, articular disc, & neck of condyle;

    Posterior ligament: non-elastic; stretched at maximum opening (as disc moves forward); prevents disc from rotating or being displaced too far anteriorly; if stretched or torn, the disc may displace forward;

    Superior elastic stratum: fibers bind disc; connects temporal bone; maintain tension on disc, toward the distal;

    Opening: at beginning, disc is at most superior ant position on condyle that posterior ligaments allow; loading on steepest part of eminence; inferior LP pulls condyle forward while superior LP relaxes so elastic fibers can pull disc to top of condyle as it moves

    forward; at max opening, condyle is below eminence w/disc in btw

    Closing: inferior LP relaxes so that condyle may move posteriorly; superior LP contracts to pull disc forward on condyle so it may slide up steepest portion of eminence;

    AV shunt (vascular knee): blood rushes into vascular retrodiscal tissue as condyle moves forward to expand tissue to fill empty space; if disc is displaced anteriorly, condyle will load on tissue causing pain;

    Locked Jaw: possible for condyle to slide too far forward, beyond articular eminence which locks jaw open

Muscles of Mastication: lateral pterygoid, masseter, medial pterygoid, temporalis, & digastric

LP muscle: when it spasms, a deviation will occur on contralateral side during opening (normal deviation is on same side for ALL

    other muscles); protraction, depression, contralateral abduction, joint stabilization; inferior head- origin is outer surface of LP plate &

    insertion is neck of condyle; jaw opening & protrusion; translation of condyle down, anteriorly, & contralaterally during opening;

    superior head- originates on greater sphenoid wing & inserts onto TMJ capsule & anterior aspect of articular disc; final closure; stabilizes condyle head & disc against articular eminence during closing;

     ndMasseter muscle: origin zygomatic arch; broad insertion from posterior lateral ramus to 2 molars; layers separated at posterior upper

    portion; forceful closing; assists in protrusion;

    Medial pterygoid muscle: origin on medial surface of LP plate & palatine bone; inserts on medial surface of angle of mandible & ramus up to mandibular foramen; protrusion, elevation & lateral positioning of mandible;

    Temporalis: origin is temporal fossa; inserts on ant border & medial surface of coronoid process & ant border of ramus; 3 component parts; positions mandible during elevation; post part retrudes mandible; ant part for clenching & final closure;

    Digastric muscle: ant digastric attachment at or near lower border of mandible & near midline; tendon btw ant & post portion attached to hyoid bone by loop-like tendon; ant part covered by platysma & beneath it lies mylohyoid & geniohyoid (all active in jaw opening);

Normal tooth wear: enamel wears ~30 µm /year (0.3 mm in 10 years); can be ~10x worse w/ abuse;

Major Closing Muscles: Masseter, medial pterygoid, anterior temporalis, & posterior temporalis

Gordon Christensen’s 6 pathologic conditions of occlusion: Bruxism- cow-clusion; excursive grinding; most prevalent (1/3 pop) &

    most destructive (teeth fucked by 40); 2 types, odontogenic or psychological (bruxism continues even after adjustments made): Tx via

    O splint & possible O equilibration (OE); Clenching- gater-clusion; centric grinding; k9 rise & incisal guidance become steeper; Tx w/ O splint or possible OE; Abfractions- caused by FL movement of teeth during occlusion; Tx w/ O splint or possible E; restore teeth if oosensitive; 1 O Trauma- abnormal loads on healthy teeth; Tx via OE; 2 O Trauma- perio disease w/ normal load; Tx via perio therapy

    & OE; TMD- often multifaceted w/psychological overlay; most (80%) short term TMD is muscular in nature & Tx via general dentist; limited opening, muscle pain, worried pt; Tx via O splint & possible E (if simple case);

Truths: everyone bruxes at night to some extent; not everyone w/ a CR/CO discrepancy needs Tx;

    Forces: post teeth accept & transmit ? vertical forces to periodontium (b/c ? root SA); ant teeth accept & transmit horizontal forces to

    periodontium;

    Anterior Coupling: in light centric contact, thin O paper (shimstock) should drag btw ants but hold on posts

     stMolar Disocclusion: measured from MB cusp tips of Man 1 molars; working 0.5mm; nonworking 1.0mm; protrusive 1.1mm;

    deviations (b/c articular disc) avg 0.3mm in working & 0.8mm in nonworking & protrusive

Restoring Bruxers: create long centric (1mm forward slide from CR) & wide centric occlusion (lateral shift) w/out much incisal

    guidance or k9 rise; posts are kept very flat & unilateral group function is used;

    Restoring Clenchers: restore worn ant teeth while maintaining I & k9 guidance at same angles present preoperatively (use I guide table & lingual contours of wax-up);

Posterior Determinants: dentist has no control over; condyle path influences mandible movement;

    Prevent Ant Guidance: interferences, rotations, supraeruptions; open or deep bite; no ant coupling; Class II or III O/skeletal; worn or missing teeth; malpositions; CR/CO discrepancy;

O Interferences: Centric- when closing w/ condyles in optimum position; Working- contact on working side must be enough to

    disocclude ant teeth; Nonworking- most destructive b/c changes in Man leverage, placement of forces outside long axis of teeth, & disruption of normal muscle function; Protrusive- occurs btw M of Man posts & D of Max posts; potentially destructive; interferes w/ pts ability to incise;

    Muscle hypertonicity: may give way to muscle fatigue & spasm w/ chronic headaches & localized muscle tenderness or TMJ dysfunction;

    Occlusion Organization: bilaterally balanced- complete dentures; maximum # of teeth should contact in ALL excursive movements; unilateral balanced (group function)- often w/flat post anatomy; use all post teeth on working side only during lateral excursion; for bruxers; for perio involved, bridged, implant, or malpositioned k9’s (class II or III); mutually (k9) protected occlusion- gater-clusion;

    ant guidance protects posts; posts protect ants at intercuspal position; depends on perio health of ants & class I orthodontic relationship

    of arches;

     oIncisal Angle vs Angle of Eminentia: condylar guidance- avg condyle incline angle ~30.4 to horizontal reference plane; protrusive ooincisal path- from I MI to edge to edge; ranges from 50-70 from horizontal reference plane; Healthy occlusion- ant guidance is ~5-10

    steeper than condylar path; Heavy molar contact- occurs when the angle of ant movement (I angle) is < angle of eminentia; causes destructive leverages (class I lever); Incisal angle must be ? angle of eminentia to prevent heavy molar contact;

    Incisal Inclination: if protrusive inclination is steep (or if I overlap is big)? post cusp height may be longer; if inclination is shallow (or if I overlap is minimal)? cusp height must be shorter;

K9s: Class II is worst; class I is Man I btw Max lat I & Max k9; Man incisal edge is higher on the L

FHO: Man I edge to Max tooth surface;

Overjet: Ortho; Max I edge to Man tooth surface

Ideal Ant Guidance & Post Disclusion: FHO= 0 mm (?= delay); VO= 4 mm (?=poor disclusion/shallow AG);

     oostPure hinge movement: 10-13 arc; 1 20-25 mm of opening; *use 10-15mm of opening for CR*

Qualitative method: only localization of O contacts can be determined; sequence or density can’t be evaluated;

Levers: class I- see-saw, hammer, scissors, hedge trimmers, pliers; class II- stapler, bottle opener, wheelbarrow, nail clippers,

    nutcracker; class III- fishing rod, tweezers, tongs, hockey stick, GS system;

    Temporalmandibular Joint: class III lever is inefficient & protective (further ant teeth receive less force)

    Protrusive interference: changes system to destructive class I lever (greater stress on ant); premature contact (Max D incline against Man M incline) causes displacement of condyle as fulcrum; change in force direction;

    CR/CO O Interference: double lever effect (class III to I); premature contact usually Man D incline contacting Max M incline; ? stress on ants; tendency to reseat condyle; bone loss, tooth & muscle symptoms

    Class II Lever: balancing side contacts; in lateral excursion, a prematurity on non-working side triggers a more forceful closure of muscles on non-working side; *if non-working premature contact is severe enough, the non-working condyle may overpower working condyle & become fulcrum, resulting in class I lever*; under these circumstances, there is a tendency to reseat working condyle into it’s fossa & restore it as fulcrum;

    Class I lever destruction: produces muscle spasms, tooth symptoms, mobility, & BL bone loss (espically on balancing side premature teeth); may also cause TMD & O trauma;

Interocclusal Pt records to relate casts: purpose of records is to provide vertical support & horizontal stability

Stable tripod: 3 widely spaced bilaterally positioned post contacts w/ good intercuspation that provide stable vertical support &

    horizontal stability;

MI: Hand Articulate- if stable tripod remains after tooth is prepped, no record in needed? use pt’s existing VDO & hand articulate

    casts (most accurate); Prep Index- if prepped tooth is part of tripod (tripod is lost) then a prep index record is needed for stability; use pt’s VDO; casts are hand articulated; Record Base- use when most of post teeth are prepped or oppose edentulous spaces; use pt’s VDO;

    CR: Record Base at slightly open VDO- pre tooth contact record taken before any tooth contacts can deflect mandible away from CR; reveals any discrepancy btw CR & MI; mounting used for O Dx; Record Base at VDO- used when (most teeth are) opposing

    edentulous ridges in areas of desired tripod stops; least accurate; Bilateral Record Base at slightly open VDO- used when more than 1

    prepped post tooth is needed to create 4 bilaterally positioned stops &/or clinician wants to mount master casts in CR;

Articulator Bennet movement: set medial wall on non-working side to accommodate for medial movement;

Lateral translation: Amount- controlled on articulator; immediate side shift- position of medial fossa wall on non-working side;

    progressive side shift- angle & contour of medial fossa wall on non-working side; Direction- controlled by superior & posterior fossa owalls contour on working side; most extreme movements fall within a 60 cone w/ a 3 mm height

O Adjustment Goals: Mandible in CR- no CR/MI discrepancy (CR=MI); cusp tip to flat surface; Simultaneous post teeth contacts- at

    least 1 centric stop per post tooth w/ even intensity; anterior coupling; Mandible in Lateral & Protrusive Excursions- tooth contact

    involves most stable teeth (not always k9 rise);

    O Adjustment contraindications: inability to define an end; more harm than good; interferences w/out signs/symptoms; few remaining teeth; ant open bite or excessive overlap; extensive crossbite; large lateral slide CR to MI; heavy wear facets or flat teeth; excessively

    mobile teeth;

    O Adjustment Steps: Baseline exam- everything in class & mobility, location/severity of wear facets & abfractions, function of closing & opening muscles, TMJ function, perio pocket depth, & radiographic eval; CR vs MI mounting- CR mounting w/ signs of instability

    (mobile teeth, wear facets, etc), restoring significant portion of dentition (over time), or restoring ants; MI mounting when pt has

    myofacial pain or TMD (CR only if possible) or if there are no signs of instability & only limited dental work is needed; Prescribe

    Optimal Excursive Patterns- exam reveals if pt’s gnathostomatic system is surviving; determine which teeth are capable of performing

    lateral excursive movements; Perform O adjustments on casts- normally ? adjustment on Max tooth & other ? on Man tooth; Decided

    if O adjustments only are needed or tooth needs to be restored- if restoration is needed, perform all adjustments on tooth (unless opposing tooth has supraerrupted);

    MUDL: mesial facing incline of upper..; identifies CR/MI interference; causes forward & vertical slide; adjustments remove CR/MI forward & vertical slide;

    LUBL: identifies potential working incline; causes lateral & vertical slide; maintenance of Rx only; adjustments remove working interferences & lateral & vertical CR/MI slide;

BULL: identifies potential balancing incline; causes lateral & vertical slide; adjustments remove non-working interferences & lateral

    & vertical CR/MI slide

DUML: identifies potential protrusive incline; corrected by equalization of ants & elimination of posts; adjustments remove protrusive

    interferences & possible non-working interferences;

    Contour Corrections: round all sharp edges on teeth or restorations, but do NOT alter functional contact areas; if O table has been broadened BL, it may be narrowed at expense of Max B & Man L;

    Posterior implants should only lightly contact when pt touches in CR/MI stAdjustments are performed on casts 1 b/c you don’t know when to stop & b/c of danger of losing VDO

    Freedom in Centric: occurs after final adjustments are made, but it is inevitable; represents tiny flat area btw terminal hinge closure in CR & pt’s old MI; if pt had a forward CR/MI slide before, they will have AP FIC; large FIC (especially laterally) is bad b/c 1 or both

    sets of working inclines are not available for immediate disclusion; prolonged contact of centric stops during lateral excursion places

    lateral stress on post teeth;

     O Marking Media: papers- thick?100-250 microns; poor flexibility (false marks & poor ability to mark mobile teeth); works poor in moisture; extra thin? 40-80 microns; poor flexibility; works fair in moisture; plastics- carbon on plastic; 21 microns (accufilm II);

    less artifacts; good flexibility (ok on mobile teeth, tough

    to tear, & good adaption); works good in moisture; liquids- 3 micron layer after solvent evaporates; for highly polished gold & ceramic; internal fit of indirect restorations; RPD frame on abutment teeth; proximal contacts; waxes- detects areas of premature O

    contact; may be used to check O reduction; 0.35mm; poor marks on mobile teeth; works excellent in moisture; sprays- test O contacts;

    accuracy of internal fit; proximal contacts; contact btw clips & implant bar;; foils- thinnest non-liquid (8-12 microns); more accurate

    than paper; greater pressure required for clinical use; final check of O contact intensity; micro abrasion- 50 micron aluminum oxide

    particles; creates dull finish on polished gold that will mark O & interproximal contacts; easily polish back to high gloss finish;

     CR/MI shift CR = MI

    Pure hinge (3-4); Initial tooth contact in CR (3); CR to MI discrepancy (3-2); Maximum opening (5); Protrusive/contacts (2-9); Incisal edge to edge (9); Maximum protrusion (6); Maximum pure hinge (4); Rest position (1); Habitual path of opening & closing (1-2); MI (2); Functional envelope (10)

Posselt’s envelope: border movements of Man are compilation of most extreme positions Man can assume; movements are traced

    from Man point incision in sagittal, horizontal (diamond) & frontal (tear drop) planes;

    Envelope of Function: determines anterior guidance; separate from condylar guidance;

    Envelope of Movement: functional movements of mandible occur within it;

Neutral Zone: major determinant of how ant teeth erupt into mouth? programs envelope of function;

Lateral Envelope of function: establish TMJ stability? create harmonious ant guidance? establish stable holding contacts of equal

    intensity on all post teeth

    Lateral excursions

Anterior Guidance & Smile Design: Man I’s should have a labio-incisal line angle (not rounded); 1) L of Max I’s should have stops

    for Man I edges so they don’t supra erupt; 2) cervical portion of labial contour; 3) incisal portion of labial contour; 4) contour &

    position incisal edge & contour of incisal plane; 5) lingual contour/ AG

    stIncisal Edge position: must 1 determine inclination of Max ant teeth & labial contours; vertical position of incisal edges is dependent

    on horizontal position which is controlled by contour & position of labial surfaces

    Functional Harmony in Ant Guidance: 1) establish coordinated centric relation stops on all ant teeth- remove interferences; if no contact? grind down centric stops, build up to contact, or do nothing; 2) extend centric stops forward at same VD to include light closure from postural rest position- articulating paper checks if stops in postural positions interfere w/ stops produced in supine

    position (if so adjust); 3) determine incisal edge position; 4) establish group function in straight protrusion; 5) establish ideal anterior

     stress distribution in lateral excursions; *Always recheck post occlusion after ant guidance is altered*

    If post teeth separate ant teeth in protrusive, a protrusive bite record should be made & condylar guidance should be set on the

    articulator; this enables you to determine how much correction is needed on post teeth;

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