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Occlusodontia in Restorations*
OCCLUSODONTIA IN RESTORATIONS* B y E . R A Y B R O W N S O N , D . D . S., L o s A n g e le s , C a lif.
H E crux of restorations is balanced physiologic cuspidation; in other words, cuspidation as near the ideal anatomic depth and sharpness as the mechanics of the individual case1 will permit. In 1917, I established, at the University of Southern California, the first course in restorations, and now after fourteen years of experience2 with the various technics and instruments, trying to attain an ideal, it is with some enthusiasm that I submit the follow ing finding, namely, that the relator and plastic technic, permitting an unlimited range of adjustment to register curves or planes, are balancing fundamentals fo r those w h o k n o w the prin cip les, technical steps3 and classifications laid down by Joseph Homer, o f N ew Y ork City, who has given us, among other things, the only instrumental incisor guidance that is technically useful.
T
H . Doregkamp, of M ilw aukee; Clark Giles, o f San Francisco; H . C. Peisch, J. W . M artin and Lee K. Stewart, of Pasadena, and E. Ray Kibler, E. E. Kirtlan, C. M . Benbrook, W . H. Spinks, C. G - Hartley and G . B. Baird, of Los Angeles.
Rewm m q Central-CCC is Ceomemt
T his finding is based on practice and the opinions o f Sam Supplee; W . A . Giffen, of D etroit; John H . Hospers, of Chicago; E. J. W eaver and G . * “ O cclu sod on tia” is defined on p age
141 ,
T h e J o u r n a l , January, 1 9 2 8 .
*R ea d b e fo re the Section on P a rtia l D e n ture Prosthesis at the S eventieth A n n u al Session o f the A m e rica n D en tal A ssociation , M in n ea polis, M inn., A u g . 22, 1928. 1. H om er, Josep h : 36:213 (A p r il) 1928.
P a cific
D ent.
G a z .,
2. Bull. C ol. Dent., U n iv. Southern C a li fo rn ia , 1918, p. 8. 3.
H om er, Josep h :
O cclu sod ontia
1927.
Jo u r. A . D . A ., Jun e, 1929
N otes,
Recording Manti buia M o v * m e n is i s E la s t ic .
F ig. 1.— T e ch n ic o f registrations and m ak in g n eg a tiv es o f m and ibu lar m ovem ents. A d etailed descrip tion is g iv e n on pages 136-139 o f T h e J o u r n a l , January, 1928. Figures 1-12 illustrate T e ch n ic 3. R estoration cases natu rally fa ll into three classes, req u irin g different technics fo r their rem edy. Class 1 includes cases in w h ich the occlu sion is partly traum atic. Class 2 includes cases in occlu sions that are entirely traum atic.
1047
1048
T h e Journal of the Am erican D en ta l Association
C lass 3 includes cases in w h ich orth odon tic treatm ent o r b ite-ad van cem en t is indicated.
A ll three technics include reproduc ing mandibular movements and the actual relation of the maxillary line of occlusion with the mandibular line of oc clusion or curve of spee under function
usual way and registrations are taken before the impressions. T h e case is mounted on a relator, and after the instrumental condyle and incisor paths or negatives are made, the cusps of the abutments and supplies, or the models o f the op p osin g natu ral teeth, are
(F ig. 1) for a preliminary survey (F ig. 2 ) and removal o f trauma when present. Technic 1 is used principally where many teeth are to be supplied in both jaws. T h e occluding abutments or in lays which collectively establish cusp height and angulation are made in the
lengthened for balance, which is “ equal ized pressure on the supporting tissues,” and shortened for interference. T h e natu ral teeth w hose m od els are so altered must be correspondingly altered after construction is complete. T h is is accomplished by placing the restorations
B row nson— Occlusodontia in Restorations
in the mouth, then spot grinding and placing inlays where necessary, having the patient grind balancing angulations on the w ax forms for these inlays in the mouth. Finished construction is finally adjusted and milled on the relator and in the mouth.
1049
lish cusp angulations and height (having regard fo r ce n tra l occlu sion o n l y ) . Castings are then made for all other preparations to just cover the cavities with no cuspidation. Registrations and impressions should be taken with the completed inlays in
F ig. 3.— Bite op en in g and a d v a n cin g splint.
T echn ic 2, which I helped to develop, is used for bite-opening cases having all natural bicuspids or second bicuspids and first molars retained, and is princi pally used where no teeth are to be supplied and the entire occlusion is constructed. A fter all preparations are completed, castings are formed on the four bicuspids or second bicuspids and first molars to open the bite and estab-
the bicuspids or “ molars” and the cast ings without cusps in the rest o f the teeth. Casts are mounted on a relator, negatives are made and w ax is built up to balance (having a regard for anatomy) on all cuspless castings, and a second set o f castings is made direct to the first castings. A n y lack of balance or interference is corrected in the bi cuspid or “ molars” castings, after which
1050
T h e Journal of the American D en ta l Association
the case is finally adjusted and milled on the relator. T echn ic 3 is indicated where orthedontic treatment4 or bite advancement is advisable, and may be used on all bite-opening cases. A bite-opening splint establishing counters of cusp height and angulation is made of vulcanite (F ig.
upper or lower cusps of the models mounted on the instrument, wherever necessary to give balance and esthetics. A ll upper wax cusps are joined together and all lowers likewise, and are cast in one piece, or separately and assembled, such clasps being made as are necessary for retention. T his makes two more,
F ig. 4.— G o ld b a lan cin g splints.
3 ) . A n y bite advan cem en t is also recorded by this splint, and after adjust ments, registrations are taken of the masticating positions with it in the mouth and reproduced on the relator. T his splint is then removed from the models and wax cusps are built on either
4. Footnote 1, p. 214.
called balancing splints (F ig. 4 ) , which are adjusted on the instrument and in the mouth by spot grinding, milling and cusp lengthening, after which a lock in cisor splint (F ig . 5 ) or fourth and last is cast, the wax being formed with the balancing splints in the mouth. T h e lock incisor splint (to maintain and check correct central occlusion in the
B row n son — Occlusodontia in Restorations
1051
open bite relation) and one balancing splint are placed in the mouth, and the operator proceeds with construction (F ig. 6) opposite the balancing splint, which is then removed, and construction fin ished (F ig. 7) on its side, the lock incisor splint being retained in position till all construction is complete.
1. A double compound impression is best for surveys, or occlusal surfaces. A n impression is seated, removed, and drawn places trimmed, semi-cooled, re seated and removed. Then, a small roll of soft compound is placed in the thoroughly chilled impression, so placed and seated as not to enter undercuts.
A ll construction is made with regard to c e n t r a l o c c lu s i o n o n ly as a ll balancing cusp angulations have been established by the balancing splints. T h e finished construction should be adjusted and milled on the relator and finally in the mouth to overcome co efficient and cumulative error. Pertinent findings by D r. H om er are :
Reheating this surface is only permissible by dipping in hot water for five seconds. 2. T h e occlusion is guided hori zontally by the condyle paths and vertically by cusps. If the occlusion were guided solely by the condyle paths, there would be no cusps. If it were controlled solely by cusps (which would in clu d e m a x illo m a n d ib u la r d e v e lo p
1052
T h e Journal of the Am erican D en ta l Association
m ent), there would be no traumatic the patient is asked to close again hard occlusion. in the same position to correct distor 3. Registration o f lateral and pro tion . T h is fre q u e n tly necessitates v u lc a n iz in g tem pora ry reg istra tion trusive mandibular stresses is artistic and plastic rather than mechanical or plates (refitted to cast with a compound g e o m e t r i c , as f o l l o w s : T r y i n g to lining) and removing obvious trauma measure tissue resiliency in pounds or before registrations, which should always controlling it with a spring mechanism be checked. is of no practical value as a few pounds 4. T w o registrations should be taken
compress the tissues as much as many for all practical purposes. So far, the best technic is to have patients close gently on a relator register between cusp in clinations selected for the case, instruct ing them to feel the teeth touch through the wax (which in reality is usually not quite or barely through at one or two places). T hen the wax is chilled and
for each masticating position: one, end to end, and another one one-sixteenth inch beyond. T his permits more accurate reproduction of condyle and incisor path curves on the relator. 5. Central occlusion is best obtained by having the patient let the jaw hang loosely about one-half inch from the maxilla and fall toward the maxilla on
B row n son — Occlusodontia in Restorations
a horseshoe-shaped piece of softened true wax. A fter chilling, say to patient “ Let the jaw hang.” “ Let your teeth fall to gether,” and “ N ow , bite hard.” Repeat until the patient gives successive iden tical closures from the same relaxed position. 6. Face-bows and gothic arch trac-
1053
tween the gingival enamel margins of opposing central incisors. 8. Balance is direct or indirect; that is there may be contact on each tooth, or there can be from one to three contacts that w ill balance masticating forces on a number of opposed, joined teeth.
F ig . 7.— U p p er and lo w e r construction com plete, w ith lock splint.
9. Balancing restorations where the bite is opened is not for the average dentist or pocketbook. 10. Natural dentures of a healthy 7. Opening the bite 2 mm. usually patient should not be mutilated by bal removes all occlusal trauma. Starting ancing restorations. points are 15, 18 and 21 mm. (fo r
ings are tim e-w astin g co m p lica tio n s because better w ork cannot be effected by their use.5
short, medium and long crow ns)
beD IS C U S S IO N
5. H om er, J o se p h : D isc, o f H anan , R. L .: J. H . H ospers, C hicago, I I I . : D r . B r o w n Bull. C h ica g o D en t. Soc., 6:8 (A u g . 6) 1928. son fa ile d to stress the use o f the instrum ent
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T h e Journal of the Am erican D en ta l Association
w ith w h ich this difficult task w a s accom plished. T h e r e should be no stint o f praise to D r. H o m e r fo r g iv in g us this unique and lo g ica l m ethod o f re p ro d u cin g the m ovem ents o f the hum an ja w . O cclu sod on tia 6 o r the science and art o f relatin g the occlu sal su rfaces o f teeth in the p rop er fu n ction in g p lane has re ce iv e d an epochal contribution in the relator, w h ich is cap able o f m a k in g an in d iv id u a l n egative o f the con d y le path and in cisor path fo r every
patient. T h e r e is nothin g g eom etric about it, an d its use requires on ly a com m on sense interpretation o f N atu re’s law s. I have used a relator f o r three and o n e -h a lf y e a rs and find it p e rfe ct. In fa ct, any im perfection s in the ba lan ce o f a com pleted denture can r e a d ily be tra ced to an e rro r on m y part. W h e n it is necessary to open a bite, I have fo u n d the fo llo w in g a satisfa ctory m ethod
o f obta in in g the co n d y la r reg istra tion s: Use the flat horseshoe plate as a tray and take an im pression o f the upper on e-th ird o f the lo w e r teeth. A p p ly w a x and lam pblack fo r the m akin g o f the g oth ic arch. A p p ly v aselin e to the up p er su rface o f the h orse shoe p late and rep la ce o v e r the lo w e r teeth. Soften the m od e lin g com p oun d and fo rm into a roll, p lace on top o f the horseshoe plate and close the up p er teeth into it. Fasten the G y si in cisor path m arker into the com
p ound at the m edian line and cool th or ough ly. T h e com p ou n d im pression o f the u p p er teeth w ill slide fr e e ly ov e r the upper su rfa ce o f the horseshoe plate. D r o p the pin in the in cisor path m arker and d evelop the triangle. T h e n , w ith the pin, in the apex o f the tria n g le, make lock blocks o f com pou n d to hold the parts together. R em ove ev eryth in g fr o m the mouth and lock the horsesh oe plate and upper com poun d to 6. Defined on page 141 of T he J o u r n a l , gether. Fit the m odels into the com poun d January, 1928. and m ount on the relator. L oosen the lock
Broivnson— Occlusodontia in Restorations blocks and raise all screw s on the relator. F ill the cups w ith soft com p oun d and make all m ovem ents by fo llo w in g the g oth ic arch tracin g. T h e entire range has been re p r o duced w ithout checkbites and b e fo re w e have an y cusp inclinations to help g u id e us. It is then p ossible to articulate the restorations alm ost p erfectly . T h e balance can then be refined b y using the usual tech nic o f w a x registers. T h e d etail w ill be sim plified to
1055
not think that deep cusps are so essential as continuous contact o f the u p p er and lo w e r fa cets in all w o r k in g positions. F ood is cut and ch op ped through the scissors action and not through m illin g as o f lon g cusps w o rk in g in deep sulci. T h e relator m akes p os sible the p rod u ction o f this continuous contact and that is w h y such efficient restor ations can be p rod u ced . I d o not like the idea o f restorin g a mouth w ith large
F ig. 9.— C om pleted case in b a la n cin g position.
a la rg e extent in T e ch n ic 2 if this p roced u re is fo llo w e d .
“ D u ra tion
o f denture
service
d epen ds on the con d ition o f the su pp ortin g tissues.
T issu es in turn are affected by the
d entures w h ich they support.
C on servation
o f these tissues is the param ou n t p rob lem . The
solution is ba lan ced o cclu sion .” '
I do
quantities o f g o ld . Instead o f g o ld crow n s, p o rce la in ven eer crow n s and occlu sal pin 7. C am pbell, D . D . : D isc, o f W rig h t, W . H .: A n a tom ic. Influences on E stablish ment o f B alan ced J a w R elations and B a l an ced O cclusions, J. A . D . A ., 15:1102 (J u n e) 1928.
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T h e Journal of the Am erican D en ta l Association
onlays held in p lace w ith three o r fo u r pins are p ra cticable. P orcela in ja ck et cro w n s must be w atched and checked fre q u e n tly fo r stress. T h e y do not w e a r d o w n and, in time, all the stress o f closure is taken by them. U nless occasional correction s are m ade, o v e r stress w ill cause break a ge o r serious im p a ir ment to the su pp ortin g tissues. G en era lly speaking, rad ica l op e n in g o f the bite is not attended w ith the m ost n e a rly p erm an ent
p ro v e d best in m y h and s a fte r m any years o f try in g different technics and p rocedures. T h e r e fo r e , I d id not g o into d eta iled d is cussion o f the relator. I am g la d D r. H ospers d id this, but he can n ot m ean that the relator is not g eom etric because it is used tech nically and accurately. In or d e r to take accurate checkbites o r registrations, w e must first estab lish cusp an gu lation and height, so as to record accurately in the register any d iscrep
results. T h e an terior teeth should be co m pleted first to get the p ro p e r length and contour. M o d e lin g com p ou n d im pressions are the best; but one m ust k n o w h o w to take a m od elin g com poun d im pression . I agree with D r. H o m e r’ s fin din gs on the fu tility o f the fa c e - b o w ; but the use o f the goth ic arch tra cin g has been a v a lu a b le aid and time sa v e r to me. D r. B ro ivn so n (c lo s in g ): M y p a p e r w as g iv en as a technic, d e scrib in g w h at has
ancies in the horizontal relations o f the m a x illa to the m an d ible in fu n ction , w h ich in ter ests us m ore than the m ovem ents o f the condyle. T a k in g registrations is not accom plished by slid in g the teeth. T h e m outh is opened and closed in the position in w h ich w e w ish to take the registration. R e fe r to the third pertinent fin din gs by D r. H om er, in m y paper. I am sorry to see D r. H ospers g o in g to the extra trou ble o f m akin g goth ic arches. I f w e look in the in cisor g u id e com -
B row n son — Occlusodontia in Restorations
1057
F ig. 11.— A : C om pleted case w ith a 5 mm. bite op e n in g and a 3 mm. ad van ce. (T h e bite w as ad v an ced to elim inate orth od on tic m ovem ent o f the low er six an terior teeth, this bein g p referre d by the patien t.) B : C ase as presented and hypertrophy of the an terior gum s due to traum a. C : L ingual gum h yp ertrop h y due to traum a.
Fig. 12.—Construction anatomy.
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T h e Journal o f the Am erican D en ta l Association
Fig. 13.— Bite op en in g o f 7 mm. w h ich retruded the lo w e r ja w 2 mm. in central relation as com p ared to central relation b e fo re construction. Casts at the right sh ow the case as p re sented. (T e c h n ic 2.)
Fig. 14-,—Anatomy of completed construction. (Technic 2.)
H artm an— G o ld F oil in the A n terior T eeth
1059
F ig. 15.— C ase b e fo r e and after con stru ction ; a reduction o f the ab n orm a l relations o f the lateral cu sp id an d bicu sp id . (T e c h n ic 1.) pound a fte r the n eg a tiv e has been m ade, w e w ill see the useful part o f the g oth ic arch, not one m ade on a flat su rface, but a path fo r the in cisor guid e, up and d o w n , o v e r cusp an g u lation and height. T h e r e fo r e , w e see w h y it is tim e w asted to trace a g oth ic arch. I h ave
record s sh ow in g tissues returned to norm al and teeth, loosen ed fr o m traum a, tightened in fr o m seven to ten days, in cases in w h ich n orm al cusps rather than sh a llow ones fu ll o f fa cets w e r e used, because, w ith norm al cusps, there is a lack o f friction a l contact.
USE OF GOLD FOIL IN THE FILLING OF CAVITIES IN THE ANTERIOR TEETH* B y L E R O Y L . H A R T M A N , D .D .S ., N e w Y o r k C ity
H E purpose o f this paper is to pre sent a definite stroke technic in cavity preparation and to emphasize certain points in the manipulation of gold foil which w ill make its use comfortable for the patient and a pleasure to the operator. In our study and treatment of caries o f teeth, our first consideration should be for our patients. T h e earlier we de tect caries and effect its removal, the
T
*R ea d b e fo r e the Section on O p era tive D en tistry at the M id w in te r C lin ic o f the C h i c a g o D ental Society, Jan. 15, 1929.
Jo u r. A . D . A ., Ju n e, 1929
greater the possibility o f safeguarding the vitality o f the dental pulp. T h e cavities should be so prepared as to minimize the recurrence o f caries and the filling mate rials used should restore the teeth to their normal function. W hen caries attacks the anterior teeth and the patients present themselves to us for treatment, they are particularly in terested in the appearance o f any restora tion which w e might suggest and one of their first questions is, usually, “ Is the
H E crux of restorations is balanced physiologic cuspidation; in other words, cuspidation as near the ideal anatomic depth and sharpness as the mechanics of the individual case1 will permit. In 1917, I established, at the University of Southern California, the first course in restorations, and now after fourteen years of experience2 with the various technics and instruments, trying to attain an ideal, it is with some enthusiasm that I submit the follow ing finding, namely, that the relator and plastic technic, permitting an unlimited range of adjustment to register curves or planes, are balancing fundamentals fo r those w h o k n o w the prin cip les, technical steps3 and classifications laid down by Joseph Homer, o f N ew Y ork City, who has given us, among other things, the only instrumental incisor guidance that is technically useful.
T
H . Doregkamp, of M ilw aukee; Clark Giles, o f San Francisco; H . C. Peisch, J. W . M artin and Lee K. Stewart, of Pasadena, and E. Ray Kibler, E. E. Kirtlan, C. M . Benbrook, W . H. Spinks, C. G - Hartley and G . B. Baird, of Los Angeles.
Rewm m q Central-CCC is Ceomemt
T his finding is based on practice and the opinions o f Sam Supplee; W . A . Giffen, of D etroit; John H . Hospers, of Chicago; E. J. W eaver and G . * “ O cclu sod on tia” is defined on p age
141 ,
T h e J o u r n a l , January, 1 9 2 8 .
*R ea d b e fo re the Section on P a rtia l D e n ture Prosthesis at the S eventieth A n n u al Session o f the A m e rica n D en tal A ssociation , M in n ea polis, M inn., A u g . 22, 1928. 1. H om er, Josep h : 36:213 (A p r il) 1928.
P a cific
D ent.
G a z .,
2. Bull. C ol. Dent., U n iv. Southern C a li fo rn ia , 1918, p. 8. 3.
H om er, Josep h :
O cclu sod ontia
1927.
Jo u r. A . D . A ., Jun e, 1929
N otes,
Recording Manti buia M o v * m e n is i s E la s t ic .
F ig. 1.— T e ch n ic o f registrations and m ak in g n eg a tiv es o f m and ibu lar m ovem ents. A d etailed descrip tion is g iv e n on pages 136-139 o f T h e J o u r n a l , January, 1928. Figures 1-12 illustrate T e ch n ic 3. R estoration cases natu rally fa ll into three classes, req u irin g different technics fo r their rem edy. Class 1 includes cases in w h ich the occlu sion is partly traum atic. Class 2 includes cases in occlu sions that are entirely traum atic.
1047
1048
T h e Journal of the Am erican D en ta l Association
C lass 3 includes cases in w h ich orth odon tic treatm ent o r b ite-ad van cem en t is indicated.
A ll three technics include reproduc ing mandibular movements and the actual relation of the maxillary line of occlusion with the mandibular line of oc clusion or curve of spee under function
usual way and registrations are taken before the impressions. T h e case is mounted on a relator, and after the instrumental condyle and incisor paths or negatives are made, the cusps of the abutments and supplies, or the models o f the op p osin g natu ral teeth, are
(F ig. 1) for a preliminary survey (F ig. 2 ) and removal o f trauma when present. Technic 1 is used principally where many teeth are to be supplied in both jaws. T h e occluding abutments or in lays which collectively establish cusp height and angulation are made in the
lengthened for balance, which is “ equal ized pressure on the supporting tissues,” and shortened for interference. T h e natu ral teeth w hose m od els are so altered must be correspondingly altered after construction is complete. T h is is accomplished by placing the restorations
B row nson— Occlusodontia in Restorations
in the mouth, then spot grinding and placing inlays where necessary, having the patient grind balancing angulations on the w ax forms for these inlays in the mouth. Finished construction is finally adjusted and milled on the relator and in the mouth.
1049
lish cusp angulations and height (having regard fo r ce n tra l occlu sion o n l y ) . Castings are then made for all other preparations to just cover the cavities with no cuspidation. Registrations and impressions should be taken with the completed inlays in
F ig. 3.— Bite op en in g and a d v a n cin g splint.
T echn ic 2, which I helped to develop, is used for bite-opening cases having all natural bicuspids or second bicuspids and first molars retained, and is princi pally used where no teeth are to be supplied and the entire occlusion is constructed. A fter all preparations are completed, castings are formed on the four bicuspids or second bicuspids and first molars to open the bite and estab-
the bicuspids or “ molars” and the cast ings without cusps in the rest o f the teeth. Casts are mounted on a relator, negatives are made and w ax is built up to balance (having a regard for anatomy) on all cuspless castings, and a second set o f castings is made direct to the first castings. A n y lack of balance or interference is corrected in the bi cuspid or “ molars” castings, after which
1050
T h e Journal of the American D en ta l Association
the case is finally adjusted and milled on the relator. T echn ic 3 is indicated where orthedontic treatment4 or bite advancement is advisable, and may be used on all bite-opening cases. A bite-opening splint establishing counters of cusp height and angulation is made of vulcanite (F ig.
upper or lower cusps of the models mounted on the instrument, wherever necessary to give balance and esthetics. A ll upper wax cusps are joined together and all lowers likewise, and are cast in one piece, or separately and assembled, such clasps being made as are necessary for retention. T his makes two more,
F ig. 4.— G o ld b a lan cin g splints.
3 ) . A n y bite advan cem en t is also recorded by this splint, and after adjust ments, registrations are taken of the masticating positions with it in the mouth and reproduced on the relator. T his splint is then removed from the models and wax cusps are built on either
4. Footnote 1, p. 214.
called balancing splints (F ig. 4 ) , which are adjusted on the instrument and in the mouth by spot grinding, milling and cusp lengthening, after which a lock in cisor splint (F ig . 5 ) or fourth and last is cast, the wax being formed with the balancing splints in the mouth. T h e lock incisor splint (to maintain and check correct central occlusion in the
B row n son — Occlusodontia in Restorations
1051
open bite relation) and one balancing splint are placed in the mouth, and the operator proceeds with construction (F ig. 6) opposite the balancing splint, which is then removed, and construction fin ished (F ig. 7) on its side, the lock incisor splint being retained in position till all construction is complete.
1. A double compound impression is best for surveys, or occlusal surfaces. A n impression is seated, removed, and drawn places trimmed, semi-cooled, re seated and removed. Then, a small roll of soft compound is placed in the thoroughly chilled impression, so placed and seated as not to enter undercuts.
A ll construction is made with regard to c e n t r a l o c c lu s i o n o n ly as a ll balancing cusp angulations have been established by the balancing splints. T h e finished construction should be adjusted and milled on the relator and finally in the mouth to overcome co efficient and cumulative error. Pertinent findings by D r. H om er are :
Reheating this surface is only permissible by dipping in hot water for five seconds. 2. T h e occlusion is guided hori zontally by the condyle paths and vertically by cusps. If the occlusion were guided solely by the condyle paths, there would be no cusps. If it were controlled solely by cusps (which would in clu d e m a x illo m a n d ib u la r d e v e lo p
1052
T h e Journal of the Am erican D en ta l Association
m ent), there would be no traumatic the patient is asked to close again hard occlusion. in the same position to correct distor 3. Registration o f lateral and pro tion . T h is fre q u e n tly necessitates v u lc a n iz in g tem pora ry reg istra tion trusive mandibular stresses is artistic and plastic rather than mechanical or plates (refitted to cast with a compound g e o m e t r i c , as f o l l o w s : T r y i n g to lining) and removing obvious trauma measure tissue resiliency in pounds or before registrations, which should always controlling it with a spring mechanism be checked. is of no practical value as a few pounds 4. T w o registrations should be taken
compress the tissues as much as many for all practical purposes. So far, the best technic is to have patients close gently on a relator register between cusp in clinations selected for the case, instruct ing them to feel the teeth touch through the wax (which in reality is usually not quite or barely through at one or two places). T hen the wax is chilled and
for each masticating position: one, end to end, and another one one-sixteenth inch beyond. T his permits more accurate reproduction of condyle and incisor path curves on the relator. 5. Central occlusion is best obtained by having the patient let the jaw hang loosely about one-half inch from the maxilla and fall toward the maxilla on
B row n son — Occlusodontia in Restorations
a horseshoe-shaped piece of softened true wax. A fter chilling, say to patient “ Let the jaw hang.” “ Let your teeth fall to gether,” and “ N ow , bite hard.” Repeat until the patient gives successive iden tical closures from the same relaxed position. 6. Face-bows and gothic arch trac-
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tween the gingival enamel margins of opposing central incisors. 8. Balance is direct or indirect; that is there may be contact on each tooth, or there can be from one to three contacts that w ill balance masticating forces on a number of opposed, joined teeth.
F ig . 7.— U p p er and lo w e r construction com plete, w ith lock splint.
9. Balancing restorations where the bite is opened is not for the average dentist or pocketbook. 10. Natural dentures of a healthy 7. Opening the bite 2 mm. usually patient should not be mutilated by bal removes all occlusal trauma. Starting ancing restorations. points are 15, 18 and 21 mm. (fo r
ings are tim e-w astin g co m p lica tio n s because better w ork cannot be effected by their use.5
short, medium and long crow ns)
beD IS C U S S IO N
5. H om er, J o se p h : D isc, o f H anan , R. L .: J. H . H ospers, C hicago, I I I . : D r . B r o w n Bull. C h ica g o D en t. Soc., 6:8 (A u g . 6) 1928. son fa ile d to stress the use o f the instrum ent
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w ith w h ich this difficult task w a s accom plished. T h e r e should be no stint o f praise to D r. H o m e r fo r g iv in g us this unique and lo g ica l m ethod o f re p ro d u cin g the m ovem ents o f the hum an ja w . O cclu sod on tia 6 o r the science and art o f relatin g the occlu sal su rfaces o f teeth in the p rop er fu n ction in g p lane has re ce iv e d an epochal contribution in the relator, w h ich is cap able o f m a k in g an in d iv id u a l n egative o f the con d y le path and in cisor path fo r every
patient. T h e r e is nothin g g eom etric about it, an d its use requires on ly a com m on sense interpretation o f N atu re’s law s. I have used a relator f o r three and o n e -h a lf y e a rs and find it p e rfe ct. In fa ct, any im perfection s in the ba lan ce o f a com pleted denture can r e a d ily be tra ced to an e rro r on m y part. W h e n it is necessary to open a bite, I have fo u n d the fo llo w in g a satisfa ctory m ethod
o f obta in in g the co n d y la r reg istra tion s: Use the flat horseshoe plate as a tray and take an im pression o f the upper on e-th ird o f the lo w e r teeth. A p p ly w a x and lam pblack fo r the m akin g o f the g oth ic arch. A p p ly v aselin e to the up p er su rface o f the h orse shoe p late and rep la ce o v e r the lo w e r teeth. Soften the m od e lin g com p oun d and fo rm into a roll, p lace on top o f the horseshoe plate and close the up p er teeth into it. Fasten the G y si in cisor path m arker into the com
p ound at the m edian line and cool th or ough ly. T h e com p ou n d im pression o f the u p p er teeth w ill slide fr e e ly ov e r the upper su rfa ce o f the horseshoe plate. D r o p the pin in the in cisor path m arker and d evelop the triangle. T h e n , w ith the pin, in the apex o f the tria n g le, make lock blocks o f com pou n d to hold the parts together. R em ove ev eryth in g fr o m the mouth and lock the horsesh oe plate and upper com poun d to 6. Defined on page 141 of T he J o u r n a l , gether. Fit the m odels into the com poun d January, 1928. and m ount on the relator. L oosen the lock
Broivnson— Occlusodontia in Restorations blocks and raise all screw s on the relator. F ill the cups w ith soft com p oun d and make all m ovem ents by fo llo w in g the g oth ic arch tracin g. T h e entire range has been re p r o duced w ithout checkbites and b e fo re w e have an y cusp inclinations to help g u id e us. It is then p ossible to articulate the restorations alm ost p erfectly . T h e balance can then be refined b y using the usual tech nic o f w a x registers. T h e d etail w ill be sim plified to
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not think that deep cusps are so essential as continuous contact o f the u p p er and lo w e r fa cets in all w o r k in g positions. F ood is cut and ch op ped through the scissors action and not through m illin g as o f lon g cusps w o rk in g in deep sulci. T h e relator m akes p os sible the p rod u ction o f this continuous contact and that is w h y such efficient restor ations can be p rod u ced . I d o not like the idea o f restorin g a mouth w ith large
F ig. 9.— C om pleted case in b a la n cin g position.
a la rg e extent in T e ch n ic 2 if this p roced u re is fo llo w e d .
“ D u ra tion
o f denture
service
d epen ds on the con d ition o f the su pp ortin g tissues.
T issu es in turn are affected by the
d entures w h ich they support.
C on servation
o f these tissues is the param ou n t p rob lem . The
solution is ba lan ced o cclu sion .” '
I do
quantities o f g o ld . Instead o f g o ld crow n s, p o rce la in ven eer crow n s and occlu sal pin 7. C am pbell, D . D . : D isc, o f W rig h t, W . H .: A n a tom ic. Influences on E stablish ment o f B alan ced J a w R elations and B a l an ced O cclusions, J. A . D . A ., 15:1102 (J u n e) 1928.
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onlays held in p lace w ith three o r fo u r pins are p ra cticable. P orcela in ja ck et cro w n s must be w atched and checked fre q u e n tly fo r stress. T h e y do not w e a r d o w n and, in time, all the stress o f closure is taken by them. U nless occasional correction s are m ade, o v e r stress w ill cause break a ge o r serious im p a ir ment to the su pp ortin g tissues. G en era lly speaking, rad ica l op e n in g o f the bite is not attended w ith the m ost n e a rly p erm an ent
p ro v e d best in m y h and s a fte r m any years o f try in g different technics and p rocedures. T h e r e fo r e , I d id not g o into d eta iled d is cussion o f the relator. I am g la d D r. H ospers d id this, but he can n ot m ean that the relator is not g eom etric because it is used tech nically and accurately. In or d e r to take accurate checkbites o r registrations, w e must first estab lish cusp an gu lation and height, so as to record accurately in the register any d iscrep
results. T h e an terior teeth should be co m pleted first to get the p ro p e r length and contour. M o d e lin g com p ou n d im pressions are the best; but one m ust k n o w h o w to take a m od elin g com poun d im pression . I agree with D r. H o m e r’ s fin din gs on the fu tility o f the fa c e - b o w ; but the use o f the goth ic arch tra cin g has been a v a lu a b le aid and time sa v e r to me. D r. B ro ivn so n (c lo s in g ): M y p a p e r w as g iv en as a technic, d e scrib in g w h at has
ancies in the horizontal relations o f the m a x illa to the m an d ible in fu n ction , w h ich in ter ests us m ore than the m ovem ents o f the condyle. T a k in g registrations is not accom plished by slid in g the teeth. T h e m outh is opened and closed in the position in w h ich w e w ish to take the registration. R e fe r to the third pertinent fin din gs by D r. H om er, in m y paper. I am sorry to see D r. H ospers g o in g to the extra trou ble o f m akin g goth ic arches. I f w e look in the in cisor g u id e com -
B row n son — Occlusodontia in Restorations
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F ig. 11.— A : C om pleted case w ith a 5 mm. bite op e n in g and a 3 mm. ad van ce. (T h e bite w as ad v an ced to elim inate orth od on tic m ovem ent o f the low er six an terior teeth, this bein g p referre d by the patien t.) B : C ase as presented and hypertrophy of the an terior gum s due to traum a. C : L ingual gum h yp ertrop h y due to traum a.
Fig. 12.—Construction anatomy.
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Fig. 13.— Bite op en in g o f 7 mm. w h ich retruded the lo w e r ja w 2 mm. in central relation as com p ared to central relation b e fo re construction. Casts at the right sh ow the case as p re sented. (T e c h n ic 2.)
Fig. 14-,—Anatomy of completed construction. (Technic 2.)
H artm an— G o ld F oil in the A n terior T eeth
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F ig. 15.— C ase b e fo r e and after con stru ction ; a reduction o f the ab n orm a l relations o f the lateral cu sp id an d bicu sp id . (T e c h n ic 1.) pound a fte r the n eg a tiv e has been m ade, w e w ill see the useful part o f the g oth ic arch, not one m ade on a flat su rface, but a path fo r the in cisor guid e, up and d o w n , o v e r cusp an g u lation and height. T h e r e fo r e , w e see w h y it is tim e w asted to trace a g oth ic arch. I h ave
record s sh ow in g tissues returned to norm al and teeth, loosen ed fr o m traum a, tightened in fr o m seven to ten days, in cases in w h ich n orm al cusps rather than sh a llow ones fu ll o f fa cets w e r e used, because, w ith norm al cusps, there is a lack o f friction a l contact.
USE OF GOLD FOIL IN THE FILLING OF CAVITIES IN THE ANTERIOR TEETH* B y L E R O Y L . H A R T M A N , D .D .S ., N e w Y o r k C ity
H E purpose o f this paper is to pre sent a definite stroke technic in cavity preparation and to emphasize certain points in the manipulation of gold foil which w ill make its use comfortable for the patient and a pleasure to the operator. In our study and treatment of caries o f teeth, our first consideration should be for our patients. T h e earlier we de tect caries and effect its removal, the
T
*R ea d b e fo r e the Section on O p era tive D en tistry at the M id w in te r C lin ic o f the C h i c a g o D ental Society, Jan. 15, 1929.
Jo u r. A . D . A ., Ju n e, 1929
greater the possibility o f safeguarding the vitality o f the dental pulp. T h e cavities should be so prepared as to minimize the recurrence o f caries and the filling mate rials used should restore the teeth to their normal function. W hen caries attacks the anterior teeth and the patients present themselves to us for treatment, they are particularly in terested in the appearance o f any restora tion which w e might suggest and one of their first questions is, usually, “ Is the