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Mandibular stabilization prosthesis
Mandibular
stabilization
prosthesis
G. E. Hartman,
D.D.S., M.S.,* and J. H. Swepston, D.D.S.** Wilford Hall USAF Medical Center, San Antonio, Tex., and Baylor College of Dentistry, Dallas, Tex
0
cclusal prostheses may be used as an aid for diagnosing and treating temporomandibular joint or muscular disorders related to occlusal problems.’ These removable prostheses allow a decrease in muscle fatigue, spasm, and tenderness; joint edema, inllammalion, and tenderness; tooth mobility and sensitivity; and a tendency to diminish or eliminate bruxism.* Bite planes, occlusal splints, stents, guide planes, bite guards, and nightguards are among the various terms used synonymously to describe this prosthesis. However, a more descriptive term that meets the criteria is “mandibular stabilization prosthesis.” Literally, this term refers to a means of correcting or preventing a skeletal deformity. Aside from being descriptive yet general enough to cover most uses, this term is more readily acceptable by third party carriers. Because of the variety of uses for the mandibular stabilization prosthesis, a technique for fabrication should be readily available. The following procedure uses available materials and may be taught to auxiliaries. The technique must be followed meticulously for the desired results.
Fig. 1. Diagnostic mounting
PROCEDURES 1. Mount the maxillary cast with a face-bow. 2. Mount the mandibular cast in centric relation with wax or zinc oxide-eugenol Occlusa Mesh (Formulator, Inc., Blue Island, Ill.) records.? The leaf gauge may aid materially in recording a more precise centric relation (Fig. l).‘, 5 Lateral wax records are used to adjust the condylar elements. A face-bow mounting is not absolutely essential to construct a mandibular stabilization prosthesis as long as the vertical dimension of occlusion is maintained. However, the lateral excursions on the articulator may vary significantly from the excursions in the mouth. The important aspect is an accurate, verified centric relation
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 2. Wax blockout of maxillary cdsi
(nrrows).
record of minimal thickness that will determine the thickness and relationship of the splint. Thus, the articulator may not be opened or closed from this centric relation record. 3. On the maxillary cast, block out with baseplate
215
HARTMAN
Fig. 3. Utility prosthesis.
wax outline
(arrows) of borders of
Fig. 4. Acrylic resin application to right side (arrow)
AND
SWEI’S’I‘I~N
Fig. 5. Acrylic resin application to left side (~WOWI.
Fig. 6. Acrylic resin application
to anterior section
(arrozc~).
wax the lingual gingival margins, embrasures, margins of restorations, deep occlusal and lingual grooves, and prominent rugae (Fig. 2). 4. Paint maxillary and mandibular casts with Alcote (The L. D. Caulk Co., Milford, Del.). 5. Establish the border of the proposed prosthesis with blockout wax and utility wax (Fig. 3). 6. Apply by a sprinkle-on technique orthodontic acrylic resin (The L. D. Caulk Co.) to a lingual posterior section, including the lingual and occlusal surfaces of the posterior teeth and tissue only (Fig. 4).” Allow the resin to polymerize before proceeding to the next section. The polymer must be saturated to minimize porosity. No tooth contacts are allowed with the acrylic resin when the anterior vertical pin stop (set by the thickness of the centric relation interocclusal record) contacts the anterior guide table. If any tooth
216
contacts exist, remove them before proceeding to the next step. 7. Apply orthodontic acrylic resin to the other posterior section and allow the resin to polymerize completely with no tooth-acrylic resin contact (Fig. 5). 8. Apply orthodontic acrylic resin to the maxillary anterior section, including the incisal edges, palate, and already polymerized posterior sections. The three separate sections are now joined, minimizing warpage (Fig. 6). The anterior vertical pin stop must contact the anterior guide table with no tooth contacts. 9. Prepare orthodontic acrylic resin by adding the polymer to the liquid monomer in a mixing ,jar until the monomer no longer incorporates any polymer. Pour off the excess polymer, tap the resin, avoid stirring to prevent incorporation of air, which will
AUGlJST
1982
VOLUME
48
NUMBER
2
MANDIBIJLAR
STABILIZATION
PROSTHESIS
Fig. 9. Acrylic Fig. 7. Acrylic resin addition sal section (arrow).
to right posterior
Fig. 8. Acrylic
to left posterior
occlu-
resin addition
Fig. 10. Completed resin addition
to
anttlritrr
section
(Urrm~).
anterior
disclusion
(wwic:,\)
occlusal
section (arrozc~). reduce the strength (indicated by its cloudiness), and allow to become tacky. 10. Form the acrylic resin into a roll and apply to a posterior occlusal portion, moistened with monomer, of the previously formed base. 11. Close the articulator repeatedly until the acrylic resin just begins to polymerize, registering the cusps of the opposing teeth. 12. Mark the stamp cusp indentations at the greatest depth with a soft lead pencil after the acrylic resin has polymerized. 13. Trim the acrylic resin carefully with a bur so that only the deepest pencil
marks remain
(Fig.
7),
providing a minimal area of contact of the mandibular stamp cusps in centric relation.
THE JOURNAL
OF PROSTHETIC
Verification
DENTISTRY
is made
with Shim Stock (0.0127 mm) (The 1rtus Corp., Englewood, N.J.) as a feeler gauge. Careful adjustments are made until there is equal resistance to the pull of the feeler gauge of all stamp cusps and the anterior
vertical
pin stop on its table.
14. Add orthodontic acrylic resin to the opposite posterior section (Fig. 8) as in step 9 and adjust the occlusal contact tolerance to 0.0127 mm 15. Add orthodontic acrylic resin as in step 9 to the anterior section (Fig. 9). Make centric. lateral, and protrusive indentations while the resin ii in the rubbery stage. 16. Develop a minimal disclusion using the mandibular canines (or premolars)
in right and let’t lateral and
protrusive movements (Fig. 10). When completed, the mandibular stabilization prosthesis should hold Shim Stock on all lower cusps in centric occlusion. The feeler
217
HARTMAN
Fig. 11. Prosthesis trimmed removal from cast.
(arrows)
AND
SWEPSTON
and ready for Fig. 13. Completed prosthesis on articulator
CONCLUSION
Fig. 12. Completed prosthesis.
gauge should drag on the anterior teeth in centric occlusion. There should be a minimal disclusion on the mandibular canines in right and left lateral and protrusive movements. There must be no contact of the mandibular posterior teeth except in centric occlusion. 17. Trim the mandibular stabilization prosthesis to & 1 mm thickness before removal from the cast, minimizing machining distortion. Care should be exercised to avoid grinding or polishing contacts in centric relation (Fig. 11). 18. Remove the prosthesis from the cast, trim the borders, and complete a high polish (Figs. 12 and 13).
218
This technique is based on the addition of separate sections of acrylic resin to the cast. Each section is allowed to complete polymerization before the next is approached. This step-by-step technique minimizes warpage and ensures a more accurate fit of the prosthesis. The completed mandibular stabilization prosthesis is precisely fitted to the patient’s maxiIlary teeth. All subsequent adjustments depend on this step. Tooth contacts in centric relation are identified with AccuFilm II (Parke& Farmingdale, N.Y.). Resistance to the drag of the feeler gauge is tested for all posterior stamp cusps and the lower anterior teeth. Meticulous adjustment will be necessary until there is simultaneous intimacy of tooth contact in centric relation. Slightly less positive contact should be apparent on the anterior teeth. Eccentric movements are relegated only to the lower canine (or first premolar) with a minimal angle of disclusion. The patient is seen again for the same type of adjustment every 24 to 48 hours, depending on symptomatology. When symptoms have subsided, the patient is examined once a week for 2 to 4 weeks, then once a month until stability of the prosthesis is assured in centric relation. Three to 6 months without change permits a predictable centric relation for whatever treatment is indicated or selected. REFERENCES I.
Goharian, K. K., and Neff. P. A.: Elfecr of occlusal rcminrrs WI :emporomandibular joint and facial pain. .J I’aos’r~~r~r f>SSl 443206, 1980.
AUGUST
1982
VOLUME
48
NUMBER
2
MANDIBULAR
STABILIZATION
PROSTHESIS
ARTICLES TO APPEAR IN FUTURE ISSUES Rational performance of occlusal adjustment Claes Riise, L.D.S.
Prosthodontic management of surgical soft tissue deformities associated with marginal mandibulectomy. Part II: Surgical flaps Arie Shifman, D.M.D.,
The shrink-free
and James B. Lepley, D.D.S.
ceramic crown
Ralph B. Sozio, D.M.D.,
and Edwin J. Riley, D.M.D.
Esthetic considerations in the use of face-bows Elwood H. Stade, D.D.S., Jay G. Hanson, D.D.S., and Constance L. Baker, D.D.S.
Retention and wear of precision-type
attachments
B. L. Stewart, M.D..%., and R. 0. Edwards, Ph.D.
Hollow polydimethylsiloxane Shlomo Taicher, D.M.D., James B. Lepley, D.D.S.
Die trimming:
facial prostheses using anatomic undercuts
Stephen F. Bergen, D.D.S., Arnold Rosen, D.D.S., Magda Levy, and
A guide to physiologic
contour
Robert A. Tanquist, D.D.S.
Preparation of furcally involved teeth Herbert E. Ward, D.D.S.
Evaluation of mandibular dentofacial morphology
rest position in subjects with diverse
George A. Wessberg, D.D.S., Michael C. Washburn, D.D.S., Bruce N. Epker, D.D.S., Ph.D., ,mcl Kent 0. Dana, MS.
The effect of retainer design on the retention of filled resin in acid-etched fixed partial dentures V. D. Williams, D.D.S., M.S., D. G. Drennon, D.D.S., M.S., and L. M. Silverstone, D.D.Sr.. Ph.D., B.Ch.D.
The geometry of the arbitrary
hinge axis as it relates to occlusion
Gabriel R. Zuckerman, D.D.S.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
219
stabilization
prosthesis
G. E. Hartman,
D.D.S., M.S.,* and J. H. Swepston, D.D.S.** Wilford Hall USAF Medical Center, San Antonio, Tex., and Baylor College of Dentistry, Dallas, Tex
0
cclusal prostheses may be used as an aid for diagnosing and treating temporomandibular joint or muscular disorders related to occlusal problems.’ These removable prostheses allow a decrease in muscle fatigue, spasm, and tenderness; joint edema, inllammalion, and tenderness; tooth mobility and sensitivity; and a tendency to diminish or eliminate bruxism.* Bite planes, occlusal splints, stents, guide planes, bite guards, and nightguards are among the various terms used synonymously to describe this prosthesis. However, a more descriptive term that meets the criteria is “mandibular stabilization prosthesis.” Literally, this term refers to a means of correcting or preventing a skeletal deformity. Aside from being descriptive yet general enough to cover most uses, this term is more readily acceptable by third party carriers. Because of the variety of uses for the mandibular stabilization prosthesis, a technique for fabrication should be readily available. The following procedure uses available materials and may be taught to auxiliaries. The technique must be followed meticulously for the desired results.
Fig. 1. Diagnostic mounting
PROCEDURES 1. Mount the maxillary cast with a face-bow. 2. Mount the mandibular cast in centric relation with wax or zinc oxide-eugenol Occlusa Mesh (Formulator, Inc., Blue Island, Ill.) records.? The leaf gauge may aid materially in recording a more precise centric relation (Fig. l).‘, 5 Lateral wax records are used to adjust the condylar elements. A face-bow mounting is not absolutely essential to construct a mandibular stabilization prosthesis as long as the vertical dimension of occlusion is maintained. However, the lateral excursions on the articulator may vary significantly from the excursions in the mouth. The important aspect is an accurate, verified centric relation
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 2. Wax blockout of maxillary cdsi
(nrrows).
record of minimal thickness that will determine the thickness and relationship of the splint. Thus, the articulator may not be opened or closed from this centric relation record. 3. On the maxillary cast, block out with baseplate
215
HARTMAN
Fig. 3. Utility prosthesis.
wax outline
(arrows) of borders of
Fig. 4. Acrylic resin application to right side (arrow)
AND
SWEI’S’I‘I~N
Fig. 5. Acrylic resin application to left side (~WOWI.
Fig. 6. Acrylic resin application
to anterior section
(arrozc~).
wax the lingual gingival margins, embrasures, margins of restorations, deep occlusal and lingual grooves, and prominent rugae (Fig. 2). 4. Paint maxillary and mandibular casts with Alcote (The L. D. Caulk Co., Milford, Del.). 5. Establish the border of the proposed prosthesis with blockout wax and utility wax (Fig. 3). 6. Apply by a sprinkle-on technique orthodontic acrylic resin (The L. D. Caulk Co.) to a lingual posterior section, including the lingual and occlusal surfaces of the posterior teeth and tissue only (Fig. 4).” Allow the resin to polymerize before proceeding to the next section. The polymer must be saturated to minimize porosity. No tooth contacts are allowed with the acrylic resin when the anterior vertical pin stop (set by the thickness of the centric relation interocclusal record) contacts the anterior guide table. If any tooth
216
contacts exist, remove them before proceeding to the next step. 7. Apply orthodontic acrylic resin to the other posterior section and allow the resin to polymerize completely with no tooth-acrylic resin contact (Fig. 5). 8. Apply orthodontic acrylic resin to the maxillary anterior section, including the incisal edges, palate, and already polymerized posterior sections. The three separate sections are now joined, minimizing warpage (Fig. 6). The anterior vertical pin stop must contact the anterior guide table with no tooth contacts. 9. Prepare orthodontic acrylic resin by adding the polymer to the liquid monomer in a mixing ,jar until the monomer no longer incorporates any polymer. Pour off the excess polymer, tap the resin, avoid stirring to prevent incorporation of air, which will
AUGlJST
1982
VOLUME
48
NUMBER
2
MANDIBIJLAR
STABILIZATION
PROSTHESIS
Fig. 9. Acrylic Fig. 7. Acrylic resin addition sal section (arrow).
to right posterior
Fig. 8. Acrylic
to left posterior
occlu-
resin addition
Fig. 10. Completed resin addition
to
anttlritrr
section
(Urrm~).
anterior
disclusion
(wwic:,\)
occlusal
section (arrozc~). reduce the strength (indicated by its cloudiness), and allow to become tacky. 10. Form the acrylic resin into a roll and apply to a posterior occlusal portion, moistened with monomer, of the previously formed base. 11. Close the articulator repeatedly until the acrylic resin just begins to polymerize, registering the cusps of the opposing teeth. 12. Mark the stamp cusp indentations at the greatest depth with a soft lead pencil after the acrylic resin has polymerized. 13. Trim the acrylic resin carefully with a bur so that only the deepest pencil
marks remain
(Fig.
7),
providing a minimal area of contact of the mandibular stamp cusps in centric relation.
THE JOURNAL
OF PROSTHETIC
Verification
DENTISTRY
is made
with Shim Stock (0.0127 mm) (The 1rtus Corp., Englewood, N.J.) as a feeler gauge. Careful adjustments are made until there is equal resistance to the pull of the feeler gauge of all stamp cusps and the anterior
vertical
pin stop on its table.
14. Add orthodontic acrylic resin to the opposite posterior section (Fig. 8) as in step 9 and adjust the occlusal contact tolerance to 0.0127 mm 15. Add orthodontic acrylic resin as in step 9 to the anterior section (Fig. 9). Make centric. lateral, and protrusive indentations while the resin ii in the rubbery stage. 16. Develop a minimal disclusion using the mandibular canines (or premolars)
in right and let’t lateral and
protrusive movements (Fig. 10). When completed, the mandibular stabilization prosthesis should hold Shim Stock on all lower cusps in centric occlusion. The feeler
217
HARTMAN
Fig. 11. Prosthesis trimmed removal from cast.
(arrows)
AND
SWEPSTON
and ready for Fig. 13. Completed prosthesis on articulator
CONCLUSION
Fig. 12. Completed prosthesis.
gauge should drag on the anterior teeth in centric occlusion. There should be a minimal disclusion on the mandibular canines in right and left lateral and protrusive movements. There must be no contact of the mandibular posterior teeth except in centric occlusion. 17. Trim the mandibular stabilization prosthesis to & 1 mm thickness before removal from the cast, minimizing machining distortion. Care should be exercised to avoid grinding or polishing contacts in centric relation (Fig. 11). 18. Remove the prosthesis from the cast, trim the borders, and complete a high polish (Figs. 12 and 13).
218
This technique is based on the addition of separate sections of acrylic resin to the cast. Each section is allowed to complete polymerization before the next is approached. This step-by-step technique minimizes warpage and ensures a more accurate fit of the prosthesis. The completed mandibular stabilization prosthesis is precisely fitted to the patient’s maxiIlary teeth. All subsequent adjustments depend on this step. Tooth contacts in centric relation are identified with AccuFilm II (Parke& Farmingdale, N.Y.). Resistance to the drag of the feeler gauge is tested for all posterior stamp cusps and the lower anterior teeth. Meticulous adjustment will be necessary until there is simultaneous intimacy of tooth contact in centric relation. Slightly less positive contact should be apparent on the anterior teeth. Eccentric movements are relegated only to the lower canine (or first premolar) with a minimal angle of disclusion. The patient is seen again for the same type of adjustment every 24 to 48 hours, depending on symptomatology. When symptoms have subsided, the patient is examined once a week for 2 to 4 weeks, then once a month until stability of the prosthesis is assured in centric relation. Three to 6 months without change permits a predictable centric relation for whatever treatment is indicated or selected. REFERENCES I.
Goharian, K. K., and Neff. P. A.: Elfecr of occlusal rcminrrs WI :emporomandibular joint and facial pain. .J I’aos’r~~r~r f>SSl 443206, 1980.
AUGUST
1982
VOLUME
48
NUMBER
2
MANDIBULAR
STABILIZATION
PROSTHESIS
ARTICLES TO APPEAR IN FUTURE ISSUES Rational performance of occlusal adjustment Claes Riise, L.D.S.
Prosthodontic management of surgical soft tissue deformities associated with marginal mandibulectomy. Part II: Surgical flaps Arie Shifman, D.M.D.,
The shrink-free
and James B. Lepley, D.D.S.
ceramic crown
Ralph B. Sozio, D.M.D.,
and Edwin J. Riley, D.M.D.
Esthetic considerations in the use of face-bows Elwood H. Stade, D.D.S., Jay G. Hanson, D.D.S., and Constance L. Baker, D.D.S.
Retention and wear of precision-type
attachments
B. L. Stewart, M.D..%., and R. 0. Edwards, Ph.D.
Hollow polydimethylsiloxane Shlomo Taicher, D.M.D., James B. Lepley, D.D.S.
Die trimming:
facial prostheses using anatomic undercuts
Stephen F. Bergen, D.D.S., Arnold Rosen, D.D.S., Magda Levy, and
A guide to physiologic
contour
Robert A. Tanquist, D.D.S.
Preparation of furcally involved teeth Herbert E. Ward, D.D.S.
Evaluation of mandibular dentofacial morphology
rest position in subjects with diverse
George A. Wessberg, D.D.S., Michael C. Washburn, D.D.S., Bruce N. Epker, D.D.S., Ph.D., ,mcl Kent 0. Dana, MS.
The effect of retainer design on the retention of filled resin in acid-etched fixed partial dentures V. D. Williams, D.D.S., M.S., D. G. Drennon, D.D.S., M.S., and L. M. Silverstone, D.D.Sr.. Ph.D., B.Ch.D.
The geometry of the arbitrary
hinge axis as it relates to occlusion
Gabriel R. Zuckerman, D.D.S.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
219