ORIENTATION JAW RELATION

INTRODUCTION
1) The recording of jaw relation is one of the most important
phases in complete denture treatment.
2) It is a known fact that the temperomandibular joint has a
significant role during this procedure.
3) Unlike the other joints of the body the temperomandibular joint
is peculiar in that it is lined by a fibro cartilage. The disc of the
joint di!ides it into 2 sino!ial ca!ities.
In otherwords the condyle of the mandible is associated with the
petrous part of temporal bone through this joint. "o it can also
be called as a #ranio$mandibular joint.
%) &a'illa is a part of the cranium and is also a fi'ed entity. The
ma'illa becomes related to the mandible when the teeth of both
jaws come in contact. "o the entire cranioma'illary comple' is
articulated with a mo!ing bone which is the mandible.
() The relationship of the ma'illa to the temporomandibular joint is
not the same in all persons i.e. the anatomy of ma'illa and the
temperomandibular joint !aries from persons to persons.
1
)) The opening mo!ement to bring the jaw from occlusal to rest
position is almost a pure hinge mo!ement. *ere the mandible
mo!es on an arc of a circle with a definite radius from the
temperomandibular joint. This path of the condyle is determined
by the cur!ature of the condylar head and the cur!ature of
glenoid fossa. "ince the radius is not constant for all the
patients it has to be determined for e!ery indi!idual patient i.e.
the relation of ma'illa to the opening and closing a'is has to be
determined.
The relationship of the ma'illa to the cranium in three planes
!i+, anteroposterior lateral and !ertical is called the orientation jaw
relation.
-arts of a face bow , condylar rods fork u$shaped frame.
There are two basic types of face bows.
a. .rbitrary face bow.
b. /inematic or hinge bow.
The arbitrary face bow helps to locate the opening a'is of the
jaws in an appro'imate manner.
It is only the kinematic face bow which can record the anatomic
a'is in an accurate way. *ere the condylar styli rest e'actly on the
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condyles. 0hen the points of the condylar styli rotate only and do not
translate the points are on the opening a'is of the jaw. The fork of a
kinematic face bow is attached to the mandible. In an edentulous
patient since the mandibular record bases cannot be stabili+ed the
kinematic face bow cannot be attached firmly. In a dentulous person
the face bow can be clutched to the mandibular teeth and the true hinge
a'is can be recorded.
DEFINITIONS
Orientation Relation: They are those that orient the mandible to the
cranium in such a way that when the mandible is kept in its most
posterior position the mandible can rotate in a sagittal plane around an
imaginary trans!erse a'is passing through or near the condyles.
The a'is can be located when the mandible is in its most
posterior position by means of a 1ace bow.
Definition of Face bow
1. It is a calper like de!ice that is used to record the relationship of
the jaws to the temporomandibular joints or the opening a'is of
the jaws and to orient the casts in this same relationship to the
opening a'is of the articulator.
$ 2oucher
3
2. It is a caliper like de!ice used to record the spatial relationship
of the ma'illary arch to sum anatomic reference point or points
and then transfer this relationship to an articulator. It orients the
dental cast in the same relationship to the opening a'is of the
articulator. #ustomarily the anatomic references are the
mandibular trans!erse hori+ontal a'is and another selected
anterior point.
$ The 3lossary of -rosthodontic terms
)
th
4dition 155%
Terminal hinge position
It is the most retruded hinge position. &o!ement from this
position a condition response is always less than median 6 full 6
mouth opening.
The terminal hinge position is significant because it is a
learnable repeatable and recordable position that coincides the position
of centric relation. The limits of the hinge mo!ement in this position
ha!e been determined to be about 12$1( degrees from ma'imum
intercuspation or about 15$27mm at the incisal edges. The condiles are
in a definiti!e position in the fossae during terminal hinge mo!ements.
. face bow relates the ma'illa to the intercondylar line. It is
commonly assumed that the opening mandibular mo!ements occur
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about this hori+ontal a'is. 3raphic records of mandibular mo!ements
and radiographic in!estigations of the temperomandibular joint ha!e
repeatedly shown that this assumption is well founded and that in
normal subjects and for small opening mo!ements the hori+ontal a'is
of rotation does infact pass through the condyles. It is true that in wider
opening mo!ements 6 the a'is becomes progressi!ely displaced
downwards. This is of anatomic interest rather than prosthetic interest.
It must be emphasi+ed that in restorati!e and prosthetic treatment we
are concerned with relations between teeth only when they are in
occlusion or at most slightly separated.
(
-arts of a 1ace bow,
It consists of,
i) u$shaped frame or assembly that is large enough to e'tend
from the region of the temperomandibular joint to a position 2$3
inches in front of the face and wide enough to a!oid contact with
sides of the face.
ii) #ondylar rods that contact the skin o!er the
temperomandibular joint.
iii) 1ork which can be attached to the occlusal rim.
The fork of the face bow attaches to the face bow by means of a
locking de!ice.
Classification of Face bow
I. .rbitrary 1ace bow
a) 1acia type.
b) 4ar piece type
II. /inematic 1ace bow
Arbitrary Face bow:
They use arbitrary or appro'imate points on the face as posterior
reference points. The condylar rods are positioned on these
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predetermined points during the face bow transfer procedure. .rbitrary
face bows are most commonly used for complete denture patients.
This placement of condylar rods will generally locate the
opening a'is within (mm of the true center of the opening a'is of the
jaws.
1acia type , 1acia type of face bow utili+es appro'imate points on the
skin o!er the temperomandibular joint region as posterior reference
points. These points are located by measuring from certain anatomical
land marks on the face.
4ar piece type , It was first described by 8albey in 151%. This type of
face bow uses the e'ternal auditory meatus as the arbitrary posterior
reference point. 1or this a special ear piece is re9uired instead of a
condylar rod. The e'ternal auditory meatus is assumed to ha!e a fi'ed
relationship to the hinge a'is. "pecial condylar compensators on the
face bow or the articulator then compensates for this by positioning the
condylar inserts at a prescribed distance behind the rotational a'is of
the articulator.
Kinematic Face bow:
It is used to determine and locate the e'act hinge$a'is points.
The fork of the kinematic face bow is attached to the mandibular
occlusal rim. Then as the patient retrudes the mandible and opens and
:
closes the jaws the dentist$obser!es the mo!ement of the points of the
condylar rods. /inematic face bow is a more comple' instrument
re9uiring the fabrication of clutches which ha!e to be attached to the
lower jaws.
"ince the face bow is used to orient the casts on the articulator in
the same relation to the opening a'is of the jaws the face$bow record
is not a ma'illomandibular record. It is a record made for the
orientation of the casts to the instrument. *owe!er the use of a
kinematic face bow can aid in recording of centric relation.
Plane of orientation
The ma'illary cast in the articulator is the base line from which
all occlusal relationships start and it should be positioned in space by
identifying three points. The plane is formed by two points located
posterior to the ma'illae and one point located anterior to it. -osterior
points are referred to as the posterior points of reference and the
anterior one is known as the anterior point of reference.
Posterior Points of Reference
The position of the terminal hinge a'is on either side of the face
is generally taken as posterior reference points.
-rior to aligning the face bow on the face the posterior
reference points$must be located and marked. They are located by,
;
a) .rbitrary method.
b) /inematic method.
a) Arbitrary method
<ften the posterior points are located by measuring prescribed
distances from skin surface landmarks. "ome of the commonly used
posterior points were shown by 2eck to be near the hinge a'is
clinically. *e concluded that the 2ergstrom point most fre9uently is
closest to the hinge a'is. *e identified the 2eyron point as the ne't
most accurate posterior point of reference.
"tudies by 0einburg show that a de!iation from the hinge a'is
of (mm will result in an anteroposterior displacement error of 7.2mm
at the second molar. .n error of this si+e is usually of no conse9uence
in remo!able prosthesis with non$rigid attachments. These prosthesis
and the mobility of supporting tissues may make a precise location of
the hinge a'is an e'ercise with no ad!antage.
1ollowing are some of the most commonly used measurements
and landmarks,
1. 1cm infront of the line from the ape' of the tragus of the
ear to the outercanthus of the eye.
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2. 2ergstrom point , 17mm anterior to the center of the
spherical insert for the e'ternal auditory meatus and :mm below
the 1rankfort hori+ontal plane.
3. 2eyron=s point , 13mm anterior to the posterior margin of
the tragus of the ear on a line from the center of tragus e'tending
to the corner of the eye.
%. 3ysi point , located 13mm in front of the most upper part
of the e'ternal auditory meatus on a line passing to the outer
canthus of the eye. This method was proposed by 3ysi *anau
"now and 3ilmer and is the most common point used today.
Meto! o" #a$#ation %Daw&on'& meto!(
.n alternati!e method of locating the hinge a'is arbitrarily is by
a method of palpation.
1rom behind the patient place the inde' finger tip o!er the joint
area and ask the patient to open wide.
.s the condyle translates forward the finger tip will drop into a
depression where the condyle was. The patient should then close. .s
the condyle translates back into centric relation position its position
can be located by finger tip.
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2y asking the patient to open and close it will be possible to
locate the a'is with an a!erage accuracy. This a'is generally occurs
near the center of the depression felt the by the finger tip.
.fter locating the point it should be marked.
b( Kinematic meto!
&ost accurate method for recording the correct hori+ontal a'is is
by a >Trial and error method? de!eloped by &c#ollum in 1521 using a
kind of kinematic de!ice.
The techni9ue of locating the terminal hinge a'is position is
essentially the same for dentulous and edentulous patients but the
methods of attaching the clutch to the mandible are 9uite different.
#lutch fabrication for edentulous patient
1irmly attaching a clutch to edentulous mandible presents a
problem,
$ &ake an accurate impression of the mandibular basal seat and
pour an accurate stone cast.
$ <n the cast make an accurate record base of self curing or
processed acrylic resin.
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$ .ttach compound occlusal rims firmly to the record base and
secure a specially designed bite fork to the rims with the stem
e'tending forward parallel to the sagittal plane.
$ .ttach this assembly to the mandible with chin clamps or chin
straps.
<nce the clutches ha!e been fabricated the following se9uence
is followed,
$ -lace the patient in a semisupine position with the head rest
tilted slightly backward @so that patient can retrude his mandible
easily).
$ #onnect the mandibular clutch to face bow.
$ . graph or grip paper is placed adjacent to the skin o!er the
temperomandibular joint region to help detect stylus mo!ments.
$ 3uide the mandible to centric position and assist the patient in
making hinge openings and closings to a ma'imum of 17$13A.
$ #heck the mo!ement of the stylusB initial mo!ement may be arc
shaped.
$ .djust the stylus tip towards the center of the arc until the tip
rotates instead of arcing.
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$ Cemo!e the grip paper and record the point on the skin with the
help of a dye.
-recaution , #are must be taken to record only the retruded hinge a'is.
The mandible is capable of producing hinge like motion at any point
along the protrusi!e pathway.
Anterior )oint o" Re"erence:
The selection of the anterior point of the triangular spatial plane
determines which plane in the head will become the plane of reference
when the prosthesis is being fabricated.
Ceasons for selecting an .nterior point of reference,
1. 0hen three points are used the position can be repeated so that
different ma'illary casts of the same patient can be positioned in
the articulator in the same relati!e position to the end controlling
guidances.
2. . planned choice of an anterior reference point will allow the
dentists and au'iliaries to !isuali+e the anterior teeth and the
occlusion in the articulator in the same frame of reference that
would be used when looking at the patient. 1or e'ample when
using the 1rankfort hori+ontal plane as the plane of reference
the teeth will be !iewed as though the patient was standing in a
normal postural position with the eyes looking straight ahead.
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Se$ection:
Darious anterior reference points that may be used are as
follows,
1. Orbitale,
In the skull orbitale is the lowest point of the infraorbital
margin. <n a patient it can be palpated through the o!erlying
tissue and skin. <ne orbitale and two posterior points that
determine the hori+ontal a'is of rotation will define the a'is$
orbital plane.
<rbitale and the two posterior land marks are transferred
from the patient to the articulator with the face bow. The
articulator must ha!e an orbital indicator guide that is in the
same plane as the hinge of the articulator.
2. Orbitale minus 7mm,
The 1rankfort hori+ontal plane passes through both poria and
one orbital point. 2ecause porion is a skull land mark "icher
recommends using the midpoint of the upper border of e'ternal
acoustic meatus as the posterior cranial landmark on the patient.
3o+ale+ pointed out that this posterior tissue landmark on the
a!erage lies :mm superior to hori+ontal a'is. The recommended
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compensation for this discrepancy is to mark the anterior point
of reference : mm below orbitale on the patient.
! "asion minus #mm
.ccording to "icher another skull landmark the nasion can
be appro'imately located in the head as the deepest part of the
midline depression just below the le!el of eye brows. The nasion
guide or positioner of Euick &ount face bow which is designed
to be used with the whip mi' articulator fits into this depression.
The cross bar @u$shaped frame) is located 23mm below the
midpoint of nasion pointer. 0hen the face bow is positioned
anteriorly by the nasion guide the cross bar will be in the
appro'imate region of orbitale. The face bow cross bar and not
the nasion guide is the actual anterior reference point locator. "o
this face bow employs an appro'imate a'is$orbital plane.
$! Alae of the nose
. part of many complete denture techni9ues is to make the
tentati!e or actual occlusal plane parallel with the hori+ontal
plane. This can be achie!ed as follows,
. line from the alae of the nose to the center of the auditory
meatus is called #amper=s line .ugsberger concluded in a
re!iew of literature that the occlusal plane parallels this line with
1(
minor !ariations in different facial types. /nowing this the
dentist can transfer #amper=s line from the patient to the
articulator by marking the right or left alae on the patient setting
the anterior reference pointer to it and with the face bow
transferring the ala anteriorly and the hinge points posteriorly
from the patient to the articulator.
Attacin* te bite For+
Darious methods are used. The method also !aries for the
complete denture patient and the dentate patient.
1or a complete denture patient the following methods may be
used,
Meto! I
$ Fow fusing base plate wa' is softened and rolled in a horse shoe
shape.
$ The prongs of the fork are embedded in the wa' and the margins
are folded o!erB thickness of wa' is appro'imately )mm.
$ The prongs with the attached wa' are placed between the
occlusal rims in the patient=s mouth with the midline of the fork
coinciding with midline of occlusal rim. "tem of the fork must
be parallel to the sagittal plane.
1)
$ Instruct the patient to close his jaws to imbed the occlusal rims
into the soft wa'.
$ The relation of ma'illa to mandible is not important at this stage
e'cept to place fa!ourable pressure to stabili+e the ma'illary
record base.
1ollowing are the ad!antages of this method,
1. -atient is in a comfortable position with the jaws closed and
arms at rest.
2. &a'illary record base is accurately seated and not subjected to
tipping.
Meto! II
The bite fork of the *anau face bow is designed to be inserted
into the ma'illary occlusal rim.
$ The bite fork is heated o!er flame and is inserted into facial
surface of ma'illary rim parallel to occlusal rim.
$ Cod e'tension should parallel the patient=s midsagittal plane.
$ The ma'illary rim along with face bow assembly is then held in
position by the patient using both thumbs with light pressure.
1:
"teps in Cecording
$ "eat the patient in a comfortable position in the dental chair with
the backrest e'tending slightly below the scapula. -atient=s head
should be in an upright position with the head rest supporting
the occiput.
$ Focate the a'is points by methods described pre!iously. Cecord
points on the skin or on adhesi!e tape placed in the area.
$ #ontour the ma'illary occlusal rim establish the occlusal plane.
$ .pply a thin layer of petroleum jelly to the occlusal rims to
facilitate separation of bite fork from the wa'.
$ Ceduce mandibular occlusal rim to allow ade9uate interocclusal
distance for attached fork and wa'.
$ .djust the condylar rods to the face for centering the bow by
placing the ends o!er the condyle points so that the ends lightly
touch the skin or tape. "ecure either the right or left condyle rodB
lock and remo!e the bow from face.
$ 0hen the infraorbital notch is used as the anterior point of
reference the pointer should be placed in the clamp pro!ided for
it on the bow. -alpate the infraorbital notch and mark it with a
skin marker. -lace the pointer tip o!er the mark and secure the
1;
clamp to the pointer. Cemo!e the assembly form the face and
allow the wa' to set hard before remo!ing the bite fork and face
bow record from the occlusal rims.
Face ,ow Mo-ntin*
1. "et the sliding condylar rods symmetrically on both the sides
until the bow gently springs o!er the articulator condylar shaft.
2. Caise or lower the face bow to adjust for the !ertical position
until the occlusal plane anteriorly is on a le!el with the groo!e
marked around the incisal pin. If an orbital pointer is used
adjust the pointer to touch the pointer plate attached to the
ma'illary member of the articulator.
3. "oak the ma'illary cast in water for atleast ( minutes to insure
adhesion of plaster to stone.
%. "ecure the incisal guide pin with its top flush with the top of
ma'illary member of the articulator. <pen the ma'illary member
of the articulator and apply a creamy mi' of dental plaster to the
top of the articulator until the incisal guide pin is stopped on the
guide table and the mounting plate is embedded in the plater.
(. #arefully remo!e the e'cess plaster. .llow the plaster to harden
before remo!ing the face bow assembly. The ma'illary cast is
related to the opening a'is in the articulator in the same
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anteroposterior and hori+ontal position as the ma'illae in the
skull are related to the opening a'is in the temperomandibular
joint.
1rom here further records can be made starting with a tentati!e
center relation record.
Di&c-&&ion o" &i*ni"icance o" orientation .aw re$ation
"ince efficient dentures are constructed with and without the use
of a face bow we may admit at the outset that a face bow is not
essential to a good prosthetic restoration in the sense that a matri'
band is essential to the insertion of a good #lass II filling.
To say that a face bow locates the ape' of the 2onwill triangle is
not an incorrect answer to the 9uestion what the face bow doesG 2ut
this merely prompts another 9uestion , what is 2onwill=s triangle and
why is its location importantG
The e9ui!alent triangle theory states that the distance between
the condyles and between each condyle and incisor point is 17cm. This
being so the use of a simple pair of calipers in the laboratory is all that
is necessary to mount the casts always at the same a!erage distance
from the intercondylar line.
2ut the 17cm !alue is just an a!erage some patients ha!e
dimensions larger or smaller than the a!erage.
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E""ect o" ca&t orientation on occ$-&ion
-roper alignment of the occlusal plane with relation to the end
controlling factors is of great importance for the cusp inclines and cusp
pathways of a prosthetic reconstruction. The effect of !arious cast
positions on cuspal inclines and pathways is demonstrated in the
figure.
1ailure to use the face bow can lead to errors in occlusion of the
denture. It is true that the errors may be small if the error in orientation
of cast is small. Fikewise the errors produced by failure to use the
face$bow would be negligible if all the interocclusal records were made
precisely at the occlusal !ertical relation and if +ero degree teeth were
used. *owe!er if cusp teeth are used or if interocclusal records are
made with the teeth out of contact so that the !ertical separation of cast
or dentures must be reduced on the articulator the face bow record is
essential. The face bow transfer allows a more accurate arc of closure
on the articulator when the interocclusal records are remo!ed and the
articulator is closed.
Huckerman @15;2) has stated that,
1. "uperiorI inferior errors in location of hinge a'is produces
greater errors in occlusion than e9ui!alent errors in posterior I
anterior location.
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2. &agnitude of error is directly proportional to the magnitude of
error in location of hinge a'is.
3. magnitude increases as !ertical dimension at which centric
relation is recorded increases.
Con&e/-ence& o" te&e error&:
0hen the #8 patient performs the function of chewing with
these errors in the dentures it may lead to,
a. Instability of the dentures which causes early resorption of the
residual ridge.
b. The path of closure of the mandible is altered and the biological
soundness of the temperomandibular joint is affected. The
symptoms manifest as pain crepitus and sublu'ation of the
joints. The symptoms are features of &-8".
"ome dentists consider that the use of a face bow is not
necessary under the following conditions,
1. 0hen monoplane teeth are arranged on a plane in occlusal
balance and the mandible is in most retruded position.
2. 0hen no altrations of the occluding surfaces of teeth are
re9uired to necessitate changes in !ertical dimension of
occlusion originally recorded.
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3. Jo interocclusal check records that would be at a different
!ertical dimension from that in the original interocclusal record.
%. 0hen articulators that are not designed to accept a face
bow transfer are used in denture procedures.
0hen these conditions are analy+ed the following arguments
may be put forth,
1. It is 9uestionable if one occlusal form of posterior tooth is
indicated for all edentulous patients.
2. #hanges do occur in the !ertical dimension of occlusion as a
result of wa'ing flasking processing and mounting procedures.
Cesorption of the bone and the changes in soft tissues that form
the basal seat for dentures alter the !ertical dimension of
occlusion.
3. 8entists use interocclusal check records to !erify articulator
mountings.
%. <ccluding surfaces are altered to correct for changes in the
!ertical dimension of occlusion.
(. There is no scientific proof that the errors when the face bow is
not used are within the acceptable physiologic range in all
indi!iduals.
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). 0hen an articulator with rotational centers that can be adjusted
to conform to rotational centers of mandibular mo!ements is
used.
Re"erence&
1. 4!aluation of use of face bow in #8 occlusion !ol. 35 15:;B ($
1%.
2. *inge a'is of mndible. K.-.8. 1 , 32: 15(1.
3. *inge a'is registration e'periments on the articulator. K.-.8.
: , 3( 15(;.
%. *inge a'is location on a e'perimental basis. K.-.8. 11 , 17(5
15)1.
(. Trans!erse hinge a'is rod or imaginary. K.-.8. 5 , ::( 15(5.
). 3eometric significance of trans!erse a'is. K.-.8. 17 , )31 15)7.
:. 4!aluation of face bow. K.-.8. 2 , )33 15(2.
;. Dariations in location of arbitrary and true hinge a'is points.
K.-.8. 11 , 22% 15)1.
5. "tudy of arbitrary center and kinematic center of rotation for
face bow mountings. K.-.8. : , 1)2 15(:.
2%
17. Focation of terminal hinge a'is by intra oral means. K.-.8. 23 ,
11 15:7.
11. 1ace bow its significance and application. K.-.8. 3 , )1; 15(3.
12. #linical e!aluation of .rlin concept of .rticulation. 5 , %75
15(5.
2(