Stabilization of the craniomandibular relationship with etched porcelain clinical report Bernard
T. Williams,
DDS*, and Thomas
Sigler,
therapeutic bonded restorations:
CDTb
Kansas City, MO.
T
his clinical report describes a restorative technique for stabilization of the mandible by bonding etched porcelain to tooth structure. L 2 This procedure represents the concluding treatment for a patient with craniofacial pain, dysfunction, and parafunction. Treatment for a 36-year-old woman with severe headaches, pain in the masticatory muscles, crepitus, and dysfunction within the temporomandibular joints (TMJs) is discussed in this report. The earlier phases of therapy consisted of exercises,3 occlusal plane orthopedic splints* (OPOS), and orthodontics. The craniomandibular relationship following these therapies resulted in a posterior open occlusion without canine guidance. However, the maxillary and mandibular central and lateral incisors contacted when the patient closed her jaws, and protrusive guidance was present on the eight anterior teeth. The posterior open occlusion did not result from intrusion of the posterior teeth. An acrylic resin splint was not inserted between the dental arches to create an anterior open occlusion that intruded the posterior teeth. Instead, this thera-
*Private practice. bCertified Dental Technician.
Fig. 2. Mandibular OPOS.
10/l/31023
Fig. 1. Craniomandibular
THE
JOURNAL
OF PROSTHETIC
peutic position was achieved by strategically positioning the mandible in an anterior position that created this posterior open occlusion. Corrected transcranial radiographs5 were obtained before and after treatment to confirm this positional change within the TMJs. The occlusion is commonly elevated with etched porcelain bonded to tooth structure, but to restore an entire
relationship with OPOS.
DENTISTRY
Fig. 3. Distal extensions of mandibular OP
Fi
snded composite resin to rna~di~~~~ first mo-
lars.
ing the years of conserva-
s transferred
to a fully adj~stab~@ artieular enar Corp.), Since the vertical
articulator and the i~tero~~~~sa~records would be registered at the same vertical dimension of occlusion, hin axis locations were ~~ne~~ssary, xtensions of the mandibular QPQ The rst m ere removed (Fig. 31, and maxi~l~y first molars were prepared for etched porcelain bonded overlay KestQratiQ~semirate Port n Systems, Myron Enternatimal, Kansas City, Kan.). cured, occi-usai re~istrat~
ETCHEDPQRCELAINBONDEDRESTORATIONS
Fig. 8. Maxillary first molar porcelain restoration constructed to mandibular first molar diagnostic wax-up.
first molars. The therapeutic position of the mandible was maintained by the patient closing on the mandibular OPOS during the interocclusal records. After setting, the interocclusal records would serve as occlusal indexes for articulating the mandibular and maxillary stone casts. Reversible hydrocolloid impressions (Acculoid, Van R Dental Products, Inc., Oxnard, Calif.) were made of the mandibular and maxillary dental arches, including the prepared maxillary first molars (Figs. 4 and 5) and were cast with artificial stone (Die Keen, Modern Materials Mfg., St. Louis, MO.). Posterior composite resins (P30, 3M Dental Products, St. Paul, Minn.) were bonded to both mandibular first molars (Fig. 6) to maintain the craniomandibular relationship while the porcelain units were constructed. These interim restorations were removed when the maxillary first molars were bonded with porcelain. The maxillary stone cast was transferred to the fully adjustable articulator using a face-bow (Denar D31 AB Face Bow, Denar Corp.) registration. Settings for the fully adjustable articulator were previously established. The mandibular artificial stone cast was articulated to the maxillary cast using the former occlusal indexes. With one occlusal index on each first molar and the anterior teeth acting as a third stop, the mandibular model could be accurately positioned against the maxillary cast (Fig. 7). A diagnostic wax-up was formed on the mandibular first molars to construct the porcelain overlay restorations on the maxillary first molars (Fig. 8). At the next appointment, the etched porcelain restorations were bonded to the maxillary first molars by conditioning (Mirage-Bond Dentin and Enamel Adhesive, Chameleon Dental Products, Inc., Kansas City, Kan.) the enamel and minimally exposed dentin. The silane-coated etched porcelain restorations were bonded to the condi-
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 9. Porcelain bonded restorations on maxillary and mandibular first molars.
Fig. 10. Occlusion stabilized by posterior first molars and anterior central and lateral incisors.
tioned tooth with a dual-cure composite resin (Mirage Dual Cure Dentinal Bonding Kit, Chameleon Dental Products, Inc.). The mandibular first molars were then prepared for the porcelain overlays. Interocclusal records were repeated with registration pastes using the mandibular OPOS to preserve the therapeutic craniomandibular relationship. Reversible hydrocolloid impressions of the maxillary arch with the bonded porcelain restorations on the first molars were made, including the mandibular impressions of the prepared first molars. The casts were transferred to a fully adjustable articulator for completion of the mandibular first molar porcelain restorations. The interocclusal records enabled the mandibular stone cast with prepared first molars to be accurately articulated to the maxillary stone cast. The mandibular first molar porcelain restorations were articulated to the previously completed maxillary first molar porcelain restorations. A glass ionomer cement (GC Miracle Mix, GC Interna-
585
WILLIAMS
AND
SIGLER
Fig, 13. Clear v~~~~rn-~orrne~ acrylic resin splints.
ed acrylic resin placed in clear acrylic resin
rn~n~~ble was now stabilized po
~~terocclusa~ records were secured at this therapeutic cclusal registration paste was placed over the premoiars and canines with the patient in an ition ad then in centric closure to the tripodized relation. rocolloid impressions were made and the casts from these impressions were IISferred to the fully adjustable articulator (Fig. II). a&fnostic wax-ups were progr the maxillary and rna~~i~~~ar premolars and ig. 12). ~rn~ress~~~s
ETCHED
PORCELAIN
BONDED
RESTORATIONS
Fig. 16. Red acrylic resin guides for mandibular tooth preparation.
Fig. 1’7. Evaluating accuracy of occlusal indexes.
Fig. 16. Completed mandibular canine, premolars, and first molar.
Fig. 18. Restored mandibular first molars.
of the wax-ups were made, poured with model cast stone, and then vacuum-formed acrylic resin splints (Clear Temporary Splint Material 0.020, Buffalo Dental Mfg. Co., Syasset, N.Y.) were formed over the casts (Fig. 13). At the next appointment, the clear acrylic resin splints were filled with red acrylic resin (DuraLay, Reliance Dent. Mfg. Co., Worth, Ill.) and were seated over the maxillary arch. Small holes were made in the clear acrylic resin splint over the buccal cusps to allow the excess acrylic resin to extrude from the splint and completely seat. The completed first molars and central and lateral incisors were the occlusal stops in the seating of this clear acrylic resin splint (Fig. 14). After the acrylic resin had set, the splint was removed. This new maxillary occlusal plane would then guide the tooth preparation for the mandibular premolars and canines (Fig. 15). After the tooth preparation for the porcelain bonded restorations, reversible hydrocolloid impres-
sions were made of the mandibular and maxillary arch with the red acrylic resin in place. Occlusal registration paste was placed over the mandibular premolars and canines an interocclusal records were made in the Frankfort horizontal plane parallel to the floor. The stone casts were again transferred to the fully adjustable articulator by a face-bow record and were articulated using the interocclusal records The treatment position was maintained by realigning the mandibular OPOS with acrylic resin (Caulk Orthodontic Resin, The L.D. Caulk Co., Milford, Del.). The established craniomandibular relationship would be maintained with porcelain over the first molars, the mandibular QPOS over the premolars and canines, with the maxillary and mandibular central and lateral incisors articulating in the closed relationship. The mandibular porcelain restorations were constructed in relation to the maxillary arch occlusal plane developed
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
canines, premolars, and
maxillary arch. The accuracy of this articulation was ensured with the interocclusal records and a checking system (Denar Vericbeck, Benar Corp.) (Fig. 17). ~ax~~~~r~ porcelain restorations were constructed on tbe premolaxs and canines to the completed mandibular arch The cusp height and location with tions were developer from the ana occlusal surfaces using the fully adjustable articulator. This mandibular occlusal anatomy was predetermined from the diagnostic wax-ups of opposing arches (Fig. 18). At the next appointment, the maxillary premolars canines were bonded with etched porcelain (Fig. 19) tbe occlusion was evaluated. For this particular pati only one occlusal adjustment was made at the intercuspal position. The eccentric guidance .s developed using canine guidance of porcelain opposi porcelain (Fig. 20).
The major advantage of this technique is sustaining the preexisting therapeutic position of the mandible during the restorative phase with minimal error in the occlusal scheme espite the type of restorative material. This clinical report demonstrated the conservative nature of bonding etched porcelain to tooth structure while concomitantly ing the ~a~d~b~e to the maxillary dental arch. Special
thanks
to Robert
T&h,
stabiliz-
DDS.
1. Jensen ME, Redford DA, Williams BT, Gardner F. Posterior etchedporceiairv restorations: an in vitro study. Compend Contin Educ Dent 1987;8:615-22. 2. Calemia JR. Etchedporcelain facial veneers: a new treatment modality based en scientific and clinical evidence. NY J Dent 1983;53:255-9. 3. Guinn J, Williams BT. Therapeutic exercises for craniofacial pain and dysfunction. Salt Lake City: TM.3 Management Systems, 1982. 4. Guinn J, Williams BT. Choosing the right appliance. J Craniomandib Pratt 1985;3:289-93. 5. Wiiliams BT. Syliabus-TMj pain and dysfunction. Anaheim, Calif: The Society for Occlusal Studies, 1984. 6. Farrar WB. DifYerentiation of temporomandibular joint dysfunction to simplify treatment. J PROSTHET DENT 1972;28:629-36. Reprint
requests
to:
DR. BERNARD T. WILLIAMS 1010 CARQNDELET, STE.~IO KANSAS Cm, MO 64114
T. Williams,
DDS*, and Thomas
Sigler,
therapeutic bonded restorations:
CDTb
Kansas City, MO.
T
his clinical report describes a restorative technique for stabilization of the mandible by bonding etched porcelain to tooth structure. L 2 This procedure represents the concluding treatment for a patient with craniofacial pain, dysfunction, and parafunction. Treatment for a 36-year-old woman with severe headaches, pain in the masticatory muscles, crepitus, and dysfunction within the temporomandibular joints (TMJs) is discussed in this report. The earlier phases of therapy consisted of exercises,3 occlusal plane orthopedic splints* (OPOS), and orthodontics. The craniomandibular relationship following these therapies resulted in a posterior open occlusion without canine guidance. However, the maxillary and mandibular central and lateral incisors contacted when the patient closed her jaws, and protrusive guidance was present on the eight anterior teeth. The posterior open occlusion did not result from intrusion of the posterior teeth. An acrylic resin splint was not inserted between the dental arches to create an anterior open occlusion that intruded the posterior teeth. Instead, this thera-
*Private practice. bCertified Dental Technician.
Fig. 2. Mandibular OPOS.
10/l/31023
Fig. 1. Craniomandibular
THE
JOURNAL
OF PROSTHETIC
peutic position was achieved by strategically positioning the mandible in an anterior position that created this posterior open occlusion. Corrected transcranial radiographs5 were obtained before and after treatment to confirm this positional change within the TMJs. The occlusion is commonly elevated with etched porcelain bonded to tooth structure, but to restore an entire
relationship with OPOS.
DENTISTRY
Fig. 3. Distal extensions of mandibular OP
Fi
snded composite resin to rna~di~~~~ first mo-
lars.
ing the years of conserva-
s transferred
to a fully adj~stab~@ artieular enar Corp.), Since the vertical
articulator and the i~tero~~~~sa~records would be registered at the same vertical dimension of occlusion, hin axis locations were ~~ne~~ssary, xtensions of the mandibular QPQ The rst m ere removed (Fig. 31, and maxi~l~y first molars were prepared for etched porcelain bonded overlay KestQratiQ~semirate Port n Systems, Myron Enternatimal, Kansas City, Kan.). cured, occi-usai re~istrat~
ETCHEDPQRCELAINBONDEDRESTORATIONS
Fig. 8. Maxillary first molar porcelain restoration constructed to mandibular first molar diagnostic wax-up.
first molars. The therapeutic position of the mandible was maintained by the patient closing on the mandibular OPOS during the interocclusal records. After setting, the interocclusal records would serve as occlusal indexes for articulating the mandibular and maxillary stone casts. Reversible hydrocolloid impressions (Acculoid, Van R Dental Products, Inc., Oxnard, Calif.) were made of the mandibular and maxillary dental arches, including the prepared maxillary first molars (Figs. 4 and 5) and were cast with artificial stone (Die Keen, Modern Materials Mfg., St. Louis, MO.). Posterior composite resins (P30, 3M Dental Products, St. Paul, Minn.) were bonded to both mandibular first molars (Fig. 6) to maintain the craniomandibular relationship while the porcelain units were constructed. These interim restorations were removed when the maxillary first molars were bonded with porcelain. The maxillary stone cast was transferred to the fully adjustable articulator using a face-bow (Denar D31 AB Face Bow, Denar Corp.) registration. Settings for the fully adjustable articulator were previously established. The mandibular artificial stone cast was articulated to the maxillary cast using the former occlusal indexes. With one occlusal index on each first molar and the anterior teeth acting as a third stop, the mandibular model could be accurately positioned against the maxillary cast (Fig. 7). A diagnostic wax-up was formed on the mandibular first molars to construct the porcelain overlay restorations on the maxillary first molars (Fig. 8). At the next appointment, the etched porcelain restorations were bonded to the maxillary first molars by conditioning (Mirage-Bond Dentin and Enamel Adhesive, Chameleon Dental Products, Inc., Kansas City, Kan.) the enamel and minimally exposed dentin. The silane-coated etched porcelain restorations were bonded to the condi-
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 9. Porcelain bonded restorations on maxillary and mandibular first molars.
Fig. 10. Occlusion stabilized by posterior first molars and anterior central and lateral incisors.
tioned tooth with a dual-cure composite resin (Mirage Dual Cure Dentinal Bonding Kit, Chameleon Dental Products, Inc.). The mandibular first molars were then prepared for the porcelain overlays. Interocclusal records were repeated with registration pastes using the mandibular OPOS to preserve the therapeutic craniomandibular relationship. Reversible hydrocolloid impressions of the maxillary arch with the bonded porcelain restorations on the first molars were made, including the mandibular impressions of the prepared first molars. The casts were transferred to a fully adjustable articulator for completion of the mandibular first molar porcelain restorations. The interocclusal records enabled the mandibular stone cast with prepared first molars to be accurately articulated to the maxillary stone cast. The mandibular first molar porcelain restorations were articulated to the previously completed maxillary first molar porcelain restorations. A glass ionomer cement (GC Miracle Mix, GC Interna-
585
WILLIAMS
AND
SIGLER
Fig, 13. Clear v~~~~rn-~orrne~ acrylic resin splints.
ed acrylic resin placed in clear acrylic resin
rn~n~~ble was now stabilized po
~~terocclusa~ records were secured at this therapeutic cclusal registration paste was placed over the premoiars and canines with the patient in an ition ad then in centric closure to the tripodized relation. rocolloid impressions were made and the casts from these impressions were IISferred to the fully adjustable articulator (Fig. II). a&fnostic wax-ups were progr the maxillary and rna~~i~~~ar premolars and ig. 12). ~rn~ress~~~s
ETCHED
PORCELAIN
BONDED
RESTORATIONS
Fig. 16. Red acrylic resin guides for mandibular tooth preparation.
Fig. 1’7. Evaluating accuracy of occlusal indexes.
Fig. 16. Completed mandibular canine, premolars, and first molar.
Fig. 18. Restored mandibular first molars.
of the wax-ups were made, poured with model cast stone, and then vacuum-formed acrylic resin splints (Clear Temporary Splint Material 0.020, Buffalo Dental Mfg. Co., Syasset, N.Y.) were formed over the casts (Fig. 13). At the next appointment, the clear acrylic resin splints were filled with red acrylic resin (DuraLay, Reliance Dent. Mfg. Co., Worth, Ill.) and were seated over the maxillary arch. Small holes were made in the clear acrylic resin splint over the buccal cusps to allow the excess acrylic resin to extrude from the splint and completely seat. The completed first molars and central and lateral incisors were the occlusal stops in the seating of this clear acrylic resin splint (Fig. 14). After the acrylic resin had set, the splint was removed. This new maxillary occlusal plane would then guide the tooth preparation for the mandibular premolars and canines (Fig. 15). After the tooth preparation for the porcelain bonded restorations, reversible hydrocolloid impres-
sions were made of the mandibular and maxillary arch with the red acrylic resin in place. Occlusal registration paste was placed over the mandibular premolars and canines an interocclusal records were made in the Frankfort horizontal plane parallel to the floor. The stone casts were again transferred to the fully adjustable articulator by a face-bow record and were articulated using the interocclusal records The treatment position was maintained by realigning the mandibular OPOS with acrylic resin (Caulk Orthodontic Resin, The L.D. Caulk Co., Milford, Del.). The established craniomandibular relationship would be maintained with porcelain over the first molars, the mandibular QPOS over the premolars and canines, with the maxillary and mandibular central and lateral incisors articulating in the closed relationship. The mandibular porcelain restorations were constructed in relation to the maxillary arch occlusal plane developed
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
canines, premolars, and
maxillary arch. The accuracy of this articulation was ensured with the interocclusal records and a checking system (Denar Vericbeck, Benar Corp.) (Fig. 17). ~ax~~~~r~ porcelain restorations were constructed on tbe premolaxs and canines to the completed mandibular arch The cusp height and location with tions were developer from the ana occlusal surfaces using the fully adjustable articulator. This mandibular occlusal anatomy was predetermined from the diagnostic wax-ups of opposing arches (Fig. 18). At the next appointment, the maxillary premolars canines were bonded with etched porcelain (Fig. 19) tbe occlusion was evaluated. For this particular pati only one occlusal adjustment was made at the intercuspal position. The eccentric guidance .s developed using canine guidance of porcelain opposi porcelain (Fig. 20).
The major advantage of this technique is sustaining the preexisting therapeutic position of the mandible during the restorative phase with minimal error in the occlusal scheme espite the type of restorative material. This clinical report demonstrated the conservative nature of bonding etched porcelain to tooth structure while concomitantly ing the ~a~d~b~e to the maxillary dental arch. Special
thanks
to Robert
T&h,
stabiliz-
DDS.
1. Jensen ME, Redford DA, Williams BT, Gardner F. Posterior etchedporceiairv restorations: an in vitro study. Compend Contin Educ Dent 1987;8:615-22. 2. Calemia JR. Etchedporcelain facial veneers: a new treatment modality based en scientific and clinical evidence. NY J Dent 1983;53:255-9. 3. Guinn J, Williams BT. Therapeutic exercises for craniofacial pain and dysfunction. Salt Lake City: TM.3 Management Systems, 1982. 4. Guinn J, Williams BT. Choosing the right appliance. J Craniomandib Pratt 1985;3:289-93. 5. Wiiliams BT. Syliabus-TMj pain and dysfunction. Anaheim, Calif: The Society for Occlusal Studies, 1984. 6. Farrar WB. DifYerentiation of temporomandibular joint dysfunction to simplify treatment. J PROSTHET DENT 1972;28:629-36. Reprint
requests
to:
DR. BERNARD T. WILLIAMS 1010 CARQNDELET, STE.~IO KANSAS Cm, MO 64114
