Suggested
modifications
for the leaf wafer
system
S. H. Lee, D.D.S.,* and J. B. Woelfel, D.D.S.** Veterans General Hospital, Taipei, Taiwan, R.O.C.,and Ohio State University, Collegeof Dentistry, Columbus,Ohio The Woelfel leaf wafer system provides an easy and accurate way to register centric relation position, which is important in dental practice. This article suggests the following modifications of the system that should enhance the accuracy and convenience of the technique: (1) custom deform wafer before deprogramming or tripodizing the mandible, (2) mark position of leaf gauge at wafer slot, (3) secure leaf gauge to wafer with cyanoacrylate glue, and (4) write pertinent information on paper leaf gauge. (J PROSTHET DENT 1991;68:287-9.)
N
euromuscular relaxation of the muscles of mastication is an integral part of a physiologically sound and scientific method for recording centric relation.l, s Based on the philosophy of anterior deprogramming, the Woelfel leaf wafer system (Girrbach Dental, Postfach, Germany) provides an easy, practical, and accurate way to record centric relation.3 According to the directions for using this system, the deprogramming procedure (5 to 15 minutes) is done before custom reshaping of the wafer (when the patient bites firmly onto the wafer in centric occlusion for approximately 10 seconds).2p3 It is doubtful that the tripodizing of the mandible from deprogramming
*Chief Resident,Dental Department,VeteransGeneralHospital. **Professor Emeritus, Division of Prosthodontics, Ohio State University, Collegeof Dentistry. 10/l/18983
would still be effective after a forceful intercuspal closure of the teeth onto the wafer. Another possible source of error could be caused by positioning the paper leaf gauge incorrectly during either the recording or mounting procedures. This article describes four modifications of the technical procedures that should make this system both accurate and convenient to use.
TECHNIQUE 1. Try-in the wafer with leaf gauge (arbitary thickness approximately 2 to 4 mm) and have the patient close the teeth together for observation of the anteroposterior position of the wafer. Make a felt-tip mark of the midline and most labial edge of maxillary central incisors before removing the assembly from the mouth (Fig. 1). 2. Place the wafer alone in the patient’s mouth, oriented by
IFig. 1. Incisor midline and most labial edge of central incisors have been marked with felt pin. IFig. 2. Bending excess facial borders of wafer.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
287
LEEANDWOELFEL
Fig. Fig. Fig. Fig.
3. 4.
5.
6. 7.
3. 4. 5. 6.
Trimming excess border of wafer with scissors. Marked junction between paper gauge and wafer (dark line). Securing gauge and wafer with cyanoacrylic. Pertinent information written on paper leaf gauge.
the previous marks and have the patient bite firmly in centric occlusion for approximately 10 seconds while you bend the excess facial borders of the wafer up and down several times3 (Fig. 2). Cut the first of three perforations in the wafer and bend the tab down. If necessary, trim the size of the wafer with scissors (Fig. 3). Determine the amount of necessary incisor opening to prevent posterior tooth contact of the interocclusal record by using a sufficient thickness of leaf gauge. Adjust the leaf gauge thickness to ensure that there is no posterior tooth contact, with continued minimum separation for a period of 2 to 5 minutes. At this time the mandible is deprogrammed4* 6 Insert the leaf gauge into the wafer and position them in the mouth according to the felt-tip mark. Have the patient close on the assembly and draw a line at the junction between the gauge and wafer (Fig. 4). Dry the surfaces thoroughly and secure the correct location (step 5) of the leaf gauge and wafer with cyanoacrylate glue (Fig. 5). Keep the teeth entirely separated213 while the check-
288
bite medium is being mixed and applied to the tooth indentations on both sides of the wafer. 8. Insert the wafer leaf gauge assembly quickly in the patient’s mouth, orienting it according to the midline and in&al edge mark (step 1). 9. Guide the first part of the retruded mandibular closure for the patient until the lower incisors engage the tab on the wafer beneath the leaf gauge. 10. Have the patient continue to hold the jaw firmly against the leaf gauge while the recording medium sets. 11. Remove the leaf wafer jaw registration, inspect it for accuracy and recordings of the necessary opposing tooth indentations. Write the patient’s name, the date, and incisor separation on the upper surface of the paper leaf gauge (Fig. 6). 12. Trim off the excess recording medium and verify that the opposing casts can be correctly assembled in the registration. Inspect for their complete seating with the slightly indented portion of the leaf gauge between the opposing dental stone incisors. The leaf gauge is intentionally left in place for added stability while sticky wax is applied.
FEBRUARYlBSl
VOLUME66
NUMBERZ
MODIFICATIONS
OF LRAF
WAFER
SYSTEM
SUMMARY
2. Woelfel JB. New device for accurately recording centric relation. J
The Woelfel leaf wafer system is accurate, quick, inexpensive, and pleasant for the patient. This article suggests four seemingly minor but significant modifications that should enhance the accuracy, usefulness, and convenience
3. Chu CJ, Woe&l JB. An easy way to take centric relation record correctly. Dentist Bridge 1989;5:58-62. 4. Carroll WJ, Woelfel JB, Huffman RW. Simple application on anterior jig or leaf gauge in routine clinical practice. J PROSTHET DENT 1988;59:611-7. 5. Huffman RW. A cusp-fossa equilibration technique using a numbered leaf gauge. J Gnatho 1987;6:23-36.
PROSTHFT DENT 1986;56:716-27.
of the technique.
They are: (1) custom deform the wafer
prior to deprogramming or tripodizing the mandible, (2) mark the position of the leaf gauge at the wafer slot, (3) secure the leaf gauge to the wafer with cyanoacrylate glue, and (4) write the name, date, thickness, and other data on the paper leaf gauge.
Reprint requests to: DR. SHYH-YUAN LEE DENTAL DEPARTMENT VETERANS GENERAL HOSPITAL TAIPEI, TAIWAN R.O.C.
REFERENCES 1. Lucia VO. A technique for recording centric relation. J PROSTHET DENT 1964;14:492-505.
Self-reported symptoms of stress with temporomandibular disorders: Comparisons to healthy men and women Randal D. Beaton, Ph.D.,* Kelly J. Egan, Helen Nak.agawa-Kogan, R.N., Ph.D.,*** Kenneth N. Morrison, D.D.S.**** University of Washington, Seattle, Wash.
Ph.D.,** and
Replies on a self-report measure of symptoms of stress obtained from men and women patient samples with diagnosed temporomandibular disorders were compared with similar replies on this test obtained from healthy men and women. On most (six of 10) of the symptoms of stress subscales, the temporomandibular disorder patients’ scores were elevated relative to the symptoms of stress averages of the heaRhy nonpatient samples. There were several statistically signi5cant group didterences. There were no statistically significant gender differences nor any gender group interactions. These data are seen as essentially supporting and extending prior studies, which have indicated that, on the average, temporomandibular disorder patients report more psychologic and somatic symptoms. Furthermore, current 5ndings indicate that male temporomandibular disorder patients and female temporomandibular disorder patients report more numerous and/or frequent somatic, psychologic, and behavioral symptoms of stress compared with DENT 1991;6S:289-93.) their healthy counterparts. (J PROSTEET
T
he psychologic and psychosocial characteristics of patients with temporomandibular joint and myofascial pain-dysfunction symptoms (TMJ/MPDS) have received Research supported in part by PHS-Nursing Special Project grant No. DlO NU20018-04. *Research Associate Professor, Departments of Psychosocial Nursing and Dental Public Health Sciences. **Associate Professor, Department of Anesthesiology. ***Professor, Department of Psychosocial Nursing. ****Professor Emeritus, Restorative Dentistry and former Director of TMJ Research Clinic. 10/l/26743
TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
theoretical and empirical attention in the dental research literature for more than 30 years.rV3There has been, as a result, an increasing appreciation of the role that psychologic and stress factors might play in the etiology and progression of TM disorders.4v5 Most clinical research regarding TM patients has found them to differ from controls on a number of psychologic and psychosocial dimensions69 7 For example, previous researchers found that TM patients endorse more “neurotic” symptomatology on paper and pencil tests and report more emotional problems, compared with controls.s, g Similarly, significantly more physical and psychophysiologic
symptoms
are likely
to be
289
modifications
for the leaf wafer
system
S. H. Lee, D.D.S.,* and J. B. Woelfel, D.D.S.** Veterans General Hospital, Taipei, Taiwan, R.O.C.,and Ohio State University, Collegeof Dentistry, Columbus,Ohio The Woelfel leaf wafer system provides an easy and accurate way to register centric relation position, which is important in dental practice. This article suggests the following modifications of the system that should enhance the accuracy and convenience of the technique: (1) custom deform wafer before deprogramming or tripodizing the mandible, (2) mark position of leaf gauge at wafer slot, (3) secure leaf gauge to wafer with cyanoacrylate glue, and (4) write pertinent information on paper leaf gauge. (J PROSTHET DENT 1991;68:287-9.)
N
euromuscular relaxation of the muscles of mastication is an integral part of a physiologically sound and scientific method for recording centric relation.l, s Based on the philosophy of anterior deprogramming, the Woelfel leaf wafer system (Girrbach Dental, Postfach, Germany) provides an easy, practical, and accurate way to record centric relation.3 According to the directions for using this system, the deprogramming procedure (5 to 15 minutes) is done before custom reshaping of the wafer (when the patient bites firmly onto the wafer in centric occlusion for approximately 10 seconds).2p3 It is doubtful that the tripodizing of the mandible from deprogramming
*Chief Resident,Dental Department,VeteransGeneralHospital. **Professor Emeritus, Division of Prosthodontics, Ohio State University, Collegeof Dentistry. 10/l/18983
would still be effective after a forceful intercuspal closure of the teeth onto the wafer. Another possible source of error could be caused by positioning the paper leaf gauge incorrectly during either the recording or mounting procedures. This article describes four modifications of the technical procedures that should make this system both accurate and convenient to use.
TECHNIQUE 1. Try-in the wafer with leaf gauge (arbitary thickness approximately 2 to 4 mm) and have the patient close the teeth together for observation of the anteroposterior position of the wafer. Make a felt-tip mark of the midline and most labial edge of maxillary central incisors before removing the assembly from the mouth (Fig. 1). 2. Place the wafer alone in the patient’s mouth, oriented by
IFig. 1. Incisor midline and most labial edge of central incisors have been marked with felt pin. IFig. 2. Bending excess facial borders of wafer.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
287
LEEANDWOELFEL
Fig. Fig. Fig. Fig.
3. 4.
5.
6. 7.
3. 4. 5. 6.
Trimming excess border of wafer with scissors. Marked junction between paper gauge and wafer (dark line). Securing gauge and wafer with cyanoacrylic. Pertinent information written on paper leaf gauge.
the previous marks and have the patient bite firmly in centric occlusion for approximately 10 seconds while you bend the excess facial borders of the wafer up and down several times3 (Fig. 2). Cut the first of three perforations in the wafer and bend the tab down. If necessary, trim the size of the wafer with scissors (Fig. 3). Determine the amount of necessary incisor opening to prevent posterior tooth contact of the interocclusal record by using a sufficient thickness of leaf gauge. Adjust the leaf gauge thickness to ensure that there is no posterior tooth contact, with continued minimum separation for a period of 2 to 5 minutes. At this time the mandible is deprogrammed4* 6 Insert the leaf gauge into the wafer and position them in the mouth according to the felt-tip mark. Have the patient close on the assembly and draw a line at the junction between the gauge and wafer (Fig. 4). Dry the surfaces thoroughly and secure the correct location (step 5) of the leaf gauge and wafer with cyanoacrylate glue (Fig. 5). Keep the teeth entirely separated213 while the check-
288
bite medium is being mixed and applied to the tooth indentations on both sides of the wafer. 8. Insert the wafer leaf gauge assembly quickly in the patient’s mouth, orienting it according to the midline and in&al edge mark (step 1). 9. Guide the first part of the retruded mandibular closure for the patient until the lower incisors engage the tab on the wafer beneath the leaf gauge. 10. Have the patient continue to hold the jaw firmly against the leaf gauge while the recording medium sets. 11. Remove the leaf wafer jaw registration, inspect it for accuracy and recordings of the necessary opposing tooth indentations. Write the patient’s name, the date, and incisor separation on the upper surface of the paper leaf gauge (Fig. 6). 12. Trim off the excess recording medium and verify that the opposing casts can be correctly assembled in the registration. Inspect for their complete seating with the slightly indented portion of the leaf gauge between the opposing dental stone incisors. The leaf gauge is intentionally left in place for added stability while sticky wax is applied.
FEBRUARYlBSl
VOLUME66
NUMBERZ
MODIFICATIONS
OF LRAF
WAFER
SYSTEM
SUMMARY
2. Woelfel JB. New device for accurately recording centric relation. J
The Woelfel leaf wafer system is accurate, quick, inexpensive, and pleasant for the patient. This article suggests four seemingly minor but significant modifications that should enhance the accuracy, usefulness, and convenience
3. Chu CJ, Woe&l JB. An easy way to take centric relation record correctly. Dentist Bridge 1989;5:58-62. 4. Carroll WJ, Woelfel JB, Huffman RW. Simple application on anterior jig or leaf gauge in routine clinical practice. J PROSTHET DENT 1988;59:611-7. 5. Huffman RW. A cusp-fossa equilibration technique using a numbered leaf gauge. J Gnatho 1987;6:23-36.
PROSTHFT DENT 1986;56:716-27.
of the technique.
They are: (1) custom deform the wafer
prior to deprogramming or tripodizing the mandible, (2) mark the position of the leaf gauge at the wafer slot, (3) secure the leaf gauge to the wafer with cyanoacrylate glue, and (4) write the name, date, thickness, and other data on the paper leaf gauge.
Reprint requests to: DR. SHYH-YUAN LEE DENTAL DEPARTMENT VETERANS GENERAL HOSPITAL TAIPEI, TAIWAN R.O.C.
REFERENCES 1. Lucia VO. A technique for recording centric relation. J PROSTHET DENT 1964;14:492-505.
Self-reported symptoms of stress with temporomandibular disorders: Comparisons to healthy men and women Randal D. Beaton, Ph.D.,* Kelly J. Egan, Helen Nak.agawa-Kogan, R.N., Ph.D.,*** Kenneth N. Morrison, D.D.S.**** University of Washington, Seattle, Wash.
Ph.D.,** and
Replies on a self-report measure of symptoms of stress obtained from men and women patient samples with diagnosed temporomandibular disorders were compared with similar replies on this test obtained from healthy men and women. On most (six of 10) of the symptoms of stress subscales, the temporomandibular disorder patients’ scores were elevated relative to the symptoms of stress averages of the heaRhy nonpatient samples. There were several statistically signi5cant group didterences. There were no statistically significant gender differences nor any gender group interactions. These data are seen as essentially supporting and extending prior studies, which have indicated that, on the average, temporomandibular disorder patients report more psychologic and somatic symptoms. Furthermore, current 5ndings indicate that male temporomandibular disorder patients and female temporomandibular disorder patients report more numerous and/or frequent somatic, psychologic, and behavioral symptoms of stress compared with DENT 1991;6S:289-93.) their healthy counterparts. (J PROSTEET
T
he psychologic and psychosocial characteristics of patients with temporomandibular joint and myofascial pain-dysfunction symptoms (TMJ/MPDS) have received Research supported in part by PHS-Nursing Special Project grant No. DlO NU20018-04. *Research Associate Professor, Departments of Psychosocial Nursing and Dental Public Health Sciences. **Associate Professor, Department of Anesthesiology. ***Professor, Department of Psychosocial Nursing. ****Professor Emeritus, Restorative Dentistry and former Director of TMJ Research Clinic. 10/l/26743
TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
theoretical and empirical attention in the dental research literature for more than 30 years.rV3There has been, as a result, an increasing appreciation of the role that psychologic and stress factors might play in the etiology and progression of TM disorders.4v5 Most clinical research regarding TM patients has found them to differ from controls on a number of psychologic and psychosocial dimensions69 7 For example, previous researchers found that TM patients endorse more “neurotic” symptomatology on paper and pencil tests and report more emotional problems, compared with controls.s, g Similarly, significantly more physical and psychophysiologic
symptoms
are likely
to be
289
