In the realm of prosthodontics and restorative dentistry, achieving an accurate centric relation (CR) is essential for ensuring the proper function and fit of dental restorations. Traditionally, recording the centric relation has required the use of multiple appliances and techniques, each with its own set of procedures, challenges, and potential for error. This study introduces a digital trifunctional intraoral appliance, which streamlines the process of CR, recording by combining the functions of an anterior deprogrammer, gothic arch tracer, and record base with occlusal rims into a single, multifunctional device. The goal of this innovation is to improve both the efficiency and accuracy of CR recording, ultimately benefiting the clinician and the patient.
The development and utilization of this digital appliance represent a significant step forward in simplifying complex dental procedures, reducing the number of devices needed, and ensuring a more consistent and reproducible outcome. This approach relies heavily on digital tools and technologies, which offer several advantages over conventional methods, such as faster fabrication times, increased accuracy, and the ability to customize the appliance to each patient’s unique anatomy.
How the Technique Works
The process of fabricating and using the trifunctional intraoral appliance involves a combination of clinical and laboratory steps, leveraging modern digital technologies such as intraoral scanners and computer-aided design (CAD) software. The key steps in the workflow are as follows:
Intraoral Scanning:
The first step involves obtaining detailed digital impressions of the patient’s dental arch. Using an intraoral scanner (such as the TRIOS 3 by 3Shape), the clinician captures scans of the maxillary and mandibular arches, as well as the maxillomandibular relationship at the Maximum Intercuspal Position (MIP). These scans are highly accurate and form the foundation for the design of the appliance.
Designing the Trifunctional Appliance:
Once the scans are obtained, the data is uploaded into a computer-aided design (CAD) software program, such as DentalDB 3.2. This software enables the clinician to design the trifunctional appliance digitally. The appliance is created to combine the three essential functions:
Anterior Deprogrammer: Used to relax the muscles of the jaw and eliminate any habitual bite positions that might interfere with the accurate recording of centric relation.
Gothic Arch Tracer: A tool that helps in mapping the movements of the jaw to accurately identify the CR position.
Record Base with Occlusal Rims: Used to record the relationship between the upper and lower jaws in the desired position.
By integrating all these functions into a single device, this technique simplifies the entire CR recording process, making it more efficient and accurate.
Fabrication of the Appliance:
After the digital design is finalized, the appliance is fabricated, typically using 3D printing or milling techniques. The material used is biocompatible and durable, ensuring that the appliance can withstand the forces applied during the CR recording process.
Advantages of the Digital Trifunctional Intraoral Appliance
The introduction of the digital trifunctional intraoral appliance represents a significant advancement in the process of recording centric relation (CR) and improving the efficiency and accuracy of restorative procedures. The appliance’s design combines three critical functions—anterior deprogramming, gothic arch tracing, and occlusal recording—into a single device, offering numerous benefits for both clinicians and patients. Below, we will delve deeper into these advantages and explore how each aspect of the technology enhances the treatment process.
1. Multifunctionality
The most prominent advantage of the digital trifunctional appliance is its multifunctionality. Traditionally, recording centric relation (CR) involved the use of several separate appliances or tools. For example, clinicians would need an anterior deprogrammer to relax the jaw muscles and eliminate any muscle memory that might interfere with an accurate CR recording. Additionally, a gothic arch tracer would be used to trace the movements of the jaw, and occlusal rims or record bases would be employed to establish the occlusion.
By integrating all these functions into one device, this trifunctional appliance reduces the need for multiple instruments. This not only saves time during the procedure but also reduces the cost of using various appliances. Moreover, it simplifies the process for the clinician, who no longer needs to manage different devices and follow multiple steps in sequence. This can also decrease the risk of errors, as fewer tools are involved, making it easier to maintain consistency throughout the procedure.
For patients, the multifunctionality of the appliance means fewer adjustments and less chairside time. In fact, the process is more efficient, resulting in a more comfortable experience, especially for those who require longer treatment sessions.
2. Increased Efficiency
The use of digital tools and a single multifunctional appliance leads to a highly efficient workflow for both the clinician and the patient. Traditional methods of CR recording often required a number of manual adjustments to ensure that each appliance fit correctly and accurately captured the necessary data. These adjustments could significantly prolong the time spent in the chair, leading to patient discomfort and clinician fatigue.
With the digital trifunctional appliance, the workflow is expedited. Once the intraoral scans are taken and the appliance is digitally designed, it is fabricated with precise specifications, allowing it to be used directly without the need for constant adjustments. This streamlined approach results in a faster procedure and shorter appointment times, both of which contribute to higher patient satisfaction. Since all three critical functions—deprogramming, tracing, and occlusal recording—are integrated into one device, clinicians can move quickly between steps, leading to more predictable outcomes.
3. Customization
One of the key advantages of digital workflows is the ability to create highly personalized devices for each patient. Using intraoral scanners and CAD software, the appliance is tailored to fit the unique anatomy of each patient’s dental arch and jaw structure. This ensures that the trifunctional appliance conforms precisely to the patient’s bite, improving both comfort and accuracy.
Customization is essential, as it directly impacts the accuracy of the CR recording. With traditional methods, a standard appliance is often used, which may not perfectly fit the patient’s specific anatomical needs. This mismatch can lead to discomfort or, in some cases, an inaccurate CR recording. With digital customization, however, the clinician can design an appliance that perfectly aligns with the patient’s arch, minimizing discomfort and ensuring that the recorded CR is as accurate as possible.
Additionally, the ability to tailor the appliance to each patient’s needs is especially beneficial for patients with complex cases, such as those who are partially edentulous, have mobile teeth, or have other unique anatomical challenges. In these situations, the trifunctional appliance can be adapted to offer a better fit, ensuring that the CR recording is not influenced by anatomical limitations or irregularities.
4. Improved Accuracy
The integration of digital scans and CAD software leads to a significant improvement in the accuracy of centric relation recordings. Traditional CR recording methods often relied on manual placement of appliances and could be influenced by the clinician’s technique, patient cooperation, and the fit of the devices. Inaccurate CR recordings can lead to poorly fitted restorations, discomfort, and compromised functionality.
With the digital trifunctional appliance, the process is far more precise. The digital workflow begins with intraoral scanning, capturing highly accurate, 3D representations of the patient’s dental arches. The scans are then processed through CAD software, where the appliance is designed to fit precisely within the patient’s oral cavity. This digital approach eliminates the variability associated with manual techniques, ensuring that the CR recording is more reliable.
Moreover, the appliance is fabricated using 3D printing or milling technologies, which further enhances accuracy. These technologies are capable of producing highly detailed and customized appliances that are directly proportional to the patient’s unique anatomy. As a result, the final CR recording will be more representative of the patient’s true centric relation, leading to better-fitting restorations and a more comfortable experience for the patient.
5. Simplified Workflow
By combining the anterior deprogramming, gothic arch tracing, and occlusal recording functions into a single appliance, the clinician’s workflow is simplified. Traditionally, CR recording required the use of multiple devices, each serving a different purpose. This not only added complexity to the procedure but also increased the risk of errors during each stage of the process.
With the trifunctional appliance, clinicians can complete the entire CR recording process in fewer steps, reducing the chances of making mistakes. The ability to have all functions in one appliance also means that fewer adjustments are required, resulting in a more predictable and efficient clinical outcome. The clinician can focus on ensuring the accuracy of the CR recording, rather than managing multiple devices and switching between them.
Additionally, the digital aspect of the workflow ensures that once the appliance is designed and fabricated, it can be used consistently for each patient, reducing the variability that can occur with traditional manual techniques. This ultimately leads to better consistency and more reliable results.
6. Clinical Impact and Patient Comfort
The combination of all these advantages significantly enhances the overall clinical experience for both the patient and the clinician. Patients benefit from faster procedures, less discomfort, and a more accurate fit, which improves the success of the final restoration. Moreover, the integration of digital technologies allows for a non-invasive and customizable approach that can address a wider range of patient needs.
Clinicians also experience greater efficiency and predictability, allowing them to provide a higher level of care with fewer resources. The digital workflow reduces the potential for human error, improves consistency, and enables better patient outcomes.
Potential Clinical and Financial Impact
This innovative approach to centric relation recording is not only beneficial in terms of clinical efficiency and accuracy but also has the potential to improve the financial aspect of dental practices:
Cost Savings: By consolidating three functions into a single device, the need for multiple appliances and additional chairside time is minimized, which can reduce overall treatment costs for both the clinician and the patient. The use of digital workflows also reduces the need for traditional materials and manual labor, leading to lower production costs for the appliance.
Time Efficiency: The time saved by using a single appliance that performs multiple functions can be reinvested into seeing more patients, improving overall clinic productivity. Additionally, the faster fabrication time of digital appliances can lead to quicker turnaround times, reducing the need for multiple appointments and improving patient satisfaction.
Increased Patient Satisfaction: With a streamlined process and reduced chairside time, patients are likely to experience a more comfortable and less time-consuming treatment. This, in turn, can lead to higher levels of patient satisfaction and potential for repeat business or referrals.
Potential for Expanded Applications: As the technology develops, the use of trifunctional intraoral appliances may expand to benefit a wider range of patients, especially those who are partially edentulous or have mobile teeth. The future integration of aligning jigs for facial scanners or optical jaw tracking devices could further enhance the accuracy and functionality of this device, making it applicable to an even broader patient population.
Future Research and Development
Although this technique has shown great promise, further research is needed to evaluate the accuracy of the recorded centric relation and assess its clinical outcomes. In particular, studies could focus on comparing the accuracy of this digital approach to traditional methods to validate its benefits. Additionally, there is potential for incorporating more advanced scanning technologies and tracking devices that could further improve the precision and ease of the process.
Another area of future exploration could involve the development of more customizable appliances, allowing clinicians to easily adapt the device for patients with unique anatomical challenges or specific treatment needs. The integration of facial scanning and jaw-tracking technologies could further refine this appliance, offering even greater accuracy in determining the centric relation position.
Conclusion
The digital trifunctional intraoral appliance represents a significant innovation in the way centric relation is recorded in dental practice. By combining the functions of an anterior deprogrammer, gothic arch tracer, and occlusal rim record base into a single device, this technique offers improved efficiency, precision, and patient comfort. With its potential for cost savings, time efficiency, and customization, this digital approach has the potential to become a standard tool in prosthodontic and restorative dentistry. As research and technology continue to advance, this technique could pave the way for even more innovative solutions in the recording and treatment of centric relation.
This dental technique outlines the clinical and laboratory workflow for fabricating the trifunctional intraoral appliance to accurately locate CR position. The trifunctional intraoral appliance can be indicated for all patients, especially partially edentulous patients and those with mobile teeth. The future integration of aligning jigs for facial scanners or optical jaw tracking devices into this appliance can be further explored. Research is needed to assess the accuracy of the recorded CR
Acknowledgments
The authors thank Dr Jessica Poon and Dr Oliver Viera for their help in grammar editing, and CDT Charles Mwele for their technical support with 3D-printing.
References
https://www.sciencedirect.com/science/article/abs/pii/S0022391324008205
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