DENTAL TECHNIQUE

Use of an optical jaw-tracking system to record mandibular

motion for treatment planning and designing interim and
definitive prostheses: A dental technique
Edmond A. Bedrossian, DDS, MSD,a Edmond Bedrossian, DDS,b John C. Kois, DMD, MSD,c and
Marta Revilla-León, DDS, MSD, PhDd

During prosthodontic treat- ABSTRACT

ment, diagnostic procedures Optical jaw-tracking systems can record mandibular motion during the various treatment phases.
include intraoral and extraoral Also, computer-aided design programs facilitate the integration of a patient’s digital information,
examinations, radiographic including recorded mandibular motion, into the design of interim and definitive prostheses. A
evaluation, and mounting technique to fabricate a complete mouth implant-supported rehabilitation by using mandibular
diagnostic casts on an articu- motion captured with an optical jaw-tracking system is described. The mandibular motion
lator.1-4 When a complete recordings obtained before the treatment are combined with the interim restorations to perform
a diagnostic waxing, design the computer-guided implant plan, and fabricate maxillary and
mouth rehabilitation is plan-
mandibular screw-retained implant-supported interim and definitive prostheses. The process
ned, the use of a max- allows occlusal adjustments by using the patient’s mandibular motion and facilitates the
illomandibular relationship prosthetic design process, minimizing chair time at delivery. (J Prosthet Dent 2024;132:659-74)
captured at centric relation
(CR) or at a reproducible reference position of the to integrate a virtual patient that also include the dy-
mandible5 is recommended.6,7 Additionally, the diag- namics of the mandible recorded by using jaw-tracking
nostic and definitive articulator-mounted casts facilitate systems for fabricating a maxillary anterior fixed dental
designing the prosthesis by adjusting the static and dy- prostheses18 and complete dentures (CDs) are sparse.19
1 ,6 ,7
namic occlusion. A clinical technique for integrating an optical jaw-
Digital technologies such as intraoral scanners tracking system for planning, designing, and
(IOSs),8-11 cone beam computed tomography (CBCT),9,10 manufacturing a complete mouth implant-supported
facial scanners,8,9,11-13 and photogrammetry systems13-15 rehabilitation is needed.
aim to capture patient information in a digital format and A technique for integrating the mandibular motion
simplify treatment planning and prosthetic design and recordings obtained before treatment and with the
manufacturing procedures.8-13 Additionally, different interim restorations acquired by using an optical jaw-
optical jaw-tracking systems have been used to digitally tracking system into the treatment planning, designing,
record and track the maxillomandibular relationship and and fabricating procedures of a maxillary and mandibular
mandibular motion.14-20 Nevertheless, clinical protocols implant-supported prosthesis is described.

a
Affiliate Assistant Professor, Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash; Private practice,
San Francisco, Calif.
b
Private practice, San Francisco, Calif.
c
Founder and Director Kois Center, Seattle, Wash and Affiliate Professor, Graduate Prosthodontics, Department of Restorative Dentistry, University of Washington, Seattle,
Wash and Private practice, Seattle, Wash.
d
Affiliate Assistant Professor, Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington, Seattle, Wash and Faculty and
Director of Research and Digital Dentistry, Kois Center, Seattle, Wash; Adjunct Professor, Department of Prosthodontics, School of Dental Medicine, Tufts University, Boston,
Mass.

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Figure 1. Initial presentation. A, Full-face frontal smile. B, Maxillary and mandibular arches in maximum intercuspation. C, Maxillary occlusal view.
D, Mandibular occlusal view. E, Panoramic radiograph.

TECHNIQUE During treatment-planning procedures, diagnostic

casts were mounted on a virtual articulator in the CR
A 71-year-old woman with a noncontributory medical
position by using an IOS and an optical jaw-tracking
history presented for treatment requesting a fixed solu-
system. A CBCT scan (Next Gen CBCT; i-CAT) was then
tion to restore her function and esthetics. The extraoral
integrated into the virtual patient visualization by using a
examination revealed a proclined maxillary anterior
computer-aided design (CAD) software program (Dental
dentition, the dental midline not coincident with the
Systems; 3Shape) to perform virtual facially driven
facial midline, and the occlusal plane not parallel to the
diagnostic waxing. Subsequently computer-aided
horizontal facial references. At rest position, she had 1.5
implant planning procedures, surgical implant guides,
to 2 mm of maxillary incisor display, a straight smile line,
and interim dental prosthesis design and fabrication were
and low lip line. She had maxillary and mandibular res-
completed.
torations with recurrent caries, fractured teeth, and re-
sidual roots. Additionally, she showed generalized pla- 1. Obtain an intraoral digital scan by using an IOS
que with signs of inflammation accompanied by (TRIOS 4, wireless; 3Shape A/S) and following the
periodontal pockets and bleeding on probing, symptoms scanning pattern recommended by the manufac-
consistent with periodontal disease grade B, stage IV turer under 1000-lx ambient illumination condi-
(Fig. 1). After discussing various treatment options, she tions,21-23 by using a previously calibrated IOS
opted for maxillary and mandibular implant-supported device following the manufacturer’s protocol.24 Ac-
prostheses. quire a full-face photograph of the patient at rest

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Figure 1. (Continued). F, Cone-beam computed tomography scan.

and in smile positions with a digital reflex camera open-close, and protrusive movements) and masti-
(D7200, 105 mm lens; Nikon) (Fig. 2A). cation patterns.16 Lastly, use a leaf gauge (Leaf
2. Capture a CBCT scan and export the digital imaging Gauge; Huffman)25 to locate the CR position with
and communications in medicine (DICOM) files. the patient positioned at 45 degrees in the dental
Import these files into a program (3D Slicer, v.5.0.2; chair.26-28 Then, record the maxillomandibular
3D Slicer) and obtain the segmented mandible and relationship by using the jaw tracker and remove
maxilla in a standard tessellation language (STL) file the trackers (Fig. 2C, D).
format.
3. Position the mandibular tracker of the selected op- Use the recorded right and left lateral move-
tical jaw-tracking system (MODJAW; Modjaw) into ments to measure the left and right Bennett angles.
the buccal surfaces of the mandibular anterior Measure the condylar inclination angulation by
dentition by using an interim autopolymerizing using the recorded protrusive movement. Calculate
composite resin material (Structur, A3; VOCO the true hinge axis by using the recorded max-
Dental) and following the manufacturer’s protocol illomandibular relationship at the CR position by
(Fig. 2B).16 Import the intraoral digital scans and using the jaw-tracking software program and
STL files of the maxilla and mandible into the pro- recalculate the mandibular motion of the patient by
gram of the jaw tracker to visualize the joint motion using this maxillomandibular relationship as the
and calibrate the device by following the recom- starting position. Export the mandibular motion
mended protocols. Capture the mandibular motion, into an extensible markup language (XML) file
including excursive dynamics (right and left lateral, format.

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Figure 2. A, Maxillary and mandibular intraoral digital scans in maximum intercuspation captured with intraoral scanner. B, Tiara and mandibular
tracker of optical jaw-tracking system (MODJAW; Modjaw) positioned. C, Cone-beam computed tomography and intraoral digital scans in maximum
intercuspation imported and aligned with jaw-tracking software program. D, Representative recorded jaw movement: right laterotrusion movement.
E, Occlusal contacts registered during right lateral movement. F, Maxillomandibular relationship in centric relation position.

4. Import the intraoral digital scans and mandibular (PROTARevo Articulator; KaVo) by using the
motion files into a CAD program (Dental Systems, XML file. If needed, increase the vertical dimen-
v.88.2.7; 3Shape A/S) to design the immediate sion by opening the incisal pin to provide restor-
CDs by following the software program workflow. ative space.29 Lastly, use the mandibular motion
Mount the virtual casts into the digital articulator to adjust the static and dynamic occlusion (Fig. 3).

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Figure 2. (Continued). G, Condylar inclination calculations from recorded protrusive movement. H, Left Bennett angle measured from recorded right
laterotrusion movement. I, Recalculated right lateral movement with recorded centric relation as starting position.
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Figure 3. Virtual immediate complete denture design. A, Virtual mounting into selected digital articulator by using recorded hinge axis. B, Opening of
incisal pin to increase available restorative space. C, Definitive virtual immediate maxillary and mandibular complete denture designs.

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Figure 4. Maxillary and mandibular milled immediate complete dentures.

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Figure 5. Virtual patient integration. A, Initial digital file alignment. B, Virtual immediate complete maxillary and mandibular denture alignment.

Finalize the immediate CD design and export the guides (Smile in a Box; Institut Straumann AG)
STL files. (Figs. 7,8).
5. Use the STL files of the immediate CD design to 7. Perform the surgical procedures, including place-
mill both maxillary and mandibular CDs (Ivotion ment of the surgical guide, tooth extraction, alveo-
Monolithic Digital Denture Disc, A2; Ivoclar AG) loplasty, and implant placement.30 If the implants
by following the manufacturer’s recommenda- have primary stability, place an intermediate abut-
tions. In the present treatment, the immediate ment (SRA abutment; Institut Straumann AG),
dentures were prepared to be converted into followed by an interim abutment (titanium cylinder
interim screw-retained implant-supported restora- for SRA abutment; Institut Straumann AG). Then,
tions (Fig. 4). use the restoration-guiding surgical guide to fabri-
6. Import the DICOM files of the CBCT, intraoral cate the screw-retained implant-supported interim
digital scans, and virtual immediate dentures into a prostheses (Fig. 9).30 Adjust the occlusion as
computer-aided implant planning software program needed.
(coDiagnostiX; Institut Straumann AG) (Figs. 5,6).
By using the tooth position of the immediate den- During the 6 months of osseointegration with periodic
tures, plan the maxillary and mandibular implants follow-ups after the surgical intervention and interim
and design and manufacture the stackable surgical prosthesis delivery, no significant issues were observed. A

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Figure 6. Maxillary computer-aided implant planning procedures. A, Tooth-supported positioning surgical guide retained by 3 fixation pins.
B, Alveoloplasty surgical guide. C, Implant surgical guide. D, Interim restoration surgical guide. E, Planned implant position in right second premolar
position.

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Figure 6. (Continued). F, Planned implant position in right lateral incisor position. G, Planned implant position in left lateral incisor position.

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Figure 6. (Continued). H, Planned implant position in left second premolar position.

new mandibular motion recording was acquired with the present technique, complete-mouth extractions with
interim prosthesis by using the same protocol as previ- implant-supported prostheses were completed,
ously described (Fig. 10). By following the conventional which required additional steps. 18 , 19 The mandibular
procedures and using the interim prosthesis and second motion recording obtained in the initial phase was
jaw-tracking recording as a reference (Fig. 11), the maxil- used to design the interim prosthesis. However, the
lary and mandibular implant-supported zirconia restora- use of the jaw motion recording technology at this
tions were delivered (Fig. 12). initial phase in patients with aberrant mastication
envelopes, such as constricted and frictional masti-
cation patterns or dysfunction, may be contra-
DISCUSSION
indicated. 33 In those situations, mandibular motion
Appropriate diagnosis and treatment planning are recording after orthodontic treatment or during the
fundamental for rehabilitation success.1-4 The patient interim phase is suggested. 34-36
described was rehabilitated with implant-supported The selected optical jaw-tracking system requires a
prostheses. Adequate lip support was obtained with a learning curve to capture the mandibular motion pre-
cleansable prosthesis, and the patient demonstrated dictably and efficiently. The fabrication of 3D printed
maintenance competency during the interim phase.31,32 custom holders attached to the mandibular tracker
The mandibular motion recordings facilitated the improves the retention and stability of the tracker,
interim and definitive prosthesis design and occlusal thereby reducing clinical complications such as move-
adjustments, reducing the time required at the interim ment or decementation of the tracker.37 However, the
and definitive delivery appointments. accuracy of these systems is still unknown.14-20 Studies
Protocols to integrate the recorded mandibular are needed to assess the accuracy and efficacy of jaw-
motion for fabricating short-span prostheses and tracking systems when compared with conventional
CDs have been described 18 , 19 ; however, in the procedures.

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Figure 7. Mandibular computer-aided implant planning procedures. A, Tooth-supported positioning surgical guide retained by 3 fixation pins.
B, Alveoloplasty surgical guide. C, Implant surgical guide. D, Interim restoration surgical guide. E, Planned implant position in right second premolar
position.

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Figure 7. (Continued) F, Planned implant position in right lateral incisor position. G, Planned implant position in left lateral incisor position.

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Figure 7. (Continued). H, Planned implant position in left second premolar position.

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Figure 8. A, Maxillary stackable surgical guides.B, Mandibular stackable surgical guides.

SUMMARY the implant surgical guides, and fabricate a maxillary and

mandibular screw-retained implant-supported interim
A technique for integrating mandibular motion recorded and definitive prosthesis. The jaw motion recordings
before the treatment and with the interim prosthesis in facilitated designing the prosthesis and reduced the
place was used to perform a diagnostic waxing, design prosthesis delivery time.

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Figure 9. Surgical and prosthodontic procedures during surgical intervention. A, Maxillary tooth-supported positioning surgical guide placed.
B, Alveoloplasty performed using maxillary alveoloplasty surgical guide. C, Maxillary implants placed. D, Maxillary interim prosthesis fabrication by using
interim restoration surgical guide. E, Mandibular tooth-supported positioning surgical guide placed. F, Alveoloplasty performed by using mandibular
alveoloplasty surgical guide. G, Mandibular implants placed. H, Mandibular interim prosthesis fabrication by using interim restoration surgical guide.

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Figure 10. Second mandibular motion recording 6 months after surgical appointment. A, Full-face smile. B, Maxillary and mandibular arches in
maximum intercuspation.
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Figure 11. Second mandibular motion recording with screw-retained implant-supported interim prosthesis captured 6 months after surgical
appointment. A, Right laterotrusion. B, Left laterotrusion. C, Protrusion. D, Mastication pattern.

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