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â 96 TheJournalofCosmeticDentistryâ˘Winter2006 Volume21â˘Number4
AbstrAct
Centricârelationâ(CR)âhasâbeenâwellâdescribedâinâtheâliteratureâ(aâpartialâ listâofâappliancesâandâtechniquesâincludeâtheâLuciaâJig,âtheâleafâgauge,âandâtheâbilateralâmanipulationâtechnique1-13);âand,âalthoughâ easyâ toâ understand,â itâ oftenâ isâ elusiveâ toâ achieveâ clini-cally.âAnyoneâwhoâhasâattemptedâtoâmountâcasesâinâCRâknowsâthatâsomeâ patientsâ canâ beâ extremelyâ difficultâ toâ manageâ forâ accurateâbiteârelationships.âTheâKoisâDeprogrammerâhasâbeenâfoundâtoâbeâanâeffectiveâdeviceâ forâachievingâ theseâbiteâ registrations.â ItâoffersâaâCRâmountingâ techniqueâandâprotocolâ thatâhelpâ theâ restorativeâdentistâachieveâpredictabilityâandâaccuracy.âItâhasâseveralâotherâusesâasâwellâandâisâanâinvaluableâtoolâinâdiagnosingâtheâthreeâmostâcom-monâtypesâofâabnormalâocclusalâattrition:âocclusalâdysfunctional,âparafunctionâ (e.g.,â bruxism),â andâ aâ constrictedâ pathâ ofâ closureââ(Figsâ1-3).
The KD is not a proprietary appliance, and it can be made by any independent laboratory.
Kois DeprogrAmmer
Theâ Koisâ Deprogrammerâ (KD)â isâ aâ palatal-coverageâ maxil-laryâacrylicâdeviceâwithâaâflatâplaneâ lingualâ toâ theâanteriorâ teeth.âItâseparatesâ theâdentalâarchesâandâprovidesâaâsingleâ lower-centralâincisorâcontactâagainstâtheâanteriorâbiteâplane.âTheâKDâcanâalsoâbeâdescribedâ asâ aâ Hawleyâ appliance14â withâ aâ modifiedâ anteriorâ biteâplane.âItâisâimportantâtoânoteâthatâtheâKDâisânotâaâproprietaryâappli-ance,âandâitâcanâbeâmadeâbyâanyâindependentâlaboratory.
A Deprogrammer for Occlusal Analysis and Simplified Accurate Case Mounting
byDon Jayne, D.D.S.
Dr. Jayne graduated from the University of Washington School of Dentistry (UWSD) in 1975. After completing a residency at Il-linois Masonic Medical Center in Chicago, he returned to teach at UWSD. While there he developed and directed the Harborview Medical Center Dental and Oral Maxillofa-cial Clinic. Dr Jayne lectures on cosmetic dentistry, occlusion, and various aspects of restorative dentistry. He maintains hands-on cosmetic and restorative study clubs and is the director the AACD Summit Affiliate Hands-On Esthetic Continuum. Dr. Jayne is a clinical instructor at the Kois Center in Seattle, Washington, where he maintains a cosmetic/restorative practice.
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â Volume21â˘Number4 Winter2006â˘TheJournalofCosmeticDentistry 97
centirc relAtion
Centricâ relationâ isâ describedâ asâtheâmaxillomandibularârelationshipâinâ whichâ theâ condylesâ articulateâwithâ theâ thinnestâavascularâportionâofâ theirâ respectiveâ disksâ withâ theâcomplexâ inâ theâ anterior-superiorâpositionâ againstâ theâ shapesâ ofâ theâarticularâeminences.12âThisâpositionâisâindependentâofâtoothâcontactâandâisâ clinicallyâ discernibleâ whenâ theâmandibleâisâdirectedâsuperiorlyâandâanteriorly.â Itâ isâ restrictedâ toâaâpure-lyâ rotationalâ movementâ aboutâ theâtransverseâhorizontalâaxis.
ApplicAtions of the KD
Numerousâ clinicalâ applicationsâforâtheâKDâhaveâbeenâdetermined.âItâcanâbeâusedâforâsimplifyingâdifficultâbiteâ registrationsâ andâ forâ accurateâmountingâofâdiagnosticâcasts,âforâpa-tientsâthatâareâdifficultâtoâmanipulateâintoâCR,âandâforâfacilitatingâocclusalâadjustmentsâ (duringâ whichâ timeâ itâisâworn).â TheâKDâcanâbeâusedâasâ aâdiagnosticâ toolâ toâ determineâ ifâ theâmandibleâneedsâtoâmoveâinâtheâan-teriorâorâposteriorâdirectionâtoâreachâCRâfromâmaximalâ intercuspalâposi-tionâ(MIP).âTheâdeviceâ isâalsoâusedâtoâdifferentiateâamongâthreeâtypesâofâabnormalâocclusalâattrition:
â˘âConstrictedâpathâofâclosureâ(CPC):âAttritionâoccursâduringâclosureâintoâMIPâwhenâanteriorâinterferencesâcreateâaâdistalâthrustâthatâmovesâtheâcondylesâdistalâtoâCRâ(Figâ4).
â˘âOcclusalâdysfunction:âOcclusalâattritionâasâaâresultâofâexcessiveâgrindingâtriggeredâbyâinterfer-encesâonâtheâposteriorâteethââ(Figâ5).
â˘âParafunctionâ(trueâbruxism):âOcclusalâwearâasâaâresultâofâexcessiveâgrindingâtriggeredâbyâtheâbrain.âItâhasânoâfunctionalâpurpose.
It is worn until the necessary muscle deprogramming is
accomplished and can be worn for days or weeks if necessary.
feAtures AnD benefits of the KD
Theâ KDâ applianceâ isâ designedâsuchâ thatâ itâ canâ beâ wornâ forâ ex-tendedâperiodsâofâtime,âasâlongâasâitâdoesânotâexceedâ20âhoursâperâday.âItâisâ wornâ untilâ theâ necessaryâ muscleâdeprogrammingâ isâ accomplishedâandâcanâbeâwornâforâdaysâorâweeksâifânecessaryâ(theâusualâcourseâ isâ forâ
oneâweek).âIfâtheâpatientâisânotâcom-pletelyâdeprogrammedâbyâthatâtime,âitâmayâbeânecessaryâforâtheâpatientâtoâwearâtheâdeprogrammerâforâupâtoâ24âhoursâperâdayâ(exceptâwhenâeating).âInâthisâcaseâtheâdurationâshouldâbeâlimited,â preferablyâ noâ longerâ thanâoneâweek.âThisâisâtoâpreventâpoten-tialâ supraeruptionâ ofâ theâ posteriorâteethâorâintrusionâofâtheâcontactingâincisor.
Manyâ typesâ ofâ appliancesâ andâtechniquesâ canâ beâ usedâ toâ attainâCR.1,2,7-9,15âTheâKDâhasâaânumberâofâfeaturesâ andâ benefitsâ thatâ makeâ itâanâ idealâ protocolâ forâ obtainingâ CRââorâ managingâ aâ numberâ ofâ occlusalâissues:
â˘âItâallowsâforâtheâpatientâtoâdeprogramâoverâtime.âItâhasâbeenâhasâshownâthatâinâpatientsâwithâaâcentricâprematurityâintroducedâforâaâshortâperiodâofâtime,âaâpercentageâofâthemâmayâtakeâdaysâorâweeksâtoâloseâtheâmuscularâdiscoordinationâinâtheâmusclesâofâmasticationâonceâtheâprematurityâisâremoved.16âThisâexplainsâwhyâsomeâpatientsâwillânotâdeprogramâinstantlyâorâinâaâfewâhours.âInâtheseâcases,âanâaccurateârecordâcannotâbeâtakenâ
CliniCal SCienCe Jayne
Figure 1: The Kois protocol recommends this design with a labial arch wire.
Figure 2: This design variation for the KD is useful for patients with high esthetic demands.
â 98 TheJournalofCosmeticDentistryâ˘Winter2006 Volume21â˘Number4
untilâtheyâhaveâbeenâcompletelyâdeprogrammed.â
â˘âTheâjawâisânotâmanipulatedâintoâCR,âbutâisâdeterminedâbyâtheâpatientâandâisâreproducible.âThisâisâaâkeyâcriterionâtoâdetermineâifâtheâpatientâisâdeprogrammed.âTheâpatientâmustâbeâableâtoâcloseâintoâtheâsameâpositionâeveryâtime,âpassively,âwithoutâanyâguidanceâorâexternalâforce.
â˘âTheâpatientâcanâbeâobservedâwhenâclosingâintoâaâreproduc-ibleâCRâmark.âThisâpositionâcanâagainâbeâverifiedâwhenâtheâbiteâregistrationâisâtaken.âTheâpatientâshouldâmakeâtheâsameâmarkâonâtheâapplianceâduringâtheâbiteâregistrationâasâwasâmadeâduringâtheâinitialârecording.â
â˘âTheâbiteâregistrationâisâtakenâwithâtheâapplianceâinâplace.âThisâallowsâgreatâcontrolâofâtheâverticalâdimensionâofâocclusionâ(VDO)âduringâbiteâregistrationâ(Figâ6).
â˘âItâisâusedâtoâfacilitateâanâoc-clusalâadjustmentâonceâtheâdeprogrammingâisâcomplete.âTheâsameâapplianceâcanâbeâused.âUseâofâtheâKDâensuresâthatâtheâdeprogrammingâwillâbeâ
maintainedâduringâtheâocclusalâadjustmentâ(Figâ7).
â˘âItâcanâbeâwornâatâaâminimallyâopenedâVDOâofâapproximatelyâ1âmmâinâtheâmolarâregion.âThisâclosedâpositionâisâoftenâmoreâcomfortableâthanâappliancesâthatârequireâaâmuchâgreaterâVDO.âThisâalsoâmakesâtheâappli-anceâmoreâestheticâifâneededâforâdaytimeâuse.
â˘âItâisâself-adjusting.âThereâisâonlyâoneâincisorâtoothâcontactâagainstâtheâappliance.âAsâtheâmusclesârelax,âtheâcondylesâareâfreeâtoâmoveâwithânoâobstaclesâtoâpreventâthemâfromâachievingâanâequilibriumâpositionâinâCR.âThisâsavesâmultipleâadjustmentâappointments.
The CPC patient often can fool the clinician; he or she may be
asymptomatic, easy to manipulate, and give reproducible mountings.
how Does it worK?
Proprioceptorsâinâtheâperiodonti-umâprovideâfeedbackâthatâprogramsâtheâ musclesâ toâ closeâ inâ MIP.â With-outâreinforcementâthroughârepeatedâ
toothâcontact,âtheâfeedbackâandâtheâinfluenceâ ofâ theâ dentitionâ onâ theâcondylarâpositionâ isâ lost.âTooth-de-flectingâinclinesâcanâtriggerâdiscoor-dinationâofâtheâmasticatoryâmuscles.âUntilâtheseâmusclesârelaxâandâfunc-tionâ inâ aâ coordinatedâ manner,â theâpatientâmayâbeâincapableâofâachiev-ingâ aâ CRâ position.â Theâ KDâ breaksâthisâ cycleâ byâ discludingâ theâ teethâandâallowsâtheâmusclesâtoâreturnâtoânormalâ function.â Theâ KDâ protocolâalsoâverifiesâthatâtheâmusclesâofâmas-ticationâareâdeprogrammed.âThisâen-suresâ thatâ theâcondylesâareâallowedâtoââmoveââtoâtheâCRâposition,âbeingâunaffectedâ byâ uncoordinatedâ mus-cles,âtoothâinterferences,âorâoperatorâerror.
Discussion
Theââclassicââpatientâforâanâante-riorâapplianceâisâoneâwhoâisâexperi-encingâobviousâmuscleâdisharmonyâandâisâveryââtightââorâdifficultâtoâma-nipulate.âThereâareâotherâcases,âhow-ever,âthatâappearâeasyâtoâmanipulateâintoâCRâandâyetârequireâtheâextendedâdeprogrammingâ timeâ inâ orderâ toâachieveâ theâ CRâ position.â Theâ ques-tionâ is,â âWhichâ patientsâ areâ they?ââThisâcanâbeâdifficultâtoâanswer.
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Figure 3: The appliance is stabilized by the palate and arch wire or clasps.
Figure 4: Anterior interferences cause the mandible to shift distal to CR.
â Volume21â˘Number4 Winter2006â˘TheJournalofCosmeticDentistry 99
Theâ CPCâ patientâ oftenâ canâ foolâtheâ clinician;â heâ orâ sheâ mayâ beââasymptomatic,â easyâ toâ manipulate,âandâ giveâ reproducibleâ mountings.âTestingâtheseâpatientsâwithâaâdepro-grammerâwillâverifyâtheâachievementâofâCR.â
PatientsâthatâpotentiallyâfallâintoâtheâCPCâcategoryâincludeâthoseâwithâaâdeepâoverbite,âaâ steepâ interincisalâangle,â thoseâ thatâ haveâ beenâ over-closedâ duringâ occlusalâ adjustment,âpost-orthodonticâ patients,â patientsâwithâ overcontouredâ anteriorâ res-torations,â andâ patientsâ whoâ haveâbeenâ previouslyâ restoredâ inâ CR.â Itâhasâ beenâ theâ authorâsâ experienceâthatâtheseâCPCâpatientsâ(thoseâwithâcondylesâpositionedâposteriorâtoâCRâinâMIP)â compriseâaâ significantâper-centageâofâtheâpopulation.âManyâofâtheseâpatientsâwereâeasyâtoâmanipu-lateâ usingâ bilateralâ manipulationâorâanteriorâdiscludingâdevices,â gaveâreproducibleâ mountings,â andâ thenâshiftedâ significantlyâ forwardâ duringâdeprogrammingâwithâtheâKD.
Accurateâmountingâallowsâforâanâaccurateâdiagnosis.âThisâisâimportantâasâCPCâpatientsâareâatâsignificantâriskâforâ damagingâ theirâ anteriorâ teethâandâ restorationsâ (Figâ 8).â Theyâ mayâalsoâdevelopâmuscleâorâ jointâsymp-
toms.â Theseâ patientsâ areâ forcedâ toâcontinuallyâadaptâtoâthisâposition.âIfâtheirâabilityâtoâadaptâisâdiminished,âpossiblyâfromâstressâorâtrauma,âtheyârunâaâmuchâgreaterâriskâ forâbecom-ingâ symptomatic.â Theseâ patientsâfunctionâ onâ theâ lingualâ surfaceâ ofâtheâmaxillaryâincisorsâduringâmasti-cation.âTheyâmayâdevelopâsignificantâwearâonâbothâtheâlingualâsurfacesâofâtheâmaxillaryâincisorsâandâonâtheâla-bialâsurfacesâofâtheâmandibularâinci-sors.âTheâCPCâmustâbeâcorrectedâinâorderâtoâalleviateâthisârisk.
Patientsâ functioningâ anteriorâ toâCRâareâatâaâlowerâriskâforâbecomingâsymptomaticâasâthereâisâmoreââgiveââtoâ theâsystem.âTheseâpatients,âhow-ever,â mayâ developâ significantâ attri-tionâ asâ aâ resultâ ofâ grindingâ causedâbyâ posteriorâ interferencesâ (occlusalâdysfunction).âThisâexcessiveâattritionâcanâbeâstoppedâbyâcorrectingâtheâoc-clusalâ interferences.â Thisâ willâ lowerâtheârestorativeâriskâasâwell.
Theâ KDâ isâ usefulâ forâ diagnosingâbetweenâ threeâ typesâ ofâ abnormalâattritionâ (CPC,â dysfunction,â andâparafunctionâ [bruxism]).â CPCâ at-tritionâ occursâ duringâ closureâ intoâMIP,âandâmastication.âDysfunction-alâ attritionâ occursâ throughoutâ theâentireâ day.â Neitherâ ofâ theseâ patientâ
groupsâwillâgrindâonâtheâKD,âasâtheâetiologyâ ofâ theâ grindingâ hasâ beenâremovedâ (i.e.,â onceâ theâ patientâ hasâbeenâdeprogrammed).âIfâtheâpatientâdoesâ developâ aâ wearâ facetâ onâ theâanteriorâ discludingâ device,â byâ pro-cessâ ofâ elimination,â theâ attritionâ isâcausedâ byâ theâ parafunctionâ habitââ(Figsâ9â&â10).â(Note:âThereâisâaâfourthâcategoryâofâpatientsâwhoâhaveâaâneu-rologicalâdisorder.âFortunately,â theyâareâ relativelyâ fewâ inâ number.â Theyâwillâusuallyâpresentâwithâanâunder-lyingâmedicalâdiagnosisâandâcanâbeâveryâdifficultâtoâmanage.)
Makingâthisâdistinctionâisâimpor-tantâbecauseâeachâdiagnosisârequiresâaâ differentâ typeâ ofâ treatment.â TheâCPCâ patientâ canâ beâ theâ mostâ diffi-cultâ toâ manage.â Correctionâ ofâ thisâproblemâ willâ requireâ thatâ theâ jawâcomeâ forwardâ toâ CR.â Thisâ meansâtheâmaxillaryâandâmandibularâante-riorâteethâmustâbeâmovedâoutâofâtheâway.â Thisâ canâ beâ doneâ byâ movingâtheâ maxillaryâ anteriorâ teethâ toâ theâlabial;âmovingâtheâmandibularâante-riorâteethâtoâtheâlingual;âopeningâtheâbite;â shorteningâ theâ anteriorâ teeth;âreducingâonâ theâ labialâofâ theâ lowerâanteriorâ teeth;â or,â inâ someâ cases,âmovingâtheâjaw.
CliniCal SCienCe Jayne
Figure 5: Posterior interferences can precipitate grinding as well as avoidance patterns. This can lead
to significant attrition of the anterior teeth.
Figure 6: The initial point of contact can easily be visualized during evaluation of deprogramming and
for the bite registration.
â 100 TheJournalofCosmeticDentistryâ˘Winter2006 Volume21â˘Number4
Theâ patientâ withâ dysfunctionalâattritionâ isâ managedâ byâ removingâtheâ interferences.â Thisâ mayâ beâ veryâsimpleâ toâ treat,â oftenâ withâ onlyâ anâocclusalâ adjustment.â Itâ canâ also,âhowever,â beâ moreâ complex.â Theâbruxismâpatientâ isâmanagedâwithâaâbiteguard,âasâtheâbruxismâcannotâbeâstoppedâ byâ occlusalâ therapy.17â Theâocclusionâ canâ alsoâ beâ modifiedâ toâredistributeâtheâocclusalâforces.â
DeprogrAmmer protocol
Theâ deprogrammerâ isâ insertedâonâ theâ maxillaryâ archâ similarâ toâ aâmaxillaryâHawleyâappliance.âTheâan-
teriorâ platformâ shouldâ beâ adjustedâhorizontalâ toâ theâ occlusalâ plane.âTheâsingleâmandibularâtoothâcontactâshouldâ beâ asâ closeâ toâ theâ midlineâasâ possible.â Thereâ shouldâ beâ onlyâoneâpointâofâ contact.â Theâplatformâshouldâ notâ causeâ theâ mandibleâ toâdeviateâ laterallyâ (Figâ 11).â Itâ shouldâallowâ theâ mandibleâ toâ moveâ freelyâinâanâanterior,âposterior,âandâlateralâdirection.âTheâsurfaceâshouldâbeâflatâandâ shouldâ extendâ farâ enoughâ an-teriorlyâandâposteriorlyâthatâtheâpa-tientâcannotâloseâcontactâwithâeitherâend.â Theâ platformâ shouldâ beâ thickâenoughâtoâpreventâcontactâwithâtheâ
opposingâteethâwhenâtheâpatientâre-laxesâintoâCR.âApproximatelyâ1âmmâofâclearanceâshouldâremain,âandâtheâclinicianâshouldâbeâsureâtoâcheck.âIfâtheâplatformâisâ tooâthick,âsomeâpa-tientsâ canâ developâ vagueâ muscularâpain.âDoânotâmakeâtheâplatformâanyâthickerâthanâisânecessaryâ(Tableâ1).6âTheâpatientâshouldânotâwearâitâdur-ingâmealsâorâwearâitâsoâmuchâthatâitâcausesâquality-of-lifeâissues.âTheâpa-tientâshouldâbeâcautionedâtoâdiscon-tinueâuseâandâtoâcontactâtheâpracticeâifâ heâ orâ sheâ experiencesâ increasedâpain,â whichâ mayâ indicateâ anâ intra-capsularâproblem.6
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Figure 7: Facial view demonstrates how the patient can be significantly closed during the bite registration.
Figure 8: CPC patients can cause significant attrition on anterior teeth. These patients often cause
significant damage to anterior restorations.
Figure 9: A satin finish aids in the rapid diagnosis of wear facets on the device.
Figure 10: The KD is an anterior discluding appliance and can be used to help manage accurate bite
relationships.
â Volume21â˘Number4 Winter2006â˘TheJournalofCosmeticDentistry 101
when is the pAtient DeprogrAmmeD?
Theâ patientâ isâ deprogrammedâwhenâheâorâsheâreproducesâtheâsameâsingleâ spotâ onâ theâ platformâ with-outâ guidanceâ orâ support.â Theâ spotâneedsâ toâbeâabsolutelyâflatâwithânoâslideâwhatsoeverâandâtheâspotâmustâbeârepeatable.âTheâpatientâshouldâbeââasymptomaticâandâwillâknowâwhenâheâ orâ sheâ continuesâ toâ contactâ theâsameâ spotâ onâ aâ toothâ immediatelyâafterâ removingâ theâ KD.â Patientsâmarkingâinâmoreâthanâoneâplaceâareânotâdeprogrammed.âTheyâwillâ thenâneedâ toâ wearâ theâ deprogrammerâmoreâhoursâperâday,âorâforâmoreâdaysââ
(Figsâ12â&â13).âMakeâ sureâ thatâ theâpatientâisânotâhittingâanyâteethâasâheâorâsheâmovesâtowardâCR.
contrAinDicAtions
Contraindicationsâ includeâ anyâpatientsâwithâjointsâthatâwillânotâac-ceptâloading.âAâpatientâwhoâcannotâacceptâ loadingâ indicatesâ thatâ thereâmayâbeâaâcapsularâproblem.âTheâKDâcontactsâ onlyâ inâ theâ incisalâ regionâand,â asâ withâ allâ anteriorâ splints,âplacesâmostâofâtheâbiteâforceâonâtheâtemporomandibularâjoint.âAâsimpleâtestâtoâdiagnoseâthisâisâtoâplaceâcot-tonârollsâbetweenâtheâanteriorâteethâandâ haveâ theâ patientâ squeeze.â Painâ
inâtheâjointâindicatesâthatâtheâpatientâcannotâacceptâloading.â
summAry
TheâKDâoffersâanâeasyâCRâmount-ingâtechniqueâandâprotocolâthatâhelpâtheâ restorativeâ dentistâ achieveâ pre-dictabilityâ andâ accuracyâ inâ anâ areaâthatâ canâ beâ veryâ difficult.â Depro-grammingâ theâ patientâ canâ takeâtimeâandâforâthatâreason,âitâmayâbeâextremelyâ difficultâ toâ obtainâ aâ trueâCRâ positionâ withoutâ deprogram-mingâ certainâ patients.â Patientsâ thatârequireâdeprogrammingâcanâbeâdif-ficultâtoâdiagnoseâinâadvance.â
CliniCal SCienCe Jayne
Figure 11: The platform should facilitate a passive anterior-posterior slide without deviation. This is
evaluated with articulating paper.
Figure 12: The pattern seen here is typical of a patient who is not deprogrammed. This patient will need to
wear the appliance for a longer period of time during the day.
Figure: 13: This patient has been successfully deprogrammed and is ready for bite records.
â 102 TheJournalofCosmeticDentistryâ˘Winter2006 Volume21â˘Number4
Theâ KDâ hasâ otherâ usesâ thatâ areâveryâ helpfulâ toâ theâ restorativeâ den-tist.â Diagnosisâ ofâ theâ accurateâ con-dylarâ positionâ isâ importantâ inâ de-velopingâ aâ properâ treatmentâ plan.âAccurateâ diagnosisâ isâ criticalâ espe-ciallyâ forâCPCâpatients.â Ifâ aâpatientâneedsâ toâ comeâ forwardâ toâ developâaâstableâ jawâposition,â thisâcanâhaveâaâ dramaticâ effectâ onâ theâ treatmentâplan.â Theâ KDâ allowsâ diagnosisâ ofâtheâ threeâ typesâ ofâ abnormalâ occlu-salâattritionsâ(eachâhavingâaâdifferentâtreatmentâprotocol).âFinally,âtheâKDâsimplifiesâ occlusalâ adjustmentsâ asâitâ canâ beâ wornâ duringâ theâ occlusalâadjustmentâtoâmaintainâdeprogram-mingâ throughoutâ theâ adjustment.âTheâ manyâ featuresâ andâ benefitsâ ofâtheâ KDâ makeâ itâ aâ powerfulâ toolâ toâincreaseâ predictabilityâ ofâ diagnosisâandâtreatment.
Acknowledgment The author thanks Dr. John Kois for allowing him to adapt portions of his manual.
References1.â Azarbalâ M.â Comparisonâ ofâ myo-moni-
torâ centricâ positionâ toâ centricâ relationâandâ centricâ occlusion.â J Prosthet Dent 38(3):331-337,â1977.
2.âDawsonâPE.âEvaluation, Diagnosis, and Treat-ment of Occlusal Problemsâ (2ndâ ed.,â pp.â183-200).âSt.âLouis,âMO:âMosby;â1989.â
3.â Dawsonâ PE.â Optimumâ TMJâ condyleâ posi-tionâinâclinicalâpractice.âInt J Periodont Rest Dent 5(3):10-31,â1985.â
4.âDawsonâPE.âAâclassificationâsystemâforâoc-clusionsâ thatâ relateâ maximalâ intercuspa-tionâtoâtheâpositionâandâconditionâofâtheâtemporomandibularâjoints.âJ Prosthet Dent 75(1):60-66,â1996.â
5.âGelbâH.âTheâoptimumâtemporomandibularâjointâcondyleâpositionâinâclinicalâpractice.âJ Periodont Rest Dentâ5(4):34-61,â1985.
6.â Koisâ J.â Occlusion:â Complexâ restorativeâmanagement.â Course 8 Manual.â Seattle,âWA;â2004.â
7.â Longâ JH.â Locatingâ centricâ relationâ withâ aâleafâgauge.â J Prosthet Dentâ29(6):608-610,â1973.â
8.â Luciaâ VO.â Aâ techniqueâ forâ recordingâ cen-tricâ relation.â J Prosthet Dentâ 14:492-505,â1964.â
9.âMcNeilâC.âScience and Practice of Occlusion.âHanoverâ Park,â IL:â Quintessenceâ Publish-ingâCo;â1997.â
10.â McNeillâ C.â Theâ optimumâ temporoman-dibularâ jointâ condyleâpositionâ inâ clinicalâ
practice.âIntâJ Periodont Rest Dent.â5(6):52-76,â1985.â
11.âPosseltâU.âTerminalâhingeâmovementâofâtheâmandible.â1957.âJ Prosthet Dent 86(1)2-9,â2001.â
12.âEditorialâCouncilâofâtheâJournal of Prosthet-ic Dentistry.â TheâGlossaryâofâProsthodon-ticâ termsâ GPT-7.â St.â Louis,â MO:â Mosby;â1999.â
13.â Weinbergâ LA.â Optimumâ temporoman-dibularâ jointâ condyleâpositionâ inâ clinicalâpractice.âInt J Periodont Rest Dent 5(1):10-27,â1985.â
14.âProffitâWR,âFieldsâJr.âHW.âContemporary Or-thodonticsâ(3rdâed.,âpp.â604,605).âSt.âLouis,âMO:âMosby;â2000.â
15.âFenlonâMR,âWoelfelâJB.âCondylarâpositionârecordedâ usingâ leafâ gaugesâ andâ specificâclosureâ forces.â Int J Prosthodontâ 6(4):402-408,â1993.â
16.âSheikholeslamâA,âRiiseâC.âInfluenceâofâex-perimentalâinterferingâocclusalâcontactsâonâtheâ activityâ ofâ theâ anteriorâ temporalâ andâmasseterâmusclesâduringâsubmaximalâandâmaximalâbiteâinâtheâintercuspalâposition. J Oral Rehabil 10(3):207-214,â1983.â
17.âSimonâRL,âNichollsâ JI.âVariabilityâofâpas-sivelyâ recordedâ centricâ relation. J Prosthet Dentâ44(1):21-26,â1980.âââ
______________________v
CliniCal SCienCe Jayne
Fabrication Protocol for the Kois Deprogrammer6
â˘âMakeâstone,âfull-archâcastsâofâtheâmaxillaryâandâmandibularâarches.
â˘âTheseâcastsâshouldâbeâmountedâinâaâmaximumâintercuspalâposition.
â˘âBiteârecordsâandâfacebowsâareânotânecessary.
â˘âFabricateâlabialâbowsâtoâextendâfromâtheâmostâdistalâtoothâonâeachâsideâofâtheâarch.âThereâshouldânotâbeâanyâwiresâtoâinterfereâwithâtheâocclusalâsurface.
â˘âCompleteâfull-palatalâcoverageâwithâacrylicâtoâallowâforâcompleteâintercuspationâofâallâteethâinitially.
â˘âAddâaâsmallâanteriorâstopâopposingâtheâlowerâcentralâincisorsâthatâslightlyââdiscludesâallâteeth.
Theâ laboratoryâshouldânoteâ thatâ theâanteriorâplatformâ(i.e.,âbiteâdiscluder)âshouldâbeâaddedâafterâtheâpalatal-coverageâportionâhasâbeenâfabricated.âThisâwillâsaveâextensiveâacrylicâgrindingâlaterâifâcompletingâtheâocclusalâadjustmentâwithâtheâappliance.
Table 1