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Figure 9 A - 9 T Combined orthodontic/prosthodontic/TMJ treatment. Combination treatment can dramatic results.  (9
A - 9 D) The comparison of facial appearance between an old upper
full denture and a new one that is the product of the Levandoski approach
is obvious in this young female TMJ pain-dysfunction patient. Her problems
include chronic retro-orbital cephalalgia(headache), bilateral TMJ crepitus,
missing posterior teeth, forward tipping of the remaining molars, inadequate
anterior and posterior vertical dimension of occlusion, and a dissatisfacion
with a recently made full upper denture that simply looked like false
teeth. Note the fuller, more natural appearance of the new denture made
by using Levandoski techniques.
(9 E) Pretreatment (i.e., pre-Levandoski treatment) occlusion
Note the deep overbite.
(9 F) The old upper denture acted as a ramp deflecting the deflecting
the mandibular teeth, hence the whole mandibular-condyle unit, posteriorly
and superiorly (due to lack of posterior vertical). Note that areas in
the denture are worn and even perforated by grinding from lower anteriors
that slid up the lingual surfaces of the anterior denture teeth to strike
the acrylic in the rugal area (black arrow).
(9 G) In this case the old upper denture acted as a base for
adding acrylic that would force the mandible-condyle unit down and forward
as per x, y-coordinate dictates of the transcranial vector analysis. Acrylic
was added to the denture mounted against the lower model in the Levandoski
articulator once corrections were made in the three-way articulator hinges
as per the vector analysis. This also opened the bite anteriorly for orthodontic
advancement of lingually tipped lower anteriors.
(9 H) The lower anteriors were leveled, aligned, rotated, and
advanced orthodontically. The mesially tipped lower molars were also uprighted all by means of the Brehm utility arch wire technique. (9 I - 9 L) Before and after appearance of the lower teeth at completion of orthodontic treatment. Note how the posterior molars are uprighted and the lower anteriors are advanced (tipped) to a more correct angulation. This make for a much more favorable path of origin and insertion for a future partial denture. (The design for the framework was drawn on post-orthodontic treatment casts).  
(9 M) The framework and upper occlusion rim are placed in the
mouth. The occlusion rim is constructed in the usual educated guesswork
fashion by using traditional parameters. A lead foil strip is placed over
the anterior central incisor contact area. Transcranial and cephalometric radiographs are then taken with the patient biting into the occlusion rim. Levandoski transcranial vector analysis is then performed on the joint radiographs, and correction of the x, y-coordinates (if needed) that would be necessary to move condyle to the Gelb 4/7 position is noted. Levandoski proportional analysis is performed on the cephalogram to scientifically and mathematically determine the anterior vertical dimension corrections. Other traditional cephalometric analysis procedures are performed to see whether future anteriors (lead foil) will be protrusive enough to provide proper lip support, etc. The master casts are then mounted in a Logic I articulator using a Levandoski Vector I Face-bow. 
(9 N) The necessary corrections are then made
to the three-way hinges (as per vector analysis) and the incisal guide
pin (as per the proportional analysis). (9
O and 9 P) Any posterior and/or anterior open bite that is then
generated between the upper occlusion rim and the lower dentition as a
result of these joint-and face-protecting? corrections is then compensated
for when the teeth are set.
(9 Q and 9 R) Completed new full upper denture
and lower partial denture. Note the increased vertical. Subsequent transcranial
radiographs confirm the new occlusion positions of the condyle in the
Gelb 4/7 position. 
(9 S and 9 T) Note the improved facial appearance
after the muscles accommodate to the new bite. The pains subsided. (Courtesy
of Dr. Ronald Levandoski.) |
