Articulators in Orthodontics

Theodore D. Freeland
This article discusses the subject of articulators in orthodontics. It is in 3 parts: the rst deals with why articulators are used; the second deals with techniques needed to use the instrumentation; and the third illustrates how they are used in diagnosis. Using articulators, occlusal problems otherwise hidden can be uncovered, especially the cases that involve the vertical dimension. As with any diagnostic instrumentation, the practitioner has to learn how to use the instrument and the limitations imposed by said instrument. (Semin Orthod 2012;18:51-62.) 2012 Elsevier Inc. All rights reserved.

he use of articulators in orthodontics is a controversial and debatable issue. This article will focus on articulators as and when they are used in orthodontics. In this discussion, the advantages of articulators will be presented as a diagnostic tool (Fig. 1). This article is divided into 3 parts: the rst part will explain why articulators are used; the second part will demonstrate the techniques needed to use the articulator system; and the third illustrates the uses in the diagnostic techniques.

Why Articulators Are Used

The articulator and its jaw-recording system are operator sensitive, as are the other diagnostic aids cephalometrics, handheld models, and photographsthat are used in diagnosis, treatment planning, and post-treatment analysis of orthodontic cases. The mounting of study models on the articulator in the retruded condylar axis is an operator-sensitive procedure requiring skill, practice, and the proper education. The

Director/Lecturer, Advanced Education in Orthodontic Group, Gaylord, MI; Adjunct Professor of Orthodontics, University of Detroit/Mercy Dental School, Detroit, MI; and Clinical Instructor, Department of Orthodontics, University of Pennsylvania, Philadelphia, PA. Address correspondence to Theodore D. Freeland, DDS, MS, 801 East M-32 Gaylord, MI 49735. E-mails: tdfortho@ freelandorthodontics.com or drfreeland@rothwilliams-aeo.com 2012 Elsevier Inc. All rights reserved. 1073-8746/12/1801-0$30.00/0 doi:10.1053/j.sodo.2011.10.002

operator must be educated in its uses and techniques. An articulator is a diagnostic recording instrument capable of receiving and registering maxillo-mandibular relations.1 It is not capable of chewing like humans, but it can record and duplicate the border movements of the chewing cycle.2 The system can be useful to the clinician in uncovering occlusal problems,3 particularly those that occur in the vertical dimension, where the maximum intercuspation of teeth causes a down and back distraction of the condyles. The articulator system can also measure the coincidence or differences between the maximum intercuspal (MI) position and the patients seated condylar position.4,5 Preand post-treatment evaluation with the articulator system can measure changes at the condylar level, providing a quantitative assessment of the treatment outcome at the condylar level. Orthodontists have often dened gnathology as the science of how articulators chew.6 Although this statement was made in jest, it is a correct description. The following statement by Stuart favors the above-stated opinion. An articulator is rst of all a diagnostic recording instrument capable of receiving and registering craniodental and maxilla-mandibular relation, the three dimensions of oral organ, the axes of mandibular rotations and the paths in which these axes travel in the various movements of the mandible. It was never intended 51

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Figure 1. Example of articulator system that can be programmed to the terminal hinge axis of the patient. (Color version of gure is available online.)

to chew like the patient, as it does not have a brain.1 The practitioner has to have an understanding of the capabilities and limitations of the articulator system and also master the technique of its use. McCollum in 1926 coined the term gnathology, which was dened as the study and treatment of the entire dentition as a functioning unit. It stressed the creation of such an occlusion that would be in harmony with other structures of the stomatognathic system, including the tem-

Figure 3. The CO bite is done with Moyco 10 wax (Moyco Industries, Inc, Philadelphia, PA). A single sheet is tted to the upper arch, and the patient then bites hard. (Color version of gure is available online.)

poromandibular joint and periodontium, during maximum intercuspation and functional movements of the mandible, with the patient requiring the least amount of neuromuscular adaptation.7

Figure 2. (A) Condylar positioning indicator instrument. (B) The CR point (red dot) is registered at the crosshairs, and the centric occlusion (CO) bite (black dot) shows the condylar position change. (Color version of gure is available online.)

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separate or disclude posterior teeth immediately, but gently, as soon as the mandible moves out of centric closure. This anterior guidance must be in harmony with the way in which the mandible moves through its border excursions; thus, in a mutually protected occlusal scheme, the mandible can execute its total range or envelop of motion without interference from teeth. In turn, the teeth will direct and maintain the centricity of the condyles in fossae during closure. In diagnosis and treatment planning, tooth position and occlusion are evaluated in the intercuspal position, that is, unmounted handheld casts and cephalograms in the position of MI. These static characteristics are poor indictors of function. A functional and biological occlusion is a realistic goal for orthodontists. As the position of teeth is altered with orth-

Figure 4. The 2-piece power bite is made from Delar Blue wax. First, a front piece is constructed at a vertical where the posterior teeth are at least 2 mm apart. Then, a soft posterior section is placed, and the patient is instructed to bite half hard. (Color version of gure is available online.)

The rst objective of a functional occlusion is to obtain a stable centric relation of the mandible and have the teeth intercusp maximally at this mandibular position. Centric relation will permit seating of the condyles into the glenoid fossa at the most superior position, against the eminentia, and also centered in the transverse plane. In an ideal orthodontic nish, this should occur when the upper and lower teeth are closed in the MI position.8 The second objective of a good functional occlusion is to have a harmonious glide path of anterior teeth working against each other to

Figure 5. The marking of the condylar location in CR and again in CO. (Color version of gure is available online.)

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Figure 6. The distance between the markings that are created in CR and CO can be evaluated. Measurement over 1.5 mm vertically and/or horizontally indicates displaced condyles. In the transverse dimension, a 0.5-mm discrepancy is signicant clinically. (Color version of gure is available online.)

odontic appliances, the patients MI adapts continuously, and the only reliable reference point is centric relation. Consideration for reconstruction of effective dental occlusion should include a minimal discrepancy between centric relation and centric occlusion (CO), maintenance of the vertical dimension, a favorable direction of forces applied to the teeth, at rest and during function. Physiological approach, which is inclusive of the dynamics of growth, does not necessarily exclude the mathematical gnathological approach. The fact that gnathology provides a mechanism for evaluation of the occlusal constants helps the orthodontist to facilitate orthodontic treatment to individualized norms. Geometry and mathematics can only provide a template to approximate nature. It certainly does not and cannot replace nature in form, function, or esthetics. It is necessary for evaluating what we are treating and approximately calculating our treatment goals. Although our treatment goals should not be mathematical, gnathology certainly provides an alternative to better approximate nature. The goal of occlusal reconstruc-

tion in orthodontics should be to achieve a structural balance to facilitate physiological adaptation. Roth in 1981 and Cordray in 1996 claimed that only by articulator mounting can the true occlusion be investigated.9,10 The fully adjustable articulator system developed by McCollum, Stuart, and Stallard gained usage in the restorative eld, but it never gained support in the orthodontic eld, which is interesting because Stallard was an orthodontist.11 The use of cephalometrics, photography, limited cone beam CT, and articulators are technique sensitive. Orthodontists are required to learn specic techniques for correct usage. The rst requirement for the use of articulators is to take and record 2 types of bite registrations. One is called the CO bite, and the other is the centric relation bite. The rst is where all the teeth are touching, and the other records the best seated condylar position that can be obtained at that time. Once these bites are recorded, the difference in condylar position between CO and centric relation can be measured in all 3 planes of space for that patient. The normal range is 1.0

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Figure 7. (A) The axiopath tracing is used to calculate the angle of the eminence. (B) Locating the terminal hinge axis, performing the eminence tracing, and determining the amount of the side shift. This information is placed on the data sheet. (Color version of gure is available online.)

mm in the anteriorposterior and vertical dimensions and 0.5 mm in the transverse direction.12 The next area involved in the use of articulator systems is the ability to receive and record the patients true terminal hinge position.13 The estimated facebow is not accurate enough for purposes of diagnosis. The practitioner must obtain a terminal hinge position from the patient and then record it so it can be transferred to the articulator. To gain such a position, the use of splints may be needed. Splints are used to eliminate neuromuscular

reexes until a stable, comfortable, repeatable jaw position has been achieved.14 Once the patients joint data are recorded, the instrument can be set to duplicate the border movements of this functional pattern.15,16 The maxillary cast can be properly positioned in the instrument using the hinge axis transfer method. Then, the Roth power centric bite technique is used to mount the lower model to the articulator.17,18 An analysis of the patients occlusion can then be carried out. By using the 5-part centric test and a split cast mounting, the centric relation position of

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Figure 8. Transferring the terminal hinge axis to the patients face. (Color version of gure is available online.)

the condyles can be veried.19-21 If the models split cast check at 5 different verticals, one can be sure of having recorded the correct terminal hinge axis position of the condyles. The diagnostic phase of using the articulator system begins after this procedure. The condylar positioning indicator (CPI) instrument (Fig. 2) permits the calculation of the amount of condylar distraction. Diagnosis of the vertical dimension discrepancies is possible with this system, which cannot be done with handheld models. Because the models are mounted on the articulator using the terminal hinge axis, a split cast analysis can be done to determine whether the malocclusion is in a vertical, horizontal, or transverse direction. This information becomes

important for deciding the treatment mechanics for that particular orthodontic problem. Other diagnostic uses of the articulator system can be the creation of diagnostic setups. This may include an orthodontic, surgical, restorative, or any combination setup. This allows the practitioner, before treatment, to determine the post-treatment relationship of the occlusion and the temporomandibular joints. In this manner, the roles of the restorative dentist, surgeon, periodontist, and orthodontist in the patients treatment can be determined pretreatment. It is beyond the scope of this article to discuss how all these techniques can be accomplished. Photographs of the technique will be used to illustrate the basic information.

Figure 9. Performing the terminal hinge axis transfer for the mounting of the maxillary cast. (Color version of gure is available online.)

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Figure 10. Placing the terminal hinge axis transfer on the mounting stand and mounting the maxillary cast. (Color version of gure is available online.)

member has a pin placed in the middle of the condylar sphere. Graph paper is then placed on the tables, and when the CR bite is placed in the instrument, the point is located on the graph paper in red. Once CR is measured, then black articulating paper is used to mark CO. The CO bite is placed between the teeth, and the condylar position is marked in black. The difference between the CR and CO markings can now be calculated (Figs. 5 and 6). The amount of discrepancy between CR and CO determines the change in the bite during treatment. The technique used to mount the upper model is called a terminal hinge axis facebow transfer. The use of palpation, arbitrary measurements, or an estimated facebow transfer is not accurate. These methods can result in a large error in the articulator mounting of the maxillary and mandibular casts.13 The recording of the terminal hinge axis location, the eminence tracing, and the amount of side shift are used to position the cast correctly and program the articulator to duplicate the patients border movements (Figs. 7-9). The terminal hinge axis facebow is now attached to the hinge axis mounting stand, and the maxillary cast is mounted to the upper member of the articulator (Fig. 10).

The Techniques Needed to Use the Articulator System

The second part of this article will deal with the techniques needed to accurately use articulators. The rst technique involves the CO or maximum intercusptation bite (Fig. 3). After the CO bite is nished, the Roth power centric bite is used to seat the condyles. The technique involves creating a hard anterior stop and then using a soft piece of blue wax in the posterior. This allows the masseteric sling to seat the condyles up and forward. Only Delar Blue wax (Delar Corp, Lake Oswego, OR) is used for this bite (Fig. 4). The CPI test is done by comparing the CO bite (black dot) and CR bite (red dot). The instrument used to make this comparison is called a condylar position indicator (CPI) instrument. It consists of upper and lower articulator pieces. The upper member has the fossa boxes replaced with moveable tables, and the lower

Figure 11. Mounting of the mandibular model using the Roth power centric bite. (Color version of gure is available online.)

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Figure 12. The centric bite (red dot) is always located at the center; if not, then a mounting error has been committed. The CO bite (black dot) is located either down and forward (A) or down and back (B). If the CO mark is down and forward, it is a Class II horizontal problem. If the black dot is down and back, it indicates a Class II vertical problem. (Color version of gure is available online.)

The comparison of the pretreatment CPI readings and post-treatment CPI readings can determine whether the orthodontic treatment was successful at the condylar level. The success of orthodontic treatment can thus be objectively measured (Fig. 13). The next diagnostic technique is the occlusal vertical analysis. Because the case is mounted using the terminal hinge axis, changes in vertical dimension can be performed by removing the posterior teeth and autorotating the mandibular member closed. Observation of the overbite and overjet can help differentiate between a vertical and a horizontal problem of the malocclusion (Fig. 14). Once the case is mounted on the articulator and the instrument is programmed to the patients condylar movements, the occlusal characteristics can be assessed. The working, balancing, and protrusive excursion can be viewed for any lateral movement interferences. Without the articulator mounting and the patients recorded joint data, the interferences in lateral movements cannot be assessed. When trying to assess this information intraorally, the neuromuscular avoidance pattern will prevent any direct observation (Fig. 15). When the patients models are mounted on a fully adjustable articulator, using the true hinge axis, accurate treatment setups can be preformed. The teeth and jaws can be set to function with the patients functioning axis, thus giving an accurate pretreatment picture of how the case will respond to the chosen treatment plan. This can be done for orthodontics, restorative dentistry, orthognathic surgery, and any combination (Fig. 16).

Once the maxillary model is mounted, the lower model is positioned using the Roth Power Centric. The mandibular model is then attached to the articulator (Fig. 11). When the models are correctly placed in the articulator, the diagnostic techniques using the articulator system can be performed by the orthodontist. The CPI instrument has the ability to measure the difference between CO and CR at the condylar level. This information can be used to determine whether the condyle is seated before starting the orthodontic treatment(Fig. 12).

Conclusions
Without the use of the articulator, there is a volume of information that is left out, resulting in diagnostic and treatment planning errors in orthodontic cases. The 3-dimensional thinking induced by the use of articulators includes the teeth, jaws, and joints, permitting the orthodontist to create optimum function in the masticatory complex. Gnathologic practice includes the vertical dimension for the diagnosis and treatment planning process, resulting in the elimination of posterior premature occlusal contacts.

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Figure 13. The post-treatment comparison of occlusal correction at the condylar level is shown. (A) Pretreatment CPI readings. (B) Post-treatment readings. (Color version of gure is available online.)

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Figure 14. The case has been mounted using the patients terminal hinge axis, so the back teeth can be removed and the articulator rotated closed. If a normal OB and OJ occur, then a vertical problem and not a horizontal problem is diagnosed. (Color version of gure is available online.)

The vertical dimension of the occlusion will be revealed by instituting articulators, terminal hinge axis, and axiopath tracings that can then be adequately dealt with in the mechanics. Applying gnathologic principles to the eld of orthodontics, through the use of articulators along with photographs, cone beam computed tomog-

raphy, and surface-mapping imaging, helps the practitioner to treat to a fully functioning gnathic system. This comprehensive approach to orthodontic diagnosis, treatment planning, and re-evaluation is appropriate for complex orthodontic problems that require surgical, prosthodontic, or

Figure 15. The occlusal analysis is done rst in protrusive, then in right working, and lastly in left working. From the example given, the occlusal interferences that exist in this post-treatment orthodontic case can be visualized. (Color version of gure is available online.)

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Figure 16. The use of the different setups in a case, showing the orthodontic, surgical, and restorative setups. The pretreatment and post-treatment images show pretreatment planning of difcult cases, using interdisciplinary treatment for the benet of the patient. (A) Axiopath recoding, (B) orthodontic setup, (C) surgical setup, (D) restorative setup, (E) pretreatment mounting, and (F) facial photo. (G) Post-treatment mounting and (H) facial photo. (Color version of gure is available online.)

periodontic interdisciplinary management. Because we do not have a way to predict the host adaptive processes, all the tools available must be used to evaluate and treat.

References
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3. Cordray FE: Three-dimensional analysis of models articulated in the seated condylar position from a deprogrammed asymptomatic population: A prospective study. part 1. Am J Orthod Dentofacial Orthop 129: 619-630, 2006 4. Woods DP, Floreani KJ, Galil KA, et al: The effect of incisal bite force on condylar seating. Angle Orthod 64:321-330, 1994 5. Utt TW, Meyers CE, Wierba TF, et al: A three dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator. Am J Orthod Dentofacial Orthop 107:278-308, 1995

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6. Iseberg A: Temporomandibular joint Dysfunction. Sweden: Pub Isis Medical Ltd. Forward, pp IX, 2001 7. McCollum BB, Stuart CE: A Research Report. South Pasadena, CA, Scientic Publishing, 1955, pp 9 8. Kasarovi PM, Meyer M, Nelson GD: Occlusion: An orthodontic perspective. J Calif Dent Assoc 28:780-790, 2000 9. Roth RH: Functional occlusion for the orthodontist. J Clin Orthod 15:32-51, 100, 1981 10. Cordray FE: Centric relation treatment and articulator mountings in orthodontics. Angle Orthod 2:153-158, 1996 11. Stallard H: Dental articulation as an orthodontic aim. JADA D Cosmos 24:348-376, 1937 12. Klar NA, Kulbersh RF, Kaczynski T, et al: Maximum intercuspation-centric relation disharmony in 200 consecutively nished cases in a gnathologically oriented practice. Semin Orthod 9:109-116, 2003 13. Freeland DF, Kulbersh T, Kaczynski R, et al: Comparison of maxillary cast positions mounted from a true hinge kinematic facebow versus an arbitrary facebow in three planes of space [masters thesis]. The University of Detroit/Mercy Orthodontic Department. RWISO 2, 2010, p. 45-56

14. Bosman AE: Hinge axis determination of the mandible. Utrecht, the Netherlands: Albert Eckart Bosman 1974, pp 83-85 15. Lee RL: Jaw movements engraved in solid plastic for articulator controls. II. Transfer Apparatus. J Prosth Dent 22:513-527, 1969 16. Lee RL: Jaw movements engraved in solid plastic for articulator controls. I. Recording apparatus. J Prosth Dent 22:209-224, 1969 17. Wood DP, Elliot RW: Reproducibility of the centric relation bite registration technique. Angle Orthod 64:211220, 1994 18. Schmitt ME, Kulbersh RF, Bever T, et al: Reproducibility of the Roth power centric in determining centric relation. Semin Orthod 9:102-108, 2003 19. Lucia VO: Ch 3: The hinge axis. Modern Gnathological Concepts. Philadelphia, PA, 1961 20. Needles JW: Mandibular movement and articulator design. J Am Dent Assoc 10:927-935, 1923 21. Lauritzen AG, Wolford LW: Occlusal relationship: The split cast method for articulation techniques. J Prosthet Dent 14:256-265, 1964