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Contents

Volume 2, No. 1, September 2010


Letter from RWISO President, Samuel B. King, DDS, MS

Letter from Editor-In-Chief, Thomas Chubb, DDS

News from the Roth Williams Teaching Centers

The Roth Williams Legacy Fund (RWLF) Committee Report

Ryan K. Tamburrino, DMD Normand S. Boucher, DDS


Robert L. Vanarsdall, DDS Antonino G. Secchi, DMD, MS
The Transverse Dimension: Diagnosis and Relevance to Functional
Occlusion

11

Byungtaek Choi, DDS, MS, PhD


Hinge Axis: The Need for Accuracy in Precision Mounting: Part 2

21

Michael J. Gunson, DDS, MD G. William Arnett, DDS, FACD


Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines

37

Dori Freeland, DDS, MS Theodore Freeland, DDS, MS


Richard Kulbersh, DMD, MS, PLC Richard Kaczynski, BS, MS, PhD
Comparison of Maxillary Cast Positions Mounted from a True Hinge
Kinematic Face-Bow vs. an Arbitrary Face-Bow in Three Planes of Space

45

Jina Lee Linton, DDS, MA, PhD, ABO Woneuk Jung, DDS
The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

57

Andrew Girardot, DDS, FACD


Physiologic Treatment Goals in Orthodontics

69

Wesley M. Chiang, DDS, MS Theodore Freeland, DDS, MS


Richard Kulbersh, DMD, MS, PLC Richard Kaczynski, BS, MS, PhD
Effect of Gnathologic Positioner Wear on Maximum Intercuspation
CR Disharmony

75

RWISO Journal | September 2010

RWISO Journal is published by the Roth Williams International Society


of Orthodontists.
Copyright 2010 RWISO. All Rights Reserved.
ISSN 2154-4395 (print)
ISSN 2154-4409 (online)
Reproduction whole or in part in any form or medium without express
written permission of RWISO is prohibited. Information furnished in
this journal is believed to be accurate and reliable; however, no responsibility is assumed for inaccuracies or for the informations use.

RWISO JOURNAL
SEPTEMBER 2010 VOL. 2, NO. 1
EDITOR IN CHIEF
Dr. Thomas K. Chubb
EXECUTIVE DIRECTOR/ADVERTISING SALES
Jeff Milde
MANAGING EDITOR
Anne Evers
CREATIVE DIRECTORS
Brad Reynolds (www.integralartandstudies.com)

Postmaster:
Send address changes to
RWISO
1712 Devonshire Road
Sacramento, CA 95864
RWISO Journal
Roth Williams International Society of Orthodontists
1712 Devonshire Road
Sacramento, CA 95864 USA
Phone: 916-270-2013
Fax: 866-746-3815
info@rwiso.org
We welcome your responses to this publication. Please send comments,
subscriptions, advertising and submission requests to: info@rwiso.org
The Roth Williams International Society of Orthodontics is the embodiment of a philosophical and technological transformation: addition of
physiologic to anatomics from a foundation of function and esthetics.

BOARD OF DIRECTORS
President
Dr. Sam King
6460 Far Hills Avenue
Centerville, OH 45459 USA
937-433-9530
samuel_king@hotmail.com
President Elect
Dr. Douglas Knight, DMD
3210 Westport Green Place
Louisville, KY 40241 USA
502-327-6453
knightortho@insightbb.com
Vice President
Dr. Renato Cocconi
Via Traversante, San Leonardo 1
43100 Parma, Italy
+0521-273682
orthosmile@studiococconi.it
Secretary
Dr. Eunah Choi
Somang BD 2F, 907-1
Bangbae 1 Dong
Seocho Gu
Seoul, 137-842 Korea
+822-583-2275
orthoi@hanmail.net
Treasurer
Dr. John F. Lawson, MS
2460 Nwy 63 North
Rochester, MN 55906 USA
507-282-6447
jlawdds@aol.com

Immediate Past President


Dr. Darrell Havener
1420 West Canal Court,
Suite 200
Littleton, CO 80120 USA
303-791-2021
dhavener@gmail.com
Executive Director
Jeff Milde
1712 Devonshire Road
Sacramento, CA 95864 USA
916-270-2013
j.milde@mra-sf.com
COUNCIL MEMBERS
Region I - Asia
Dr. Satoshi Adachi
#202, 5-11-8 Minoh
Minoh, Osaka 562-0001 Japan
+81-72-724-2866
teeth@adachi-ortho.com
Dr. Eunah Choi
Somang BD 2F, 907-1
Bangbae 1 Dong
Seocho Gu
Seoul, 137-842 Korea
+822-583-2275
orthoi@hanmail.net

Region II - Europe
Dr. Claudia Aichinger
Billrothstr. 58
Vienna, A-1190 Austria
+43-1-367-7222
smile@draichinger.at
Dr. Renato Cocconi
Via Traversante, San Leonardo 1
43100 Parma, Italy
+0521-273682
orthosmile@studiococconi.it
Dr. Domingo Martin
Plaza Bilbao 2-2A
San Sebastian, 20005 Spain
+34-943-427-814
martingoenaga@arrakis.es
Region III - USA, Canada
Dr. Ramon Marti, MSC
281 Oxford Street E.
London, Ontario N6A 1V3
Canada
519-672-7740
rmarti3@hotmail.com

Region IV - South America


Dra. Solange M. deFantini, MSD
Al Janu 176 cj 42
Sao Paulo, SP 01420-002 Brazil
+55-11-3081-8440
smfantin@usp.br
Dra. Marisa Gianesella Bertolaccini
Rua Tabapu, 649 - Conj. 83
Itaim Bibi, So Paulo, SP, 04533012 Brazil
+11- 505-25417
mgianesella.odonto@gmail.com

Letter from the President


Samuel B. King, DDS, MS
RWISO President
The world is changing rapidly. Technology is enabling us to do things never
before possible. Orthodontics is changing too. New technologies, evolution
of procedures, ease in obtaining information are just a few of the things that
are advancing the orthodontic profession. The Roth Williams International
Society of Orthodontists continues to evolve to provide the very best for our
patients, but as we move forward with these new technologies, we are ever
mindful of our treatment goals and the standards of our philosophy.
The RWISO Journal embodies our commitment to remain true to our treatment goals and the standards of our philosophy. As orthodontic treatment
changes, it is our duty to ensure, through evidence-based research, that new
techniques and modalities achieve our goals and maintain our standards. Our
Journal serves to educate our global organization about these advancements
so that our members can confidently deliver the Roth Williams goals and
standards to their patients.
The Roth Williams International Society of Orthodontists is in the midst of
an exciting time. Today we are able to treat our patients better than ever before with exciting new advancements in our profession. It is truly a great time
to be part of the Roth Williams International Society of Orthodontists.
Respectfully,

Samuel B. King, DDS, MS


RWISO President

RWISO Journal | September 2010

Letter from the Editor


Thomas Chubb, DDS
Editor-In-Chief of RWISO Journal

I would first like to thank all the authors in this years Journal for the amount of time
and energy they devoted to giving us another first class issue. They are the lifeblood of
the RWISO Journal. I know the authors would be interested in your feedback. Their
e-mail addresses are listed on their articles, so please contact them with any comments
you might have. I apologize to any author whose submission did not make it into this
issue. We are already working on the next issue, which we hope will come out between
now and the next meeting.
I would like to thank Anne Evers, our managing editor, and Irene Elmer, our copy
editor, for all their hard work and professionalism. Many of the authors have felt the
sting of Irenes sharp pen and the exacting revisions they both required. Their many
hours of hard work were needed to bring this issue to fruition. I would also like to
thank all our sponsors who contributed generously to help publish this issue and to
Jeff Milde for all his logistical support.
After reading the reports from the Roth Williams regional directors, I was struck by
the level of involvement in education to which this group has devoted itself. Unfortunately, we meet only once a year to reconnect with our far-flung colleagues to reinvigorate and recommit ourselves. I see the RWISO Journal as having a vital function
in sharing information for those members who attend the annual meeting and, more
importantly, for those who cannot. It gives us something to hand to our non-Roth
Williams orthodontists and dental colleges to show the type of research and clinical results that is being produced. The articles is this issue are diverse and some are
groundbreaking.
You will note this issue of the Journal is mostly articles with only one case report.
Oddly, we have had very few case reports submitted. My feeling is that the RWISO
Journal needs a better balance of articles and case reports. Over the years I have seen
many outstanding cases presented at the RWISO meetings. One of the strengths of our
group has always been in showing well-treated cases with beautiful finishes. However,
more importantly, these cases have one more thing in common: stable joints with
good function of the teeth and joints. And how do we know this? We know because
we evaluate our results with the use of centrically mounted models, condylar recording systems, and TMJ scans. I believe it is the documentation of our orthodontic cases
that defines our group. Any journal can show a pretty orthodontic finish. It is another
thing to show all the records, the treatment planning, and then the clinical execution
and a measured outcome of a challenging case. Since this Journal will be seen by many
non-Roth Williams orthodontists, I think it is critical we show more of our clinical
orthodontic work in this journal.
I hope to see this Journal grow and become a vital part of our organization as it is a
reflection of who we are and what we believe in.

Thomas Chubb, DDS


Editor-in-Chief
tkchubb1@earthlink.net

Dr. Thomas Chubb | Letter from the Editor

News from the Roth Williams Teaching Centers


ARGENTINA
We are pleased to announce that in May of this year we began the Roth
Williams FACE (The Foundation for Advanced Continuing Education)
Course in cooperation with the Catholic University of Argentina. Dr.
Oscar Palmas, Dr. Guillermo Ochoa and Dr. Eduardo Rubio (surgeon)
were he instructors for this course. They had the honor of working
alongside Dr. Domingo Martin and Dr. Jorge Ayala. The highlight was a
lecture given by Dr. Martin on interdisciplinary treatment.
Many feeder courses were developed this year in different provinces,
including Salta, Jujuy, Rio Gallegos and Santiago del Estero. More than
300 hundred students were taught about the Roth Williams philosophy. In September 2011, Dr. Jorge Ayala will give a feeder course
entitled Biomechanical Treatment in Roth Philosophy.
For next year we are planning a Roth Williams FACE national meeting
in Jujuy, an Argentinean province. The Roth Williams Center Argentina will participate in the Mendoza Society Orthodontic Meeting in
September. Dr. Oscar Palmas will give a lecture on self-ligation and
micro-screw in Roth Philosophy.
We are very happy to see the poster contributions for the Rome meeting from our Roth Williams students. We would also like to take this
opportunity to congratulate the Journal on its second issue. We encourage you all to continue working!!
Dr. Oscar Palmas
Director, Roth Williams Center Argentina

BRAZIL
The Brazilian Center began a new CCO group in June 2009. It has
attracted students from the northwest to the southwest of Brazil. Dr.
Fantini has been traveling to various places in Brazil to spread the
Roth Philosophy. She has been teaching courses and has even lectured
at an advanced-level specialization course, where her talks about the
Philosophy have become a tradition.
In October 2010, the SPO meeting, which is the most important meeting in Latin America, will take place in Brazil. Dr. Fantini will speak
on Roths Philosophy: multidisciplinary treatment of skeletal class II
malocclusion with bilateral condylar degeneration and generalized root
resorption.
Since 2009 four abstracts have been published in conference proceedings, three articles have been accepted in orthodontic magazines, and
two book chapters have been dedicated to the Roth Philosophy. Dr.
Fantini has participated in 10 MA, PhD, and qualifying examinations
as an examiner, enhancing the concepts of the Roth Philosophy. For a
complete list of the articles and abstracts, please contact the RWISO
office.
The study group founded in the beginning of 2008 remains active with
reunions every 2 months. We believe we have found an interesting formula to deepen the knowledge of those who took the CCOs. At each

group meeting, our program includes 3 activitiesa participant presentation on a given theme, a clinical case presentation and discussion,
and a talk on a new topic of current interest. This format has made the
study group very popular.
We plan to start a new CCO group in June 2011.
Finally, we are considering organizing a memorial meeting for all South
America in So Paulo in November 2010.
Dra. Marisa Gianesella Bertolaccini
Director, Roth Williams Center Brazil

CHILE
As is traditional, our educational activities have remained very active
through continuing courses, 2- or 3-day courses, and participation
in various meetings. We are currently offering long-term courses in
Mexico (two), Argentina, Paraguay, and Chile with a total of 170
students. In 2009 thru 2010 we held 34 courses.
In 2010 we will offer two new continuing courses, one in Michoacn,
Mxico, and the other one at the Universidad de Tucumn, Argentina.
A course in Brazil, to be held in collaboration with Dr. Solange Fantini,
is also being organized.
Drs. Jorge Ayala and Gonzalo Gutierrez
Directors, Roth Williams Center Chile

JAPAN
We are pleased to announce that we now have 45 members. Members
are doctors who have graduated from the 2-year course and have also
presented cases with stable and repeatable jaw position. Each year we
hold an annual meeting where each participant shows his/her cases
treated according to the Roth philosophy. Along with the annual meeting, we are now preparing for the 15th anniversary meeting in Tokyo
on November 28-29. This meeting is open to all interested doctors.
We are expecting a great attendance. We of course welcome RWISO
members from all over the world.
The ninth 2-year course is steadily ongoing and session 5 was held for
5 days in June, and featured Dr. Jorge Ayala from Chile as a special
instructor. The 14th basic course will be held in the fall.
Dr. Kazumi Ikeda
Director, Roth Williams Center Japan

continued on next page...

RWISO Journal | September 2010

KOREA

UNITED STATES

In March 2010 the eighth Roth Williams International Seminar was


held. The 10 participants in the course were instructed by Drs. Byungtaek Choi, Eunah Choi, and Gyehyeong Lee. All participants enthusiastically took part in the course.

New and exciting things are happening within the Advanced Education in Orthodontics (AEO) group. In June of 2010, Group VIII will
have their graduation. Group VIII is the largest class, with 25 doctors.
A total of 125 doctors have finished the rigorous seven sessions. The
directors have been extremely uplifted by the positive responses given
by the graduates as to their overall educational experience. Comments
like this are the usual: Keep up the good work. I thank you daily in
the back of my mind for telling me I needed to take this course and
that I would be a better orthodontist. You guys were absolutely right
and as challenging as our profession is and as smart as our colleagues
are, I feel light years ahead of them and my GPs thank you. Ben.

As visiting professors, Drs. Byungtaek Choi and Eunah Choi lectured


on the Roth philosophy to the residents of the Department of Orthodontics at the Seoul National University Dental Hospital. The lectures
were held weekly during the month of June 2010.
The Roth Williams Center Korea has been encouraging our members
to contribute to the Roth Williams Legacy Fund. We expect a desirable
outcome by the 2010 annual meeting in Rome.
Dr. Eunah Choi
Director, Roth Williams Center Korea

SPAIN
Without any doubt 2009 was a great year for RW Spain/Portugal.
Concerning the RW 2-year course, this year we finished group number
10 (26 students) and we started group number 11 (28 students). The
2-year course has truly grown to be a comprehensive orthodontic
course. We now have three full-time teachers who come to every
session and not only help in the clinic but also present as teachers.
They are Drs. Alberto Canabez from Barcelona, Eugenio Martins
from Portugal, and Iigo Gomez from Bilbao. All three of them have
contributed to the excellent quality of the RW course. Apart from these
full-time teachers, we have also incorporated into our courses experts
in the different fields of dentistry, who have come and taught different sessions. They are Dr. Iaki Gamborena, prosthodontist, Drs. Jon
Zabalegui and Iigo Sada, periodontists, Dr. Dave Hatcher, radiologist,
Dr. Borja Zabalegui, endodontist, Dr. Renato Cocconi, orthodontist,
and Dr. Mirco Raffaini, surgeon. All of these teachers have given the
RW courses a truly interdisciplinary approach, which is what FACE
promotes worldwide.
Another important aspect of 2009 that has been fundamental in
making RW a truly interdisciplinary course is the fact that we have
organized two different courses, Bioesthetics with Dr. Ken Hunt and Dr
Alejandro James, and Orthognathic Surgery with Dr. Lucho Quevedo.
Many of our former students have signed up for the courses, and this
has given them a greater understanding of the importance of incorporating both disciplines into our interdisciplinary approach. But we
cannot forget that with Osteoplac now organizing and promoting our
courses they have become truly professional, and without this support
we could have never reached the status that we now enjoy.
Dr. Domingo Martn
Director, Roth Williams Center Spain and Portugal

The course is continuing to improve and evolve without sacrificing any


of the Roth Williams basics. Techniques such as the true horizontal
hinge axis mountings combined with true horizontal hinge axis 3-D
imaging have been introduced to improve accuracy of diagnosis and
treatment planning. In the past, AEO was successful in improving the
Visual Treatment Options (VTO) both in ease of use and in teaching
technique. Now the course incorporates the latest in 3-D technology.
The directors have been instrumental in developing software that enhances the efficiency of orthodontic diagnosis and treatment planning.
The next step is to develop 3-D software that is based on the true hinge
axis. This is being handled by Dr. Robert Frantz.
Dr. Andrew Girardot is responsible for editing and publishing the longawaited Roth Williams Philosophy textbook. Because of the substantial
commitment required for this important project, Andy will not be
teaching formally until his work on the book is complete.
The true standard wide archform (SWA) system that Dr. Roth developed
is continuing to evolve. With the help of the Head of Product Development at GAC, Tom Macari, and AEO, improvements to the bracket are
in the works.
The teaching techniques developed at AEO are evolving as well. With
the advent of new computer technology, many new and exciting things
will be happening in the next year.
The Roth Williams USA center has a new home base. Due to an excellent opportunity afforded us by Dr. Carlos Navarro, AEO will be moving to Houston, Texas. So in October of 2010, Group IX will travel to
Texas for the new class. The new facility will have adequate space for
teaching the total Roth Williams experience. The clinical, laboratory,
and lecture will now be in one location. This location is close to many
fine restaurants and entertainment.
Drs. Andy Girardot, Bob Frantz, and Ted Freeland
Directors, Roth Williams Center USA

URUGUAY
Once again, it is a pleasure for the Roth Williams Center Uruguay for
Functional Occlusion (RWCUFO) to be present in our Journal.
We would like to inform you that finally in December 2009, our 3-year
course started in the Faculty of Odontology, Catholic University of
Montevideo, Uruguay. The first three sessions have been completed, with
a total of 13 participants. We are having real success with the contributions of our friends and outstanding speakers from all over the world.

News from the Roth Williams Teaching Centers

In addition, three 8-hour courses were scheduled in April, August,


and December 2010. Presentations include Dr. Roths Philosophy: the
importance of the condyle setting in the fossae:physiological principles
for neuromuscular deprogramming, by Dr. Guillermo Ochoa; Treatment planning according to Roths Philosophy, by Dr. Oscar Palmas;
and Evidence-based Roths Philosophy and its application in multidisciplinary treatments, by Dr. Domingo Martn. Dr. Martn will also be
giving a 4-day course for all the specialists related to orthodontics.
To know more about our courses, please visit the Web page www.ucu.
edu.uy/Odontologia, or contact us by e-mail at rwcuruguay@gmail.
com.
Our group is concerned about research. To address this concern, we
are encouraging our students to make a weekly commitment to our
study group. We are working hard in order to achieve the best results.
Dr. Daniela Domnguez Di Prisco
Director, Roth Williams Center Uruguay

Scenes from RWISO 2009


16th Annual Conference, Boston, MA

RWISO Journal | September 2010

The Roth Williams Legacy Fund Committee Report


Dr. Milton D. Berkman, Chairman, RWLF

Fund-Raising Progress
As of June 1, 2010, $208,650 had been donated to the Roth Williams Legacy Fund (RWLF).
Of the money donated, $178,650 has been given to the general research and education portion
of the fund and $30,000 has been specifically donated to the Roth Williams textbook portion
of the fund.
As of June 1, 2010, $107,290 had been pledged to RWLF but had not yet been donated.

Dr. Milton D. Berkman,


Chairman RWLF

RWLF is proud of the progress that has been made to date. Due in part to the worldwide
economic recession, we realize that our campaign goal of $1 million in 5 years may not be
attainable. However, we truly believe that the goal of $1 million will be reached as RWISO
continues to grow in stature and respect. The future is bright for the Roth Williams Philosophy
of goal-directed interdisciplinary patient care.

A special thanks to Drs. Jeff McClendon and Milt Berkman for giving the Coordinating Orthodontic and Restorative Efforts
(CORE) course and raising almost $9,000 for RWLF. As of July 2010, the course will have been given four times.

2009 Boston Meeting and Journal


At the RWISO International meeting held in Boston, Massachusetts, in May 2009, the Committee was pleased with the
memberships response to the RWLF fund-raising campaign for the general endowment fund and for the Roth Williams
Philosophy textbook fund. The publication of the first issue of the RWISO Journal, in May 2009, came to fruition in part
because of a grant from the RWLF general endowment fund for $14,000. As Dr. Domingo Martn said in the first issue of
the Journal, I cannot forget it was Dra. Anka Sapunar who first founded a journal for this group, and we must all be very
grateful to her for the great job that she did. This is a continuation of what she started. Muchas gracias, Anka!!!
The renewal of the Journal would not have been possible without the seed money from RWLF. This is just one of the many
ways that RWLF is able to fulfill its mission to advance the scientific and clinical benefits of the Roth Williams Philosophy
of goal-directed interdisciplinary patient care. What a great moment for the RWISO membership! For RWLF it was a significant first step, because it demonstrated the important role of an endowment fund in the future growth and longevity of an
organization and a philosophy of patient care. RWLF and the RWISO membership are looking forward to the second issue
of the RWISO Journal at the Rome Conference with great anticipation.

Research Evaluation and Approval Committee (REAC)


The RWLF Committees initial major efforts have been directed toward fund-raising, and toward gaining the trust and
confidence of the RWISO membership. Now that 30% of the $1 million goal has been pledged or donated, the Committee is ready for a new endeavorto develop research grant evaluation, approval, and funding. One of the mission
statements of RWLF is partial or full support of research projects that lead to publication of scientific and clinical
papers in peer-reviewed international journals. The Committee is pleased to announce that two research grants have
been approved and are in the process of being funded by RWISO/RWLF.

Roth Williams Legacy Fund

Drs. Edson Illipronti and Solange Fantini from Brazil were awarded a grant for a research project entitled Evaluation
of functional morphology in children with unilateral posterior crossbite before and after rapid maxillary expansion.
The grant is to pay in part for MRI studies. The grant is for $16,000 over a 3-year period.
Drs. Carol Weinstein and Sigal Bentolila Weiner from Chile were awarded a grant for a research project entitled Degree of apical root proximity, periodontitis, and root resorption of the upper canine and first bicuspid found in sample
of Roth prescription-treated orthodontic cases using cone beam radiography compared to panoramic radiography.
The grant is to pay in part for cone beam radiography studies. The grant is for $3,000 over a 3-year period.

Donation and Pledges


Donations to RWLF can be made in the following ways:
1. Professional Courtesy/Grateful Patient. Persons to whom you offer orthodontic services as a courtesy are invited to
demonstrate their appreciation by making a contribution to RWLF in your name.
2. Case for the Future of the Roth Williams Philosophy. Doctors can donate one new case as a case for the future
by paying the fee to RWLF.
3. Doctors giving courses or lectures can donate a portion of the honorarium or course fees to RWLF.
4. Donations can be made in memory of, or in honor of, a colleague, friend, relative, or parent.
5. Or just make a donation because of what the Roth Williams Philosophy has meant to your professional life
Donations can be designated for the general research and education fund or for publication of the Roth Williams
Philosophy textbook.
For more on how to donate, visit the RWISO Web site at www.rwiso.org.

RWLF Committee
Thank you to those individuals who serve on the Legacy Fund Committee.








Milton D. Berkman, Chairman RWLF


Peggy Brazones
Alan Marcus
Domingo Martn
Jeff Milde, Executive Director RWISO
Joe Pelle
Straty Righellis, Chairman REAC
Manny Wasserman
David Way

RWISO Journal | September 2010

Roth Williams Legacy Fund Donors


Tribute to Donors
We thank all of our loyal and faithful donors for their support of the Legacy Fund. Below, we pay tribute to those donors who have given from
January 1, 2006, through June 21, 2010.

Platinum (10,000 - $49,999)

Bronze Circle ($1 - $999)

Pledge Circle

Thank you to these donors who have pledged


donations to the Legacy Fund over multiple years.

Dr. Milton D. Berkman


Dr. Domingo Martin
Dr. Straty Righellis
Dr. Carl Roy
Dr. Manny Wasserman
Dr. Robert E. Williams

Gold Circle ($5,000 - $9,999)












Dr. Margaret Brazones


Dr. Byungtaek Choi
Dr. Andrew Girardot
Dr. Darrell Havener
Dr. John Lawson
Dr. Jina Linton
Dr. Jeffrey McClendon
Dr. James Sieberth
Dr. Wayne Sletten
Dr. David Way
GAC International

Silver Circle ($1,000 - $4,999)


























Dr. Terry Adams


Dr. Claudia Aichinger
Dr. Robert Angorn
Dr. Joachim Bauer
Dr. Patricia Boice
Dr. Renato Cocconi
Dr. Frank Cordray
Dr. K. George Elassal
Dr. Keenman Feng
Dr. Michael Goldman
Dr. Frank Gruber
Dr. David Hatcher
Dr. Kazumi Ikeda
Dr. John Kharouf
Dr. L. Douglas Knight
Dr. Young Jun Lee
Dr. Gerald Malovos
Dr. Alan Marcus
Dr. Ramon Marti
Dr. Roger Pitl
Dr. Paul Rigali
Dr. Nile Scott
Dr. Sean Smith
Dr. Katsuji Tanaka
Reliance Orthodontic Products

10

Legacy Fund Donors

Dr. Hideaki Aoki


Dr. George Babyak
Dr. Mary Burns
Dr. Dara Chira
Dr. Tom Chubb
Dr. Warren Creed
Dr. Graciela de Bardeci
Dr. Chieko Himeno
Dr. Takehiro Hirano
Dr. Akira Kawamura
Dr. Mi Hee Kim
Dr. Yutaka Kitahara
Dr. Shunji Kitazono
Dr. Felix Lazaro
Dr. N. Summer Lerch
Dr. Ilya Lipkin
Dr. George Marse
Jeff Milde
Dr. Kouichi Misaki
Dr. Hideaki Miyata
Dr. Yo Mukai
Dr. Yoshihiro Nakajima
Dr. Joseph Pelle
Dr. Akiyuki Sakai
Dr. Atsuyo Sakai
Dr. Hidetoshi Shirai
Dr. Motoyasu Taguchi
Dr. Naoyuki Takahashi
Dr. Hiroshi Takeshita
Dr. Yasoo Watanabe
Dr. Benson Wong
Dr. Koji Yasuda
Dr. Yeong-Charng Yen

Estate Planning

Dr. Charles R. de Lorimier


Dr. Donald W. Linck, II

Friends of Roth Williams





Advanced Education in Orthodontics


Jewish Communal Fund
T&T Design Lab (Japan)
Timothy McCarthy

Dr. Satoshi Adachi


Dr. Scott Anderson
Dr. Jorge Ayala
Dr. Milton Berkman
Dr. Margaret Brazones
Dr. Warren Creed
Dr. Robert Good
Dr. Mila Gregor
Dr. Tateshi Hiraki
Dr. Maria Karpov
Dr. Mi Hee Kim
Dr. Masako Komatsu
Dr. Jina Lee Linton
Dr. Ilya Lipkin
Dr. Dave Livingston
Dr. Yuci Ma
Dr. Alan Marcus
Dr. Ramon Marti
Dr. Joseph M. Pelle
Dr. Paul Rigali
Dr. Nile Scott
Dr. Wayne Sletten
Dr. Manny Wasserman
Dr. Benson Wong
Dr. Yeong-Charng Yen
Dr. Michael Yitschaky

The Transverse Dimension:


Diagnosis and Relevance to Functional Occlusion
Ryan K. Tamburrino, DMD Normand S. Boucher, DDS Robert L. Vanarsdall, DDS
Antonino G. Secchi, DMD, MS
Ryan K. Tamburrino , DMD
rktambur@dental.upenn.edu
Clinical AssociateUniv. of Penn.
School of Dental Medicine, Dept.
of Orthodontics
N ormand S. B oucher, DDS
Clinical Associate Professor
Univ. of Penn. School of Dental
Medicine, Dept. of Orthodontics
R obert L. Vanarsdall , DDS
Professor and Chair
Univ. of Penn. School of Dental
Medicine, Dept. of Orthodontics
A ntonino G. S ecchi , DMD, MS
Assistant Professor of Orthodontics,
Clinician Educatorand Clinical
DirectorUniv. of Penn. School of
Dental Medicine, Dept. of Orthodontics

Summary
Much focus of orthodontic diagnoses has been placed on the sagittal and vertical dimensions. However, a proper evaluation of the transverse dimension
must also have equal importance. Research has shown that interferences from
an exaggerated curve of Wilson due to a maxillary transverse deficiency play
a role in centric relation (CR)/central occlusion (CO) discrepancies, adverse
periodontal stresses, and craniofacial development. This article illustrates
three scientifically validated methods for evaluating the transverse dimension:
Ricketts P-A cephalometric analysis, Andrews Element III analysis, and the
University of Pennsylvania Cone-Beam CT transverse analysis. The aim is to
show methods using traditional cephalometry, study models, and cone-beam
computed tomography, not to compare one method to another. The reader
may then choose to use the method that is most appropriate for his practice.

For complete contributor information, please see end of article.

Introduction
The goals of orthodontic treatment are well established
for static and functional occlusal relationships. In order
to achieve Andrews six keys to normal occlusion for the
dentition,1 the jaws must be optimally proportioned in
three planes of space and positioned in CR. Orthodontists
have a multitude of cephalometric analyses available to diagnose skeletal and dental variations of the sagittal and
vertical dimensions.26 Several analyses for the transverse
dimension are also available,3,6,7 but these analyses are not
well accepted as forming part of a traditional orthodontic
diagnosis.
In the sagittal dimension, when the jaws do not relate
optimally, the dentition will attempt to compensate, resulting
in excessively proclined or retroclined anterior teeth. In the
transverse dimension, when the jaws do not relate optimally,
usually due to a deficiency in the width of the maxilla,7,8 the
teeth will erupt into a crossbite or reconfigure their inclinations to avoid a crossbite. This compensation typically
involves lingual tipping of the mandibular posterior teeth,
which are then described as being excessively negatively inclined. In addition, the maxillary posterior teeth are tipped

facially. These teeth are then described as being excessively


positively inclined (Figure 1).

Figure 1 Example of excessive tooth angulations.

Transverse Deficiency and CR/CO Discrepancy


In the prosthodontic literature, these transverse tooth compensations have been graphically illustrated with a crossarch arc constructed through the buccal and palatal cusps of
RWISO Journal | September 2010

11

the maxillary molars. This is known as the curve of Wilson.


With excessive inclination of the maxillary molars to compensate for insufficient maxillary width, the curve of Wilson
is greatly exaggerated, and the palatal cusps are positioned
below the buccal cusps (Figure 2).

Figure 2 An exaggerated curve of Wilson


(note palatal cusps below buccal cusps).

Many articles that describe the impact of CR/CO discrepancies on occlusion focus on how these discrepancies
affect diagnosing the sagittal and vertical dimensions. The
literature has suggested that the plunging palatal cusps
shown in Figure 3 are often the primary contacts that induce vertical condylar distraction on closure from CR. From
a seated condylar position, the patient may fulcrum off the
premature contacts of the terminal molars to obtain the
maximal intercuspal position. The Panadent Condylar Position Indicator (CPI) and the SAM Mandibular Position Indicator (MPI) graphically identify this vertical component of
condylar distraction.9-12

According to McNamara and Brudon,13 the orientation of


the lingual cusps of the maxillary posterior teeth often lie[s]
below the occlusal plane This common finding in patients
with malocclusions often is due to maxillary constriction and
subsequent dentoalveolar compensation in which the maxillary
posterior teeth are in a slightly flared orientation. The results
of a study by McMurphy and Secchi14 indicate that vertical distraction of the condyles in CR/CO discrepancies can be related
to an exaggerated curve of Wilson, secondary to a transverse
deficiency of the maxilla. These authors conclude that, in the
absence of a posterior crossbite, the plunging palatal cusps and
exaggerated curve of Wilson become the fulcrum point for the
vertical condylar distraction from CR to maximum intercuspation. Furthermore, extrapolation of this statement suggests that
if the transverse skeletal dimension is normalized, the curve of
Wilson is flattened, and the arches are coordinated, an important component of the CR/CO discrepancy is eliminated.

Transverse Deficiency and Working/Nonworking


Interferences
It has been a prosthetic maxim that an exaggerated curve of
Wilson increases the potential for working and non-working
side interferences. Studies have shown that posterior occlusal
contacts or interferences are linked to increased masticatory
muscle activity.15,16 In studies where these interferences have
been removed, it has been demonstrated that the activity of the
closing musculature is reduced.16,17 In addition, a study that artificially created non-working interferences reported increased
muscle activity.18 These results suggest that it is prudent to normalize the transverse jaw relationship and flatten the curve of
Wilson to eliminate the potential for excursive posterior interferences or contacts.

Transverse Deficiency and the Periodontium

Figure 3 Note plunging palatal cusps and extreme curve


of Wilson on molars of an arch that was expanded
with arch wires and brackets only.

12

Herberger and Vanarsdall19 have shown an increased risk for


gingival recession in the orthodontic patient with a narrow
maxilla when the skeletal transverse deficiency is camouflaged
with dental expansion. The envelope of treatment in the transverse, with expansion of only the dentition, is more limited than
the envelope of treatment in the sagittal dimension.20 Due to the
constraints of the thin layer of cortical bone of the alveolus, as
shown in Figure 4 [see next page], very little tooth movement
needs to occur before the roots are fenestrated, the volume of
buccal alveolar bone is reduced, and, with thinning gingival tissues, the risk of gingival recession increases.
In recent studies, Harrell21 and Nunn and Harrell22,23 have
shown that the elimination of working and nonworking interferences enhances the long-term periodontal prognosis in patients
susceptible to periodontal disease. Therefore, normalizing the
transverse jaw relationship to eliminate an exaggerated curve

Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

In one recent study,26 patients with transverse deficiencies due to a narrow maxilla who were treated with rapid
palatal expansion, showed an increase of 8% to 10% in the
volume of the upper airway. In another study, 27 patients with
dental posterior crossbites who were treated with palatal expansion also showed an increase in the volume of the upper
airway. Oliveria de Felippe, et al28 found that palatal expansion decreased nasal resistance and improved nasal breathing. While additional research in this area is certainly needed,
the current literature suggests that any improvement in the
volume of the airway, as an effect of palatal expansion to
optimize the transverse dimension of the jaws, may greatly
benefit overall growth and development.
Figure 4 Patient with gingival recession due to orthodontic
treatment in the presence of an undiagnosed severe skeletal
transverse discrepancy. Note minimal alveolar bone on
the buccal surface of the maxillary molars.

of Wilson and nonworking interferences would be beneficial


for adult patients who are periodontally at risk, and might
prophylactically reduce the risk for younger patients.

Transverse Deficiency and the Airway


Ricketts description of adenoid facies24 also suggests a relationship between a constricted nasopharyngeal airway and
a narrow maxilla. Ricketts states children with any impairment of the nasal passages become predominantly mouth
breathers. Since the tongue is positioned in the floor of the
mouth to allow airflow, it cannot provide support to shape
the developing palate; thus pressure from the circumoral
musculature acts unopposed. The palate is narrowed, and
an exaggerated curve of Wilson develops upon tooth eruption. Because the tongue is positioned low in the mouth, the
patient may also develop a retruded, high-angle mandibular
shape, which can increase the risk for sleep apnea.25 An example of adenoid facies is shown in Figure 5.

Figure 5 A teenager who had nasopharyngeal airway impairment


during growth and development. The images show the facial,
dental, skeletal, and airway presentation upon growth cessation.

Methods of Transverse Diagnosis


With a transverse deficiency due to a narrow maxilla, the
temporomandibular joints, musculature, periodontal tissue,
and airway can be adversely affected in the susceptible patient. Our goal as orthodontists should be to develop skeletal
relationships and a functional occlusion that are as close to
optimal as possible, to lessen the role that any discrepancies
of the occlusion would play in exacerbating the detrimental effects to the joints, periodontium, or dentition. In order
to achieve this a correct skeletal and dental diagnosis in all
three planes of space is mandatory.
In this section, we present three different methods for
diagnosing the transverse dimensionone using traditional
cephalometry, one using dental casts, and one using conebeam CT (computed tomography). We do not endorse any
one of these methods over the others; our purpose here is
simply to describe all three methods, so that readers will be
able to incorporate a transverse skeletal diagnosis into their
practice, no matter what level of technology is available.
Regardless of which of these methods one chooses, the doctor
must keep optimal treatment goals in mind as a rationale for
normalizing the transverse dimension (Figures 6 and 7).

Figure 6 Goals for normalizing the transverse dimension.


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13

below and medial to the gonial angle.3


Once the measurements have been taken, the mandibular
width (Ag-Ag) is subtracted from the maxillary width (MxMx) to get the difference in width between the jaws. Ricketts
then determined skeletal age-determined normative relationships between the maxilla and the mandible (Figure 9). This
allows the analysis to accommodate growing patients, and
allows for the differential growth rates and potentials of the
maxilla and the mandible.

Figure 7 Rationale for normalizing the transverse dimension.

Ricketts P-A Analysis


In 1969, Ricketts introduced analysis of the transverse skeletal dimension as part of his method of cephalometric diagnosis.3 His method uses the frontal, or posteroanterior
(P-A) cephalogram, and is based on the dimensions of the
jaws compared to a table of age-adjusted normative values.
The premise of the analysis is based on locating two skeletal
points to determine maxillary width and two additional skeletal points to determine mandibular width (Figure 8).

Figure 8 Locations of Mx (green) and Ag (yellow).

For the maxilla, the jugal point (Mx) is located on the right
and left sides of the maxillary skeletal base at the depth
of the concavity of the lateral maxillary contours, at the
junction of the maxilla and the zygomatic buttress.3 The
maxillary width is determined by the horizontal distance
connecting these two points. For the mandible, a similar
measurement is taken between the two antegonial notches
(Ag). These notches are located on the right and left sides
of the mandibular body at the innermost height of contour
along the curved outline of the inferior mandibular border,

14

Figure 9 Table for determining the age-normal


difference between the maxilla and the mandible.

In order to determine the skeletal age of a patient, a handwrist film is taken and is compared to an atlas of male and
female skeletal age standards.29 To determine the amount of
expansion needed, the age-adjusted expected difference between the jaws is subtracted from the measured difference.
An example of the Ricketts method is shown in Figure 10.

Figure 10 Example of Ricketts P-A analysis.

Andrews Element III Analysis


In 1970, L. F. Andrews published his landmark paper describing the six keys to normal static occlusion.1 Over the next
several decades, he and his son, W. A. Andrews, worked to develop the six elements philosophy of orthodontic diagnosis.
One of the diagnostic criteria, Element III, is devoted to analyzing the transverse relationship of the maxilla and mandible
and is based on both bony and dental landmarks.10
The Element III analysis is based on the assumption that
the WALA (named after Will Andrews and Larry Andrews)

Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

ridge determines the width of the mandible. According to


Andrews definition, the WALA ridge is coincident with the
most prominent portion of the buccal alveolar bone when
viewed from the occlusal surface (Figure 11).

Figure 12 Determination of mandibular


WALA-WALA and FA-FA distances.

The width of the maxilla is based on optimization of the


angulation of the maxillary molars. To determine this width,
one measures the horizontal distance from the FA point of
the left molar to the FA point of the right molar and records
the measurement.

Figure 13 Determining maxillary FA-FA distance and


estimating the change in maxillary molar inclination.

Figure 11 Demarcation of the WALA ridge.

The WALA ridge is essentially coincident with the


mucogingival junction and approximates the center of resistance of the mandibular molars. In a mature patient,
the WALA ridge and the width of the mandible cannot be
modified with conventional treatment. Thus the WALA ridge
forms a stable basis for the Element III analysis.6
The Element III analysis is based on the width change,
if any, of the maxilla needed to have upper and lower posterior teeth upright in bone, centered in bone, and properly
intercuspated. To determine the discrepancy, the first step is
to determine the width of the mandible, or the horizontal
distance from the WALA ridge on the right side to the WALA
ridge on the left side. According to Andrews, optimally positioned mandibular molars will be upright in the alveolus,
and their facial axis (FA) point, or center of the crown, will
be horizontally positioned 2 mm from the WALA ridge. With
this information, the width of the mandible is then defined as
the WALA-WALA distance minus 4 mm.6

One then looks at the angulation of the maxillary molars and estimates the amount of horizontal change that will
occur between the FA points of the right and left molars
when they are optimally angulated. The estimated amount of
change is subtracted from the original FA-FA measurement.
The result represents the width of the maxilla.6
In order to have optimally positioned and optimally inclined molar teeth that intercuspate well, Andrews states that
the maxillary width must be 5 mm greater than the mandibular width.6 In order to determine the amount of transverse
discrepancy, or Element III change, needed to produce an
ideal result, one takes the optimal mandibular width, adds
5 mm, and subtracts the maxillary width. An example of the
entire analysis is shown in Figure 14.

Figure 14 Example of Andrews Element III


transverse analysis.
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University of Pennsylvania Cone-Beam CT Analysis


The current trend in orthodontic imaging and diagnosis is
toward three-dimensional analysis. With the advent of conebeam imaging, orthodontists can obtain precise measurements without any distortion caused by radiographic projections or ambiguity of point identification. The same rationale
can subsequently be applied to the transverse measurement
of the maxilla and the mandible. Ricketts and Andrews
methods for determining the amount of transverse discrepancy between the jaws are based on using readily discernable
landmarks that represent the width of the base of the alveolar housing. For Ricketts, these landmarks are Mx-Mx for
the maxilla and Ag-Ag for the mandible. For Andrews, these
landmarks are the two sides of the WALA ridge and the FA
points of the maxillary and mandibular molars. The WALAWALA measurement represents the width of the mandible,
and the FA-FA points are used, as described above, to determine the width of the maxilla. Both of these methods have
merit. However, with cone-beam CT imaging, it is no longer necessary to have a measurement dictated by ease with
which landmarks can be identified to represent the widths
of the jaws.
Before choosing a method for measuring the base of the
jaws, we must first decide what location to use for measurement. In determining the location of the WALA ridge, Andrews stated that the WALA ridge is an approximation of the
center of resistance of the mandibular teeth. Above the WALA
ridge, the alveolus can be dimensionally molded and altered,
depending on the change in angulation of the teeth. However,
the same cannot be said for the portion of the alveolus below
the WALA ridge. Thus, in a mature patient, any portion of the
alveolus apical to the WALA ridge can be assumed to be reasonably dimensionally stable during tooth movement, and,
therefore, can define the dimensions of the patients arch. In
Ricketts analysis, Ag-Ag represents the basal portion of the
mandible. However, when one looks at the position of Ag on
a three-dimensional image, one sees that its correlation with
the base of the alveolus is relatively weak in all three planes
of space for mature patients (Figure 15).

16

Figure 15 Correlations of Mx and Ag to skeletal bases in adults.

Thus, to locate the beginning of the base of the mandible


with a CT scan, it would seem best to find the skeletal representation of the WALA ridge. This is approximately at the edge of
the cortical bone opposite the furcation of the mandibular first
molars. We can also use this technique to locate the beginning of
the base of the maxilla. If we assume that the maxilla begins at
the projection of the center of resistance of the maxillary teeth
onto the buccal surface of the cortical bone, Ricketts use of Mx
to determine maxillary width appears to be at approximately at
the same horizontal position. Additionally, by using Mx point,
any exostoses present along the buccal portion of the alveolus will not interfere with the measurement. Andrews method,
on the other hand, has no directly definable skeletal landmark
for the maxilla; it relies on estimated changes in the angulation
of the molars to determine the skeletal transverse discrepancy.
Therefore, Ricketts method of defining the basal skeletal width
of the maxilla appears to be more appropriate.
We begin, then, by defining locations for measuring maxillary and mandibular skeletal basal width. Next, we explore
concepts for defining these locations on cone-beam CT imaging.
The basic premise for the mandible is to locate the most buccal
point on the cortical plate opposite the mandibular first molars
at the level of the center of resistance. According to Katona, this
location is approximately coincident with the furcation of the
roots of the molars.30 As we explained above, the authors chose
this point due to the relative immutability of the alveolus apical
to this location with orthodontics and because it represents the
absolute minimal width of the basal bone for each jaw.
For the purposes of this technique, the authors used Dolphin 3D, release 11 (Patterson Dental, Chatsworth, CA), but
the concepts can be applied to any software with the capability to analyze a cone-beam CT image. After properly orienting
the image, we open the multiplanar view (MPV) screen to see
simultaneous axial, sagittal, and coronal cuts of the image.

Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

Figure 16 MPV of a cone-beam CT scan.

Figure 18 Measurement of mandibular skeletal width.

To determine the width of the mandible, we scroll down


through the image until we locate the furcation of the first
molar. Then we scroll posteriorly through the scan until we
locate the coronal cross-section through the center of the
mandibular first molars.

For the maxilla, a similar method is employed. The only


difference is that the axial and coronal cuts must be taken at
the position Mx-Mx, and the same measurement as in the
Ricketts analysis is used.

Figure 17 Location of the mandibular axial and coronal cuts.

Figure 19 Measurement of maxillary axial and coronal cuts.

Now we switch to full-screen axial view. Using the cut


lines as a guide, we measure the width of the mandible from
the intersection of the cut line with the most buccal portion
of the cortical plate on both the right and left sides.

Figure 20 Measurement of maxillary skeletal width.

The analysis of the width of the maxilla and mandible at


the level of the first molars is straightforward once we have
RWISO Journal | September 2010

17

taken the measurements of both jaws. By subtracting the


mandibular width from the maxillary width, we determine
the difference between the two jaws. Both Ricketts and Andrews analyses demonstrate that the optimal transverse difference between the maxilla and mandible is 5 mm in mature
patients. A preliminary analysis of 5 cases where the maxillary and mandibular molars were upright in the alveolus,
centered in the alveolus, and well intercuspated, produced
measurements where the difference between the width of the
jaws approximated 5 mm on a consistent basis. Therefore,
the seemingly ideal difference for the width of the jaws in
mature patients using the Penn CBCT analysis would also
appear to be 5 mm. To determine the amount of expansion
necessary to achieve an ideal jaw relationship in the transverse dimension, the measured difference between the jaws
should be subtracted from 5.

that is not perpendicular to the alveolus, a false perception of


the thickness of cortical bone is possible, as shown in Figure
22. Therefore, to reduce errors in judgment and to improve
visualization of the most buccal portion of the cortical bone,
the authors believe that the axial cut allows for greater precision of measurement over the coronal cross section.

Figure 22 Visualization of cortical bone thickness


on coronal and axial cuts of the same patient

Future Directions
Now that the methodology of the Penn CBCT analysis has
been verified, the next goal will be to extrapolate the analysis
to determine a diagnostic transverse relationship for the canines. With this, the goal will be to determine the appropriate
arch form for proper stability and function on an individual
basis. An additional studys aim will be to develop age-specific transverse normative criteria for Penn CBCT analysis,
similar to Ricketts norms for the P-A ceph.

References
1. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;
62(3):296-309.
2. Jarabak cephalometric analysis. In: Roth-Williams/AEO Course
Manual; 2006.
3. Ricketts RM. Introducing Computerized Cephalometrics. Rocky
Mountain Data Systems; 1969.

Figure 21 Example of optimal transverse skeletal


relationships using cone-beam CT analysis.

Research performed by Simontacchi-Gbologah, et al31,


has verified the validity of the University of Pennsylvania
CBCT analysis for the transverse diagnosis. However, the
difference between the described method here and the method in the aforementioned research is that the measurements
were taken on coronal cuts, not axial ones. Due to the cross
section of the mandibular coronal cut being taken at an angle

18

4. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod. 1960; (29):8.
5. Downs WB. Analysis of the dentofacial profile. Angle Orthod. 1956;
(26):191.
6. Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual;
2001.
7. McNamara JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 2nd ed. Ann Arbor, MI: Needham Press; 2002: 102-103.

Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

8. Vanarsdall RL. Transverse dimension and long-term stability. Sem in


Orthod. 1999; 5(3):171-180.

24. Ricketts RM. Respiratory obstruction syndrome. Am J Orthod.


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9. Cordray FE. Three-dimensional analysis of models articulated in the


seated condylar position from a deprogrammed asymptomatic population: a prospective study, I. Am J Orthod Dentofac Orthop. 2006;
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25. Comyn FL. MRI Comparison of Craniofacial Structures in Sleep


Apneic Patients [masters thesis]. University of Pennsylvania; 2009.

10. Utt TW, Meyers CE, Wierzbe TF, Hondrum SO. A three-dimensional comparison of condylar position changes between centric relation
and centric occlusion using the mandibular position indicator. Am J
Orthod Dentofac Orthop. 1995; (107): 298-308.
11. Crawford SD. The relationship between condylar axis position
as determined by the occlusion and measured by the CPI instrument
and signs and symptoms of TM joint dysfunction. Angle Orthod.
1999;(69): 103-115.
12. Tamburrino RK, Secchi AG, Katz SH, Pinto AA. Assessment of the
three-dimensional condylar and dental positional relationships in CRto-MIC shifts. RWISO Journal 2009; 1(1): 33-42.
13. McNamara JA, Brudon WL. Orthodontics and Dentofacial Orthopedics. 2nd ed. Ann Arbor, MI: Needham Press; 2002: 104-105.
14. McMurphy JS, Secchi AG. Effect of Skeletal Transverse Discrepancies on Functional Position of the Mandible [thesis]. University of
Pennsylvania; 2007.

26. Cappetta LS, Chung CH, Boucher NS. Effects of Bonded Rapid
Palatal Expansion on Nasal Cavity and Pharyngeal Airway Volume: A
Study of Cone-Beam CT Images [thesis]. University of Pennsylvania;
2009.
27. Kilic N, Oktay H. Effects of rapid maxillary expansion on nasal
breathing and some naso-respiratory and breathing problems in growing children: a literature review. Int J Pediatr Otorhinolaryngol. 2008;
72(11): 1595-1601.
28. Oliveira de Felippe NL, Da Silveira AC, Viana G, Kusnoto B, Smith
B, Evans CA. Relationship between rapid maxillary expansion and
nasal cavity size and airway resistance: short- and long-term effects.
Am J Orthod Dentofac Orthop. 2008; 134(93): 370-382.
29. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development
of the Hand and Wrist. 2nd ed. Stanford, CA: Stanford University
Press; 1959.
30. Katona TR. An engineering analysis of dental occlusion principles.
Am J Orthod Dentofac Orthop. 2009; 135(6): 696.

15. Greco PM, Vanarsdall RL, Levrini M, Read R. An evaluation of


anterior temporal and masseter muscle activity in appliance therapy.
Angle Orthod. 1999; 69(2): 141-141.

31. Simontacchi-Gbologah MS, Tamburrino RK, Boucher NS, Vanarsdall RL, Secchi AG. Comparison of Three Methods to Analyze
the Skeletal Transverse Dimension in Orthodontic Diagnosis [thesis].
University of Pennsylvania; 2010.

16. Williamson EH, Lundquist DO. Anterior guidance: its effect on


electromyographic activity of the temporal and masseter muscles. J.
Prosthet Dent. 1983; (69): 816-823.

For complete contributor information, please see next page.

17. Manns A, Chan C, Miralles R. Influence of group function and


canine guidance on electromyographic activity of elevator muscles. J
Prosthet Dent. 1987; (57): 494-501.
18. Okano N, Baba K, Igarashi Y. Influences of altered occlusal guidance on masticatory muscle activity during clenching. J Oral Rehab.
2007; (9): 679-684.
19. Herberger T, Vanarsdall RL. Rapid Palatal Expansion: Long-Term
Stability and Periodontal Implications [thesis]. University of Pennsylvania; 1987.
20. Sarver DM, Proffit WR. In: Graber TM, Vig KL, Vanarsdall RL,
eds. Orthodontics: Current Principles and Techniques. 4th ed. St.
Louis, MO: Elsevier-Mosby; 2005: 15.
21. Harrell SK. Occlusal forces as a risk factor for periodontal disease.
Periodon. 2003; (32): 111-117.
22. Nunn ME, Harrell SK. The effect of occlusal discrepancies on
periodontitis: relationship of initial occlusal discrepancies to initial
clinical parameters. J Periodontol. 2001; (72): 485-494.
23. Nunn ME, Harrell SK. The effect of occlusal discrepancies on
periodontitis: relationship of occlusal treatment to the progression of
periodontal disease. J Periodontol. 2001; (72): 495-505.

RWISO Journal | September 2010

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Contributors
Ryan K. Tamburrino, DMD
Clinical AssociateUniv. of Penn., School of Dental Medicine,
Dept. of Orthodontics
Andrews Foundation Six Elements Philosophy Course2007
Advanced Education in OrthodonticsRoth-Williams Center
for Functional Occlusion2008
University of Pennsylvania, School of Dental Medicine,
Certificate in Orthodontics2008
University of Pennsylvania, School of Dental Medicine, DMD
2006
Normand S. Boucher, DDS
McGill University, School of Dental Medicine, DMD, 1974
University of Pennsylvania, School of Dental Medicine,
Certificates in Orthodontics and Periodontics, 1982
Advanced Education in Orthodontics, Roth-Williams Center
for Functional Occlusion, 1993
Andrews Foundation, Six Elements Philosophy Course, 1998
Clinical Associate Professor, University of Pennsylvania, School
of Dental Medicine, Department of Orthodontics
Robert L. Vanarsdall, DDS
Professor and Chair University of Pennsylvania School of
Dental Medicine, Department of Orthodontics
DDSMedical College of Virginia
Certificates in Orthodontics and PeriodonticsUniversity of
Pennsylvania
80 publications and 11 textbook contributions
Former President of the Philadelphia Society of Orthodontists
and Eastern Component of the EH Angle Society
Antonino G. Secchi, DMD, MS
Assistant Professor of Orthodontics-Clinician Educator and
Clinical Director, Dept. of Orthodontics, University of Penn.
Andrews Foundation Six Elements Philosophy Course, USA,
2005
Institute for Comprehensive Oral Diagnosis and Rehabilitation,
OBI Level III2005
Advanced Education in OrthodonticsRoth/Williams Center
for Functional Occlusion USA2005
University of Pennsylvania, MS in Oral Biology2005
University of Pennsylvania, DMD2005
University of Pennsylvania, Certificate in Orthodontics2003
University of ChileChile, Certificate in Occlusion, 1998
University of ValparaisoChile, DDS, 1996

20

Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

Hinge Axis: The Need for Accuracy in Precision Mounting


Part 2
Byungtaek Choi, DDS, MS, PhD
B yungtaek C hoi , DDS, MS, P h D
joydog@unitel.co.kr
Graduated from Seoul National
University, College of Dentistry
(DDS), Seoul, Korea, 1981
Graduated from Seoul National
University, College of Dentistry
(MS), Seoul, Korea, 1984
Graduated from Seoul National
University, College of Dentistry
(PhD), Seoul, Korea, 1990
Private Practice, Seoul, Korea
Chairman of Korean Foundation of
Gnatho-Orthodontic Research
Director of Roth Williams Center,
Korea
Attending Professor of Medical
School of Hanlim University
Attending Professor at Seoul
National University

Summary
This is the second part of a two-part paper discussing the need for accuracy
in the mounting of dental models for orthodontic diagnosis and treatment.
Part 1 discussed the accuracy differences between an arbitrary hinge axis
(AHA) mounting and a true hinge axis (THA) mounting. Part 2 discusses the
differences between two popular true hinge axis recording devices, the Panadent Axi-Path system and the Axiograph III system.

The Axi-Path System


Many clinicians use the Panadent Axi-Path system for the
following purposes: (Figure 17)
To locate the true hinge axis (THA)
To determine the sagittal anterior condylar path inclination, non-working-side sagittal lateral condylar path inclination, and the Bennett movement to
select the Motion Analog Blocks
To assess the functional structural conditions of the
temporomandibular joint

a thumbscrew. A straight ruler can be used to make the two


flag tables parallel to each other. (Figure 19).

Figure 17 Axi-Path recording: Panadent Company.

The upper head frame of the Axi-Path recorder is composed of two symmetrical arms that move around a hinge
joint at the center of the frame (Figure 18). The upper frame
is fitted and fastened to the head by tightening the hinge with

Figure 18 Head frame (upper frame).

RWISO Journal | September 2010

21

Figure 19 Flag tables are set to be parallel to each other.

The lower head frame of the Axi-Path recorder is attached to the lower jaw with the use of a clutch. Two side
arms which hold the styli are attached to the cross rod to
record the mandibular movement (Figure 20).

Figure 22 Schematic drawing of the head viewed from the


top when the Axi-Path recorder has been placed on the head.

Figure 20 Lower frame for adjustable axis-locating arms.

To place the Axi-Path recorder correctly, the upper


frame is first fitted and fastened to the head. The lower frame
is then attached to the lower jaw. Finally, the axis-locating
arms are attached to the lower jaw (Figure 21).

Figure 21-a The upper frame is placed and fastened to the head.
Figure 21-b Axis-locating arms are attached to the lower jaw.

Figure 22 is the schematic drawing of the head viewed


from the top when the Axi-Path recorder has been placed on
the head correctly.

22

Figure 23 Asymmetrical head configuration.

If the patients head configuration is asymmetrical, the


face-bow may not be centered on the head when the nasion
relator is placed on Nasion (Figure 23). Since the nasion relator cannot move transversely, the face-bow should be rotated
until the nasion relator sits on Nasion (Figure 24). When the
lower frame is placed, the stylus may not be perpendicular

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

to the flag table (Figure 25). The Axi-Path is not a collinear


system, and errors often occur when the clinician attempts
to determine the THA. If a recording system is not collinear
and rectilinear, the clinician is likely to mark the inaccurate
hinge points on the skin.

The following experiment can be used to determine the


magnitude of measurement error. The experiment is set up so
that the measurement shows the right condyle 5 mm forward
of its actual position. For purposes of illustration, the situation is assumed to be noncollinear (Figure 26).

Figure 26 Supposition. Right condyle moved 5 mm forward.

The new hinge axis diverges from the original hinge axis
as it goes farther from the anatomic structure (Figure 27).
Figure 24 Nasion relator cannot
move along the horizontal part of the bow.

Figure 27 New hinge axis passing through


newly positioned condyle.

The right recording stylus is placed at the new hinge


point on the flag table (Figure 28).
Figure 25 When the lower frame is placed, the
stylus may not be perpendicular to the flag table.
RWISO Journal | September 2010

23

The example assumes that the distance between the


centers of the two condyles is 110 mm, and the distance at
skin level is 140 mm (Figure 31). If the condyle moves 5 mm
forward, it will appear to move slightly more on the graph
(Figure 32). If the condyle moves 5 mm forward, the hinge
point on the skin moves 5.68 mm forward (Figure 33).

Figure 28 Stylus placed at the new


hinge point on the flag table.

A hinge axis is not a line that connects the centers of the


condyles. It is the axis around which the mandible shows
pure hinge movement. Therefore, the hinge axis may pass
through any point in the condyle. In Figure 29, the center
points have been marked for clarity. Figure 30 is a magnified
view of the right joint area.

Figure 31 The supposition is that the distance


between the centers of the two condyles is 110 mm,
and the distance at the skin level is 140 mm.

Figure 32 If the condyle moves 5 mm forward,


it will appear to move slightly more on the graph.
Figure 29
Right condyle 5 mm
anterior to the left
condyle.

Figure 30 Magnified view of the right joint area.

24

Figure 33 If the condyle moves 5 mm forward,


the hinge point on the skin moves 5.68 mm forward.

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

The Axi-Path is designed so that the flag table is very


close to the preauricular skin. For some patients, depending
on the configuration of the temporal region, the flag table
may be farther from the skin. Figure 34 shows 5 mm of distance between the skin and the flag table.

Figure 36 Advantages of Axi-Path system:


Proximity of the flag table to the skin.

Figure 34 Axi-Path is designed so that the flag table is


very close to the preauricular skin. This picture shows
5 mm of distance between the skin and the flag table.

If the distance from where the stylus contacts the flag


table to the skin is 5 mm, the measurement error will be 0.23
mm. The amount of error will decrease as the stylus gets
closer to the skin. The Axi-Path system uses the skin mark
for face-bow transfer. Hence, the smaller the error, the more
accurate the hinge axis. Accuracy depends on the distance
between the flag table and the skin (Figure 35).

Figure 37 Advantages of Axi-Path system:


Proximity of the flag table to the skin.

However, the Axi-Path system also has shortcomings.


The head frame often cannot be fastened tightly to the head.
It is somewhat unstable compared to the frame of the Axiograph III. An unstable frame can make it difficult or impossible to get a reproducible reference point and may be
misdiagnosed as an unstable joint (Figure 38).

Figure 35 If the distance from the stylus to the skin is 5 mm,


the amount of error is calculated as follows:
5.68 : 125 = X : 5 mm (X = 284 125 = 0.23 mm)

The Axi-Path system has some advantages. Because the


flag table is very close to the skin, measurement error can be
minimized (Figure 36). And the reference tattoo on the skin
can be used for precision mounting at any time, once it has
been marked (Figure37).

Figure 38 Shortcomings of Axi-Path system:


Unstable head frame.

RWISO Journal | September 2010

25

Since the nasion relator is not movable transversely on


the face-bow, it is difficult to center the midline of the bow
perpendicular to the hinge axis in asymmetrical cases. If we
attempt to do so, the face-bow will be seated off center (Figure 39).

The Axiograph III System


The Axiograph III system is shown in Figure 41. Orthodontists use this system for the same purposes as the Axi-Path
system. The Axiograph III system differs from the Axi-Path
system in several important ways.

Figure 41 Axiograph III: SAM.

Figure 42 is a schematic drawing of the head viewed


from the top when the upper frame of the Axiograph III has
been placed on the head correctly. If the patients head is
symmetrical, every part of the frame will be parallel or perpendicular to the sagittal plane of the head.

Figure 39 Shortcomings of Axi-Path system:


Off-center placement of the upper frame in asymmetrical cases.

In short, the Axi-Path system records the hinge axis on a


flag table that is relatively close to the skin. If the flag table is
close to the skin, it produces a more accurate hinge mark on
the skin. However, the primary disadvantages of this system
are the structural instability of the head frame when fastened
to the head and the off-centered seating of the face-bow on
the asymmetrical head.
Figure 42 Schematic drawing and real picture of upper frame.

This system is collinear and rectilinear. Since the nasion


relator moves transversely, the upper frame can be placed
on the head without losing the parallelism, even when the
patients head is asymmetrical (Figure 43).
Figure 44 shows the upper and lower frames placed on
the head. The lower frame has two side arms, with a stylus
on the end of each arm. The two styli are in collinear alignment, rectilinear with the upper Axiomatic flag-bow recording plates (Figure 45).

26

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

The upper frame is fastened to the head first, and the


lower frame is placed next. If earplugs are inserted into the
auditory canals, the alignment pins automatically indicate
the approximate hinge positions. The alignment pins also
make the upper and lower parts of the face-bow parallel and
perpendicular to each other (Figure 46).

Figure 46 If ear plugs are inserted into auditory canals,


alignment pins automatically indicate approximate hinge
positions. The alignment pins also make the upper and lower
parts of the face-bow parallel and perpendicular to each other.
Figure 43 Nasion relator moves transversely along
the horizontal part of frame so the frame can be
placed on the head without losing parallelism.

As was done in the Axi-Path experiment, the amount of


measurement error is then determined when the right condyle is moved 5 mm forward (Figure 47). This movement
produces a new hinge axis, which in turn makes new hinge
points on the skin. The new hinge axis diverges from the
original hinge axis as it moves farther from the anatomic
structure (Figure 48).

Figure 44 Upper and lower frames


that have been placed on the head.

Figure 47 Supposition: Right condyle moved 5 mm forward.

Figure 45 Axiograph III uses two recording styli in a


collinear alignment, rectilinear with the upper
Axiomatic flag-bow recording plates.
RWISO Journal | September 2010

27

Figure 50 If the condyle moves 5 mm forward,


it will appear to move slightly more on the graph.

Figure 48 New hinge axis passing


through newly positioned condyle.

Figure 49 is a magnified view of the right joint area.

Figure 51 The recording styli will point


to the new hinge on the flag table.
Right condyle 5 mm
anterior to the left
condyle.

Figure 49 The supposition is that the distance between


the centers of the two condyles is 110 mm, and the
distance at the skin level is 140 mm.

The example assumes that the distance between the centers of the two condyles is 110 mm, and that the distance at
skin level is 140 mm. If the condyle moves 5 mm forward, it
will appear to move slightly more on the graph (Figure 50).
The recording stylus will point to the new hinge on the
flag table (Figure 51).
If the condyle moves 5 mm forward, the hinge point on
the skin will move 5.68 mm forward (Figure 52).

28

Figure 52 IIf the condyle moves 5 mm forward,


the hinge point on the skin will move 5.68 forward.
The distance between the skin and the graph table
is usually greater in Axiograph III than in Axi-Path.
Taking this into account, the distance between the
skin and the graph was set at 8 mm in Axiograph III,
instead of 5 mm, as in Axi-Path.

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

The distance between the preauricular skin and the flag


table is usually greater in the Axiograph III than it is in the
Axi-Path. Taking this into account, the distance between the
skin and the flag table was set at 8 mm in the Axiograph III.
When the flag table is 8 mm away from the skin, the measurement error will be 0.36 mm. This is 0.13 mm larger than
the 0.23 mm measurement error with the Axi-Path, which
has the flag table 5 mm away from the skin (Figure 53).

Although this situation is one that we may not encounter in practice, it is useful as an example to explain an extreme case (Figure 55).

Figure 55 Magnified view.

It is obvious that the measurement error becomes larger


when the distance from the stylus to the skin is 50 mm (Figure
56). In fact, the measurement error will be 2.3 mm (Figure 57).
Figure 53 If the distance from the stylus to the skin is 8 mm,
the amount of error will be calculated as follows:
5.68 : 125 = X : 8 mm (X = 45.4 125 = 0.36 mm)

If we were to transfer the face-bow of the Axiograph III


system in the same way as we transfer the face-bow of the
Axi-Path system, we would have to shorten the distance between the skin and the flag table to reduce the measurement
error. However, in the Axiograph III system we use hinge
marks on the graph, rather than hinge marks on the skin, for
precision mounting.
Now let us further suppose that the stylus is placed 50
mm, rather than 8 mm, away from the skin (Figure 54).

Figure 56 The measurement error becomes larger


when the distance from the stylus to the skin
changes from 8 mm to 50 mm.

Figure 54 Supposition: The stylus is 50 mm away from the skin.


Figure 57 If the distance from the stylus to the skin
is 50 mm, the amount of error will be calculated as follows:
5.6 8: 125 = X : 50 mm (X = 284 125 = 2.3 mm)
RWISO Journal | September 2010

29

This is an extremely large error when we are attempting


to locate a THA. Fortunately, it seldom happens that we attempt to locate a THA from a distance of 50 mm in clinical
practice (Figure 58).

Next, let us examine the precision mounting system of


the Axiograph III. Figure 61 shows a magnified view of the
highlighted area. The various parts of the highlighted area
are shown in Figure 62. They are, respectively, the side arm
of the upper frame, the flag table attached to the side arm,
the recording arm of the lower frame, and the stylus attached
to the recording arm.

Figure 58 If we try to extend the stylus to the skin to mark a


hinge point from a point located at a far distance from the
skin using Axiograph III, it would result in a very large error.

The fact remains, however, that the greater the distance


between the skin and the stylus, the less accurate are the
marks on the skin (Figure 59). Therefore, we are likely to
make a large error if we use a false hinge axis that deviates
substantially from the THA (Figure 60).

Figure 61 Schematic drawing and


real picture of the stylus area.

Figure 59 The greater the distance between the skin


and the stylus, the less accurate the marks of
the THA on the skin will be.
Precision mounting
using a false hinge
axis results in a very
large error.

Figure 62 Magnified view

The THA is the line that connects the left and the right
styli. It passes through an imaginary hole in the flag table.
The stylus marks the hinge point in red or blue on the graph
of the flag table (Figures 63 and 64).

Figure 60 We are likely to create a large error if we use the


false hinge axis, which deviates substantially from the THA.

30

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

Figure 63 Flag table.

Figure 66 Schematic drawing and real


picture of the flag table and the clamp.

The precision mounting stand has two hinge axis alignment pins. These pins are designed to fit into the small holes
on the inner bar of the hinge axis clamp (Figures 67-a, b).

Figure 64 Flag table.

The hinge point on the graph is isolated with the hinge


axis clamp. The hinge axis clamp has two bars. Each bar has
a hole in it, and the two holes are aligned (Figures 65 and
66).

Figure 67-a Hinge axis alignment pin


fits into the inner clamp hole.

Figure 65 Flag table with hinge axis clamp.

Figure 67-b Hinge axis alignment belongs to mounting stand.

RWISO Journal | September 2010

31

In this respect, the Axiograph III system differs from


the Axi-Path system; in the Axi-Path, the stylus of the lower
frame fits into the female part of the mounting shaft. Therefore, we do not need to re-mark the hinge point on the skin
with the Axiograph III as we do with the Axi-Path. Instead,
we use the hinge points on the graphs for precision mounting. In other words, we treat the graph as if it were the skin
in the Axiograph III system (Figure 68).

Figure 68 In Axi-Path, the stylus (axis pin) of the lower frame


is adapted to the female part of the mounting shaft. In
Axiograph III, the hinge axis alignment pins of the mounting
stand are fitted into the small holes on the inner bar of the
hinge axis clamp. Therefore, we need not re-mark the hinge
point on the skin, as we do with Axi-Path. Instead, we use
the hinge points on the graphs for precision mounting.

Figure 70 Measurement error increases as the


flag table moves closer to the skin medially.

The distance from the tip of the hinge axis alignment


pin to the THA is the measurement error (Figure 69). It is interesting to observe that the measurement error increases as
the flag table moves closer to the skin medially (Figure 70).
Conversely, the measurement error decreases as the flag table
moves farther from the skin laterally (Figure 71).
Figure 71 Measurement error decreases as the
flag table moves farther from the skin laterally.

If we try to extend the hinge axis-locating stylus from


the flag to the skin to mark an axis as we do in the Axi-Path
system, the new hinge point on the skin will not correspond
to the true hinge point. As a result, the precision mounting
will be inaccurate. In the Axiograph III system, the measurement error decreases as the flag table gets farther away from
the skin and the constructed hinge axis gets closer to the
THA (Figure 72).

Figure 69 The distance from the tip of the hinge axis


alignment pin to the THA is the measurement error.

Now let us consider two situations that we may encounter in clinical practice. In the first situation, the side arm of
the upper frame contacts the skin of supraauricular area
(Figure 73). The side arm is 6 mm wide and the flag table is
4.5 mm thick.
In the second situation, there may be some distance between the condyle and the recording flag, depending on the
configuration of the patients head. For the purposes of illustration, we will assume that the side arm is 3 mm away from

32

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

In this example (Figure 74) the thickness of the hinge


axis clamp is 5.75 mm; the distance from the skin to the
inner surface of the flag table is 6.5 mm; the distance from
the skin to the outer surface of the flag table is 11 mm; the
distance from the left condyle to the skin on the right side of
is 110 + 15 mm; and the distance from the left condyle to the
inner surface of the flag table is 110 + 15 + 6.5 mm. This is
indicated by the yellow arrow.
The measurement error at the position indicated by the
arrow is calculated as follows:

Figure 72

Y is the measurement error on the inner surface of the


flag table. The amount of error is 0.20 mm (Figure 75).

Figure 73 Supposition: The side arm contacts the skin.


Figure 75 Y is the measurement error on the inner surface
of the flag table. The amount is 0.20 mm.

The measurement error at the inner entrance of the


hinge axis clamp increases slightly (Figure 76).

Figure 74 Supposition: The side arm is separated


3 mm from the skin. The hinge point is measured
at level of entrance of the clamp hole.

the skin. In fact, this does not actually happen in clinical


practice, because we always push the side arm onto the skin
to fasten the upper frame to the head. If, however, we assume
3 mm of separation, this means that the flag table will be 6.5
mm away from the skin, and the hinge point locator clamp
will be attached to the flag table (Figure 74).

Figure 76 Supposition: The side arm is separated 3 mm


from the skin. The hinge point is measured at
level of entrance of the clamp hole.

RWISO Journal | September 2010

33

The measurement error at the inner entrance is 0.47


mm (Figure 77).

The measurement error on the inner surface of the


flag table is 0.20 mm and this is almost the same as
or smaller than that of Axi-Path.

Although the clamp hole provides a bit of leeway with


the pin fitted, this seems to have no clinical significance. Since
the Axiograph III system uses the hinge point on the graph,
while the Axi-Path system uses the hinge mark on the skin,
the two systems seem to yield almost the same accuracy in
precision mounting (Figure 80).

Figure 77 The amount of measurement error will be 0.47 mm.

The measurement error on the skin increases even


more (Figure 78).

Figure 80 The measurement error on the inner surface


of the flag table is 0.20 mm. Error is the same as,
or less than, with Axi-Path.

Summary and Conclusions

Figure 78 Supposition: The side arm is separated 3 mm


from the skin. The hinge point is measured at
level of entrance of the clamp hole.

The measurement error on the skin is 0.5 mm


(Figure 79).

The measurement errors of the hinge axis locations were


calculated for the two recording systems, the Axi-Path of
Panadent and the Axiograph III of SAM. The amount of
the measurement errors were nearly the same for both systems. While the Axiograph III system locates the hinge axis
using hinge points on the flag table, the Axi-Path system
locates the hinge axis using hinge marks on the skin. Although the distance between the flag table and the skin is
greater in the Axiograph, we found no significant difference in accuracy between the two systems, as explained
previously. (Figure 83)

Figure 79 The amount of measurement error will be 0.5 mm.

34

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

Figure 83 The distance between the flag table and the skin is longer in Axiograph III than in Axi-Path.
But since Axiograph III uses hinge points on graph paper to locate the hinge axis, it is equally accurate.

Since the Axiograph III system does not mark hinge


points on the skin, it may be necessary to relocate the axes
for each mounting. Mechanical stability of the recording device is very important for precision. The device must remain
firmly seated on the head. In this respect, the Axiograph III
seems to be superior to the Axi-Path (Figure 85).

Figure 85 Mechanical stability of the recording device is very important for precision.
In this respect Axiograph III seems to be superior to Axi-Path.

Further Reading
Baldauf A, Mack H, Wirth C G. Bestommung der Scharnierachse mittels des ueren Gehrgangs. IOK, 28. JAHRG. 1996.

Hobo S. Twin-tables technique for occlusal rehabilitation. Pt. 2: Clinical procedures. J Prosthet Dent. 1991;66:471477.

Broderson S P. Anterior guidance: The key to successful occlusal treatment. J Prosthet Dent. 1978;39:396400.

Lee R L. Panadent instruction manual for advanced articulator system.


Panadent Corporation, CA, USA, 1988.

Cho Y, Hobo S, Takahashi H.Occlusion. Seoul: Kunja; 1996.

Lundeen H C, Gibbs C H. The Function of Teeth. L and G; 2005.

Dawson P E. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd ed. St. Louis, Mo: Mosby; 1989.

Nagy W W, Smithy T J, Wirth C G. Accuracy of a predetermined transverse horizontal mandibular axis point. J Prosthet Dent. 2002;87:387
394.

Glossary of Dental Prosthodontics. Korea: Korean Association of


Prosthodontics; 2006.
Hobo S. Twin-tables technique for occlusal rehabilitation. Pt. 1:
Mechanism of anterior guidance. J Prosthet Dent. 1991;66:299303.

Okeson J P. Fundamentals of Occlusion and Temporomandibular


Disorders. St. Louis, Mo: Mosby; 1985.

continued on next page...

RWISO Journal | September 2010

35

Ramfjord S, Ash M M. Occlusion. 3rd ed. Philadelphia: WB Saunders;


1983.
Simpson J W, Hesby R A, Pfeifer D L, Pelleu G B Jr. Arbitrary mandibular hinge axis locations. J Prosthet Dent. 1984;51:819822.
Takahashi I. Surgical-orthodontic treatment of a patient with temporomandibular disorder stabilized with a gnathologic splint. Am J Orthod
Dentofacial Orthop. 2008;133: 909919.
Theusner J, Plesh O, Curtis D A, Hutton J E. Axiographic tracings of
temporomandibular joint movements. J Prosthet Dent. 1993;69:209
215.
Wirth C G. 20 Jahre Axiographie. IOK, 28. JAHRG. 1996.

36

Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2

Condylar Resorption, Matrix Metalloproteinases,


and Tetracyclines
Michael J. Gunson, DDS, MD G. William Arnett, DDS, FACD
M ichael J. G unson , DDS, MD
gunson@arnettgunson.com
Graduated from UCLA School of
Dentistry, 1997
Graduated from UCLA School of
Medicine 2000
Specialty Certificate in Oral and
Maxillofacial Surgery UCLA, 2003
G. William A rnett , DDS, FACD
Graduated from USC School of
Dentistry, 1972
Specialty Certificate in Oral and
Maxillofacial Surgery UCLA, 1975

Summary
Mandibular condylar resorption occurs as a result of inflammation and hormone imbalance. The cause of the bone loss at the cellular level is secondary
to the production of matrix metalloproteinases (MMPs). MMPs have been
shown to be present in diseased temporomandibular joints (TMJs). There is
evidence that tetracyclines help control bone erosions in arthritic joints by
inactivating MMPs. This article reviews the pertinent literature in support of
using tetracyclines to prevent mandibular condylar resorption.

Introduction
Orthodontists and maxillofacial surgeons are well acquainted with the effects of condylar resorption (Figure 1).

has been well studied. A number of cytokines and proteases


are found in joints that show osseous erosions that are not
present in healthy joints, namely TNF-, IL-1, IL-6, and
RANKL and matrix metalloproteinases.

Matrix Metalloproteinases

Figure 1 Tomograms reconstructed from cone-beam CT scan.


They show severe condylar resorption in a 19-year-old female
over a 2-year period. Note the progressive osseous destruction.

The clinical outcomes of condylar resorption have been described at length in the literature.1-6 The causes, however,
have been elusive, hence the common name idiopathic condylar resorption. Over the last several years, the pathophysiology of articular bone erosion secondary to inflammation

MMPs are of interest because they are directly responsible


for the enzymatic destruction of extracellular matrix in normal conditions (angiogenesis, morphogenesis, tissue repair)
and in pathological conditions (arthritis, metastasis, cirrhosis, endometriosis). MMPs are endopeptidases that are made
in the nucleus as inactive enzymes, or zymogens. The zymogens travel to the cell membrane, where they are incorporated. The zymogen is then cleaved into the extracellular matrix
as the active enzyme, where it makes cuts into the protein
chains (collagen types I through IV, gelatin, etc). These cuts
cause the proteins to denature, which results in the destruction of the matrix. The action of the MMP requires the mineral zincwhich is an important part of the MMPs protein
structure; hence the name metalloproteinase (Figure 2).

RWISO Journal | September 2010

37

porated. Activation of the MMP occurs when the active side


of the MMP is cleaved from the cell and liberated into the extracellular matrix. Extracellular inhibition comes from proteins called tissue inhibitors of metalloproteinases (TIMPs).
TIMPs bind to active matrix metalloproteinases and inhibit
their activity (Figure 4c). The ratio of MMP:TIMP activity
influences the amount of matrix degradation.7-10

Figure 2 The zymogen pro-MMP is transcribed in the nucleus


and then attached to the cell membrane. It is activated when
it is cleaved from the membrane. The zinc (Zn) portion binds
to protein and the enzyme cleaves the protein, destroying the
extracellular matrix.

In joints, MMPs are produced by monocytes, macrophages, polymorphonuclear neutrophils, synoviocytes, osteoblasts, and osteoclasts. MMPs are generally classified by
the kind of matrix they degrade; thus collagenase, gelatinase
and stromelysin (Figure 3).

Figure 3 A list of the 28 known MMPs. They are generally


named after the extracellular protein that they degrade.

The extracellular activity of MMPs is regulated in two


ways, by transcription and by extracellular inhibition. The
transcription of MMPs in the nucleus is controlled by multiple pathways. MMP transcription is activated by sheer stress
to the cell, by free radicals, and by the cytokines TNF-, IL1, Il-6 and RANKL (Figure 4a). Transcription is suppressed
by the cytokine osteoprotegerin and by the the hormones
vitamin D and estradiol (Figure 4b). After transcription, the
pro-MMP is then sent to the cell membrane, where it is incor-

38

Figure 4-a MMP transcription is activated in the cell nucleus by


cytokines (TNF-, IL-1, Il-6, and RANKL); by metabolic
by-products (free radicals); and by direct sheer stress
to the cell membrane.

Figure 4-b MMP transcription is inhibited by hormones such


as vitamin D and estradiol, as well as the bone-protective
cytokine osteoprotegerin.

Gunson, Arnett | Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines

des. This evidence supports the presence of 6 of the known


28 matrix metalloproteinases (MMP-1, MMP-2, MMP-3,
MMP-8, MMP-9, and MMP-13) in fluid or tissue samples
obtained from diseased human TMJs.13, 16, 17, 19-34 Some cases
of degenerative joint disease also result from an imbalance
between the activities of MMPs and TIMPs, favoring unregulated degradation of tissue by MMPs. 35, 36

Tetracyclines

Figure 4-c The extracellular activity of MMPs is controlled by the


presence of inhibitory proteins called tissue inhibitors of
metalloproteinases, or TIMPs. TIMPs bind directly to the
MMPs, causing conformational changes that prevent the
destruction of matrix proteins.

MMPs and Arthritis


The hallmark sign of arthritis is articular bone loss. In the
past, clinicians have differentiated between inflammatory arthritis and osteoarthritis (OA). Recently, however, the cellular
processes that result in bone and cartilage loss in both forms
of arthritis have been shown to be quite similar.11 While inflammatory arthritis is promoted by a systemic problem, the
result is an inflammatory cytokine cascade, which ultimately
results in osteoclastic activity and bone loss at the articular
surface. OA is not a systemic problem but a local one, secondary to oxidation reactions, free radical production, or sheer
stressall three of which result from overuse.12, 13 Despite
the localized nature of OA, the cascade of cellular events that
cause articular surface loss is the same as the systemically induced cascade. An increase in TNF- and IL-1 increases the
number of osteoclasts and their activity. TNF-, IL-1, IL6, and RANKL all cause increased expression of the MMP
genes. The end result is destruction of cartilage, bone, and
connective tissue in both arthritis models.14-18
MMPs also respond to systemic hormones such as estrogen, vitamin D, and parathyroid hormones. We found an association between low estrogen levels and low vitamin D levels in patients with severe condylar resorption.3 All of these
hormones and cytokines are intimately involved in osteoclast
differentiation and activation. This makes sense: MMPs are
osteoclast produced and are responsible for bone and cartilage destruction.

MMPs and the TMJ


There is substantial evidence indicating that MMPs play an
important role in bone and cartilage degradation associated
with degenerative temporomandibular joint (TMJ) arthriti-

Because MMPs are found to be elevated in patients with


TMJ arthritis and are so destructive to articular tissues, finding a way to reduce their activity or their production would
be helpful in treating patients with arthritis and condylar
resorption.
From 1972-1982, at the School of Dental Medicine in
Stony Brook New York, Ramurmathy and Golub discovered that tetracyclines have anti-collagenolytic properties.
In 1998, Golub and colleagues showed that tetracyclines
inhibit bone resorption in two waysby controlling the expression and activity of MMPs and by regulating osteoclasts
and their activity.37

Controlling MMPs With Tetracyclines


Tetracyclines inhibit MMPs by chelating zinc and by regulating MMP gene expression. As noted above, MMPs need
zinc to actively cleave collagen proteins. Tetracyclines bind
divalent ions, such as zinc. By reducing the amount of free
zinc in tissues, tetracyclines reduce the number of MMPs
available.38 In addition, tetracyclines bind to the MMP itself,
which causes a conformational change in the enzyme, inactivating it (Figure 5).39 Tetracyclines have also been shown to
decrease the transcription of MMPs by blocking both protein kinase C and calmodulin pathways.40, 41

Figure 5 Tetracycline binds directly to the zinc of the MMP.


This deactivates the enzyme and protects the matrix
from degradation. Tetracycline also controls osteoclastic
activity and MMP transcription.
RWISO Journal | September 2010

39

Regulating Osteoclasts With Tetracyclines


Osteoclasts are responsible for the breakdown of bone and
cartilage. Their activity is tightly controlled by cytokines
such as IL-6, TNF-, nitric oxide, and IL-1. Tetracyclines
have been shown to prevent the liberation of these cytokines,
diminishing the activity of osteoclasts.42-46 Tetracyclines also
prevent the differentiation of osteoclast precursor cells into
osteoclasts.47 Finally, tetracyclines promote the programmed
cell death (apoptosis) of osteoclasts.48, 49 All these actions result in a decrease of bone and cartilage loss secondary to
osteoclast activity when tetracyclines are present.

Tetracyclines and Arthritis


In short, the literature shows that tetracyclines exert control
over MMP transcription and activity and regulate osteoclast
activity as well. The clinical evidence supporting the use of
tetracyclines to protect articular bone and cartilage from arthritic inflammation is encouraging.
In the animal model of arthritis, tetracyclines have been
shown to inhibit MMPs and to prevent the progression of
osseous disease.50-52 Yu et al52 induced knee arthritis in dogs
by severing the anterior cruciate ligament. Half the dogs
were pretreated with doxycycline. Doxycycline prevented
the full-thickness cartilage ulcerations that were seen in the
untreated group.
In human studies, tetracyclines have been successfully
used to diminish bone erosions in patients with inflammatory arthritis. One meta-analysis of 10 clinical trials that used
tetracycline for rheumatoid arthritis (RA) showed significant
improvement in disease activity with no side effects.53 In a
single-blinded controlled study, doxycycline was shown to
be as effective as methotrexate in treating inflammatory arthritis.54
Israel et al reported that doxycycline administered at a
dose of 50 mg twice daily for 3 months significantly suppressed MMP activity in three patients diagnosed with advanced osteoarthritis of the TMJ. Two of the three patients
reported marked improvement in symptoms, including improved mandibular range of motion. One patient did not
experience symptomatic relief despite a marked reduction in
MMP activity.55 While symptomatic relief would be important, it must be noted that inhibition of MMPs has a direct
effect on bony resorption, which is often unrelated to TMJ
symptoms. Clinicians need to keep this in mind when reviewing the literature.

racyclines may be considered for the treatment of rapidly


progressive condylar resorption, and in patients with degenerative TMJ disease. They may also be used in patients at increased risk for resorption. This includes patients with bruxism, inflammatory arthritis, or a past history of resorption
who are undergoing occlusal treatment. Of all the available
tetracyclines, Golub et al found that doxycycline was the
most effective at suppressing MMP activity.56 Appropriate
studies to determine effective dose schedules have not been
conducted to date. However, based on the limited clinical
data, it is reasonable to consider doxycycline at a dose of 50
mg twice daily.

Side Effects
The adverse effects of tetracyclines are well known. They
include allergic reactions; gastrointestinal symptoms (ulcers,
nausea, vomiting, diarrhea, Candida superinfection); photosensitivity; vestibular toxicity with vertigo and tinnitus; decreased bone growth in children; and discoloration of teeth
if administered during tooth development. Tetracyclines may
also reduce the effectiveness of oral contraceptives, potentiate lithium toxicity, increase digoxin availability and toxicity, and decrease prothrombin activity.57
If tetracycline therapy is initiated, the patient should be
advised of the potential for reduced efficacy of oral contraception. In addition, the patient should be cautioned against
sun exposure, and should be monitored for other side effects.
If surgery is contemplated, the patients coagulation status
should be evaluated.
There is some question as to whether bacterial resistance may develop with the chronic use of antibiotics. Studies show that long-term low-dose doxycycline (20 mg twice
daily) does not lead to a significant increase in bacterial resistance or to a change in fecal or vaginal flora.58, 59

Other Medications to Control MMPs


Tetracyclines are not the only medications that can prevent
MMP-induced bone erosions. There are promising studies
that show the benefits of TNF- inhibitors; osteoprotegerin
analogues; HMG-CoA reductase inhibitors (eg, simvastatin); and hormone replacement therapies, including vitamin
D and estradiol.60-63 These medications, along with doxycycline, show great promise in controlling articular bone loss
in the face of inflammation.

Conclusion
Dosing
At present, there are no definitive studies demonstrating the
efficacy of tetracycline therapy for degenerative TMJ arthritides. However, based on the available information, tet-

40

When patients present with condylar resorption, clinicians


have long been resigned to two choices: watch and wait or
surgical resection with the resulting disability and deformity.
Doxycycline is just one pharmacological intervention that

Gunson, Arnett | Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines

shows promise in curbing the bone loss associated with arthritis and condylar resorption (Figures 6-a, b, c, d, e).

Figure 6-a, b, c, d, e This is a 31-year-old patient with condylar


resorption secondary to rheumatoid arthritis. She was treated
with orthognathic surgery to correct her malocclusion. The
effects of MMPs were controlled pre- and postoperatively by
prescribing the following medications: doxycycline, simvastatin,
Enbrel, Feldene, vitamin D, and omega-3 fatty acids. She is 10
months postsurgery with minimal osseous change to her condyles
and a stable class I occlusion with good overbite and overjet.

RWISO Journal | September 2010

41

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50. Ramamurthy N, Greenwald R, Moak S, et al. CMT/Tenidap


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51. Yu LP Jr, Burr DB, Brandt KD, OConnor BL, Rubinow A, Albrecht
M. Effects of oral doxycycline administration on histomorphometry
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37. Golub LM, Lee HM, Ryan ME, Giannobile WV, Payne J, Sorsa T.
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52. Yu LP Jr, Smith GN Jr, Brandt KD, Myers SL, OConnor BL, Brandt
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38. Golub LM, Lee HM, Greenwald RA, et al. A matrix metalloproteinase inhibitor reduces bone-type collagen degradation fragments and
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53. Stone M, Fortin PR, Pacheco-Tena C, Inman RD. Should tetracycline treatment be used more extensively for rheumatoid arthritis?
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54. Sreekanth VR, Handa R, Wali JP, Aggarwal P, Dwivedi SN. Doxycycline in the treatment of rheumatoid arthritis--a pilot study. J Assoc
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40. Schlondorff D, Satriano J. Interactions with calmodulin: potential


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55. Israel HA, Ramamurthy NS, Greenwald R, Golub L. The potential


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41. Webster GF, Toso SM, Hegemann L. Inhibition of a model of in


vitro granuloma formation by tetracyclines and ciprofloxacin: involvement of protein kinase C. Arch Dermatol. 1994;130(6):748-752.

56. Golub LM, Sorsa T, Lee HM, et al. Doxycycline inhibits neutrophil
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tetracyclines selectively inhibit IL-6 expression in osteoblasts by decreasing mRNA stability. Biochem Pharmacol. 2003;66(9):1809-1819.

57. Baxter BT, Pearce WH, Waltke EA, et al. Prolonged administration
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58. Walker C, Preshaw PM, Novak J, Hefti AF, Bradshaw M, Powala


C. Long-term treatment with sub-antimicrobial dose doxycycline
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59. Walker C, Puumala S, Golub LM, et al. Subantimicrobial dose
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44

Gunson, Arnett | Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines

Comparison of Maxillary Cast Positions Mounted from a True Hinge


Kinematic Face-Bow vs. an Arbitrary Face-Bow in Three Planes of Space
Dori Freeland, DDS, MS Theodore Freeland, DDS, MS
Richard Kulbersh, DMD, MS, PLC Richard Kaczynski, BS, MS, PhD
D ori F reeland , DDS, MS
tdfortho@freelandorthodontics.com
Private Practice, Lake Orion, MI
T heodore F reeland , DDS, MS
Adjunct Professor, Orthodontic
Dept., School of Dentistry,
University of Detroit Mercy
Director Roth/Williams USA
Private Practice, Gaylord, MI
R ichard Kulbersh , DMD, MS, PLC
Program Director, Orthodontic
Dept., School of Dentistry,
University of Detroit Mercy
R ichard K aczynski , BS, MS, P h D
Statistician, Dept. of Psychiatry,
Yale University School of Medicine

Summary
There are many methods of performing a face-bow transfer, but only two
current methods of replicating the position of the maxilla in three planes of
space: with a true hinge face-bow or with an arbitrary earpiece face-bow. The
purpose of this study was to determine if a clinically significant difference in
three planes of space occurs in the mounting of the maxillary cast when the
mounting is done with an arbitrary earpiece face-bow versus a true hinge
face-bow.
The sample consisted of 51 subjects with complete permanent dentitions
through the second molars, including class I, class II, and class III subjects.
Two maxillary impressions were taken on each subject. One maxillary cast
was mounted using an arbitrary earpiece face-bow and the other using a true
hinge face-bow. Each cast was measured and compared in three planes of
space on an adjustable occlusal table containing graph paper. The positions
of the maxillary right central and right and left first molars were recorded for
the true hinge mounting in red on the graph paper and the arbitrary earpiece
face-bow measurements were recorded in blue. The vertical, anteroposterior
(A-P), and transverse differences between the two mountings were recorded,
and a paired t-test was used to analyze the data. The two face-bow techniques
were statistically significantly different in all three planes of space (p .001).

Introduction
The quest to understand the multifaceted movements of
the mandible and its relationship to the rest of the cranial
complex began in the early 1800s.1 Grays Anatomy was
one of the first sources to publish the fact that the mandible
moves on a hinge as well as by forward and lateral movements from the condyles in the glenoid fossae.1 Thus, the
temporomandibular joint (TMJ) became known as a ginglymo-arthrodial joint and was seen as one of the most complex
joints in the human body. Although the TMJ is considered
a compound joint, it consists of only two actual bones. An
articular disc interposed between the condyles and the mandibular fossa of the temporal bone keeps the two bones from
direct articulation. The disc serves as a nonossified bone; it
serves as the third bone of the compound joint and allows
complex movements to occur.2
When occlusal function is ideal, the condyles are positioned in the glenoid fossae and the mandible should be
able to move by joint-dictated patterns without any interfer-

ence from the teeth.3 According to Okeson, this position is


achieved when the muscles of mastication and the ligaments
combine to seat the condyle into the glenoid fossa.2 Stability
of the joint is maintained by constant muscle activity, even
in resting states, which allows the articular surfaces to come
into contact, although a true structural attachment or union
is not present in the TMJ.2 The muscles play an active role in
the opening and closing of the mandible, while the ligaments
act as passive restraining devices to limit joint movements.
Specifically, the temporomandibular ligament plays a role
in limiting the extent of mouth opening. During the initial
phase of opening, the condyle rotates around a fixed point
for about 20 mm, until the temporomandibular ligament
becomes strained and the condyle is forced into a forward
movement down the articular eminence.2 Posselt defined
this opening as the mandibular terminal hinge opening and
closing.4 The Glossary of Prosthodontic Terms similarly describes this movement as an imaginary line around which
the mandible may rotate through the sagittal plane and
RWISO Journal | September 2010

45

terms the movement the transverse horizontal axis.5


Study of mandibular movements raised questions among
the dental profession as to whether a hinge axis actually exists, and if so, whether it is one axis or more than one. The
dental profession also debated how accurately the hinge axis
can be located, if in fact one exists; the clinical usefulness of
locating it; and whether an arbitrary point on the face can
satisfactorily be substituted for a specific point as a location
for the hinge axis.6 No other topic inspires more controversy
in oral physiology than the role of the jaw joints in dental
articulation.

Campion, working in 1902, made the first graphic
record of the mandibular movements in a patient. He concluded that both a rotation of the bone on an axis and a
forward-downward movement of the condyles occurred.
Campion designed an adjustable face-bow fixed to the mandibular teeth with modeling plaster to graphically record the
various positions of the condyles on the face with a succession of dots. He concluded that the only part of the opening
movement which an articulator reproduction is concerned
with is the initial stage, which is seen in the tracings to be a
simple rotation about an axis passing through the condyles. 7, 8
Bennett also recognized that the mandible was capable of
two independent movements, but he felt that no single fixed
center of rotation for the mandible existed.8 He judged that
the initial center of rotation of the mandible was located behind and below the condyle.8
During this same period, Stallard introduced the term
and the concept ofgnathologythe study of the harmonious, interrelated functioning of the jaws and teeth.1,7,9 In
1924, McCollum developed the first method of locating the
hinge axis with an instrument called the gnathoscope, and
its later model, the gnathograph.1,7 McCollum demonstrated
that no external anatomical landmarks would indicate the
position of the opening axis, nor could this be done by palpating the joint or by measuring a distance in any direction.1,7
McCollum explained that the hinge axis must be determined
instrumentally, and that the movement of this axis is a component of every masticatory movement of the mandible.1,7
After McCollums death, Stuart continued to study mandibular movement and developed his own gnathological system,
including a fully adjustable articulator and pantograph.1,7
Gnathologically oriented studies produced and still produce conflicting conclusions that divide the dental community. One group believes that there is a definite transverse
hinge axis, and that it is necessary to find its point of rotation. Another group believes that methods of locating an
arbitrary hinge point are just as reliable, and more operator
friendly. Still others believe that it is not necessary to locate
the transverse axis at all.

46

Freeland et al | Comparison of Maxillary Cast Positions

Trapozzano and Lazzari found that 57.2% of the subjects in their study had more than one condylar hinge axis
point located on either one or both sides of the mandible.
Therefore, the attempt to locate the hinge axis, was seriously
questioned because multiple axis points may exist.10,11 Other
studies have demonstrated that the center of rotation is movable during every phase of jaw opening and closing; therefore these studies also refute the hinge axis theory.12,13 Still
other studies have questioned the use of a hinge axis, due
to the complexity of its location, and the technical operator
error that is inherent in the procedure.14,15 Many investigators believe that it may be impractical to construct clutches,
locate the hinge axis, make multiple interocclusal records,
and use a fully adjustable articulator on every patient.16 Still
the theory that the hinge axis is a reliable referenceone in
which the position of the maxillary cast on an articulator can
be reproducedis a very strong one.4
Many studies have demonstrated that the terminal hinge
movements of the mandible pass through both condyles.
These studies support the theory that there is only one hinge
axis .4,17-19 Beard and Clayton reached this conclusion by using an apparatus that records arcs on paper; they argued that
the terminal hinge axis can be accurately located by finding
the one and only stylus position where no arcing occurs.19
There are many methods of locating the arbitrary hinge
axis for transfer to an articulator. Following are some examples of these methods.
1. The Gysi point is located 13 mm in front of the
most upper part of the external auditory meatus on
a line passing to the ectocanthion.
2. The Lauritzen-Bodner axis is located 12 mm anterior to and 2 mm below the porion.
3. Abdal-Hadi axis is located using a linear regression
formula to predict the anteroposterior (A-P) site of
the hinge point, according to the width profile axis
theory of the face.
4. The arbitrary hinge axis is located using the earpiece face-bow. In this method, the ear rods of a
fixed face-bow are inserted into the external auditory meati.
5. The arbitrary hinge axis is located by external palpation of the condylar anatomy.20,21
Studies have shown that when an arbitrary earpiece
face-bow is used to reproduce the condylar positions, the
results are fairly reliable.22-27 Clinically, it has become acceptable that as long as the arbitrary point is within 5 mm of the
true hinge axis, the arbitrary earpiece face-bow is accurate
enough to study the patients occlusion.22-27 Nagy et al conducted another study comparing the location of an anatomically predetermined hinge axis point with marked hinge axis

points. They found that the mean distance between any two
points was 1.1 mm. More than 96% of predetermined points
were within 2 mm of the true hinge axis.23 Schallhorn also
found that approximately 98% of all true anatomical hinge
axis points were within a 5-mm radius.26
In comparison, studies that compared maxillary cast positions mounted with four different face-bows showed wide
variation in the mounted maxillary cast positions. All arbitrary hinge axis points deviated from the true hinge baseline
point by anywhere from 1.5 mm to 4 mm. Therefore, the
authors of these studies concluded that it was not possible
to establish the clinical superiority of one arbitrary face-bow
over another.28,29
Lauritzen and Bodner located 100 true hinge points on
50 subjects. They found that 67% of the axis points were
5 mm to 13 mm away from the arbitrarily marked hinge
points. This discrepancy may introduce gross errors in the
mounting of the casts on an articulator, resulting in large
occlusal errors.30 Palik et al got similar results. They found
that only 50% of the arbitrary hinge axes located with the
arbitrary earpiece face-bow were within a 5-mm radius of
the terminal hinge axis. This indicated that the arbitrary
earpiece face-bow hinge axis location does not represent the
total population.31 Schulte et al concluded from their study
that errors in locating the arbitrary hinge axis will produce
a three-dimensional occlusal error.32 This study and others
have recommended that if a thick vertical dimension of wax
was used for an interocclusal record, or if the vertical dimension will be changed with treatment, a true hinge axis should
be located on the patient.32,33 Due to anatomical variations,
the arbitrary earpiece face-bow may introduce significant errors in an A-P or vertical dimension, resulting in mandibular
displacement.34,35 The only way to be relatively certain that
errors due to malpositioning of maxillary casts on an articulator have been avoided is to locate the true hinge axis.30,36-40
Studies indicate that coincidence between the two hinge
axis points does not usually occur.41 This results in a discrepancy between the arbitrary hinge axis and the true hinge axis
points. This discrepancy will cause changes in the mounted
position of the maxillary cast, which in turn can produce a
positional change of all teeth in the three planes of space.41
Zuckerman mathematically demonstrated that discrepancies
between the true hinge axis and the arbitrary hinge axis points
can produce changes in the A-P direction of the occlusion. He
verified in his analog tracing that the arc of the incisal edge
does not change in the A-P direction in centric occlusion, as
long as the mandible is also coincident in centric relation.
However, when an error in the arbitrary hinge axis occurs
and it is anterior to the true hinge, the incisor arc of closure
is anterior to the actual arc of closure.41 Errors in the verti-

cal position of the arbitrary hinge axis (AHA) produce the


largest A-P discrepancies upon mandibular closing.41 Other
authors have graphically illustrated how errors in true hinge
axis location can produce occlusal aberrations.33,35,36,42 These
authors also showed that the greatest errors occurred when
the hinge axis was incorrectly located in a vertical direction
perpendicular to the correct hinge axis closure. An arbitrary
hinge axis positioned superior to the true hinge axis also
produced premature contacts on the anterior teeth. In addition, if the arbitrary hinge axis was placed inferior to the true
hinge axis, premature posterior contacts occured.33,35,36,42
Brotmans geometric representation related changes in
the hinge axis point locations between the true hinge axis
and the arbitrary axis to differences produced at the occlusal level in mounted casts.43 Brotman concluded that if the
hinge axis has been improperly located by as much as 3 mm,
the error at the occluding position of the casts (anteroposteriorly) will be about .09 mm or less than 1/250 inch.43
Gordon et al looked at the location of the terminal hinge
axis and its effect on the second molar cusp position on the
position of the second molar cusp.6 Their results showed that
incorrect anterior location of the hinge axis produced the effect of having moved the mandibular arch backward. Incorrect posterior location of the hinge axis produced the effect
of having moved the mandibular arch forward. Incorrect inferior location of the hinge axis caused slight retrusion of the
mandibular cast with premature posterior contacts. Incorrect
superior location of the hinge axis caused protrusion of the
mandibular cast with premature anterior contacts.6
Since studies vary in reporting the percentage of placement of the arbitrary hinge axis less than 5 mm from the true
hinge axis, it can be assumed that larger errors in occlusion
may occur. It has been found that an occlusal discrepancy of
0.01 inch can cause pulpitis or periodontal disease, though
the patient may not be able to detect so small a discrepancy.44
To limit occlusal errors in mountings, it is necessary to locate
the hinge axis to within 1 mm, and the kinematic true hinge
can be done to this degree of accuracy.44 Therefore, the importance of the true hinge axis is substantial when changing
the vertical dimension upon mandibular closure.38
Orthodontics deals specifically with the movement of
all teeth and their occlusal fit. Therefore, it calls for extreme
accuracy during diagnosis, treatment planning, and rendering treatment.9 Clinically finding the true hinge axis may be
the only way to ensure a reproducible and accurate starting
pointone from which optimum esthetic and functional results can be obtained.6,38,45 The purpose of this study was to
compare the maxillary cast mountings of 51 patients in three
planes of space when mounted using a true hinge axis facebow versus an arbitrary earpiece face-bow.
RWISO Journal | September 2010

47

Materials and Methods


The records of 51 patients34 females and 17 malestreated in a gnathologically oriented practice constituted the sample. Subjects ranged in age from 13 to 57 years, and all had
unremarkable medical histories with no contraindications to
orthodontic treatment. All upper and lower permanent teeth,
except third molars, were present on all subjects. TMJ exams
were conducted by a single operator before orthodontic records were conducted. Evaluation included subjective symptomatology, as well as clinical examination. Subjects who
presented with TMJ symptoms were placed on a gnathological maxillary splint for a minimum of 3 months, or until
subjects were symptom free. Twenty of the 51 subjects had
records taken after splint therapy. The remaining 31 subjects,
all in active orthodontic treatment and with asymptomatic
TMJ, had records taken one appointment prior to deband.
All subjects had two maxillary alginate impressions taken using Jeltrate alginate (Dentsply, Milford, Delaware). The
impressions were taken using sterilized metal rim lock trays
(Dentsply, Milford, Delaware). All impressions were disinfected using Sterall Plus Spray (Colgate-Palmolive Company,
Canton, Massachusetts), and were rinsed with water and air
dried before being poured up.
All impressions were wrapped in moistened paper towels and placed in plastic bags for approximately 20 minutes
prior to being poured up with Velmix (KerrLab, Orange,
California). Each model was poured up utilizing a waterpowder ratio consistent with the manufacturers instructions
for Velmix. The Velmix was vacuum mixed to remove any
entrapped air. The models were trimmed, and all bubbles
were removed from the occlusal surfaces.
Arbitrary earpiece face-bow transfers using the external
auditory meati were taken on each subject. (Panadent, Grand
Terrace, California) (Figure 1).

Figure 1-a, b Estimated facebow.

Figure 1-b

A true hinge face-bow was then taken on each subject,


using the true hinge axis instrument (Panadent, Grand Terrace, California) (Figure 2). A single operator completed
both face-bow records within 20 minutes of each procedure.
Intraoperator reliability tests for each of the two transfer
techniques were calculated.

48

Freeland et al | Comparison of Maxillary Cast Positions

Figure 2-a, b True-hinge facebow.

Figure 3 Maxillary cast mounted with


occlusal relater and pin at zero.

A 1-mm step ruler (Panadent, Grand Terrace, California)


was used to measure the vertical distance of the mesiobuccal
cusp tip of the right and left first permanent molar and the
upper right central incisor (Figure 4).

Figure 2-b.

One maxillary cast was mounted using the true hinge


kinematic face-bow transfer on a single Panadent articulator (Panadent, Grand Terrace, California), with Snow White
Plaster #2 (Kerrlab, Orange, California) mixed according to
the manufacturers instructions. The second maxillary cast
was mounted with the arbitrary face bow on a single Panadent articulator (Panadent, Grand Terrace, California), using
the same mounting plaster as was used for the first cast.
The true hinge maxillary cast was placed on a single
Panadent articulator, and an adjustable occlusal table (Panadent, Grand Terrace, California), with graph paper adhered
to the surface, was attached to the articulator in place of the
mandibular cast. With the occlusal pin at zero, the occlusal
plane relater was stabilized by allowing contact at the maximum number of maxillary cast teeth (Figure 3).

Figure 4-a Vertical measurements with 1-mm


incremental step ruler: Measurement of anterior tooth
vertical discrepancy.

Figure 4-b Vertical measurements with 1-mm


incremental step ruler: Measurement of posterior tooth
vertical discrepancy.
RWISO Journal | September 2010

49

A straight wire with a 90-degree bend at the tip was


held with the handle parallel to the occlusal plane relater
(Figure 5).

This allowed the instrument to register the position of


each tooth on the graph paper (Figure 8).

Figure 5 Straight-lined measurement instruments.

Figure 8 Comparing arbitrary hinge axis points vs.


true hinge axis point:
1= Lower incisor will arc closed posterior to actual arc of closure
if AHA is inferior to TH.
2= Lower incisor will arc closed anterior to actual arc of closure
if AHA is superior to TH.
3= Lower incisor will arc closed slightly posterior to actual arc of
closure if AHA is anterior to TH.
4= Lower incisor will arc closed slightly anterior to actual arc of
closure if AHA is posterior to TH.

The tip was placed perpendicular to the tooth and held


touching the height of contour of the upper first permanent molars and the upper right permanent central incisor (Figure 6).

Figure 6 Articulating paper used with straight-lined


measurement instrument for tooth markings.

It was then used to mark the position of the mesiobuccal


cusp of the upper molars and the entire incisal-edge position
of the upper central incisor. Red articulating paper for the
maxillary cast mounted with the true hinge axis face-bow
mounted maxillary cast was then placed beneath each tooth
(Figure 7).

The occlusal plane relater was left in place, and the same
measuring procedure was then conducted on the maxillary
cast mounted with the estimated face-bow, utilizing blue articulating paper. A new sheet of graph paper was adhered to
the occlusal plane relater each time a new set of casts was
measured.
To measure the differences between the red and blue
markings, a Boley gauge was used. Five total measurement
comparisons were done. The first measurement assessed the
change in vertical dimension between the casts at the mesiobuccal cusp tip of the maxillary right permanent first
molar. The second measurement assessed the vertical discrepancy of the upper left first permanent molar. The third
measurement assessed the vertical discrepancy between the
upper right permanent central incisors. The fourth measurement compared the difference in an A-P direction between
the mesiobuccal cusp tips of the upper right and left first
permanent molars. The fifth measurement assessed the transverse discrepancy between the mesiobuccal cusp tips of the
upper molars. All measurements were conducted by a single
operator. Intraoperator reliability testing was used to validate this measurement technique.

Results

Figure 7 Tooth markings on graph paper.

50

Freeland et al | Comparison of Maxillary Cast Positions

A two-tailed matched-pairs t-test was used to evaluate for


significant difference in occlusal measurements in three
planes of space between maxillary casts mounted with a true
hinge face-bow and mounted with an estimated face-bow.
For this experiment, an level of 0.05 was chosen. Given
the number of measurements being evaluated (8), we decided

to adjust for experimentwide error by reducing our desired


significance level to 0.001.
Measurements

Table 1 Mean values of the two face-bow techniques.

Table 1 shows the means and standard deviations for


the arbitrary face-bow technique and the true hinge facebow technique in the vertical, A-P, and transverse dimensions
with respect to the maxillary right and left first molars and
the maxillary right central incisor. The mean measurements
taken on the cast mounted with a true hinge face-bow were
significantly smaller than those measured on the arbitrary
earpiece face-bow mountings. The standard deviations for
the true hinge face-bow were also one-half to one-third
smaller, indicating less variation around the sample mean.
Results of the paired t-test are shown in Table 2.

Table 2 Paired t-tests for differences between


estimated and true hinge technique.

The two face-bow techniques differed significantly in


all three planes of space. The mean vertical discrepancy of
the maxillary right first molar between the estimated and the
true hinge face-bow was 2.19 +/- 2.31 (t = 6.76, df = 50, p
< .001). The mean vertical discrepancy for the maxillary left
first molar was 2.45 +/- 2.21 (t = 7.90, df = 50, p < .001).
The mean vertical discrepancy for the upper right central
was 1.90 +/- 1.75 (t = 7.76, df = 50, p < .001).
The mean difference in the A-P dimension was 3.82 +/5.51 (t = 8.163, df = 50, p < .001) for the maxillary right first
molar and 3.10 +/- 2.63 (t = 8.28, df = 50, p < .001) for the
maxillary left first molar. The maxillary right central incisor
showed a mean difference of 3.05 +/- 2.62 (t = 8.25, df = 50,
p < .001). Finally, the transverse dimension was evaluated.
The mean difference for the maxillary right first molar was
2.23 +/- 1.33 (t = 12.11, df = 50, p < .001). The mean differ-

ence for the maxillary left first molar was 2.60 +/- 1.49 (t =
11.57, df = 50, p < .001).
The measurement differences in the vertical direction of
the maxillary right first molar ranged from 0.0 to 3.0 mm.
The measurement differences in the vertical direction of the
maxillary left second molar ranged from 1.0 mm to 3.0 mm.
The measurement differences in the vertical direction of the
maxillary upper right central incisor ranged from 0.0 to 5.0
mm. The differences in the A-P dimension of the upper right
molar ranged from 0.0 to 13.1 mm; of the upper left molar
from 0.0 to 15.0 mm; and of the upper central incisor from
0.0 to 13.0 mm. The differences in the transverse dimension
ranged from 0.0 to 7.0 mm for the upper right first molar
and from 0.5 to 7.9 mm for the upper left first molar.

Discussion
Mounting dental casts on an articulator allows the clinician
to simulate maxillo-mandibular position in centric relation
and makes possible a visible simulation of mandibular border movements. It has been recommended that mounting
diagnostic dental casts on an articulator should be incorporated into routine clinical orthodontic practices.3,46 Recording the hinge axis and transferring it to an articulator is of
considerable value in the diagnosis and treatment of occlusal
malfunction.42 In this diagnostic process, a face-bow transfer is one of the first steps in taking accurate intermaxillary
records. Many face-bow techniques are in use today.20,21
However, this study conducted a comparison of only two
face-bow techniques, an arbitrary earpiece face-bow and a
true hinge face-bow.
The null hypothesis for this study: There is no difference in the vertical, horizontal, or transverse position of the
maxillary cast mounted with a true hinge face-bow versus an
arbitrary earpiece face-bow was rejected. Paired t-tests indicated that the maxillary cast position using an arbitrary facebow transfer was significantly different in all three planes of
space from the maxillary cast position mounted using a true
hinge face-bow transfer.
In previous comparison studies when the arbitrary earpiece face-bow is located anywhere along a 5-mm radius of
the true hinge axis point, some authors have found that the
mandibular arc of closure may not be very different from the
true hinge arc of closure.21,26,39,40,42 However, Lauritzen and
Bodner found that in only 33% of the 50 patients they examined did the arbitrary hinge point fall within 5 mm of the
true hinge point. In the other 67%, the arbitrary hinge points
were 5 mm to 13 mm away from the true hinge points. Arbitrary markings of the hinge axis introduce severe errors
in mounting casts on an articulator, which may introduce
occlusal errors in the centric jaw relation record.30 Ricketts
RWISO Journal | September 2010

51

found that there can be extreme variation in the soft tissue


around the ear.34 This variation can make it difficult to locate the hinge point with an arbitrary earpiece face-bow.
The present study found larger mean values for the arbitrary
earpiece face-bow measurements. This suggests that the true
hinge face-bow may not be as sensitive to anatomical changes as the arbitrary earpiece face-bow.
Goska and Christensen conducted a similar study to
to the present study, in which they compared the positions
of maxillary cast permanent first molars in three planes of
space, using four different face-bow techniques. A true hinge
face-bow determined axis point was chosen as a baseline
against which to compare the other three arbitrary face-bow
techniques.28 They found that deviations between this baseline and the other three face-bow mountings ranged from 1.5
mm to 4 mm.28 They found that deviations between the true
hinge face-bow and the arbitrary earpiece face-bow ranged
from 1.9 mm to 3.8 mm. Like the authors of the present
study, they concluded that variations in the arbitrary earpiece face-bows might have resulted from naturally occurring variations in ear anatomy or the fact that the arbitrary
earpiece face-bow is an average measurement.28
In general, the present study suggests that error introduced from arbitrary earpiece face-bow hinge axis location
may produce occlusal discrepancies caused by malpositioning of the maxillary cast. The present study differs from
other previous studies in that it evaluates changes at the
occlusal level of the maxillary cast, as opposed to looking
at the joint level when comparing arbitrary and true hinge
mounting techniques. This study also differs from previous
studies in that it does not measure the occlusal discrepancies that result from contacts during the mandibular arc of
closure, since the mandibular cast was not incorporated into
the measurements.
Zuckerman, in analog tracing the arc of the incisal edge,
verified that no A-P change occurred in the arc of closure, as
long as the mandible rotated along the accurate hinge axis.
However, when an error in the arbitrary earpiece face-bow
hinge axis occurred anterior to the true hinge, the incisor arc
of closure was anterior to the actual arc of closure, and when
the arbitrary earpiece face-bow hinge axis occurred posterior
to the true hinge axis, the opposite effect occurred. Errors in
the vertical position of the arbitrary earpiece face-bow hinge
axis were found to produce the largest A-P discrepancies
upon mandibular closing41 (Figure 9).

52

Freeland et al | Comparison of Maxillary Cast Positions

Figure 9-a True hinge mandibular cast vs. estimated hinge


maxillary cast: True hinge mounting.

Figure 9-b True hinge mandibular cast vs. estimated hinge


maxillary cast: Estimated hinge mounting substituted for true
hinge maxillary mounting.

Zuckerman found that an anterior incisor displacement


of 1.5 mm could occur if the arbitrary hinge axis was off from
the true hinge axis by approximately 10 mm.41 Although the
method for the present study does not incorporate the mandibular cast arc of closure, wax bite thickness, or condylar
positioning, it is interesting to note that the largest discrepancy in maxillary cast position occurred in the A-P direction
with a mean difference greater than 3 mm in all three areas
measured (maxillary right and left first permanent molar and
the upper right permanent central incisor).
Gordon et al conducted a mathematical study to calculate the amount of cusp height and mesiodistal error at the
second molar that results from arbitrary earpiece face-bow
hinge axis location 5 mm and 8 mm anterior, superior, posterior, and inferior to the true hinge axis.6 They concluded
that incorrect location of the hinge axis caused a positional
change in the occlusal relationship between the maxilla and
the mandible, resulting in various premature contacts. De-

pending upon the direction in which the arbitrary earpiece


face-bow hinge axis was displaced from the true hinge axis,
the premature contacts occurred either anterior or posterior
to the actual arc of closure. Total error that could occur at
the second molar cusp ranged from 0.15 mm of open cuspal
space to 0.4 mm of excess cuspal height. The mesiodistal
error of the second molar cusps ranged from 0.51mm toward the distal to 0.52 mm toward the mesial.6 Brotman also
found that a 0.09-mm A-P discrepancy would occur between
occluding casts if the arbitray earpiece face-bow hinge axis
was improperly located by as much as 3 mm from the true
hinge point. Brotman concluded that if the arbitrary earpiece
face-bow hinge axis is incorrectly placed superior to the true
hinge axis, the lower cast will occlude in a more protrusive
direction, with premature contacts on the anterior teeth.
If the arbitrary earpiece face-bow hinge axis is incorrectly
placed inferior to the true hinge axis, the lower cast will occlude in a more distal direction, with premature contacts on
the posterior teeth.43 This conclusion resembles the findings
of Gordon et al. Weinberg and Fox drew similar conclusions;
the values they obtained for calculated horizontal error in
cusp heights closely resembled each other.35,44 This suggests
that errors of several millimeters in axis location might produce occlusal errors that are clinically intolerable on the part
of the patient.43
The authors of the present study found a mean difference in incisor position of 3.04 mm. The occlusal discrepancies found in the present study suggest that a range greater
than 5 mm existed between hinge axis points located with
the arbitrary earpiece face- bow mounting and the true hinge
face-bow. The discrepancy in maxillary cast position found
in this study might possibly introduce a change in the closure of the mandible into occlusion. The problems caused
by the occlusal errors resulting from inaccurate location of
the hinge axis point are illustrated in Figure 10. The photos
suggest an exaggerated discrepancy between the two casts
because two completely different face-bow techniques were
used. They serve to illustrate occlusal error that may result
from error in maxillary cast position. In some cases, however, the autorotated mandibular casts closed with only a
small degree of occlusal error (Figure 9). Other casts showed
severe positional changes resulting in larger occlusal errors
when this was attempted. (Figure10).

Figure 10-a Mounted maxillary estimated cast vs.


true hinge mounted maxillary cast: True hinge mounting.

Figure 10-b Mounted maxillary estimated cast vs.


true hinge mounted maxillary cast: Estimated hinge mounting
substituted for true hinge maxillary mounting.

It may be difficult to detect which patients have arbitrary earpiece face-bow hinge points naturally located within
5 mm of their true hinge point. Therefore, if any degree of
accuracy is needed or if any change in vertical dimension,
such as an occlusal equilibration or orthognathic surgery, is
planned, use of a true hinge axis face-bow should be considered. Previous studies have suggested that location of a
kinematic true hinge axis point prior to treatment for dentulous patients who require extensive treatment saves time and
results in a more satisfactory occlusion.6 The present study
found a statistically significant difference in the maxillary
cast position in all three planes of space between the two
face-bow techniques compared.

Conclusions
1. Statistically significant differences (p < .001) were
found between the true hinge face-bow mounted maxillary
cast and the estimated earpiece face-bow hinge mounted maxRWISO Journal | September 2010

53

illary cast in the vertical dimension, with a mean of 2.19 mm


for the maxillary right first molar, 2.45 mm for the maxillary
left first molar, and 1.90 mm for the maxillary right central
incisor.
2. Statistically significant differences (p < .001) were
found between the true hinge face-bow mounted maxillary
cast and the estimated earpiece face-bow hinge mounted
maxillary cast in the A-P direction, with a mean difference
of 3.82 mm between the maxillary right first molars, 3.10
mm between the maxillary left first molars, and 3.05 mm
between the maxillary right central incisors.
3. Statistically significant differences (p < .001) were
found between the true hinge face-bow mounted maxillary
cast and the estimated earpiece face-bow hinge mounted
maxillary cast in the transverse dimension, with a 2.23-mm
difference between the maxillary right first molars and a
2.60-mm difference between the maxillary left first molars.
4. This study found that there is a significant difference between the arbitrary earpiece face-bow hinge axis and
the true hinge face-bow hinge aixs. Thus, when an arbitray
earpiece face-bow hinge axis transfer is used, the maxillarymandibular complex is placed in an incorrect position in the
articulator. The end result is a lack of functional harmony.

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37. Brotman DN. Hinge axes, part I: the transverse hinge axis. J Prosthet Dent. 1960;(10): 436-440.
38. Preston JD. A reassessment of the mandibular transverse horizontal
axis theory. J Prosthet Dent. 1979; 41: 605-613.
39. Teteruck WR. Lundeen HC. The accuracy of an ear face-bow. J
Prosthet Dent. 1966;(16):1039-1046.
40. Walker PM. Discrepancies between arbitrary and true hinge axes. J
Prosthet Dent. 1980;(43): 279-285.
41. Zuckerman GR. The geometry of the arbitrary hinge axis as it
relates to the occlusion. J Prosthet Dent. 1982;(48): 725-733.
42. Collett Henry A. The movements of the temporomandibular
joint and their relation to the problems of occlusion. J Prosthet Dent.
1955;(5): 486-496.
43. Brotman DN. Hinge Axes, ,part II: geometric significance of the
transverse axis. J Prosthet Dent. 1960;(10): 631-636.
44. Fox SS. The significance of errors in hinge axis location. J Am Dent
Assoc. 1967;(74):1262-1272.
45. Williamson EH, Evans DL, Barton WA, Williams BH. The effect
of bite plane use of terminal hinge axis location. Angle Orthod.
1977;(47): 25-33.

RWISO Journal | September 2010

55

Notes

56

Notes

The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2


Jina Lee Linton, DDS, MA, PhD, ABO Woneuk Jung, DDS
Jina Lee Linton, DDS, MA, PhD, ABO
jinalinton@hotmail.com
Graduated from Yonsei University
(DDS, PhD), 1986
Graduated from Columbia University,
SDOS, 1988
Graduated from Columbia University
Orthodontic Department (MA), 1991
Private Practice in Seoul, Korea,
1991present
Woneuk Jung , DDS
Graduated from Dan Kook
University, 1991
Private practice in Seoul, Korea,
1991present

Summary
Malocclusion and occlusal interference in excursive movement is the major
cause of pathologic tooth wear. Tooth wear starts with shortening of the anterior teeth. As interference in mandibular movement increases, the posterior
teeth gradually become more flat. Recognizing tooth wear before and after
orthodontic treatment is important for retention of the treated result and for
ensuring functional occlusion. For this reason, orthodontic treatment should
be detailed and completed with restorative rehabilitation of the lost tooth
material.

Introduction
Tooth attrition is classified as tooth disease under the International Classification of Diseases, published by the World
Health Organization. According to Jablonski, tooth attrition
takes place when tooth-to-tooth contact, as in mastication,
occurs on the occlusal, incisal, and proximal surfaces.1 It is
differentiated from tooth abrasion (the pathologic wearing
away of the tooth substance by friction, as brushing, bruxism, clenching, and other mechanical causes) and from tooth
erosion (the loss of substance caused by chemical action
without bacterial action).
In reality, the wear may be related to a combination of
factors including attrition, abrasion, and erosion; that is,
physical-mechanical and chemical effects can have an impact
on the loss of physiologic and habitual tooth surface morphology.2 Grippo et al state that three physical and chemical
mechanisms are involved in the etiology of tooth surface lesions. These mechanisms are stress, corrosion, and friction.
The various types of dental lesion are caused by these mechanisms acting either alone or in combination. Friction, including abrasion (which is exogenous) and attrition (which is
endogenous), leads to the dental manifestation of wear. Corrosion leads to the dental manifestation of chemical or elec-

trochemical degradation. Stress, which results in compression, flexure, and tension, leads to the dental manifestation
of microfracture.3
Loss and excessive wear of hard dental tissues is a permanent problem of the dentition, especially in the modern
man; it is found in almost all age groups. Tooth wear is an
inherent part of the aging process; it occurs continuously but
slowly throughout life. In some individuals, tooth wear occurs more rapidly than in others, leading to severe morphologic, functional, and vital damage to the teeth, which cannot
be considered normal.4 Hand et al found that in a sample of
520 adults, 84.2% had enamel attrition, 72.9% had dentin
attrition, and 4.2% had severe attrition.5 In cases of severe
attrition, Sivasithamparam et al found that 11.6% of 448
adult patients had either near-pulpal exposures or frank pulpal exposures.6
Schneider and Peterson found that 15% of children
demonstrate tooth wear due to bruxism.7 Most of the prevalence studies in Europe and North America indicate that the
prevalence of wear on enamel in children is common (up to
60% involvement), while the prevalence of exposed dentin
varies from 2% to 10%.8,9

RWISO Journal | September 2010

57

Case Reports

Case 3: No Attrition Occurred During Orthodontic Treatment

The six cases below show individual clinical cases with various severity of attrition with or without treatment.

A 17-year-old male had class II div. 2 malocclusion (Figure


3) and displayed no wear on the upper right canine tip (September 1995). After 22 months of treatment with mandibular advancement surgery, the sharp canine tip remained (July
1997).

Case 1: Attrition Occurred With no Orthodontic Treatment


An 11-year-old female came in for checkup in April 2006,
at which time the upper lateral incisor edges and canine tips
showed wear (Figure 1). She had class I canine and molar
relationships and a 3-mm overbite and overjet (April 2006).
When she came back for orthodontic treatment 3 years later
(January 2009), the wear on the laterals and canines had
progressed significantly (red arrows).

Figure 1 Attrition occurred with no orthodontic treatment.

Case 2: Attrition Occurred During Orthodontic Treatment


A 12-year-old male had a crossbite on the left laterals and an
open bite on the central incisors (Figure 2). His canines and
molars were in class I relationship (September 2002). After
a year and a half without treatment, the upper left canine
showed slight wear on the mesial side (January 2004). After 8 months of fixed appliance therapy, that canine showed
marked flattening on the tip (October 2004).

Figure 3 No attrition occurred during orthodontic treatment.

Case 4: Slight Attrition Occurred During Orthodontic


Treatment
A 13-year-old male with class I malocclusion came in presented with sharp upper canine tips (June 1998). After 1
years of fixed-appliance therapy (January 2000), the right
canine tip remained intact (blue arrow), while the left canine tip showed wear. A photograph taken 2 years posttreatment (January 2002) showed wear on the right canine
tip (Figure 4).

Figure 2 Attrition occurred during orthodontic treatment.

58

Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

Case 6: Attrition Occurred During Orthodontic Treatment


A 13-year-old male came to the clinic in January 2000 for
treatment of protruding upper incisors. The patients face
showed a protrusive upper lip and a normal-size mandible,
with no apparent asymmetry. He had class II malocclusion
with maxillary dentoalveolar protrusion, severe crowding
in the upper and lower arches, and a constricted maxillary
arch. The upper right canine had not erupted due to lack of
space, even though the root had almost formed (Figure 6).
Figure 6 Preorthodontic treatment photographs and x-rays.

Figure 4 Slight attrition occurred during orthodontic treatment.

Case 5: No Attrition Occurred During or Following


Orthodontic Treatment
A 24-year-old female came in for treatment of bimaxillary
dentoalveolar protrusion (June 1998). The canine tip remained the same immediately after orthodontic treatment
(April 2001) and 7 years posttreatment (April 2008). This patient had no apparent anterior tooth attrition over the 10-year
observation period (Figure 5). On lateral excursive movement,
canine guidance existed with adequate separation of posterior
teeth on both the chewing and the nonchewing sides.

Figure 6-a Front facial


smiling photograph.

Figure 6-b Lateral facial


photograph showing lip
protrusion and strained
mentalis muscle.

Figure 6-c Right lateral intraoral photograph


showing class II molar relationship in MIP.

Figure 5 No attrition occurred during or after orthodontic treatment.

Figure 6-d Front intraoral photograph in MIP showing


crowding and crossbite in the upper right lateral incisor.

RWISO Journal | September 2010

59

Figure 6-e Left lateral intraoral photograph in MIP showing


class II molar relationship and retained deciduous canine.

Figure 6-f Panoramic x-ray. The upper left canine showing


root apex almost formed, but not erupted, due to lack of space.

Figure 6-g Lateral cephalogram showing slightly


retrusive mandible and protrusive upper incisors.

Jarabaks cephalometric analysis showed a strong counterclockwise growth tendency expressed in such measurements as a posterior facial height-anterior facial height ratio
of 70%, a long ramus height in comparison to the posterior
cranial base length, and a small Y-axis-to-SN angle (Table 1).

60

Table 1 Jarabaks analysis of case 6 in January 2000.

The maxillary arch was rapidly expanded with a fixedtype expander, which was retained for 6 months. Growth
modification of the maxillary protrusion was accomplished
simultaneously with a high-pull headgear for 10 months. The
diagnostic study models mounted before and after headgear
therapy clearly showed the effect of the growth modification
treatment (Figure 7).

Figure 7 Mounted models of the case before and after the


first phase of growth modification treatment. The models were
mounted on a semiadjustable articulator with estimated
face-bow transfer and with centric relation bite registration
records. The class II relationship of the first molars (blue lines)
in January 2001, was improved compared to the molar
relationship of the case in January 2000.

Subsequent to headgear therapy, the four first premolars were extracted, and the patient received fixed-appliance
therapy for the following 20 months. Class I canine and
molar relationships were achieved with maximum anchorage in the upper arch and moderate anchorage in the lower
arch in December 2002. The patients facial appearance was

Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

improved, with retraction of the upper anterior teeth and


favorable mandibular growth (Figure 8).
Figure 8 Postorthodontic treatment records.

Figure 8-a Front facial


smiling photograph.

Figure 8-b Lateral facial


photograph showing
improvement in profile
compared to Figure 1b.

Figure 8-c Right lateral intraoral photograph showing


that class I canine and molar relationships were achieved.

Figure 8-d Front intraoral photograph showing


that approximately 2 mm of overjet was achieved.

Figure 8-e Left lateral intraoral photograph showing


that class I canine and molar relationships were achieved.

Figure 8-f Maxillary arch showing alignment


without any extraction spaces left.

Figure 8-g Panoramic x-ray showing overcorrection in


root angulation of the canines and developing third molars.

RWISO Journal | September 2010

61

The patient returned to the clinic for correction of lower


anterior tooth crowding at age 20 in April 2008 (Figure 9).
Figure 9 Four-year retention photographs.

Figure 9-a Front facial


smiling photograph showing
well-developed gonial angle.

Figure 9-b Lateral facial


photograph.

Figure 8-h Lateral cephalogram.

Figure 9-c Right lateral intraoral photograph showing that


class I canine and molar relationships were retained.

Figure 8-i Superimposition of cephalometric tracings before


(black line) and after (red line) orthodontic treatment shows
that maximum anchorage control of the upper molars was
accomplished. The maxilla and the mandible grew
downward and forward as predicted.

62

Figure 9-d Front intraoral photograph showing that the


lower dental midline was shifted 2 mm to the left.

Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

Figure 9-e Left lateral intraoral photograph


showing end-on class II canine relationship.

Figure 9-f Panoramic x-ray.

Figure 9-h Superimposition of the cephalometric tracings


after orthodontic treatment (red line) and 4-year retention
(green line), showing that there was little change in the
soft-tissue and hard-tissue structures.

Upon clinical examination, wear on the maxillary canine


tips was noted as being quite severe for his age. Upon further
questioning, the patient complained of occasional headache
and pain in the area of the temporomandibular joint (TMJ).
His static occlusion showed 1.5 mm of overbite at the central
incisors and no overbite on the left lateral incisor. The lower
anterior teeth were tipped to the left side, resulting in a lower
midline shift to the left side. Dentin exposures were present on the upper lateral incisal edges and the lower anterior
teeth. The upper and lower first molars also showed marked
wear on the cusp tips. Upon excursive movement of both
right and left sides of the madible, the posterior teeth on the
chewing side showed simultaneous contactsthat is, group
functionand teeth on the nonchewing side showed harmful contacts (Figure 10).

Figure 9-g Lateral cephalogram.

RWISO Journal | September 2010

63

Figure 10 Mandibular movements.

The patients records were reviewed to compare the


amount of tooth wear at age 15 immediately after orthodontic treatment (December 2002) with the amount of tooth
wear at age 20 (Figure 11).

Figure 10-a Due to wear on the canine tip, there are multiple
tooth contacts on the right chewing side and harmful contacts
on the left nonchewing side during the right chewing movement.

Figure 11 Comparison of tooth wear over a 5-year period.


Progression of tooth wear from 1.5 mm of vertical overbite
in the upper and lower canines in December 2002 down to
minimum vertical overbite in April 2008.
(Red arrows indicate flattened anterior teeth.)

Figure 10-b Incisive movement indicates


multiple contacts on the posterior teeth.

Figure 10-c Due to wear on the canine tip, there are multiple
tooth contacts on the left chewing side and harmful contacts on
the right nonchewing side during the left chewing movement.

64

The canine tips already showed wear at age 15. Progression of tooth wear was evident; 1.5 mm of vertical overbite in
the upper and lower canines in December 2002 was reduced
down to minimum vertical overbite in April 2008. The occlusal views showed the beginning of dentin exposure on the
upper lateral incisors and the canines. The first molar wear
caused no obvious incisal changes but the progression of the
wear was definitely observable as wider wear facets and dimples on the molar cusp tips in April 2008 (Figure 12).

Figure 12 Occlusal views of tooth wear. Wear on the posterior


teeth is less apparent than wear on the anterior teeth. On close
examination, tooth wear (red arrows) is shown as facets or
dimples on the cusp tips.

Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

All available intraoral photographs that had been taken


in the past were put together to analyze the event of tooth
wear in this patient (Figure 13).

the wear progressed during the fixed-appliance therapy. In


the absence of anatomy at the cusp tips and incisal edges, as
in Figures 3-c and 3-e, proper anterior guidance and canine
guidance in movement would not have taken place (Figure
14). This in turn would have caused further wear with the
passage of time, as shown in Figures 6 and 7.10
Figure 14 Mandibular movement of the mounted models.

Figure 14-a Intraoral movement shown in Figure 5-a was


reproduced with models mounted on a semiadjustable
articulator in SCP. There were nonchewing-side interferences
of the functional cusps of the upper left molars (red arrows).

Figure 14-b Intraoral movement shown in Figure 5-b was reproduced using models. There were nonchewing-side interferences
of the functional cusps of the right upper molars (red arrows).

Stable condylar position (SCP) could not be recorded in


the presence of dysfunction of the masticatory system,11 so
a maxillary anterior-guided orthosis12 was prepared and the
patient wore it for 2 months, until all clinical signs and symptoms of TMJ dysfunction disappeared. The orthosis (Figure
15) allowed the condyles to assume their superior, anterior,
and medial (SAM) positions in intimate contact with the
thinnest part of the biconcavity of the disc, and made possible the diagnosis of a SCP from the maximum intercuspal
position (MIP). The SCP was recorded with Axi-Path recording, so the mounted models would arc close in centric.13,14

Figure 13 The event of upper canine wear during orthodontic


treatment. The right canine shows definite wear (red arrows)
during fixed-appliance therapy. The sharp anatomy (blue circle)
of the left canine tip at the time of eruption is shown in the
photograph (May 2000). It was gone before the
fixed-appliance therapy.

The upper right canine showed no wear before the


initial stage of fixed-appliance therapy in June 2001. The
canine wear occurred sometime during the following 8
months, and further wear seemed to have occurred between
February 2002 and December 2002. The upper left canine
erupted with sharp anatomy in May 2000. However, the tip
was worn down already on the day of bracket bonding, and

Figure 15 Maxillary anterior guided orthosis. The patient


wore the removable plate continuously until all the
symptoms disappeared and SCP was obtained.
RWISO Journal | September 2010

65

Subtractive coronaplasty15 was done on the posterior


teeth to achieve equal stops and maximum intercuspation in
SCP, and to preserve the natural tooth forms (Figure 16).
Figure 16 Before and after coronaplasty.

The average unworn maxillary central incisor is approximately 12 mm and the mandibular central incisors are 10
mm according to the American Academy of Cosmetic Dentistry (AACD). In the patients case, they were 12 mm and
7.7 mm and were restored to 12.3 mm and 9.8 mm respectively (Figure 19).17

Figure 16-a The maxillary arch after coronaplasty shows


that coronaplasty does not necessarily flatten the occlusal
surfaces. Rather, it can redefine the anatomy.

Figure 19 Measurements of the teeth before and after positive


coronaplasty. The upper central incisors were 12.0 mm long
and became 12.3 mm long. The lower central incisor was
7.7 mm long and became 9.8 mm long.
Figure 16-b The mandibular arch after coronaplasty also
shows redefined anatomic form of the posterior teeth.

Anterior maxillary and mandibular teeth were built up


with wax on the diagnostic casts to relegate all eccentric
tooth contacts to the anterior teeth (Figure 17).

According to Lee, adequate anterior guidance can be obtained with incisor vertical overlap of 3 mm to 4 mm and
horizontal overlap of 2 mm to 3 mm.18 Initially in April 2008
the patients MIP and SCP did not coincide and his overjet
was 2 mm. In SCP the overjet increased to 3.5 mm, which was
corrected to 2 mm with additive coronaplasty (Figure 20).

Figure 17 Wax-up on the mounted model to achieve 3 mm to 4


mm of vertical overbite and 2 mm to 3 mm of horizontal overjet.

The additive coronaplasty was done by duplicating the


wax-up of the casts on the anterior teeth with composite
resin (Figure 18).16

Figure 20 Overjet change after coronaplasty. When MIP


and SCP did not coincide, the overjet was 2 mm. In SCP,
the overjet increased to 3.5 mm, which was corrected
to 2 mm with additive coronaplasty.

Only after additive coronaplasty could a complete elimination of eccentric occlusal interferences be achieved with
excursive movements of the mandible (Figure 21).

Figure 18 Additive coronaplasty was done with a hybrid-type


composite resin on each anterior tooth according to the
wax-up in Figure 12.

66

Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

Figure 21 Mandibular movement after coronaplasty.

Figure 22 Comparison of the case before and after coronaplasty.

Figure 21-a In the right chewing movement, both the chewing


and the nonchewing sides show sufficient clearance between
the upper and lower posterior teeth (blue arrows).

Figure 22-a Full-smile facial photograph taken after


coronaplasty shows that the patients smile became
more esthetically pleasing.
Figure 21-b In the left chewing movement, both the chewing and
the nonchewing sides show sufficient clearance (blue arrows).

With coronaplasty the patients bite was stable, and the


patient was pleased with his smile and with the overall appearance of his face (Figure 22).
The abnormal tooth wear the patient demonstrated before coronaplasty was due to improper incisal guidance and
canine guidance. Since tooth wear progresses much faster in
the dentin layer than in enamel, his entire dentition would
have become significantly shorter over the next 10 to 20
years, if no intervention had taken place. The patients occlusion was completed with coronaplasty, and the longevity
and stability of his dentition were greatly enhanced.

Discussion
At the present, the majority of dentists believe that teeth
can successfully compensate for the loss of tissue by migration and elongation, and that these do not disturb the basic
functions of the masticatory system (mastication, speech,
and swallowing).19 However, some researchers have argued
that anatomical tooth form plays an important role in the
proper function of the masticatory system.17,18 Knight and
et al conducted a longitudinal study on 223 orthodontically
treated patients 20 years posttreatment. They found that
there was a strong relationship between incisal and occlusal tooth wear during the mixed dentition and subsequent
wear of the adult dentition.20 Tooth wear that occurred during the mixed dentition in these subjects actually occurred
on the permanent incisors. Even though the malocclusion
was corrected, the loss of tissue due to wear in the previously affected teeth persisted. Consequently, the patients
incomplete anterior and canine guidance systems continued
to influence their permanent dentition.

Figure 22-b Lateral facial photographs taken


before and after coronaplasty show little change.

With regard to interferences in mandibular movement,


Masatoshi and Masanori studied occlusal factors in relation
to TMD in 146 young adults; they concluded that molarguided occlusion patterns were associated with a high risk
of TMD.21 All subjects with TMD had nonchewing interferences in border excursions and in tooth-dictated excursions.
Without additive coronaplasty to restore the lost volume of
tooth material, complete elimination of interferences may
not be possible, nor may it be possible to maintain the optimal health of the teeth.16 As we saw in case 6, the teeth
were too worn down to allow for adequate function, and
the post-orthodontic result was an incomplete occlusion vulnerable to relapse. The patients TMJ symptoms would have
persisted, and the attrition process would have accelerated
once the dentin layer was exposed. Tooth wear that occurred
while the patient was receiving treatment was unavoidable in
this case. Early intervention of malocclusion in mixed dentiRWISO Journal | September 2010

67

tion might have enabled us to circumvent pathologic tooth


wear while the patient was undergoing treatment?
In canine guidance, the horizontal forces are minimized
by limiting the contact of the supporting cusps with their opposing fossae at or near their intercuspal position. All other
lateral contacts are prevented by the steeper inclination of
the canines. This causes the chewing movement to be more
vertical in the frontal view. Case 5 exemplifies the preservation of tooth material in the presence of functional occlusion. Upon lateral excursive movements, the canine guidance
provided sufficient clearance in the posterior teeth.
Many of our orthodontic patients already have worn
canines and incisors. Occlusal interferences, premature contacts, and habitual bruxism and/or clenching all may act as
stressors. Tooth contact during swallowing occurs 2,400
times a day, according to Straub23 and Kydd.24 These repetitive static and cyclic occlusal loads could also cause wear
on the anterior, as well as the posterior, teeth. Although it is
difficult to quantify the amount of tooth wear precisely, especially in cross-sectional studies, orthodontists can appraise
attrition of the incisal edges and canine tip most easily from
intraoral photographs. Why should orthodontists be aware
of tooth wear? What happens if the dentist ignores if they
ignore the problem? These are important questions, because
any patient who is not informed of tooth surface loss is put
at risk of having no choice in treating what can become a
severe condition.

References
1. Jablonski, S. Jablonskis Dictionary of Dentistry. 2nd ed. Philadelphia: Saunders, 1992.
2. Litonjua L, Andreana S, Bush PJ, et al. Tooth wear: attrition, erosion,
and abrasion. Quintessence Int. 2003;(34):435-446.
3. Grippo J, Simring M, Schreiner S. A new perspective on tooth surface lesions. J Am Dent Assoc. 2004;135(8):1109-1118.
4. Badel T, Keros J, egovi S, Komar D. Clinical and tribological view
on tooth wear. Acta Stomatol Croat. 2007;41(4):355-365.
5. Hand J, Beck J, Turner K. The prevalence of occlusal attrition and
considerations for treatment in a noninstitutionalized older population.
Spec Care Dentist. 1987;(7):202-206.

9. Bardsley P, Taylor S, Milosevic A. Epidemiological studies of tooth wear


and dental erosion in 14-year-old children in north west England, part I:
the relationship with water fluoridation and social deprivation. Br Dent J.
2004;197(7):413-416.
10. Cordray F. Centric relation treatment and articulator mountings
inorthodontics. Angle Orthod. 1996;66(2):153-158.
11. Lee R. Jaw movements engraved in solid plastic for articulator controls, part I: recording apparatus. J Prosthet Dent. 1969;(22):209-224.
12. Academy of Prosthodontics. Glossary of prosthodontic terms.
J Prosthet Dent. 2005;94(7):10-92.
13. Lundeen H. Centric relation records: the effect of muscle action.
J Prosthet Dent. 1974;31(3):244-253.
14. Crawford S. Condylar axis position, as determined by the occlusion
and measured by the CPI instrument, and signs and symptoms of temporomandibular dysfunction. Angle Orthod.1999;69(2):103-116.
15. Hunt K. Bioesthetics: Working with nature to improve function and
appearance. Am Acad Cosmet Dent. 1996;12(2):45-50.
16. Hunt, K. Full-mouth rejuvenation using the biologic approach: an 11year case report follow-up. Contemp Esthet Restor Pract. 2002;6(6):1-6.
17. Lee R. Esthetics and its relationship to function. In: Rufenacht CR, ed.
Fundamentals of Esthetics. Chicago: Quintessence; 1990:137-209.
18. Hunt K, Turk M. Correlation of the AACD accreditation criteria and
the human biologic mode. J Cosmet Dent. 2005;21(3):120-131.
19. Ash M, Nelson S. Dental Anatomy, Physiology and Occlusion. 8th ed.
St Louis, MO: Saunders; 2003.
20. Knight D, Leroux B, Zhu C, Almond J, Ramsay D. A longitudinal
study of tooth wear in orthodontically treated patients. Am J Orthod
Dentofac Orthop. 1997;112(6):17-18.
21. Masatoshi K, Masanori F. Occlusal factors associated with temporomandibular disorder based on a prospective cohort study of young adults.
Prosthod Res Pract. 2006;5(2):72-79.
22. Jemt T, Lundquist S, Hedegard B. Group function or canine protection.
J Prosthet Dent. 1982;(48):719-724.
23. Straub W. Malfunctions of the tongue. Am J Orthod. 1960;(40):404-420.
24. Kydd W. Maximum forces exerted on the dentition by the perioral and
lingual musculature. J Am Dent Assoc. 1957;(55):646-651.

6. Sivasithamparam K, Harbrow D, Vinczer E, et al. Endodontic sequelae of dental erosion. Aust Dent J. 2003;(48):97-101.
7. Schneider P, Peterson J. Oral habits: considerations in management.
Pediatr Clin North Am. 1982;(29):523-546.
8. Dugmore C, Rock W. The prevalence of tooth erosion in 12-year-old
children. Br Dent J. 2004;196(5):279-282.

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Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2

Physiologic Treatment Goals in Orthodontics


Andrew Girardot, DDS, FACD
A ndrew G irardot , DDS, FACD
ragfishing@hotmail.com
Graduated from USC School of
Dentistry (DDS), 1968
Graduated from USC School of
Dentistry, Dept. of Orthodontics
(certificate in orthodontics), 1972
Part-time Faculty University of
Colorado, School of Dentistry,
Dept. of Orthodontics
Cofounder, codirector and faculty,
Roth Williams USA, 1997-present

Summary
Angles class I has long served the orthodontic specialty as a morphologic
treatment goal and a means of communication. Certainly a physiologic
treatment goal would be of equal value. There are sound data to define and
support such a physiologic goal, which can help orthodontists to better serve
their patients, communicate with other dental professionals, and avoid numerous clinical problems.

Introduction
For the better part of a hundred years, orthodontists have
used Angles classification as a means of communication.
When we say Class I, orthodontists share the same image,
which is generally a positive concept of how teeth should fit
together. There certainly can be a Class I case with problems,
but Class I is the first major step in describing optimal tooth
relationships. To this day, Angles Class I describes a morphologic treatment goal for the orthodontic specialty.
Why do we not have a similar physiologic treatment
goal? Often we talk about occlusion in orthodontics, but
it clearly means different things to different people. The term
occlusion lacks the communication value of Class I. A good
occlusion is a nebulous term that varies depending on the
person using it. We have a communication problem. We enjoy general agreement, and hence communication clarity,
regarding morphology, but this is not the case for physiology. It would certainly be of value to our patients and the
orthodontic specialty if we had a clear definition of what
constitutes optimal physiology or good occlusion.
As in all biologic systems, the structural elements of
the human gnathic system have evolved to perform best un-

der certain conditions of form and function. For example,


there is considerable evidence to support a clear definition
of healthy function for the temporomandibular joint in its
loaded state, such as during a swallow. When loaded, the
condyle should be positioned upward, forward and midsagittally. This definition of optimal joint position is agreed
upon by most authorities1-15 and is well supported by the
literature.16-36 Okeson defines this as the most musculoskeletally stable position of the mandible.7(112) There also are
data indicating the optimal relationship of the condyle, disc,
and eminence when the mandible is moving into or out of
the loaded position. In this condition, there should be constant contact between the condyle, disc, and eminence.37-40
There are numerous data indicating that neuromuscular
function is highly influenced by tooth contacts and tooth positions.41-55 For example, as the mandible moves into and out
of intercuspation, guidance from properly positioned anterior teeth aids in separating the posterior teeth. This reduces
the activity of the powerful elevating muscles, which, in turn,
downloads the system while facilitating constant contact between the condyle, disc, and eminence.39,43,46,47,55-64
Thus, current data point to an optimal physiologic relaRWISO Journal | September 2010

69

tionship between the teeth, the joints, and the neuromusculature. This information provides a physiologic treatment goal
for the orthodontist, a summary of which can be made by analyzing the system in loaded and unloaded conditions. When
loaded, eg, during a swallow, the condyles are fully seated
upward and forward in the fossae, the elevating muscles are
active, and the dentition is in full intercuspation.41,55,62,63,65,66
When unloaded, the condyles remain in firm and constant
contact with the disc and eminence, elevating muscles are inactive and positioning muscles (eg, lateral pterygoids) are active, posterior teeth are out of contact, and the anterior teeth
play a major role in guiding mandibular movements.67-75
Given a reliable perspective of optimal static and dynamic relationships between the teeth, joints, and neuromusculature,
we can consider some additional principles regarding gnathic
function. There are at least three reasons why the intercuspal
position is important. First, the positions and the shapes of
the teeth determine mandibular movements at and near the
intercuspal position.7,50,61,76-100 Second, when the mandible is
brought to full intercuspation in a functionally healthy system, the powerful elevating muscles are active and the system
is heavily loaded; the bulk of the resultant force is absorbed
by posterior teeth.32,50-52,101-103 Third, condylar position is determined by the dentition at intercuspation.61,83,104-106
An additional important factor well supported in the literature is the clinical observation that the neuromusculature
is exquisitely programmed to guide the mandible to the intercuspal position80,85-100,107; the intercuspal position is dominant over condylar position.61,83,103,105,106,108-110 Thus, asking
a patient to bite down provides no dependable information as to where the condyle is positioned. Moreover, efforts
to identify the seated condylar position through clinical
maneuvers such as manipulating the mandible are not reliable.28,111-116 To quote the master clinician Dr. Thomas Basta,
Dont believe what you see in the mouth.2 Thus the value
of using interocclusal devices such as cotton rolls, anterior
jigs, and splints to deprogram the neuromusculature.
If we are to apply these physiologic principles to the
practice of orthodontics, we need additional information
besides that which we have traditionally used; for example,
techniques that record the optimal or seated position of
the condyle. Currently there are numerous such techniques
employed in restorative dentistry. Many clinicians use a hard
stop at the incisor midline to separate the posterior teeth,
along with a soft posterior material that can be hardened
thermally or chemically. When the patient bites against the
hard anterior stop and the neuromusculature seats the condyles superioranteriorly, the posterior material is hardened,
and the musculoskeletally stable position of the mandible is
recorded (Figure 1).

70

Girardot | Physiologic Treatment Goals in Orthodontics

Figure 1 The anterior stop is hard and flat; it separates the


posterior teeth to create appropriate space for a recording
medium. The patient is instructed to close firmly, which
seats the condyles to the musculoskeletally stable
position of the mandible.

The information then must be transferred from the patient to a device that will allow study and treatment planning of the gnathic system in three dimensions. Currently,
the articulator appears to be the best tool for this purpose,
although computer-generated three-dimensional technology
may replace the articulator in the near future. Casts mounted
on an articulator provide invaluable physiological information for diagnosis and treatment planning. For example,
numerous studies show that there is nearly always vertical
distraction of the condyle when the patient closes to intercuspation.33,113,117-122 It is all but impossible to record, analyze, and treatment plan this vertical discrepancy without the
use of a device such as an articulator.
Joint images are another tool that can serve orthodontists with regard to physiologic treatment. Tomograms, as
first advocated by Ricketts, have provided an effective way
to study the health of the temporomandibular joint and the
position of the condyle in the fossa.123-125 At present, cone
beam CT is a more effective way to study the temporomandibular joint, as it provides a more-lucid, three-dimensional
view of joint structures.36
There are sound data to support the concept that optimal gnathic function can be defined and used as an evidence-based treatment goal. There is little doubt that this
would also aid communication between orthodontists and
other dental professionals. In addition, knowledge of gnathic
physiology is of substantial value to orthodontists in that it
helps them to recognize and avoid myriad problems that occur in everyday practice.

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Effect of Gnathologic Positioner Wear on Maximum


Intercuspation CR Disharmony
Wesley M. Chiang, DDS, MS Theodore Freeland, DDS, MS
Richard Kulbersh, DMD, MS, PLC Richard Kaczynski, BS, MS, PhD
Wesley M. C hiang , DDS, MS
MA Candidate, Orthodontic Dept.,
University of Detroit Mercy School
of Dentistry

Summary
The goal of a gnathological approach in orthodontics is to achieve a functional
occlusion, in which the mandible can close into maximum intercuspation (MI) without deflecting the condyles from centric relation (CR). Gnathologic positioners are

T heodore F reeland , DDS, MS


tdfortho@freelandorthodontics.com
Adjunct Professor, Orthodontic
Dept., University of Detroit Mercy
School of Dentistry
Director Roth/Williams USA;
Private Practice, Gaylord, MI

used at the end of orthodontic treatment to settle the occlusion while maintaining

R ichard Kulbersh , DMD, MS, PLC


Program Director, Orthodontic
Dept., University of Detroit Mercy
School of Dentistry

using the Roth prescription straight-wire appliance. A gnathologic positioner was

R ichard K aczynski , BS, MS, P h D


Statistician, Dept. of Psychiatry,
Yale University School of Medicine

mounted using a true hinge transfer and CR bite. The control group consisted of 8

MI-CR harmony. The objective of this prospective study was to examine the effect
of gnathologic positioners on MI-CR discrepancy for patients treated with the Roth
gnathological approach.
Methods.The sample consisted of 26 consecutively finished cases in a gnathologically
oriented practice. All cases were treated with a gnathological treatment approach,
delivered at the time of debonding and was worn for a period of 2 months. Pre- and
postpositioner records were taken. These included a maximum-intercuspation wax
bite; a two-piece Roth power centric CR bite registration; and upper and lower models
randomly selected finished cases in the orthodontic clinic at the University of Detroit
Mercy and was retained with Hawley retainers. MI-CR discrepancy was measured
with a condylar position Indicator (CPI).

Results. Results indicate a statistically significant improvement in MI-CR discrepancy


in the right horizontal, right vertical, left vertical, and transverse planes after 2 months
of gnathologic positioner wear. The amount of condylar distraction in these 4 measurements showed statistically significant improvement and came within the envelope
of susceptibility.

Conclusions.The positioner and control groups tend to change differently over time
in the vertical and horizontal planes, with the positioner group improving and the
control group getting worse. In the transverse plane, gnathologic positioners improve
the result of orthodontic treatment with respect to condylar axis distraction.

Introduction
Centric relation (CR) refers to a physiologic position of the
mandible when the condyles are located in the superoanterior position in the articular fossae, fully seated and resting
against the posterior slopes of the articular eminences with
the discs properly interposed.1 It is a reproducible position
that is obtained independent of the occlusion by manipulating the mandible in a purely rotary movement about the
transverse horizontal axis.2
Orthodontic treatment is aimed at achieving static goals
from Andrews six keys to normal occlusion and the functional scheme of mutually protected occlusion recommended
by Stuart and Stallard.3,4 In the 1970s, Roth introduced gna-

thological concepts into orthodontic treatment.5,6,7 The goal


of a gnathological approach in orthodontics is to achieve a
functional occlusion, in which the mandible can close into
maximum intercuspation (MI) without deflecting the condyles from CR.8 Dr. Roth believed that a large discrepancy
between MI and CR can lead to breakdown in the stomatognathic system, because the condyles are distracted from
the glenoid fossae when the teeth come into occlusion. Signs
and symptoms of occlusal disharmony include temporomandibular joint pain-dysfunction syndrome, occlusal wear and
bruxism, excessive tooth mobility associated with periodontal disease, and movement or relapse of tooth positions.9
Occlusal discrepancies, if associated with joint compression,
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75

can also lead to condylar resorption.10


The clinical acceptable difference between CR and MI
in terms of condylar position is approximately 1.0 mm anteroposteriorly, 1.0 mm vertically, and 0.5 mm transversely.11,12,13,14 The condylar position indicator (CPI) has been
used to accurately record condylar movements.15 A comparison between pretreatment and posttreatment records in patients treated in a gnathologically oriented practice showed a
statistically significant reduction in MI-CR discrepancy in all
3 planes of space.16 The posttreatment records were obtained
before delivery of the gnathologic positioner.
The purpose of this study was to examine the effect of
gnathologic positioners on MI-CR discrepancy for patients
treated with the Roth gnathological approach. The effectiveness of gnathologic positioners can be determined if there
is a decrease in MI-CR discrepancy following 2 months of
positioner wear.

The models were poured with a vacuum mixed white stone


(Whip Mix Corporation, Louisville, Kentucky) and mounted
with Whip Mix mounting plaster (Whip Mix corp, Louisville, Kentucky), using a true hinge transfer and CR bite
(Figures 2,3).

Figure 2 True hinge axis.

Research Design and Methods


The positioner group consisted of 26 consecutively finished
cases in a gnathologically oriented practice (Theodore Freeland, DDS, MS, Gaylord, Michigan). The sample consisted of
15 males and 11 females. The average age was 15 years and
8 months. All cases were treated with a gnathological treatment approach, using the Roth prescription straight-wire
appliance (GAC, Glendora, California).12 Seven cases were
treated with 4 premolar extractions, while 19 cases were
treated with nonextraction. Four weeks prior to the debonding appointment, prepositioner records were taken (time 1).
The records included upper and lower alginate impressions
in rim lock trays, a true hinge face-bow transfer; an MI wax
bite taken using 10x pink wax (Myoco Industries, Inc, Philadelphia, Pennsylvania); and CR bite registration taken using
a two-piece Roth power centric method with Delar blue wax
(Delar Corporation, Lake Oswego, Oregon) (Figure 1).

Figure 1 Two-piece CR bite anterior segment (A).


Two-piece CR bite posterior and anterior segments (B).
MI bite (C). Two-piece CR and MI bite (D).

76

Figure 3 True hinge mounted models with two-piece CR bite.

Fabrication of Gnathologic Positioner


The gnathologic positioner was fabricated using Oralastic
80 silicone. The true hinge positioner set up is fabricated
according to posterior determinants (angle of the articular
eminence and Bennett side shift). At time 1, a second set of
upper and lower alginate impressions was taken and poured
with white stone. The models were left unmounted, while the
first set of models was mounted using true hinge face-bow
transfer and CR bite. Unmounted models were used to fabricate the gnathologic positioner, using the mounted models
as a reference. Teeth were separated from the models, and
brackets were ground off the teeth. Mandibular teeth were
set to an occlusal plane with proper curve of Spee and curve
of Wilson, and set on arc of closure in CR. The upper teeth
were set to the lower teeth in accordance with ideal overbite/
overjet (OB/OJ).
At the debonding appointment, the braces were removed,
and the gnathologic positioner was delivered. The arc of clo-

Chiang, Freeland, et al | Effect of Gnathologic Positioner Wear on Maximum Intercuspation CR Disharmony

sure was first checked in the mounting on the true hinge articulator and then checked intraorally with and without the
positioner. The patient was instructed to wear the positioner
full time for the first 3 days (with the exception of eating and
brushing). After the first 3 days, the patient was instructed to
wear the positioner at night, with 4 hours of positioner exercise during the day. If the positioner should fall out during
the night, the patient was instructed to wear the positioner
for 6 hours during the day.

Positioner Exercise and Wear Protocol


The patient was instructed to bite into the positioner just
enough to seat all of the teeth and to fully engage the teeth in
the positioner. The patient was instructed to bite with pressure for about 10 seconds and then to relax for about 15
seconds. The exercise was done in 15-minute intervals, with
15 to 20 minutes of rest in between. For nighttime wear, the
patient was instructed to put the positioner into the mouth
and close the mouth to engage the positioner as much as possible without putting pressure on the positioner.
The gnathologic positioner was checked for fit and arc
of closure at 1, 2, and 4 weeks after delivery. After 2 months
of positioner wear, postpositioner records were taken (time
2). These consisted of the same records that had been taken
at time 1. Upper splint and lower spring retainers were then
delivered.
The control group consisted of 8 randomly selected
finished cases in the orthodontic clinic at the University of
Detroit Mercy. The control group was not preselected with
regard to MI-CR discrepancy at debond. At the debonding
appointment (time 1), braces were removed and records
were taken. Upper and lower Hawley retainers were delivered, and the patient was instructed to wear them full time.
After 2 months of Hawley retainer wear, records were taken
again (time 2).
MI-CR discrepancy was measured with a CPI (Panadent
Corporation, Grand Terrace, California) at times 1 and 2 for
both groups (Figure 4,5).

Figure 4 CPI registration with two-piece CR bite (A).


CPI registration with MI bite (B). CPI Recording transverse (C).
CPI Recording right (D).

Figure 5 Condylar position indicator recording graph


(CR red dot, MI blue dot).

Results
The mean differences between MI and CR of the articulators condylar axis position were recorded for the transverse,
and separately for the right and for the left condyles in the
vertical and anteroposterior (A-P) directions. Pre- and posttreatment measurements of MI-CR discrepancy of the control and positioner groups are summarized in Table 1.

RWISO Journal | September 2010

77

Table 1 MI-CR Discrepancy Assessment of Control and Positioner Groups.

Control
(n=8)
Time 1
Time 2
Mean
SD (mm) Mean
(mm)
(mm)

SD
(mm)

Positioner
(n=26)
Time 1
Time 2
Mean
SD
Mean
(mm)
(mm)
(mm)

0.700
0.863

0.499
0.407

1.225
1.238

1.383
0.845

1.306
1.217

0.897
0.969

0.733
0.623

Left AP
Left vertical

0.750
0.825

0.864
0.292

1.625
1.062

1.201
0.686

0.867
1.162

1.010
0.794

0.671
0.669

Transverse

0.350

0.267

0.288

0.309

1.031

1.106

0.248

Measurements
Right AP
Right vertical

As the table shows, pretreatment means for the control


group were all within the clinical envelope of 1.0 mm for
the A-P and vertical dimensions, and 0.5 mm for the transverse. Conversely, 4 out of 5 pretreatment means for the positioner group were outside this envelope; only the mean left
A-P measurement, at 0.87, was within the clinical envelope.
The control and positioner groups were then assessed by an
independent t-test for any statistically significant pretreatment differences. As shown in Table 2, no differences were
found between the two groups (0.08 < p <0.77).
Table 2 Independent t-test for MI-CR Discrepancies of Control Versus Positioner Group.

t
Right AP
Right vertical
Left AP
Left vertical
Transverse

1.812
1.000
0.296
1.164
1.709

df
32
32
32
32
32

p
.079
.325
.769
.253
.097

A paired t-test was used to evaluate change in MI-CR discrepancy from time 1 to time 2 in the positioner group (Table 3).
Table 3 Paired t Tests for MI-CR discrepancies between time 1 and time 2 for the positioner group (df=25).

MI/CR
discrepancy

Mean Differences

(mm, absolute values)


Right AP
.5731
Right vertical .5942
Left AP
.1962
Left vertical .4923
Transverse
.7827
*Significant at p<.01
78

Standard
Error
.189
.213
.214
.162
.224

3.025
2.791
0.915
3.047
3.490

.006*
.009*
.369
.005*
.002*

Chiang, Freeland, et al | Effect of Gnathologic Positioner Wear on Maximum Intercuspation CR Disharmony

For these analyses, the desired significance level of 0.05


was reduced by a factor of 5 (for the 5 variable CPI readings:
right A-P, right vertical, left A-P, left vertical, and transverse)
to control experimentwide alpha and to avoid the risk of
type I errors. Thus a significance level of = 0.01 was used
for each test of the condylar axis position measurements. The
results indicated statistically significant differences between
time 1 and time 2 for the positioner group in the right A-P (
= 0.57 mm, t = 3.03, p = .006); right vertical ( = 0.59 mm,
t = 2.79, p = .009); left vertical ( = 0.49 mm, t = 3.05, p =
.005); and transverse ( = 0.78 mm, t = 3.49, p = .002) measurements. There was no statistically significant difference in
the magnitude of condylar distraction in the left condyle in
the A-P direction ( = 0.20 mm, t = 0.92, N.S.).
Mixed-design analyses of variance compared the positioner and control groups change in MI-CR discrepancy
over time (Table 4).
Table 4 Mixed Design Analysis of Variance for MI-CR Discrepancies from time 1 to time 2 between Control Versus Positioner Group.

Right AP
Right vertical
Left AP
Left vertical
Transverse

Effect
Time
Time x group
Time
Time x group
Time
Time x group
Time
Time x group
Time
Time x group

F*
0.012
6.096
0.266
5.203
2.431
6.053
0.599
4.917
4.102
2.978

p
.915
.019
.609
.029
.129
.019
.445.
034
.051
.094

* df for all tests are 1, 32.


Using the adjusted significance level described above
( = 0.01), these comparisons between the 2 groups showed
no statistically significant differences in any of the 5 CPI
measurements. However, 4 of the 5 dimensions fell below

the traditional = 0.05 level. Graphical representations of


the change in MI-CR discrepancy over time for the positioner and control groups are shown in Figures 6 through 10.

Figure 6 Right horizontal MI/CR discrepancy.

Figure 7 Right vertical MI/CR discrepancy.


RWISO Journal | September 2010

79

Discussion

Figure 8 Left horizontal MI/CR discrepancy.

Figure 9 Left vertical MI/CR discrepancy.

Figure 10 Transverse MI/CR discrepancy.

80

Results of the present study indicate a statistically significant improvement in MI-CR discrepancy in the right horizontal, right vertical, left vertical, and transverse planes
with 2 months of gnathologic positioner wear. The condylar axis distraction differences in the left horizontal planes
were not statistically significantly different. Before positioner
wear, the mean right horizontal, right vertical, left vertical,
and transverse measurements were 1.306 mm, 1.217 mm,
1.162 mm, and 1.031 mm respectively, and fell outside the
1.0 mm vertical and horizontal as well as the 0.5 mm
transverse distraction envelope proposed by Crawford, Utt
et al, and Slavicek.12,13,14 Following 2 months of positioner
wear, the amount of condylar distraction in these 4 measurements showed statistically significant improvement and
came within the distraction envelope. Before positioner wear,
3 patients (11.5%) had MI-CR discrepancy that fell within
the envelope of susceptibility in all 5 of the measurements
examined, while 11 patients had all 5 measurements within
the envelope after positioner wear (42.3%). Reducing MICR discrepancies is an important treatment goal in the gnathological philosophy, and the use of gnathologic positioner
is essential to achieving this goal.
Although these changes were nonsignificant when compared to change in the control group, the level of significance in the right horizontal, right vertical, and left vertical
planes was very close to the significance level of 0.01 used
for this study, and below the more common 0.05 level of
significance. Figures 6, 7 and 9 show a similar pattern with
reduction in MI-CR discrepancy over time with positioner
wear, while the group with the Hawley retainers shows an
increase in MI-CR discrepancy. This trend is observed in 3 of
the 5 measurements studied (right horizontal, right vertical,
and left vertical planes). The positioner and control groups
tend to change differently over time in the vertical and horizontal planes, with the positioner group improving and the
control group getting worse. This is consistent with Roths
claim that general retention protocols with Hawley-type appliances following orthodontic therapy will tend to make
MI-CR discrepancy worse, while gnathologic positioners
will improve MI-CR discrepancy. Interestingly enough, all
mean vertical and horizontal CPI measurements for the control group started within the distraction envelope of 1.0
mm and finished outside the envelope following 2 months of
Hawley retainer wear.
The small sample size of the control group is a limitation
of this study. A larger sample size would eliminate type II error and might show a statistically significant difference in the
change in MI-CR discrepancy over time between the control
and the positioner group. However, the p-values are below

Chiang, Freeland, et al | Effect of Gnathologic Positioner Wear on Maximum Intercuspation CR Disharmony

the .05 level of significance in the right horizontal, right vertical, and left vertical planes. Furthermore, the MI-CR pattern is observed, suggesting that this is not a purely random
phenomenon. Since the control group was small, there is the
possibility of an underpowered study.
In the transverse plane, there appears to be no difference
between the 2 groups over time. A condylar axis distraction
in the transverse plane is more sensitive to clinical problems
than a condylar axis distraction in the horizontal and vertical
planes.17,18,19 It appears that gnathologic positioners improve
the result of orthodontic treatment with respect to condylar
axis distraction.

Conclusion
Results of the present study indicate a statistically significant
improvement in MI-CR discrepancy in the right horizontal, right vertical, left vertical, and transverse planes with 2
months of gnathologic positioner wear. The amount of condylar distraction in these 4 measurements showed statistically significant improvement and came within the envelope
of susceptibility. The positioner and control groups tend to
change differently over time in the vertical and horizontal
planes, with the positioner group improving and the control
group getting worse. In the transverse plane, gnathologic positioners improve the result of orthodontic treatment with
respect to condylar axis distraction.

References
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Notes

82

Notes

RWISO Journal | September 2010

83

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