T O R V E R E S T O R A T I V ER EDS E N T IASTTI R Y

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Occlusion: 3.Articulators and Related Instruments

ALEX MILOSEVIC
Abstract: Dental articulators are instruments that reproduce jaw movements to
varying degrees of accuracy. This article aims to give an overview of the various types of articulator and describe their applications and limitations. Dent Update 2003; 30: 511515

Clinical Relevance: An understanding of the use of articulators is central to the successful provision of indirect restorations.

surfaces so that the FGP record can be located on the working cast. Once the crown is waxed up on the working die, the FGP record is fully seated on it and any interferences that show up on the wax can be removed prior to casting.

PLANE LINE AND AVERAGE VALUE

rticulators can be classified as in Table 1. A further division relates to whether or not the condyle is attached to the upper arm of the articulator: if it is, the articular is ARCON anatomically articulated condyle, e.g. Denar, Whipmix. When the condylar ball is on the lower arm, the articulator is NON-ARCON (nonanatomically articulated condyle), e.g. Dentatus. The ARCON articulator reproduces mandibular movement more accurately.

HINGE ARTICULATOR
The hinge articulator is NOT an articulator! At best it is a cast holder. The only movement is an inaccurate opening and closing. The shorter radius from the centre of rotation to the lower incisors on the hinge articulator, compared to the patient, results in a more curved arc or pathway for the incisor. After the casts are mounted in ICP using an interocclusal record, the record is discarded and the
Alex Milosevic, PhD, BDS, FDS RCS, DRD RCS(Edin.), Consultant and Honorary Senior Lecturer in Restorative Dentistry, Liverpool University Dental Hospital, Pembroke Place, Liverpool L3 5PS.

casts are closed through the thickness of the record. Because of the more curved (shorter) pathway taken by the incisors, these meet prematurely with a wedgeshaped space manifest between the teeth, the greatest gap occurring posteriorly (Figure 1). The consequent high spot on the restoration needs grinding down, more so the further posterior the restoration. Thinner records are preferable.1 Providing there are sufficient teeth to gain ICP manually, it may be better not to take any interocclusal record but relate the casts by visual and tactile methods.2 There is no possibility of lateral or protrusive movement on this articulator. Therefore, its applications are limited to the manufacture of a single crown in an otherwise fully dentate arch. It has no place in diagnostic assessment. The risk of introducing interferences on any restoration can be reduced if the hinge is used in conjunction with a Functionally Generated Pathway. The FGP is obtained by asking the patient to carry out excursions on soft wax held within a copper ring tightly placed on the preparation (Figure 2). The cuspal paths carved into the wax (-ve impression) are copied in impression plaster (+ve cast) with inclusion of the adjacent occlusal

The average value instrument tends to be larger than the plane line and consequently better equipped to reproduce jaw movement. Both articulators have limited lateral and protrusive movement, usually set at 30o for condylar guidance angle, 15o for

Hinge Plane line Average value Semi-adjustable (Arcon or Non-arcon) Fully-adjustable Fossa-moulded/stereographic

Table 1. Classification of dental articulators.

Figure 1. The shorter radius from the articulator centre of rotation to the incisor results in a more curved arc of closure. Removal of a wax interocclusal ICP record and closure through the thickness of wax leads to initial contact at the incisors and a wedge-shaped gap, widest posteriorly. 511

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compensation allows other systems to use an earbow placed into the external auditory meatus, which is arguably more user-friendly. The true position of the terminal hinge axis can only be determined dynamically using a kinematic bow which is attached to mandibular teeth. Pure rotation of the side arm pointers indicates the place to mark the skin for placement of the separate maxillary bow and thus accurately relate the maxillary cast to the hinge axis on the articulator. Facebows correctly position the maxillary cast spatially in 3-D by way of the third reference point (usually the orbital pointer) and thus give the technician an aesthetic perspective. The ability to adjust condylar guidance

Figure 2. (a) Functionally generated path in soft wax retained within copper ring on prepared 6/ (46). (b) Plaster positive of FGP held in silicone putty (another case). (c) FGP placed on waxed up crown. (d) Single waxed up crown on hinge articulator with harmonious occlusal anatomy.

incisal guidance and 110 mm for intercondylar distance. For a couple of posterior crowns or a short span posterior bridge (max 3 units), an average value can be used in preference to a plane line, although for complete denture construction this distinction may be less important. Some intra-oral adjustment may well be necessary, particularly RCP
a

ICP and on lateral excursions. For replacement anterior teeth, the semiadjustable articulator is the instrument of choice.

THE SEMI-ADJUSTABLE ARTICULATOR

These instruments are the workhorses for many restorative problems (Figures 3 and 4). Although several different manufacturers make semi-adjustable articulators (see Table 2), the principles of record taking and programming are similar. They require a facebow to relate the maxillary cast to the hinge axis accurately, plus interocclusal records in protrusion and left/right lateral excursion to programme condylar guidance angle and Bennett shift and/or angle, respectively. For all diagnostic procedures (e.g. orthognathic treatment planning, occlusal analysis) an RCP (tooth apart) record is required, whereas for restorative procedures either an RCP or ICP record is indicated. Once again, the latter can be dispensed with if a sufficient number of teeth allow accurate visual manipulation into ICP. The average position of the hinge axis for placement of the condylar points of the facebow is 13 mm anterior to the tragus on the trago-canthal line. In-built

Figure 4. Denar MKII semi-adjustable.

<ICD

>ICD

Figure 5. The effect of varying inter-condylar distance (ICD) on cuspal paths. Red line indicates true path with ICD of 110 mm. If ICD is greater (blue path) or less than (green path) true ICD, paths followed by the teeth on the articulator will differ.

Figure 3. (a) Dentatus semi-adjustable articulator. (b) Dentatus with facebow attached to condylar ball (Non-arcon) and related to orbital pointer.

Figure 6. Illustration of both the horizontal and vertical centres of rotation and the radius to a cusp tip. Dental Update November 2003

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ARCON Denar MKII (Water Pik Inc. supplier Prestige Dental) KaVo EWL (KaVo, POB 1320, Leutkirch, D-88293, Germany) SAM (Prazisionstechnik, Munich, D-8000, Germany) Whip Mix 3040 (Whip Mix Corp. POB 17183, Louisville, Kentucky, USA) NON-ARCON Dentatus ARL/ARH (Dentatus Int. AB, Hagersten, Sweden, 126-53) Gerber (Condylator, Zurich 8028, Switzerland) Hanau (Teledyne Hanau, Buffalo, NY, USA)

angle. Examples of fully adjustable articulators are: l Denar D5A (see Figure 9) and l Stuart. These articulators require pantographic tracings to set the adjustments. Upper and lower bows are attached to the teeth via clutches and separated by an intra-oral central bearing point. Styli record the paths on tracing tables after which the bows are locked, dismantled from the clutches and reassembled on the articulator. Apart from recording mandibular border movements accurately, the pantograph has also been applied as a diagnostic and prognostic tool in the management of TMJ dysfunction. The Pantographic Reproducibility Index (PRI) was developed to confirm dysfunction and to monitor progress of treatment.6 However, technique sensitivity, equipment expense and the time involved in clutch construction, recording and programming have deterred many dentists from investing in such instrumentation.

Table 2. Types of semi-adjustable articulator. a b

Figure 7. (a and b) Techniques to check reproducibility of intra-oral records. These show the Lauritzen split cast with two different RCP records for the same patient.The gap in (b) alerts the dentist to a discrepancy during record taking. Its best to take at least three records in each position.

angle and Bennett shift will facilitate occlusal harmony of restorations within any given stomato-gnathic system. If incisal guidance is unknown, i.e. in cases with an old partial denture replacing all four upper incisors or four poorly contoured pontics on an upper six-unit bridge, then incisal guidance can be customized in acrylic and then adjusted on the incisal guidance table of the articulator. Some instruments allow limited adjustment of the inter-condylar distance. The horizontal path taken by a molar cusp across the opposing tooth with either a greater or lesser inter-condylar width on the articulator is illustrated in Figures 5 and 6. For clarity, this illustration does not consider the effect of Bennett shift. Some semi-adjustable articulators facilitate the waxing-in of RCP-ICP movement, freedom in centric. Despite these added features, most interocclusal records taken in wax are prone to distortion.3 On withdrawal from the mouth, great care is needed to avoid bending the heels of the record inwards. Closure into wax with muscle force risks tooth and/or mandibular displacement/ flexion4,5 which can be avoided by using buccal indices taken whilst the patient
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holds the appropriate position and silicone is injected around the teeth (see previous paper on the RCP record). None of the current techniques or materials is ideal (see Table 3), although certain waxes distort less (Moyco Beauty Pink supplied by Procare). Finally, the paths taken between two points are linear on the semiadjustable articulator but curved in the human condyle. Pathways on fossamoulded and fully adjustable instruments are curved and thus more accurately reproduced. Dynamic methods rather than static wax records are utilized by some semi-adjustable articulators, such as the Gerber. In this instrument, condylar guidance angle is gained using a kinematic bow and the gothic arch tracing relates the casts in RCP. Techniques to check the accuracy of an RCP record are shown in Figures 7 and 8.

Figure 8. Another technique to check RCP record accuracy or consistency. The Denar Vericheck or Centricheck uses a special upper arm with flags and pointers. Note the silicone buccal index record and the custom-made acrylic incisal guidance table.
l l Does not displace teeth during intercuspation. Little or no dimensional change on setting. Accurate reproduction of occlusal/incisal surfaces. Remains rigid after setting. Offers minimal resistance during closure in order to reduce mandibular flexion or displacement.

FULLY ADJUSTABLE ARTICULATORS

As the name implies, these instruments provide more adjustments and greater accuracy, particularly in respect of changes in vertical dimension, border movements, Bennett shift and Bennett

l l l

Table 3. Ideal requirements of a material used for inter-occlusal records. Dental Update November 2003

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CONCLUSION
Occlusion is not an inherently complicated subject. Understanding occlusion is not easy because explanation of condylar and mandibular movement is difficult. This has more to do with the author or teacher trying to get a message across to his/her audience. Hopefully, readers will have their appetites whetted for further study.

Figure 9. (a and b) The Denar D5A fully-adjustable articulator and close-up view of the complex condylar assembly.

b R EFERENCES
1. Adrien P, Schouver J. Methods for minimising the errors in mandibular model mounting on an articulator. J Oral Rehabil 1997; 24: 929935. Walls AWG, Wassell RW, Steele JG. A comparison of two methods for locating the intercuspal position (ICP) whilst mounting casts on an articulator. J Oral Rehabil 1991; 18: 4348. Mullick SC, Stackhouse JA, Vincent GR. A study of interocclusal record materials. J Prosthet Dent 1981; 46: 304307. Teo CS, Wise MD. Comparison of retruded axis articular mountings with and without applied muscular force. J Oral Rehabil 1981; 8: 363376. Omar R, Wise MD. Mandibular flexure associated with muscle force applied in the retruded axis position. J Oral Rehabil 1981; 8: 209221. Shields JM, Clayton JA, Sindledecker LD. Using pantographic tracings to detect TMJ and muscle dysfunction. J Prosthet Dent 1978; 39: 8087.

2.

3.

c
4.

Figure 10. (a) Denar Cadiax facebow in position via mandibular clutch. (b) Close-up of electronic digitizing table/sensor assembly. (c) Monitor showing left and right condylar path during protrusion.

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6.

Moreover, for most restorative treatment, the semi-adjustable articulator should prove perfectly acceptable. Recent development of an electronic jaw-tracking device significantly reduces chairside time (Figure 10). The system facilitates determination of condylar guidance angle and Bennett shift by having flags akin to recording tables over each TMJ, with a stylus or sensor on a mandibular bow attached to the teeth via a clutch. The movements are digitized by the table/ stylus assembly and subsequently shown on a LCD or printed as a permanent record for the patients file.

STEREOGRAPHIC OR FOSSA-MOULDED
Stereographic techniques simplify articulator programming by dispensing with the pantograph and using intra-oral clutches with studs which mould soft acrylic during border movements. These
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dynamically carved, intra-oral 3D records are then transferred to the articulated casts (Figure 11). Cold cure acrylic is placed in special fossa inserts and articulator excursions are guided by the intra-oral engravings. Whilst the articulator arm is moved, the condylar head on the instrument carves the acrylic resin in the fossa insert, thus generating permanent condylar moulds that incorporate condylar inclination, Bennett shift and angle at the correct intercondylar width. Other devices utilize premoulded plastic fossa analogues with fixed Bennett angle and various Bennett shifts. Condylar Guidance angle can be varied either by orienting the analogue or some analogues also have pre-set condylar inclines. Such instruments include: l TMJ Stereographic system; l Denar Combi and Anamark; l Panadent Corp. USA.

F URTHER READING
Klineberg I. Occlusion: Principles and Assessment, 1st ed. Oxford: Wright, 1991. Warren K, Capp NJ. Occlusal accuracy in restorative dentistry: the role of the clinician in controlling clinical and laboratory procedures. Quintessence Int 1991; 22: 695702. Winstanley RB. A retrospective analysis of the treatment of occlusal disharmony by selective grinding. J Oral Rehabil 1986; 13: 169181. Wise MD. A Clinical Guide to Occlusion, 1st ed. BDJ Publications, 2002.

Figure 11. Upper intra-oral clutch for dynamic stereographic reproduction of mandibular movement. Note: the three acrylic engravings with a gothic arch trace. 515