GNATHOLOGY

MUSCLE+ JOINTS+TEETH= NEUROMUSCULAR DENTISTRY

CONTENTS OF THE SEMINAR

1.INTRODUCTION 2.DEFINITION 3.AIMS AND OBJECTIVES OF GNATHOLOGY 4. THE NUTRIMENTAL FOUNDATION OF GNATHOLOGY 5.ORGANIC OCCLUSION THE GOAL OF GNATHOLOGY

6.THE TOOLS F0R GNATHOLOGIC MEASUREMENTS

7.TEN CHARECTERISTICS OF ORGANIC OCCLUSION 8.GNATHOLOGICAL CONCEPT OF COMPLETE DENTURE CONSTRUCTION 9.CONCLUSION 10.BIBLIOGRAPHY

IntroductionThough the primary function of teeth is mastication ,teeth are not chewing organs by themselves.They are capable of performing their function only when it is used collectively with the other components of the stomatognathic system which include the maxilla,mandible,the temperomandibular joints,the teeth with their investing periodontal membranes,and the neuromuscular mechanism.These are collectively known as the masticatory apparatus and should be treated as one unit which is the goal of Gnathology

DefinitionThe science that treats the biology of the masticatory mechanism as a whole i.e the morphology, anatomy,histology,physiology,pathology, therapeutics of the masticatory system and the teeth as they relate to the health of the whole body including applicable diagnostic,therapeutic and rehabilitation procedures.

Aims and objectives of Gnathology

1.Optimum oral health
2.Anatomic harmony 3.Functional harmony 4.Occlusal stability

THE NUTRIMENTAL FOUNDATION OF GNATHOLOGY

In dental science and practice we as professional healers have got the cart before the horse i.e we are trying to cure the disease problems only after they have been allowed to manifest themselves. Because it has been a well observed fact that primitive people had generally less dental problems,well formed dental arches & uncrowded teeth where as in comparison to the modern man who has caries index approaching 98% & a malocclusion index approaching the same magnitude depending on what criteria one uses for defining malocclusion.

The role that nutrition plays in physical wholesomeness is profoundly complex & extremely complicated in its minute details. The physical degeneration of isolated primitive people when they took up the prevalent diet of the modern man is lesson that we all should understand before we cope with the daily administrations of our treatments of diseased teeth , jaws & their relationships.

we should direct our efforts towards to return the modern man to the whole grain nutrition in his breads,cereals and flours & if we could do these things collectively & individually we could realize the health & wholeness inherent in our well being and eliminate the need for gnathology

FUNCTIONAL GNATHOLOGY IS NUTRITION

Gnathology is the science that treats the biologics of the masticatory system,considering it as a single functional unit.Nutrition is the act of supporting life & causing it to grow by supplying matter to any living tissue or organized body & the structural form is a resultant of matter applied by function. Nutrition concerns every human being every single day of life & nutrition is truly incorporation of the environment into our well being. Nutrition is the one science that can least afford to remain in the laboratory & it concerns every single human being every single day of life.

GNATHOLOGYS ROLE
Gnathology has a biological role in the solution of mans oral ills.This role is to demonstrate that the wholeness of the food & breath has a relationship to the structure jaws & the whole body. If there is any imbalance between at the gross anatomic level & the molecular level than the resultant gross structure will not reach its true or optimum form.

Mc COLLUMS KEY
Beverly McCollum the father of Gnathology has said that the function of the mouth is the key to biological dentistry & keeping the physiological integrity of the oral organ as intact as possible is the basic aim of all our preventive work & no other professional group should earnestly desire to practice prevention than dentists.

ORGANIC OCCLUSION THE ULTIMATE GOAL OF GNATHOLOGY Organic occlusion can be defined as the parts that are mutually dependant or intrinsically related and having a systematic coordination with each each other. To be a good Prosthodontist one must also be a gnathologist & should use the face bow, the mounted casts to understand & diagnose the structural deformities which must be corrected to achieve an organic occlusion. The goal of the gnathologist is to combat the inevitable wear & tear of the human masticatory system so that it remains in optimal chewing and digestive function for a life time.

THE ORGANIC MASTICATORY SYSTEM

The awakening began in the 1970s as to the effect of the jaw system has on the health & function of distant parts of the body as cranial osteopaths.kinesiologists & dentists have been documenting ailments that are organically oriented. All related structures jaws,joints,teeth,muscles,ligaments,tongue,lips & cheeks all serve in an interrelating dynamic harmony which promotes the usefulness & longevity of the entire system and we may discover to our own dismay that our therapies can be the cause as well as the cure of this dysfunction

THE DEVELOPMENT OF ORGANIC OCCLUSION

The first teeth to meet in occlusion are the primary incisors and when the molars erupt they become related to the incisors by means of their occlusion & vertical dimension.Interocclusal space, mandibular rest position,the hard & soft tissues have an effect on the development of organic occlusion. Nature organizes the posterior occlusion by coupling the anterior teeth first & if this coupling does not occur due to cross bites or open bites then organic problems will surely develop. Stallard stated that an organic occlusion is the highest mechanical arrangement that can be given to the teeth

REFERANCE PLANES-A BASE LINE FOR FOR MEASUREMENTS IN GNATHOLOGY

Coronal plane

Axis orbital plane

Sagittal plane

Gnathological instruments have made it possible to analyze the components of organic occlusion. Dr.McCollum in 1921 discovered the first positive method of locating the most retruded position of the mandibular hinge axis & a repeatable baseline was established from which measurements could be made.

THE TOOLS FOR GNATHOLOGICAL MEASUREMENTS 1.Mandibular movement recorders 2.A Gnathological instrument for routine mounting of the casts 1.Mandibular movement recorders
The first mandibular movement recorder was introduced by Dr.Stuart in 1950 which to till date is unchanged & unequalled in precision,sturdiness & practicality.Dr.Stuarts recorders had a horizontal condylar styli in line with the hinge axis & therefore recorded the effects of the condyle movement with a magnification,reliability & legibility that opened new horizons for study & gave dentistry the repeatable precision it needs for Gnathological restorations

2.A Gnathological instrument for routine mounting of the casts

The whip mix face bow establishes the axis-orbital plane by the indigenious use of anatomical structures & it can be accurately repeated to a tolerance level of 1mm The correspondence of the whip mix anatomical face bow to the kinematic location of the hinge axis was within 6mm,75.5% of the time which in contrast to the arbitrary face bow had 33%.

The reason for the high correspondence to the hinge axis is that the leading edge of the ear plug is closely aligned with the axis.

Thus the whip mix face bow & articulator can be used to accurately relate the maxilla & the maxillary teeth to the axis orbital plane in a manner that can be repeated and consecutively referred in order to assess the three dimensional effects on tooth position.

TEN CHARECTERISTICS OF ORGANIC OCCLUSION

1.CENTRIC RELATION OCCLUSION
2.UNIFORM CONTACTS IN CENTRIC RELATION 3.CUSP FOSSA OCCLUSION 4.PRIMARY MARGINAL RIDGE CONTACTS

5.TRIPODISM
6.CROSS TOOTH STABILITY(TWIN CENTRIC) 7.FORCES ALONG THE LONG AXIS 8.NARROW OCCLUSAL TABLE 9.MAXIMUM CUSP HIEGHT AND FOSSA DEPTH 10.DISCLUSION i) Ridge and groove directions

ii) the effects of transtrusion on ridge and groove direction

iii) Principles of obtaining disclusion iv) Canine disclusion vi) Disclusive prematurities

1.CENTRIC RELATION OCCLUSION Centric relation occlusion is the morphologic position of the mandible in the centric relation when the posterior teeth are intercusped in occlusion.As such it represents the true profile of the face.The mandible is muscularly suspended in centric relation occlusion by the external pterygoid muscles posteriorly & the genioglossus muscle anteriorly.All forces acting upon the TMJ and the periodontal membranes are reciprocated which results in equilibrium and balance.

The sagittal tracing of the envelope of motion will demonstrate centric relation occlusion to be at the uppermost end of the arc which is traced at the rearmost hinge axis & organic occlusion can be established at any point on this arc.

Centric relation occlusion can only be demonstrated with axis oriented casts mounted on an articulator and the elimination of centric prematurities is necessary to gain centric relation occlusion

2.UNIFORM CONTACTS IN CENTRIC RELATION When all the posterior teeth meet at once in centric relation,the mandible is tripodized by means of the two temperomandibular joints and the teeth in unison acting as one unit.The elimination of centric prematurities is necessary to establish uniform contacts in centric relation.If the centric prematurities are not removed there are four possible effects

i)

Faceting & wear-The first teeth to contact on the arc of centric relation closure will show faceting at the initial point of contact. The mandible will be deflected forward by these prematurities and the wear of the incisors will result .If the deflection is laterally the tips of the cuspids are seen to wear off. TMJ Dysfunctioning & muscle soreness-If centric prematurities are present than they will result in soreness of the posterior belly of the digastrics and the middle temporal muscles.If there is unilateral closure which precedes or replaces bilateral closure than it will result in soreness of the middle temporal,medial pterygoid and masseter muscles.

ii)

iii) Infrabony periodontal bone loss. iv) Recession and gingival erosion

3.CUSP FOSSA OCCLUSION

One of the primary goals of restorative gnathologists is cusp fossa occlusion.Cusp to fossa is a paired relationship between the one upper & one lower teeth whereby the teeth in occlusion act as a single column or a unit of occlusion.The buccal cusp of the lower bicuspid is received by the mesial fossa of the upper & the palatal cusp of the upper bicuspid is received by the distal of the lower bicuspid and thus one balances the other. In case of the molars the three lower buccal cusps oppose the fossae and the upper palatal cusps oppose the central and the distal fossae of the lower molar,thus a natural dove tail is established which has the effect of a loose mortoise when the teeth are in occlusion.

The tip of the lower first bicuspid should fit into the mesial fossae of the upper bicuspid front of the triangular ridge which is essential for proper vertical development,stability and function. This design lends much stability & reciprocation of the forces of occlusion and when cusps fit into fossae instead of inclined planes is assures that the centric relation will be the most closed position of the mandible. Cusp fossa relation is always preferable to cusp embrasure occlusion but are not always achievable ,this is when occlusal adjustments procedures become necessary or else teeth will not be in contact and there will have to be diastemas at some places.

4.PRIMARY MARGINAL RIDGE CONTACTS

This is a sagittal plane projection wherein there is contact of the distal incline of the upper mesial marginal ridge against the mesial marginal ridge of the lower buccal cusp .The distal marginal has a similar contact with the mesial incline of the opposing distal marginal ridge & these contacts are called as closure stoppers as they resist the forward component of the arc of closure The significant aspect of these closure stoppers is in case the posterior teeth are lost & the vertical dimension decreases the upper anterior teeth will be splayed & if the posterior teeth are present the closure stoppers prevent the wear and possible separation of the anteriors.

5.TRIPODISM
In a cusp fossa occlusion every closure stopper is coupled with a contact on the distal incline of the lower triangular ridge or the mesial incline of the upper triangular ridge.This contributes to mesio-distal stability to the occlusion. Every cusp has four ridges i.e. a mesial marginal ridge,a distal marginal ridge,a triangular ridge and a central ridge.three out of these four ridges can contact an opposing cusp in cusp fossa occlusion.In gnathology this tripodism is a goal because the tripod is the most stable system in mechanics.

In unworn or less worn dentitions the total area of maximum intermaxillary contacts in occlusion does not exceed three or four square millimeters. Since all the ridges are rounded in all three dimensions and when these two rounded surfaces meet at a point the contacts will be small.If this type of tangency is obtained there will be a built in adjustability to wear and the cusp tips will be preserved & the occlusion will wear in not wear out.The ridges will wear evenly and thus preventing the formation of non-uniform contacts

6.CROSS TOOTH STABILITY (TWIN CENTRIC) This is a coronal projection of the tooth contacts.In this view one can appreciate that the functional cusps of the upper & the lower posterior teeth occupy nearly 60% of the total bucco-lingual width of the tooth & occlude near the center of the opposing fossae.These are also designated as stamp cusps as these are responsible of the maximum shearing capability of the mammalian dentitions.

The contact patterns of these stamp cusps in the coronal plane are designated as A-B-C contacts.
The A-contacts are between the upper buccal triangular ridge & the central ridge of the lower buccal cusps.

The B-contacts are between the triangular ridges of the upper lingual & lower buccal cusps & it is the common contact between the stamp cusps.
The C-contacts are between the convex central ridge of the upper lingual cusp & the lower lingual triangular ridge.Any contacts between the lingual cusps is a C-contact. The Bucco-lingual stability results from these contacts being present. If the B-contact is lost torquing forces will result in a deflective occlusion.The B-contact cannot be seen unless a medium is placed between the teeth which will mark it.

7.FORCES ALONG THE LONG AXIS

The sixth character of organic occlusion which relates the tooth contacts is by which the forces of occlusion are directed along the long axis of the tooth.

All of the previous factors described i.e. the cusp fossa relations,closure stoppers & equalizers,tripodal contacts,the ABC contacts & the narrow occlusal table tend to balance the occlusal forces & keep them directed within the perimeters of the root thereby minimizing the destructive offaxial forces.

8.NARROW OCCLUSAL TABLE

Natural teeth with little wear have a narrow occlusal tables. The average distance from the buccal cusp tip to the lingual cusp tip is 55% of the total bucco-lingual width The remaining 45% should be divided with 15% from the tip of the shear cusp to the height of contour & 30%from the tip of the stamp cusp to the height of contour so the average distance between the A & C contacts is 45% of the total bucco-lingual width. If the occlusal table of the artificial teeth is kept within these perimeters the forces of closure will be kept within the perimeters of the teeth and directed along the long axis of the teeth. The key to narrow occlusal table is to protect the natural tooth from wear by deflective occlusal contacts.

9.MAXIMUM CUSP HIEGHT AND FOSSA DEPTH

The restorative gnathologist must attempt to restore the teeth with tallest cusps possible as they offer the greatest shear efficiency.
This can be done by mounting the casts in centric relation & correctly programming the eccentrics of the articulator & the determinants of the cusp height can be outlined as follows. A) Angle of eminence(sagittal plane determinant) Rule-The more the condyles detrude beneath the eminences the cups should be shorter and if the eminence is steeper the cusps should be longer B) Transtrusion(side shift-coronal plane determinant) Rule-if the side shift is greater the cusps should be shorter

C) Vertical laterotrusion of the working condyle(coronal plane determinant) Rule-the rotating condyle move laterally & if the condyle moves upward as it goes laterally than the cusps should be short & if it moves downward as it goes laterally (laterodetrusion) the cusps must be longer.

D) Inclination of the occlusal plane Rule-The more nearly the plane of occlusion parallels the the angle of the eminentia the cusps should be shorter

10.DISCLUSION
The principle of disclusion is next to centric relation occlusion & the most important characteristic of organic occlusion. Disclude means to separate,unclose or keep apart.its exists in the post-canine teeth so that they contact only in centric relation occlusion. The disclusive characteristic of organic occlusion allows each part of the dentition to perform that function for which it is best suited (e.g.) the incisors are designed for fine nibbling,cutting into food & each incisor should be free to contact the opposing incisor at an edge to edge relationship without any other tooth in the mouth contacting. Thus a mutually protective mechanism results whereby the anterior teeth disclude the posterior teeth in eccentrics & the posterior teeth disclude the anterior teeth in centric occlusion

Principles of obtaining disclusionThe degree of detrusion of lower incisors should be equal or be slightly greater than the detrusion of the condyles beneath the eminentia.The horizontal,vertical overlaps & the inclination of the upper incisors to the horizontal will affect the angle of detrusion.

Often the mesial marginal ridge of the buccal cusp of the lower first bicuspid may assist in the first of protrusive disclusion by making contact with the distal incisal edge of the upper cuspid.keeping the lower first bicuspids prominent makes this possible

Disclusive prematuritiesThese are the most destructive interocclusal prematurities which occur in the non-working mesial inclines of the upper lingual cusps & the distal inner inclines of the lower buccal cusps.These are the B contact areas which are important to obtain centric relation occlusion but must be avoided in the eccentrics. If these are not avoided then the muscle groups which are affected are the lateral pterygoid on the non-working side & the lateral,medial pterygoid,masseter & the middle temporal muscles are affected on the working side.

The ten characteristics of organic occlusion evolved from the research of Dr.McCollum,Dr.Stuart & Dr.Stallard the founders of gnathology,the impetus they had was to learn, to preserve the dentition & masticatory function of humans.They applied the principles of biologics,geometry, physics & mechanics to decipher the code that God & natural development of human being wrote on the occlusal surfaces of the teeth. The achievement of organic occlusion is the greatest challenge & the highest goal that a restorative dentist will ever have.

Gnathological concept with complete denture construction

Complete denture construction is a full mouth reconstruction with extra complications to consider because no teeth are present. The TMJ, muscles, meniscus, ligaments, mandible & maxilla are still there & dentures should be made in harmony & in consultation with them. There are similarities in procedures for reconstructing the mouths with or without teeth,but with dentures the dentist must restore the teeth with the new freedom of space.

If centric relation & centric occlusion are in harmony,then the dentures can be reasonably successful.
The goal of completed dentures is to have tripod contacts in the posterior teeth in centric occlusion.

The balance of nature must be respected.Each part has its own sphere of activity as well as fusing with & complimenting other related parts. Altering one part for instance may affect half a dozen others-most often to our own disadvantage and it is entirely possible that some dental therapeutics may not be in the best interest of the patients and if we as dentists must respond to the awesome responsibility of treating the dental disease then,every effort should be made to see that our therapies fit to the patients organic system,otherwise we may do more harm than good to the patient .

Dentistry should not be just reduced to the level of repair and service on a trade but gnathology however makes dentistry a true science.

BIBLIOGRAPHY
1.ORTHOPEDIC GNATHOLOGY-JACK.L.HOCKEL 2.MANAGEMENT OF TMJ DISORDERS & OCCLUSIONJEFERY.P.OKESON

3.EVALUATION,DIAGNOSIS & TREATMENT OF OCLUSAL PROBLEMSDAWSON

4.OCCLUSION IN RESTORATIVE DENTISTRY-MARTIN.GROSS 5.SCIENCE & PRACTICE OF OCCLUSION-CHARLES McNeil 6.OCCLUSION:PRINCIPLES & CONCEPTS-JOES DOS SANTOS 7.AN EVALUATION OF 50 YEARS OF RECONSTRUCTIVE DENTISTRY PART I-JPD;1981;45:383

8.GNATHOLOGIC CONCEPTS OF TOOTH PREPERATIONCHARLES.STUART

9.TREATMENT OF THE EDENTULOUS PATIENTS-VICTOR.O.LUCIA

Thank you