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The contraindication clinical report

Howard Sutcher, College of Dentistry,

of restoration

to centric

relation:

DDS, MSa University of Illinois at Chicago, Chicago, Ill.

dentists believe that an occlusion established with the condyles in the most retruded position in the glenoid fossa, near or accessible to centric relation (CR), is the best way to rebuild a seriously mutilated l-4 However, there are some paocclusion for all patients. tients for whom access to CR unimpeded by the teeth is clearly contraindicated. A variety of patients have been treated successfully by positioning the mandible anteriorly in occlusion. Anterior mandibular placement has been used in the fabrication of complete dentures for many patients who had difficulty wearing conventional complete dentures.5 Dentulous patients have also been treated in this manner but have not been reported. Nine patients with idiopathic or spontaneous orofacial dyskinesia and one with a condylotomy have been the subjects of numerous articles.6-g Patients with tardive dyskinesia also require anterior mandibular positioning when the disorder is treated dentally. With many of these patients repeated attempts to use a mandibular retruded occlusion were ineffectual or unattainable or even exacerbated symptoms. In contrast, mandibular protruded occlusions helped these patients. This clinical report describes the treatment of a patient who was an exception to the use of CR as a true maxillomandibular registration record for removable partial dentures.

M any

CLINICAL

REPORT

A 61-year-old woman had her dentition carefully reconstructed with her condyle in CR by a graduate student supervised by the staff of the University of Illinois College of Dentistry. Maxillary reconstruction consisted of an eightunit anterior fixed partial denture and a posterior removable partial denture. The mandibular removable partial denture replaced anterior and posterior teeth. The patient subsequently had unusual subjective and objective complaints. The patient perceived a postnasal drip and felt that she did not have enough room for her tongue to rest comfortably in her mouth. She also had difficulty swallowing. The tip of her tongue appeared to be uncontrollably hyperactive and would seek sharp edges on the maxillary removable partial denture. The tongue became sore, irritated, and abraded. Because the patient was uncomfortable with her reconstruction, her removable prostheses were selectively

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Professor, Department DENT 1996;75:588-90.

of Restorative Dentistry.

ground to provide her with a long centric. However, the symptoms did not abate, and she visited the clinic frequently for several years. Later she reported that for 3 years her preoccupation with her son, who was dying of cancer, had reduced the frequency of her complaints to her dentists but not the presence of her symptoms. After the death of her son, she returned to the University of Illinois with her numerous and unusual symptoms. Ultimately, the large number of dentists involved in her treatment felt that her complaints were psychogenic, and she was referred to me. Successful therapy began with the belief that the patients complaints were based in reality.lO By use of an alternate approach that was successful in treating other patients, the patients mandible was repositioned into an anterior occlusal position. While she was leaning slightly forward in a posture to simulate eating, the patient was asked to approximate her jaws in a comfortable position without retruding or protruding the mandible. This position was recorded by placing a roll of doughy autopolymerizing acrylic resin on the occlusal surface of the maxillary removable partial denture and by having the patient close into it until her lubricated mandibular teeth touched something hard with a feather touch. The acrylic resin was aIlowed to set while the patients teeth were approximated to form an occlusal appliance that locked her mandibular teeth into position. This position was more than 9 mm anterior to their placement when the condyle was in CR (Fig. 1). The patient had an orthodontic class II occlusion so severe that the anterior positioning of the mandible was accomplished without increasing the vertical dimension of occlusion. The appliance was initially adjusted so that there were indentations approximately 1 mm deep into which the mandibular teeth fit. Within 2 weeks the patient no longer perceived a postnasal drip. Her tongue rested comfortably in her mouth without any evidence of hyperactivity, and she swallowed normally. At a later date, to test whether she would be able to move her mandible on her own to Iind a more advantageous position, the appliance was ground flat. All the initial signs and symptoms reappeared by the next day. When the locking)) feature was reintroduced, all her problems again disappeared almost immediately. The patient volunteered that, without the locking feature of the appliance, she felt that her mandible would drift backward, especially when she was sleeping on her back. The efficacy of locking the patients mandible into a po-

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Fig. 1. Solid line, Mandibular retrnded (uncomfortable) occlusion. Dotted l&e, Ivfandibular protruded tcomfo~able) occlusion.

Fig. 2. In arbitrary retruded occlusion, tongue pressed forward forcefully between maxillary and mandibular incisors.

sition substantially anterior to CR was tested further with the patients informed consent. With a Joe Dandy disk, a jagged area was cut into the anterior palatal edge of the existing maxillary removable partial denture. Even the resultant metal burs remained in place. One week later the patient reported that she perceived the roughened area but simply avoided touching it with her tongne, which remained unabraded. She did not consider the jagged area to bs a problem. When the condyles were in CR, the tongue appeared to be too large for the patients mouth and prot~d~ between the maxillary and mandibular incisors. When the mandim ble was locked into the protruded position, the tongue rested comfortably inside the patients mouth because adequate space was provided (Figs. 2 and 3). After 6 months, during which the patient reported no symptoms or company, new removable partial dentures (RPDs) were constructed with 33-degree porcelain posterior teeth. These dentures locked her occlusion into the predetermined position. The rn~~b~~ condyles were more than 9 mm anterior to CR. The patient was recalled at 6-month intervals for 2 years, and she continued to report that her mouth was comfortable. Her symptoms of irritated tongue, postnasal drip, and d.ifficulty in swallowing no longer existed. Her only complaint was with the poor esthetics of the RPDs that were fabricated for heq she was unhappy with the appearance of the ~b~t-c~o~~ clasps. After 2 years of follow-up, the patient was returned to the regular routine of the dental clinic. On her next 6-month recal1, a new graduate student and instructor did not give credence to the extensive notes in the chart and corre&ed her occlusion to allow this patient to approximate her teeth w&b the condyle in CR.

Fig. 3. In arbitrary protruded occlusion, tongue rested comfortably in mouth. All her original symptoms reappearedwithin days. Then the 33- degree teeth locking her mandible more than 9 mm anterior to CR were reintroduced. Her symptoms again disappeared almost immediately.

This report is anecdotal, so it lacks the safeguards against bias and misinterpretation inherent in the scientific epistemology. However, the large number of patients who have responded positively to a mandibular anterior occlusion challenge the presnmption that CR is the best registration treatment for all patients. This clinical report contains three cycles of s~ptom alleviation and relapse in the same patient. In each cycle CR-based occlusal reconstruction led to symptoms that were soon resolved by anterior positioning of the mandible. When the patient% RPD was originally roconstrncted with the mandible in a retrnded position, CR, the mandibular muse~at~ was forced posteriorly, which rodueed space 589

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for the tongue. The posterior part of the tongue was pressed against the posterior wall of the pharynx to reduce the pharyngeal space and cause the sensation of a postnasal drip. Pressure of the pharynx on the posterior part of the tongue could cause avoidance behavior or hyperactivity in the anterior part of the tongue. Previous studies of spontaneous orofacial dyskinesia link mandibular protruded occlusion to relief of lingual hyperactivity. Posterior positioning of the mandible in occlusion has been considered the best way to rebuild a severely mutilated occlusion or to fabricate complete dentures. CR has been considered to be a position of the mandibular condyles in the glenoid fossa that is inviolate, immutable, eternal, universal, and reproducible. It has been defined differently at least twice, and the concept is now becoming obsolete.lO, l1 What began simply as a reference point has achieved the status of an ideal physiologic positionl, I2 It must be emphasized that the universal applicability of CR has never been scientifically proved. Constant repetition may well have created a truth, but has reproducibility been confused with validity? Anecdotal information suggests that many dentists may soon abandon CR as ineffective in practice. The concept of CR as a universal or ideal physiologic position is invalid. It is more likely that, with the teeth occluded, no single physiologic position exists for all people.

4. Further research is required to determine the percentage of the population the various groups represent.
I thank members of the staff of of Dentistry for critical reviews owsky, DDS, MS, for tracing the John Everingham, PhD, and my itorial assistance. the University of Illinois College of this manuscript; Cyril Sadcephalometric radiographs; and wife, Rosalie, for invaluable ed-

REFERENCES
1. Stuart CE, Stalard H. Principles involved in restoring occlusion to natural teeth. J PROSTHET DENT 1960;10:304-13. 2. Lucia VO. Modern gnathological concepts-updated. Chicago: Quintessence, 1983. 3. Mann AW, Pankey LD. Concepts of occlusion: the PM philosophy of occlusal rehabilitation. Dent Clin North Am 1963:621-36. 4. Damon PE. Evaluation, diagnosis and treatment of occlusal problems. 2nd ed. St. Louis, CV Mosby, 1989:261-73. 5. Sutcher HD, Beatty RA, Underwood RB. Orofacial dyskinesia: effective prosthetic therapy. J PROSTHET DENT 1973;30:257-8. 6. Sutcher HD, Underwood RB, Beatty RA, Sugar 0. Orofacial dyskinesix a dental dimension. JAMA 1971;216:1459-63. 7. Sutcher HD, Beatty RA, Underwood RB. Orofacial dyskinesia: effective prosthetic therapy. J PROSTHET DENT 1973;30:252-62. 8. Sutcher HD, Sugar 0. Etiology and dental treatment of severe involuntary orofacial-cervical movement disorders. J PROSTHET DENT 1982;48:703-7. 9. Sutcher HD, Andria L. Occlusal therapy to correct apertognatbia tier mandibular osteotomy. Gen Dent 1985;33:212-6. 10. Sutcher HD. Special problems in restorative dentistry for wind musicians: four cases. Compendium Cant Dent Ed 1986;7:365-8. 11. Zwemer TJ, ed. Bowhe& clinical dental terminology: a glossary of accepted terms in all disciplines of dentistry. 3rd ed. St. Louis: CV Mosby, 1982. 12. Academy of Prosthodontics. Glossary of prosthodontic terms. J PROSTEIET DENT 1994;71:41-112.

CONCLUSIONS
1. With the teeth occluded no single position of the condyles in the glenoid fossa exists that is physiologically acceptable for all patients. 2. Centric relation is valid only as a convenience or reference position. For any other use it is a specious concept. 3. Free access of the mandibular condyles to CR, with the teeth in occlusion, is unacceptable for some patients who require a mandibular protruded occlusion.

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DR. HOWARD SLWXER DEPARTME~OFRESTORATIVEDENTISTRY UNIVERSITYOFklNOISAT&ICAGO ~O~S.PAULWAST. CHICAGO, IL 60612-7212

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