Analysis of the condyle/fossa relationship before and after prosthetic

rehabilitation with maxillary complete denture and mandibular removable

partial denture
Vania Cristina Pintaudi Amorim, DDS, MSD,
a
Dalva Cruz Lagana, DDS, MSD, PhD,
b
Jose Virgilio de Paula Eduardo, DDS, MSD, PhD,
c
and Artemio Luiz Zanetti, DDS, MSD, PhD
d
School of Dentistry, University of Sao Paulo and University of Sao Paulo City, Sao Paulo, Brazil;
Paulista University, Campinas, Brazil
Statement of problem. The inuence of the loss of posterior teeth on the condylar position and on tem-
poromandibular disorders (TMDs) remains a controversial issue.
Purpose. This study investigated whether prosthetic rehabilitation promoted modication of the condylar
position in subjects without symptoms of TMDs.
Material and methods. The temporomandibular joints (TMJs) of 12 women (age 37 to 74), all with existing
maxillary complete dentures but no removable partial denture (RPD) restoring the Kennedy class I partially
edentulous mandibular arch and no clinical signs of TMDs according to the criteria established by Helkimo, were
viewed in maximal intercuspal position with corrected lateral tomography before and after prosthetic rehabilita-
tion with a new maxillary complete denture and a mandibular RPD. Before prosthetic rehabilitation, a mandib-
ular stabilizing base was fabricated to prevent the existing maxillary complete denture from dislodging during
tomographic examination. Two methods were used to evaluate tomograms: (1) linear measurements of the
subjective narrowest anterior and posterior intra-articular joint spaces made from the tomograms by use of a
digital caliper and (2) linear measurements of the anterior and posterior intra-articular joint spaces on the basis of
drawings and tracings. Repeated-measures analysis of variance followed by orthogonal contrasts were used to
evaluate differences between measurements carried out on the same subject under the different test conditions of
the study (before prosthetic rehabilitation, before prosthetic rehabilitation with a mandibular stabilizing base in
position, and after prosthetic rehabilitation) (P.05).
Results. Before prosthetic rehabilitation, a predominance of posterior condylar positions was observed. Before
prosthetic rehabilitation with a mandibular stabilizing base in position, a signicant decrease was observed in
posterior condylar positions (P.03). This decrease was more marked after prosthetic rehabilitation (P.02).
The subjective evaluation and comparison on the basis of drawings and tracings used to analyze the tomograms
produced similar results (P.70).
Conclusion. Within the limitations of this study, signicant changes in the condylar position occurred after
prosthetic rehabilitation in subjects without symptoms of TMDs. (J Prosthet Dent 2003;89:508-14.)
CLINICAL IMPLICATIONS
In this study, posterior condyle displacement was more frequent than other positions in patients
missing mandibular posterior teeth with existing maxillary complete dentures but no mandib-
ular RPD. Prosthetic rehabilitation appeared to be responsible for a more favorable condyle/
fossa relationship; however, there was no evidence that this improved the patients status relative
to the health of the TMJs or TMD signs and symptoms, because the patients were symptom free
initially.
Different methods have been used to determine the
condylar position according to the relative dimensions
of anterior and posterior joint spaces between the fossa
and the condylar surface.
1-5
In spite of variations among
the methods used, 3 types of condylar positions can be
identied:
6
(1) condylar concentricity, in which the an-
terior and posterior joint spaces are equal; (2) posterior
condylar position, in which the posterior joint space is
smaller than the anterior joint space; and (3) anterior
condylar position, in which the posterior joint space is
greater than the anterior joint space. Some authors have
investigated the accuracy and reliability of the methods
used to evaluate the position of the condyle.
1-3
In this
Supported by CNPq.
a
Assistant Professor, Department of Prosthodontics, University of Sao
Paulo City.
b
Associate Professor, Department of Removable Prosthodontics,
University of Sao Paulo.
c
Professor and Chairman, Department of Prosthodontics, Paulista
University of Campinas.
d
Professor and Chairman, Department of Removable Prosthodontics,
University of Sao Paulo and University of Sao Paulo City.
508 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 89 NUMBER 5
study, 2 methods described as reliable in the literature
were used, one method done by linear measurements of
the subjective closest anterior and posterior intra-artic-
ular space on the tomogram with a digital caliper,
1
and
another method that took into account the linear mea-
surements of the anterior and posterior intra-articular
space on the basis of tracings and drawings.
2
Several authors have associated nonconcentric posi-
tions with temporomandibular disorders (TMDs).
7-12
However, in asymptomatic populations with no history
of occlusal or orthodontic treatment, a wide variety of
condylar positions in the articular fossa have been ob-
served. Not withstanding, a relatively greater number of
concentric positions in symptom-free subjects has been
reported.
13,14
In at least 2 studies, no association was found be-
tween TMDs and nonconcentric positions of the con-
dyle.
15,16
Radiographic investigations, however, have
shown that patients with temporomandibular joint
(TMJ) pain presented a higher ratio of posterior condy-
lar positions than symptom-free subjects.
17-21
This pos-
terior displacement of the condyle has frequently been
associated with the loss of posterior teeth
17-19
and also
may be associated with anterior disk displacement.
20,21
A more superior and anterior position of the condyle
in the presence of good, integrated muscular activity,
optimum occlusal stability, and an interposed articular
disk has been considered the ideal status of the con-
dyle.
22-25
Radiographically, however, this ideal depends
on the thickness of the articular soft tissues, tissue de-
generation and remodeling, and mandible posture, all of
which might alter the position of the condyle.
26,27
Many patients can adapt to occlusion or condylar
positions that are not considered ideal. Because of fac-
tors that reduce adaptive ability and cause unbalance of
the masticatory system, other patients may have devel-
opment of TMDs.
24,25
The inuence of condylar posi-
tion and the loss of posterior teeth on TMDs remains a
controversial issue, as does the inuence of lost molar
replacement by a removable partial denture (RPD).
28-31
Nevertheless, some researchers have shown the impor-
tance of prosthetic rehabilitation for reducing the symp-
toms of TMDs.
32,33
The purpose of this study was to analyze condylar
position by means of corrected lateral tomography in 12
patients with existing maxillary complete dentures but
no RPD for the partially edentulous mandibular arch
(Kennedy class I). Analysis was performed before pros-
thetic rehabilitation (with and without a stabilizing base
in position) and after prosthetic rehabilitation (consist-
ing of a new maxillary complete denture and a mandib-
ular RPD). The goal was to determine whether the as-
sociated prosthetic rehabilitation resulted in an
alteration of the condyle position.
MATERIAL AND METHODS
The sample of this study consisted of 12 women, ages
37 to 74, in good general health, without symptoms of
TMD according to the criteria established by Hel-
kimo,
34
and presenting edentulous mandibular arches
(Kennedy class I) but no mandibular RPDs. All subjects
had worn a maxillary complete denture for more than 5
years and were seeking prosthetic rehabilitation at the
dental clinics of the University of Sa o Paulo or the Uni-
versity of Sa o Paulo City. The TMJs of the patients were
viewed with corrected lateral tomography (Quint Secto-
graph, Los Angeles, California) twice before prosthetic
rehabilitation (with an existing maxillary complete den-
ture in position only, and with an existing maxillary
complete denture and a mandibular stabilizing base in
position) and once again after prosthetic rehabilitation
(with a new maxillary complete denture and a mandib-
ular RPD), always in maximal intercuspal position.
Before prosthetic rehabilitation with a new maxillary
complete denture and a mandibular RPD, a mandibular
stabilizing base
35-37
was fabricated for the purpose of
stabilizing the existing maxillary complete denture, pre-
venting it from becoming dislodged and losing contact
with the mucosa in maximal intercuspal position during
the tomographic examination. The mandibular stabiliz-
ing base was fabricated on a mandibular diagnostic cast
of each patient and consisted of an acrylic resin (Jet;
Classico Ltd, Sa o Paulo, Brazil) base relined with a zinc
oxide-eugenol paste (Lysanda; Lysanda Ltd, Sa o Paulo,
Brazil) on the cast lubricated with petroleum jelly (Va-
selina; Beira Alta Ltd, Sa o Paulo, SP, Brazil) to offset the
distortion caused by the acrylic resin polymerization con-
traction. Anocclusionrimmade of wax (Wilson; Polidental
Ind e Com Ltd, Sa o Paulo, Brazil) was fabricated on this
acrylic resin base, which was placed in the mouth and con-
toured to coincide with the existing vertical dimension of
occlusion and maximal intercuspal position presented by
the patient while wearing the existing maxillary complete
denture. Afterward, 1 mm of the wax was removed to
receive a layer of zinc oxide-eugenol paste (Lysanda; Ly-
sanda Ltd). The occlusion rimwas once again placed in the
patients mouth to make a record of the maximal intercus-
pal position at the vertical dimension of occlusion.
Standardized procedures were performed for the fab-
rication of the maxillary complete dentures and the man-
dibular RPDs. After clinical examination, diagnostic im-
pressions and casts of the maxillary and mandibular
arches were made. New record bases and occlusion rims
were fabricated on the casts and transferred to a semi-
adjustable articulator (Dent-ex 10600; Dent-ex Ind
Com Ltd, Ribeira o Preto, Brazil) with the aid of a face-
bow transfer and a record made with the patient in the
centric relation position.
22
Treatment planning was carried out for each patient.
The mandibular diagnostic cast previously used to fab-
PINTAUDI AMORIM ET AL THE JOURNAL OF PROSTHETIC DENTISTRY
MAY 2003 509
ricate the stabilizing base was mounted in a parallelom-
eter (Bioart; Bioart Ltda, Sa o Carlos, Brazil) to deter-
mine the path of insertion and the need for abutment
tooth preparation to accommodate the desired RPDde-
sign.
37,38
After mouth preparation, a mandibular im-
pression was made to evaluate the correctness of the
mouth preparations. A maxillary functional impres-
sion
39,40
was made and transferred to the articulator
with the aid of a face-bow and transferring devices.
41
A
nal mandibular impression was made and the cast was
formed in stone (Durone; Dentsply Ind e Com Ltd,
Petro polis, Brazil). The RPD design was nalized, and
the metal framework was fabricated. Determination of
the plane of occlusion was based on anatomic landmarks
(retromolar pads and maxillary lip line).
35,36
The vertical
dimension of occlusion was established by combining
the methods described by Willis,
42
Pleasure,
43
Silver-
man,
44
and Ricketts.
45,46
Centric relation was initially
recorded by use of Dawsons
22
bilateral manipulation
technique and then conrmed by the procedure for re-
cording the centric relation as described by Smith.
47
The
nal mandibular cast and framework, along with the
mandibular and maxillary occlusion rims, were then
transferred to the articulator. Prosthetic teeth with 33-
degree cusp inclines (Biotone; Dentsply Ltda, Sa o
Paulo, Brazil) were selected and arranged in the maximal
intercuspal position. The characteristics of the teeth
were assumed to have been standardized by the manu-
facturer and were chosen because of their reduced cost.
After trial insertion and conrmation of tooth arrange-
ment, the prostheses were nished and processed in the
usual manner.
48
The new maxillary complete denture
and the mandibular RPD were remounted in the artic-
ulator, and occlusal adjustments were then made as
needed before insertion of the prostheses.
49
Corrected lateral tomography (Quint Sectograph)
was used to viewthe TMJs of all patients. All tomograms
were made at the Institute for Orthodontic Documen-
tation and Radiodiagnosis (Instituto de Documentaca o
Ortodontica e Radiodiagno sticoINDOR S/C Ltda,
Sa o Paulo, Brazil), in the maximal intercuspal position:
(1) before prosthetic rehabilitation (existing maxillary
complete denture only) (Fig. 1, A and B); (2) before
prosthetic rehabilitation with a mandibular stabilizing
base in position (existing maxillary complete denture
and mandibular stabilizing base in position) (Fig. 1, C
and D); and (3) after prosthetic rehabilitation (newmax-
illary complete denture and mandibular RPD) (Fig. 2).
Two methods were used to analyze the tomographic
images. Method A was a subjective analysis on the basis
Fig. 1. Subject 4. A, Existing maxillary complete denture without mandibular stabilizing base in maximal intercuspal position.
B, Tomograms of right and left TMJs seen in A. C, Existing maxillary complete denture with mandibular stabilizing base in
maximal intercuspal position. D, Tomograms of right and left TMJs seen in C.
THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL
510 VOLUME 89 NUMBER 5
of a method established by Pullinger and Hollender,
1
which consisted of linear measurement of the narrowest
joint spaces, both anterior (A) and posterior (P), with a
digital caliper (Starrett; Starrett Ltd, Itu, Brazil). The
values were transferred to the following formula from
Pullinger et al:
11
P A
P A
100
This equation determined the percentage of anterior or
posterior displacement of the condyle, with concentric-
ity as a reference. Results smaller than 12 indicated that
the condyles were in a posterior position; results ranging
from 12 to 12 indicated that the condyles were in a
concentric position; and results greater than 12 indi-
cated that condyles were in an anterior position. The
measurement was repeated 3 times to avoid errors, and
the arithmetic mean of the 3 values was recorded as the
nal result.
In method B (Fig. 3), drawings and tracings for each
TMJ were made on tracing paper with a 0.3-mm lead
pencil in accordance with Kamelchuk et al.
2
Posterior
and anterior joint spaces of all tomograms were mea-
sured with the digital caliper. The formula proposed by
Pullinger et al
11
to evaluate condylar position was used
with this method as well.
5
Because several different distances were obtained
from the tomograms of each patient, it was felt that
these measurements could be used for correlation pur-
poses. Repeated-measures analysis of variance followed
by orthogonal contrasts was considered appropriate for
statistical analysis of the data, because of its ability to
address the issue of covariation between measurements
in the same subject.
50
Among the available techniques,
prole analysis was chosen.
51
Differences were consid-
ered signicant at P.05.
Because measurements obtained by methods A and B
were based on the anterior and posterior joint spaces,
these 2 methods were compared. A single model was
adjusted for the statistical analysis, which included the
method of evaluation, joint side, and type of prosthesis
as factors and determined any interactions among these
factors.
RESULTS
The distribution of condylar positions on the right
and left sides are shown in Figures 4 (method A) and 5
(method B). Prole analysis (Fig. 6) showed that pros-
thesis type had a signicant effect (F
2,11
10.21,
P.003) but that the measurement method did not
(F
1,11
0.15, P.70). The mean distances obtained by
the 2 methods were considered equivalent.
An effect on the basis of the particular side seemed to
exist (in spite of a nding of F
1,11
2.94, P.11) be-
cause, on average, the gures representing the left side
condylar position were higher than those representing
the right side. This suggested that there was a distinct
behavior difference between the 2 sides, even though
the data from the study did not detect this difference.
Because no signicant effect of method was found, an-
other analysis was performed that included only side and
type of prosthesis as factors (Fig. 7). This second analysis
Fig. 2. Subject 4. A, New maxillary complete denture with mandibular RPD in maximal intercuspal position. B, Tomograms
of right and left TMJs seen in A.
Fig. 3. TMJ tomography with tracings used in Method B. A,
Anterior joint space; P, posterior joint space.
PINTAUDI AMORIM ET AL THE JOURNAL OF PROSTHETIC DENTISTRY
MAY 2003 511
indicated that the interaction of prosthesis and side was
not signicant (F
2,24
0.13, P.88). Nevertheless,
prosthesis alone (F
2,24
20.11, P.0001) and side
alone (F
1,24
5.55, P.03) signicantly affected the
condylar position.
The increase in the mean value of the condylar posi-
tions was signicant when a stabilizing base was added
to the existing maxillary complete denture (F
1,24

5.08, P.03), regardless of whether it was on the right
or left side. Likewise, the mean value of condylar posi-
tions increased signicantly after prosthetic rehabilita-
tion compared to the existing maxillary complete den-
ture without a stabilizing base (F
1,24
5.65, P.02),
and with a stabilizing base (F
1,24
4.59, P.04).
DISCUSSION
In this study, patients who had lost posterior support
showed a predominance of posterior condylar positions.
This reduction of the posterior intra-articular space may
Fig. 4. Method A results. A, Condylar positions on right side TMJ. B, Condylar positions on left side TMJ.
Fig. 5. Method B results. A, Condylar positions on right side TMJ. B, Condylar positions on left side TMJ.
Fig. 6. Mean proles of condylar position standard devi-
ation (in relation to method and side).
Fig. 7. Mean proles of condylar position standard devi-
ation (in relation to side but independent of method).
THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL
512 VOLUME 89 NUMBER 5
represent a compression on the bilaminar zone, which is
responsible for the blood supply and the nutrition of the
TMJ
26
and may also be related to the anterior displace-
ment of the joint disk.
20,21
It was observed that prosthetic rehabilitation caused
changes in the condyle/fossa relationship, reducing the
incidence of posterior condylar positions and increasing
the incidence of concentric condylar positions. After
prosthetic rehabilitation, the degree of retrusion was
observed to be smaller, even when the condyles re-
mained in a posterior position (retrusion). These nd-
ings were conrmed by statistical analysis, which dem-
onstrated that the mean values of condylar positions
increased (condyles moved to a more anterior position)
when a mandibular stabilizing base was added to the
existing complete denture before treatment. The in-
crease was even more pronounced after prosthetic reha-
bilitation with a new maxillary complete denture and a
mandibular RPD.
A larger incidence of concentricity was found on the
left side, conrming the results of other studies.
6,13
Con-
dylar asymmetry may be an indication of osseous unbal-
ance caused by different growth patterns or different
remodeling effects as a result of occlusal disturbance.
12
It was not the aim of this study to analyze the occur-
rence of unilateral chewers among the subjects evalu-
ated. Future studies should attempt to verify the possible
relationship between the asymmetry of the condylar po-
sition and the incidence of unilateral chewing. It is fur-
ther recommended that long-term follow-up controls
be established to assess whether the condylar position
after prosthetic rehabilitation is maintained.
Statistical analysis revealed no signicant difference
between the methods (A and B) used to evaluate the
position of the condyle. Method A is recommended
because it is easier and does not require drawings or
tracings.
CONCLUSIONS
Within the limitations of this study, subjects with a
maxillary complete denture but no RPDfor the partially
edentulous mandibular arch showed a predominance of
posterior condylar positions in maximal intercuspal po-
sition. Also, when mandibular stabilizing bases were
used during tomographic examination with the existing
maxillary complete dentures in maximal intercuspal po-
sition, a decrease in posterior condylar positions and an
increase in condylar concentricity were observed. After
prosthetic rehabilitation, more pronounced decreases in
posterior condylar positions and increases in concentric
condylar positions were observed in the maximal inter-
cuspal position. Regardless of when the condylar posi-
tions were analyzed (before or after rehabilitation), the
TMJ on the left side displayed a higher frequency of
concentric condylar positions than its counterpart on
the right side.
We thank Prof Israel Chilvarquer, for his encouragement, support
and valuable collaboration with the tomograms, and Dr Luiz Paulo
Restiffe de Carvalho, for his large contribution to this work.
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Reprint requests to:
DR VANIA C. P. AMORIM
RUA IBITIRAMA, 670
SAO PAULO
CEP: 03134-001
BRAZIL
FAX: 55-11-63471990
E-MAIL: pintaudi.amorim@bol.com.br
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1016/S0022-3913(03)00029-5
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porcelain
Harrington Z, McDonald A, Knowles J. Int J Prosthodont
2003;16:54-8.
Purpose. The aim of this study was to investigate the effect of occlusal veneer porcelain thickness
on the load at fracture of Procera AllCeram crowns.
Materials and Methods. Fifty resin dies were manufactured to incorporate the features of an
all-ceramic crown preparation on a premolar tooth. Fifty corresponding crowns were constructed
and divided into ve groups. Groups 1, 2, 3, and 4 were crowns with 0.6-mm-thick Procera cores
and 0.4-mm-thick axial veneer porcelain and occlusal veneer porcelain thicknesses of 0.0 mm, 0.4
mm, 0.9 mm, and 1.4 mm, respectively. Group 5 specimens consisted of 0.6-mmthick In-Ceram
cores with 0.4 mm of axial porcelain and 0.4 mm of occlusal porcelain. The crowns were cemented
onto their respective dies with a resin luting agent. Specimens were stored in distilled water at 37C
for 24 hours prior to placing them in a universal testing machine and applying a controlled
compressive load at a cross-head speed of 0.1 mm/min until fracture occurred.
Results. The mean loads at fracture were 419 N (group 1), 702 N (group 2), 1,142 N (group 3),
1,297 N (group 4), and 732 N (group 5). Statistical analysis revealed signicant differences (P
.05) in the load at fracture between the groups, except for between groups 2 and 5.
Conclusion. Increasing the thickness of the occlusal veneer porcelain increased the load at fracture
for Procera AllCeram crowns. There was no signicant difference in load at fracture between the
Procera and In-Ceram crowns.Reprinted with permission of Quintessence Publishing.
THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL
514 VOLUME 89 NUMBER 5