Professional Documents
Culture Documents
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Jina Lee Linton, DDS, MA, PhD, ABO Woneuk Jung, DDS
The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
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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
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
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.
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
KOREA
UNITED STATES
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.
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
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.
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.
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.
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.
RWLF Committee
Thank you to those individuals who serve on the Legacy Fund Committee.
Pledge Circle
10
Estate Planning
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.
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
11
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
12
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.
13
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
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.
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.
15
16
17
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.
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.
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.
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.
19
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
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 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
21
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 21-a The upper frame is placed and fastened to the head.
Figure 21-b Axis-locating arms are attached to the lower jaw.
22
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
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.
23
24
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
25
26
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
27
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
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
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).
29
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).
30
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
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).
31
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
Figure 72
33
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.
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.
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.
35
36
Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
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).
Matrix Metalloproteinases
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
37
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).
38
Tetracyclines
39
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
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
shows promise in curbing the bone loss associated with arthritis and condylar resorption (Figures 6-a, b, c, d, e).
41
References
1. Arnett GW, Milam SB, Gottesman L. Progressive mandibular
retrusion-idiopathic condylar resorption, II. Am J Orthod Dentofac
Orthop. 1996 August;110(2):117-27.
3. Gunson MJ, Arnett GW, Formby B, Falzone C, Mathur R, Alexander C. Oral contraceptive pill use and abnormal menstrual cycles in
women with severe condylar resor ption: a case for low serum 17betaestradiol as a major factor in progressive condylar resorption. Am J
Orthod Dentofac Orthop. 2009;136(6):772-779.
18. Abramson SB, Yazici Y. Biologics in development for rheumatoid arthritis: relevance to osteoarthritis. Adv Drug Deliv Rev.
2006;58(2):212-225.
6. Hwang SJ, Haers PE, Seifert B, Sailer HF. Non-surgical risk factors
for condylar resorption after orthognathic surgery. J Craniomaxillofac
Surg. 2004;32(2):103-111.
7. Cambray GJ, Murphy G, Page-Thomas DP, Reynolds JJ. The
production in culture of metalloproteinases and an inhibitor by joint
tissues from normal rabbits, and from rabbits with a model arthritis, I:
synovium. Rheumatol Int. 1981;1(1):11-16.
8. Murphy G, Cambray GJ, Virani N, Page-Thomas DP, Reynolds
JJ. The production in culture of metalloproteinases and an inhibitor
by joint tissues from normal rabbits, and from rabbits with a model
arthritis, II: Articular cartilage. Rheumatol Int. 1981;1(1):17-20.
9. Milner JM, Rowan AD, Cawston TE, Young DA. Metalloproteinase
and inhibitor expression profiling of resorbing cartilage reveals procollagenase activation as a critical step for collagenolysis. Arthritis Res
Ther. 2006;8(5):R142.
10. Dean DD, Martel-Pelletier J, Pelletier JP, Howell DS, Woessner
JF Jr. Evidence for metalloproteinase and metalloproteinase inhibitor imbalance in human osteoarthritic cartilage. J Clin Invest.
1989;84(2):678-685.
11. Burrage PS, Mix KS, Brinckerhoff CE. Matrix metalloproteinases:
role in arthritis. Front Biosci. 2006;11:529-543.
20. Miyamoto K, Ishimaru J, Kurita K, Goss AN. Synovial matrix metalloproteinase-2 in different stages of sheep temporomandibular joint
osteoarthrosis. J Oral Maxillofac Surg. 2002;60(1):66-72.
21. Yamaguchi A, Tojyo I, Yoshida H, Fujita S. Role of hypoxia and
interleukin-1beta in gene expressions of matrix metalloproteinases in
temporomandibular joint disc cells. Arch Oral Biol. 2005;50(1):81-87.
22. Tiilikainen P, Pirttiniemi P, Kainulainen T, Pernu H, Raustia A.
MMP-3 and -8 expression is found in the condylar surface of temporomandibular joints with internal derangement. J Oral Pathol Med.
2005;34(1):39-45.
23. Lai YC, Shaftel SS, Miller JN, et al. Intraarticular induction
of interleukin-1beta expression in the adult mouse, with resultant
temporomandibular joint pathologic changes, dysfunction, and pain.
Arthritis Rheum. 2006;54(4):1184-1197.
24. Yoshida K, Takatsuka S, Hatada E, et al. Expression of matrix metalloproteinases and aggrecanase in the synovial fluids of patients with
symptomatic temporomandibular disorders. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2006;102(1):22-27.
25. Srinivas R, Sorsa T, Tjaderhane L, et al. Matrix metalloproteinases
in mild and severe temporomandibular joint internal derangement
synovial fluid. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2001;91(5):517-525.
12. Miyamoto K, Ishimaru J, Kurita K, Goss AN. Synovial matrix metalloproteinase-2 in different stages of sheep temporomandibular joint
osteoarthrosis. J Oral Maxillofac Surg. 2002;60(1):66-72.
13. Mizui T, Ishimaru J, Miyamoto K, Kurita K. Matrix metalloproteinase-2 in synovial lavage fluid of patients with disorders of the temporomandibular joint. Br J Oral Maxillofac Surg. 2001;39(4):310-314.
27. Tanaka A, Kawashiri S, Kumagai S, et al. Expression of matrix metalloproteinase-2 in osteoarthritic fibrocartilage from human mandibular condyle. J Oral Pathol Med. 2000; 29(7):314-320.
14. Lai YC, Shaftel SS, Miller JN, et al. Intraarticular induction
of interleukin-1beta expression in the adult mouse, with resultant
temporomandibular joint pathologic changes, dysfunction, and pain.
Arthritis Rheum. 2006;54(4):1184-1197.
42
29. Zardeneta G, Milam SB, Lee T, Schmitz JP. Detection and preliminary characterization of matrix metalloproteinase activity in
temporomandibular joint lavage fluid. Int J Oral Maxillofac Surg.
1998;27(5):397-403.
30. Kubota E, Imamura H, Kubota T, Shibata T, Murakami K. Interleukin 1 beta and stromelysin (MMP3) activity of synovial fluid as
possible markers of osteoarthritis in the temporomandibular joint. J
Oral Maxillofac Surg. 1997;55(1):20-27.
31. Kubota E, Kubota T, Matsumoto J, Shibata T, Murakami KI. Synovial fluid cytokines and proteinases as markers of temporomandibular
joint disease. J Oral Maxillofac Surg. 1998;56(2):192-198.
32. Kanyama M, Kuboki T, Kojima S, et al. Matrix metalloproteinases and tissue inhibitors of metalloproteinases in synovial fluids of
patients with temporomandibular joint osteoarthritis. J Orofac Pain.
2000;14(1):20-30.
33. Marchetti C, Cornaglia I, Casasco A, Bernasconi G, Baciliero U,
Stetler-Stevenson WG. Immunolocalization of gelatinase-A (matrix
metalloproteinase-2) in damaged human temporomandibular joint
discs. Arch Oral Biol. 1999;44(4):297-304.
43. Arner EC, Hughes CE, Decicco CP, Caterson B, Tortorella MD.
Cytokine-induced cartilage proteoglycan degradation is mediated by
aggrecanase. Osteoarthritis Cartilage. 1998;6(3):214-228.
44. Amin AR, Attur MG, Thakker GD, et al. A novel mechanism of action of tetracyclines: effects on nitric oxide synthases. Proc Natl Acad
Sci U S A. 1996;93(24):14014-14019.
45. Borderie D, Hernvann A, Hilliquin P, Lemarchal H, Kahan
A, Ekindjian OG. Tetracyclines inhibit nitrosothiol production
by cytokine-stimulated osteoarthritic synovial cells. Inflamm Res.
2001;50(8):409-414.
46. Shlopov BV, Stuart JM, Gumanovskaya ML, Hasty KA. Regulation
of cartilage collagenase by doxycycline. J Rheumatol. 2001;28(4):835842.
47. Holmes SG, Still K, Buttle DJ, Bishop NJ, Grabowski PS. Chemically modified tetracyclines act through multiple mechanisms directly
on osteoclast precursors. Bone. 2004;35(2):471-478.
48. Bettany JT, Peet NM, Wolowacz RG, Skerry TM, Grabowski PS.
Tetracyclines induce apoptosis in osteoclasts. Bone. 2000;27(1):75-80.
49. Bettany JT, Wolowacz RG. Tetracycline derivatives induce apoptosis selectively in cultured monocytes and macrophages but not in
mesenchymal cells. Adv Dent Res. 1998;12(2):136-143.
36. Kanyama M, Kuboki T, Kojima S, et al. Matrix metalloproteinases and tissue inhibitors of metalloproteinases in synovial fluids of
patients with temporomandibular joint osteoarthritis. J Orofac Pain.
2000;14(1):20-30.
51. Yu LP Jr, Burr DB, Brandt KD, OConnor BL, Rubinow A, Albrecht
M. Effects of oral doxycycline administration on histomorphometry
and dynamics of subchondral bone in a canine model of osteoarthritis.
J Rheumatol. 1996;(23):137-142.
37. Golub LM, Lee HM, Ryan ME, Giannobile WV, Payne J, Sorsa T.
Tetracyclines inhibit connective tissue breakdown by multiple nonantimicrobial mechanisms. Adv Dent Res. 1998;(12):12-26.
52. Yu LP Jr, Smith GN Jr, Brandt KD, Myers SL, OConnor BL, Brandt
DA. Reduction of the severity of canine osteoarthritis by prophylactic
treatment with oral doxycycline. Arthritis Rheum. 1992;(35):11501159.
38. Golub LM, Lee HM, Greenwald RA, et al. A matrix metalloproteinase inhibitor reduces bone-type collagen degradation fragments and
specific collagenases in gingival crevicular fluid during adult periodontitis. Inflamm Res. 1997;(46):310-319.
53. Stone M, Fortin PR, Pacheco-Tena C, Inman RD. Should tetracycline treatment be used more extensively for rheumatoid arthritis?
Metaanalysis demonstrates clinical benefit with reduction in disease
activity. J Rheumatol. 2003;30(10):2112-2122.
39. Smith GN Jr, Mickler EA, Hasty KA, Brandt KD. Specificity of inhibition of matrix metalloproteinase activity by doxycycline: relationship
to structure of the enzyme. Arthritis Rheum. 1999;42(6):1140-1146.
54. Sreekanth VR, Handa R, Wali JP, Aggarwal P, Dwivedi SN. Doxycycline in the treatment of rheumatoid arthritis--a pilot study. J Assoc
Physicians India. 2000;(48):804-807.
56. Golub LM, Sorsa T, Lee HM, et al. Doxycycline inhibits neutrophil
(PMN)-type matrix metalloproteinases in human adult periodontitis
gingiva. J Clin Periodontol. 1995; 22(2):100-109.
57. Baxter BT, Pearce WH, Waltke EA, et al. Prolonged administration
of doxycycline in patients with small asymptomatic abdominal aortic
aneurysms: report of a prospective (phase II) multicenter study. J Vasc
Surg. 2002;36(1):1-12.
43
44
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-
45
46
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-
47
Figure 1-b
48
Figure 2-b.
49
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
50
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
52
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
References
1. McCollum BB. The mandibular hinge axis and a method of locating
it. J Prosthet Dent. 1960;(10): 430-435.
2. Okeson JP. Functional Anatomy and Biomechanics of the Masticatory System: Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis, MO: Mosby; 1998: 3-38.
3. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod.
1981;(15):32-51.
4.Posselt, U. Terminal hinge movement of the mandible. J Prosthet
Dent. 1957;(7): 787-796.
5. Glossary of prosthodontic terms. J Prosthet Dent. 1987; (58): 721.
6. Gordon SR, Stoffer WM, Connor SA. Location of the terminal hinge
axis and its effect on the second molar cusp position. 1984;(52): 99105.
7. Starcke EN. The history of articulators: from face-bows to the
gnathograph, a brief history of early devices developed for recording
condylar movement, Part II. J Prosthet Dent. 2002;(11): 53-62.
8. Winstanley RB. The hinge-axis: a review of the literature. J Oral
Rehab. 1985;(12): 135-139.
9. Klar NA, Kulbersh R, Freeland TD, Kaczynski R. Maximum tntercuspation- centric relation disharmony in 200 consecutively finished cases in
a gnathologically oriented practice. Semin in Orthod. 2003;(9): 109-116.
54
55
Notes
56
Notes
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
57
Case Reports
The six cases below show individual clinical cases with various severity of attrition with or without treatment.
58
Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
59
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
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).
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
61
62
Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
63
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 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).
Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
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).
65
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
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).
Only after additive coronaplasty could a complete elimination of eccentric occlusal interferences be achieved with
excursive movements of the mandible (Figure 21).
66
Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
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.
67
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.
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.
68
Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
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-
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
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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74
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
used at the end of orthodontic treatment to settle the occlusion while maintaining
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).
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-
75
76
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.
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.
77
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
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
Standard
Error
.189
.213
.214
.162
.224
3.025
2.791
0.915
3.047
3.490
.006*
.009*
.369
.005*
.002*
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
79
Discussion
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
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
1. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 3rd ed. St Louis, MO: Mosby; 1998:109-125.
2. Schmitt ME, Kulbersh R, Freeland T, et al. Reproducibility of the
Roth power centric in determining centric relation. Semin in Orthod.
2003;9(2):102-108.
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Notes
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Notes
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RWISO 2011