MAXILLOFACIAL PROSTHETICS

TEMPQROMANDIBULAR JOINT . DENTAL IMPLANTS

SECTION EDITORS

I. KENNETH ADISMAN LOUIS J. BOUCHER

Studies on the validity of the terminal hinge axis

C. C. Beard, D.D.S., M.S.,* and J. A. Clayton, D.D.S., M.S.**
University of Michigan, School of Dentistry, Ann Arbor, Mich.

I f a single terminal hinge axis exists, then centric

relation registrations can be made at an increased
placed along a protrusive path. All styli were said to
rotate, without arcing, thus showing a different
vertical dimension of occlusion on a patient. This terminal hinge axis point for each styli. Their con-
record can be transferred to mounted casts on an clusions were more emphatic that multiple hinge
articulator, and the cast can be closed into the same axes do exist and the concept that only one terminal
centric relation as in the patient’s mouth. This axis existed was “fallacious.” However, the discrep-
concept, based on the existence of only one terminal ancies between Trapozzano and Lazzar? and Aull”
hinge axis in a position synonomous with centric might depend more on the accuracy of the apparatus
relation, was established by McCollum and Stuart.’ and techniques used rather than on the validity of
Studies in the past have shown that, by using various the hinge axis registration.
instruments attached to a patient, there is a single, Kurth and Feinstein,” using visual perception and
reproducible terminal hinge axis. Other studies, an articulator, could not achieve an accuracy of less
using different instruments attached to a patient’s than 2 mm in locating the articulator hinge axis.
jaw, have shown the existence of multiple terminal However, Santa@ used an electrical device to elimi-
hinge axes and suggest that the concept of one nate the error of the human eye and found that the
terminal hinge axis is faltacious. terminal hinge axis could be located accurately
Trapozzano and Lazzari’ showed that patients within 0.15 mm error on an articulator and within
have more than one terminal hinge axis. In 1961, 0.3 mm error on a subject. The question of the type
they reported that 57.2% of their patients had more of apparatus used for hinge axis determination was
than one “condylar axis point.” This led them to raised recently by Preston’ in his study of the
conclude that “the high degree of infallibility attrib- mandibular horizontal axis theory. .He stated that
uted to hinge axis points may be seriously ques- the observations of Trapozzano and Lazzari may
tioned.“’ Aull,” however, questioned the accuracy of have been attributed to the evasiveness of a single
their study. He used four flags and four styli placed definite arc center when a traditional hinge axis
on long bars to show that “the horizontal axis is a location apparatus was used. Preston also suggested
hypothetical line connecting the two horizontal that multiple hinge axis centers with a single arc defy
rotation centers of the two condyles of the mandi- geometric laws. However, to date, no investigations
ble.” Aull’s results gave no evidence to lead him to have been reported to disprove Trapozzano and
believe that there was more than one hinge axis Lazzari’s hypothesis.
location. He also concluded that the accuracy of the This study was initiated to determine whether the
location of the terminal hinge position was a matter results of their study would have been different had
of interpretation. Trapozzano and Lazzari used a different apparatus.
In 1967, Trapozzano and Lazzari’ reported a To test this hypothesis, the recording apparatus they
study to offer additional evidence of the presence of used was changed to one where the arcs were
multiple terminal hinge axis points and stated that recorded on paper, thus eliminating the errors of
these multiple points followed a pattern. They dem- visual perception.
onstrated multiple hinge axes using multiple styli
MATERIAL AND METHODS
The subject for this study was a completely
*Assistant Professor, Department of Crown and Bridge. dentulous 45-year-old woman. Examination of the
**Professor, Department of Crown and Bridge, muscles and temporomandibular joints (TMJ)

00’22-3913/81/080185 + 07$00.70/08 1981 The C. V. Mosby Co. THE JOURNAL OF PROSTHETIC DENTISTRY 185
 BEARD AND CLAYTON

Fig. 2. A, Flag. B, Modified hinge axis location. Both are

used to locate terminal hinge axis. Additional styli permit
recording of more than one position at a time.

Maxillary and mandibular casts, obtained from

irreversible hydrocolloid impressions, were mounted
on a Denar D5-A fully adjustable articulator (Denar
Corp., Anaheim, Calif.). Orientation of the casts was
made by using a face-bow transfer and centric
relation records. The casts were surveyed, and exist-
ing undercuts on the soft tissues and the teeth were
blocked out.
Custom clutches were fabricated by adapting
baseplate wax to the occlusal and buccolingual
Fig. 1. Acrylic resin clutches used to attach the hinge surfaces of the teeth and tissue on the casts. Care was
axis apparatus to the maxillae and mandible. A, Bearing taken to place a minimal thickness of wax over the
screw contacts bearing plate. B, Bearing plate records occlusal surfaces to minimize the opening of the
Gothic arch tracing for checking consistency of numerous vertical dimension of occlusion by the clutches.
closures.
Modified cross-bar assemblies, embedded into the
wax at the anterior section of each clutch, were used
revealed that the right anterior temporal and right to attach the hinge axis flag and the styli holders. A
lateral pterygoid muscles were tender to palpation. metal-bearing surface plate was positioned anterior
The subject was treated with a complete occlusal to the mandibular incisors and posterior to the rod
coverage maxillary splint to relieve muscle incoordi- attachment. An adjustable bearing screw was posi-
nation. The occlusal splint was adjusted for even tioned in the maxillary clutch, opposing the bearing
contact of all teeth in centric relation, and lateral surface. Both waxed clutches were processed in
guidance was controlled by the canines. There were heat-curing acrylic resin (Fig. 1).
no balancing contacts or protrusive interferences on The posterior styli assembly was modified to
the opposing posterior teeth. The subject wore the incorporate four styli onto the horizontal arm. Trac-
occlusal splint ‘24 hours a day. Frequent adjustments ing pressure and location were adiustable for each
were made to maintain the occlusal scheme. stylus, allowing multiple placement of the styli
A 3-month period elapsed before there was relief concurrently. Plain roll, nonlined pressure-sensitive
of all symptoms. An occlusal adjustment performed paper (Graphic Control Corp., Medical Division,
on the teeth was refined in each of several appoint- Buffalo, N.Y.) was used on the recording flag to
ments. The subject was then monitored for TMJ register a thin permanent recording (Fig. 2).
dysfunction, using the pantographic reproducibility Completed clutches and the recording apparatus
index (PRI).“, ’ The study proceeded only after the were mounted on the articulator for the laboratory
relief of all symptoms and the registration of a low phase of the study (Fig. 3). The hinge axis of the
PRI score. (A score of 4 was considered good.) articulator was found through arc:ing the articula-

186 AUGUST 1981 VOLUME 46 NUMBER 2

TERMINAL HINGE AXIS

Fig. 3. Clutches, flag, and hinge axis recorder assembly

on articulator in laboratory phase of study.

tor, locked in centric position, and opening and

closing while the position of one of the posterior styli Fig. 4. Upper member of articulator was held stationary
was adjusted. From the terminal hinge axis point, a while lower member was opened on a hinge movement,
protrusive movement was made and recorded by a analagous to movement of subject. Note that styli over
posterior stylus. The remaining three styli were axis rotates (no arcing), while styli along protrusive path
positioned along this path. Arcing movements of the produce arcs.
articulator were made again and recorded by the
styli on the flag (Fig. 4). checked by placing the stylus against the recording
The clutches were placed in the subject’s mouth paper to see if an arc was recorded. The position of
for the clinical phase of the study. Retention and no arcing was accepted as the terminal hinge axis. If
stability were assessed first. The only desired contact a stylus was positioned and an arc was recorded, it
between the clutches was that of the bearing screw could not be considered in the terminal hinge axis
on the bearing plate. All acrylic resin contacts position.
between the clutches were eliminated. The clutches With the posterior stylus on the terminal hinge
were secured in place with polyether impression axis, the subject performed a protrusive movement
material. while keeping the bearing screw in touch with the
An arbitrary hinge axis was marked on the flag to bearing plate. This movement was traced on the
serve as a starting point for positioning the flag and recording paper. The mandible was repositioned to
styli assemblies (Fig. 5, A). The flag and styli were the terminal hinge axis location with the posterior
secured on the cross-bars as close to the skin as stylus over the located point. The arcing of the stylus
possible without contacting it (Fig. 5, B). was again verified. The remaining styli were placed
Dentist No. 1 (JAC) concentrated his efforts on anteriorly along the protrusive path at distances of
arcing the subject’s mandible along the terminal 2.2, 5.2, and 12.0 mm (Fig. 6). With all styli
hinge axis. Guidance was given to the subject recording, the patient was guided through opening
through thumb pressure on the chin with the den- arcs while on the terminal hinge axis. The terminal
tist’s first finger under the chin. Dentist No. 2 (CCB) hinge closure was verified to be the s.ame each time
used the microadjustable side arms to adjust a by using the apex of the Gothic arc tracing on the
posterior stylus toward the center of the arcs. Pure bearing plate as a reference point.
rotation of the stylus without arcing was verified In our search for alternate hinge axes, the styli
through a X 7 magnification lens. When the termi- assembly was moved inferior to see if other terminal
nal hinge axis was located, dentists Nos. 1 and 2 hinge axes existed. Again a protrusive path was
exchanged positions to verify the accuracy of the registered, and the styli were positioned on this line.
recordings. The terminal hinge axis was further The subject’s mandible was guided through an

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 BEARD AND CLAYTON

Fig. 6. Multiple styli placement along protrusive path

was used to record points simultaneously. One stylus has
been removed to show arc that was recorded. This was
suggested by Trapozzano and Lazzari.’

laboratory study, the styli were po:sitioned on the

protrusive path extending from the terminal hinge
axis. Recordings were made while the articulator was
arced in open and closed movements. Only the stylus
over the terminal hinge axis produced pure rotation
without arcing. Styli positioned anterior to or away
from the axes produced arcs. The length of each arc
increased in proportion to the distance the stylus was
Fig. 5. A, Hinge axis apparatus attached to the clutches. anterior to the terminal hinge axis (Fig. 4).
B, Modified hinge axis locator placed on subject for In the clinical phase, the arcing of the subject’s
clinical phase of study.
mandible produced arcs on all styli except the one on
the terminal hinge axis. The stylus at 2.2 mm
opening movement. This entire procedure was registered an arc of 0.2 mm in length. The stylus at
repeated several times, and each time the styli 5.2 mm scribed a 0.5 mm arc; and the stylus at 12.0
assembly was moved inferiorly. mm scribed a 0.7 mm arc (Fig. 7). These arcs were all
The study was extended further by surrounding produced while moving the subject’s mandible
the terminal hinge axis point with the four styli. The through a 10 mm arc at a point 100 mm anterior to
subject’s mandible was arced opened and closed the terminal hinge axis. The length of the scribed
while the styli recorded simultaneously anteriorly, arcs was measured using a caliper with a dial
posteriorly, superiorly, and inferiorly to the terminal gauge.
hinge axis. With new recording paper in place, the terminal
Materials and methods in this study duplicate hinge axis stylus was lowered below the terminal
those established by Trapozzano and Lazzari as hinge axis point and a new protrusive path was
closely as possible. The main difference between the recorded. Styli were again positioned along this
two studies was in the method of recording the path. The dentist guided the opening of the subject’s
arcing of the styli. The styli tracings on recording mandible. Each stylus traced an arc. No stylus
paper indicated the arcing or lack of it rather than produced pure rotation. The arcs on the flag were of
visual perception. When the opening and closing a length proportional to their distance from the
movements were made, a terminal hinge axis was the terminal hinge axis (Fig. 8). No alternate terminal
point where no arcing of the stylus was recorded on hinge axis points were recorded at this new posi-
the paper. tion.
The terminal hinge axis stylus was again lowered,
RESULTS and the procedure was repeated. A.rcing was again
The laboraotry phase was used to test the hypoth- produced by each stylus. All styli arced and failed to
esis and check the recording apparatus. In the register new terminal hinge axis points (Fig. 8). Even

188 AUGUST 1981 VOLUME 46 NUMBER 2

TERMINAL HINGE AXIS

t t
4 3

Fig. 7. Enlargement of protrusive path recording shown in Fig. 6. Placement of three styli
along protrusive path in this photograph shows arcs for styli at positions 43, and 4. Stylus No.
4 was extended beyond protrusive path to show increase in arc size as styli are positioned
away from terminal hinge axis. Only one terminal hinge axis (position No. 1) was recorded
during this recording. Portion of a millimeter ruler was photographed along with tracings tc
show size and distance relationships.

Fig. 8. Enlargement of protrusive paths and styli recording made during opening move-
ments. Trapozzano and Lazzari” claimed that multiple terminal hinge axes could be located on
different protrusive paths. In this photograph, styli were positioned at points 1, 2, 3, and 4
along different protrusive paths A, B, C, and D. There was only one position where stylus
rotated, without arcing, and that was position No. 1 on path A. All other styli placements
produced arcs of varying length depending on their relationship to terminal hinge axis. Path
tracing for D was not recorded so that arcs would be obvious. Some arcs near and below
terminal hinge axis were in line with protrusive paths B and C.

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 BEAKD AND CLAYTON

Fig. 9. Styli were placed anterior A, posteriorly P, superiorly S, and inferiorly I to the located
terminal hinge axis point in center. Note that stylus on terminal hinge axis point did not arc.
This photograph shows arcing of styli placed in any position other than terminal hinge
axis.

position No. 1 on protrusive path to B, C, and D were They administered two Fiorinal tablets 1 hour prior
arcs. to the procedure. In our study, the ease of manipu-
With new recording paper in place, the styli were lating the mandible to locate the terminal hinge axis
positioned superiorly, inferiorly, anteriorly, and pos- was related to the amount of muscle splinting and
teriorly to the terminal hinge axis recorded arcs incoordination of the muscles of mastication. No
while the subject’s mandible was opened. All record- drug therapy was administered. Occlusal splint ther-
ings were arcs that had centers originating at the apy was used until there were relief of symptoms,
terminal hinge axis. No styli recorded pure rotation, ease of mandibular manipulation, and reproducible
and no new terminal hinge axes were produced pantographic tracings. Occlusal splint therapy was
(Fig. 9). followed by occlusal adjustment therapy to remove
occlusal interferences and maintain muscle coordi-
DISCUSSION nation. This regimen of therapy assured an ease of
The skill to accurately record the terminal hinge mandibular manipulation without medication.
axis is determined by the operator’s visual acuity to If muscle splinting existed, a bracing of the man-
discern small distances. When a subject’s mandible is dible or condyle was possible. When trying to locate
opened and closed 10 mm at a distance 100 mm from axes close to the terminal hinge axis position, the
the terminal.hinge axis, it is relatively easy to see the splinted muscles could produce a point where an arc
movement. When the stylus approaches within 1 should register. When dealing in tenths of millime-
mm of the terminal hinge axis point, this same ters, such distortions are probable unless preventive
subject will only scribe a 0.1 mm arc. Inside of 1 mm measures are taken.
concentration, visual perception and skill are In our endeavor to locate alternate terminal hinge
demanded of the dentist to approach the terminal axis points, styli were placed in several locations.
hinge axis. In this manner, small arcs can be viewed They were placed above, behind, below, and in front
as pure rotation and interpreted as alternate termi- of the terminal hinge axis, as well as on protrusive
nal hinge axis points. paths inferior to the terminal hinge axis. No alter-
Trapozzano and Lazzari’ previously stated that nate terminal hinge axis points were found, nor was
the ease with which these registrations can be made there a pattern leading to any additional points.
depended on the emotional condition of the subject. The results of this study indicate that apparatus

190 AUGUST 1951 VOLUME 46 NUMBER 2

TERMINAL HINGE AXIS

and procedures were at fault and not the concept of a 2. Trapozzano, V. R., and Lazzari, J. D.: A study of hinge axis
single terminal hinge axis. The methods used in the determination. J PRO~THET DENT 11:858, 1961.
3. Aull, A. E.: A study of the transverse axis. J PROSTHET DENT
investigation by Trapozzano and Lazzari’ were fol-
13:469, 1963.
lowed. Using a different means of determining 4. Trapozzano, V. R., and Lazzari, J. D.: The physiology of the
arcing or nonarcing of the styli tips, the authors terminal position of the condyles in the ternporomandibular
recorded one terminal hinge axis. Whereas, Trapoz- joint. J PROSTHET DENT 17:122, 1967.

zano and Lazzari, using visual perception found 5. Kurth, L. E., and Feinstein, J. K.: The hinge axis of the
mandible. J PROSTHET DENT 1:327, 1951.
multiple terminal axis points.
6. Santos, J. L.: An Electrical Device to Locate the Terminal
This investigation substantiates other studies that Hinge Axis. Thesis, University of Michigan, School of
reported the presence of only one terminal hinge Dentistry, 1969.
axis. 7. Preston, J. D.: A reassessment of the mandibular transverse
horizontal axis theory. J PROSTHET DENT ,41:605, 1979.
CONCLUSIONS 8. Shields, J. M., Clayton, J. A., and Sindledecker, L. D.: Using
pantographic tracings to detect TMJ and muscle dysfunc-
1. Trapozzano and Lazzari’s’ study was repro- tions. J PROSTHET DENT 39:80, 1978.
duced, and the results were different when a differ- 9. Crispin, B. J., Myers, G. E., and Clayton, J. A.: Effects of
ent means of determining the arcing of the styli were occlusal therapy on pantographic reproducibility of mandib-
used. ular border movements. J PROSTHET DENT 40:29, 1979.

2. Using an apparatus that records arcs on paper, Reprint requeststo:

there is only one stylus position where no arcing DR. CHARLES C. BEARD
occurs. This position is the terminal hinge axis. UNIVERSITY OF MICHIGAN
SCHOOL OF DENTISTRY
REFERENCES ANN ARBOR, MI 48109
1. McCollum, B. B., and Stuart, C. E.: A Research Project.
South Pasadena, Calif., 1955, Scientific Press.

THE JOURNAL OF PROSTHETIC DENTISTRY 191