Rwiso Journal Sept2010

Contents
Volume 2, No. 1, September 2010

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Robert L. Vanarsdall, DDS ɵ $QWRQLQR*6HFFKL'0'06
The Transverse Dimension: Diagnosis and Relevance to Functional
Occlusion
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Hinge Axis: The Need for Accuracy in Precision Mounting: Part 2
Michael J. Gunson, DDS, MD ɵ *:LOOLDP$UQHWW''6)$&' 37

Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines
Dori Freeland, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 45

Richard Kulbersh, DMD, MS, PLC ɵ 5LFKDUG.DF]\QVNL%6063K'
Comparison of Maxillary Cast Positions Mounted from a True Hinge
Kinematic Face-Bow vs. an Arbitrary Face-Bow in Three Planes of Space
Jina Lee Linton, DDS, MA, PhD, ABO ɵ :RQHXN-XQJ''6 57

The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
Andrew Girardot, DDS, FACD 69

Physiologic Treatment Goals in Orthodontics
:HVOH\0&KLDQJ, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 75

Richard Kulbersh, DMD, MS, PLC ɵ 5LFKDUG.DF]\QVNL%6063K'
Effect of Gnathologic Positioner Wear on Maximum Intercuspation
CR Disharmony
RWISO Journal | September 2010 1

RWISO Journal is published by the Roth Williams International Society
of Orthodontists.
Copyright © 2010 RWISO. All Rights Reserved.
ISSN 2154-4395 (print)

ISSN 2154-4409 (online)
Reproduction whole or in part in any form or medium without express

written permission of RWISO is prohibited. Information furnished in
this journal is believed to be accurate and reliable; however, no respon-
sibility is assumed for inaccuracies or for the information’s use.
RWISO JOURNAL Postmaster:

SEPTEMBER 2010 VOL. 2, NO. 1 Send address changes to
RWISO
EDITOR IN CHIEF 1712 Devonshire Road
Dr. Thomas K. Chubb Sacramento, CA 95864
RWISO Journal
EXECUTIVE DIRECTOR/ADVERTISING SALES
Roth Williams International Society of Orthodontists
Jeff Milde 1712 Devonshire Road
Sacramento, CA 95864 USA
MANAGING EDITOR Phone: 916-270-2013
Anne Evers Fax: 866-746-3815
info@rwiso.org
CREATIVE DIRECTORS
Brad Reynolds (www.integralartandstudies.com) 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 embodi-

ment 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 Immediate Past President
Centerville, OH 45459 USA Dr. Darrell Havener
937-433-9530 1420 West Canal Court, Region II - Europe
samuel_king@hotmail.com Suite 200 Dr. Claudia Aichinger
Littleton, CO 80120 USA Billrothstr. 58 Region IV - South America
President Elect 303-791-2021 Vienna, A-1190 Austria Dra. Solange M. deFantini, MSD
Dr. Douglas Knight, DMD dhavener@gmail.com +43-1-367-7222 Al Janu 176 cj 42
3210 Westport Green Place smile@draichinger.at Sao Paulo, SP 01420-002 Brazil
Louisville, KY 40241 USA Executive Director +55-11-3081-8440
502-327-6453 Jeff Milde Dr. Renato Cocconi smfantin@usp.br
knightortho@insightbb.com 1712 Devonshire Road Via Traversante, San Leonardo 1
Sacramento, CA 95864 USA 43100 Parma, Italy Dra. Marisa Gianesella Bertolaccini
Vice President 916-270-2013 +0521-273682 Rua Tabapuã, 649 - Conj. 83
Dr. Renato Cocconi j.milde@mra-sf.com orthosmile@studiococconi.it Itaim Bibi, São Paulo, SP, 04533-
Via Traversante, San Leonardo 1 012 Brazil
43100 Parma, Italy Dr. Domingo Martin +11- 505-25417
+0521-273682 COUNCIL MEMBERS
Plaza Bilbao 2-2A mgianesella.odonto@gmail.com
orthosmile@studiococconi.it Region I - Asia San Sebastian, 20005 Spain
Dr. Satoshi Adachi +34-943-427-814
Secretary martingoenaga@arrakis.es
Dr. Eunah Choi #202, 5-11-8 Minoh
Somang BD 2F, 907-1 Minoh, Osaka 562-0001 Japan
+81-72-724-2866 Region III - USA, Canada
Bangbae 1 Dong
Seocho Gu teeth@adachi-ortho.com Dr. Ramon Marti, MSC
Seoul, 137-842 Korea 281 Oxford Street E.
+822-583-2275 Dr. Eunah Choi London, Ontario N6A 1V3
orthoi@hanmail.net Somang BD 2F, 907-1 Canada
Bangbae 1 Dong 519-672-7740
Treasurer Seocho Gu rmarti3@hotmail.com
Dr. John F. Lawson, MS Seoul, 137-842 Korea
2460 Nwy 63 North +822-583-2275
Rochester, MN 55906 USA orthoi@hanmail.net
507-282-6447
jlawdds@aol.com
2
Letter from the President
Samuel B. King, DDS, MS

RWISO President
The world is changing rapidly. Technology is enabling us to do things never
before possible. Orthodontics is changing too. New technologies, evolution
of procedures, ease in obtaining information are just a few of the things that
are advancing the orthodontic profession. The Roth Williams International
Society of Orthodontists continues to evolve to provide the very best for our
patients, but as we move forward with these new technologies, we are ever
mindful of our treatment goals and the standards of our philosophy.
The RWISO Journal embodies our commitment to remain true to our treat-
ment goals and the standards of our philosophy. As orthodontic treatment
changes, it is our duty to ensure, through evidence-based research, that new
techniques and modalities achieve our goals and maintain our standards. Our
Journal serves to educate our global organization about these advancements
so that our members can confidently deliver the Roth Williams goals and
standards to their patients.
The Roth Williams International Society of Orthodontists is in the midst of

an exciting time. Today we are able to treat our patients better than ever be-
fore with exciting new advancements in our profession. It is truly a great time
to be part of the Roth Williams International Society of Orthodontists.
Respectfully,
Samuel B. King, DDS, MS

RWISO President

Letter from the Editor
Thomas Chubb, DDS I would first like to thank all the authors in this year’s Journal for the amount of time
Editor-In-Chief of RWISO Journal 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 Irene’s 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. Unfortu-
nately, we meet only once a year to reconnect with our far-flung colleagues to rein-
vigorate 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 clini-
cal 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 record-
ing 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.
Thomas Chubb, DDS

Editor-in-Chief
tkchubb1@earthlink.net
4 Dr. Thomas Chubb | Letter from the Editor

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ARGENTINA group meeting, our program includes 3 activities—a participant pre-

sentation on a given theme, a clinical case presentation and discussion,
We are pleased to announce that in May of this year we began the Roth and a talk on a new topic of current interest. This format has made the
Williams FACE (The Foundation for Advanced Continuing Education) study group very popular.
Course in cooperation with the Catholic University of Argentina. Dr.
Oscar Palmas, Dr. Guillermo Ochoa and Dr. Eduardo Rubio (surgeon) We plan to start a new CCO group in June 2011.
were he instructors for this course. They had the honor of working
alongside Dr. Domingo Martin and Dr. Jorge Ayala. The highlight was a Finally, we are considering organizing a memorial meeting for all South
lecture given by Dr. Martin on interdisciplinary treatment. America in São Paulo in November 2010.
Many feeder courses were developed this year in different provinces, Dra. Marisa Gianesella Bertolaccini
including Salta, Jujuy, Rio Gallegos and Santiago del Estero. More than Director, Roth Williams Center Brazil
300 hundred students were taught about the Roth Williams philoso-
phy. In September 2011, Dr. Jorge Ayala will give a feeder course
entitled “Biomechanical Treatment in Roth Philosophy.”
CHILE
For next year we are planning a Roth Williams FACE national meeting
in Jujuy, an Argentinean province. The Roth Williams Center Argen- As is traditional, our educational activities have remained very active
tina will participate in the Mendoza Society Orthodontic Meeting in through continuing courses, 2- or 3-day courses, and participation
September. Dr. Oscar Palmas will give a lecture on self-ligation and in various meetings. We are currently offering long-term courses in
micro-screw in Roth Philosophy. Mexico (two), Argentina, Paraguay, and Chile with a total of 170
students. In 2009 thru 2010 we held 34 courses.
We are very happy to see the poster contributions for the Rome meet-
ing from our Roth Williams students. We would also like to take this In 2010 we will offer two new continuing courses, one in Michoacán,
opportunity to congratulate the Journal on its second issue. We encour- México, and the other one at the Universidad de Tucumán, Argentina.
age you all to continue working!! A course in Brazil, to be held in collaboration with Dr. Solange Fantini,
is also being organized.
Dr. Oscar Palmas
Director, Roth Williams Center Argentina Drs. Jorge Ayala and Gonzalo Gutierrez
Directors, Roth Williams Center Chile
BRAZIL
JAPAN
The Brazilian Center began a new CCO group in June 2009. It has
attracted students from the northwest to the southwest of Brazil. Dr. We are pleased to announce that we now have 45 members. Members
Fantini has been traveling to various places in Brazil to spread the are doctors who have graduated from the 2-year course and have also
Roth Philosophy. She has been teaching courses and has even lectured presented cases with stable and repeatable jaw position. Each year we
at an advanced-level specialization course, where her talks about the hold an annual meeting where each participant shows his/her cases
Philosophy have become a tradition. treated according to the Roth philosophy. Along with the annual meet-
ing, we are now preparing for the 15th anniversary meeting in Tokyo
In October 2010, the SPO meeting, which is the most important meet- on November 28-29. This meeting is open to all interested doctors.
ing in Latin America, will take place in Brazil. Dr. Fantini will speak We are expecting a great attendance. We of course welcome RWISO
on Roth’s Philosophy: multidisciplinary treatment of skeletal class II members from all over the world.
malocclusion with bilateral condylar degeneration and generalized root
resorption. 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
Since 2009 four abstracts have been published in conference proceed- instructor. The 14th basic course will be held in the fall.
ings, three articles have been accepted in orthodontic magazines, and
two book chapters have been dedicated to the Roth Philosophy. Dr. Dr. Kazumi Ikeda
Fantini has participated in 10 MA, PhD, and qualifying examinations Director, Roth Williams Center Japan
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 for-
mula to deepen the knowledge of those who took the CCOs. At each continued on next page...

KOREA UNITED STATES
In March 2010 the eighth Roth Williams International Seminar was New and exciting things are happening within the Advanced Educa-
held. The 10 participants in the course were instructed by Drs. Byung- tion in Orthodontics (AEO) group. In June of 2010, Group VIII will
taek Choi, Eunah Choi, and Gyehyeong Lee. All participants enthusias- have their graduation. Group VIII is the largest class, with 25 doctors.
tically took part in the course. A total of 125 doctors have finished the rigorous seven sessions. The
directors have been extremely uplifted by the positive responses given
As visiting professors, Drs. Byungtaek Choi and Eunah Choi lectured by the graduates as to their overall educational experience. Comments
on the Roth philosophy to the residents of the Department of Ortho- like this are the usual: “Keep up the good work. I thank you daily in
dontics at the Seoul National University Dental Hospital. The lectures the back of my mind for telling me I needed to take this course and
were held weekly during the month of June 2010. 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
The Roth Williams Center Korea has been encouraging our members are, I feel light years ahead of them and my GP’s thank you.” Ben.
to contribute to the Roth Williams Legacy Fund. We expect a desirable
outcome by the 2010 annual meeting in Rome. The course is continuing to improve and evolve without sacrificing any
of the Roth Williams basics. Techniques such as the true horizontal
Dr. Eunah Choi hinge axis mountings combined with true horizontal hinge axis 3-D
Director, Roth Williams Center Korea imaging have been introduced to improve accuracy of diagnosis and
treatment planning. In the past, AEO was successful in improving the
Visual Treatment Options (VTO) both in ease of use and in teaching
SPAIN technique. Now the course incorporates the latest in 3-D technology.
Without any doubt 2009 was a great year for RW Spain/Portugal. The directors have been instrumental in developing software that en-
Concerning the RW 2-year course, this year we finished group number hances the efficiency of orthodontic diagnosis and treatment planning.
10 (26 students) and we started group number 11 (28 students). The The next step is to develop 3-D software that is based on the true hinge
2-year course has truly grown to be a comprehensive orthodontic axis. This is being handled by Dr. Robert Frantz.
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. Dr. Andrew Girardot is responsible for editing and publishing the long-
They are Drs. Alberto Canabez from Barcelona, Eugenio Martins awaited Roth Williams Philosophy textbook. Because of the substantial
from Portugal, and Iñigo Gomez from Bilbao. All three of them have commitment required for this important project, Andy will not be
contributed to the excellent quality of the RW course. Apart from these teaching formally until his work on the book is complete.
full-time teachers, we have also incorporated into our courses experts
in the different fields of dentistry, who have come and taught differ- The true standard wide archform (SWA) system that Dr. Roth developed
ent sessions. They are Dr. Iñaki Gamborena, prosthodontist, Drs. Jon is continuing to evolve. With the help of the Head of Product Develop-
Zabalegui and Iñigo Sada, periodontists, Dr. Dave Hatcher, radiologist, ment at GAC, Tom Macari, and AEO, improvements to the bracket are
Dr. Borja Zabalegui, endodontist, Dr. Renato Cocconi, orthodontist, in the works.
and Dr. Mirco Raffaini, surgeon. All of these teachers have given the
RW courses a truly interdisciplinary approach, which is what FACE The teaching techniques developed at AEO are evolving as well. With
promotes worldwide. the advent of new computer technology, many new and exciting things
will be happening in the next year.
Another important aspect of 2009 that has been fundamental in
making RW a truly interdisciplinary course is the fact that we have The Roth Williams USA center has a new home base. Due to an excel-
organized two different courses, Bioesthetics with Dr. Ken Hunt and Dr lent opportunity afforded us by Dr. Carlos Navarro, AEO will be mov-
Alejandro James, and Orthognathic Surgery with Dr. Lucho Quevedo. ing to Houston, Texas. So in October of 2010, Group IX will travel to
Many of our former students have signed up for the courses, and this Texas for the new class. The new facility will have adequate space for
has given them a greater understanding of the importance of incor- teaching the total Roth Williams experience. The clinical, laboratory,
porating both disciplines into our interdisciplinary approach. But we and lecture will now be in one location. This location is close to many
cannot forget that with Osteoplac now organizing and promoting our fine restaurants and entertainment.
courses they have become truly professional, and without this support
we could have never reached the status that we now enjoy. Drs. Andy Girardot, Bob Frantz, and Ted Freeland
Directors, Roth Williams Center USA
Dr. Domingo Martín
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 contribu-
tions of our friends and outstanding speakers from all over the world.
6 News from the Roth Williams Teaching Centers

In addition, three 8-hour courses were scheduled in April, August,
and December 2010. Presentations include Dr. Roth’s Philosophy: the
importance of the condyle setting in the fossae:physiological principles
for neuromuscular deprogramming, by Dr. Guillermo Ochoa; Treat-
ment planning according to Roth’s Philosophy, by Dr. Oscar Palmas;
and Evidence-based Roth’s Philosophy and its application in multidis-
ciplinary treatments, by Dr. Domingo Martín. Dr. Martín will also be
giving a 4-day course for all the specialists related to orthodontics.
To know more about our courses, please visit the Web page www.ucu.
edu.uy/Odontologia, or contact us by e-mail at rwcuruguay@gmail.
com.
Our group is concerned about research. To address this concern, we

are encouraging our students to make a weekly commitment to our
study group. We are working hard in order to achieve the best results.
Dr. Daniela Domínguez Di Prisco

Director, Roth Williams Center Uruguay
Scenes from RWISO 2009

16th Annual Conference, Boston, MA

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Dr. Milton D. Berkman, Chairman, RWLF
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
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continues to grow in stature and respect. The future is bright for the Roth Williams Philosophy
Chairman RWLF
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.
2009 Boston Meeting and Journal
At the RWISO International meeting held in Boston, Massachusetts, in May 2009, the Committee was pleased with the
membership’s response to the RWLF fund-raising campaign for the general endowment fund and for the Roth Williams
Philosophy textbook fund. The publication of the first issue of the RWISO Journal, in May 2009, came to fruition in part
because of a grant from the RWLF general endowment fund for $14,000. As Dr. Domingo Martín said in the first issue of
the Journal, “I cannot forget it was Dra. Anka Sapunar who first founded a journal for this group, and we must all be very
grateful to her for the great job that she did. This is a continuation of what she started. Muchas gracias, Anka!!!”
The renewal of the Journal would not have been possible without the seed money from RWLF. This is just one of the many
ways that RWLF is able to fulfill its mission to advance the scientific and clinical benefits of the Roth Williams Philosophy
of goal-directed interdisciplinary patient care. What a great moment for the RWISO membership! For RWLF it was a signifi-
cant first step, because it demonstrated the important role of an endowment fund in the future growth and longevity of an
organization and a philosophy of patient care. RWLF and the RWISO membership are looking forward to the second issue
of the RWISO Journal at the Rome Conference with great anticipation.
Research Evaluation and Approval Committee (REAC)
The RWLF Committee’s initial major efforts have been directed toward fund-raising, and toward gaining the trust and
confidence of the RWISO membership. Now that 30% of the $1 million goal has been pledged or donated, the Com-
mittee is ready for a new endeavor—to develop research grant evaluation, approval, and funding. One of the mission
statements of RWLF is “partial or full support of research projects that lead to publication of scientific and clinical
papers in peer-reviewed international journals.” The Committee is pleased to announce that two research grants have
been approved and are in the process of being funded by RWISO/RWLF.
8 Roth Williams Legacy Fund

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 De-
gree 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.
Donation and Pledges
Donations to RWLF can be made in the following ways:
1. Professional Courtesy/Grateful Patient. Persons to whom you offer orthodontic services as a courtesy are invited to
demonstrate their appreciation by making a contribution to RWLF in your name.
2. Case for the Future of the Roth Williams Philosophy. Doctors can donate one new case as a “case for the future”
by paying the fee to RWLF.
3. Doctors giving courses or lectures can donate a portion of the honorarium or course fees to RWLF.
4. Donations can be made in memory of, or in honor of, a colleague, friend, relative, or parent.
5. Or just make a donation because of what the Roth Williams Philosophy has meant to your professional life
Donations can be designated for the general research and education fund or for publication of the Roth Williams
Philosophy textbook.
For more on how to donate, visit the RWISO Web site at www.rwiso.org.
RWLF Committee
Thank you to those individuals who serve on the Legacy Fund Committee.
Milton D. Berkman, Chairman RWLF

Peggy Brazones
Alan Marcus
Domingo Martín
Jeff Milde, Executive Director RWISO
Joe Pelle
Straty Righellis, Chairman REAC
Manny Wasserman
David Way

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We thank all of our loyal and faithful donors for their support of the Legacy Fund. Below, we pay tribute to those donors who have given from
January 1, 2006, through June 21, 2010.
Platinum (10,000 - $49,999) Bronze Circle ($1 - $999) Pledge Circle

Dr. Milton D. Berkman Dr. Hideaki Aoki Thank you to these donors who have pledged
Dr. Domingo Martin Dr. George Babyak donations to the Legacy Fund over multiple years.
Dr. Straty Righellis Dr. Mary Burns
Dr. Carl Roy Dr. Dara Chira Dr. Satoshi Adachi
Dr. Manny Wasserman Dr. Tom Chubb Dr. Scott Anderson
Dr. Robert E. Williams Dr. Warren Creed Dr. Jorge Ayala
Dr. Graciela de Bardeci Dr. Milton Berkman
Dr. Chieko Himeno Dr. Margaret Brazones
Dr. Takehiro Hirano Dr. Warren Creed
Gold Circle ($5,000 - $9,999) Dr. Akira Kawamura Dr. Robert Good
Dr. Margaret Brazones
Dr. Mi Hee Kim Dr. Mila Gregor
Dr. Byungtaek Choi
Dr. Yutaka Kitahara Dr. Tateshi Hiraki
Dr. Andrew Girardot
Dr. Shunji Kitazono Dr. Maria Karpov
Dr. Darrell Havener
Dr. Felix Lazaro Dr. Mi Hee Kim
Dr. John Lawson
Dr. N. Summer Lerch Dr. Masako Komatsu
Dr. Jina Linton
Dr. Ilya Lipkin Dr. Jina Lee Linton
Dr. Jeffrey McClendon
Dr. George Marse Dr. Ilya Lipkin
Dr. James Sieberth
Jeff Milde Dr. Dave Livingston
Dr. Wayne Sletten
Dr. Kouichi Misaki Dr. Yuci Ma
Dr. David Way
Dr. Hideaki Miyata Dr. Alan Marcus
GAC International
Dr. Yo Mukai Dr. Ramon Marti
Dr. Yoshihiro Nakajima Dr. Joseph M. Pelle
Dr. Joseph Pelle Dr. Paul Rigali
Silver Circle ($1,000 - $4,999) Dr. Akiyuki Sakai Dr. Nile Scott
Dr. Terry Adams Dr. Atsuyo Sakai Dr. Wayne Sletten
Dr. Claudia Aichinger Dr. Hidetoshi Shirai Dr. Manny Wasserman
Dr. Robert Angorn Dr. Motoyasu Taguchi Dr. Benson Wong
Dr. Joachim Bauer Dr. Naoyuki Takahashi Dr. Yeong-Charng Yen
Dr. Patricia Boice Dr. Hiroshi Takeshita Dr. Michael Yitschaky
Dr. Renato Cocconi Dr. Yasoo Watanabe
Dr. Frank Cordray Dr. Benson Wong
Dr. K. George Elassal Dr. Koji Yasuda
Dr. Keenman Feng Dr. Yeong-Charng Yen
Dr. Michael Goldman
Dr. Frank Gruber
Dr. David Hatcher Estate Planning
Dr. Kazumi Ikeda Dr. Charles R. de Lorimier
Dr. John Kharouf Dr. Donald W. Linck, II
Dr. L. Douglas Knight
Dr. Young Jun Lee
Dr. Gerald Malovos
Friends of Roth Williams
Dr. Alan Marcus
Advanced Education in Orthodontics
Dr. Ramon Marti
Jewish Communal Fund
Dr. Roger Pitl
T&T Design Lab (Japan)
Dr. Paul Rigali
Timothy McCarthy
Dr. Nile Scott
Dr. Sean Smith
Dr. Katsuji Tanaka
Reliance Orthodontic Products
10 Legacy Fund Donors

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Ryan K. Tamburrino, DMD ɵ Normand S. Boucher, DDS ɵ Robert L. Vanarsdall, DDS
ɵ Antonino G. Secchi, DMD, MS
RYAN K. TAMBURRINO , DMD 6XPPDU\

rktambur@dental.upenn.edu Much focus of orthodontic diagnoses has been placed on the sagittal and ver-
ɵ Clinical Associate—Univ. of Penn. tical dimensions. However, a proper evaluation of the transverse dimension
School of Dental Medicine, Dept.
of Orthodontics
must also have equal importance. Research has shown that interferences from
an exaggerated curve of Wilson due to a maxillary transverse deficiency play
N ORMAND S. B OUCHER, DDS
a role in centric relation (CR)/central occlusion (CO) discrepancies, adverse
ɵ Clinical Associate Professor—
Univ. of Penn. School of Dental periodontal stresses, and craniofacial development. This article illustrates
Medicine, Dept. of Orthodontics three scientifically validated methods for evaluating the transverse dimension:
Ricketts’ P-A cephalometric analysis, Andrews’ Element III analysis, and the
R OBERT L. VANARSDALL , DDS
ɵ Professor and Chair— University of Pennsylvania Cone-Beam CT transverse analysis. The aim is to
Univ. of Penn. School of Dental show methods using traditional cephalometry, study models, and cone-beam
Medicine, Dept. of Orthodontics computed tomography, not to compare one method to another. The reader
A NTONINO G. S ECCHI , DMD, MS may then choose to use the method that is most appropriate for his practice.
ɵ Assistant Professor of Orthodontics,
Clinician Educatorand Clinical
Director—Univ. of Penn. School of
Dental Medicine, Dept. of Orthodontics
For complete contributor information, please see end of article.
,QWURGXFWLRQ facially. These teeth are then described as being excessively

The goals of orthodontic treatment are well established positively inclined (Figure 1).
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 di-
agnose skeletal and dental variations of the sagittal and
vertical dimensions.2–6 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 Figure 1 Example of excessive tooth angulations.
teeth will erupt into a crossbite or reconfigure their incli-
nations to avoid a crossbite. This compensation typically 7UDQVYHUVH'HÀFLHQF\DQG&5&2'LVFUHSDQF\
involves lingual tipping of the mandibular posterior teeth, In the prosthodontic literature, these transverse tooth com-
which are then described as being excessively negatively in- pensations have been graphically illustrated with a cross-
clined. In addition, the maxillary posterior teeth are tipped arch arc constructed through the buccal and palatal cusps of

the maxillary molars. This is known as the curve of Wilson. According to McNamara and Brudon,13 “the orientation of
With excessive inclination of the maxillary molars to com- the lingual cusps of the maxillary posterior teeth… often lie[s]
pensate for insufficient maxillary width, the curve of Wilson below the occlusal plane… This common finding in patients
is greatly exaggerated, and the palatal cusps are positioned with malocclusions often is due to maxillary constriction and
below the buccal cusps (Figure 2). subsequent dentoalveolar compensation in which the maxillary
posterior teeth are in a slightly flared orientation.” The results
of a study by McMurphy and Secchi14 indicate that vertical dis-
traction of the condyles in CR/CO discrepancies can be related
to an exaggerated curve of Wilson, secondary to a transverse
deficiency of the maxilla. These authors conclude that, in the
absence of a posterior crossbite, the plunging palatal cusps and
exaggerated curve of Wilson become the fulcrum point for the
vertical condylar distraction from CR to maximum intercuspa-
tion. Furthermore, extrapolation of this statement suggests that
if the transverse skeletal dimension is normalized, the curve of
Wilson is flattened, and the arches are coordinated, an impor-
tant component of the CR/CO discrepancy is eliminated.
7UDQVYHUVH'HÀFLHQF\DQG:RUNLQJ1RQZRUNLQJ
Figure 2 An exaggerated curve of Wilson
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(note palatal cusps below buccal cusps).
It has been a prosthetic maxim that an exaggerated curve of
Many articles that describe the impact of CR/CO dis- Wilson increases the potential for working and non-working
crepancies on occlusion focus on how these discrepancies side interferences. Studies have shown that posterior occlusal
affect diagnosing the sagittal and vertical dimensions. The contacts or interferences are linked to increased masticatory
literature has suggested that the “plunging” palatal cusps muscle activity.15,16 In studies where these interferences have
shown in Figure 3 are often the primary contacts that in- been removed, it has been demonstrated that the activity of the
duce vertical condylar distraction on closure from CR. From closing musculature is reduced.16,17 In addition, a study that ar-
a seated condylar position, the patient may fulcrum off the tificially created non-working interferences reported increased
premature contacts of the terminal molars to obtain the muscle activity.18 These results suggest that it is prudent to nor-
maximal intercuspal position. The Panadent Condylar Posi- malize the transverse jaw relationship and flatten the curve of
tion Indicator (CPI) and the SAM Mandibular Position In- Wilson to eliminate the potential for excursive posterior inter-
dicator (MPI) graphically identify this vertical component of ferences or contacts.
condylar distraction.9-12
7UDQVYHUVH'HÀFLHQF\DQGWKH3HULRGRQWLXP
Herberger and Vanarsdall19 have shown an increased risk for
gingival recession in the orthodontic patient with a narrow
maxilla when the skeletal transverse deficiency is camouflaged
with dental expansion. The envelope of treatment in the trans-
verse, with expansion of only the dentition, is more limited than
the envelope of treatment in the sagittal dimension.20 Due to the
constraints of the thin layer of cortical bone of the alveolus, as
shown in Figure 4 [see next page], very little tooth movement
needs to occur before the roots are fenestrated, the volume of
buccal alveolar bone is reduced, and, with thinning gingival tis-
sues, the risk of gingival recession increases.
In recent studies, Harrell21 and Nunn and Harrell22,23 have
shown that the elimination of working and nonworking interfer-
Figure 3 Note plunging palatal cusps and extreme curve ences enhances the long-term periodontal prognosis in patients
of Wilson on molars of an arch that was expanded
susceptible to periodontal disease. Therefore, normalizing the
with arch wires and brackets only.
transverse jaw relationship to eliminate an exaggerated curve
12 Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

In one recent study,26 patients with transverse deficien-
cies 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 ex-
pansion also showed an increase in the volume of the upper
airway. Oliveria de Felippe, et al28 found that palatal expan-
sion decreased nasal resistance and improved nasal breath-
ing. 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 0HWKRGVRI7UDQVYHUVH'LDJQRVLV

treatment in the presence of an undiagnosed severe skeletal With a transverse deficiency due to a narrow maxilla, the
transverse discrepancy. Note minimal alveolar bone on temporomandibular joints, musculature, periodontal tissue,
the buccal surface of the maxillary molars.
and airway can be adversely affected in the susceptible pa-
of Wilson and nonworking interferences would be beneficial tient. Our goal as orthodontists should be to develop skeletal
for adult patients who are periodontally at risk, and might relationships and a functional occlusion that are as close to
prophylactically reduce the risk for younger patients. optimal as possible, to lessen the role that any discrepancies
of the occlusion would play in exacerbating the detrimen-
7UDQVYHUVH'HÀFLHQF\DQGWKH$LUZD\ tal effects to the joints, periodontium, or dentition. In order
Ricketts’ description of “adenoid facies”24 also suggests a re- to achieve this a correct skeletal and dental diagnosis in all
lationship between a constricted nasopharyngeal airway and three planes of space is mandatory.
a narrow maxilla. Ricketts states children with any impair- In this section, we present three different methods for
ment of the nasal passages become predominantly mouth diagnosing the transverse dimension—one using traditional
breathers. Since the tongue is positioned in the floor of the cephalometry, one using dental casts, and one using cone-
mouth to allow airflow, it cannot provide support to shape beam CT (computed tomography). We do not endorse any
the developing palate; thus pressure from the circumoral one of these methods over the others; our purpose here is
musculature acts unopposed. The palate is narrowed, and simply to describe all three methods, so that readers will be
an exaggerated curve of Wilson develops upon tooth erup- able to incorporate a transverse skeletal diagnosis into their
tion. Because the tongue is positioned low in the mouth, the practice, no matter what level of technology is available.
patient may also develop a retruded, high-angle mandibular Regardless of which of these methods one chooses, the doctor
shape, which can increase the risk for sleep apnea.25 An ex- must keep optimal treatment goals in mind as a rationale for
ample of adenoid facies is shown in Figure 5. normalizing the transverse dimension (Figures 6 and 7).
Figure 5 A teenager who had nasopharyngeal airway impairment

during growth and development. The images show the facial, Figure 6 Goals for normalizing the transverse dimension.
dental, skeletal, and airway presentation upon growth cessation.
below and medial to the gonial angle.”3
Once the measurements have been taken, the mandibular
width (Ag-Ag) is subtracted from the maxillary width (Mx-
Mx) to get the difference in width between the jaws. Ricketts
then determined skeletal age-determined normative relation-
ships between the maxilla and the mandible (Figure 9). This
allows the analysis to accommodate growing patients, and
allows for the differential growth rates and potentials of the
maxilla and the mandible.
Figure 7 Rationale for normalizing the transverse dimension.
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In 1969, Ricketts introduced analysis of the transverse skel-
etal dimension as part of his method of cephalometric di-
agnosis.3 His method uses the frontal, or posteroanterior
(P-A) cephalogram, and is based on the dimensions of the Figure 9 Table for determining the age-normal
jaws compared to a table of age-adjusted normative values. difference between the maxilla and the mandible.
The premise of the analysis is based on locating two skeletal
In order to determine the skeletal age of a patient, a hand-
points to determine maxillary width and two additional skel-
wrist film is taken and is compared to an atlas of male and
etal points to determine mandibular width (Figure 8).
female skeletal age standards.29 To determine the amount of
expansion needed, the age-adjusted expected difference be-
tween the jaws is subtracted from the measured difference.
An example of the Ricketts method is shown in Figure 10.
Figure 10 Example of Ricketts’ P-A analysis.

Figure 8 Locations of Mx (green) and Ag (yellow).
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For the maxilla, the jugal point (Mx) is located on the right
In 1970, L. F. Andrews published his landmark paper describ-
and left sides of the maxillary skeletal base at “the depth
ing the six keys to normal static occlusion.1 Over the next
of the concavity of the lateral maxillary contours, at the
several decades, he and his son, W. A. Andrews, worked to de-
junction of the maxilla and the zygomatic buttress.”3 The
velop the six elements philosophy of orthodontic diagnosis.
maxillary width is determined by the horizontal distance
One of the diagnostic criteria, Element III, is devoted to ana-
connecting these two points. For the mandible, a similar
lyzing the transverse relationship of the maxilla and mandible
measurement is taken between the two antegonial notches
and is based on both bony and dental landmarks.10
(Ag). These notches are located on the right and left sides
The Element III analysis is based on the assumption that
of the mandibular body at the “innermost height of contour
the WALA (named after Will Andrews and Larry Andrews)
along the curved outline of the inferior mandibular border,

ridge determines the width of the mandible. According to
Andrews’ definition, the WALA ridge is coincident with the
most prominent portion of the buccal alveolar bone when
viewed from the occlusal surface (Figure 11).
Figure 12 Determination of mandibular

WALA-WALA and FA-FA distances.
The width of the maxilla is based on optimization of the

angulation of the maxillary molars. To determine this width,
one measures the horizontal distance from the FA point of
the left molar to the FA point of the right molar and records
the measurement.
Figure 13 Determining maxillary FA-FA distance and

estimating the change in maxillary molar inclination.
One then looks at the angulation of the maxillary mo-

lars 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
Figure 11 Demarcation of the WALA ridge.
change is subtracted from the original FA-FA measurement.
The result represents the width of the maxilla.6
The WALA ridge is essentially coincident with the
In order to have optimally positioned and optimally in-
mucogingival junction and approximates the center of re-
clined molar teeth that intercuspate well, Andrews states that
sistance of the mandibular molars. In a mature patient,
the maxillary width must be 5 mm greater than the mandib-
the WALA ridge and the width of the mandible cannot be
ular width.6 In order to determine the amount of transverse
modified with conventional treatment. Thus the WALA ridge
discrepancy, or Element III change, needed to produce an
forms a stable basis for the Element III analysis.6
ideal result, one takes the optimal mandibular width, adds
The Element III analysis is based on the width change,
5 mm, and subtracts the maxillary width. An example of the
if any, of the maxilla needed to have upper and lower pos-
entire analysis is shown in Figure 14.
terior teeth upright in bone, centered in bone, and properly
intercuspated. To determine the discrepancy, the first step is
to determine the width of the mandible, or the horizontal
distance from the WALA ridge on the right side to the WALA
ridge on the left side. According to Andrews, optimally po-
sitioned mandibular molars will be upright in the alveolus,
and their facial axis (FA) point, or center of the crown, will
be horizontally positioned 2 mm from the WALA ridge. With
this information, the width of the mandible is then defined as
the WALA-WALA distance minus 4 mm.6
Figure 14 Example of Andrews’ Element III

transverse analysis.

8QLYHUVLW\RI3HQQV\OYDQLD&RQH%HDP&7$QDO\VLV
The current trend in orthodontic imaging and diagnosis is
toward three-dimensional analysis. With the advent of cone-
beam imaging, orthodontists can obtain precise measure-
ments without any distortion caused by radiographic projec-
tions or ambiguity of point identification. The same rationale
can subsequently be applied to the transverse measurement
of the maxilla and the mandible. Ricketts’ and Andrews’
methods for determining the amount of transverse discrep-
ancy between the jaws are based on using readily discernable
landmarks that represent the width of the base of the alveo-
lar housing. For Ricketts, these landmarks are Mx-Mx for
the maxilla and Ag-Ag for the mandible. For Andrews, these
Figure 15 Correlations of Mx and Ag to skeletal bases in adults.
landmarks are the two sides of the WALA ridge and the FA
points of the maxillary and mandibular molars. The WALA- Thus, to locate the beginning of the base of the mandible
WALA measurement represents the width of the mandible, with a CT scan, it would seem best to find the skeletal represen-
and the FA-FA points are used, as described above, to deter- tation of the WALA ridge. This is approximately at the edge of
mine the width of the maxilla. Both of these methods have the cortical bone opposite the furcation of the mandibular first
merit. However, with cone-beam CT imaging, it is no lon- molars. We can also use this technique to locate the beginning of
ger necessary to have a measurement dictated by ease with the base of the maxilla. If we assume that the maxilla begins at
which landmarks can be identified to represent the widths the projection of the center of resistance of the maxillary teeth
of the jaws. onto the buccal surface of the cortical bone, Ricketts’ use of Mx
Before choosing a method for measuring the base of the to determine maxillary width appears to be at approximately at
jaws, we must first decide what location to use for measure- the same horizontal position. Additionally, by using Mx point,
ment. In determining the location of the WALA ridge, An- any exostoses present along the buccal portion of the alveo-
drews stated that the WALA ridge is an approximation of the lus will not interfere with the measurement. Andrews’ method,
center of resistance of the mandibular teeth. Above the WALA on the other hand, has no directly definable skeletal landmark
ridge, the alveolus can be dimensionally molded and altered, for the maxilla; it relies on estimated changes in the angulation
depending on the change in angulation of the teeth. However, of the molars to determine the skeletal transverse discrepancy.
the same cannot be said for the portion of the alveolus below Therefore, Ricketts’ method of defining the basal skeletal width
the WALA ridge. Thus, in a mature patient, any portion of the of the maxilla appears to be more appropriate.
alveolus apical to the WALA ridge can be assumed to be rea- We begin, then, by defining locations for measuring max-
sonably dimensionally stable during tooth movement, and, illary and mandibular skeletal basal width. Next, we explore
therefore, can define the dimensions of the patient’s arch. In concepts for defining these locations on cone-beam CT imaging.
Ricketts’ analysis, Ag-Ag represents the basal portion of the The basic premise for the mandible is to locate the most buccal
mandible. However, when one looks at the position of Ag on point on the cortical plate opposite the mandibular first molars
a three-dimensional image, one sees that its correlation with at the level of the center of resistance. According to Katona, this
the base of the alveolus is relatively weak in all three planes location is approximately coincident with the furcation of the
of space for mature patients (Figure 15). roots of the molars.30 As we explained above, the authors chose
this point due to the relative immutability of the alveolus apical
to this location with orthodontics and because it represents the
absolute minimal width of the basal bone for each jaw.
For the purposes of this technique, the authors used Dol-
phin 3D, release 11 (Patterson Dental, Chatsworth, CA), but
the concepts can be applied to any software with the capabil-
ity to analyze a cone-beam CT image. After properly orienting
the image, we open the multiplanar view (MPV) screen to see
simultaneous axial, sagittal, and coronal cuts of the image.

Figure 16 MPV of a cone-beam CT scan. Figure 18 Measurement of mandibular skeletal width.
To determine the width of the mandible, we scroll down

For the maxilla, a similar method is employed. The only
through the image until we locate the furcation of the first
difference is that the axial and coronal cuts must be taken at
molar. Then we scroll posteriorly through the scan until we
the position Mx-Mx, and the same measurement as in the
locate the coronal cross-section through the center of the
Ricketts’ analysis is used.
mandibular first molars.
Figure 19 Measurement of maxillary axial and coronal cuts.

Figure 17 Location of the mandibular axial and coronal cuts.
Now we switch to full-screen axial view. Using the cut

lines as a guide, we measure the width of the mandible from
the intersection of the cut line with the most buccal portion
of the cortical plate on both the right and left sides.
Figure 20 Measurement of maxillary skeletal width.
The analysis of the width of the maxilla and mandible at

the level of the first molars is straightforward once we have

taken the measurements of both jaws. By subtracting the that is not perpendicular to the alveolus, a false perception of
mandibular width from the maxillary width, we determine the thickness of cortical bone is possible, as shown in Figure
the difference between the two jaws. Both Ricketts’ and An- 22. Therefore, to reduce errors in judgment and to improve
drews’ analyses demonstrate that the optimal transverse dif- visualization of the most buccal portion of the cortical bone,
ference between the maxilla and mandible is 5 mm in mature the authors believe that the axial cut allows for greater preci-
patients. A preliminary analysis of 5 cases where the maxil- sion of measurement over the coronal cross section.
lary and mandibular molars were upright in the alveolus,
centered in the alveolus, and well intercuspated, produced
measurements where the difference between the width of the
jaws approximated 5 mm on a consistent basis. Therefore,
the seemingly ideal difference for the width of the jaws in
mature patients using the Penn CBCT analysis would also
appear to be 5 mm. To determine the amount of expansion
necessary to achieve an ideal jaw relationship in the trans-
verse dimension, the measured difference between the jaws
should be subtracted from 5.
Figure 22 Visualization of cortical bone thickness

on coronal and axial cuts of the same patient
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 ca-
nines. With this, the goal will be to determine the appropriate
arch form for proper stability and function on an individual
basis. An additional study’s aim will be to develop age-spe-
cific transverse normative criteria for Penn CBCT analysis,
similar to Ricketts’ norms for the P-A ceph. ɵ
References
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Contributors
Ryan K. Tamburrino, DMD
ɵ Clinical Associate—Univ. of Penn., School of Dental Medicine,
Dept. of Orthodontics
ɵ Andrews Foundation “Six Elements Philosophy” Course—2007
ɵ Advanced Education in Orthodontics—Roth-Williams Center
for Functional Occlusion—2008
ɵ University of Pennsylvania, School of Dental Medicine,
Certificate in Orthodontics—2008
ɵ University of Pennsylvania, School of Dental Medicine, DMD
—2006
Normand S. Boucher, DDS

ɵ McGill University, School of Dental Medicine, DMD, 1974
ɵ University of Pennsylvania, School of Dental Medicine,
Certificates in Orthodontics and Periodontics, 1982
ɵ Advanced Education in Orthodontics, Roth-Williams Center
for Functional Occlusion, 1993
ɵ Andrews Foundation, “Six Elements Philosophy” Course, 1998
ɵ Clinical Associate Professor, University of Pennsylvania, School
of Dental Medicine, Department of Orthodontics
Robert L. Vanarsdall, DDS

ɵ Professor and Chair— University of Pennsylvania School of
Dental Medicine, Department of Orthodontics
ɵ DDS—Medical College of Virginia
ɵ Certificates in Orthodontics and Periodontics—University of
Pennsylvania
ɵ 80 publications and 11 textbook contributions
ɵ Former President of the Philadelphia Society of Orthodontists
and Eastern Component of the EH Angle Society
Antonino G. Secchi, DMD, MS

ɵ Assistant Professor of Orthodontics-Clinician Educator and
Clinical Director, Dept. of Orthodontics, University of Penn.
ɵ Andrews Foundation “Six Elements Philosophy” Course, USA,
—2005
ɵ Institute for Comprehensive Oral Diagnosis and Rehabilitation,
OBI Level III—2005
ɵ Advanced Education in Orthodontics—Roth/Williams Center
for Functional Occlusion USA—2005
ɵ University of Pennsylvania, MS in Oral Biology—2005
ɵ University of Pennsylvania, DMD—2005
ɵ University of Pennsylvania, Certificate in Orthodontics—2003
ɵ University of Chile—Chile, Certificate in Occlusion, 1998
ɵ University of Valparaiso—Chile, DDS, 1996

+LQJH$[LV7KH1HHGIRU$FFXUDF\LQ3UHFLVLRQ0RXQWLQJ
Part 2
Byungtaek Choi, DDS, MS, PhD
B YUNGTAEK C HOI , DDS, MS, P H D 6XPPDU\

joydog@unitel.co.kr This is the second part of a two-part paper discussing the need for accuracy
ɵ Graduated from Seoul National in the mounting of dental models for orthodontic diagnosis and treatment.
University, College of Dentistry
(DDS), Seoul, Korea, 1981
Part 1 discussed the accuracy differences between an arbitrary hinge axis
ɵ Graduated from Seoul National (AHA) mounting and a true hinge axis (THA) mounting. Part 2 discusses the
University, College of Dentistry differences between two popular true hinge axis recording devices, the Pana-
(MS), Seoul, Korea, 1984 dent Axi-Path system and the Axiograph III system.
ɵ Graduated from Seoul National
University, College of Dentistry
(PhD), Seoul, Korea, 1990
ɵ Private Practice, Seoul, Korea
ɵ Chairman of Korean Foundation of
Gnatho-Orthodontic Research
ɵ Director of Roth Williams Center,
Korea
ɵ Attending Professor of Medical
School of Hanlim University
ɵ Attending Professor at Seoul
National University
7KH$[L3DWK6\VWHP a thumbscrew. A straight ruler can be used to make the two

Many clinicians use the Panadent Axi-Path system for the flag tables parallel to each other. (Figure 19).
following purposes: (Figure 17)
r To locate the true hinge axis (THA)
r To determine the sagittal anterior condylar path in-
clination, non-working-side sagittal lateral condy-
lar path inclination, and the Bennett movement to
select the Motion Analog Blocks
r To assess the functional structural conditions of the
temporomandibular joint
Figure 17 Axi-Path recording: Panadent Company.

The upper head frame of the Axi-Path recorder is com- Figure 18 Head frame (upper frame).
posed 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

Figure 19 Flag tables are set to be parallel to each other.
The lower head frame of the Axi-Path recorder is at-

tached 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 22 Schematic drawing of the head viewed from the

top when the Axi-Path recorder has been placed on the head.
Figure 20 Lower frame for adjustable axis-locating arms.
To place the Axi-Path recorder correctly, the upper

frame is first fitted and fastened to the head. The lower frame
is then attached to the lower jaw. Finally, the axis-locating
arms are attached to the lower jaw (Figure 21).
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.
Figure 23 $V\PPHWULFDOKHDGFRQÀJXUDWLRQ
Figure 22 is the schematic drawing of the head viewed
from the top when the Axi-Path recorder has been placed on If the patient’s head configuration is asymmetrical, the
the head correctly. face-bow may not be centered on the head when the nasion
relator is placed on Nasion (Figure 23). Since the nasion rela-
tor cannot move transversely, the face-bow should be rotated
until the nasion relator sits on Nasion (Figure 24). When the
lower frame is placed, the stylus may not be perpendicular
22 Choi | Hinge Axis: The Need for Accuracy in Precision Mounting Part 2
to the flag table (Figure 25). The Axi-Path is not a collinear The following experiment can be used to determine the
system, and errors often occur when the clinician attempts magnitude of measurement error. The experiment is set up so
to determine the THA. If a recording system is not collinear that the measurement shows the right condyle 5 mm forward
and rectilinear, the clinician is likely to mark the inaccurate of its actual position. For purposes of illustration, the situa-
hinge points on the skin. tion is assumed to be noncollinear (Figure 26).
Figure 26 Supposition. Right condyle moved 5 mm forward.
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.
Figure 27 New hinge axis passing through

newly positioned condyle.
The right recording stylus is placed at the new hinge

point on the flag table (Figure 28).
Figure 25 When the lower frame is placed, the
VW\OXVPD\QRWEHSHUSHQGLFXODUWRWKHÁDJWDEOH

The example assumes that the distance between the
centers of the two condyles is 110 mm, and the distance at
skin level is 140 mm (Figure 31). If the condyle moves 5 mm
forward, it will appear to move slightly more on the graph
(Figure 32). If the condyle moves 5 mm forward, the hinge
point on the skin moves 5.68 mm forward (Figure 33).
Figure 28 Stylus placed at the new

KLQJHSRLQWRQWKHÁDJWDEOH Figure 31 The supposition is that the distance
between the centers of the two condyles is 110 mm,
A hinge axis is not a line that connects the centers of the
and the distance at the skin level is 140 mm.
condyles. It is the axis around which the mandible shows
pure hinge movement. Therefore, the hinge axis may pass
through any point in the condyle. In Figure 29, the center
points have been marked for clarity. Figure 30 is a magnified
view of the right joint area.
Figure 32 If the condyle moves 5 mm forward,

it will appear to move slightly more on the graph.
Figure 29
Right condyle 5 mm
anterior to the left
condyle.

Figure 30 0DJQLÀHGYLHZRIWKHULJKWMRLQWDUHD the hinge point on the skin moves 5.68 mm forward.
The Axi-Path is designed so that the flag table is very
close to the preauricular skin. For some patients, depending
on the configuration of the temporal region, the flag table
may be farther from the skin. Figure 34 shows 5 mm of dis-
tance between the skin and the flag table.
Figure 36 Advantages of Axi-Path system:

3UR[LPLW\RIWKHÁDJWDEOHWRWKHVNLQ
Figure 34 $[L3DWKLVGHVLJQHGVRWKDWWKHÁDJWDEOHLV
very close to the preauricular skin. This picture shows
PPRIGLVWDQFHEHWZHHQWKHVNLQDQGWKHÁDJWDEOH
If the distance from where the stylus contacts the flag

table to the skin is 5 mm, the measurement error will be 0.23
Figure 37 Advantages of Axi-Path system:
mm. The amount of error will decrease as the stylus gets 3UR[LPLW\RIWKHÁDJWDEOHWRWKHVNLQ
closer to the skin. The Axi-Path system uses the skin mark
for face-bow transfer. Hence, the smaller the error, the more
accurate the hinge axis. Accuracy depends on the distance However, the Axi-Path system also has shortcomings.
between the flag table and the skin (Figure 35). The head frame often cannot be fastened tightly to the head.
It is somewhat unstable compared to the frame of the Ax-
iograph III. An unstable frame can make it difficult or im-
possible to get a reproducible reference point and may be
misdiagnosed as an unstable joint (Figure 38).
Figure 35 If the distance from the stylus to the skin is 5 mm,

the amount of error is calculated as follows:
5.68 : 125 = X : 5 mm (X = 284 ÷ 125 = 0.23 mm)
Figure 38 Shortcomings of Axi-Path system:

The Axi-Path system has some advantages. Because the Unstable head frame.
flag table is very close to the skin, measurement error can be
minimized (Figure 36). And the reference tattoo on the skin
can be used for precision mounting at any time, once it has
been marked (Figure37).
Since the nasion relator is not movable transversely on 7KH$[LRJUDSK,,,6\VWHP
the face-bow, it is difficult to center the midline of the bow The Axiograph III system is shown in Figure 41. Orthodon-
perpendicular to the hinge axis in asymmetrical cases. If we tists use this system for the same purposes as the Axi-Path
attempt to do so, the face-bow will be seated off center (Fig- system. The Axiograph III system differs from the Axi-Path
ure 39). system in several important ways.
Figure 41 Axiograph III: SAM.
Figure 42 is a schematic drawing of the head viewed

from the top when the upper frame of the Axiograph III has
been placed on the head correctly. If the patient’s head is
symmetrical, every part of the frame will be parallel or per-
pendicular to the sagittal plane of the head.
Figure 39 Shortcomings of Axi-Path system:

Off-center placement of the upper frame in asymmetrical cases.
In short, the Axi-Path system records the hinge axis on a

flag table that is relatively close to the skin. If the flag table is
close to the skin, it produces a more accurate hinge mark on
the skin. However, the primary disadvantages of this system
are the structural instability of the head frame when fastened
to the head and the off-centered seating of the face-bow on
the asymmetrical head.
Figure 42 Schematic drawing and real picture of upper frame.
This system is collinear and rectilinear. Since the nasion

relator moves transversely, the upper frame can be placed
on the head without losing the parallelism, even when the
patient’s head is asymmetrical (Figure 43).
Figure 44 shows the upper and lower frames placed on

the head. The lower frame has two side arms, with a stylus
on the end of each arm. The two styli are in collinear align-
ment, rectilinear with the upper Axiomatic flag-bow record-
ing plates (Figure 45).
The upper frame is fastened to the head first, and the
lower frame is placed next. If earplugs are inserted into the
auditory canals, the alignment pins automatically indicate
the approximate hinge positions. The alignment pins also
make the upper and lower parts of the face-bow parallel and
perpendicular to each other (Figure 46).
Figure 46 If ear plugs are inserted into auditory canals,

alignment pins automatically indicate approximate hinge
positions. The alignment pins also make the upper and lower
parts of the face-bow parallel and perpendicular to each other.
Figure 43 Nasion relator moves transversely along
the horizontal part of frame so the frame can be As was done in the Axi-Path experiment, the amount of
placed on the head without losing parallelism. measurement error is then determined when the right con-
dyle is moved 5 mm forward (Figure 47). This movement
produces a new hinge axis, which in turn makes new hinge
points on the skin. The new hinge axis diverges from the
original hinge axis as it moves farther from the anatomic
structure (Figure 48).
Figure 44 Upper and lower frames

that have been placed on the head.
Figure 47 Supposition: Right condyle moved 5 mm forward.
Figure 45 Axiograph III uses two recording styli in a

collinear alignment, rectilinear with the upper
$[LRPDWLFÁDJERZUHFRUGLQJSODWHV

it will appear to move slightly more on the graph.
Figure 48 New hinge axis passing

through newly positioned condyle.
Figure 49 is a magnified view of the right joint area.
Figure 51 The recording styli will point

WRWKHQHZKLQJHRQWKHÁDJWDEOH
Right condyle 5 mm
anterior to the left
condyle.
Figure 49 The supposition is that the distance between

the centers of the two condyles is 110 mm, and the
distance at the skin level is 140 mm.
The example assumes that the distance between the cen-

ters 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

Figure 52 IIf the condyle moves 5 mm forward,
flag table (Figure 51). the hinge point on the skin will move 5.68 forward.
The distance between the skin and the graph table
If the condyle moves 5 mm forward, the hinge point on is usually greater in Axiograph III than in Axi-Path.
the skin will move 5.68 mm forward (Figure 52). Taking this into account, the distance between the
skin and the graph was set at 8 mm in Axiograph III,
instead of 5 mm, as in Axi-Path.
The distance between the preauricular skin and the flag Although this situation is one that we may not encoun-
table is usually greater in the Axiograph III than it is in the ter in practice, it is useful as an example to explain an ex-
Axi-Path. Taking this into account, the distance between the treme case (Figure 55).
skin and the flag table was set at 8 mm in the Axiograph III.
When the flag table is 8 mm away from the skin, the mea-
surement error will be 0.36 mm. This is 0.13 mm larger than
the 0.23 mm measurement error with the Axi-Path, which
has the flag table 5 mm away from the skin (Figure 53).
Figure 55 0DJQLÀHGYLHZ
It is obvious that the measurement error becomes larger

when the distance from the stylus to the skin is 50 mm (Figure
56). In fact, the measurement error will be 2.3 mm (Figure 57).
Figure 53 If the distance from the stylus to the skin is 8 mm,

the amount of error will be calculated as follows:
5.68 : 125 = X : 8 mm (X = 45.4 ÷ 125 = 0.36 mm)
If we were to transfer the face-bow of the Axiograph III

system in the same way as we transfer the face-bow of the
Axi-Path system, we would have to shorten the distance be-
tween the skin and the flag table to reduce the measurement
error. However, in the Axiograph III system we use hinge
marks on the graph, rather than hinge marks on the skin, for
precision mounting.
Now let us further suppose that the stylus is placed 50 Figure 56 The measurement error becomes larger
when the distance from the stylus to the skin
mm, rather than 8 mm, away from the skin (Figure 54).
changes from 8 mm to 50 mm.
Figure 54 Supposition: The stylus is 50 mm away from the skin.
Figure 57 If the distance from the stylus to the skin

is 50 mm, the amount of error will be calculated as follows:
5.6 8: 125 = X : 50 mm (X = 284 ÷ 125 = 2.3 mm)

This is an extremely large error when we are attempting Next, let us examine the precision mounting system of
to locate a THA. Fortunately, it seldom happens that we at- the Axiograph III. Figure 61 shows a magnified view of the
tempt to locate a THA from a distance of 50 mm in clinical highlighted area. The various parts of the highlighted area
practice (Figure 58). are shown in Figure 62. They are, respectively, the side arm
of the upper frame, the flag table attached to the side arm,
the recording arm of the lower frame, and the stylus attached
to the recording arm.
Figure 58 If we try to extend the stylus to the skin to mark a

hinge point from a point located at a far distance from the
skin using Axiograph III, it would result in a very large error.
The fact remains, however, that the greater the distance

between the skin and the stylus, the less accurate are the
marks on the skin (Figure 59). Therefore, we are likely to Figure 61 Schematic drawing and
make a large error if we use a false hinge axis that deviates real picture of the stylus area.
substantially from the THA (Figure 60).
Figure 59 The greater the distance between the skin

Figure 620DJQLÀHGYLHZ
and the stylus, the less accurate the marks of
the THA on the skin will be.
The THA is the line that connects the left and the right
Precision mounting styli. It passes through an imaginary hole in the flag table.
using a false hinge
The stylus marks the hinge point in red or blue on the graph
axis results in a very
large error. of the flag table (Figures 63 and 64).
Figure 60 We are likely to create a large error if we use the

false hinge axis, which deviates substantially from the THA.
Figure 63 Flag table. Figure 66 Schematic drawing and real
SLFWXUHRIWKHÁDJWDEOHDQGWKHFODPS
The precision mounting stand has two hinge axis align-

ment pins. These pins are designed to fit into the small holes
on the inner bar of the hinge axis clamp (Figures 67-a, b).
Figure 64 Flag table.
The hinge point on the graph is isolated with the hinge

axis clamp. The hinge axis clamp has two bars. Each bar has
a hole in it, and the two holes are aligned (Figures 65 and
Figure 67-a Hinge axis alignment pin
66). ÀWVLQWRWKHLQQHUFODPSKROH
Figure 65 Flag table with hinge axis clamp. Figure 67-b Hinge axis alignment belongs to mounting stand.

In this respect, the Axiograph III system differs from
the Axi-Path system; in the Axi-Path, the stylus of the lower
frame fits into the female part of the mounting shaft. There-
fore, we do not need to re-mark the hinge point on the skin
with the Axiograph III as we do with the Axi-Path. Instead,
we use the hinge points on the graphs for precision mount-
ing. In other words, we treat the graph as if it were the skin
in the Axiograph III system (Figure 68).
Figure 70 Measurement error increases as the

ÁDJWDEOHPRYHVFORVHUWRWKHVNLQPHGLDOO\
Figure 68 In Axi-Path, the stylus (axis pin) of the lower frame
is adapted to the female part of the mounting shaft. In
Axiograph III, the hinge axis alignment pins of the mounting
VWDQGDUHÀWWHGLQWRWKHVPDOOKROHVRQWKHLQQHUEDURIWKH
hinge axis clamp. Therefore, we need not re-mark the hinge
point on the skin, as we do with Axi-Path. Instead, we use
the hinge points on the graphs for precision mounting.
The distance from the tip of the hinge axis alignment

pin to the THA is the measurement error (Figure 69). It is in-
teresting to observe that the measurement error increases as
the flag table moves closer to the skin medially (Figure 70).
Conversely, the measurement error decreases as the flag table
moves farther from the skin laterally (Figure 71).
Figure 71 Measurement error decreases as the
ÁDJWDEOHPRYHVIDUWKHUIURPWKHVNLQODWHUDOO\
If we try to extend the hinge axis-locating stylus from

the flag to the skin to mark an axis as we do in the Axi-Path
system, the new hinge point on the skin will not correspond
to the true hinge point. As a result, the precision mounting
will be inaccurate. In the Axiograph III system, the measure-
ment error decreases as the flag table gets farther away from
the skin and the constructed hinge axis gets closer to the
THA (Figure 72).
Now let us consider two situations that we may encoun-

ter in clinical practice. In the first situation, the side arm of
Figure 69 The distance from the tip of the hinge axis the upper frame contacts the skin of supraauricular area
alignment pin to the THA is the measurement error. (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 be-

tween the condyle and the recording flag, depending on the
configuration of the patient’s head. For the purposes of illus-
tration, we will assume that the side arm is 3 mm away from
In this example (Figure 74) the thickness of the hinge
axis clamp is 5.75 mm; the distance from the skin to the
inner surface of the flag table is 6.5 mm; the distance from
the skin to the outer surface of the flag table is 11 mm; the
distance from the left condyle to the skin on the right side of
is 110 + 15 mm; and the distance from the left condyle to the
inner surface of the flag table is 110 + 15 + 6.5 mm. This is
indicated by the yellow arrow.
The measurement error at the position indicated by the

arrow is calculated as follows:
r Y is the measurement error on the inner surface of the

Figure 72
flag table. The amount of error is 0.20 mm (Figure 75).
Figure 73 Supposition: The side arm contacts the skin.

Figure 75 Y is the measurement error on the inner surface
RIWKHÁDJWDEOH7KHDPRXQWLVPP
r The measurement error at the inner entrance of the

hinge axis clamp increases slightly (Figure 76).
Figure 74 Supposition: The side arm is separated

3 mm from the skin. The hinge point is measured
at level of entrance of the clamp hole.
the skin. In fact, this does not actually happen in clinical

practice, because we always push the side arm onto the skin Figure 76 Supposition: The side arm is separated 3 mm
to fasten the upper frame to the head. If, however, we assume from the skin. The hinge point is measured at
3 mm of separation, this means that the flag table will be 6.5 level of entrance of the clamp hole.
mm away from the skin, and the hinge point locator clamp
will be attached to the flag table (Figure 74).

r The measurement error at the inner entrance is 0.47 r The measurement error on the inner surface of the
mm (Figure 77). flag table is 0.20 mm and this is almost the same as
or smaller than that of Axi-Path.
Although the clamp hole provides a bit of leeway with

the pin fitted, this seems to have no clinical significance. Since
the Axiograph III system uses the hinge point on the graph,
while the Axi-Path system uses the hinge mark on the skin,
the two systems seem to yield almost the same accuracy in
precision mounting (Figure 80).
Figure 77 The amount of measurement error will be 0.47 mm.
r The measurement error on the skin increases even

more (Figure 78).
Figure 80 The measurement error on the inner surface

RIWKHÁDJWDEOHLVPP(UURULVWKHVDPHDV
or less than, with Axi-Path.
6XPPDU\DQG&RQFOXVLRQV
The measurement errors of the hinge axis locations were
calculated for the two recording systems, the Axi-Path of
Panadent and the Axiograph III of SAM. The amount of
the measurement errors were nearly the same for both sys-
tems. While the Axiograph III system locates the hinge axis
Figure 78 Supposition: The side arm is separated 3 mm
from the skin. The hinge point is measured at using hinge points on the flag table, the Axi-Path system
level of entrance of the clamp hole. locates the hinge axis using hinge marks on the skin. Al-
though the distance between the flag table and the skin is
r The measurement error on the skin is 0.5 mm
greater in the Axiograph, we found no significant differ-
(Figure 79).
ence in accuracy between the two systems, as explained
previously. (Figure 83)
r
Figure 79 The amount of measurement error will be 0.5 mm.
Figure 837KHGLVWDQFHEHWZHHQWKHÁDJWDEOHDQGWKHVNLQLVORQJHULQ$[LRJUDSK,,,WKDQLQ$[L3DWK
But since Axiograph III uses hinge points on graph paper to locate the hinge axis, it is equally accurate.
Since the Axiograph III system does not mark hinge

points on the skin, it may be necessary to relocate the axes
for each mounting. Mechanical stability of the recording de-
vice is very important for precision. The device must remain
firmly seated on the head. In this respect, the Axiograph III
seems to be superior to the Axi-Path (Figure 85). ɵ
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.
)XUWKHU5HDGLQJ
Baldauf A, Mack H, Wirth C G. Bestommung der Scharnierachse mit- Hobo S. Twin-tables technique for occlusal rehabilitation. Pt. 2: Clini-
tels des äußeren Gehörgangs. IOK, 28. JAHRG. 1996. cal procedures. J Prosthet Dent. 1991;66:471–477.
Broderson S P. Anterior guidance: The key to successful occlusal treat- Lee R L. Panadent instruction manual for advanced articulator system.
ment. J Prosthet Dent. 1978;39:396–400. Panadent Corporation, CA, USA, 1988.
Cho Y, Hobo S, Takahashi H.Occlusion. Seoul: Kunja; 1996. Lundeen H C, Gibbs C H. The Function of Teeth. L and G; 2005.
Dawson P E. Evaluation, Diagnosis, and Treatment of Occlusal Prob- Nagy W W, Smithy T J, Wirth C G. Accuracy of a predetermined trans-
lems. 2nd ed. St. Louis, Mo: Mosby; 1989. verse horizontal mandibular axis point. J Prosthet Dent. 2002;87:387–
394.
Glossary of Dental Prosthodontics. Korea: Korean Association of
Prosthodontics; 2006. Okeson J P. Fundamentals of Occlusion and Temporomandibular
Disorders. St. Louis, Mo: Mosby; 1985.
Hobo S. Twin-tables technique for occlusal rehabilitation. Pt. 1:
Mechanism of anterior guidance. J Prosthet Dent. 1991;66:299–303. continued on next page...

Ramfjord S, Ash M M. Occlusion. 3rd ed. Philadelphia: WB Saunders;
1983.
Simpson J W, Hesby R A, Pfeifer D L, Pelleu G B Jr. Arbitrary man-

dibular hinge axis locations. J Prosthet Dent. 1984;51:819–822.
Takahashi I. Surgical-orthodontic treatment of a patient with temporo-

mandibular disorder stabilized with a gnathologic splint. Am J Orthod
Dentofacial Orthop. 2008;133: 909–919.
Theusner J, Plesh O, Curtis D A, Hutton J E. Axiographic tracings of

temporomandibular joint movements. J Prosthet Dent. 1993;69:209–
215.
Wirth C G. 20 Jahre Axiographie. IOK, 28. JAHRG. 1996.
&RQG\ODU5HVRUSWLRQ0DWUL[0HWDOORSURWHLQDVHV
DQG7HWUDF\FOLQHV
Michael J. Gunson, DDS, MD ɵ G. William Arnett, DDS, FACD
M ICHAEL J. G UNSON , DDS, MD 6XPPDU\

gunson@arnettgunson.com Mandibular condylar resorption occurs as a result of inflammation and hor-
ɵ Graduated from UCLA School of mone imbalance. The cause of the bone loss at the cellular level is secondary
Dentistry, 1997
ɵ Graduated from UCLA School of to the production of matrix metalloproteinases (MMPs). MMPs have been
Medicine 2000 shown to be present in diseased temporomandibular joints (TMJs). There is
ɵ Specialty Certificate in Oral and evidence that tetracyclines help control bone erosions in arthritic joints by
Maxillofacial Surgery UCLA, 2003 inactivating MMPs. This article reviews the pertinent literature in support of
G. WILLIAM A RNETT , DDS, FACD
using tetracyclines to prevent mandibular condylar resorption.
ɵ Graduated from USC School of
Dentistry, 1972
ɵ Specialty Certificate in Oral and
Maxillofacial Surgery UCLA, 1975
,QWURGXFWLRQ has been well studied. A number of cytokines and proteases

Orthodontists and maxillofacial surgeons are well acquaint- are found in joints that show osseous erosions that are not
ed with the effects of condylar resorption (Figure 1). present in healthy joints, namely TNF-Ơ, IL-1ơ, IL-6, and
RANKL and matrix metalloproteinases.
0DWUL[0HWDOORSURWHLQDVHV
MMPs are of interest because they are directly responsible
for the enzymatic destruction of extracellular matrix in nor-
mal conditions (angiogenesis, morphogenesis, tissue repair)
and in pathological conditions (arthritis, metastasis, cirrho-
sis, endometriosis). MMPs are endopeptidases that are made
in the nucleus as inactive enzymes, or zymogens. The zymo-
gens travel to the cell membrane, where they are incorporat-
Figure 1 Tomograms reconstructed from cone-beam CT scan. ed. The zymogen is then cleaved into the extracellular matrix
They show severe condylar resorption in a 19-year-old female as the active enzyme, where it makes cuts into the protein
over a 2-year period. Note the progressive osseous destruction.
chains (collagen types I through IV, gelatin, etc). These cuts
cause the proteins to denature, which results in the destruc-
The clinical outcomes of condylar resorption have been de- tion of the matrix. The action of the MMP requires the min-
scribed at length in the literature.1-6 The causes, however, eral zinc—which is an important part of the MMP’s protein
have been elusive, hence the common name idiopathic con- structure; hence the name metalloproteinase (Figure 2).
dylar resorption. Over the last several years, the pathophysi-
ology of articular bone erosion secondary to inflammation

porated. Activation of the MMP occurs when the active side
of the MMP is cleaved from the cell and liberated into the ex-
tracellular matrix. Extracellular inhibition comes from pro-
teins called tissue inhibitors of metalloproteinases (TIMPs).
TIMPs bind to active matrix metalloproteinases and inhibit
their activity (Figure 4c). The ratio of MMP:TIMP activity
influences the amount of matrix degradation.7-10
Figure 2 The zymogen pro-MMP is transcribed in the nucleus

and then attached to the cell membrane. It is activated when
it is cleaved from the membrane. The zinc (Zn) portion binds
to protein and the enzyme cleaves the protein, destroying the
extracellular matrix.
In joints, MMPs are produced by monocytes, mac-

rophages, polymorphonuclear neutrophils, synoviocytes, os-
teoblasts, and osteoclasts. MMPs are generally classified by
the kind of matrix they degrade; thus collagenase, gelatinase
and stromelysin (Figure 3). Figure 4-a MMP transcription is activated in the cell nucleus by
F\WRNLQHV71)Ơ,/ơ,ODQG5$1./E\PHWDEROLF
E\SURGXFWVIUHHUDGLFDOVDQGE\GLUHFWVKHHUVWUHVV
to the cell membrane.
Figure 3 A list of the 28 known MMPs. They are generally

named after the extracellular protein that they degrade.
Figure 4-b MMP transcription is inhibited by hormones such
The extracellular activity of MMPs is regulated in two as vitamin D and estradiol, as well as the bone-protective
ways, by transcription and by extracellular inhibition. The cytokine osteoprotegerin.
transcription of MMPs in the nucleus is controlled by multi-
ple pathways. MMP transcription is activated by sheer stress
to the cell, by free radicals, and by the cytokines TNF-Ơ, IL-
1ơ, Il-6 and RANKL (Figure 4a). Transcription is suppressed
by the cytokine osteoprotegerin and by the the hormones
vitamin D and estradiol (Figure 4b). After transcription, the
pro-MMP is then sent to the cell membrane, where it is incor-
38 Gunson, Arnett | Condylar Resorption, Matrix Metalloproteinases, and Tetracyclines

des. This evidence supports the presence of 6 of the known
28 matrix metalloproteinases (MMP-1, MMP-2, MMP-3,
MMP-8, MMP-9, and MMP-13) in fluid or tissue samples
obtained from diseased human TMJs.13, 16, 17, 19-34 Some cases
of degenerative joint disease also result from an imbalance
between the activities of MMPs and TIMPs, favoring unreg-
ulated degradation of tissue by MMPs. 35, 36
7HWUDF\FOLQHV
Because MMPs are found to be elevated in patients with
TMJ arthritis and are so destructive to articular tissues, find-
ing a way to reduce their activity or their production would
be helpful in treating patients with arthritis and condylar
Figure 4-c The extracellular activity of MMPs is controlled by the
resorption.
presence of inhibitory proteins called tissue inhibitors of
metalloproteinases, or TIMPs. TIMPs bind directly to the From 1972-1982, at the School of Dental Medicine in
MMPs, causing conformational changes that prevent the Stony Brook New York, Ramurmathy and Golub discov-
destruction of matrix proteins. ered that tetracyclines have anti-collagenolytic properties.
In 1998, Golub and colleagues showed that tetracyclines
MMPs and Arthritis inhibit bone resorption in two ways—by controlling the ex-
The hallmark sign of arthritis is articular bone loss. In the
pression and activity of MMPs and by regulating osteoclasts
past, clinicians have differentiated between inflammatory ar-
and their activity.37
thritis and osteoarthritis (OA). Recently, however, the cellular
processes that result in bone and cartilage loss in both forms
&RQWUROOLQJ003V:LWK7HWUDF\FOLQHV
of arthritis have been shown to be quite similar.11 While in-
Tetracyclines inhibit MMPs by chelating zinc and by regu-
flammatory arthritis is promoted by a systemic problem, the
lating MMP gene expression. As noted above, MMPs need
result is an inflammatory cytokine cascade, which ultimately
zinc to actively cleave collagen proteins. Tetracyclines bind
results in osteoclastic activity and bone loss at the articular
divalent ions, such as zinc. By reducing the amount of free
surface. OA is not a systemic problem but a local one, second-
zinc in tissues, tetracyclines reduce the number of MMPs
ary to oxidation reactions, free radical production, or sheer
available.38 In addition, tetracyclines bind to the MMP itself,
stress—all three of which result from overuse.12, 13 Despite
which causes a conformational change in the enzyme, inacti-
the localized nature of OA, the cascade of cellular events that
vating it (Figure 5).39 Tetracyclines have also been shown to
cause articular surface loss is the same as the systemically in-
decrease the transcription of MMPs by blocking both pro-
duced cascade. An increase in TNF-Ơ and IL-1ơ increases the
tein kinase C and calmodulin pathways.40, 41
number of osteoclasts and their activity. TNF-Ơ, IL-1ơ, IL-
6, and RANKL all cause increased expression of the MMP
genes. The end result is destruction of cartilage, bone, and
connective tissue in both arthritis models.14-18
MMPs also respond to systemic hormones such as estro-
gen, vitamin D, and parathyroid hormones. We found an as-
sociation between low estrogen levels and low vitamin D lev-
els in patients with severe condylar resorption.3 All of these
hormones and cytokines are intimately involved in osteoclast
differentiation and activation. This makes sense: MMPs are
osteoclast produced and are responsible for bone and carti-
lage destruction.
003VDQGWKH70- Figure 5 Tetracycline binds directly to the zinc of the MMP.

There is substantial evidence indicating that MMPs play an This deactivates the enzyme and protects the matrix
important role in bone and cartilage degradation associated from degradation. Tetracycline also controls osteoclastic
activity and MMP transcription.
with degenerative temporomandibular joint (TMJ) arthriti-

5HJXODWLQJ2VWHRFODVWV:LWK7HWUDF\FOLQHV racyclines may be considered for the treatment of rapidly
Osteoclasts are responsible for the breakdown of bone and progressive condylar resorption, and in patients with degen-
cartilage. Their activity is tightly controlled by cytokines erative TMJ disease. They may also be used in patients at in-
such as IL-6, TNF-Ơ, nitric oxide, and IL-1ơ. Tetracyclines creased risk for resorption. This includes patients with brux-
have been shown to prevent the liberation of these cytokines, ism, inflammatory arthritis, or a past history of resorption
diminishing the activity of osteoclasts.42-46 Tetracyclines also who are undergoing occlusal treatment. Of all the available
prevent the differentiation of osteoclast precursor cells into tetracyclines, Golub et al found that doxycycline was the
osteoclasts.47 Finally, tetracyclines promote the programmed most effective at suppressing MMP activity.56 Appropriate
cell death (apoptosis) of osteoclasts.48, 49 All these actions re- studies to determine effective dose schedules have not been
sult in a decrease of bone and cartilage loss secondary to conducted to date. However, based on the limited clinical
osteoclast activity when tetracyclines are present. data, it is reasonable to consider doxycycline at a dose of 50
mg twice daily.
7HWUDF\FOLQHVDQG$UWKULWLV
In short, the literature shows that tetracyclines exert control Side Effects
over MMP transcription and activity and regulate osteoclast The adverse effects of tetracyclines are well known. They
activity as well. The clinical evidence supporting the use of include allergic reactions; gastrointestinal symptoms (ulcers,
tetracyclines to protect articular bone and cartilage from ar- nausea, vomiting, diarrhea, Candida superinfection); photo-
thritic inflammation is encouraging. sensitivity; vestibular toxicity with vertigo and tinnitus; de-
In the animal model of arthritis, tetracyclines have been creased bone growth in children; and discoloration of teeth
shown to inhibit MMPs and to prevent the progression of if administered during tooth development. Tetracyclines may
osseous disease.50-52 Yu et al52 induced knee arthritis in dogs also reduce the effectiveness of oral contraceptives, potenti-
by severing the anterior cruciate ligament. Half the dogs ate lithium toxicity, increase digoxin availability and toxic-
were pretreated with doxycycline. Doxycycline prevented ity, and decrease prothrombin activity.57
the full-thickness cartilage ulcerations that were seen in the If tetracycline therapy is initiated, the patient should be
untreated group. advised of the potential for reduced efficacy of oral contra-
In human studies, tetracyclines have been successfully ception. In addition, the patient should be cautioned against
used to diminish bone erosions in patients with inflammato- sun exposure, and should be monitored for other side effects.
ry arthritis. One meta-analysis of 10 clinical trials that used If surgery is contemplated, the patient’s coagulation status
tetracycline for rheumatoid arthritis (RA) showed significant should be evaluated.
improvement in disease activity with no side effects.53 In a There is some question as to whether bacterial resis-
single-blinded controlled study, doxycycline was shown to tance may develop with the chronic use of antibiotics. Stud-
be as effective as methotrexate in treating inflammatory ar- ies show that long-term low-dose doxycycline (20 mg twice
thritis.54 daily) does not lead to a significant increase in bacterial resis-
Israel et al reported that doxycycline administered at a tance or to a change in fecal or vaginal flora.58, 59
dose of 50 mg twice daily for 3 months significantly sup-
pressed MMP activity in three patients diagnosed with ad- Other Medications to Control MMPs
vanced osteoarthritis of the TMJ. Two of the three patients Tetracyclines are not the only medications that can prevent
reported marked improvement in symptoms, including im- MMP-induced bone erosions. There are promising studies
proved mandibular range of motion. One patient did not that show the benefits of TNF-Ơ inhibitors; osteoprotegerin
experience symptomatic relief despite a marked reduction in analogues; HMG-CoA reductase inhibitors (eg, simvasta-
MMP activity.55 While symptomatic relief would be impor- tin); and hormone replacement therapies, including vitamin
tant, it must be noted that inhibition of MMPs has a direct D and estradiol.60-63 These medications, along with doxycy-
effect on bony resorption, which is often unrelated to TMJ cline, show great promise in controlling articular bone loss
symptoms. Clinicians need to keep this in mind when rein the face of inflammation.
viewing the literature.
Conclusion
'RVLQJ When patients present with condylar resorption, clinicians
At present, there are no definitive studies demonstrating the have long been resigned to two choices: watch and wait or
efficacy of tetracycline therapy for degenerative TMJ ar- surgical resection with the resulting disability and deformity.
thritides. However, based on the available information, tet- Doxycycline is just one pharmacological intervention that

shows promise in curbing the bone loss associated with ar-
thritis and condylar resorption (Figures 6-a, b, c, d, e). ɵ
Figure 6-a, b, c, d, e This is a 31-year-old patient with condylar

resorption secondary to rheumatoid arthritis. She was treated
with orthognathic surgery to correct her malocclusion. The
effects of MMPs were controlled pre- and postoperatively by
prescribing the following medications: doxycycline, simvastatin,
Enbrel, Feldene, vitamin D, and omega-3 fatty acids. She is 10
months postsurgery with minimal osseous change to her condyles
and a stable class I occlusion with good overbite and overjet.

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63. Tetlow LC, Woolley DE. Expression of vitamin D receptors and

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&RPSDULVRQRI0D[LOODU\&DVW3RVLWLRQV0RXQWHGIURPD7UXH+LQJH
.LQHPDWLF)DFH%RZYVDQ$UELWUDU\)DFH%RZLQ7KUHH3ODQHVRI6SDFH
Dori Freeland, DDS, MS ɵ Theodore Freeland, DDS, MS
ɵ Richard Kulbersh, DMD, MS, PLC ɵ Richard Kaczynski, BS, MS, PhD
D ORI F REELAND , DDS, MS 6XPPDU\

tdfortho@freelandorthodontics.com There are many methods of performing a face-bow transfer, but only two
ɵ Private Practice, Lake Orion, MI
current methods of replicating the position of the maxilla in three planes of
T HEODORE F REELAND , DDS, MS space: with a true hinge face-bow or with an arbitrary earpiece face-bow. The
ɵ Adjunct Professor, Orthodontic
purpose of this study was to determine if a clinically significant difference in
Dept., School of Dentistry,
University of Detroit Mercy three planes of space occurs in the mounting of the maxillary cast when the
ɵ Director Roth/Williams USA mounting is done with an arbitrary earpiece face-bow versus a true hinge
ɵ Private Practice, Gaylord, MI face-bow.
R ICHARD KULBERSH , DMD, MS, PLC The sample consisted of 51 subjects with complete permanent dentitions
ɵ Program Director, Orthodontic through the second molars, including class I, class II, and class III subjects.
Dept., School of Dentistry, Two maxillary impressions were taken on each subject. One maxillary cast
University of Detroit Mercy
was mounted using an arbitrary earpiece face-bow and the other using a true
R ICHARD K ACZYNSKI , BS, MS, P H D hinge face-bow. Each cast was measured and compared in three planes of
ɵ Statistician, Dept. of Psychiatry, space on an adjustable occlusal table containing graph paper. The positions
Yale University School of Medicine
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).
,QWURGXFWLRQ ence from the teeth.3 According to Okeson, this position is

The quest to understand the multifaceted movements of achieved when the muscles of mastication and the ligaments
the mandible and its relationship to the rest of the cranial combine to seat the condyle into the glenoid fossa.2 Stability
complex began in the early 1800s.1 Gray’s Anatomy was of the joint is maintained by constant muscle activity, even
one of the first sources to publish the fact that the mandible in resting states, which allows the articular surfaces to come
moves on a hinge as well as by forward and lateral move- into contact, although a true structural attachment or union
ments from the condyles in the glenoid fossae.1 Thus, the is not present in the TMJ.2 The muscles play an active role in
temporomandibular joint (TMJ) became known as a gingly- the opening and closing of the mandible, while the ligaments
mo-arthrodial joint and was seen as one of the most complex act as passive restraining devices to limit joint movements.
joints in the human body. Although the TMJ is considered Specifically, the temporomandibular ligament plays a role
a compound joint, it consists of only two actual bones. An in limiting the extent of mouth opening. During the initial
articular disc interposed between the condyles and the man- phase of opening, the condyle rotates around a fixed point
dibular fossa of the temporal bone keeps the two bones from for about 20 mm, until the temporomandibular ligament
direct articulation. The disc serves as a nonossified bone; it becomes strained and the condyle is forced into a forward
serves as the third bone of the compound joint and allows movement down the articular eminence.2 Posselt defined
complex movements to occur.2 this opening as the mandibular terminal hinge opening and
When occlusal function is ideal, the condyles are po- closing.4 The Glossary of Prosthodontic Terms similarly de-
sitioned in the glenoid fossae and the mandible should be scribes this movement as “an imaginary line around which
able to move by joint-dictated patterns without any interfer- the mandible may rotate through the sagittal plane” and

terms the movement the transverse horizontal axis.5 Trapozzano and Lazzari found that 57.2% of the sub-
Study of mandibular movements raised questions among jects in their study had more than one condylar hinge axis
the dental profession as to whether a hinge axis actually ex- point located on either one or both sides of the mandible.
ists, and if so, whether it is one axis or more than one. The Therefore, the attempt to locate the hinge axis, was seriously
dental profession also debated how accurately the hinge axis questioned because multiple axis points may exist.10,11 Other
can be located, if in fact one exists; the clinical usefulness of studies have demonstrated that the center of rotation is mov-
locating it; and whether an arbitrary point on the face can able during every phase of jaw opening and closing; there-
satisfactorily be substituted for a specific point as a location fore these studies also refute the hinge axis theory.12,13 Still
for the hinge axis.6 No other topic inspires more controversy other studies have questioned the use of a hinge axis, due
in oral physiology than the role of the jaw joints in dental to the complexity of its location, and the technical operator
articulation. error that is inherent in the procedure.14,15 Many investiga-
Campion, working in 1902, made the first graphic tors believe that it may be impractical to construct clutches,
record of the mandibular movements in a patient. He con- locate the hinge axis, make multiple interocclusal records,
cluded that both a rotation of the bone on an axis and a and use a fully adjustable articulator on every patient.16 Still
forward-downward movement of the condyles occurred. the theory that the hinge axis is a reliable reference—one in
Campion designed an adjustable face-bow fixed to the man- which the position of the maxillary cast on an articulator can
dibular teeth with modeling plaster to graphically record the be reproduced—is a very strong one.4
various positions of the condyles on the face with a succes- Many studies have demonstrated that the terminal hinge
sion of dots. He concluded that “the only part of the opening movements of the mandible pass through both condyles.
movement which an articulator reproduction is concerned These studies support the theory that there is only one hinge
with is the initial stage, which is seen in the tracings to be a axis .4,17-19 Beard and Clayton reached this conclusion by us-
simple rotation about an axis passing through the condyles.” 7, 8 ing an apparatus that records arcs on paper; they argued that
Bennett also recognized that the mandible was capable of the terminal hinge axis can be accurately located by finding
two independent movements, but he felt that no single fixed the one and only stylus position where no arcing occurs.19
center of rotation for the mandible existed.8 He judged that There are many methods of locating the arbitrary hinge
the initial center of rotation of the mandible was located be- axis for transfer to an articulator. Following are some ex-
hind and below the condyle.8 amples of these methods.
During this same period, Stallard introduced the term— 1. The Gysi point is located 13 mm in front of the
and the concept of—gnathology—the study of the harmo- most upper part of the external auditory meatus on
nious, interrelated functioning of the jaws and teeth.1,7,9 In a line passing to the ectocanthion.
1924, McCollum developed the first method of locating the 2. The Lauritzen-Bodner axis is located 12 mm ante-
hinge axis with an instrument called the gnathoscope, and rior to and 2 mm below the porion.
its later model, the gnathograph.1,7 McCollum demonstrated 3. Abdal-Hadi axis is located using a linear regression
that no external anatomical landmarks would indicate the formula to predict the anteroposterior (A-P) site of
position of the opening axis, nor could this be done by pal- the hinge point, according to the width profile axis
pating the joint or by measuring a distance in any direction.1,7 theory of the face.
McCollum explained that the hinge axis must be determined 4. The arbitrary hinge axis is located using the ear-
instrumentally, and that the movement of this axis is a com- piece face-bow. In this method, the ear rods of a
ponent of every masticatory movement of the mandible.1,7 fixed face-bow are inserted into the external audi-
After McCollum’s death, Stuart continued to study mandib- tory meati.
ular movement and developed his own gnathological system, 5. The arbitrary hinge axis is located by external pal-
including a fully adjustable articulator and pantograph.1,7 pation of the condylar anatomy.20,21
Gnathologically oriented studies produced and still pro- Studies have shown that when an arbitrary earpiece
duce conflicting conclusions that divide the dental commu- face-bow is used to reproduce the condylar positions, the
nity. One group believes that there is a definite transverse results are fairly reliable.22-27 Clinically, it has become accept-
hinge axis, and that it is necessary to find its point of ro- able that as long as the arbitrary point is within 5 mm of the
tation. Another group believes that methods of locating an true hinge axis, the arbitrary earpiece face-bow is accurate
arbitrary hinge point are just as reliable, and more operator enough to study the patient’s occlusion.22-27 Nagy et al con-
friendly. Still others believe that it is not necessary to locate ducted another study comparing the location of an anatomi-
the transverse axis at all. cally predetermined hinge axis point with marked hinge axis
46 Freeland et al | Comparison of Maxillary Cast Positions

points. They found that the mean distance between any two cal position of the arbitrary hinge axis (AHA) produce the
points was 1.1 mm. More than 96% of predetermined points largest A-P discrepancies upon mandibular closing.41 Other
were within 2 mm of the true hinge axis.23 Schallhorn also authors have graphically illustrated how errors in true hinge
found that approximately 98% of all true anatomical hinge axis location can produce occlusal aberrations.33,35,36,42 These
axis points were within a 5-mm radius.26 authors also showed that the greatest errors occurred when
In comparison, studies that compared maxillary cast po- the hinge axis was incorrectly located in a vertical direction
sitions mounted with four different face-bows showed wide perpendicular to the correct hinge axis closure. An arbitrary
variation in the mounted maxillary cast positions. All arbi- hinge axis positioned superior to the true hinge axis also
trary hinge axis points deviated from the true hinge baseline produced premature contacts on the anterior teeth. In addi-
point by anywhere from 1.5 mm to 4 mm. Therefore, the tion, if the arbitrary hinge axis was placed inferior to the true
authors of these studies concluded that it was not possible hinge axis, premature posterior contacts occured.33,35,36,42
to establish the clinical superiority of one arbitrary face-bow Brotman’s geometric representation related changes in
over another.28,29 the hinge axis point locations between the true hinge axis
Lauritzen and Bodner located 100 true hinge points on and the arbitrary axis to differences produced at the occlus-
50 subjects. They found that 67% of the axis points were al level in mounted casts.43 Brotman concluded that “if the
5 mm to 13 mm away from the arbitrarily marked hinge hinge axis has been improperly located by as much as 3 mm,
points. This discrepancy may introduce gross errors in the the error at the occluding position of the casts (anteroposte-
mounting of the casts on an articulator, resulting in large riorly) will be about .09 mm or less than 1/250 inch.”43
occlusal errors.30 Palik et al got similar results. They found Gordon et al looked at the location of the terminal hinge
that only 50% of the arbitrary hinge axes located with the axis and its effect on the second molar cusp position on the
arbitrary earpiece face-bow were within a 5-mm radius of position of the second molar cusp.6 Their results showed that
the terminal hinge axis. This indicated that the arbitrary incorrect anterior location of the hinge axis produced the ef-
earpiece face-bow hinge axis location does not represent the fect of having moved the mandibular arch backward. Incor-
total population.31 Schulte et al concluded from their study rect posterior location of the hinge axis produced the effect
that errors in locating the arbitrary hinge axis will produce of having moved the mandibular arch forward. Incorrect in-
a three-dimensional occlusal error.32 This study and others ferior location of the hinge axis caused slight retrusion of the
have recommended that if a thick vertical dimension of wax mandibular cast with premature posterior contacts. Incorrect
was used for an interocclusal record, or if the vertical dimen- superior location of the hinge axis caused protrusion of the
sion will be changed with treatment, a true hinge axis should mandibular cast with premature anterior contacts.6
be located on the patient.32,33 Due to anatomical variations, Since studies vary in reporting the percentage of place-
the arbitrary earpiece face-bow may introduce significant er- ment of the arbitrary hinge axis less than 5 mm from the true
rors in an A-P or vertical dimension, resulting in mandibular hinge axis, it can be assumed that larger errors in occlusion
displacement.34,35 The only way to be relatively certain that may occur. It has been found that an occlusal discrepancy of
errors due to malpositioning of maxillary casts on an articu- 0.01 inch can cause pulpitis or periodontal disease, though
lator have been avoided is to locate the true hinge axis.30,36-40 the patient may not be able to detect so small a discrepancy.44
Studies indicate that coincidence between the two hinge To limit occlusal errors in mountings, it is necessary to locate
axis points does not usually occur.41 This results in a discrep- the hinge axis to within 1 mm, and the kinematic true hinge
ancy between the arbitrary hinge axis and the true hinge axis can be done to this degree of accuracy.44 Therefore, the im-
points. This discrepancy will cause changes in the mounted portance of the true hinge axis is substantial when changing
position of the maxillary cast, which in turn can produce a the vertical dimension upon mandibular closure.38
positional change of all teeth in the three planes of space.41 Orthodontics deals specifically with the movement of
Zuckerman mathematically demonstrated that discrepancies all teeth and their occlusal fit. Therefore, it calls for extreme
between the true hinge axis and the arbitrary hinge axis points accuracy during diagnosis, treatment planning, and render-
can produce changes in the A-P direction of the occlusion. He ing treatment.9 Clinically finding the true hinge axis may be
verified in his analog tracing that the arc of the incisal edge the only way to ensure a reproducible and accurate starting
does not change in the A-P direction in centric occlusion, as point—one from which optimum esthetic and functional re-
long as the mandible is also coincident in centric relation. sults can be obtained.6,38,45 The purpose of this study was to
However, when an error in the arbitrary hinge axis occurs compare the maxillary cast mountings of 51 patients in three
and it is anterior to the true hinge, the incisor arc of closure planes of space when mounted using a true hinge axis face-
is anterior to the actual arc of closure.41 Errors in the verti- bow versus an arbitrary earpiece face-bow.

Materials and Methods
The records of 51 patients—34 females and 17 males—treat-
ed in a gnathologically oriented practice constituted the sam-
ple. Subjects ranged in age from 13 to 57 years, and all had
unremarkable medical histories with no contraindications to
orthodontic treatment. All upper and lower permanent teeth,
except third molars, were present on all subjects. TMJ exams
were conducted by a single operator before orthodontic re-
cords were conducted. Evaluation included subjective symp-
tomatology, as well as clinical examination. Subjects who
presented with TMJ symptoms were placed on a gnatho-
logical maxillary splint for a minimum of 3 months, or until
subjects were symptom free. Twenty of the 51 subjects had
records taken after splint therapy. The remaining 31 subjects,
all in active orthodontic treatment and with asymptomatic
TMJ, had records taken one appointment prior to deband.
All subjects had two maxillary alginate impressions tak-
en using Jeltrate alginate (Dentsply, Milford, Delaware). The
impressions were taken using sterilized metal rim lock trays
(Dentsply, Milford, Delaware). All impressions were disin- Figure 1-a, b Estimated facebow.
fected using Sterall Plus Spray (Colgate-Palmolive Company,
Canton, Massachusetts), and were rinsed with water and air
dried before being poured up.
All impressions were wrapped in moistened paper tow-
els and placed in plastic bags for approximately 20 minutes
prior to being poured up with Velmix (KerrLab, Orange,
California). Each model was poured up utilizing a water-
powder ratio consistent with the manufacturer’s instructions
for Velmix. The Velmix was vacuum mixed to remove any
entrapped air. The models were trimmed, and all bubbles
were removed from the occlusal surfaces.
Arbitrary earpiece face-bow transfers using the external
auditory meati were taken on each subject. (Panadent, Grand
Terrace, California) (Figure 1).
Figure 1-b
A true hinge face-bow was then taken on each subject,

using the true hinge axis instrument (Panadent, Grand Ter-
race, California) (Figure 2). A single operator completed
both face-bow records within 20 minutes of each procedure.
Intraoperator reliability tests for each of the two transfer
techniques were calculated.

Figure 3 Maxillary cast mounted with
Figure 2-a, b True-hinge facebow.
occlusal relater and pin at zero.
A 1-mm step ruler (Panadent, Grand Terrace, California)
was used to measure the vertical distance of the mesiobuccal
cusp tip of the right and left first permanent molar and the
upper right central incisor (Figure 4).
Figure 2-b.
One maxillary cast was mounted using the true hinge Figure 4-a Vertical measurements with 1-mm
kinematic face-bow transfer on a single Panadent articula- incremental step ruler: Measurement of anterior tooth
tor (Panadent, Grand Terrace, California), with Snow White vertical discrepancy.
Plaster #2 (Kerrlab, Orange, California) mixed according to
the manufacturer’s instructions. The second maxillary cast
was mounted with the arbitrary face bow on a single Pana-
dent articulator (Panadent, Grand Terrace, California), using
the same mounting plaster as was used for the first cast.
The true hinge maxillary cast was placed on a single
Panadent articulator, and an adjustable occlusal table (Pana-
dent, Grand Terrace, California), with graph paper adhered
to the surface, was attached to the articulator in place of the
mandibular cast. With the occlusal pin at zero, the occlusal
plane relater was stabilized by allowing contact at the maxi-
mum number of maxillary cast teeth (Figure 3).
Figure 4-b Vertical measurements with 1-mm

incremental step ruler: Measurement of posterior tooth
vertical discrepancy.

A straight wire with a 90-degree bend at the tip was This allowed the instrument to register the position of
held with the handle parallel to the occlusal plane relater each tooth on the graph paper (Figure 8).
(Figure 5).
Figure 5 Straight-lined measurement instruments. Figure 8 Comparing arbitrary hinge axis points vs.
true hinge axis point:
The tip was placed perpendicular to the tooth and held
1= Lower incisor will arc closed posterior to actual arc of closure
touching the height of contour of the upper first permanent mo- if AHA is inferior to TH.
lars and the upper right permanent central incisor (Figure 6). 2= Lower incisor will arc closed anterior to actual arc of closure
if AHA is superior to TH.
3= Lower incisor will arc closed slightly posterior to actual arc of
closure if AHA is anterior to TH.
4= Lower incisor will arc closed slightly anterior to actual arc of
closure if AHA is posterior to TH.
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 ar-
ticulating 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
Figure 6 Articulating paper used with straight-lined change in vertical dimension between the casts at the me-
measurement instrument for tooth markings.
siobuccal cusp tip of the maxillary right permanent first
It was then used to mark the position of the mesiobuccal molar. The second measurement assessed the vertical dis-
cusp of the upper molars and the entire incisal-edge position crepancy of the upper left first permanent molar. The third
of the upper central incisor. Red articulating paper for the measurement assessed the vertical discrepancy between the
maxillary cast mounted with the true hinge axis face-bow upper right permanent central incisors. The fourth measure-
mounted maxillary cast was then placed beneath each tooth ment compared the difference in an A-P direction between
(Figure 7). the mesiobuccal cusp tips of the upper right and left first
permanent molars. The fifth measurement assessed the trans-
verse discrepancy between the mesiobuccal cusp tips of the
upper molars. All measurements were conducted by a single
operator. Intraoperator reliability testing was used to vali-
date this measurement technique.
Results
A two-tailed matched-pairs t-test was used to evaluate for
significant difference in occlusal measurements in three
planes of space between maxillary casts mounted with a true
hinge face-bow and mounted with an estimated face-bow.
For this experiment, an Ơ level of 0.05 was chosen. Given
Figure 7 Tooth markings on graph paper. the number of measurements being evaluated (8), we decided

to adjust for experimentwide error by reducing our desired ence for the maxillary left first molar was 2.60 +/- 1.49 (t =
significance level to 0.001. 11.57, df = 50, p < .001).
The measurement differences in the vertical direction of
Measurements
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
Table 1 Mean values of the two face-bow techniques.
from 0.0 to 15.0 mm; and of the upper central incisor from
Table 1 shows the means and standard deviations for 0.0 to 13.0 mm. The differences in the transverse dimension
the arbitrary face-bow technique and the true hinge face- ranged from 0.0 to 7.0 mm for the upper right first molar
bow technique in the vertical, A-P, and transverse dimensions and from 0.5 to 7.9 mm for the upper left first molar.
with respect to the maxillary right and left first molars and
the maxillary right central incisor. The mean measurements Discussion
taken on the cast mounted with a true hinge face-bow were Mounting dental casts on an articulator allows the clinician
significantly smaller than those measured on the arbitrary to simulate maxillo-mandibular position in centric relation
earpiece face-bow mountings. The standard deviations for and makes possible a visible simulation of mandibular bor-
the true hinge face-bow were also one-half to one-third der movements. It has been recommended that mounting
smaller, indicating less variation around the sample mean. diagnostic dental casts on an articulator should be incorpo-
Results of the paired t-test are shown in Table 2. rated into routine clinical orthodontic practices.3,46 Record-
ing 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 trans-
fer 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 differ-
Table 2 Paired t-tests for differences between ence in the vertical, horizontal, or transverse position of the
estimated and true hinge technique. maxillary cast mounted with a true hinge face-bow versus an
The two face-bow techniques differed significantly in arbitrary earpiece face-bow” was rejected. Paired t-tests indi-
all three planes of space. The mean vertical discrepancy of cated that the maxillary cast position using an arbitrary face-
the maxillary right first molar between the estimated and the bow transfer was significantly different in all three planes of
true hinge face-bow was 2.19 +/- 2.31 (t = 6.76, df = 50, p space from the maxillary cast position mounted using a true
< .001). The mean vertical discrepancy for the maxillary left hinge face-bow transfer.
first molar was 2.45 +/- 2.21 (t = 7.90, df = 50, p < .001). In previous comparison studies when the arbitrary ear-
The mean vertical discrepancy for the upper right central piece face-bow is located anywhere along a 5-mm radius of
was 1.90 +/- 1.75 (t = 7.76, df = 50, p < .001). the true hinge axis point, some authors have found that the
The mean difference in the A-P dimension was 3.82 +/- mandibular arc of closure may not be very different from the
5.51 (t = 8.163, df = 50, p < .001) for the maxillary right first true hinge arc of closure.21,26,39,40,42 However, Lauritzen and
molar and 3.10 +/- 2.63 (t = 8.28, df = 50, p < .001) for the Bodner found that in only 33% of the 50 patients they ex-
maxillary left first molar. The maxillary right central incisor amined did the arbitrary hinge point fall within 5 mm of the
showed a mean difference of 3.05 +/- 2.62 (t = 8.25, df = 50, true hinge point. In the other 67%, the arbitrary hinge points
p < .001). Finally, the transverse dimension was evaluated. were 5 mm to 13 mm away from the true hinge points. Ar-
The mean difference for the maxillary right first molar was bitrary markings of the hinge axis introduce severe errors
2.23 +/- 1.33 (t = 12.11, df = 50, p < .001). The mean differ- in mounting casts on an articulator, which may introduce
occlusal errors in the centric jaw relation record.30 Ricketts

found that there can be extreme variation in the soft tissue
around the ear.34 This variation can make it difficult to lo-
cate the hinge point with an arbitrary earpiece face-bow.
The present study found larger mean values for the arbitrary
earpiece face-bow measurements. This suggests that the true
hinge face-bow may not be as sensitive to anatomical chang-
es as the arbitrary earpiece face-bow.
Goska and Christensen conducted a similar study to
to the present study, in which they compared the positions
of maxillary cast permanent first molars in three planes of
space, using four different face-bow techniques. A true hinge
face-bow determined axis point was chosen as a baseline
against which to compare the other three arbitrary face-bow
techniques.28 They found that deviations between this base- Figure 9-a True hinge mandibular cast vs. estimated hinge
line and the other three face-bow mountings ranged from 1.5 maxillary cast: True hinge mounting.
mm to 4 mm.28 They found that deviations between the true
hinge face-bow and the arbitrary earpiece face-bow ranged
from 1.9 mm to 3.8 mm. Like the authors of the present
study, they concluded that variations in the arbitrary ear-
piece face-bows might have resulted from naturally occur-
ring variations in ear anatomy or the fact that the arbitrary
earpiece face-bow is an average measurement.28
In general, the present study suggests that error intro-
duced from arbitrary earpiece face-bow hinge axis location
may produce occlusal discrepancies caused by malposition-
ing of the maxillary cast. The present study differs from
other previous studies in that it evaluates changes at the
occlusal level of the maxillary cast, as opposed to looking
at the joint level when comparing arbitrary and true hinge
Figure 9-b True hinge mandibular cast vs. estimated hinge
mounting techniques. This study also differs from previous
maxillary cast: Estimated hinge mounting substituted for true
studies in that it does not measure the occlusal discrepan- hinge maxillary mounting.
cies that result from contacts during the mandibular arc of
closure, since the mandibular cast was not incorporated into Zuckerman found that an anterior incisor displacement
the measurements. of 1.5 mm could occur if the arbitrary hinge axis was off from
Zuckerman, in analog tracing the arc of the incisal edge, the true hinge axis by approximately 10 mm.41 Although the
verified that no A-P change occurred in the arc of closure, as method for the present study does not incorporate the man-
long as the mandible rotated along the accurate hinge axis. dibular cast arc of closure, wax bite thickness, or condylar
However, when an error in the arbitrary earpiece face-bow positioning, it is interesting to note that the largest discrep-
hinge axis occurred anterior to the true hinge, the incisor arc ancy in maxillary cast position occurred in the A-P direction
of closure was anterior to the actual arc of closure, and when with a mean difference greater than 3 mm in all three areas
the arbitrary earpiece face-bow hinge axis occurred posterior measured (maxillary right and left first permanent molar and
to the true hinge axis, the opposite effect occurred. Errors in the upper right permanent central incisor).
the vertical position of the arbitrary earpiece face-bow hinge Gordon et al conducted a mathematical study to calcu-
axis were found to produce the largest A-P discrepancies late the amount of cusp height and mesiodistal error at the
upon mandibular closing41 (Figure 9). second molar that results from arbitrary earpiece face-bow
hinge axis location 5 mm and 8 mm anterior, superior, pos-
terior, and inferior to the true hinge axis.6 They concluded
that incorrect location of the hinge axis caused a positional
change in the occlusal relationship between the maxilla and
the mandible, resulting in various premature contacts. De-

pending upon the direction in which the arbitrary earpiece
face-bow hinge axis was displaced from the true hinge axis,
the premature contacts occurred either anterior or posterior
to the actual arc of closure. Total error that could occur at
the second molar cusp ranged from 0.15 mm of open cuspal
space to 0.4 mm of excess cuspal height. The mesiodistal
error of the second molar cusps ranged from 0.51mm to-
ward the distal to 0.52 mm toward the mesial.6 Brotman also
found that a 0.09-mm A-P discrepancy would occur between
occluding casts if the arbitray earpiece face-bow hinge axis
was improperly located by as much as 3 mm from the true
hinge point. Brotman concluded that if the arbitrary earpiece
face-bow hinge axis is incorrectly placed superior to the true
hinge axis, the lower cast will occlude in a more protrusive Figure 10-a Mounted maxillary estimated cast vs.
direction, with premature contacts on the anterior teeth. true hinge mounted maxillary cast: True hinge mounting.
If the arbitrary earpiece face-bow hinge axis is incorrectly
placed inferior to the true hinge axis, the lower cast will oc-
clude in a more distal direction, with premature contacts on
the posterior teeth.43 This conclusion resembles the findings
of Gordon et al. Weinberg and Fox drew similar conclusions;
the values they obtained for calculated horizontal error in
cusp heights closely resembled each other.35,44 This suggests
that errors of several millimeters in axis location might pro-
duce occlusal errors that are clinically intolerable on the part
of the patient.43
The authors of the present study found a mean differ-
ence in incisor position of 3.04 mm. The occlusal discrepan-
cies found in the present study suggest that a range greater
than 5 mm existed between hinge axis points located with
the arbitrary earpiece face- bow mounting and the true hinge Figure 10-b Mounted maxillary estimated cast vs.
true hinge mounted maxillary cast: Estimated hinge mounting
face-bow. The discrepancy in maxillary cast position found
substituted for true hinge maxillary mounting.
in this study might possibly introduce a change in the clo-
sure of the mandible into occlusion. The problems caused It may be difficult to detect which patients have arbi-
by the occlusal errors resulting from inaccurate location of trary earpiece face-bow hinge points naturally located within
the hinge axis point are illustrated in Figure 10. The photos 5 mm of their true hinge point. Therefore, if any degree of
suggest an exaggerated discrepancy between the two casts accuracy is needed or if any change in vertical dimension,
because two completely different face-bow techniques were such as an occlusal equilibration or orthognathic surgery, is
used. They serve to illustrate occlusal error that may result planned, use of a true hinge axis face-bow should be con-
from error in maxillary cast position. In some cases, how- sidered. Previous studies have suggested that location of a
ever, the autorotated mandibular casts closed with only a kinematic true hinge axis point prior to treatment for dentu-
small degree of occlusal error (Figure 9). Other casts showed lous patients who require extensive treatment saves time and
severe positional changes resulting in larger occlusal errors results in a more satisfactory occlusion.6 The present study
when this was attempted. (Figure10). 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 max-

illary cast in the vertical dimension, with a mean of 2.19 mm 10. Trapozzano VR, Lazzari JB. The physiology of the terminal
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lar hinge axis locations. J Prosthet Dent. 1984;(51):819-823
30. Lauritzen AG, Bodner GH. Variations in location of arbitrary and

true hinge axis points. J Prosthet Dent. 1961;(11): 224-229.
31. Palik JF, Nelson DR, White JT. Accuracy of an earpiece face-bow. J
Prosthet Dent. 1985;(53): 800-804.
32. Schulte JK, Rooney DJ, Erdman AG. The hinge axis transfer pro-
cedure: a three-dimensional error analysis. J Prosthet Dent. 1984;(51):
247-251.
33. Morneburg TR, Proschel PA. Predicted incidence of occlusal errors

in centric closing around arbitrary axes. Int J Prosthod. 2002;(15):
358-364.
34. Ricketts, RM, Perspectives in the Clinical Application of Cephalo-

metrics. Angle Orthod. 1981;(51): 115-150.
35. Weinberg LA. An evaluation of the face-bow mounting. J Prosthet

Dent. 1961;(11): 32-42.
36. Adrien P., Schouver J., Methods for minimizing the errors
in mandibular model mounting on an articulator. J Oral Rehab.
1997;(24):929-935.
37. Brotman DN. Hinge axes, part I: the transverse hinge axis. J Pros-
thet Dent. 1960;(10): 436-440.
38. Preston JD. A reassessment of the mandibular transverse horizontal

axis theory. J Prosthet Dent. 1979; 41: 605-613.
39. Teteruck WR. Lundeen HC. The accuracy of an ear face-bow. J

Prosthet Dent. 1966;(16):1039-1046.
40. Walker PM. Discrepancies between arbitrary and true hinge axes. J
Prosthet Dent. 1980;(43): 279-285.
41. Zuckerman GR. The geometry of the arbitrary hinge axis as it

relates to the occlusion. J Prosthet Dent. 1982;(48): 725-733.
42. Collett Henry A. The movements of the temporomandibular

joint and their relation to the problems of occlusion. J Prosthet Dent.
1955;(5): 486-496.
43. Brotman DN. Hinge Axes, ,part II: geometric significance of the
transverse axis. J Prosthet Dent. 1960;(10): 631-636.
44. Fox SS. The significance of errors in hinge axis location. J Am Dent
Assoc. 1967;(74):1262-1272.
45. Williamson EH, Evans DL, Barton WA, Williams BH. The effect
of bite plane use of terminal hinge axis location. Angle Orthod.
1977;(47): 25-33.

Notes
56 Notes
7KH(IIHFWRI7RRWK:HDURQ3RVWRUWKRGRQWLF3DLQ3DWLHQWV3DUW
Jina Lee Linton, DDS, MA, PhD, ABO ɵ Woneuk Jung, DDS
JINA LEE LINTON, DDS, MA, PHD, ABO 6XPPDU\

jinalinton@hotmail.com Malocclusion and occlusal interference in excursive movement is the major
ɵ Graduated from Yonsei University cause of pathologic tooth wear. Tooth wear starts with shortening of the an-
(DDS, PhD), 1986
ɵ Graduated from Columbia University, terior teeth. As interference in mandibular movement increases, the posterior
SDOS, 1988 teeth gradually become more flat. Recognizing tooth wear before and after
ɵ Graduated from Columbia University orthodontic treatment is important for retention of the treated result and for
Orthodontic Department (MA), 1991 ensuring functional occlusion. For this reason, orthodontic treatment should
ɵ Private Practice in Seoul, Korea,
1991–present
be detailed and completed with restorative rehabilitation of the lost tooth
material.
WONEUK JUNG , DDS
ɵ Graduated from Dan Kook
University, 1991
ɵ Private practice in Seoul, Korea,
1991–present
,QWURGXFWLRQ trochemical degradation. Stress, which results in compres-

Tooth attrition is classified as tooth disease under the Inter- sion, flexure, and tension, leads to the dental manifestation
national Classification of Diseases, published by the World of microfracture.3
Health Organization. According to Jablonski, tooth attrition Loss and excessive wear of hard dental tissues is a per-
takes place when tooth-to-tooth contact, as in mastication, manent problem of the dentition, especially in the modern
occurs on the occlusal, incisal, and proximal surfaces.1 It is man; it is found in almost all age groups. Tooth wear is an
differentiated from tooth abrasion (the pathologic wearing inherent part of the aging process; it occurs continuously but
away of the tooth substance by friction, as brushing, brux- slowly throughout life. In some individuals, tooth wear oc-
ism, clenching, and other mechanical causes) and from tooth curs more rapidly than in others, leading to severe morpho-
erosion (the loss of substance caused by chemical action logic, functional, and vital damage to the teeth, which cannot
without bacterial action). be considered normal.4 Hand et al found that in a sample of
In reality, the wear may be related to a combination of 520 adults, 84.2% had enamel attrition, 72.9% had dentin
factors including attrition, abrasion, and erosion; that is, attrition, and 4.2% had severe attrition.5 In cases of severe
physical-mechanical and chemical effects can have an impact attrition, Sivasithamparam et al found that 11.6% of 448
on the loss of physiologic and habitual tooth surface mor- adult patients had either near-pulpal exposures or frank pul-
phology.2 Grippo et al state that three physical and chemical pal exposures.6
mechanisms are involved in the etiology of tooth surface le- Schneider and Peterson found that 15% of children
sions. These mechanisms are stress, corrosion, and friction. demonstrate tooth wear due to bruxism.7 Most of the preva-
The various types of dental lesion are caused by these mecha- lence studies in Europe and North America indicate that the
nisms acting either alone or in combination. Friction, includ- prevalence of wear on enamel in children is common (up to
ing abrasion (which is exogenous) and attrition (which is 60% involvement), while the prevalence of exposed dentin
endogenous), leads to the dental manifestation of wear. Cor- varies from 2% to 10%.8,9
rosion leads to the dental manifestation of chemical or elec-

Case Reports Case 3: No Attrition Occurred During Orthodontic Treatment
The six cases below show individual clinical cases with vari- A 17-year-old male had class II div. 2 malocclusion (Figure
ous severity of attrition with or without treatment. 3) and displayed no wear on the upper right canine tip (Sep-
tember 1995). After 22 months of treatment with mandibu-
Case 1: Attrition Occurred With no Orthodontic Treatment lar advancement surgery, the sharp canine tip remained (July
An 11-year-old female came in for checkup in April 2006, 1997).
at which time the upper lateral incisor edges and canine tips
showed wear (Figure 1). She had class I canine and molar
relationships and a 3-mm overbite and overjet (April 2006).
When she came back for orthodontic treatment 3 years later
(January 2009), the wear on the laterals and canines had
progressed significantly (red arrows).
Figure 1 Attrition occurred with no orthodontic treatment.
Case 2: Attrition Occurred During Orthodontic Treatment

Figure 3 No attrition occurred during orthodontic treatment.
A 12-year-old male had a crossbite on the left laterals and an
open bite on the central incisors (Figure 2). His canines and
molars were in class I relationship (September 2002). After Case 4: Slight Attrition Occurred During Orthodontic
a year and a half without treatment, the upper left canine Treatment
showed slight wear on the mesial side (January 2004). Af- A 13-year-old male with class I malocclusion came in pre-
ter 8 months of fixed appliance therapy, that canine showed sented with sharp upper canine tips (June 1998). After 1½
marked flattening on the tip (October 2004). years of fixed-appliance therapy (January 2000), the right
canine tip remained intact (blue arrow), while the left ca-
nine tip showed wear. A photograph taken 2 years post-
treatment (January 2002) showed wear on the right canine
tip (Figure 4).
Figure 2 Attrition occurred during orthodontic treatment.
58 Linton, Jung | The Effect of Tooth Wear on Postorthodontic Pain Patients: Part 2
Case 6: Attrition Occurred During Orthodontic Treatment
A 13-year-old male came to the clinic in January 2000 for
treatment of protruding upper incisors. The patient’s face
showed a protrusive upper lip and a normal-size mandible,
with no apparent asymmetry. He had class II malocclusion
with maxillary dentoalveolar protrusion, severe crowding
in the upper and lower arches, and a constricted maxillary
arch. The upper right canine had not erupted due to lack of
space, even though the root had almost formed (Figure 6).
Figure 6 Preorthodontic treatment photographs and x-rays.
Figure 4 Slight attrition occurred during orthodontic treatment.
Case 5: No Attrition Occurred During or Following

Orthodontic Treatment
A 24-year-old female came in for treatment of bimaxillary
dentoalveolar protrusion (June 1998). The canine tip re- Figure 6-a Front facial Figure 6-b Lateral facial
mained the same immediately after orthodontic treatment smiling photograph. photograph showing lip
protrusion and strained
(April 2001) and 7 years posttreatment (April 2008). This pa-
mentalis muscle.
tient had no apparent anterior tooth attrition over the 10-year
observation period (Figure 5). On lateral excursive movement,
canine guidance existed with adequate separation of posterior
teeth on both the chewing and the nonchewing sides.
Figure 6-c Right lateral intraoral photograph

showing class II molar relationship in MIP.
Figure 6-d Front intraoral photograph in MIP showing

Figure 5 No attrition occurred during or after orthodontic treatment. crowding and crossbite in the upper right lateral incisor.

Figure 6-e Left lateral intraoral photograph in MIP showing
class II molar relationship and retained deciduous canine.
Table 1 Jarabak’s analysis of case 6 in January 2000.

Figure 6-f Panoramic x-ray. The upper left canine showing
root apex almost formed, but not erupted, due to lack of space.
The maxillary arch was rapidly expanded with a fixed-
type 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).
Figure 6-g Lateral cephalogram showing slightly

Figure 7 Mounted models of the case before and after the
retrusive mandible and protrusive upper incisors.
ÀUVWSKDVHRIJURZWKPRGLÀFDWLRQWUHDWPHQW7KHPRGHOVZHUH
mounted on a semiadjustable articulator with estimated
Jarabak’s cephalometric analysis showed a strong coun- face-bow transfer and with centric relation bite registration
terclockwise growth tendency expressed in such measure- UHFRUGV7KHFODVV,,UHODWLRQVKLSRIWKHÀUVWPRODUVEOXHOLQHV
ments as a posterior facial height-anterior facial height ratio in January 2001, was improved compared to the molar
relationship of the case in January 2000.
of 70%, a long ramus height in comparison to the posterior
cranial base length, and a small Y-axis-to-SN angle (Table 1). Subsequent to headgear therapy, the four first premo-
lars were extracted, and the patient received fixed-appliance
therapy for the following 20 months. Class I canine and
molar relationships were achieved with maximum anchor-
age in the upper arch and moderate anchorage in the lower
arch in December 2002. The patient’s facial appearance was
improved, with retraction of the upper anterior teeth and
favorable mandibular growth (Figure 8).
Figure 8 Postorthodontic treatment records.
Figure 8-a Front facial Figure 8-b Lateral facial

smiling photograph. photograph showing
LPSURYHPHQWLQSURÀOH Figure 8-e Left lateral intraoral photograph showing
compared to Figure 1b. that class I canine and molar relationships were achieved.
Figure 8-c Right lateral intraoral photograph showing Figure 8-f Maxillary arch showing alignment
that class I canine and molar relationships were achieved. without any extraction spaces left.
Figure 8-g Panoramic x-ray showing overcorrection in

root angulation of the canines and developing third molars.
Figure 8-d Front intraoral photograph showing
that approximately 2 mm of overjet was achieved.

The patient returned to the clinic for correction of lower
anterior tooth crowding at age 20 in April 2008 (Figure 9).
Figure 9 Four-year retention photographs.
Figure 9-a Front facial Figure 9-b Lateral facial

smiling photograph showing photograph.
well-developed gonial angle.
Figure 8-h Lateral cephalogram.
Figure 9-c Right lateral intraoral photograph showing that

class I canine and molar relationships were retained.
Figure 8-i Superimposition of cephalometric tracings before

(black line) and after (red line) orthodontic treatment shows
that maximum anchorage control of the upper molars was Figure 9-d Front intraoral photograph showing that the
accomplished. The maxilla and the mandible grew lower dental midline was shifted 2 mm to the left.
downward and forward as predicted.
Figure 9-e Left lateral intraoral photograph
showing end-on class II canine relationship.
Figure 9-f Panoramic x-ray.

Figure 9-h Superimposition of the cephalometric tracings
after orthodontic treatment (red line) and 4-year retention
(green line), showing that there was little change in the
soft-tissue and hard-tissue structures.
Upon clinical examination, wear on the maxillary canine

tips was noted as being quite severe for his age. Upon further
questioning, the patient complained of occasional headache
and pain in the area of the temporomandibular joint (TMJ).
His static occlusion showed 1.5 mm of overbite at the central
incisors and no overbite on the left lateral incisor. The lower
anterior teeth were tipped to the left side, resulting in a lower
midline shift to the left side. Dentin exposures were pres-
ent on the upper lateral incisal edges and the lower anterior
teeth. The upper and lower first molars also showed marked
wear on the cusp tips. Upon excursive movement of both
right and left sides of the madible, the posterior teeth on the
chewing side showed simultaneous contacts—that is, group
function—and teeth on the nonchewing side showed harm-
ful contacts (Figure 10).
Figure 9-g Lateral cephalogram.

Figure 10 Mandibular movements. The patient’s records were reviewed to compare the
amount of tooth wear at age 15 immediately after orthodon-
tic treatment (December 2002) with the amount of tooth
wear at age 20 (Figure 11).
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 11 Comparison of tooth wear over a 5-year period.

Progression of tooth wear from 1.5 mm of vertical overbite
in the upper and lower canines in December 2002 down to
minimum vertical overbite in April 2008.
5HGDUURZVLQGLFDWHÁDWWHQHGDQWHULRUWHHWK
The canine tips already showed wear at age 15. Progres-

sion 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 oc-
clusal views showed the beginning of dentin exposure on the
Figure 10-b Incisive movement indicates upper lateral incisors and the canines. The first molar wear
multiple contacts on the posterior teeth.
caused no obvious incisal changes but the progression of the
wear was definitely observable as wider wear facets and dim-
ples on the molar cusp tips in April 2008 (Figure 12).
Figure 10-c Due to wear on the canine tip, there are multiple
Figure 12 Occlusal views of tooth wear. Wear on the posterior
tooth contacts on the left chewing side and harmful contacts on
teeth is less apparent than wear on the anterior teeth. On close
the right nonchewing side during the left chewing movement.
examination, tooth wear (red arrows) is shown as facets or
dimples on the cusp tips.
All available intraoral photographs that had been taken the wear progressed during the fixed-appliance therapy. In
in the past were put together to analyze the event of tooth the absence of anatomy at the cusp tips and incisal edges, as
wear in this patient (Figure 13). in Figures 3-c and 3-e, proper anterior guidance and canine
guidance in movement would not have taken place (Figure
14). This in turn would have caused further wear with the
passage of time, as shown in Figures 6 and 7.10
Figure 14 Mandibular movement of the mounted models.
Figure 14-a Intraoral movement shown in Figure 5-a was

reproduced with models mounted on a semiadjustable
articulator in SCP. There were nonchewing-side interferences
of the functional cusps of the upper left molars (red arrows).
Figure 14-b Intraoral movement shown in Figure 5-b was repro-

duced using models. There were nonchewing-side interferences
of the functional cusps of the right upper molars (red arrows).
Stable condylar position (SCP) could not be recorded in

the presence of dysfunction of the masticatory system,11 so
a maxillary anterior-guided orthosis12 was prepared and the
patient wore it for 2 months, until all clinical signs and symp-
toms of TMJ dysfunction disappeared. The orthosis (Figure
15) allowed the condyles to assume their superior, anterior,
and medial (SAM) positions in intimate contact with the
thinnest part of the biconcavity of the disc, and made pos-
sible the diagnosis of a SCP from the maximum intercuspal
position (MIP). The SCP was recorded with Axi-Path record-
ing, so the mounted models would arc close in centric.13,14
Figure 13 The event of upper canine wear during orthodontic

WUHDWPHQW7KHULJKWFDQLQHVKRZVGHÀQLWHZHDUUHGDUURZV
GXULQJÀ[HGDSSOLDQFHWKHUDS\7KHVKDUSDQDWRP\EOXHFLUFOH
of the left canine tip at the time of eruption is shown in the
photograph (May 2000). It was gone before the
À[HGDSSOLDQFHWKHUDS\
The upper right canine showed no wear before the

initial stage of fixed-appliance therapy in June 2001. The
canine wear occurred sometime during the following 8
months, and further wear seemed to have occurred between
February 2002 and December 2002. The upper left canine
Figure 15 Maxillary anterior guided orthosis. The patient
erupted with sharp anatomy in May 2000. However, the tip wore the removable plate continuously until all the
was worn down already on the day of bracket bonding, and symptoms disappeared and SCP was obtained.

Subtractive coronaplasty15 was done on the posterior The average unworn maxillary central incisor is approx-
teeth to achieve equal stops and maximum intercuspation in imately 12 mm and the mandibular central incisors are 10
SCP, and to preserve the natural tooth forms (Figure 16). mm according to the American Academy of Cosmetic Den-
Figure 16 Before and after coronaplasty. tistry (AACD). In the patient’s case, they were 12 mm and
7.7 mm and were restored to 12.3 mm and 9.8 mm respec-
tively (Figure 19).17
Figure 16-a The maxillary arch after coronaplasty shows

WKDWFRURQDSODVW\GRHVQRWQHFHVVDULO\ÁDWWHQWKHRFFOXVDO
VXUIDFHV5DWKHULWFDQUHGHÀQHWKHDQDWRP\
Figure 19 Measurements of the teeth before and after positive

coronaplasty. The upper central incisors were 12.0 mm long
and became 12.3 mm long. The lower central incisor was
7.7 mm long and became 9.8 mm long.
Figure 16-b The mandibular arch after coronaplasty also
According to Lee, adequate anterior guidance can be ob-
VKRZVUHGHÀQHGDQDWRPLFIRUPRIWKHSRVWHULRUWHHWK
tained with incisor vertical overlap of 3 mm to 4 mm and
Anterior maxillary and mandibular teeth were built up horizontal overlap of 2 mm to 3 mm.18 Initially in April 2008
with wax on the diagnostic casts to relegate all eccentric the patient’s MIP and SCP did not coincide and his overjet
tooth contacts to the anterior teeth (Figure 17). was 2 mm. In SCP the overjet increased to 3.5 mm, which was
corrected to 2 mm with additive coronaplasty (Figure 20).
Figure 17 Wax-up on the mounted model to achieve 3 mm to 4

mm of vertical overbite and 2 mm to 3 mm of horizontal overjet.
The additive coronaplasty was done by duplicating the Figure 20 Overjet change after coronaplasty. When MIP
wax-up of the casts on the anterior teeth with composite and SCP did not coincide, the overjet was 2 mm. In SCP,
resin (Figure 18).16 the overjet increased to 3.5 mm, which was corrected
to 2 mm with additive coronaplasty.
Only after additive coronaplasty could a complete elimi-

nation of eccentric occlusal interferences be achieved with
excursive movements of the mandible (Figure 21).
Figure 18 Additive coronaplasty was done with a hybrid-type

composite resin on each anterior tooth according to the
wax-up in Figure 12.
Figure 21 Mandibular movement after coronaplasty. Figure 22 Comparison of the case before and after coronaplasty.
Figure 21-a In the right chewing movement, both the chewing

DQGWKHQRQFKHZLQJVLGHVVKRZVXIÀFLHQWFOHDUDQFHEHWZHHQ
the upper and lower posterior teeth (blue arrows).
Figure 22-a Full-smile facial photograph taken after

coronaplasty shows that the patient’s smile became
more esthetically pleasing.
Figure 21-b In the left chewing movement, both the chewing and
WKHQRQFKHZLQJVLGHVVKRZVXIÀFLHQWFOHDUDQFHEOXHDUURZV
With coronaplasty the patient’s bite was stable, and the

patient was pleased with his smile and with the overall ap-
pearance of his face (Figure 22).
The abnormal tooth wear the patient demonstrated be-
fore coronaplasty was due to improper incisal guidance and
canine guidance. Since tooth wear progresses much faster in
the dentin layer than in enamel, his entire dentition would
have become significantly shorter over the next 10 to 20
years, if no intervention had taken place. The patient’s oc-
clusion was completed with coronaplasty, and the longevity
and stability of his dentition were greatly enhanced.
Figure 22-b Lateral facial photographs taken
Discussion before and after coronaplasty show little change.
At the present, the majority of dentists believe that teeth
can successfully compensate for the loss of tissue by migra- With regard to interferences in mandibular movement,
tion and elongation, and that these do not disturb the basic Masatoshi and Masanori studied occlusal factors in relation
functions of the masticatory system (mastication, speech, to TMD in 146 young adults; they concluded that molar-
and swallowing).19 However, some researchers have argued guided occlusion patterns were associated with a high risk
that anatomical tooth form plays an important role in the of TMD.21 All subjects with TMD had nonchewing interfer-
proper function of the masticatory system.17,18 Knight and ences in border excursions and in tooth-dictated excursions.
et al conducted a longitudinal study on 223 orthodontically Without additive coronaplasty to restore the lost volume of
treated patients 20 years posttreatment. They found that tooth material, complete elimination of interferences may
there was a strong relationship between incisal and occlus- not be possible, nor may it be possible to maintain the op-
al tooth wear during the mixed dentition and subsequent timal health of the teeth.16 As we saw in case 6, the teeth
wear of the adult dentition.20 Tooth wear that occurred dur- were too worn down to allow for adequate function, and
ing the mixed dentition in these subjects actually occurred the post-orthodontic result was an incomplete occlusion vul-
on the permanent incisors. Even though the malocclusion nerable to relapse. The patient’s TMJ symptoms would have
was corrected, the loss of tissue due to wear in the previ- persisted, and the attrition process would have accelerated
ously affected teeth persisted. Consequently, the patients’ once the dentin layer was exposed. Tooth wear that occurred
incomplete anterior and canine guidance systems continued while the patient was receiving treatment was unavoidable in
to influence their permanent dentition. this case. Early intervention of malocclusion in mixed denti-

tion might have enabled us to circumvent pathologic tooth 9. Bardsley P, Taylor S, Milosevic A. Epidemiological studies of tooth wear
and dental erosion in 14-year-old children in north west England, part I:
wear while the patient was undergoing treatment?
the relationship with water fluoridation and social deprivation. Br Dent J.
In canine guidance, the horizontal forces are minimized 2004;197(7):413-416.
by limiting the contact of the supporting cusps with their op-
posing fossae at or near their intercuspal position. All other 10. Cordray F. Centric relation treatment and articulator mountings
inorthodontics. Angle Orthod. 1996;66(2):153-158.
lateral contacts are prevented by the steeper inclination of
the canines. This causes the chewing movement to be more 11. Lee R. Jaw movements engraved in solid plastic for articulator con-
vertical in the frontal view. Case 5 exemplifies the preserva- trols, part I: recording apparatus. J Prosthet Dent. 1969;(22):209-224.
tion of tooth material in the presence of functional occlu-
12. Academy of Prosthodontics. Glossary of prosthodontic terms.
sion. Upon lateral excursive movements, the canine guidance
J Prosthet Dent. 2005;94(7):10-92.
provided sufficient clearance in the posterior teeth.
Many of our orthodontic patients already have worn 13. Lundeen H. Centric relation records: the effect of muscle action.
J Prosthet Dent. 1974;31(3):244-253.
canines and incisors. Occlusal interferences, premature con-
tacts, and habitual bruxism and/or clenching all may act as 14. Crawford S. Condylar axis position, as determined by the occlusion
stressors. Tooth contact during swallowing occurs 2,400 and measured by the CPI instrument, and signs and symptoms of tem-
times a day, according to Straub23 and Kydd.24 These repeti- poromandibular dysfunction. Angle Orthod.1999;69(2):103-116.
tive static and cyclic occlusal loads could also cause wear
15. Hunt K. Bioesthetics: Working with nature to improve function and
on the anterior, as well as the posterior, teeth. Although it is appearance. Am Acad Cosmet Dent. 1996;12(2):45-50.
difficult to quantify the amount of tooth wear precisely, es-
pecially in cross-sectional studies, orthodontists can appraise 16. Hunt, K. Full-mouth rejuvenation using the biologic approach: an 11-
year case report follow-up. Contemp Esthet Restor Pract. 2002;6(6):1-6.
attrition of the incisal edges and canine tip most easily from
intraoral photographs. Why should orthodontists be aware 17. Lee R. Esthetics and its relationship to function. In: Rufenacht CR, ed.
of tooth wear? What happens if the dentist ignores if they Fundamentals of Esthetics. Chicago: Quintessence; 1990:137-209.
ignore the problem? These are important questions, because
18. Hunt K, Turk M. Correlation of the AACD accreditation criteria and
any patient who is not informed of tooth surface loss is put the human biologic mode. J Cosmet Dent. 2005;21(3):120-131.
at risk of having no choice in treating what can become a
severe condition. ɵ 19. Ash M, Nelson S. Dental Anatomy, Physiology and Occlusion. 8th ed.
St Louis, MO: Saunders; 2003.
References 20. Knight D, Leroux B, Zhu C, Almond J, Ramsay D. A longitudinal

1. Jablonski, S. Jablonski’s Dictionary of Dentistry. 2nd ed. Philadel- study of tooth wear in orthodontically treated patients. Am J Orthod
phia: Saunders, 1992. Dentofac Orthop. 1997;112(6):17-18.
2. Litonjua L, Andreana S, Bush PJ, et al. Tooth wear: attrition, erosion, 21. Masatoshi K, Masanori F. Occlusal factors associated with temporo-
and abrasion. Quintessence Int. 2003;(34):435-446. mandibular disorder based on a prospective cohort study of young adults.
Prosthod Res Pract. 2006;5(2):72-79.
3. Grippo J, Simring M, Schreiner S. A new perspective on tooth sur-
face lesions. J Am Dent Assoc. 2004;135(8):1109-1118. 22. Jemt T, Lundquist S, Hedegard B. Group function or canine protection.
J Prosthet Dent. 1982;(48):719-724.
4. Badel T, Keros J, Šegoviþ S, Komar D. Clinical and tribological view
on tooth wear. Acta Stomatol Croat. 2007;41(4):355-365. 23. Straub W. Malfunctions of the tongue. Am J Orthod. 1960;(40):404-420.
5. Hand J, Beck J, Turner K. The prevalence of occlusal attrition and 24. Kydd W. Maximum forces exerted on the dentition by the perioral and
considerations for treatment in a noninstitutionalized older population. lingual musculature. J Am Dent Assoc. 1957;(55):646-651.
Spec Care Dentist. 1987;(7):202-206.
6. Sivasithamparam K, Harbrow D, Vinczer E, et al. Endodontic seque-

lae 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.
3K\VLRORJLF7UHDWPHQW*RDOVLQ2UWKRGRQWLFV
Andrew Girardot, DDS, FACD
A NDREW G IRARDOT , DDS, FACD 6XPPDU\

ragfishing@hotmail.com Angle’s class I has long served the orthodontic specialty as a morphologic
ɵ Graduated from USC School of treatment goal and a means of communication. Certainly a physiologic
Dentistry (DDS), 1968
ɵ Graduated from USC School of treatment goal would be of equal value. There are sound data to define and
Dentistry, Dept. of Orthodontics support such a physiologic goal, which can help orthodontists to better serve
(certificate in orthodontics), 1972 their patients, communicate with other dental professionals, and avoid nu-
ɵ Part-time Faculty University of merous clinical problems.
Colorado, School of Dentistry,
Dept. of Orthodontics
ɵ Cofounder, codirector and faculty,
Roth Williams USA, 1997-present
,QWURGXFWLRQ der certain conditions of form and function. For example,

For the better part of a hundred years, orthodontists have there is considerable evidence to support a clear definition
used Angle’s classification as a means of communication. of healthy function for the temporomandibular joint in its
When we say “Class I,” orthodontists share the same image, loaded state, such as during a swallow. When loaded, the
which is generally a positive concept of how teeth should fit condyle should be positioned upward, forward and mid-
together. There certainly can be a Class I case with problems, sagittally. This definition of optimal joint position is agreed
but Class I is the first major step in describing optimal tooth upon by most authorities1-15 and is well supported by the
relationships. To this day, Angle’s Class I describes a mor- literature.16-36 Okeson defines this as the “most musculosk-
phologic treatment goal for the orthodontic specialty. eletally stable position of the mandible.”7(112) There also are
Why do we not have a similar physiologic treatment data indicating the optimal relationship of the condyle, disc,
goal? Often we talk about “occlusion” in orthodontics, but and eminence when the mandible is moving into or out of
it clearly means different things to different people. The term the loaded position. In this condition, there should be con-
occlusion lacks the communication value of Class I. A “good stant contact between the condyle, disc, and eminence.37-40
occlusion” is a nebulous term that varies depending on the There are numerous data indicating that neuromuscular
person using it. We have a communication problem. We en- function is highly influenced by tooth contacts and tooth po-
joy general agreement, and hence communication clarity, sitions.41-55 For example, as the mandible moves into and out
regarding morphology, but this is not the case for physiol- of intercuspation, guidance from properly positioned ante-
ogy. It would certainly be of value to our patients and the rior teeth aids in separating the posterior teeth. This reduces
orthodontic specialty if we had a clear definition of what the activity of the powerful elevating muscles, which, in turn,
constitutes optimal physiology or “good occlusion.” downloads the system while facilitating constant contact be-
As in all biologic systems, the structural elements of tween the condyle, disc, and eminence.39,43,46,47,55-64
the human gnathic system have evolved to perform best un- Thus, current data point to an optimal physiologic rela-

tionship between the teeth, the joints, and the neuromuscula-
ture. This information provides a physiologic treatment goal
for the orthodontist, a summary of which can be made by an-
alyzing 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 in-
active and positioning muscles (eg, lateral pterygoids) are ac-
tive, 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 re-
lationships 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
Figure 1 7KHDQWHULRUVWRSLVKDUGDQGÁDWLWVHSDUDWHVWKH
the teeth determine mandibular movements at and near the posterior teeth to create appropriate space for a recording
intercuspal position.7,50,61,76-100 Second, when the mandible is PHGLXP7KHSDWLHQWLVLQVWUXFWHGWRFORVHÀUPO\ZKLFK
brought to full intercuspation in a functionally healthy sys- seats the condyles to the musculoskeletally stable
tem, the powerful elevating muscles are active and the system position of the mandible.
is heavily loaded; the bulk of the resultant force is absorbed The information then must be transferred from the pa-
by posterior teeth.32,50-52,101-103 Third, condylar position is de- tient to a device that will allow study and treatment plan-
termined by the dentition at intercuspation.61,83,104-106 ning of the gnathic system in three dimensions. Currently,
An additional important factor well supported in the lit- the articulator appears to be the best tool for this purpose,
erature is the clinical observation that the neuromusculature although computer-generated three-dimensional technology
is exquisitely programmed to guide the mandible to the in- may replace the articulator in the near future. Casts mounted
tercuspal position80,85-100,107; the intercuspal position is domi- on an articulator provide invaluable physiological informa-
nant over condylar position.61,83,103,105,106,108-110 Thus, asking tion for diagnosis and treatment planning. For example,
a patient to “bite down” provides no dependable informa- numerous studies show that there is nearly always vertical
tion as to where the condyle is positioned. Moreover, efforts distraction of the condyle when the patient closes to inter-
to identify the seated condylar position through clinical cuspation.33,113,117-122 It is all but impossible to record, ana-
maneuvers such as manipulating the mandible are not reli- lyze, and treatment plan this vertical discrepancy without the
able.28,111-116 To quote the master clinician Dr. Thomas Basta, use of a device such as an articulator.
“Don’t believe what you see in the mouth.”2 Thus the value Joint images are another tool that can serve orthodon-
of using interocclusal devices such as cotton rolls, anterior tists with regard to physiologic treatment. Tomograms, as
jigs, and splints to deprogram the neuromusculature. first advocated by Ricketts, have provided an effective way
If we are to apply these physiologic principles to the to study the health of the temporomandibular joint and the
practice of orthodontics, we need additional information position of the condyle in the fossa.123-125 At present, cone
besides that which we have traditionally used; for example, beam CT is a more effective way to study the temporoman-
techniques that record the optimal or “seated” position of dibular joint, as it provides a more-lucid, three-dimensional
the condyle. Currently there are numerous such techniques view of joint structures.36
employed in restorative dentistry. Many clinicians use a hard There are sound data to support the concept that op-
stop at the incisor midline to separate the posterior teeth, timal gnathic function can be defined and used as an evi-
along with a soft posterior material that can be hardened dence-based treatment goal. There is little doubt that this
thermally or chemically. When the patient bites against the would also aid communication between orthodontists and
hard anterior stop and the neuromusculature seats the con- other dental professionals. In addition, knowledge of gnathic
dyles superioranteriorly, the posterior material is hardened, physiology is of substantial value to orthodontists in that it
and the musculoskeletally stable position of the mandible is helps them to recognize and avoid myriad problems that oc-
recorded (Figure 1). cur in everyday practice. ɵ
70 Girardot | Physiologic Treatment Goals in Orthodontics

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(IIHFWRI*QDWKRORJLF3RVLWLRQHU:HDURQ0D[LPXP
,QWHUFXVSDWLRQ&5'LVKDUPRQ\
Wesley M. Chiang, DDS, MS ɵ Theodore Freeland, DDS, MS
ɵ Richard Kulbersh, DMD, MS, PLC ɵ Richard Kaczynski, BS, MS, PhD
WESLEY M. C HIANG , DDS, MS 6XPPDU\
ɵ MA Candidate, Orthodontic Dept., The goal of a gnathological approach in orthodontics is to achieve a functional
University of Detroit Mercy School occlusion, in which the mandible can close into maximum intercuspation (MI) with-
of Dentistry
out deflecting the condyles from centric relation (CR). Gnathologic positioners are
T HEODORE F REELAND , DDS, MS used at the end of orthodontic treatment to settle the occlusion while maintaining
tdfortho@freelandorthodontics.com
MI-CR harmony. The objective of this prospective study was to examine the effect
ɵ Adjunct Professor, Orthodontic
of gnathologic positioners on MI-CR discrepancy for patients treated with the Roth
Dept., University of Detroit Mercy
School of Dentistry gnathological approach.
ɵ Director Roth/Williams USA; Methods.The sample consisted of 26 consecutively finished cases in a gnathologically
ɵ Private Practice, Gaylord, MI oriented practice. All cases were treated with a gnathological treatment approach,
R ICHARD KULBERSH , DMD, MS, PLC using the Roth prescription straight-wire appliance. A gnathologic positioner was
ɵ Program Director, Orthodontic delivered at the time of debonding and was worn for a period of 2 months. Pre- and
Dept., University of Detroit Mercy
postpositioner records were taken. These included a maximum-intercuspation wax
School of Dentistry
bite; a two-piece Roth power centric CR bite registration; and upper and lower models
R ICHARD K ACZYNSKI , BS, MS, P H D mounted using a true hinge transfer and CR bite. The control group consisted of 8
ɵ Statistician, Dept. of Psychiatry,
randomly selected finished cases in the orthodontic clinic at the University of Detroit
Yale University School of Medicine
Mercy and was retained with Hawley retainers. MI-CR discrepancy was measured
with a condylar position Indicator (CPI).
Results. Results indicate a statistically significant improvement in MI-CR discrepancy
in the right horizontal, right vertical, left vertical, and transverse planes after 2 months
of gnathologic positioner wear. The amount of condylar distraction in these 4 mea-
surements showed statistically significant improvement and came within the envelope
of susceptibility.
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.
,QWURGXFWLRQ thological concepts into orthodontic treatment.5,6,7 The goal

Centric relation (CR) refers to a physiologic position of the of a gnathological approach in orthodontics is to achieve a
mandible when the condyles are located in the superoante- functional occlusion, in which the mandible can close into
rior position in the articular fossae, fully seated and resting maximum intercuspation (MI) without deflecting the con-
against the posterior slopes of the articular eminences with dyles from CR.8 Dr. Roth believed that a large discrepancy
the discs properly interposed.1 It is a reproducible position between MI and CR can lead to breakdown in the stom-
that is obtained independent of the occlusion by manipu- atognathic system, because the condyles are distracted from
lating the mandible in a purely rotary movement about the the glenoid fossae when the teeth come into occlusion. Signs
transverse horizontal axis.2 and symptoms of occlusal disharmony include temporoman-
Orthodontic treatment is aimed at achieving static goals dibular joint pain-dysfunction syndrome, occlusal wear and
from Andrews’ six keys to normal occlusion and the func- bruxism, excessive tooth mobility associated with periodon-
tional scheme of mutually protected occlusion recommended tal disease, and movement or relapse of tooth positions.9
by Stuart and Stallard.3,4 In the 1970s, Roth introduced gna- Occlusal discrepancies, if associated with joint compression,

can also lead to condylar resorption.10 The models were poured with a vacuum mixed white stone
The clinical acceptable difference between CR and MI (Whip Mix Corporation, Louisville, Kentucky) and mounted
in terms of condylar position is approximately 1.0 mm an- with Whip Mix mounting plaster (Whip Mix corp, Louis-
teroposteriorly, 1.0 mm vertically, and 0.5 mm transverse- ville, Kentucky), using a true hinge transfer and CR bite
ly.11,12,13,14 The condylar position indicator (CPI) has been (Figures 2,3).
used to accurately record condylar movements.15 A compari-
son between pretreatment and posttreatment records in pa-
tients treated in a gnathologically oriented practice showed a
statistically significant reduction in MI-CR discrepancy in all
3 planes of space.16 The posttreatment records were obtained
before delivery of the gnathologic positioner.
The purpose of this study was to examine the effect of
gnathologic positioners on MI-CR discrepancy for patients
treated with the Roth gnathological approach. The effective-
ness of gnathologic positioners can be determined if there
is a decrease in MI-CR discrepancy following 2 months of
positioner wear.
Figure 2 True hinge axis.
5HVHDUFK'HVLJQDQG0HWKRGV
The positioner group consisted of 26 consecutively finished
cases in a gnathologically oriented practice (Theodore Free-
land, DDS, MS, Gaylord, Michigan). The sample consisted of
15 males and 11 females. The average age was 15 years and
8 months. All cases were treated with a gnathological treat-
ment approach, using the Roth prescription straight-wire
appliance (GAC, Glendora, California).12 Seven cases were
treated with 4 premolar extractions, while 19 cases were
treated with nonextraction. Four weeks prior to the debond-
ing appointment, prepositioner records were taken (time 1).
The records included upper and lower alginate impressions
in rim lock trays, a true hinge face-bow transfer; an MI wax Figure 3 True hinge mounted models with two-piece CR bite.
bite taken using 10x pink wax (Myoco Industries, Inc, Phila-
delphia, Pennsylvania); and CR bite registration taken using )DEULFDWLRQRI*QDWKRORJLF3RVLWLRQHU
a two-piece Roth power centric method with Delar blue wax The gnathologic positioner was fabricated using Oralastic
(Delar Corporation, Lake Oswego, Oregon) (Figure 1). 80 silicone. The true hinge positioner set up is fabricated
according to posterior determinants (angle of the articular
eminence and Bennett side shift). At time 1, a second set of
upper and lower alginate impressions was taken and poured
with white stone. The models were left unmounted, while the
first set of models was mounted using true hinge face-bow
transfer and CR bite. Unmounted models were used to fab-
ricate the gnathologic positioner, using the mounted models
as a reference. Teeth were separated from the models, and
brackets were ground off the teeth. Mandibular teeth were
set to an occlusal plane with proper curve of Spee and curve
of Wilson, and set on arc of closure in CR. The upper teeth
were set to the lower teeth in accordance with ideal overbite/
overjet (OB/OJ).
Figure 1 Two-piece CR bite – anterior segment (A).
Two-piece CR bite – posterior and anterior segments (B). At the debonding appointment, the braces were removed,
MI bite (C). Two-piece CR and MI bite (D). and the gnathologic positioner was delivered. The arc of clo-
76 Chiang, Freeland, et al | Effect of Gnathologic Positioner Wear on Maximum Intercuspation CR Disharmony

sure was first checked in the mounting on the true hinge ar-
ticulator 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 ex-
ercise 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.
3RVLWLRQHU([HUFLVHDQG:HDU3URWRFRO
The patient was instructed to bite into the positioner just
enough to seat all of the teeth and to fully engage the teeth in
the positioner. The patient was instructed to bite with pres-
sure for about 10 seconds and then to relax for about 15 Figure 4 CPI registration with two-piece CR bite (A).
CPI registration with MI bite (B). CPI Recording – transverse (C).
seconds. The exercise was done in 15-minute intervals, with
CPI Recording – right (D).
15 to 20 minutes of rest in between. For nighttime wear, the
patient was instructed to put the positioner into the mouth
and close the mouth to engage the positioner as much as pos-
sible without putting pressure on the positioner.
The gnathologic positioner was checked for fit and arc
of closure at 1, 2, and 4 weeks after delivery. After 2 months
of positioner wear, postpositioner records were taken (time
2). These consisted of the same records that had been taken
at time 1. Upper splint and lower spring retainers were then
delivered.
The control group consisted of 8 randomly selected
finished cases in the orthodontic clinic at the University of
Detroit Mercy. The control group was not preselected with
regard to MI-CR discrepancy at debond. At the debonding
appointment (time 1), braces were removed and records
were taken. Upper and lower Hawley retainers were deliv-
Figure 5 Condylar position indicator recording graph
ered, and the patient was instructed to wear them full time. (CR – red dot, MI – blue dot).
After 2 months of Hawley retainer wear, records were taken
again (time 2).
MI-CR discrepancy was measured with a CPI (Panadent
Corporation, Grand Terrace, California) at times 1 and 2 for
both groups (Figure 4,5).
Results
The mean differences between MI and CR of the articula-
tors’ 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 post-
treatment measurements of MI-CR discrepancy of the con-
trol and positioner groups are summarized in Table 1.

Table 1 MI-CR Discrepancy Assessment of Control and Positioner Groups.
Control Positioner
(n=8) (n=26)
Time 1 Time 2 Time 1 Time 2
Mean SD (mm) Mean SD Mean SD Mean
(mm) (mm) (mm) (mm) (mm) (mm)
Measurements
Right AP 0.700 0.499 1.225 1.383 1.306 0.897 0.733
Right vertical 0.863 0.407 1.238 0.845 1.217 0.969 0.623
Left AP 0.750 0.864 1.625 1.201 0.867 1.010 0.671

Left vertical 0.825 0.292 1.062 0.686 1.162 0.794 0.669
Transverse 0.350 0.267 0.288 0.309 1.031 1.106 0.248
As the table shows, pretreatment means for the control

group were all within the clinical envelope of ± 1.0 mm for
the A-P and vertical dimensions, and ± 0.5 mm for the trans-
verse. Conversely, 4 out of 5 pretreatment means for the po-
sitioner group were outside this envelope; only the mean left
A-P measurement, at 0.87, was within the clinical envelope.
The control and positioner groups were then assessed by an
independent t-test for any statistically significant pretreat-
ment differences. As shown in Table 2, no differences were
found between the two groups (0.08 < p <0.77).
Table 2 Independent t-test for MI-CR Discrepancies of Control Versus Positioner Group.
t df p
Right AP 1.812 32 .079
Right vertical 1.000 32 .325
Left AP 0.296 32 .769
Left vertical 1.164 32 .253
Transverse 1.709 32 .097
A paired t-test was used to evaluate change in MI-CR discrep-

ancy 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 Mean Differences Standard t p

discrepancy Error
(mm, absolute values)
Right AP .5731 .189 3.025 .006*
Right vertical .5942 .213 2.791 .009*
Left AP .1962 .214 0.915 .369
Left vertical .4923 .162 3.047 .005*
Transverse .7827 .224 3.490 .002*
6LJQL¿FDQWDWS

For these analyses, the desired significance level of 0.05
was reduced by a factor of 5 (for the 5 variable CPI readings:
right A-P, right vertical, left A-P, left vertical, and transverse)
to control experimentwide alpha and to avoid the risk of
type I errors. Thus a significance level of Į = 0.01 was used
for each test of the condylar axis position measurements. The
results indicated statistically significant differences between
time 1 and time 2 for the positioner group in the right A-P (∆
= 0.57 mm, t = 3.03, p = .006); right vertical (∆ = 0.59 mm,
t = 2.79, p = .009); left vertical (∆ = 0.49 mm, t = 3.05, p =
.005); and transverse (∆ = 0.78 mm, t = 3.49, p = .002) mea-
surements. There was no statistically significant difference in
the magnitude of condylar distraction in the left condyle in
the A-P direction (∆ = 0.20 mm, t = 0.92, N.S.).
Mixed-design analyses of variance compared the po-
sitioner and control groups’ change in MI-CR discrepancy
over time (Table 4).
Table 4 Mixed Design Analysis of Variance for MI-CR Discrepancies from time 1 to time 2 between Control Versus Positioner Group.
Effect F* p
Right AP Time 0.012 .915
7LPH[JURXS 6.096 .019
Right vertical Time 0.266 .609
7LPH[JURXS 5.203 .029
Left AP Time 2.431 .129
7LPH[JURXS 6.053 .019
Left vertical Time 0.599 .445.
7LPH[JURXS 4.917 034
Transverse Time 4.102 .051
7LPH[JURXS 2.978 .094
* df for all tests are 1, 32.
Using the adjusted significance level described above the traditional Į= 0.05 level. Graphical representations of
(Į= 0.01), these comparisons between the 2 groups showed the change in MI-CR discrepancy over time for the position-
no statistically significant differences in any of the 5 CPI er and control groups are shown in Figures 6 through 10.
measurements. However, 4 of the 5 dimensions fell below
Figure 6 Right horizontal MI/CR discrepancy. Figure 7 Right vertical MI/CR discrepancy.

Discussion
Results of the present study indicate a statistically signifi-
cant improvement in MI-CR discrepancy in the right hori-
zontal, right vertical, left vertical, and transverse planes
with 2 months of gnathologic positioner wear. The condy-
lar 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
Figure 8 Left horizontal MI/CR discrepancy. et al, and Slavicek.12,13,14 Following 2 months of positioner
wear, the amount of condylar distraction in these 4 mea-
surements 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 MI-
CR discrepancies is an important treatment goal in the gna-
thological philosophy, and the use of gnathologic positioner
is essential to achieving this goal.
Although these changes were nonsignificant when com-
pared to change in the control group, the level of signifi-
Figure 9 Left vertical MI/CR discrepancy. cance 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 hori-
zontal planes, with the positioner group improving and the
control group getting worse. This is consistent with Roth’s
claim that general retention protocols with Hawley-type ap-
pliances following orthodontic therapy will tend to make
Figure 10 Transverse MI/CR discrepancy.
MI-CR discrepancy worse, while gnathologic positioners
will improve MI-CR discrepancy. Interestingly enough, all
mean vertical and horizontal CPI measurements for the con-
trol 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 er-
ror 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 ver- 9. Roth, RH. The maintenance system and occlusal dynamics. Dent
Clin North AM 1976;20:761-788
tical, and left vertical planes. Furthermore, the MI-CR pat-
tern is observed, suggesting that this is not a purely random 10. Arnett GW, Milam SB, Gottesman L. Progressive mandibular
phenomenon. Since the control group was small, there is the retrusion-idiopathic condylar resorption, part II. Am J Orthod.
possibility of an underpowered study. 1996;(110):117-127.
In the transverse plane, there appears to be no difference

11. Roth RH. Functional occlusion for the orthodontist, part I. J Clin
between the 2 groups over time. A condylar axis distraction Orthod. 1981;(15):32-51.
in the transverse plane is more sensitive to clinical problems
than a condylar axis distraction in the horizontal and vertical 12. Crawford SD. Condylar axis position, as determined by the occlu-
sion and measured by the CPI instrument, and signs and symptoms of
planes.17,18,19 It appears that gnathologic positioners improve
temporomandibular dysfunction. Angle Orthod. 1999;(69):103-116.
the result of orthodontic treatment with respect to condylar
axis distraction. 13. Utt TW, Meyers CE Jr, Wierzba TF, Hondrum SO. A three-dimen-
sional comparison of condylar position changes between centric rela-
tion and centric occlusion using the mandibular position indicator. Am
Conclusion J Orthod Dentofac Orthop. 1995;(107):298-308.
Results of the present study indicate a statistically significant
improvement in MI-CR discrepancy in the right horizon- 14. Slavicek R. Interviews on clinical and instrumental functional
analysis for diagnosis and treatment planning, part I. J Clin Orthod.
tal, right vertical, left vertical, and transverse planes with 2
1988;(22):358-370.
months of gnathologic positioner wear. The amount of con-
dylar distraction in these 4 measurements showed statisti- 15. Lavine D, Kulbersh R, Bonner P, Pink FE. Reproducibility of the
cally significant improvement and came within the envelope condylar position indicator. Semin in Orthod. 2003;9(2):96-101.
of susceptibility. The positioner and control groups tend to

16. Klar NA, Kulbersh R, Freeland T, et al. Maximum intercuspation-
change differently over time in the vertical and horizontal centric relation disharmony in 200 consecutively finished cases in a
planes, with the positioner group improving and the control gnathologically oriented practice. Semin in Orthod. 2003;9(2):109-
116.
group getting worse. In the transverse plane, gnathologic po-
sitioners improve the result of orthodontic treatment with 17. Kulbersh R, Dhutia M, Navarro M, et al. Condylar distraction
respect to condylar axis distraction. ɵ effects of standard edgewise therapy versus gnathologically based
edgewise therapy. Semin in Orthod. 2003;9(2):117-127.
References
18. Freeland T, Kulbersh R. Orthodontic therapy using the Roth gna-
1. Okeson JP. Management of Temporomandibular Disorders and Oc-
thologic approach. Semin in Orthod. 2003;9(2):140-152.
clusion. 3rd ed. St Louis, MO: Mosby; 1998:109-125.
19. Roth RH, Rolfs DA. Functional occlusion for the orthodontist, part
2. Schmitt ME, Kulbersh R, Freeland T, et al. Reproducibility of the
II. J Clin Orthod. 1981;(15):100-123.
Roth power centric in determining centric relation. Semin in Orthod.
2003;9(2):102-108.
3. Andrews LF. The six keys to normal occlusion. Am J Orthod.

1972;(62):196-309.
4. Stuart CE. Good occlusion for natural teeth. J Prosthet Dent.

1964;(14):716-724.
5. Roth RH. Temporomandibular pain dysfunction and occlusal rela-

tionships. Angle Orthod. 1973;(43):136-153.
6. Roth RH. Treatment mechanics for the straight wire appliance. In:
Graber TM, Swain BH, eds. Orthodontics: Current Principles and
Techniques. St Louis, MO: Mosby; 1985:665-716.
7. Roth RH. Occlusion and condylar position. Am J Orthod Dentofac

Orthop. 1995;(107):315-318.
8. Pangrazio-Kulbersh V, Poggio V, Kulbersh R, et al. Condylar distrac-

tion effects of two-phase functional appliance/edgewise therapy versus
one-phase Gnathologically based edgewise therapy. Semin in Orthod.
2003;9(2):128-139.

Notes
82 Notes
This year, Rome, next year. . .
Hotel Swissôtel Chicago!
Registration opens December 1, 2010
RWISO 2011
18th Annual Conference
May 18-20, 2011 Swissôtel Chicago
Chicago, Illinois, USA

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Contents

Volume 2, No. 1, September 2010

7KH5RWK:LOOLDPV/HJDF\)XQG 5:/) ³&RPPLWWHH5HSRUW 8

Michael J. Gunson, DDS, MD ɵ *:LOOLDP$UQHWW''6)$&' 37

Dori Freeland, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 45

Jina Lee Linton, DDS, MA, PhD, ABO ɵ :RQHXN-XQJ''6 57

Andrew Girardot, DDS, FACD 69

:HVOH\0&KLDQJ, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 75

RWISO Journal | September 2010 1

ISSN 2154-4395 (print)

Reproduction whole or in part in any form or medium without express

RWISO JOURNAL Postmaster:

The Roth Williams International Society of Orthodontics is the embodi-

Samuel B. King, DDS, MS

The Roth Williams International Society of Orthodontists is in the midst of

Samuel B. King, DDS, MS

RWISO Journal | September 2010 3

Thomas Chubb, DDS

4 Dr. Thomas Chubb | Letter from the Editor

ARGENTINA group meeting, our program includes 3 activities—a participant pre-

RWISO Journal | September 2010 5

6 News from the Roth Williams Teaching Centers

Our group is concerned about research. To address this concern, we

Dr. Daniela Domínguez Di Prisco

Scenes from RWISO 2009

RWISO Journal | September 2010 7

2009 Boston Meeting and Journal

Research Evaluation and Approval Committee (REAC)

8 Roth Williams Legacy Fund

Donation and Pledges

Donations to RWLF can be made in the following ways:

Milton D. Berkman, Chairman RWLF

RWISO Journal | September 2010 9

Platinum (10,000 - $49,999) Bronze Circle ($1 - $999) Pledge Circle

10 Legacy Fund Donors

RYAN K. TAMBURRINO , DMD 6XPPDU\

For complete contributor information, please see end of article.

,QWURGXFWLRQ facially. These teeth are then described as being excessively

RWISO Journal | September 2010 11

12 Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

Figure 4 Patient with gingival recession due to orthodontic 0HWKRGVRI7UDQVYHUVH'LDJQRVLV

Figure 5 A teenager who had nasopharyngeal airway impairment

Figure 7 Rationale for normalizing the transverse dimension.

Figure 10 Example of Ricketts’ P-A analysis.

14 Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

Figure 12 Determination of mandibular

The width of the maxilla is based on optimization of the

Figure 13 Determining maxillary FA-FA distance and

One then looks at the angulation of the maxillary mo-

Figure 14 Example of Andrews’ Element III

RWISO Journal | September 2010 15

16 Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

To determine the width of the mandible, we scroll down

Figure 19 Measurement of maxillary axial and coronal cuts.

Now we switch to full-screen axial view. Using the cut

Figure 20 Measurement of maxillary skeletal width.

The analysis of the width of the maxilla and mandible at

RWISO Journal | September 2010 17

Figure 22 Visualization of cortical bone thickness

2. Jarabak cephalometric analysis. In: Roth-Williams/AEO Course

3. Ricketts RM. Introducing Computerized Cephalometrics. Rocky

4. Steiner CC. The use of cephalometrics as an aid to planning and as-

18 Tamburrino et al | The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion

16. Williamson EH, Lundquist DO. Anterior guidance: its effect on

7KH5RWK:LOOLDPV/HJDF\)XQG5:/)³&RPPLWWHH5HSRUW 8

Michael J. Gunson, DDS, MD ɵ *:LOOLDP$UQHWW''6)$&' 37

Dori Freeland, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 45

Jina Lee Linton, DDS, MA, PhD, ABO ɵ :RQHXN-XQJ''6 57

:HVOH\0&KLDQJ, DDS, MS ɵ 7KHRGRUH)UHHODQG''606 75

7KH$[L3DWK6\VWHP a thumbscrew. A straight ruler can be used to make the two