ANATOMY & PHYSIOLOGY OF TMJ

TEMPOROMANDIBULAR JOINT The area where cranio-mandibular articulator occurs is called the temporomandibular joint. Ginglymo-arthroidal compounds synovial joints: Ginglymoid joint hinging movement in one plane. Arthroidal joint hinge + gliding movements. Compound Presence o three bones !articular disc is considered as non-ossi ied bone". EMBRYOLOGY The temporomandibular joint develops relatively late in embryonic li e compared with the large joints o the e#tremities. $uring the seventh prenatal wee% the jaw joint lac%s the condylar growth cartilage& joint cavities& synovial tissue and articular capsule. The two s%eletal elements& mandible and temporal bone are not yet in articular contact with each other. 'n contrast with this in the same prenatal specimen all the major components o the elbow& hip and %nee joints are present in a orm and arrangements closely resembling that seen in the adult. 'n a wee%-old human embryo& (ec%el)s cartilage& the cartilage bar o the irst branchial area e#tends all the way rom the chin to the base o the s%ull. 't persists in this orm& serving as a temporary strut or sca olding against with the mandible and the base o the s%ull develop until the temporomandibular joint ta%es over this unction in etal li e. *

The articular dis% is one o the irst components o the joint to become organi+able rom its earlier appearance& in the ,wee% old embryo. The dis% is associated with the mandibular component o the joint and seems to be a derivative o the irst branchial arch. -umber o investigators . /jellberg !*012"& 3apman and 4oolard !*056"& 7ymmons !*089"& (o ett !*08: believe the e#tension o the lateral pterygoid muscle posteriorly between the temporal s;uama and the mandibular condyle to the malleus contributes to the ormation o the medial part o the articular dis%. <ther investigators re er to this connection as the retrodiscal ligament. (ost synovial joints develop rom blastemata. The temporomandibular joint& li%e the joints o the clavicle is ormed rom discontinuous blastemata separated rom each other by a +one o undi erentiated mesenchyme in the embryo. As the bastemata approach each other through growth o the condyle& the intervening mesenchyme condenses in to layers o orm the peculiar articular tissue seen in this joint. $uring the twelth wee% the condylar growth cartilage ma%es its appearance and the condyle begins to develop a hemispherical articular sur ace. =y the thirteenth wee% the condyle and articular dis% have moved up into contact with the temporal bone. <nly when such articular contact has been made to do the joint cavities develop& the in erior space appearing irst. =e ore the dis% actually becomes compressed between the condyle and the temporal bone& the entire dis% is vasculari+ed. =lood vessels rom the terminal branches o the e#ternal carotid artery and the associated veins enter the dis% posteriorly and e#tend completely through it to anastamose with branches coming in anteriorly rom the pterygoid vascular ple#us. =y the twenty-si#th wee% all the components o the temporomandibular joint are present e#cept or the articular eminence. (ec%el)s cartilage still e#tends through 9 irst ibrous connective tissue& which

the Claserian issure& but by the thirty- irst wee% it has been trans ormed into the sphenomandibular ligament. The Claserian issure is the opening between the s;uamous and tympanic parts o the temporal bone through which (ec%el)s cartilage passes into the middle ear in the etus. 't becomes the s;uamo-tympanic issure a ter birth. I) Anatomy of the TMJ

The TMJ consists of 4 main structures: a" Condyle. b" 7;uamous part o the temporal bone. c" The articular disc. d" >igaments. a) Condyle: The portion o the mandible which articulates with the cranium around which movement occurs. ?rom the anterior view& it has medial and lateral projections called poles. (edial pole is more prominent than the lateral pole. (edia . >ateral length *8-91mm. Anterio-posterior width 6-*1mm. The actual articulating sur ace o the condyle e#tends both anteriorly and posteriorly to the most superior aspect o sur ace. the condyle. The posterior articulating sur ace is greater than the anterior articulating

A given point on each condyle has a

ree but relatively limited

mobility along its cranial joint sur ace. this is called as @contact movement sur aceA o the condylar point. 't is about *1-*9mm long and 9-5mm broad. Contact movement sur ace o the incisal point is slightly over **mm deep !sagittal direction" and 91mm broad ! rontal direction". The tooth bearing part o the mandible there ore has a complete

reedom o movement inside a relatively marrow but long space. b) Squamus part of the temporal bone: (andibular condyle articulates at the base o the cranium with the s;uamous portion o articularBglenoid ossa. Posterior to this medio-laterally. 'mmediately anterior to the ossa is a conve# bony prominence called the articular eminence. 7teepness o this sur ace dictates the pathway o the condyle when the mandible is positioned anteriorly. The posterior roo o the mandibular ossa is ;uite thin& indicating that this area o temporal bone is not designed to sustain heavy loads. The articular eminences however is composed o thic% dense bone and is more li%ely to tolerate such heavy orces. c) The articular disc: Composed o dense ibrous connective tissue devoid o any blood vessels or nerves. 'n the sagittal plane& it can be divided into 5 regions according to thic%ness. The central area is the thinnest& called the intermediate 2 ossa is the s;uamo-tympanic issure which runs the temporal bone. it is re erred to as the

+one. The disc becomes thic%er anteriorly and posteriorly with the posterior +one& slightly thic%er than the anterior +one. ?rom an anterior view& the disc is more thic%er medially that laterally& which results in increased space between the condyle and the ossa towards the medial aspect o the joint. The articular disc is attached posteriorly to a region o the retrodiscal tissue. 7uperiorly 7uperior retrodiscal lamina !elastic ibers" attaches the disc to tympanic plate . =ilaminary +one. 'n eriorly 'n eriorly retrodiscal lamina !collagenous ibres" attaches the in erior border o the disc to the posterior margin o the articulate sur ace o the condyle. Anteriorly& the articular disc is attached to the capsular ligaments. loose

connective tissue which is highly vascularised and innervated called

7uperior attachment anterior margin o the articular sur ace o the temporal bone. 'n erior attachment anterior margin o the articular sur ace o the condyle. Articular disc divides the joint into i. distinct cavities:

7uperior cavity bordered by the mandibular ossa and the superior sur ace o the disc.

ii.

'n erior cavity bordered by the mandibular condyle and the in erior sur ace o the disc.

d)

!i"aments:

!"a##$f$e% a# i. ?unctional ligaments: Collateral ligaments. Capsular ligaments. Temporomandibular ligament. ii. Accessory ligament - 7phenomandibular ligaments. 7tylo-mandibular ligaments. i# Collateral$li"ament %discal li"aments): Attach the medial and lateral borders o the articular disc to the poles o the condyle. They unction to instruct the movements o the disc away rom the condyle. ii# They are responsible or the hinging movement o the T(C. Capsular li"ament: The entire T(C is surrounded and incompassed by the capsular ligament. 't is attached superiorly to the temporal bone along the borders o the articular sur aces o the mandibular ossa and articular eminence. 'n eriorly it attaches to the nec% o the condyle. 't resists any medial& lateral or in erior orces that tend to separate or dislocate the articular sur aces. A signi icant unction is to encompass the joint and retain the synovial luid. ,

iii# i"

Temporomandibular li"ament %lateral li"ament)

parts:

<uter obli;ue portion . it e#tends rom the outer sur ace o the articular tubercle and +ygomatic process posteroin eriorly to the outer sur ace o the condylar nec%. 't resists the e#cessive dropping o the condyle& limiting the e#tent o mouth opening. ' the mouth was to open wider& the condyle would need to move downward and orward across the eminence. This change in opening movement is brought about by the tightening o the T( ligament.

ii"

'nner hori+ontal portion: e#tends

rom outer

sur ace o articular tubercle and +ygomatic process and attaches to the lateral pole o condyle and posterior part o articular disc. 't limits the posterior movement o the condyle and disc. iii" 7phenomandibular ligaments: Arises rom spine o sphenoid and attaches to lingual. $oes not have signi icant limiting e ects on the mandible. iv" 7tylomandibular ligament: Across the styloid process and attaches to angle and posterior border o ramus o the mandible limits e#cessive protrusive movement o mandible. Ne&'om&#(&"a' a#)e(t of the ma#t$(ato'y #y#tem The energy re;uired to move the mandible and allow unction o the masticatory system is provided by the muscles. The most important o these are the muscles o mastication each o which has a di erent unction but all act in a cooperative way to e ect jaw movement. 3owever to produce ade;uate mandibular unction& they must

collaborate with other muscle groups namely the suprahyoids& in rahyoids and the post vertebral muscle groups. :

I* Ma#t$(ato'y M&#("e# *. 9. 5. 2. (asseter. Temporalis. (edial pterygoid. >ateral pterygoid

II* S&)'ahyo$% m&#("e# *. (ylohyoid. 9. Geniohyoid. 5. 7tylohyoid. 2. $igastric. Their function is t&o fold: ' the muscles o mastication& close the jaws and i# the mandible in its position& the suprahyoid muscles will elevate the hyoid bone and laryn# which is attached to it by a membrane& which is necessary or swallowing. ' however the in rahyoids are contracted& the hyoid bone is made stable and immovable. ' the suprahyoids then contract& against the secured hyoid bone the mandible will be retracted and depressed. 'ts movement will be down and bac%. III* Inf'ahyo$% m&#("e# *. 9. 5. 7ternohyoid. <mohyoid. Thyrohyoid. 6

They mainly unction to depress the hyoid bone and along with the suprahyoid muscles stabili+e the hyoid bone during unction. 'DE The post vertebral muscles are also important in chewing and maintaining unctional balance. They orm a continuous chain rom the base o the s%ull to the base o the spine. They are anti-gravity muscles which sustain unctional posture in relation to chewing. (asseter Flevation Protraction F#treme lateral movements Temporalis Principal positioner. Flevator Gnilateral contraction leads to lateral movement on side (P Flevation >ateral positioning o mandible 7imple protraction 7ub activity dividing protraction and opening same

>P

Protrusion >ateral movement !>P + (P + ( + T"

BLOOD SUPPLY Generally& all blood vessels in the vicinity o a joint contribute to its supply. Thus joints are usually e#cellent sites or the development o a collateral circulation. 'ts blood supply is derived rom articular branches o the numerous arteries that ma%e up the terminal ield o the e#ternal carotid artery. LYMPHATI! DRAINAGE The lymphatic drainage o the joint has been described brie ly by Tanasesco !*0*9" who ound lymph channels on each sur ace o the joint. These channels are most prominent on the lateral and posterior sur aces. The lymphatic vessels on the lateral sur ace drain into the preauricular and parotid nodes. <n the posterior sur ace& si# or seven channels converge on the e#ternal carotid artery& use in to large trun%s& across the digastric muscle& and enter the submandibular nodes. NER+E SUPPLY Auriculo temporal nerve. (assetric nerve laterally. Me(han$(# of man%$,&"a' mo-ement# (andibular movements occur as a comple# series o inter related 5dimensional rotational and translational activities. 't is determined by combined and simultaneous activities o both T(C)s. Two types o movements occur in the T(C: !i" !ii" Hotational. Translational.

*1

I)

Rotat$ona" mo-ement# Hotation is the movement o a body about aits a#is. Hotation occurs

when the mouth opens and closes around a i#ed point or a#is within the condyles. Hotation occurs in the in erior cavity o the joint between the superior sur ace o the condyle and in erior sur ace o the articular disc. Hotation o the mandible can occur in 5 re erence planes around a point called the a#is. They are: a) 'ori(ontal a)is of rotation: (andibular movement around a hori+ontal a#is o rotation is an opening and closing motion. 't is re erred to as hinge movement and the hori+ontal a#is around which it occurs is re erred to as hinge a#is. The hinge movement is the only e#ample o mandibular activity in which a pure rotational movement occurs. 4hen the condyles are in the most superior position in the articular ossa& and the mouth is purely rotated open& a#is around which movement occurs is the @terminal hinge a#isA . to study in detail. b) *rontal %vertical a)is of rotation): (andibular movement around the rontal a#is occurs when one condyle moves anteriorly out o the terminal hinge position with the vertical a#is o the opposite condyle remaining in the terminal hinge position.

**

c) Sa"ittal a)is: (andibular movement around the sagittal a#is occurs when one condyle moves in eriorly while other remains in the terminal hinge position. II) T'an#"at$ona" mo-ement# 't can be de ined as a movement in which every point o the growing de ect has simultaneously the same velocity and direction. Translation occurs within the superior joint cavity between the superior sur ace o the articular disc and in erior sur ace o the articular ossa. Bo'%e' mo-ement# 4hen the mandible moves through the outer range o motion&

reproducible desirable limits result& which are called as border movements. +order movements can be described in , reference planes: !i" !ii" !iii" !i" 7agittal. 3ori+ontal. ?rontal. 7agittal plane border and unctional movements:

-n the sa"ittal plane. it has 4 distinct components: a" Posterior opening border. b" Anterior opening border. c" 7uperior contact border. <cclusal and incisal sur aces d" ?unctional neuromuscular system
$etermined by ligaments and morphology o T.(.C.

*9

a)

Po#te'$o' o)en$n. ,o'%e' mo-ement# <ccurs as two stage hinging movements. 'n the irst stage& the condyles

are stabili+ed in their most superior positions in the articular ossae. The most superior condyle position rom which hinge a#is movement occur is called anterior relation. !Hetruded contact position& terminal hinge a#is or ligamentous position". 'n anterior relation& mandible can be rotated around the hori+ontal a#is to a distance o only 91-98mm as measured between the incisal edges o the ma#illary and mandibular teeth. At this point o condyles. This is the 9ns stage o the posterior opening border movements. As the condyles translate& a#is o rotation o the mandible shi ts into the bodies o the rami& most li%ely in the area o attachment o the sphenomandibular ligament. (a#imum opening is reached when the capsular ligament will prevent urther movement o the condyles. This opening is in the range o 21-,1mm measured between the incisal edges o the (# and (d teeth. b) Anterior openin" border movement: 4hen the mandible is ma#imally opened& closure accompanied by contraction o the in erior lateral pterygoids !which %eep the condyles positioned anteriorly" will generate the anterior opening border movement. 7ince the ma#imum protrusive position is determined in part by the stylomandibular ligaments& as closure occurs& tightening o produces a posterior movement o the condyles. *5 the ligament opening& the T(C ligament tightens& a ter which& the

continued opening results in an anterior and in erior translation o

Condylar position is most anterior in the ma#imally open but no the ma#imally protruded position. c) Superior contact border movements: Throughout this entire movement& tooth contact is present. 't depends on: Amount o variation between centric relation and ma#imum

intercuspation positions. 7teepness o cuspal inclines o posterior teeth. Amount o vertical and hori+ontal overlap o anterior teeth. >ingual morphology o ma#illary anterior teeth. The general inter arch relationships o the teeth. The initial contact in terminal hinge closure !centric relation occurs between the mesial inclines o a ma#illary tooth and the distal inclines o the mandibular tooth. 4hen muscular orce is applied to the mandible& a supero-anterior movement or shi t will occur until the intercuspal position is reached. This slide is present in *1I o the population and is appro# *.98mm J*mm. 4hen the mandible is protruded rom ma#imum intercuspation contact between the incisal edges o the mandibular anterior tooth and lingual inclines o the ma#illary anterior teeth results in an antero-in erior movement o the mandible. This continues until the ma#illary and the mandibular teeth are in an edge to edge relationship& at which time a hori+ontal pathway is ollowed. *2

As the incisal edges o the mandibular teeth pass beyond the incisal edges o the ma#illary teeth& the mandible moves in a superior direction& until the posterior teeth contact.

The occlusal sur aces o

the posterior teeth& then dictate the the anterior opening

remaining pathway o the ma#imum protrusive movement which joins with the most superior position o border movement. d) *unctional movements: They usually ta%e place between the border movement and there ore considered ree movements. (ost unctional activities re;uire ma#imum intercuspation and there ore typically begin at and below the intercuspal position. 4hen the mandible is at rest it is ound to be located appro#-92mm below the intercuspal position. This position has been called cervical rest position. This position is variable. The myostatic re le# is active at this position& and the teeth can be ;uic%ly and e ectively brought together or immediate unction. Po#t&'a" effe(t# on f&n(t$ona" mo-ement# a" position o 3ead position is erect: Postural the mandible is 9-2mm below the intercuspal position !elevator muscles contact mandible goes directly to 'CP". b" 3ead positioned 28K upward:

postural position o the mandible will be altered to a slightly retruded position. This change is related to the stretching and elongation o various tissues that are attached to and support the jaws !elevation

*8

muscles contact . path o closure is slightly posterior to path o closure in erect position". c" 3ead positioned 51K downward !alert eeding position". ' the elevator muscles contact with the head in this position& the path o closure will be slightly anterior to that in upright position. !Flevator muscles contract . path o closure is slightly anterior to path o closure in erect position". Ho'$/onta" )"ane ,o'%e' mo-ement# Gothic arch tracer is used to record mandibular movements in the hori+ontal plane. Consists o recording plate attached to the ma#illary teeth and a recording stylus attached to the mandibular teeth. As the mandible moves& stylus generates a line on the recording plate that coincides with this movement. The mandibular movements when viewed in a hori+ontal plane are rhomboid-shaped and has 2 distinct component movements plus a unctional movement. a" b" protrusion. c" d" protrusion. a) !eft lateral border: Hight lateral border. Continued right lateral border with >e t lateral border. Continued le t lateral border with

*,

4ith the condyles in CH position& contraction o the right in erior lateral pterygoid& will cause the right condyle to move anteriorly and medially. ' the le t in erior lateral pterygoid stays rela#ed the le t condyle will remain situated in CH and the result will be a le t lateral border movements. b" Continued le t lateral border movements with protrusion with the mandible in the le t lateral border position contraction o the le t in erior lateral pterygoid muscle along with continued contraction o the right in erior lateral pterygoid muscle will cause the le t condyle to move anteriorly and to the right. This causes a shi t in the mandibular midline bac% to coincide with the midline o the ace. c) /i"ht lateral border movement: <nce the le t border movements have been recorded the mandible is returned to CH and the right lateral border movements are recorded. Contraction o the le t in erior lateral pterygoid muscle will cause the le t condyle to move anteriorly and medially. ' the right in erior lateral pterygoid muscle stays rela#ed& the right condyle will remain situated in the CH position. The resultant movement will be right lateral border movement. d" Continued right lateral border movement with protrusion contraction o the right in erior lateral pterygoid muscle along with the continued contraction o the le t in erior lateral pterygoid muscle will cause the right condyle to move anteriorly and to the le t. 7ince the le t condyle is already in its ma#imum anterior position& the movement o the right condyle to its ma#imum anterior position will cause the shi t in the mandibular midline bac% to coincide with the midline o the ace. e) *unctional movements: *:

As in the sagittal plane& unctional movements in the hori+ontal plane most o ten near the intercuspal position. $uring chewing& range o jaw movements begins same distance away rom ('CP but as ood is bro%en down into smaller particles& jaw action moves closer and closer to 'CP. III) mo-ement# 4hen mandibular motion is viewed in the rontal plane& a should li%e pattern can be seen that has 2 distinct movement components: a" b" c" d" >e t lateral superior border. >e t lateral opening border. Hight lateral superior border. Hight lateral opening border. F'onta" 0-e't$(a") ,o'%e' an% f&n(t$ona"

The movement in the plane has not been traditionally traced& on understanding o dimensionally. a) !eft lateral superior movement: 4hen the mandible in ma#imum intercuspation a lateral movement is made to the le t. A recording device will disclose an in eriorly concave path being generated. The precise mi#ture o this path is primarily determined by the them is use ul in revisuali+ing mandibular activity 5-

morphology and inter arch relationships o the ma#illary and mandibular teeth that are un contact during this movement. < secondary in luences are the condyle-disc- ossa relationships and morphology o the wor%ing or rotating side T(C. *6

b) !eft lateral openin" border: ?rom the ma#imum le t& lateral superior border position on opening movement produces a laterally conve# path. As ma#imum opening is approached& the ligaments lighter and produce a medially directed movement that causes a shi t in the mandibular midline to coincide with the midline o the ace. c) /i"ht lateral superior border movements: <nce the le t rontal border movements are recorded the mandible is returned to ma#imum intercuspation rom this position a lateral movement is made to the right that is similar to le t lateral superior border movements. d) /i"ht lateral openin" border movements: ?rom the right lateral superior border position on opening movement produces a laterally conve# path similar to that o the le t lateral opening border movements. e) *unctional movements: As in other planes& unctional movements in the rontal plane begin and end and the intercuspal position. $uring chewing& the mandible drops directly in eriorly until the desired opening& is achieved. 't then shi ts to the side the bolus is placed and rises up. As it approaches ma#imum intercuspation& the bolus is bro%en down between the opposing teeth. 't the inal mm o closure the mandible ;uic%ly shi ts bac% to the 'CP. En-e"o)e of mot$on 0.$-en ,y Po##e"t) =y combining mandibular border movements in all 5 planes a 5-$ envelope o motion is produced. This represents ma#imum range o movement o the mandible. *0

The superior sur ace o the envelope is determined by tooth contacts. <ther borders are primarily determined by ligaments and joint anatomy.

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REFEREN!E POINTS
POSTERIOR POINTS OF REFEREN!E The arbitrary method is an accepted techni;ue or locating the mandibular hinge a#is. Although many studies have compared various arbitrary hinge a#is points with %inematic location& there is no consensus as to which arbitrary point most closely and consistently lies on or near the %inematic a#is.

0arious arbitrary hin"e a)is points: -ame $enar >ocation *9mm anterior to posterior border o tragus and 8mm in erior to line e#tending rom the superior border o tragus to <CF. T7*9mm anterior to center o TA( and 9mm ?ran% ort plane. *9mm anterior to center o FA( and 9mm in erior to portioncanthus line. 4hip-(i# According to the design o their ear-bow in anteroposterior direction at anterior wall o FA( and in superior-in erior direction appro#imately at level o most prominent point o 9*

posterior border o tragus. Prothero <n line rom superior margin o FA( to <CF interecting with line *5 edge o FA( according to Hachey condyle mar%er. =arndrup4ognsen =eryon *9mm anterior to most prominent point o posterior border o tragus on line rom it to <CF. *5mm anterior to posterior margin o tragus online rom the center o tragus to <CF. Gvst *5mm anterior to anterior margin o FA( on line rom superior margin o FA( to <CF. =ergstrom *1mm anterior to center o spherical insert o his ace-bow and :mm below ?ran% ort plane.

99

ANTERIOR POINTS OF REFEREN!E Three points in space determine the position o the ma#illary cast in an articulator the dentist is most re;uently concerned with selecting the posterior two o the three re erence points. The selections o the anterior point o the triangular spatial plane determine which plane o the head will become the plane o re erence when the prosthesis is being abricated. The dentist can ignore but cannot avoid the selection o an anterior point. The act o a i#ing a ma#illary cast to an articulator relates the cast to the articulators hinge a#is& to the anterior guidance& and to the mean plane o the articulator. The act achieves greater importance by the use o a constant third point o re erence. 4hen three points are used the position can be repeated& so that di erent ma#illary casts o the same patient can be positioned in the articulator in the same relative position to the end controlling guidances. SELE!TION OF AN ANTERIOR REFEREN!E POINT1 'n selecting the re erence plane& the dentist should have %nowledge o the ollowing anterior points and the rationale or selection o each. *. <rbitale. 'n the s%ull& orbitale is the lowest point o the in raorbital rim. <n a patient it can be palpated through the overlying tissues and the s%in <ne orbitale and two posterior points that determine the hori+ontal a#is o rotation will de ine the a#is-orbital plane. Helating the ma#illae to this plane will slightly lower the ma#illary cast anteriorly rom the position that would be established i the ?ran% ort hori+ontal plane were used. Practically& the a#isorbital plane is used because o the ease o locating the mar%ing and because the concept is easy to teach and understand.

95

9. <rbitale minus :mm. The ?ran% ort hori+ontal plane passes through both poria and one orbital point. =ecause potion is a s%ull landmar%-& 7icher recommends using the midpoint o the upper border o the e#ternal auditory meatus as the posterior cranial 'andmar% on a patient. =ergstromLs arcon articulator automatically compensates or this error by placing the orbital inde# :mm higher than the condylar hori+ontal a#is.

5. -asion minus 95mm. According to 7icher& another s%ull landmar%& the -asion can be appro#imately located in the head as the deepest part o the midline depression just below the level o eyebrows. The -asion guide& or positioner& o the Muic%-mount ace-bow& which is designed to be used with. the 4hip(i# articulator& its Linto this depression.

92

2. 'ncisal edge plus articulator midpoint to articulator a#is-hori+ontal plane distance. Guichet has emphasi+ed that a logical position or the casts in the articulator would be one which would position the plane o the articulator. A deviation rom this objective may position casts high or low relative to the instrumentLs upper and lower arms. The e ects o these high or low positions may be inaccurate occlusal relationships due to dimensional changes in the arti icial stone or plaster used or cast-mounting purpose 'n accordance with this concept& the distance rom the articulatorLs midhori+ontal plane to the articulatorLs a#is-hori+ontal plane is measured. This same distance is measured above the e#isting or planned incisal edges on the patient& and its uppermost point is mar%ed as the anterior point o re erence on the ace. The inner canthus is used because it is an accessible& unchanging landmar% on the head. 4ith this techni;ue the ace-bow trans er will carry the predetermined posterior points o re erence and this anterior point o re erence to the articulatorLs a#ishori+ontal plane. 8. Alae o the nose. A part o many complete denture techni;ues is to ma%e the tentative or the actual occlusal plane parallel with the hori+ontal plane. A line rom the ala o the nose to the center o the auditory meatus describes the CamperLs line. Augsburger concluded& in a review that the occlusal plane parallels this line with minor variations in di erent acial orms.

98

<ther intraoral landmar%s& esthetics& consideration or the residual ridges& and tongue and chee% guidance actors may alter the inal occlusal plane. Also when relating the ma#illary case in space to a hori+ontal re erence plane& the relating planes are usually thought o and being viewed rom the lateral aspect. 4hen viewed rom the rontal aspect& there are re erence lines as well. The hinge line&-- the interpupillary line& and a transverse line across the occlusal sur aces are three common rontal-view re erence lines. The later two are observed in the articulator. Generally these three lines are not parallel. This is caused by posterior hinge re erence points that are not e;uidistant rom the eye pupas. An occlusal plane that is parallel to the interpupillaly line will be pleasing to the eye o the viewer. 't cannot be guaranteed that an occlusal plane parallel to the hinge will have the same pleasing appearance.

9,

+ARIOUS S!HOOLS OF THOUGHT ?rom early e#periments there have evolved our main schools o thought regarding the hori+ontal a#is. They are as ollows. 1roup -# Absolute location of the a)is# There are those who believe that there is a de inite transverse a#is and it should be located as accurately as possible. (cCollum& 7tuart N>ucia believe that the hinge a#is is a component o every masticatory movement and cannot be disregarded. The investigators who endorsed this concept have established a repeatable point o reorientation rom which the above in ormation and relationships may be obtained. 1roup --: Arbitrary location of the a)is# The second group includes those who believe that the arbitrary location is not worth the added e ect. Craddoc% or one stated that the search or the a#is& in addition to being troublesome& is- o no more than academic interest. Though& this group believed in location o the a#is. 1roup --- 2onbelievers in the transverse a)is locations# Then& there is a third group who believes it is impossible to locate the terminal hinge position with accuracy. >aurit+en and 4at ord con irm this& and /urth and ?einstein& using an articulator and a range o 9mm. That could be considered a point o rotation or non-movement. The opening and closing movement was limited to appro#imately *1 to ** degrees. =orgh and Posselt could not record the a#is on a modi ied 3anau 3 articulator without errors. The errors amounted -to * to 8mm. At a *1 to *8 degree opening.

9:

=ec% has proposed another reason or doubting the validity o the hinge a#is location. 3e claims that there can be many compensating movements o the condyle other than pure rotation& and that these compensating movements are movements o translation and side shi t that are integrated with the movement o rotation. 3e concludes that the opening and closing hinge movement o the mandible& together with its ragmentary movements& cannot be repeated by the opening and closing movements o an articulator& which is about one a#is only. There ore& an arbitrary terminal hinge position would or could be just as accurate as one located with a %inematic ace-bow. 1roup -0 Split a)is rotation These are believers o the Transographic theory. They believe in the Osplit a#isO with which each condyle rotates independently o the other. 7lavens states Oby de inition& an a#is is always a line& never a point. Again& by de inition& an a#is is invariably perpendicular to the path or plane o rotation 't controls. That means that the transverse a#is o each joint is a line and both o these are perpendicular to the same plane o opening and closing rotation. The signi icance o the act that these two transverse a#es are never symmetrically positioned in the same head becomes Linescapable. =eing perpendicular to the same plane o rotation& they are parallel to each other even though asymmetrically positioned and& by de inition parallel lines never meetO. SINGLE A2IS OR MULTIPLE About *081& $r. 4illiam =ransted& $r. Haymond Gravy and $ r. Hobert <%ey conducted an e#periment& which should the presence o a single a#is. $r. Arne >aurit+en.& wor%ing with a study group in *08:& repeated the same e#periment and arrived at the same conclusion. 96

'n *080 the committee o the greater -ew Por% academy o prosthodontics repeated this e#periment and concluded that there was only one transverse a#is through both condyles. >ater >ucia also conducted e#tensive e#periments and concluded the presence o a single a#is. (cCollum And 7tuart stated that only when a single T3A e#its& can the CH registrations be made at an increased D$ o occlusion.. The Transographic concepts postulated the e#istence o 9 materially

independent& non-collinear a#es. Trapo+anno N >a++ari support this theory. >ater 4ienberg :L conducted e#periments to support this Transographic theory. They concluded that multiple a#es e#ist and their presence opens the ?ield or interesting conjecture. Aull discussed the impossibility o the presence o a split 3A& or o a di erent 3A or each condyle acting simultaneously. 3arry page in his e#perimentation in *0:0 also supported the above views. They donLt de y the basic concept but view the rotational movement as occurring in a manner di erent rom that which is commonly thought o as occurring in the type o movement. 't is a tangential type o hinge movement occurring between a movable e#tension and a i#ed sur ace !condyle and glenoid ossa".

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THE HINGE A2IS AND !ENTRI! RELATION To secure a centric inter-occlusal record&& we attempt to O ree+eO the terminal hinge closure at a convenient vertical opening. 4ithout the hinge a#is& we would be unable to secure an accurate centric inter-occlusal record because to obtain such a record the recording medium must not be penetrated by the teeth or the occlusion rims. 'n order to -avoid penetration !atleast in dentulous cases"& we must obtain our centric interocclusal record in an open relationship& and i we were not in the same arcs o closure& our e orts would be useless. 't is impossible to chec% a centric inter-occlusal record without an a#is mounting.

LO!ATION OF THE HINGE A2IS $i erent methods have been used to locate and trans er the hinge a#is to the articulator. The irst actual %inematic location was evolved through the Cali ornia Gnathologic society under the leadership o (cCollum and credit or the idea o the mechanical location o an a#is was given to 3arlan. The irst location employed a modi ied 7now ace-bow and consumed as much as 6 hours. 51

'n *08: Posselt analy+e the transverse hinge movement by geometric construction rom pro ile roentgenograms& a#is points recorded by means o %inematic ace-bow and chec%ed by pro ile roentgenograms and also by Gnathothesiometric measurements. The Gnathothesiometer a device which was proved use ul or the measurement o the position o the mandible. This apparatus allows measurements !at three points" in the three main planes on reely movable casts o the lower law.

'n *0:1 /napp developed a measuring device using , potentiometers as sensors.

>ong in *0:1 used a intraoral device to locate the transverse hinge a#is and he used a =uhnergraph to veri y the records. 3e encountered errors in either location or its trans er to the articulator& which he corrected by moving the recording sha t to the =uhnergraph and until the records made by it coincides.

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The computer graphics simulation was developed in *0:6 to display the e ects o mandibular movement parameters o both the ma#illary and mandibular teeth in the occlusal plane& which can be graphically observed in the hori+ontal plane. 'n *0:0 Pantographic tracing using $enar Pantograph was used by Cac%son to record the mandibular movement. =eard and Clayton in *06* devised a modi ied hinge a#is locator which was very similar to that used by Trapo++ano and >a++ari but has multiple styli. The results obtained by this were supporting the single a#is theory.

3obo et al in *065 developed a new electronic measuring device capable o measuring , degrees o reedom with an accuracy J1.1,mm. 59

'n the year *066 Get+O et al used a double recording styli !at a distance o 9-2 inches rom estimated a#is area" to identi y the true a#is o rotation.

'n *009 the terminal hinge a#is was located on the individuals using the A#iotron& a computeri+ed A#iograph by /inder%necht et al. 'n the later years there have been very ew e#periments& which used any newer techni;ues.

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TE!HNI3UE FOR LO!ATING THE HINGE A2IS The location and trans erence o the hinge a#is are not very di icult procedures& but they must be care ully carried out with great care because they orm the oundation or many other procedures. A re erence plane or clutch is cemented to the lower teeth with Truplastic. Graphlined lags are placed on the side o the ace over the condyle areas to eliminate any s%in movement distraction. These lags may be attached to the ma#illae by means o a crossbar and a ma#illary clutch& or they may be held in place by a head rame or other contrivance. A crossbar is attached to the lower re erence plate or clutch. Adjustable side arms are placed on the lower. cross bar with the styli in the vicinity o the condyles. The patient must now be instructed Qin the hinge type o movement. The pivoting part o the compass is on the center o rotation in the patientLs condyle. The stylus point is the tracing part o the compass. ' we get the tracing point e#actly on the pivoting point& there will be no arcing on the tracing point. As we-approach the center& the arcs will become smaller and little more arcing is re;uired to magni y the arc. ' there is any arcing we continue adjusting until it disappears completely. The a#is center must -be located on each. side. 4hat we are locating is the hinge action on the 52

side o the ace. 't is a point on the hinge a#is and not the actual center o rotation. The actual center is appro#imately *1 or ** mm medial to this location.

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POSSIBLE NEED FOR BITE PLANE THERAPY The patient naturally opens downward and orward combination o rotation and translation. 4e must separate the rotation rom the -translation so that we can locate the center o vertical opening. 'n addition&& this opening and closing must be accomplished in the terminal hinge position& or here we can get repeated concentric arcs that will permit us to locate their center. ' a patient has di iculty in e#ecuting a pure hinge movement& it may be. necessary to train him in this abnormal Lopening and closing movement. Training can be accomplished by using the jig.

MAR4ING THE A2IS LO!ATION ON THE PATIENT 4hen we are satis ied that we have located these points on the a#is the mar%ing medium& 7uchn as an indelible pencil& is rubbed on the end o the stylus. 4e ma%e sure the patient is in the terminal hinge position and then have him move his head out o the headrest& ma%ing sure that he does not also move out o the terminal hinge position. The stylus is gently pushed against his ace to trans er the point to the s%in. These mar%s are made permanent by using a special needle and a little pin% mar%ing dye -sul ide o mercury.

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Gordon has presented an alternate techni;ue or recording the located a#is point by non-tattoing method. SELE!TION OF A FA!E5BO6 ?rom a purely theoretical point o view an ordinary ace-bow such as a 7now or 3anau can be used to locate the hinge a#is. To attempt to use either one o them in actual practice& however is impossibility. 't is ar easier and more accurate to use a ully adjustable ace-bow !i.e. one with arms that can be independently adjusted by means o micrometer screws" or both the a#is locations and the trans ers. =y means o a ace-bow trans er and the mounting rame the upper cast can be properly mounted to the a#is o the patient. There are two types o ace bow& the %inematic and arbitrary. The %inematic is used to locate the true terminal hinge a#is. The arbitrary acebow is the one generally used in the construction o complete dentures and is based on average computations o an a#is opening o the jaw. 't is simple to use and relatively accurate. A',$t'a'y a7$# fo' Hana& fa(e ,o8 4hen using a 3anau ace bow& a Hichey condylar mar%er is used to scribed an arc about *5 mm anterior to the e#ternal auditory meatus. 5:

A',$t'a'y a7$# fo' 6h$) 5 M$7 fa(e ,o8 >ocating the arbitrary a#is is not necessary when using the 4hip-(i# articulator. The insertion o plastic ear pieces into the e#ternal auditory meatus automatically locates the ace bow in the proper position.

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