Analysis of the condyle/fossa relationship before and after prosthetic
rehabilitation with maxillary complete denture and mandibular removable
partial denture Vania Cristina Pintaudi Amorim, DDS, MSD, a Dalva Cruz Lagana, DDS, MSD, PhD, b Jose Virgilio de Paula Eduardo, DDS, MSD, PhD, c and Artemio Luiz Zanetti, DDS, MSD, PhD d School of Dentistry, University of Sao Paulo and University of Sao Paulo City, Sao Paulo, Brazil; Paulista University, Campinas, Brazil Statement of problem. The inuence of the loss of posterior teeth on the condylar position and on tem- poromandibular disorders (TMDs) remains a controversial issue. Purpose. This study investigated whether prosthetic rehabilitation promoted modication of the condylar position in subjects without symptoms of TMDs. Material and methods. The temporomandibular joints (TMJs) of 12 women (age 37 to 74), all with existing maxillary complete dentures but no removable partial denture (RPD) restoring the Kennedy class I partially edentulous mandibular arch and no clinical signs of TMDs according to the criteria established by Helkimo, were viewed in maximal intercuspal position with corrected lateral tomography before and after prosthetic rehabilita- tion with a new maxillary complete denture and a mandibular RPD. Before prosthetic rehabilitation, a mandib- ular stabilizing base was fabricated to prevent the existing maxillary complete denture from dislodging during tomographic examination. Two methods were used to evaluate tomograms: (1) linear measurements of the subjective narrowest anterior and posterior intra-articular joint spaces made from the tomograms by use of a digital caliper and (2) linear measurements of the anterior and posterior intra-articular joint spaces on the basis of drawings and tracings. Repeated-measures analysis of variance followed by orthogonal contrasts were used to evaluate differences between measurements carried out on the same subject under the different test conditions of the study (before prosthetic rehabilitation, before prosthetic rehabilitation with a mandibular stabilizing base in position, and after prosthetic rehabilitation) (P.05). Results. Before prosthetic rehabilitation, a predominance of posterior condylar positions was observed. Before prosthetic rehabilitation with a mandibular stabilizing base in position, a signicant decrease was observed in posterior condylar positions (P.03). This decrease was more marked after prosthetic rehabilitation (P.02). The subjective evaluation and comparison on the basis of drawings and tracings used to analyze the tomograms produced similar results (P.70). Conclusion. Within the limitations of this study, signicant changes in the condylar position occurred after prosthetic rehabilitation in subjects without symptoms of TMDs. (J Prosthet Dent 2003;89:508-14.) CLINICAL IMPLICATIONS In this study, posterior condyle displacement was more frequent than other positions in patients missing mandibular posterior teeth with existing maxillary complete dentures but no mandib- ular RPD. Prosthetic rehabilitation appeared to be responsible for a more favorable condyle/ fossa relationship; however, there was no evidence that this improved the patients status relative to the health of the TMJs or TMD signs and symptoms, because the patients were symptom free initially. Different methods have been used to determine the condylar position according to the relative dimensions of anterior and posterior joint spaces between the fossa and the condylar surface. 1-5 In spite of variations among the methods used, 3 types of condylar positions can be identied: 6 (1) condylar concentricity, in which the an- terior and posterior joint spaces are equal; (2) posterior condylar position, in which the posterior joint space is smaller than the anterior joint space; and (3) anterior condylar position, in which the posterior joint space is greater than the anterior joint space. Some authors have investigated the accuracy and reliability of the methods used to evaluate the position of the condyle. 1-3 In this Supported by CNPq. a Assistant Professor, Department of Prosthodontics, University of Sao Paulo City. b Associate Professor, Department of Removable Prosthodontics, University of Sao Paulo. c Professor and Chairman, Department of Prosthodontics, Paulista University of Campinas. d Professor and Chairman, Department of Removable Prosthodontics, University of Sao Paulo and University of Sao Paulo City. 508 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 89 NUMBER 5 study, 2 methods described as reliable in the literature were used, one method done by linear measurements of the subjective closest anterior and posterior intra-artic- ular space on the tomogram with a digital caliper, 1 and another method that took into account the linear mea- surements of the anterior and posterior intra-articular space on the basis of tracings and drawings. 2 Several authors have associated nonconcentric posi- tions with temporomandibular disorders (TMDs). 7-12 However, in asymptomatic populations with no history of occlusal or orthodontic treatment, a wide variety of condylar positions in the articular fossa have been ob- served. Not withstanding, a relatively greater number of concentric positions in symptom-free subjects has been reported. 13,14 In at least 2 studies, no association was found be- tween TMDs and nonconcentric positions of the con- dyle. 15,16 Radiographic investigations, however, have shown that patients with temporomandibular joint (TMJ) pain presented a higher ratio of posterior condy- lar positions than symptom-free subjects. 17-21 This pos- terior displacement of the condyle has frequently been associated with the loss of posterior teeth 17-19 and also may be associated with anterior disk displacement. 20,21 A more superior and anterior position of the condyle in the presence of good, integrated muscular activity, optimum occlusal stability, and an interposed articular disk has been considered the ideal status of the con- dyle. 22-25 Radiographically, however, this ideal depends on the thickness of the articular soft tissues, tissue de- generation and remodeling, and mandible posture, all of which might alter the position of the condyle. 26,27 Many patients can adapt to occlusion or condylar positions that are not considered ideal. Because of fac- tors that reduce adaptive ability and cause unbalance of the masticatory system, other patients may have devel- opment of TMDs. 24,25 The inuence of condylar posi- tion and the loss of posterior teeth on TMDs remains a controversial issue, as does the inuence of lost molar replacement by a removable partial denture (RPD). 28-31 Nevertheless, some researchers have shown the impor- tance of prosthetic rehabilitation for reducing the symp- toms of TMDs. 32,33 The purpose of this study was to analyze condylar position by means of corrected lateral tomography in 12 patients with existing maxillary complete dentures but no RPD for the partially edentulous mandibular arch (Kennedy class I). Analysis was performed before pros- thetic rehabilitation (with and without a stabilizing base in position) and after prosthetic rehabilitation (consist- ing of a new maxillary complete denture and a mandib- ular RPD). The goal was to determine whether the as- sociated prosthetic rehabilitation resulted in an alteration of the condyle position. MATERIAL AND METHODS The sample of this study consisted of 12 women, ages 37 to 74, in good general health, without symptoms of TMD according to the criteria established by Hel- kimo, 34 and presenting edentulous mandibular arches (Kennedy class I) but no mandibular RPDs. All subjects had worn a maxillary complete denture for more than 5 years and were seeking prosthetic rehabilitation at the dental clinics of the University of Sa o Paulo or the Uni- versity of Sa o Paulo City. The TMJs of the patients were viewed with corrected lateral tomography (Quint Secto- graph, Los Angeles, California) twice before prosthetic rehabilitation (with an existing maxillary complete den- ture in position only, and with an existing maxillary complete denture and a mandibular stabilizing base in position) and once again after prosthetic rehabilitation (with a new maxillary complete denture and a mandib- ular RPD), always in maximal intercuspal position. Before prosthetic rehabilitation with a new maxillary complete denture and a mandibular RPD, a mandibular stabilizing base 35-37 was fabricated for the purpose of stabilizing the existing maxillary complete denture, pre- venting it from becoming dislodged and losing contact with the mucosa in maximal intercuspal position during the tomographic examination. The mandibular stabiliz- ing base was fabricated on a mandibular diagnostic cast of each patient and consisted of an acrylic resin (Jet; Classico Ltd, Sa o Paulo, Brazil) base relined with a zinc oxide-eugenol paste (Lysanda; Lysanda Ltd, Sa o Paulo, Brazil) on the cast lubricated with petroleum jelly (Va- selina; Beira Alta Ltd, Sa o Paulo, SP, Brazil) to offset the distortion caused by the acrylic resin polymerization con- traction. Anocclusionrimmade of wax (Wilson; Polidental Ind e Com Ltd, Sa o Paulo, Brazil) was fabricated on this acrylic resin base, which was placed in the mouth and con- toured to coincide with the existing vertical dimension of occlusion and maximal intercuspal position presented by the patient while wearing the existing maxillary complete denture. Afterward, 1 mm of the wax was removed to receive a layer of zinc oxide-eugenol paste (Lysanda; Ly- sanda Ltd). The occlusion rimwas once again placed in the patients mouth to make a record of the maximal intercus- pal position at the vertical dimension of occlusion. Standardized procedures were performed for the fab- rication of the maxillary complete dentures and the man- dibular RPDs. After clinical examination, diagnostic im- pressions and casts of the maxillary and mandibular arches were made. New record bases and occlusion rims were fabricated on the casts and transferred to a semi- adjustable articulator (Dent-ex 10600; Dent-ex Ind Com Ltd, Ribeira o Preto, Brazil) with the aid of a face- bow transfer and a record made with the patient in the centric relation position. 22 Treatment planning was carried out for each patient. The mandibular diagnostic cast previously used to fab- PINTAUDI AMORIM ET AL THE JOURNAL OF PROSTHETIC DENTISTRY MAY 2003 509 ricate the stabilizing base was mounted in a parallelom- eter (Bioart; Bioart Ltda, Sa o Carlos, Brazil) to deter- mine the path of insertion and the need for abutment tooth preparation to accommodate the desired RPDde- sign. 37,38 After mouth preparation, a mandibular im- pression was made to evaluate the correctness of the mouth preparations. A maxillary functional impres- sion 39,40 was made and transferred to the articulator with the aid of a face-bow and transferring devices. 41 A nal mandibular impression was made and the cast was formed in stone (Durone; Dentsply Ind e Com Ltd, Petro polis, Brazil). The RPD design was nalized, and the metal framework was fabricated. Determination of the plane of occlusion was based on anatomic landmarks (retromolar pads and maxillary lip line). 35,36 The vertical dimension of occlusion was established by combining the methods described by Willis, 42 Pleasure, 43 Silver- man, 44 and Ricketts. 45,46 Centric relation was initially recorded by use of Dawsons 22 bilateral manipulation technique and then conrmed by the procedure for re- cording the centric relation as described by Smith. 47 The nal mandibular cast and framework, along with the mandibular and maxillary occlusion rims, were then transferred to the articulator. Prosthetic teeth with 33- degree cusp inclines (Biotone; Dentsply Ltda, Sa o Paulo, Brazil) were selected and arranged in the maximal intercuspal position. The characteristics of the teeth were assumed to have been standardized by the manu- facturer and were chosen because of their reduced cost. After trial insertion and conrmation of tooth arrange- ment, the prostheses were nished and processed in the usual manner. 48 The new maxillary complete denture and the mandibular RPD were remounted in the artic- ulator, and occlusal adjustments were then made as needed before insertion of the prostheses. 49 Corrected lateral tomography (Quint Sectograph) was used to viewthe TMJs of all patients. All tomograms were made at the Institute for Orthodontic Documen- tation and Radiodiagnosis (Instituto de Documentaca o Ortodontica e Radiodiagno sticoINDOR S/C Ltda, Sa o Paulo, Brazil), in the maximal intercuspal position: (1) before prosthetic rehabilitation (existing maxillary complete denture only) (Fig. 1, A and B); (2) before prosthetic rehabilitation with a mandibular stabilizing base in position (existing maxillary complete denture and mandibular stabilizing base in position) (Fig. 1, C and D); and (3) after prosthetic rehabilitation (newmax- illary complete denture and mandibular RPD) (Fig. 2). Two methods were used to analyze the tomographic images. Method A was a subjective analysis on the basis Fig. 1. Subject 4. A, Existing maxillary complete denture without mandibular stabilizing base in maximal intercuspal position. B, Tomograms of right and left TMJs seen in A. C, Existing maxillary complete denture with mandibular stabilizing base in maximal intercuspal position. D, Tomograms of right and left TMJs seen in C. THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL 510 VOLUME 89 NUMBER 5 of a method established by Pullinger and Hollender, 1 which consisted of linear measurement of the narrowest joint spaces, both anterior (A) and posterior (P), with a digital caliper (Starrett; Starrett Ltd, Itu, Brazil). The values were transferred to the following formula from Pullinger et al: 11 P A P A 100 This equation determined the percentage of anterior or posterior displacement of the condyle, with concentric- ity as a reference. Results smaller than 12 indicated that the condyles were in a posterior position; results ranging from 12 to 12 indicated that the condyles were in a concentric position; and results greater than 12 indi- cated that condyles were in an anterior position. The measurement was repeated 3 times to avoid errors, and the arithmetic mean of the 3 values was recorded as the nal result. In method B (Fig. 3), drawings and tracings for each TMJ were made on tracing paper with a 0.3-mm lead pencil in accordance with Kamelchuk et al. 2 Posterior and anterior joint spaces of all tomograms were mea- sured with the digital caliper. The formula proposed by Pullinger et al 11 to evaluate condylar position was used with this method as well. 5 Because several different distances were obtained from the tomograms of each patient, it was felt that these measurements could be used for correlation pur- poses. Repeated-measures analysis of variance followed by orthogonal contrasts was considered appropriate for statistical analysis of the data, because of its ability to address the issue of covariation between measurements in the same subject. 50 Among the available techniques, prole analysis was chosen. 51 Differences were consid- ered signicant at P.05. Because measurements obtained by methods A and B were based on the anterior and posterior joint spaces, these 2 methods were compared. A single model was adjusted for the statistical analysis, which included the method of evaluation, joint side, and type of prosthesis as factors and determined any interactions among these factors. RESULTS The distribution of condylar positions on the right and left sides are shown in Figures 4 (method A) and 5 (method B). Prole analysis (Fig. 6) showed that pros- thesis type had a signicant effect (F 2,11 10.21, P.003) but that the measurement method did not (F 1,11 0.15, P.70). The mean distances obtained by the 2 methods were considered equivalent. An effect on the basis of the particular side seemed to exist (in spite of a nding of F 1,11 2.94, P.11) be- cause, on average, the gures representing the left side condylar position were higher than those representing the right side. This suggested that there was a distinct behavior difference between the 2 sides, even though the data from the study did not detect this difference. Because no signicant effect of method was found, an- other analysis was performed that included only side and type of prosthesis as factors (Fig. 7). This second analysis Fig. 2. Subject 4. A, New maxillary complete denture with mandibular RPD in maximal intercuspal position. B, Tomograms of right and left TMJs seen in A. Fig. 3. TMJ tomography with tracings used in Method B. A, Anterior joint space; P, posterior joint space. PINTAUDI AMORIM ET AL THE JOURNAL OF PROSTHETIC DENTISTRY MAY 2003 511 indicated that the interaction of prosthesis and side was not signicant (F 2,24 0.13, P.88). Nevertheless, prosthesis alone (F 2,24 20.11, P.0001) and side alone (F 1,24 5.55, P.03) signicantly affected the condylar position. The increase in the mean value of the condylar posi- tions was signicant when a stabilizing base was added to the existing maxillary complete denture (F 1,24
5.08, P.03), regardless of whether it was on the right or left side. Likewise, the mean value of condylar posi- tions increased signicantly after prosthetic rehabilita- tion compared to the existing maxillary complete den- ture without a stabilizing base (F 1,24 5.65, P.02), and with a stabilizing base (F 1,24 4.59, P.04). DISCUSSION In this study, patients who had lost posterior support showed a predominance of posterior condylar positions. This reduction of the posterior intra-articular space may Fig. 4. Method A results. A, Condylar positions on right side TMJ. B, Condylar positions on left side TMJ. Fig. 5. Method B results. A, Condylar positions on right side TMJ. B, Condylar positions on left side TMJ. Fig. 6. Mean proles of condylar position standard devi- ation (in relation to method and side). Fig. 7. Mean proles of condylar position standard devi- ation (in relation to side but independent of method). THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL 512 VOLUME 89 NUMBER 5 represent a compression on the bilaminar zone, which is responsible for the blood supply and the nutrition of the TMJ 26 and may also be related to the anterior displace- ment of the joint disk. 20,21 It was observed that prosthetic rehabilitation caused changes in the condyle/fossa relationship, reducing the incidence of posterior condylar positions and increasing the incidence of concentric condylar positions. After prosthetic rehabilitation, the degree of retrusion was observed to be smaller, even when the condyles re- mained in a posterior position (retrusion). These nd- ings were conrmed by statistical analysis, which dem- onstrated that the mean values of condylar positions increased (condyles moved to a more anterior position) when a mandibular stabilizing base was added to the existing complete denture before treatment. The in- crease was even more pronounced after prosthetic reha- bilitation with a new maxillary complete denture and a mandibular RPD. A larger incidence of concentricity was found on the left side, conrming the results of other studies. 6,13 Con- dylar asymmetry may be an indication of osseous unbal- ance caused by different growth patterns or different remodeling effects as a result of occlusal disturbance. 12 It was not the aim of this study to analyze the occur- rence of unilateral chewers among the subjects evalu- ated. Future studies should attempt to verify the possible relationship between the asymmetry of the condylar po- sition and the incidence of unilateral chewing. It is fur- ther recommended that long-term follow-up controls be established to assess whether the condylar position after prosthetic rehabilitation is maintained. Statistical analysis revealed no signicant difference between the methods (A and B) used to evaluate the position of the condyle. Method A is recommended because it is easier and does not require drawings or tracings. CONCLUSIONS Within the limitations of this study, subjects with a maxillary complete denture but no RPDfor the partially edentulous mandibular arch showed a predominance of posterior condylar positions in maximal intercuspal po- sition. Also, when mandibular stabilizing bases were used during tomographic examination with the existing maxillary complete dentures in maximal intercuspal po- sition, a decrease in posterior condylar positions and an increase in condylar concentricity were observed. After prosthetic rehabilitation, more pronounced decreases in posterior condylar positions and increases in concentric condylar positions were observed in the maximal inter- cuspal position. Regardless of when the condylar posi- tions were analyzed (before or after rehabilitation), the TMJ on the left side displayed a higher frequency of concentric condylar positions than its counterpart on the right side. We thank Prof Israel Chilvarquer, for his encouragement, support and valuable collaboration with the tomograms, and Dr Luiz Paulo Restiffe de Carvalho, for his large contribution to this work. REFERENCES 1. Pullinger A, Hollender L. Variation in condyle-fossa relationships accord- ing to different methods of evaluation in tomograms. Oral Surg Oral Med Oral Pathol 1986;62:719-27. 2. Kamelchuk LS, Grace MG, Major PW. Post-imaging temporomandibular joint space analysis. Cranio 1996;14:23-9. 3. Karpac JR, Pandis N, Williams B. Comparison of four different methods of evaluation on axially corrected tomograms of the condyle/fossa relation- ship. J Prosthet Dent 1992;68:532-6. 4. Weinberg LA. Role of condylar position in TMJ dysfunction-pain syn- drome. J Prosthet Dent 1979;41:636-43. 5. Ruf S, Pancherz H. Long-term TMJ effects of Herbst treatment: a clinical and MRI study. Am J Orthod Dentofacial Orthop 1998;114:475-83. 6. Weinberg LA. Correlation of temporomandibular dysfunction with radio- graphic ndings. J Prosthet Dent 1972;28:519-39. 7. Mikhail MG, Rosen H. The validity of temporomandibular joint radio- graphs using the head positioner. J Prosthet Dent 1979;42:441-6. 8. Rieder CE, Martinoff JT. Comparison of the multiphasic dysfunction prole with lateral transcranial radiographs. J Prosthet Dent 1984;52:572-80. 9. Mongini F. The importance of radiography in the diagnosis of TMJ dys- functions: a comparative evaluation of transcranial radiographs and serial tomography. J Prosthet Dent 1981;45:186-98. 10. Kokich VG. Whats new in dentistry? Angle Orthod 1991;61:5-6. 11. Pullinger AG, Solberg WK, Hollender L, Guichet D. Tomographic analysis of mandibular condyle position in diagnostic subgroups of temporoman- dibular disorders. J Prosthet Dent 1986;55:723-9. 12. Abdel-Fattah RA. Simplied approach in interpretation of the temporo- mandibular joint tomography. Cranio 1995;13:121-7. 13. Blaschke DD, Blaschke TJ. Normal TMJ bony relationships in centric occlusion. J Dent Res 1981;60:98-104. 14. Pullinger AG, Hollender L, Solberg WK, Petersson A. A tomographic study of mandibular condyle position in an asymptomatic population. J Prosthet Dent 1985;53:706-13. 15. Katzberg RW, Keith DA, Ten Eick WR, Guralnick WC. Internal derange- ments of the temporomandibular joint: an assessment of condylar position in centric occlusion. J Prosthet Dent 1983;49:250-4. 16. Bean LR, Thomas CA. Signicance of condylar positions in patients with temporomandibular disorders. J Am Dent Assoc 1987;114:76-7. 17. Ricketts RM. Laminography in the diagnosis of temporomandibular joint. J Am Dent Assoc 1953;46:629-48. 18. Ireland VE. The problem of the clicking jaw. J Prosthet Dent 1953;3: 200-12. 19. Weinberg LA. Superior condylar displacement: its diagnosis and treat- ment. J Prosthet Dent 1975;34:59-76. 20. Weinberg LA. The etiology, diagnosis, and treatment of TMJ dysfunction- pain syndrome. J Prosthet Dent 1980;43:58-77. 21. Tallents RH, Macher DJ, Kyrkanides S, Katzberg RW, Moss ME. Preva- lence of missing posterior teeth and intraarticular temporomandibular disorders. J Prosthet Dent 2002;87:45-50. 22. Dawson PE. Optimum TMJ condyle position in clinical practice. Int J Periodontics Restorative Dent 1985;5:10-31. 23. McNeill C. The optimum temporomandibular joint condyle position in clinical practice. Int J Periodontics Restorative Dent 1985;5:52-76. 24. McNeill C. Science and practice of occlusion. Chicago: Quintessence; 1997. p. 306-48. 25. Okeson JP. Management of temporomandibular disorders and occlusion. 4th ed. St. Louis: Mosby; 1997. p. 109-26. 26. Hatcher DC, Blom RJ, Baker CG. Temporomandibular joint spatial rela- tionships: osseous and soft tissues. J Prosthet Dent 1986;56:344-53. 27. Heffez L, Jordan S, Going R Jr. Determination of radiographic position of the temporomandibular joint disk. Oral Surg Oral Med Oral Pathol 1988; 65:272-80. 28. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8:457-62. PINTAUDI AMORIM ET AL THE JOURNAL OF PROSTHETIC DENTISTRY MAY 2003 513 29. Budtz-Jorgensen E, Luan W, Holm-Pedersen P, Fejerskov O. Mandibular dysfunction related to dental, occlusal and prosthetic conditions in a selected elderly population. Gerodontics 1985;1:28-33. 30. Abdel-Fattah RA. Incidents of symptomatic temporomandibular (TM) joint disorders in female population with missing permanent rst molar(s). Cranio 1996;14:55-62. 31. Witter DJ, van Elteren P, Kayser AF, van Rossum MJ. The effect of remov- able partial dentures on the oral function in shortened dental arches. J Oral Rehabil 1989;16:27-33. 32. Barghi N, dos Santos J Jr, Narendran S. Effects of posterior teeth replace- ment on temporomandibular joint sounds: a preliminary report. J Prosthet Dent 1992;68:132-6. 33. Salonen MA, Raustia AM, Huggare JA. Changes in head and cervical-spine postures and EMG activities of masticatory muscles following treatment with complete upper and partial lower denture. Cranio 1994;12:222-6. 34. Helkimo M. Studies on function and disfunction of the masticatory system. Swed Dent J 1974; 67:101-19. 35. Mamootil JA. Plane of occlusiona new concept. Aust Dent J 1994;39: 306-9. 36. Celebic A, Valentic-Peruzoviv M, Kraljevic K, Brkic H. A study of the occlusal plane orientation by intra-oral method (retromolar pad). J Oral Rehabil 1995;22:233-6. 37. Graber G. Removable partial dentures. New York: Thieme; 1988. p. 90-113. 38. McCracken WL. A philosophy of partial denture treatment. J Prosthet Dent 1963;13:889-900. 39. Hoffman W Jr, Bomberg TJ, Hatch RA, Benson BW. Complete dentures: a review. Quintessence Int 1985;16:344-55. 40. Rapuano JA, Samant A, Grieder A. Assuring successful impression making in complete dental construction. Clin Prev Dent 1987;9:23-6. 41. Zanetti AL, Ribas R. A new method to simplify and increase the precision of maxillary cast mounting procedures in fully adjustable or semiadjust- able articulators. J Prosthet Dent 1997;77:219-24. 42. Willis FM. Esthetics of full denture construction. J Am Dent Assoc 1930; 17:636-41. 43. Pleasure MA. Correct vertical dimension and freeway space. J Am Dent Assoc 1951;43:160-3. 44. Silverman MM. The speaking method in measuring vertical dimension. J Prosthet Dent 1953;3:193-9. 45. Ricketts RM. The golden divider. J Clin Orthod 1981;15:752-9. 46. Ricketts RM. The biologic signicance of the divine proportions the Fi- bonacci series. Am J Orthod 1982;8:351-70. 47. Smith EH. Registration of centric and protrusive records for construction of complete dentures. J Am Dent Assoc 1956;53:403-10. 48. Tuckeld WD, Worner HK, Guerin BD. Acrylic resins in dentistry: part II. Aust Dent J 1943;47:172. 49. Lauciello FR. Technique for remounting removable partial dentures op- posing maxillary complete dentures. J Prosthet Dent 1981;45:336-40. 50. Littell RC, Pendergast J, Natarajan R. Modelling covariance structure in the analysis of repeated measures data. Stat Med 2000;19:1793-819. 51. Singer JM, Andrade DF. Analysis of longitudinal data. In: Sen PK, Rao CR. Handbook of statistics: bio-environmental and public health statistics, Vol. 18. Amsterdam: Elsevier Science; 2000. p. 115-60. Reprint requests to: DR VANIA C. P. AMORIM RUA IBITIRAMA, 670 SAO PAULO CEP: 03134-001 BRAZIL FAX: 55-11-63471990 E-MAIL: pintaudi.amorim@bol.com.br Copyright 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 0 doi:10.1016/S0022-3913(03)00029-5 Noteworthy Abstracts of the Current Literature An in vitro study to investigate the load at fracture of Procera AllCeramcrowns with various thickness of occlusal veneer porcelain Harrington Z, McDonald A, Knowles J. Int J Prosthodont 2003;16:54-8. Purpose. The aim of this study was to investigate the effect of occlusal veneer porcelain thickness on the load at fracture of Procera AllCeram crowns. Materials and Methods. Fifty resin dies were manufactured to incorporate the features of an all-ceramic crown preparation on a premolar tooth. Fifty corresponding crowns were constructed and divided into ve groups. Groups 1, 2, 3, and 4 were crowns with 0.6-mm-thick Procera cores and 0.4-mm-thick axial veneer porcelain and occlusal veneer porcelain thicknesses of 0.0 mm, 0.4 mm, 0.9 mm, and 1.4 mm, respectively. Group 5 specimens consisted of 0.6-mmthick In-Ceram cores with 0.4 mm of axial porcelain and 0.4 mm of occlusal porcelain. The crowns were cemented onto their respective dies with a resin luting agent. Specimens were stored in distilled water at 37C for 24 hours prior to placing them in a universal testing machine and applying a controlled compressive load at a cross-head speed of 0.1 mm/min until fracture occurred. Results. The mean loads at fracture were 419 N (group 1), 702 N (group 2), 1,142 N (group 3), 1,297 N (group 4), and 732 N (group 5). Statistical analysis revealed signicant differences (P .05) in the load at fracture between the groups, except for between groups 2 and 5. Conclusion. Increasing the thickness of the occlusal veneer porcelain increased the load at fracture for Procera AllCeram crowns. There was no signicant difference in load at fracture between the Procera and In-Ceram crowns.Reprinted with permission of Quintessence Publishing. THE JOURNAL OF PROSTHETIC DENTISTRY PINTAUDI AMORIM ET AL 514 VOLUME 89 NUMBER 5