Seminars in Orthodontics

VOL 9, NO 2

JUNE 2003

Introduction
he study of gnathology concerns itself with
the h a r m o n i o u s functioning of the jaws
and teeth; stated this way, who would feel comfortable arguing that "gnatholoD," has no place
in orthodontics? Since the formation of the Gnathological Society in 1926 by McColhun, the
study of jaw m o v e m e n t as it is related to occlusion was a central focus in reconstructive dentistry. It was not, however, until the 1970s that Dr
Ronald Roth' proposed the introduction of gnathological principles, modified for considerations of natural teeth, into orthodontic diagnosis and treatment philosophy. This formally
attempted to m a n y jaw function and tooth fit
within a mutually protected functional scheme.
Before that time, orthodontic goals were mostly
aimed at attempting to achieve an acceptable
static occlusion such as later described by Andrews ~ in his 1972 article, "Six Keys to Normal
Occlusion," or more recently in "The American
Board of Orthodontics (ABO) Objective Grading System for Dental Casts and Panaoramic
Radiographs" presented in 2000) A h h o u g h the
ABO required in its case workups tor hoard
certification an assessment of the fnnctional occlusion, its characteristics and measurement
were tbr the most part not formally considered
in traditional orthodontic treatment.
Since the mid-1980s, a paradigm shift has
occurred from the traditional prima W etiologic
cause and effect occlusion views to the new current view stated as follows: "We have to come to
understand the e n o r m o u s range of structural
variability a m o n g h u m a n masticatol y systems,
that what individuals do with their occlusions
may be more important than structural relationships, and that this system, like all musculoskeletal systems, often adapts to changing structural
and functional demands. We are not implying
that therapy, once initiated, should not adhere

Cop),Hgq~t 2003, Elsevier Scie*u'e (U&I). All @dlts te~e~wed.

doi: 10.1053/~odo. 2003. 34029

to strict technical standards. However, arriving

at a decision of when to treat, and toward what
end, deserves a less rigid ontlook at the present
time."~
Under these new philosophical considerations, interest ii1 and concern about gnathological concepts are considered either unwarranted or unnecessa U. It should be noted,
however, that even these individuals fnlly recognize and appreciate the tact that if fnll-mouth
rehabilitation is required, either prosthetically
or orthodontically, that traditional gnathological concepts lend themselves to clinically relevant reconstructive techniques that have been
empMcally shown to provide acceptable patient
outcolnes.

Central to any flfll-mouth rehabilitation technique, e.itlmr orthodontic or prosthetic, is the

concept of a centric relation that is reproducible, stable, and can be obtained i n d e p e n d e n t of
the occlusion. It is determined by manipulation
of the mandible and is a purely rotary movement
about tile transverse horiz(mtal axis) Its use as a
therapeutic condylar reference position for restoring the occlusion is empirically valid and
central to diagnosis, treatment planning, aud
case completion. '~
In orthodontics, a specialty essentially dealing
with full-mouth reconstruction in enamel, centric relation (CR) considerations should also be
a central theme for evmT orthodontist. The
power centric bite advocated by Roth allows tile
condyles to be positioned superior and anterior
in the fossa and seated against the posterior
slope of the eminence with tile thin avascular
portion of the disc interposed and centered.
According to Roth, ~ this CR position must be
coincident with maximum intercuspation (MI)
of the teeth to achieve an ideal flmctional postorthodontic occlusion.
Tile purpose of the articles in this issue of
Semi~a,:~ in Orthodontics is two-fold: illst, to explore the accuracy and reproducibility of various
aspects of the gnathological technique, which

Seminars in Orthodontics, Vol 9, No 2 (]u~e), 2003: pp 9;'-95

93

94

Kulbersh, Kaczynski, and Freeland

uses instrumentation to diagnose, treat, and establish a mutually protected functional scheme;
and, second, to tiT and assess whether, in fact,
any difference really exists between orthodontic
t r e a t m e n t r e n d e r e d with the utilization of gnathological instrumentation using m o u n t e d models or a less rigid a p p r o a c h guided solely by
o p e r a t o r experience and chairside visualization
of the occluso-functional e n d result.
In the first two articles, the authors evaluate
the following aspects of gnathological instrum e n t a t i o n used in the Roth orthodontic technique: the Condylar Position Indicator (CPI, Pan a d e n t Corp, G r a n d Terrace, CA) and the Roth
power centric 2-piece Delar blue wax registration bite (Delar Co, Lake Oswego, OR). In the
next three articles, the authors assess one central
aspect of the gnathological approach: MI-CR coincidence. In other words, they address whether
or not finished orthodontic cases exhibit greater
MI-CR h a r m o n y if treated with the gnathological
instrumentation a p p r o a c h using m o u n t e d models, rather than the less rigid, operator-visualized
n o n i n s t r u m e n t a t i o n technique. T h e third article by Klar et al explores the MI-CR change f r o m
pre- to post-treatment in 200 consecutively
treated gnathological cases. Is there a difference? In the next article by Kulbersh et al,
MI-CR postorthodontic t r e a t m e n t differences
between a gnathological sample versus a nongnathological control are assessed. Is there a
difference between these t r e a t m e n t modalities?
Pangrazio-Kulbersh et al address the issue of
MI-CR p o s t t r e a t m e n t differences in two-phase
functional treatment, involving a first-stage functional appliance r e g i m e n followed by a second
stage of f u l l - b a n d e d / b o n d e d orthodontic appliances versus one-phase gnathologic-oriented treatrnent. Do functional appliances used for a phase I
treatment affect the MI-CR outcome? Finally, Freeland and Kulbersh present two cases in which the
patient's dysfunctional occlusion is clearly indicated by articulator mountings and further evaluated t h r o u g h the use of hinge axis and condylar position indicator (CPI) recordings. Could
one have r e a c h e d the same t r e a t m e n t diagnosis
and orthodontic end result without this gnathologically oriented instrumentation approach? In
all instances, the CPI was used to measure condylar position change in five dimensions (right x
and y, left x and y, and transverse) as affected by
interferences at the occlusal level. This informa-

tion was then used with a p p r o p r i a t e analyses to

establish a t r e a t m e n t plan as well as to assess the
MI-CR o u t c o m e postorthodontic therapy.
Although, the general trend in current dental
t r e a t m e n t philosophy considers the issue of
MI-CR disharmony and its relationship to temp o r o m a n d i b u l a r j o i n t dysfunction (TMD) problems as unclear, 7 the following quote should be
considered: "The most conspicuous lapse of
logic is perhaps the statement that the majority
of studies show no association between occlusal
factors and TMD; therefore, they are not causally linked. T h e reiteration of such an obvious
error in reasoning in articles on TMDs only
serves to misdirect research efforts. Absence of
evidence is not evidence of absence. TM
It should be noted, first, that based on the
work presented here, MI-CR h a r m o n y can be
improved by orthodontic therapy using a gnathological a p p r o a c h tbr diagnosis and t r e a t m e n t
planning. And, second, that in all the articles
presented here assessing pre-treatment and postt r e a t m e n t records of gnathological versus nongnathological therapy, a single statistically significant difference was consistently n o t e d in all
situations--the vertical. In fact, were it not tbr
the case selection exclusionary parameters (ie,
very careful o p e r a t o r clinical assessment of
MI-CR h a r m o n y p o s t d e b a n d for the u o n g n a t h o logical g r o u p and m o u n t e d models showing
only 1-2 m m vertical discrepancy at the pin before gnathological positioner) statistically significant differences may well have been noted in
m o r e than .just the vertical dimension. It would
a p p e a r that the vertical dimension cannot be
appropriately diagnosed unless m o u n t e d models are used. T h e consistency of this vertical
discrepancy difference is worth noting. Its implications with regard to patient's stomatognathic
functional health are not clearly research docum e n t e d but warrant further investigation. Certainly, vertical condylar distractions in the o r d e r
of 2 to 3 m m may not only require t r e a t m e n t
plan modifications but also potentially affect patient occlusofunctional health. ~
In summary, although the dental scientific
literature has its naysayers regarding the relationship between occlusal dysfunction and
TMD, this issue is far from resolved. In fact,
articles based on good sample size and sound
research design continue to appear, implicating
various aspects of occlusal dysfunction as sus-

Introduction

raining or contributing factors in the developm e n t o f TMD problems." It appears prudent

as dentists, therefore, to h o n o r the c o n c e p t of
h a r m o n i o u s stomatognathic system function. Irrespective o f definitive, research-documented,
health-related issues, a gnathological approach
as advocated by Dr Roth serves another vmT
valuable purpose: it sets goals that are necessaD~
and clinically useful when orthodontically reconstructing a functional bite.
R i c h a r d K u l b e r s h , D M D , MS
Richard Kaczynski, PHD

Theodore F r e e l a n d , DDS, MS
Guest Editor~

References
1. Roth RH. Gnathologie concepts and orthodontic treatment goals. In: Jarabak JR (cd). Technique and Treatment with light wire cdgewise appliances (vol 2). St Louis,
MO: CV Mosby Co, 1972;1160-1224.

95

2. Andrews LF. The six keys to normal occlusion. Am .]

Orthod 1972;69:296-309.
3. Casko JS, Vaden JI., Kokich VG, et al. The American
Board of Orthodontics Objective Grading System for
Dental Casts and Panoramic Radiographs. Am J Orthod
Dentolhc Orthop 2000; 114:589-599.
4. Mohl ND, Zarb (;A, Carlsson GE, et al (eds.) A Tex~bo~k
of Occlusion. Chicago, IL, Quintessence, 1988;13-14.
5. Posselt U. Terminal hinge movelnent of the mandible. ,]
Prosflmt Dent 1957;7:787-789.
6. Roth RH. (,nathologic Considerations lot Orlhodontic
Therapy. In: Mcneil C (ed). Science and Praclice o[ Occlusion. Chicago, IL, Quintessence, 1997;502-512.
7. Laskin D, Grcenfiehl W, Gale E, el al. The President's
Conlbrence on the Examination, Diagnosis and Managemenl of Temporomanditmlar Disorders. Chicago, I k
Ouintessence, 1982:183.
8. Kirveskari P. Emperor's new clothes on occlusion and
TMD. Cranio1999;17:3,151
9. Thilander B, Rubio G, Pena 1, de Mayorga C. Prexalence
of temporomandibular dystimction and its association
with malocclusion in children and adolescents: An epidemiologic study related to specified stages of dental dcvelopl'llenl. Anglc Orlhod 2002;72:146-154.