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have adjunctive orthognathic surgery. The authors lamented that they had not performed a pretreatment
mounting, which might have aided in the diagnosis of
the hidden dental/skeletal problem.
Logically, one would think that the change in
definition and the movement of CR from a posteriorsuperior to an anterior-superior position would have
eliminated or reduced the magnitude of centric slides
and possibly the importance of mounting.29 To a
degree, this has proven to be true. Furthermore, only
minor differences for MI-CR discrepancies have been
found between gnathologically treated and nongnathologically treated orthodontic cases as determined via
articulator mountings and only for the vertical (not
horizontal or transverse) dimension. The MI-CR difference is only about 1 mm (discussed further in next
paragraph).38 Nonetheless, gnathologists argue that
consideration and measurements of minor MI-CR
slides (discrepancies) are still valid and can be diagnosed only by articulator mountings.1-21,40
Using a Roth power centric bite registration and
articulator-mounted models, Utt et al13 found centric
occlusion (CO) condyles (via student articulating module articulator with mandibular position indicator) located on average 0.53 mm posterior and 0.72 mm
inferior to the anterior-superior CR. There was, however, much individual variation, with 39% of the CO
condyles positioned anteroinferiorly from anterior-superior CR.13 Recent studies comparing gnathological
(Panadent articulator with condylar-position indicator and
Roth principles) with nongnathologic finished orthodontic cases have generally found articulator-recorded
MI-CR differences of 1 mm greater in the vertical plane
in nongnathologically treated patients (1.41 mm for the
nongnathologically treated v 0.41 mm for the gnathologically treated; difference of 1 mm).18 Based on the
results of Utt et al13 and Crawford,11 orthodontic
gnathologists claim that anterior-superior CR slides
average 0.6 to 0.7 mm horizontally, 0.7 to 0.8 mm
vertically, and 0.27 to 0.3 mm transversely.40 Klar et
al41 found a small but statistically significant (perhaps
not clinically significant) change in the before and after
MI-CR recordings of 200 consecutively treated orthodontic patients for whom gnathologic principles were used:
horizontally, 0.81 to 0.53 mm (difference of 0.28 mm);
vertically, 0.99 to 0.60 mm (difference of 0.39 mm);
transversely, 0.44 to 0.25 mm (difference of 0.20 mm).
A subissue of the mounting debate involves
whether some or all orthodontic cases need to be
mounted. Some gnathologists believe that only certain
ones need mounting: patients requiring orthognathic
surgery, TMD patients, most adult patients, those with
many missing permanent teeth, those with functional
The use of the POLY involves taking a submentovertex radiograph, measuring the angle and distance of
each condyle, and programming this information into a
fully adjustable polycentric hinge joint articulator.
Nuelle46 proposed that, if 1 condyle imaged from
submentovertex is cocked and at a higher angle than the
opposite condyle, the condyle with the higher angle
will move faster than the opposite condyle with a lower
intercondylar angle. Nuelle and Alpern47 asserted that
this type of condyle variation and others can be
incorporated into the POLY.
UNDERSTANDING THE ISSUES RELATED TO
MOUNTING
The validity of mounted dental casts very much depends on the reliability and validity of the patients bite
registrations.30,31 Therefore, although the Roth bite
registration might be reliable, is it valid? Does the
technique actually capture condyles in anterior-superior CR? Does this have any relationship to human jaw
function and stomatognathic health?
Interestingly, recent MRI data have indicated that
condyles are not located where clinicians think they
will be as a result of certain bite registrations.30
Therefore, the validity of the Roth centric bite registration has been questioned.25,29,30 A study by Alexander
et al30 compared and evaluated the MRI condyle
positions of 28 TMD-asymptomatic men in regard to 3
different occlusal and jaw bite registrations. The CO
(maximum intercuspation) bite-generated condyles
were considered the ideal condyle position because
they naturally existed in the 28 TMD-asymptomatic
subjects. The CO condyles were compared with bite
registered retruded condyles (RE) and anterior-superior
(CR) condyles. Interestingly, the CO-generated condyles were shown to be distinct and positioned inferior
and anterior to the retruded (RE) and CR condyles.
Furthermore, the CO-generated condyles were not coincident with CR (anterior-superior) condyles. And it
was not possible to discriminate between the positions
in retruded (RE) and CR condyles. Alexander et al30
concluded that the clinical concept of treating to CR as
a preventive measure to improve disk-to-condyle relationships was unsupported.
Furthermore, Roth propagated the notion that the
power centric bite registration is physiologic and unmanipulated based on his claim that it is muscle
dictated.1,9,13,17 However, the converse is probably
true; the power centric record is operator manipulated
and unphysiologic.25 Parenthetically, manipulated centric records (doctor manipulates subjects mandible)
have been demonstrated to be more reliable than
unmanipulated centric records, but they are less physiologic.25 Nuelle and Alpern47 reflected on the absurdity of gnathologic bite registrations:
Gnathologists . . . believe that the dentist can be
properly trained to manipulate, romance, dual wax
bite take, or other techniques which supposedly
permit the dentist or orthodontist to take control of all
the neuromuscular inputs to the patient and position
the mandible with the condyles positioned up and
forward against the eminence. . . . [N]o dentist or
orthodontist is knowledgeable enough to know the
proper three-dimensional position for two asymmetrically angulated condyles, irregularly and individually
suspended in a polycentric hinged joint . . . Doctor se-
An additional point somewhat related to bite registration is that the occlusal records used in mounting are
static and not dynamic. Patients or subjects are not
asked to chew food, swallow, or exercise any parafunction movement. Perhaps the way a patient or subject
uses his or her occlusion is far more important than the
occlusal morphology. Furthermore, the chewing-pattern shape varies from subject to subject. Some people
possess a more vertical chewing pattern, and others
have a more horizontal pattern; this appears to be
independent of the occlusal scheme.25 A more erudite
explanation is that the chewing-pattern shape is sexspecific, and there are more than half a dozen different
chewing patterns directly related to craniofacial morphology.60 How then does the orthodontic gnathologist
justify articulator mountings that come from static and
not dynamic occlusal registrations? Even if the patient
was asked to perform any of these movements, how is
this incorporated into the articulator mounting?
Next, in the gnathologic approach, bite registrations
and mounted casts are taken just short of tooth contact.
Cordray9 addresses the reasoning for this:
The mandibular cast must be mounted at a point on
the seated condylar axis before first tooth contact
occurs, using an interocclusal record to relate it to the
maxillary cast. This is necessary to prevent a centric
prematurity from deflecting the mandible upon closure, which in turn allows for diagnosis of the
problems.
Although the rationale for taking the bite registration and mounting short of occlusal contact is clear, is
it valid? The fact remains that the articulator (vertical
stop pin) must eventually be released so that the teeth
(or perhaps a single tooth) finally drop into contact
(occlusion). Does gravity ultimately determine the final
seating of the casts after all the trouble and effort of
mounting?
Curiously, the mounting advocates believe that the
mounting process and instrumentation are accurate
(valid) without verification. Cordray9 wrote, When
these records are properly transferred to an articulator,
the relationships between the teeth and jaws can be
studied accurately. However, the validity of the articulator and the methods used in mounting are dubious.
Alpern and Alpern44 stated, Nearly all existing single
centric hinge joint articulators produce only two paths
of straight-line movement, whereas the patient has an
infinite number of unique multiple paths of movement
as teeth function.
Finally, the anatomy of the articulator does not
and fraction of millimeter differences between subjects in the studies might not be clinically significant.
The use of average condylar readings and no report
of the exact error involved in the bite registrations
and mounting procedures are problematic.
The studies did not validate the power centric bite
registration and demonstrated that this registration
actually seats human condyles in the predicted fossa
position of anterior-superior CR.
The study by Crawford11 was perplexing. Its purpose was to determine whether there is a relationship
between occlusion-dictated Panadent articulator condylar position axis and signs and symptoms of TMD. That
is, do subjects having mutually protected occlusions
with MI and CR relatively coincident have fewer signs
and symptoms of TMD than subjects without these
types of occlusion and condyle position?73 The findings
purport that a relationship exists between occlusiondictated condylar position and TMD symptomatology.
However, the study has many limitations, the most
apparent of which is the sample. Thirty subjects with a
gnathologic, ideal occlusions, in which CR was coincident with CO (intercuspal position, MI), were compared with 30 subjects randomly selected from the
general population. Curiously, the so-called ideal sample was selected from a population that had undergone
full-mouth reconstruction with gnathologic principles.
The author11 claims that he used a selected sample
because the incidence of adult occlusion with CR coincident with CO (ICP; MI) is very low in the general
population, making the acquisition of an adequate
sample of ideal occlusions by random selection impractical. Crawford11 wrote:
This was a sample of convenience, and it was highly
selected. The contributing clinicians chose subjects
according to their own concept of ideal, and the
number selected was determined by the availability
and willingness of the subjects to participate.
DEPROGRAMMING SPLINTS
The articulator can never simulate human mandibular movement and is based on the faulty theory of the
terminal hinge-axis.
There is no evidence that orthodontic treatment
results (outcomes) are better when articulators are
used in terms of improved patient TMD status and
stomatognathic health.
No scientific evidence suggests that the use of
articulators will influence orthodontic diagnoses in
any meaningful way.
Although the polycentric hinge articulator is possibly
better than the hinge axis arcon articulator, it is by no
means ideal.
CR records have only been demonstrated to be
reliable under controlled laboratory conditions.
The errors involved in taking the bite registrations
and the mounting procedures reduce the significance
of the gnathologic findings.
Bite registrations used in the mounting process are
static records and do not encompass any meaningful
movement of the human mandible.
The internal validity of the Roth power centric bite
registration has not been established. Roth did not
demonstrate where patients condyles are positioned
as a result of the power centric bite registration; he
assumed they are in an anterior-superior seated
position, but he gave no documentation.
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