9

POINT/COUNTERPOINT

Orthodontic dental casts: The case against

routine articulator mounting
Donald J. Rinchusea and Sanjivan Kandasamyb
Greensburg, Pa, and Midland, Western Australia, Australia

here is no doubt that dental casts, whether

plaster or digital, are one of many important
tools routinely used in orthodontics for assessing dentitions or malocclusions. Unfortunately, to
this day, a convincing case has still not been made
for the routine mounting of all casts on articulators.
Drs Martin and Cocconi, however, would like you to
believe otherwise. The issue of articulator mountings
in orthodontics must be considered within the broad
framework of orthodontic gnathology. Under the
premise of pursuing what is best for the patient,
Drs Martin and Cocconi have conveniently left out
the term gnathology in their Point article; however, the principles of gnathology (right or wrong)
form the basis of their argument for using articulators. We have written and expressed the evidencebased view on gnathology and articulator mounting
in orthodontics several times and advise the reader
to review relevant literature for a more thorough understanding on this topic.1-11
Drs Martin and Cocconi make many unsupported
claims in their article. Statements such as the articulator is just another tool . . . an orthodontist can
do good orthodontics without using an articulator,
but an articulator can help him or her to provide better treatment in many clinical situations, and
whether research is always good for clinical practice y in the face of evidence-based practice and
the basic tenets of science. With comments like
these, are they really putting forward an intellectual
and scientic discussion on the use of articulators
in orthodontics?

Professor and graduate orthodontic program director, Seton Hill University,

Greensburg, Pa.
b
Clinical senior lecturer in orthodontics, Dental School, The University of Western Australia, Nedlands, WA, Australia; visiting assistant professor in orthodontics, Center for Advanced Dental Education, St. Louis University, St. Louis, Mo;
private practice, Midland, WA, Australia.
Reprint requests to: Donald J. Rinchuse, Seton Hill University, Center for Orthodontics, 2900 Seminary Drive, Greensburg, PA 15601-1599; e-mail, rinchuse@
setonhill.edu.
Am J Orthod Dentofacial Orthop 2012;141:8-16
0889-5406/$36.00
Copyright 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.11.008

Clearly, several issues need to be discussed: articulators in relation to centric relation and records,
centric slides, occlusion and temporomandibular disorders, and occlusion and periodontal disease.
Articulators can play a role in prosthodontics,
restorative dentistry, and orthognathic surgery to maintain a certain vertical dimension for laboratory purposes.
For some orthodontists, mounted dental casts help elucidate various 3-dimensional and static jaw and occlusal
relationships and deviations. Nonetheless, using articulators as a routine diagnostic aid in orthodontics appears to
be a perfunctory exercise. The premise for the use of articulators dates back to well over a half century ago,
when occlusion and condyle position were believed to
be the primary cause of temporomandibular disorders.11
However, the modern view is that specic occlusion, condylar position, and jaw alignment factors are no longer
considered the primary causes of temporomandibular
disorders.6,12-18 The diagnosis and treatment for
temporomandibular disorders has changed from a dental-based model to a biopsychosocial model that integrates biologic, behavioral, and social factors to the
onset, maintenance, and mitigation of temporomandibular disorders.12,19-30 A medical orthopedic approach
that focuses on the biomedical sciences and musculoskeletal treatments similar to those for chronic pain are
the current approaches for temporomandibular disorders. Biopsychosocial treatment approaches such as
cognitive-behavioral therapies and biofeedback are contemporary treatment modalities for temporomandibular
disorders. The exciting future research topics for temporomandibular disorders are genetics (vulnerabilities
related to pain), central-brain processing, imaging of
the pain-involved brain, endocrinology, behavioral
risk-conferring factors, sexual dimorphism, and psychosocial traits and states.12-15,19-30 Conservative and
reversible forms of temporomandibular disorder treatments are preferred (at least initially) over aggressive
and irreversible forms. In the evidence-based view, orthodontics is considered temporomandibular disorders
neutral ie, orthodontics does not cause and will not
necessarily correct or improve a patients temporomandibular disorder condition now or in the future.31-34
Because orthodontics has not been demonstrated to

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11

cause temporomandibular disorders, this further supjoint condyles in the glenoid fossa has not been found
ports the notion that occlusion and condyle position
to predict temporomandibular disorders.5 Johnston36
wrote: I know of no convincing evidence that condyles
do not cause temporomandibular disorders: ie, the
of patients with intact dentitions should be placed in
premise that orthodontics could cause temporomanCR or that once placed or that once having been placed
dibular disorders is grounded in the dental-based
there, the resulting improvement on nature will be stamodel.
ble. Interestingly, centric slides greater than 4 mm that
Of note, the evidence-based view does not argue
have been found to be associated with temporomanthat occlusion and condyle position have no relationdibular joint arthropathies are most likely the result
ship to temporomandibular disorders and that orthoof the temporomandibular disorders rather than the
dontists should ignore them. The gross evaluation of
cause, contrary to the beliefs of Drs Martin and Cocthe patients occlusion still are useful: assessment of
coni.32
occlusion is necessary as part of the initial oral examiMany of the problems we have with articulators as
nation to identify and eliminate gross occlusal discrepdiagnostic aids in orthodontics start before the articuancies.35 The amelioration of gross occlusal
interferences that cause tooth mobility, fremitus, and
lator is actually used (Fig 1). Centric relation records
deviation or deection on mandibular closure and
can be demonstrated to be reliable, but there is no evmovement are within the scope of the evidence-based
idence to support their validity.5 Nonetheless, proper
attention to an orthodontic patients centric records
paradigm.
is an important consideration in orthodontics and all
Because there has been a paradigm shift regarding
of dentistry. We do know that
the etiology, diagnosis, and
doctor-generated patient centreatment of temporomandibular disorders away from The premise for the use of articula- tric records are more reliable
occlusion and condyle positors dates back to well over a half than patient-generated retion, occlusionists and gnacentury ago, when occlusion and cords, but they are5 also less
valid (physiologic). In addithologists should reconsider
condyle position were believed to tion, the same bite registraand abandon age-old views
be the primary cause of temporo- tions used to make dental
and techniques that are not
casts should be consistently
supported by science and evmandibular disorders.
used throughout all the paidence.
Certainly,
the
tient recordsdental models,
evidence-based view on the
photographs, cephalometric radiographs, and so on.
role of occlusion in relation to temporomandibular disAnd, to merely ask orthodontic patients to bite on their
orders should have had a negative impact on the rouback teeth will not always provide an accurate centric
tine use of articulators in orthodontics.4,12
Greene16,17 wrote: I would encourage orthodontists
bite registration, and one might miss diagnosing
to be somewhat exible in applying the standards of
a Sunday bite.
ideal jaw relationships as well as ideal occlusion relaGnathologic centric records are static and not functionships to their nishing of patients . . . we should
tional (Fig 1). Patients are not asked to exercise any relnot have conversations about tenths of millimeters
evant physiologic mandibular movements to generate
when discussing where the condyle should be. . . .
centric relation records. Chewing kinematics are not
The failure to produce some experts version of a soevaluated, such as chewing pattern dynamics, which
called good/ideal occlusion or CR position is not
might determine whether a patient is more or less a vera risk for developing TMD. Does it make sense to focus
tical or horizontal chewer.4,37 Furthermore, the harshest occlusal forces are those generated via
and study occlusion and condyle position the same way
parafunctional mandibular movements, such as bruxthat we did more than 50 years ago?
ing and clenching. These movements and forces are
The belief that centric occlusion or (or maximum innot evaluated by centric relation records and articulator
tercuspation or intercuspal position) should be coincimountings.4
dent with an arbitrary centric relation position is not
Based on information from the study of Alexander
evidence-based. The preponderance of evidence suget al,38 clinicians, in general, cannot predict where congests that for the population at large there is a range
dyles are positioned and recorded based on their particof acceptable positions and not 1 centric relation posiular type of centric bite registration. This makes it
tion that is optimal for every patient.5 That is, a particular 3-dimensional position of the temporomandibular
imperative that orthodontic gnathologists provide

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13

Fig 1. Limitations of centric relation, condyle position records, and measurements.

Fig 2. Limitations of articulators.

magnetic resonance imaging research data of the temporomandibular joints that substantiate that the subjects condyles are actually placed and recorded in
positions determined by such registrations. In addition,
the difference between gnathologic and nongnathologic diagnostics is on average as little as 1 mm or
less, and this is mostly in the vertical dimension.39
Are such minor differences really a health concern?
Also, in growing children, the temporomandibular joint
condyle-glenoid fossa complex changes location with
growth; the fossae on average are displaced posteriorly
and inferiorly.40 One would therefore need to perform
new mountings regularly throughout treatment to diagnose and maintain their so-called ideal centric relation position. This however does not occur.
The shortcomings of articulators in orthodontics
were discussed in detail in our article and are listed in
Figure 2.4 Diseases of the temporomandibular joint

such as disc displacement and osteoarthrosis are best diagnosed with magnetic resonance imaging of the temporomandibular joints and a clinical examination, and
not with articulators. The major premise for the use of
articulators is based on the incorrect concept of a terminal hinge axis of Posselt41 dating back more than
a half century. Posselt conjectured that, in the initial
20 mm or so of opening and closing, the mandible (condyles) only rotates similar to a door hinge (and does not
simultaneously translate). However, Posselts theory
was made in the era when centric relation was considered a retruded, posterior position of the condyles in
the glenoid fossa. During this time period, retruded centric relation was recorded with distal guided pressure
applied to the chin, a probable reason for Posselts nding of a terminal hinge axis. In 1995, Lindauer et al42
demonstrated that, during opening and closing, the
condyles not only rotate, but also simultaneously

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Counterpoint

translate (move downward and forward). They demonstrated that the terminal hinge axis does not exist, and
their ndings support an instantaneous center of rotation that varies in every patient and cannot be simulated via an articulator (Fig 2).4
Drs Martin and Cocconi failed to point out that an
association between occlusal discrepancies and the
progression of periodontal disease is controversial.
In this respect, they referenced an article by Harrel
et al43 entitled Is there an association between occlusion and periodontal destruction? Yesocclusal forces
can contribute to periodontal destruction. Unfortunately, this was only 1 side of a debate published in
the Journal of the American Dental Association in
October 2006; they neglected to mention the accompanying counterpoint article in which Deas and
Mealey44 discussed several clinical studies with results
contradicting those of Harrel and Nunn,45 Nunn,46
Nunn and Harrel.47 As Deas and Mealey44 pointed
out, the determining factor of whether an occlusal
contact produces occlusal trauma is the presence of
periodontal injury, not the physical manifestation of
the teeth, temporomandibular joints or muscles of
mastication. Even Harrel et al43 acknowledged the
limitations of their research: Our study should be
viewed in the context of its design. It does not meet
the level of what is considered the gold standard of
clinical research. . . . Our study was retrospective in nature, a single practitioner performed all evaluations and
data gathering. Furthermore, the patients oral hygiene
and maintenance compliance was not standardized. All
these are signicant concerns regarding our research
design. Interestingly, according to the research by
Nunn44 and Deas and Mealey,43 the recording of subjects occlusal discrepancies was not determined by the
use articulated mounted dental casts in this research.
So we ask Drs Martin and Cocconi, if they think it so
important to use articulators to deduce occlusal discrepancies, why did they cite and focus on research
that did not use articulators as the clinical tool of
choice for recording such discrepancies?
CONCLUSIONS

If we know that specic condylar positions, slides,

and the minute details of occlusion are not predictive
of temporomandibular disorders, that articulators do
not simulate condylar movements accurately, and that
centric relation records do not really place condyles in
their deemed positions, then what are we actually trying
to achieve by routinely mounting dental casts on articulators? Such a mechanistic and instrument-oriented
approach to patient diagnosis and treatment planning

15

is only a disservice to patients. The burden of proof is

and should always lie on those who are advocating
a controversial tool or procedure. So we ask the readers,
did Drs Martin and Cocconi present a convincing argument for the routine use of articulators in orthodontics
based on scientic and evidence-based considerations
rather than on anecdotes and blind rhetoric? The convincing evidence is against the routine mounting of
casts on articulators. What would William Shakespeare
say, as Hamlets famous quote is placed in the context
of this debate on articulators? Perhaps it is whether
one chooses to believe or not to believe.
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