RWISO Journal

Roth Williams International

Society of Orthodontists
Welcome to the
RWISO

Vol. 1, No. 1 May 2009

16th Annual Conference! Journal Volume 1, No. 1 May 2009
Boston, MA
May 7-9, 2009
With thanks to our Sponsors:
Platinum Sponsor

Dentsply GAC

Exhibitors
3dMD

Advanced Dental Designs Domingo Martín, MD, DDS ■ Elisabeth Aguirrebengoa, MD, DDS, PhD
■ Ana Armendáriz, MD, DDS ■ Santiago Guisasola, DDS ■ Iñigo Zárate
Orthodontics and Bioesthetics: A Perfect Symbiosis
Springstone Patient Financing
Ryan Tamburrino, DMD ■ Antonino Secchi, DMD, MS
■ Solomon Katz, PhD ■ Andres Pinto, DMD, MPH

Opal Orthodontics Assessment of the Three-Dimensional Condylar and Dental Positional

Relationships in CR-to-MIC Shifts

Roth Williams International Society of Orthodontists

Straty Righellis, DDS, Associate Clinical Professor, UCSF
Ortho Arch Company Canine Substitution for the Missing Upper Lateral Incisor—Strategies to
Obtain Optimal Dento-Gingival Esthetics and Functional Occlusion

Jina Lee Linton DDS, MA, PhD, ABO ■ Woneuk Jung, DDS
Reliance Orthodontic Products, Inc. The Effect of Tooth Wear on a Postorthodontic Pain Patient

Byungtaek Choi, DDS, MS, Phd

The Ortho Club Hinge Axis — The Need for Accuracy in Precision Mounting

topsOrtho
This year, Boston,
next year. . . Rome!
Stay tuned for details.

RWISO
2010
17th Annual Conference
Rome, Italy
Contents

Volume 1, No. 1, May 2009

Letter from RWISO President, Darrell L. Havener, Jr., DDS 3

Letter from Editor-In-Chief, Thomas Chubb, DDS 4

News from the Roth Williams Teaching Centers 5

The Roth Williams Legacy Fund (RWLF) — Q & A for

Prospective Donors 8

Domingo Martín, MD, DDS ■ Elisabeth Aguirrebengoa, MD, DDS, PhD 11

■ Ana Armendáriz, MD, DDS ■ Santiago Guisasola, DDS
■ Iñigo Zárate
Orthodontics and Bioesthetics: A Perfect Symbiosis

Ryan Tamburrino, DMD ■ Antonino Secchi, DMD, MS 33

■ Solomon Katz, PhD ■ Andres Pinto, DMD, MPH
Assessment of the Three-Dimensional Condylar and Dental Positional
Relationships in CR-to-MIC Shifts

Straty Righellis, DDS, Assoc. Clinical Prof., UCSF 43

Canine Substitution for the Missing Upper Lateral Incisor—Strategies
to Obtain Optimal Dento-Gingival Esthetics and Functional Occlusion

Jina Lee Linton DDS, MA, PhD, ABO ■ Woneuk Jung, DDS 47
The Effect of Tooth Wear on a Postorthodontic Pain Patient

Byungtaek Choi, DDS, MS, Phd 53

Hinge Axis — The Need for Accuracy in Precision Mounting

RWISO Journal | May 2009 1


RWISO JOURNAL
MAY 2009 VOL. 1, NO. 1
EDITOR IN CHIEF
Dr. Thomas K. Chubb
EXECUTIVE DIRECTOR/ADVERTISING SALES
Jeff Milde
MANAGING EDITOR
Anne Evers
CREATIVE DIRECTORS
Brad Reynolds, Stanley de Passos
BOARD OF DIRECTORS
President
Dr. Darrell Havener
1420 West Canal Court,
Suite 200
Littleton, CO 80120 USA
303-791-2021
dhavener@gmail.com
President Elect
Dr. Sam King
6460 Far Hills Avenue
Centerville, OH 45459 USA
937-433-9530
samuel_king@hotmail.com
Vice President
Dr. Douglas Knight DMD
3210 Westport Green Place
Louisville, KY 40241 USA
502-327-6453
knightortho@insightbb.com
Secretary
Dr. Renato Cocconi
Via Traversante, San Leonardo 1
43100 Parma, Italy
+0521-273682
orthosmile@studiococconi.it
Treasurer
Dr. John F. Lawson, MS
2460 Nwy 63 North
Rochester, MN 55906 USA
507-282-6447
jlawdds@aol.com
2
Immediate Past President
Dr. Masako Komatsu
56-3 Honmachi Narumi Midori
Nagoya, Aichi 458-0801 Japan
+81-52-626-0066
smallpinetree@kxa.biglobe.ne.jp
Executive Director
Jeff Milde
1712 Devonshire Road
Sacramento, CA 95864 USA
916-270-2013
j.milde@mra-sf.com
COUNCIL MEMBERS
Region I - Asia
Dr. Satoshi Adachi
#202, 5-11-8 Minoh
Minoh, Osaka 562-0001 Japan
+81-72-724-2866
teeth@adachi-ortho.com
Dr. Byungtaek Choi, Ph.D
406-1 Acrotower, Dowha 1-dong,
Mapo-gu, Seoul, Korea
+82-2-784-2809/+82-2-785-0589
+82-2-785-6666
joydog@unitel.co.kr
Dr. Soon-Jung Park
Lime Dental Clinic
501 Family Charment Bldg.
150-26 Moon-Jung Dong
Song-Pa Gu, Seoul,138-200
Republic Of Korea
+82-2-402-3528
sjp610@hanmail.net
RWISO Journal is published by the Roth Williams International Society
of Orthodontists.
Copyright © 2009 RWISO. All Rights Reserved.
Reproduction whole or in part in any form or medium without express
written permission of RWISO is prohibited. Information furnished in
this journal is believed to be accurate and reliable; however, no respon-
sibility is assumed for inaccuracies or for the information’s use.
Postmaster:
Send address changes to
RWISO
1712 Devonshire Road
Sacramento, CA 95864
RWISO Journal
Roth Williams International Society of Orthodontists
1712 Devonshire Road
Sacramento, CA 95864 USA
Phone: 916-270-2013
Fax: 866-746-3815
info@rwiso.org
Periodicals postage paid at Lawrence, KS and at additional mailing offices.
We welcome your responses to this publication. Please send comments,
subscriptions, advertising and submission requests to: info@rwiso.org
The Roth Williams International Society of Orthodontics is the embodi-
ment of a philosophical and technological transformation: addition of
physiologic to anatomics from a foundation of function and esthetics.
Dr. Jina Lee Linton Region IV - South America
#1704 Kyobo Life Building Dra. Solange M. deFantini, MSD
Chongro-ku, Seoul, Al Janu 176 cj 42
Republic Of Korea Sao Paulo, SP 01420-002 Brazil
+011-82-2-735-2851 +55-11-3081-8440
jinalinton@hotmail.com smfantin@usp.br
Dr. Michael Yitschaky Dra. Marisa Gianesella Bertolaccini
Herzel 98/c Avenida Sabia, 26 Moemo
Jerusalem, Israel 96347 Sao Paulo 04515-000 Brazil
+972-54-6611114 +55-11-5052-5417
yits@cc.huji.ac.il magiaber@gmail.com
Region II - Europe
Dr. Claudia Aichinger
Billrothstr. 58
Vienna, A-1190 Austria
+43-1-367-7222
smile@draichinger.at
Dr. Renato Cocconi
Via Traversante, San Leonardo 1
43100 Parma, Italy
+0521-273682
orthosmile@studiococconi.it
Region III - USA, Canada
Dr. Domingo Martin
Plaza Bilbao 2-2A
San Sebastian, 20005 Spain
+34-943-427-814
martingoenaga@arrakis.es
Dr. Ramon Marti, MSC
281 Oxford Street E.
London, Ontario N6A 1V3
Canada
519-672-7740
rmarti3@hotmail.com
Letter from the President
Darrell L. Havener, Jr., DDS
RWISO President
On behalf of the Board of Directors of the Roth Williams International
Society of Orthodontists, I am pleased to offer congratulations to our Editor,
Dr. Tom Chubb and his team, for their successful introduction of this new
RWISO Journal. They have broken ground on the foundation for a Journal
that is long overdue.
Dr. Ronald H. Roth devoted his clinical practice, his teaching career and his
writing to the promotion of a comprehensive approach towards orthodontics
and functional occlusal health. He and Dr. Robert E. Williams always began
their courses with a statement of the goals we must consider as we embark on
our processes of diagnosis, treatment planning and clinical execution. Unfor-
tunately the goals Drs. Roth and Williams taught us to pursue are not univer-
sally viewed as essential throughout the worldwide dental and orthodontic
professions. Dr. Roth lamented the inadequacy of much of the published
literature, often because of articles or opinions that advanced conclusions or
principles in violation of our comprehensive goals or philosophy.
This Journal will share case presentations, research and editorial content with
attention finally focused on the attainment of comprehensive Roth Williams
goals: a healthy, functional occlusion featuring optimal condylar position,
joint health, facial and dental esthetics, periodontal and dental health, and
stability. The RWISO Journal features the synthesis and embodiment of the
Roth Williams goals. This Journal will illustrate the ideas and techniques in-
volved in the quest for Roth Williams goals. The goals are the same through-
out the world. They unite doctors from across the globe.
Please join us in supporting this Journal and its mission. May this Journal
inspire doctors from all disciplines and from all nations to seek the ultimate
in healthy, functional orthodontic outcomes. Dr. Roth, we thank you for your
vision and we hope these efforts may continue your legacy.
Respectfully,
Darrell L. Havener, Jr., DDS
RWISO President
RWISO Journal | May 2009 3
Letter from the Editor

Thomas Chubb, DDS The front cover of this publication, the first issue of the RWISO Journal,
Editor-In-Chief of RWISO Journal shows an image of Dr. Roth looking down on Dr. Williams as he is speaking
before a group of orthodontists. The picture says a lot.

Dr. Williams was once the student and now he is our teacher emeritus.
Fortunately, he is not alone; note the flags behind him. And he has a large
faculty to support him. There are those who head the Roth Williams centers
around the world, faculty teaching in orthodontic residency programs, Roth
Williams graduates lecturing at dental and orthodontic conferences world-
wide, orthodontists imparting their knowledge to local dental groups, and
finally, the Roth Williams orthodontist explaining the importance of the oc-
clusion and joint health to his patients. The cumulative impact on thousands
of patients is incalculable.

In virtually every field of endeavor, we stand upon the shoulders of those

who went before us and as Roth Williams orthodontists, our situation has
been no different. This Journal is our opportunity to validate our organi-
zation’s growth and the contributions it has given the field of orthodontics.
Also, the more we learn about our profession, the more we realize we need
the knowledge and skills of other dental specialties and of those who support
our profession. Our philosophy and our journal should be open to the input
of restorative dentists, oral and maxillofacial surgeons, radiologists, perio-
dontists, software developers, etc. The Journal will give us the opportunity to
share with each other and also with the rest of the dental profession. I believe
Roth Williams orthodontists treat to the highest standards in our profession
and our journal should live up to this standard.

I would like to give many thanks to the authors who contributed to this issue.
They devoted a great deal of time and effort to help make our first edition a
great success. I’d also like to thank Anne Evers, the managing editor of the
RWISO Journal, whose incredible organizational skills, insight, and persever-
ance was key to bringing this journal to life.

Finally, I would like solicit the members to support the Journal. The Journal
will reflect the commitment and direction of the group. It is time to put the
rest of the orthodontic profession on notice. The “standard of care” is changing.

Thomas Chubb, DDS

Editor-in-Chief
tkchubb1@earthlink.net

4 Dr. Thomas Chubb | Letter from the Editor

News from the Roth Williams Teaching Centers
BRAZIL
Dr. Fantini has been travelling within Brazil, teaching courses and in-
tensively communicating our philosophy. In northeast Brazil she gave
a one-week course for an orthodontic program, and reports that they
were amazed with the Roth Williams orthodontic vision. After that she
went to João Pessoa, another northeast capital, and lectured at a high-
level specialization course, where I (Dra. Bertolaccini) have lectured
previously.
In October, we had the SPO Meeting, considered one of the most impor-
tant meetings in Latin America. Dr. Fantinia lectured on Roth’s Mechan-
ics. We suggested the event organizers invite Anka and Jeff McLendon,
and it was tough work to convince them, but it worked. Their participa-
tion was remarkable. Finally, in November, Dr. Fantini gave a course in
Curitiba—Paraná state capital, at the south of Brazil, and we received
excellent feedback on that as well.
The study group founded in early 2008 remains active, with reunions
every two months. We believe we have found an interesting formula to
deepen the knowledge of those who took the CCOs. In all of the group
meetings, our program includes three activities. In the first, one of the
participants presents and discusses a theme given in the CCO course.
In our last meeting, which took place yesterday, the subject for the day
was “Jarabak Analysis.” Our objective with this activity is to allow the
students to really understand the philosophy. We don’t want our former
students saying they follow the teaching of Roth and Williams, without
knowing what it is really about. The second activity is a clinical case pre-
sentation and discussion, which is particularly attractive to participants.
It is a practical way to apply the philosophy with case analysis and di-
agnosis elaboration to the technical execution of treatment and finaliza-
tion. For the third activity, we discuss new topics of current interest.
For our next study group, for example, the theme to be explored will
be the role of lasertherapy in dentistry and in orthodontics in particular.
This way we have the opportunity to update ourselves on other subjects
that are not necessarily a part of orthodontics, but that may still involve
us directly. With this format we believe the study group has become
very attractive and now we are going to share it with the participants
of earlier CCOs.
The presence of Roth’s philosophy at the University of São Paulo is
also becoming more consolidated every day, thanks to Dr. Fantini’s hard
work. In the next two months, two more of her students will be defend-
ing their theses—one is a master’s thesis and the other a Ph.D. thesis.
The students studied the same sample, but with different approaches.
The first compared the clinical exams and the electovibratography as
methods to detect the articular disk displacement. The second study per-
formed MRI, CT scan of the joints. The results of these studies will be
compared.
As the current student groups are finishing at the University, new ones
are already selected for the next specialization course, the Master’s and
Ph.D. There will be 22 differentiated new professionals ready for the
Universe of Roth’s Philosophy, after completing their courses. For these
new groups, there will be a selection of new patients and other research
projects to start.
As far as the next CCO, we may start a new group in June 2009. We
believe all the work done over the past few years and the marketing and
publicizing work done by the specialized group we have contracted with
is showing results.
We are looking forward to seeing you at the meeting in Boston.
With very best regards,
Dra. Marisa Gianesella Bertolaccini
Delegate, Roth Williams Center Brazil
Dra. Solange Mongelle de Fantini
Director, Roth Williams Center Brazil
ITALY
It is a great pleasure to let you know that Roth Williams Courses are do-
ing great in Italy. Carlo Lella (carlolella@orteam.it) directs Continuing
Education, and is taking care of all the Courses.
This year we are starting the fifth group, which is divided into two sub-
groups (Northern and Southern Italy), with 30 doctors each. For the
first time we are sharing some sessions with the Spanish and the Turkish
group in San Sebastian and Rome. We are also organizing three Inter-
national Events in order to align our philosophy with other more tradi-
tional ones. It is our strategy to spread our message to a larger audience
and to highlight the strength of our philosophy.
Our September 25th – 27th 2009 on Class 2 meeting, titled “When,
How, Why” is very important. Drs. Domingo Martin, Kazumi Ikeda,
Jorge Ayala, David Hatcher and myself will be involved in the three-day
meeting, with Hans Pancherz (Herbst), Jonathan Sandler (Twin Block),
Tiziano Baccetti. It will be a great opportunity to compare different
goals and approaches to Class 2.
I am also involved in the preparation of the next Roth Williams Inter-
national Meeting that will take place in Rome 22- 25 September 2010
(date to be confirmed by the Council).
We are well respected and most of the participants of our Courses are
dedicated students.
Regards,
Dr. Renato Cocconi
Director, Roth Williams Center Italy
JAPAN
We now have 47 doctors as members. Our membership growth has been
steady. Members that have graduated from the two-year course have
also presented cases with stable and repeatable jaw position. Each year
we get together and every participant shows cases treated according to
the Roth philosophy. We are now preparing for the 15th anniversary
continued on next page...
RWISO Journal | May 2009 5
meeting in Tokyo in November 2010. Over two days there will be many
clinical cases from about 15 doctors. Three hundred participants are
expected, and of course, guests are also welcome.
Our current course, the 9th Two-Year Course, started in February, with
13 participants. Dr. Robert Williams, Dr. Masaru Sakai, Dr. Satoshi Ada-
chi and Dr. Kazumi Ikeda are the instructors. Dr. Jorge Ayala is a special
instructor. The 14th Basic Course will be held in autumn.
To carry over Roth Philosophy to the next generation, one country is
not enough. It is absolutely necessary to spread the philosophy inter-
nationally.
Dr. Kazumi Ikeda
Director, Roth Williams Center Japan
SPAIN/PORTUGAL
As Director of Roth Williams Center Spain and Portugal, it gives me
great joy to see that once again a Journal has been created to spread
the message and, above all, the clinical excellence of the Roth group.
Seeing this first issue I cannot forget it was Dra. Anka Sapunar who first
founded a Journal for this group and we must all be very grateful to her
for the great job that she did. This is a continuation of what she started.
Muchas gracias Anka!!!
Concerning the Roth group in Spain and Portugal, the year 2009 could
not have started any better. In a recent survey organized by the Spanish
Journal of Orthodontics, our course (RWCC) was chosen as the best
private continuing orthodontic course in Spain, and when compared to
university post-graduate courses, our courses rated very high. We have
many people to thank for this and, although I can’t list all names here,
this clearly shows that this is a team effort.

SOUTH KOREA Currently we have group No. 10 going in Spain, and the group is in-
credible. Many of our ex-alumni come to the sessions. The Roth group
Over 150 doctors attended the special lecture meeting that introduced
is growing in Spain! In two months we are organizing a joint meeting
Roth philosophy, held at Seoul National University Dental Hospital on
where we are going to join the Italian, Turkish and Spanish students for
July 20th, 2008. Dr. Byungtaek Choi, Dr. Eunah Choi, Prof. Sunjung
a meeting in San Sebastian on multidisciplinary treatment. The goal of
Hwang, Dr. Jinna Lee Linton, and Dr. Youngjun Lee gave lectures about
the meeting is, of course, to learn, but also to give the different doctors
how to achieve the functional occlusion and esthetics through orthodon-
the opportunity to meet and socialize.
tic-only treatment and orthognathic surgery-combined orthodontics.

Recently we organized the first Multidisciplinary Approach to Sleep

The third orthognathic surgery course was held at the Roth Williams
Apnea meeting in Pamplona and it was highly regarded. The feedback
Center Korea in October for four days. Dr. Byungtaek Choi, the Di-
was outstanding. We had specialists from all the fields involved in sleep
rector of RW Center Korea, gave lectures about the correct diagnosis
apnea participate. We plan to organize another one in 2010.
and steps for preparation for orthognathic surgery for achieving the
final functional occlusion. The participants in the lecture learned how
Before I finish, I want to ask all of you to send in articles to the Journal.
to use the SAM3 articulators, surgical planning using Choi’s analysis,
If we do not have articles, the Journal cannot survive. We need case
STO practice, and model surgery. Professor Sunjung Hwang (Orofacial
reports, research papers and above all, your support!
Surgery department, Seoul National University) gave a lecture about
considerations of orthognathic surgery for orthodontists.
Dr. Domingo Martín
Director, Roth Williams Center Spain and Portugal
Before Roth Williams Center Korea was founded, doctors who complet-
ed the Roth Williams course worked in RWKSO (Roth Williams Korean
Society of Korea). Our society has been reorganized under the director-
ship of Dr. Byungtaek Choi and is now called the Roth Williams Center UNITED STATES
Korea (RWCK). The main members are Dr. Eunah Choi, Dr. Young-
Andy, Bob and Ted have started Group VIII, which is now been through
sung Hur, Prof. Sunjung Hwang, and Dr. Yongchan Lee. Every fourth
the first two sessions. There are 25 participants from the U.S., Brazil
Wednesday we have academic meetings at Roth-Williams Center Korea.
and Poland. To date the Roth Williams USA group has trained over 125
orthodontists. These participants have learned complicated procedures,
Dr. Byungtaek Choi and Dr. Eunah Choi visited SAM company in Ger-
such as the Axiopath, VTO, STO additive and occlusal equilibrations.
many, in September 2008. They met Dr. Karl Wirth, who developed the
SAM articulator and Axiograph, and discussed the Axioquick recorder,
The Directors of the Roth William USA group have added another
a newly developed electric device.
teacher, Dr. Scot Anderson, who has made the commitment to audit our
The 7th Roth-Williams International Seminar started in Feb. 2008, and
course two times. Welcome Dr. Anderson!
is progressing steadily. In Session 4 that was held Dec. 12-14th, the cur-
riculum contained VTO preparation, growth forecast, Axiopgraph re-
The Directors have instituted many new and innovative teaching tech-
cording, and precision mounting. The course will end in Sep. 2009.
niques to help participants become proficient in the axiopath, visual
treatment objective, soft tissue cephalometric analysis, surgical treat-
Dr. Byungtaek Choi
ment objective, additive coronalplasty and occlusal equilibrations.
Director, Roth Williams Center Korea

The AEO-Roth computerized VTO has been completed with Dolphin’s

help and is included in Version 11. The Surgical technique for diagnostic
and surgical setups has been finished and is in CD format. We hope in
the near future to put all the techniques on CDs.

6 News from the Roth Williams Teaching Centers

Group VII will be finishing in June 2009 and Group IX is scheduled to
start in October 2009. The dates and application can be downloaded
form the website (www.rothwilliams-usa.com).
We completed the 3rd Annual Roth/Williams USA-AEO Alumni meet-
ing in Denver in November 2008. Andy and his staff put the program,
accommodation and dinner together. There was a variety of information
presented, including practice management, labor laws, lasers, and a re-
view of particular Roth Williams techniques.
As part of our ongoing research, Roth Williams USA has just completed
the eleventh Masters Research paper at the University of Detroit orth-
odontic department. Two more Masters research papers are just starting
with first-year students.
As you can see, Roth Williams USA is busy trying to provide the best
course possible so the orthodontic endeavour will remain a health pro-
fession.
Drs. Andy Girardot, Bob Frantz, and Ted Freeland
Directors, Roth Williams Center USA
URUGUAY
It is a pleasure for the Roth Williams Center Uruguay for Functional
Occlusion (RWCUFO) to be present in this, the first issue of our Jour-
nal. This is a very important step that will help spread Roth Williams
philosophy all over the world. It will show how we have advanced in
our search for excellence in orthodontics and connect members all over
the world. Congratulations and thanks to everyone involved in making
this Journal a reality.
We would like to inform you that in August 2009, the second three-year
RWCUFO course will begin. It will be held in the Faculty of Odontology
– Catholic University of Uruguay, and we are working on getting speak-
ers, colleagues and friends from many different countries. It will be a
great opportunity to share our knowledge and friendship. The course is
the result of hard work and the support of many RWISO members and
Directors, and I would like to take this opportunity to express our deep
gratitude to those who have contributed to make this course a reality.
We would also like to share with you our enthusiasm and joy as we see
how the RWISO is growing, and as Dr. Roth and Dr. Williams taught us,
we are looking forward to continuing to work together pursuing their
vision of a stronger and united RWISO.
Dr. Daniela Domínguez Di Prisco
Director, Roth Williams Center Uruguay
RWISO Journal | May 2009 7
The Roth Williams Legacy Fund (RWLF)
—Q & A for Prospective Donors
Prospective RWLF donors often have questions about donating. The RWLF Committee feels
that there is no better place to answer these questions than in our new Journal.
— Dr. Milton D. Berkman, Chairman RWLF

Q: Why should RWISO doctors donate to RWLF?

A: Because there is no other endowment fund that is totally dedicated to the encouragement
and financial backing of research and educational enterprises that document as well as dem-
onstrate the benefits of the Roth Williams Philosophy for our patients. A good example of
what can be accomplished with the support of an endowment fund is this first issue of the
Journal With an endowment fund to provide seed money for a journal, RWISO was
RWISO Journal.
Dr. Milton D. Berkman, able to move forward, knowing that the start-up costs of a new journal would not create
Chairman RWLF undue financial stress. The RWISO Journal is an idea that is long overdue and vital to the life-
blood of the membership. A significant endowment increases the stature of the organization and ensures a bright future
for the Philosophy. With the support of membership RWLF can reach its campaign goal of $1 million in five years.

Q: What are the different ways that I can donate to RWLF?

A: 1) “Professional Courtesy/Grateful Patient”: Several RWISO orthodontists are fulfilling their pledges through a
“professional courtesy” or “grateful patient” arrangement. In this scenario, persons to whom you offer orthodontic
services as a courtesy are invited to demonstrate their appreciation by making a contribution to RWLF in your name.
Orthodontic treatment is provided in the usual manner, but the check is made payable to RWLF, rather than to you.
You and the other party(ies) will need to discuss the arrangement’s tax advantages so that both you and they under-
stand who might be allowed to take the tax deduction. A sample letter can be downloaded from the RWISO website
for this situation.

2) “Case for the Future of the Roth Philosophy”: Each doctor should consider donating one new case as “A Case for
the Future.” The doctor pays the fee to RWLF. The doctor receives a tax deduction for the donation.

3) Doctors who give courses or lectures and receive an honorarium might consider donating a portion of the course
fees or honorarium to RWLF. In this way the educator expands the benefits of the educational experience and makes
the course attendees aware of RWLF and its objectives.

4) Another thoughtful idea is to make a donation to the Fund in memory of, or in honor of, a colleague, a friend, a
relative or parents. It is a dignified way to express your admiration.

Q: How do I know that the money I donate will be used only for the endowment fund since it is part of the RWISO
organization? How is the money invested at this time?

A: Although the money goes into a RWISO account, the money is not commingled with other RWISO monies. RWLF
has a separate account under RWISO. The money is invested in money market funds. The money is earning a low
interest rate because of economic conditions. Capital preservation is our financial strategy at this time. More aggres-
sive financial investing will be considered at the appropriate time by the Committee in consultation with investment
advisors, with the approval of RWISO Council.

8 Roth Williams Legacy Fund

Q: How do you pledge to RWLF?

A: You can pledge by going to the RWISO website and click on “Roth Williams Legacy Fund.” Next, click on “Dona-
tion Letter” and in the letter you can click to make a pledge or click to make a donation. When you click, it will lead
you either to a form that can be filled out for a pledge (commitment to make a donation) or a donation form (paid
by check or credit card). If you prefer, you can contact one of RWLF Committee members to discuss your pledge or
donation. There are three factors (amount, time frame and frequency of billing) to consider when you pledge. The
RWLF committee members have asked each member to pledge the equivalent of one orthodontic case. Some members
have pledged more and some less depending upon their circumstances. The committee wishes to see as many members
participate as possible. The time frame of pledge is usually over a three-year period, although it can vary depending
upon circumstances. The frequency of billing is yearly in November for that year’s pledged amount. If you wish, the
pledge can be paid sooner than the initially agreed-upon time.

Q: Can my donation be made to a specific project instead of the general endowment fund?

A: Previously, all pledges and donations were made to the general endowment fund. Recently, RWLF has determined
that donated monies can be designated for the general endowment or for writing and publishing a textbook about
“The Roth Williams Philosophy: Principles, Diagnosis, Treatment and Case Studies.” For more information on the
textbook you can contact Dr. Andy Girardot. The monies designated for the textbook project will be solely used
for publication and distribution of the textbook and any other expenses specifically related to making this textbook
readily available worldwide. Any monies received from the sale of the textbook will be donated to RWLF for future
educational and research projects.

As of March 20, 2009 $137,300 has been donated to RWLF general endowment.

As of March 20, 2009 $155,200 has been pledged to RWLF, but not fulfilled.

Please contact Jeff Milde through the RWISO website or his e-mail (j.milde@mra-sf.com), if you need more information.

We, the Committee of the Roth Williams Legacy Fund, thank the members and friends of RWISO for their philanthropy.

Gratefully yours,
Milton D. Berkman, Chairman RWLF
Peggy Brazones
David Livingston
Domingo Martin
Joe Pelle
Straty Righellis
Manny Wasserman
David Way
Jeff Milde, Executive Director

RWISO Journal | May 2009 9

Roth Williams Legacy Fund Donors
Tribute to Donors

We thank all of our loyal and faithful donors for their support of the Legacy Fund. Below, we pay tribute to those donors who have given from
January 1, 2006 through March 20, 2009.

Platinum (10,000 - $49,999) Bronze Circle ($1 - $999)

Dr. Milton Berkman Dr. Hideaki Aoki
Dr. Domingo Martin Dr. Warren Creed
Dr. Straty Righellis Dr. Graciela de Bardeci
Dr. Emanuel Wasserman Dr. Andrew Girardot
Dr. Chieko Himeno
Dr. Takehiro Hirano
Dr. Akira Kawamura
Gold Circle ($5,000 - $9,999) Dra. Mi Hee Kim
Dr. Margaret Brazones
Dr. Yutaka Kitahara
Dr. Byungtaek Choi
Dr. Shunji Kitazono
Dr. James Sieberth
Dr. Ilya Lipkin
Dr. Wayne Sletten
Jeff Milde
Dr. David Way
Dr. Kouichi Misaki
Dr. Robert Williams
Dr. Hideaki Miyata
Dr. Yoshihiro Nakajima
Dr. Joseph Pelle
Silver Circle ($1,000 - $4,999) Dr. Atsuyo Sakai
Dr. Terry Adams Dr. Akiyuki Sakai
Dr. Claudia Aichinger Dr. Hidetoshi Shirai
Dr. Joachim Bauer Dr. Motoyasu Taguchi
Dr. Patricia Boice Dr. Naoyuki Takahashi
Dr. Renato Cocconi Dr. Hiroshi Takeshita
Dr. Frank Cordray Dr. Yasoo Watanabe
Dr. K. George Elassal Dr. Benson Wong
Dr. Keenman Feng Dr. Koji Yasuda
Dr. David Hatcher Dr. Yeong-Charng Yen
Dr. Darrell Havener
Dr. Kazumi Ikeda
Dr. Douglas Knight Estate Planning
Dr. John Lawson Dr. Charles R. de Lorimier
Dr. Young Jun Lee Dr. Donald W. Linck, II
Dr. Jina Linton
Dr. Gerald Malovos
Dr. Alan Marcus
Dr. Jeffrey McClendon
Dr. Roger Pitl
Dr. Paul Rigali
Dr. Katsuji Tanaka
T&T Design Labs
AEO Group, LLC

10 Roth Williams Legacy Fund Donors

Orthodontics and Bioesthetics:
A Perfect Symbiosis
Domingo Martín, MD, DDS ■ Elisabeth Aguirrebengoa, MD, DDS , PhD
Ana Armendáriz, MD, DDS ■ Santiago Guisasola, DDS ■ Iñigo Zárate

Domingo Martín, MD, DDS Summary

■ Masters in Orthodontics
Elisabeth Aguirrebengoa, MD, DDS
■ Diploma in Bioesthetics
Ana Armendáriz, MD, DDS
■ Diploma in Bioesthetics
Santiago Guisasola, DDS
■ Diploma in Bioesthetics
Iñigo Zárate
■ Dental Technician, Diploma in Bioesthetics
In this article we present the concept of bioesthetics as a tool to help ortho-
dontists achieve their final treatment goals: facial esthetics, dental esthetics,
functional occlusion, periodontal health, and long-term stability. These goals
cannot always be met with orthodontic treatment alone, but with the help of
bioesthetics we can now treat patients who have significant dental wear, slight
skeletal discrepancies, and centric relation-centric occlusion discrepancies and
still meet all our initial treatment objectives. We will present five clinical cases
that illustrate the principles of bioesthetics; in all of the cases we begin by do-
ing preprosthetic orthodontics and finish with bioesthetics.

Introduction
What is bioesthetics? No one can answer this question bet-
ter than its founder, Dr. Robert L. Lee. (1) “Bioesthetics,” he
says, “is the discipline in dentistry that studies the beauty
of human beings in its natural forms and functions.” It is a
process of continuous study that accepts the biologic form
as its basis of function, diagnosis, and rehabilitation of the
stomatognathic system. The term bioesthetic dentistry was
coined to signify not only the union of, but also the inter-
relationship between, dentistry and biology. Figure 1 Principles of bioesthetics.
Scientific studies done on perfect natural dentitions (2-4)
—dentitions without dental wear or missing teeth that sur- Principles of Bioesthetics
vived over a lifetime—helped Dr. Lee to formulate the three Principle One
principles of bioesthetics. Dr. Lee found that all of these patients had in common a
A well-known prosthodontist and the creator of the stable condylar position (SCP). (8-15) The condyles of the
Panadent system, Dr. Lee dedicated many years to study- mandible were located within the glenoid fossa in its most
ing the stomatognathic systems of patients with natural and superior and anterior position, held against the articular em-
untouched dentitions, and to comparing them with the sto- inence, centered in the transverse position, and with the disc
matognathic systems of patients with poor dentitions. Dr. interposed. This is a reproducible position from a functional
Lee used his training as a biologist to observe and register the point of view and can therefore be registered with the use of
differences and similarities between the different dentitions, models and articulators.
and to develop the biologic model. The dentitions that Dr.
Lee studied had many shared characteristics. (5-7). Based on Principle Two
his observation of these characteristics, Dr. Lee formulated Dr. Lee found that these long-lasting dentitions had in com-
the following three principles (see Figure 1). mon an overbite of approximately 3 to 4 millimeters and an
overjet of 2 to 3 millimeters with the dentition in occlusion.

RWISO Journal | May 2009 11

(16-18) This amount of overbite and overjet helps guide the
mandible, and therefore the condyles, back to the fossa. This
amount of overjet and overbite is also necessary to achieve
posterior desocclusion in anterior and lateral movements of
approximately 3 millimeters.
Principle Three
Dr. Lee found that the patients in his sample had perfect
dental morphology. (19-24) Dr. Lee strongly believed that
this was one of the keys to long-lasting dentition. He stated
on many occasions that in biology, “form is function and
function is form,” and in his dental samples he observed the
following characteristics, which he believed strongly support
this statement:
• Long upper central incisors
• Slightly smaller and more rounded upper lateral incisors
• Long and pointed canines
• Posterior teeth with long and well-developed cusps
Dr. Lee believed that these characteristics led to long-
lasting natural beauty. As these three principles suggest, bio-
esthetic dentistry is not just a technique; it is a philosophy—a
philosophy that comprises the study, observation, and diag-
nosis of long-lasting dentitions. (25-26) Dr. Lee discusses his
observations of these samples, and the numerous studies in
Rufenacht ed. (27)
Mandibular Relationship: Stable Condylar Position
(SCP)
In bioesthetics, SCP is defined as a stable maxillomandibular
position. (28-29) In this position, the condyles are bilaterally
seated in the most anterior and superior zone of the fossa,
with the disc interposed in its thinnest area. This position
is anatomically and physiologically ideal. It supports mas-
tication, respiration, and the swallowing movement of the
lips and tongue. It also supports the soft-tissue envelope and
therefore helps create good facial esthetics.
Even in the case of chronic temporomandibular joint
(TMJ) pathologies, in which the disc is displaced without
reduction, it is important to establish an SCP. The concept
of centric relation (CR) implies that the disc and the TMJ
are healthy. In prosthodontic cases, we do not always have
an ideal articular situation, but we can obtain an SCP even
though the disc is displaced. The objective is to ensure that
the teeth in maximum intercuspation do not displace the
condyles, and that the condyles are in an SCP. The goal of
bioesthetics is to create a harmonious interaction between
the dental morphology and the physiologic position of the
condyles.
If the condylar position does not coincide with maxi-
mum intercuspation (centric occlusion), the patient displaces
12 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis
the condyle from the centric position to establish an occlu-
sion in a forward position of the mandible, generating a mas-
ticatory pattern of contact guidance.
When interferences in the posterior segments get in the
way of the arc of closure of the mandible and if the mandible
is in centric relation, the patient avoids this prematurity by
a forward displacement of the mandible. The external ptery-
goid muscles (opening and forward positioning of the man-
dible) are active together with the closing and facial muscles
(masseter, internal pterygoid, temporal and muscles inner-
vated by the 7th cranial nerve). (30-33)
This massive contraction of the musculature often causes
symptoms of muscular pain and stress and thus the system is no
longer in equilibrium. This situation in many occasions can lead
to dental abrasions, wedge erosions, microfractures of the enamel,
pulpitis, recessions, abfractions and dental displacement.
To explain this pathology, it is important to analyze the
forces that the different structures of the masticatory system
receive. These forces are perfectly explained by the physi-
cal laws of lever systems. A posterior interference in CR can
transform a class III lever into a class I lever. This is why it is
important to evaluate the occlusion by making an occlusal di-
agnosis, as well as to assess the articular position of the TMJ.
The most appropriate tool for making a three-dimen-
sional diagnosis of the occlusion is analysis of dental casts
mounted on an articulator, using registration techniques
that seat the condyle and then reproducing its position on
the mounted casts. The reason for using an articulator is to
avoid the action of the neuromusculature that can on many
occasions hide the true discrepancy between CO and CR.
It is not possible to make an occlusal analysis by simple
clinical observation of the occlusion. This is again because the
patient’s neuromuscular system can avoid occlusal discrepan-
cies and not show the true difference between CO and CR.
Dental Morphology
The majority of studies done on tooth length and dental
morphology are based on teeth with a certain degree of wear.
(34-35) This wear is generally assumed to be normal, but it
leads to incorrect measurements of tooth length. Measured
teeth in patients with ideal occlusion and no dental wear
are in general longer, and the bioesthetic model is based on
these cases. Average measured lengths of these teeth are as
follows:
• Upper central incisor: 10.5 to 12.5 millimeters
• Upper lateral incisor: 9 to 10 millimeters
• Upper canine: 10.5 to 12.5 millimeters
• Lower incisor: 8.5 to 10 millimeters
The incisal edges are rounded, with a width of 0.5 mil-
limeters. The premolars and molars have pointed cusps.
Overbite and Overjet
The overbite and overjet values that Dr. Lee observed in his
sample are necessary to ensure occlusal function that pro-
duces a mutually protected occlusion. These values are as
follows:
• Vertical overbite of the upper incisors: 3 to 5
millimeters
• Vertical overbite of the canines: 4 to 5 millimeters
• Horizontal overjet of the incisors: 2 to 3 millimeters
(ideally 2.5 millimeters)
• Horizontal overjet of the canines: 0.5 to 1 millimeter
The overjet measurement is taken by measuring from
the facial aspect of the incisor or the lower canine to the
corresponding incisal edge. The vertical dimension of the oc-
clusion is measured from the CEJ of the upper incisors to the
CEJ of the lower incisors and is approximately 16.0 to 20.0
millimeters. (36-37) Figure 2 shows the ideal relationship be-
tween the overjet and the overbite.
Figure 2 Diagram of the ideal overjet-overbite relationship.
The importance of the overbite has its origin in the an-
terior guidance of the mandibular movements, and in pro-
prioception.
Proprioception is influenced by the intensity of the con-
tact between the teeth, and by the dental anatomic biology. It
is also affected by the position of the contact in CR, and by
the incursive movements of the mandible.
The process of mastication takes place from outside to
inside; that is, the sharp portions of the teeth of the man-
dible (the incisal edges and the cusps) direct the motion of
the mandible from the eccentric position to CO. One of the
keys to biologic occlusion is the importance of propriocep-
tion produced by the contact of the incisors.
During mastication the incisal edges of teeth no. 26, 25,
24, and 23 make contact with the cingulum and the marginal
ridges of teeth no. 8 and 9. Anterior guidance is the contact
produced at the level of the incisors when the patient goes
from edge-to-edge occlusion to maximum intercuspation.
This contact is guided by the mesial marginal ridges of teeth
no. 8 and 9. These teeth are convex, so that they guide with
the least possible contact between the surfaces.
In the posterior segments, this anterior guidance posi-
tion of edge-to-edge incisal occlusion produces a disclusion
of approximately 3 millimeters. The lateral mandibular
movements are guided by the canines and should produce a
disclusion of 1 to 2 millimeters on the working side and 2 to
3 millimeters on the nonworking side.
In order for form and function to be correct, the gingival
margins and the cusps of the posterior dental teeth draw a
line from canine to the first molar that converge distally. This
progressive convergence of the cusps and margins create a
progressive lateral guidance (Figure 3).
Figure 3 Distal converging lines show height of CEJ,
interproximal contact points, and buccal cusp tips.
It is important to observe that the dental anatomy pro-
duces wide embrasures that permit the bolus to go either on
the lingual or on the palatal side.
Bioesthetics simply copies nature. Based as it is on long-
lasting dentitions, the biologic model takes into account the
ideal form and its influence on function. It is not an artificial
occlusion, or an occlusion based on theory. The three prin-
ciples of bioesthetics imply that an SCP and the coincidence
of CR and CO, together with an absence of dental wear, pro-
duce healthy dentitions, occlusal stability, and long-lasting
natural beauty. (38-42)
This leads us to a biological concept that says, “when
something functions in nature, it possesses form and propor-
tions that make it beautiful, which does not mean that the
contrary is true, that is, that not all that is esthetic pleasing
functions correctly.”
MAGO
The term MAGO is the acronym for maxillary anterior guid-
ed orthosis. Literally, a MAGO is a maxillary orthosis with
anterior guidance; it is used to relax the musculature and
position the condyles within the glenoid fossa. In so doing,
it gives us an SCP that is functional and reproducible. From
this SCP we can make a definitive diagnosis, and having done
so, can decide what our treatment goal should be.
RWISO Journal | May 2009 13
 A MAGO is a superior occlusal splint. It is worn to re-
veal prematurities or occlusal interferences that do not per-
mit the mandible to close on the terminal hinge axis from
the CR position.
In order to achieve this, it is necessary that the patient
wear the MAGO 24 hours a day for at least 6 to 12 months.
It should be adjusted periodically. The MAGO also has a
positive influence on the tissues of the TMJ. It facilitates the
repair and regeneration of these tissues and helps to resolve
inflammation of the joints.
An SCP is attained when three criteria have been met.
These criteria are: 1) the patient is comfortable; 2) after the
MAGO has been adjusted many times, there is no change
in mandibular position; and 3) there are no changes in the
semiadjustable articulator mountings in CR for a period of
three consecutive weeks and fourth records taken with the
same vertical dimension, and verified with the condylar posi-
tion indicator (CPI).
When the mandible is stable, we do a hinge axis re-
cording. With this, we locate the hinge axis, the angle of the
eminence, and the immediate side shift of Bennet. The hinge
axis is marked on the patient’s skin, and the articulator is
programmed with the information obtained with the hinge
axis recording.
We now use the hinge axis to mount the definitive
mounted models on the articulator. We then use these models
to plan treatment. Our plan will take into consideration vari-
ous treatment options, depending upon the requirements of
the case. These options include negative coronaplasty, posi-
tive coronaplasty, prosthodontics, orthodontics, orthogna-
thic surgery, or a combination of all of the above. (43-48)
We fabricate and adjust the MAGO as follows:
1. We take precise impressions of both arches.
2. Using a metallic bite plate with an anterior stop of
compound, we then take the centric bite record.
3. With a similar bite plate, we take a protrusive bite to
obtain the preliminary angle of the eminence.
4. We take a face-bow recording.
5. We mount models on the articulator.
6. We register the CPI with the initial condylar position
in the patient’s maximum occlusion. We record this
setting so that we can verify it in subsequent appointments.
7. Initially (for the first one or two days), the lower
anterior teeth make contact with the MAGO on the
anterior platform only. This platform has a slope of
approximately 25º and a length of 6 millimeters—4
millimeters for protrusive movements and 2 millimeters
behind the point where the incisal edges of the lower
anteriors make contact. (The facial aspects of the
14 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis
teeth should not make contact.)
8. The canines, premolars, and molars do not occlude,
and in combination with the musculature this
produces a class III lever that seats the condyle in the
fossa in its most superior, anterior, and medial position.
9. After the condyles are seated, we add the posterior
contacts to the splint. This converts into a full splint
with a contact point for each centric of the lower
arch. Pressure of contact is minimal and equal on all
of the contact points. Finally, we add canine guidance.
Coronaplasty
The objective of coronaplasty is to protect and restore the
dental morphology and anatomy and to recontour the teeth
without mutilation. Coronaplasty is divided into two stages;
the first is negative coronaplasty and the second, positive
coronaplasty.
Negative Coronaplasty
Negative coronaplasty consists of decreasing the vertical di-
mension. This is achieved by modifying the form of the teeth
by occlusal adjustment. This sometimes changes the form
and size of the teeth but the original morphology is kept.
To understand selective grinding in CR, it is useful to re-
member the rule MUDL (mesial upper, distal lower). When
we perform negative coronaplasty we grind the mesial aspect
of the molar and upper premolars cusps and the distal aspect
of the lower premolars and molar cusps. The purpose of this
subtractive procedure is to ensure a correct cusp relationship
during excursive movements.
The selective grinding consists of modifying the slopes,
deepening the occlusal grooves and fossa, creating secondary
grooves, refining contacts on the marginal ridges between
adjacent teeth and reshaping the axial contours of the teeth.
The objective is to create a dental anatomy with efficient
cusps for mastication and improve cusp-fossa relationship.
The process of negative coronaplasty is first done on the
articulator. Following the same sequence, it is done in the
mouth. In performing negative coronaplasty it is important
to bear two things in mind.
First, the anterior vertical dimension measured from the
CEJ of tooth no. 8 to tooth no. 25 is approximately 18 mil-
limeters. And second, it is important not to grind the pos-
terior segments in excess so that the vertical dimension is
diminished. It is very important not to grind the posterior
interferences during excursive movements until the length
of the anterior teeth and the canines has been established.
Negative coronaplasty is usually performed on the molars
and premolars.
Positive Coronaplasty
Once we have completed the negative coronaplasty, the
MAGO should be adjusted as soon as possible so we can
perform the positive coronaplasty at the next appointment.
The positive coronaplasty is performed on the mounted
models through the diagnostic wax-up of the cusps and the
incisal edges. The objective of the positive coronaplasty is to
generate a vertical masticatory pattern from an incisal and
canine guidance, and a perfect dental anatomy in which CR
coincides with CO. The correct incisal relationship also gen-
erates a correct support of the lip. This in turn improves dic-
tion and produces a pleasing esthetic effect.
To transfer the occlusal adjustment to the mouth, we
keep the vertical dimension by using an “anterior jig.” It is
useful to have a photographic sequence of the laboratory
procedures that are then used to reproduce the sequence
in the mouth. Once these laboratory procedures have been
Figures 4-a, 4-b, 4-c Facial photographs. Initial stage of treatment.
Figures 5-a, 5-b, 5-c Intraoral photographs. Initial stage of treatment.
completed, we take impressions of the wax-up models with a
silicon transparent material. This silicon material adapts per-
fectly to the teeth and once it hardens it can be perforated so
that fluid composite can be injected into each tooth. Teflon
strips can be used to isolate contiguous teeth. One quadrant
of the dental arch is done at each appointment. It is essential
to adjust the MAGO during each appointment in order to
maintain CR.
To verify the changes, new dental casts are taken and
they are mounted on the articulator in CR. Any necessary
corrections can then be made.
Clinical Cases
Patient 1
A 26-year-old woman (Fig. 4a-c) presented with the follow-
ing complaint: “I want my mouth to look prettier.”
RWISO Journal | May 2009 15

Figure 6 Initial panoramic radiographic.
Diagnosis. The patient presented a class I division 2 ten-
dency; lingualization of the upper and lower incisors; a deep
overbite; and wear facets on the upper incisors. The wear
facets in combination with the extrusion of the incisors were
responsible for the inverse architecture of the gingival line
(uneven marginal levels) (Fig. 5a-c). The patient also pre-
sented crowding in both arches. Her profile was slightly re-
trusive, partly because of the lingualization of the upper inci-
sors. From the periodontal point of view, signs of generalized
gingivitis were present. We saw moderate loss of insertion
of the periodontium in the upper arch (4 to 6 millimeters)
and severe loss in the lower arch (6 to 9 millimeters). Ra-
diologically we saw moderate destruction of alveolar bone
with a horizontal pattern of resorption of bone loss; bone
loss was more severe in the area of the molars (Fig. 6). The
consequences of the periodontal disease were manifest in the
absence of interdental papillae of the upper incisors.

Figures 7-a, 7-b, 7-c Intraoral photographs during orthodontic treatment.

Figures 8-a, 8-b, 8-c, 8-d Procedure to develop interdental papillae.

Objectives of treatment. The initial objective was to re-
cuperate periodontal health. Posteriorly, we wanted to give
form to the upper and lower arches, protrude the upper in-
cisors, and recover the architecture of the gingiva. We also
wanted to create interdental papillae in the anterior-supe-
rior area. We wanted to achieve all of these esthetic objec-
tives without forgetting our occlusal objective, which was
to equalize CR with CO. By doing so, we hoped to obtain
a functional occlusion that would make it much easier to
perform the negative and positive coronaplasty.

Figures 9-a, 9-b, 9-c Photographs taken after orthodontic treatment.

There is not enough overbite, due to dental wear.

16 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figure 10-a, 10-b, 10-c MAGO.

Figure 11 Axiograph record. Figure 12 Hinge axis mounting. Figure 13 Negative coronaplasty shown
on the working dental casts.

Figures 14-a, 14-b Positive coronaplasty in situ in the mouth.

Treatment plan. The patient smoked heavily. The first
point was to convince her to stop smoking and to refer her
to a periodontist for periodontal treatment. After this treat-
ment was finished, we started to align both arches, protrude
the upper incisors, and recover the gingival architecture (Fig.
7a-c). We performed interproximal stripping to create papil-
lae in the anterior-superior area (Fig. 8a-d) and placed fixed
retention in both arches (Fig. 9a-c). We then deprogrammed
the patient with the MAGO (Fig. 10a-c). We made an axio-
graph recording and located the hinge axis (Fig. 11,12). The
models were then mounted using this axis and the negative
and positive coronaplasty was performed (Fig. 13). Finally,
we transferred the positive coronaplasty to the mouth of the
patient (Fig. 14a-b, 15a-c, 16a-b, 17, 18a-b).

Figures 15-a, 15-b, 15-c Intraoral photographs. Final treatment.

RWISO Journal | May 2009 17

 Figures 16-a, 16-b Extraoral photographs. Final treatment.

Figure 17 Final panoramic radiograph.

Figures 18-a, 18-b Frontal extraoral photographs during smiling. Pre- and posttreatment.

18 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

Figures 19-a, 19-b Profile photographs. Pre- and posttreatment.

Patient 2
A 33-year-old male (Fig. 20a-b) presented with the following
chief complaint: “I want to align my lower anterior teeth.”

Figures 20-a, 20-b Extraoral photographs. Pretreatment.

Figures 21-a, 21-b, 21-c Intraoral photographs. Pretreatment.

RWISO Journal | May 2009 19

 Esthetic analysis. The patient presented a nice symmetri-
cal face with labial competence and adequate projection of
the lips. His facial growth pattern was dolichofacial, and his
nasolabial angle was correct. He presented a normal smile,
but this smile did not fully expose his teeth.
Diagnosis. A dental class I (Fig. 21a-c) I was seen intra-
orally; however, the mounted casts showed a class II maloc-
clusion, caused by the discrepancy between CR and maximum
intercuspation. There was a small amount of crowding on the
anterior lower segment, possibly related to the condylar dis-
crepancy. We also saw deficient overbite and wear facets. Tooth
no. 1 was impacted, and teeth no. 16, 17 and 32 were absent.

Figures 22-a, 22-b, 22-c Intraoral photographs. Intraorthodontic treatment.

Figure 23 MAGO. Postorthodontic treatment. Figure 24 Axiograph recording.

Figures 25-a, 25-b Mounted models on the true hinge axis.

Figure 27 Measurement of the vertical

dimension after negative and positive
coronaplasty.

Figures 26-a, 26-b Mounted models after negative and positive coronaplasty.

20 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Treatment plan. Treatment was started with orthodontic
appliances on both arches, not only to align teeth but also
to align the gingival margins and to recover arch form (Fig.
22a-c). Once these orthodontic goals were met, we started
treatment with the MAGO (Fig. 23). The patient wore the
MAGO 24 hours a day for a period of four months. Once
an SCP was obtained, an axiograph recording was done to
locate the true hinge axis (Fig. 24). Using the hinge axis, we
mounted the models in the articulator (Fig. 25a-b) and per-
formed the negative and positive coronoplasty (Fig. 26a-b,
27). We then transferred the positive coronaplasty to the
mouth of the patient (Fig. 28a-b, 29a-c).

Figures 28-a, 28-b Extraoral photographs. Pre- and posttreatment.

Figures 29-a, 29-b, 29-c Intraoral photographs. Posttreatment.

Patient 3
A 31-year-old male (Fig. 30a-c) presented with the chief
complaint of “gingival recessions and dental anarchy.”

Figures 30-a, 30-b, 30-c Extraoral photographs. Pretreatment.

RWISO Journal | May 2009 21
 Figures 31-a, 31-b, 31-c Intraoral photographs.. Pretreatment.

Figure 32-a Initial panoramic radiograph.

Esthetic analysis. The patient presented a symmetrical

face with good labial competence. He also presented a slight
maxillary hypoplasia, with a vertical maxillary defect. This
defect prevented full exposure of the teeth at rest and when
the patient smiled. The facial lower third was slightly in- Figure 32-b Initial cephalometric radiograph.
creased, and the nasolabial angle was flat (Fig. 30a-c).
Dental and occlusal analysis. The patient presented a
class III malocclusion with an open bite and lingualization
(compensations) of the lower incisors. He also presented
crowding of both arches, and small upper lateral incisors.
The gingival margins of the upper incisors were not level
(Fig. 31a-c). Gingival recessions and wear facets were pres-
ent on teeth no. 19 and 30, which had had root canal treat-
ment. Teeth no. 1, 16, 17 and 32 were erupted (Fig. 32a-b).

Figures 33-a, 33-b, 33-c Presurgical intraoral photographs.

22 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figures 34-a, 34-b, 34-c Postsurgical intraoral photographs.

Figures 35-a, 35-b, 35-c, 35-d Reconstruction of the small upper lateral incisors.

Diagnosis. The patient presented with periodontal dis- morphology, and their roots were short. Both upper lateral
ease, skeletal class III, maxillary hypoplasia, vertical maxil- incisors were small when compared to the central incisors,
lary defect, open bite, and lingualization of the upper and and gingival recessions were present.
lower incisors. The upper incisors presented an irregular

Figures 36-a, 36-b, 36-c Intraoral photographs. Final orthodontic treatment.

Figure 37 Final panoramic radiograph.

Treatment plan. The patient was referred to a periodon- This consisted of installing fixed appliances on the upper and
tist for treatment. Once the periodontal treatment was fin- lower arches (Fig. 33a-c). When both arches were correctly
ished, we performed the presurgical orthodontic treatment. aligned and leveled, we performed orthognathic surgery,

RWISO Journal | May 2009 23

consisting of maxillary surgery with advancement, expan-
sion, (segmented) and downgraft of the maxilla. During the
postsurgical orthodontic treatment, we reconstructed teeth
no. 7 and 10 with composites (Fig. 34a-c, 35a-d, 36a-c). We
then installed a MAGO, which the patient wore for three
months to stabilize the mandibular position (Fig. 37). When
the patient was stabilized, we made an axiograph recording.
The models were mounted on the hinge axis, and we per-
formed the negative and positive coronaplasty (Fig. 38a-c,
39a-c, 40). Improvement of the gingival recession of tooth
no. 30 is noteworthy; this improvement was realized with-
out a graft or periodontal regenerative therapy. This gingival
recession may be due to the combination of occlusal trauma
and periodontal inflammation.

Figures 38-a, 38-b, 38-c Intraoral photographs. Final photographs after negative and positive coronaplasty.

Figures 39-a, 39-b, 39-c . Extraoral photographs. Posttreatment.

Figure 40 Smile. Posttreatment.

24 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figures 41-a, 41-b, 41-c Extraoral photographs. Pretreatment.

Figures 42-a, 42-b, 42-c Intraoral photographs. Pretreatment.

Patient 4 with severe wear facets of the anterior teeth, extrusion of

An 18-year-old male (Fig. 41a-c) presented with the fol-
lowing complaint: “I don’t show my teeth enough when I
smile.”
Esthetic analysis. The patient had a slight asymmetry of
the mandible toward the left, an increased lower-third facial
height, and a correct nasolabial angle. He did present a de-
ficient smile.
Diagnosis. The patient was diagnosed as class I with a
class III tendency. His occlusion was an edge-to-edge bite
the worn teeth, and uneven gingival margins. There was no
dental guidance (Fig. 42a-c).
Treatment objectives. The principal objective of treat-
ment was to recuperate the position of the upper incisors,
so that the gingival margins of the incisors would be back in
harmony with the rest of the dentition. We did all of these
knowing that we were going to follow them up with bioes-
thetic treatment.

Figures 43-a, 43-b, 43-c Intraoral photographs. Pre- and posttreatment.

RWISO Journal | May 2009 25

 Figures 44-a, 44-b, 44-c Smile after recovering the ideal gingival architecture.

Figure 45 Provisional reconstruction of the upper incisors. Figure 46 MAGO.

Figure 47 Axiographic record. Figure 48 Mounted models on hinge axis.

Treatment plan. We used fixed appliances on both arches
to align and recover the correct position of the gingival mar-
gins by intruding the upper incisors (Fig. 43a-c, 44a-c). Pos-
teriorly, we made provisional crowns for the upper incisors,
so that we could finish the orthodontic treatment properly
(Fig. 45). Once it was finished, we installed a splint MAGO
(Fig. 46). When a stable position was obtained, we did an ax-
iograph recording (Fig. 47), and the models were mounted
on the hinge axis (Fig. 48). We performed negative and posi-
tive coronaplasty on the models (Fig. 49a-c) and transferred
the coronaplasty to the patient’s mouth (Fig. 50a-b, 51a-c).

Figures 49-a, 49-b, 49-c Negative and positive coronaplasty on the models.

26 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figures 50-a, 50-b Extraoral photographs. Posttreatment.

Figures 51-a, 51-b, 51-c Intraoral photographs. Posttreatment.

Patient 5
A 16-year-old female (Fig. 52a-c) came to our office saying,
“My dentist told me that I don’t have enough space for all
my teeth.”

Figures 52-a, 52-b, 52-c Extraoral photographs. Pretreatment.

RWISO Journal | May 2009 27

 Figures 53-a, 53-b, 53-c Intraoral photographs. Pretreatment.

Figures 54-a, 54-b, 54-c Postorthodontic treatment extraoral photographs. Pretreatment.

Figures 55-a, 55-b, 55-c Postorthodontic treatment intraoral photographs.

Dental and skeletal analysis. The patient presented with have no space), and discrepancy between CR and maximum
a canine and molar class II, insufficient overbite for a correct intercuspation. Wear facets, dental extrusions, and unleveled
occlusion, crowding in the upper arch (teeth no. 6 and 11 gingival margins were also present (Fig. 54a-c).

Figure 56 MAGO. Figure 57 Axiographic record.

28 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figure 58 Mounted models on hinge axis.

Figures 59-a, 59-b, 59-c Mounted models on hinge axis.

Figure 60 Mounted models after the negative coronaplasty. Figure 61 Mounting after negative and positive coronaplasty.

Treatment plan. In a previous orthodontic treatment,
fixed appliances had been used, and teeth no. 5 and 12 had
been extracted. Following this orthodontic treatment, den-
tal guidance was inadequate, and there was an important
discrepancy between CR and maximum intercuspation (Fig.
54a-c, 55a-c).
We observed poor exposure of dental material during
smiling. This was due to the wear facets and to the deficient
size of the upper incisors. We decided that a second orth-
odontic treatment was needed, using fixed appliances to
level the gingival margins and to restore the shape of the
arches. After this, we used a splint MAGO to stabilize the
condylar position (Fig 56), made an axiograph recording
(fig. 57), mounted the models on the hinge axis (Fig. 58, 59a-
c), and performed a negative and positive coronaplasty on
the mounted models (Fig. 60, 61). Finally, we transferred the
coronaplasty to the patient’s mouth (Fig. 62a-b, 63, 64a-c,
65a-c). ■

RWISO Journal | May 2009 29

 Figures 62-a, 62-b Extraoral photographs. Posttreatment.

Figure 63 Smile. Posttreatment, postcoronaplasty.

Figures 64-a, 64-b, 64-c Intraoral photographs. Posttreatment, postcoronaplasty.

Figures 65-a, 65-b, 65-c Protrusive movement. Posttreatment, postcoronaplasty.

30 Martin et al. | Orthodontics and Bioesthetics: A Perfect Symbiosis

 Figures 66-a, 66-b Left laterality movement. Posttreatment, postcoronaplasty.

Figures 67-a, 67-b Right laterality movement. Posttreatment, postcoronaplasty.

Figures 68-a, 68-b Pretreatment and posttreatment postcoronaplasty.

Acknowledgements
We would like to thank Evelina Del Carmen Montero for her help in
the translation and publication of this paper. We would also like to
thank Ken Hunt for permission to use his photos.

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Assessment of the Three-Dimensional Condylar and
Dental Positional Relationships in CR-to-MIC Shifts
Ryan Tamburrino, DMD ■ Antonino Secchi, DMD, MS ■ Solomon Katz, PhD
Andres Pinto, DMD, MPH ■ University of Pennsylvania School of Dental Medicine
Department of Orthodontics

Ryan K. Tamburrino DDS Summary

■ Clinical Assistant Professor— Many previous studies have attempted to qualify a relationship between
University of Pennsylvania School of
Dental Medicine, Dept. of
temporomandibular dysfunction (TMD) and various aspects of static and
Orthodontics functional occlusion. Every study was attempting to associate joint dysfunc-
Antonino G. Secchi, DMD, MS
tion and displacement with what could be readily observed at the level of
■ Assistant Professor of Orthodontics- the dentition, when this may or may not be a valid observation. The purpose
Clinician Educator and Clinical of this study was to investigate the magnitude of dental slides and occlusal
Director, Dept. of Orthodontics, changes related to the magnitude of the corresponding condylar shift. The
University of Pennsylvania
results suggest there is no relationship between the amount of dental slide
Solomon H. Katz, MA, PhD in any direction and condylar displacement from CR to MIC. Therefore,
■ Professor of Orthodontics—
University of Pennsylvania, School
assuming the direction and/or magnitude of condylar displacement from an
of Dental Medicine observed intraoral dental slide from CR to MIC is not appropriate.
Andres A. Pinto, DMD, MPH
■ Assistant Professor/Clinician
Educator and Director of the Oral
Medicine/Medically Complex Patient
Care Clinic at the University of
Pennsylvania
For complete contributor information,
please see end of article.

Introduction against the posterior slopes of the articular eminence with

Many previous studies have attempted to qualify a relation-
ship between temporomandibular dysfunction and various
aspects of static and functional occlusion. These projects
have studied static criteria, such as molar Angle classifica-
tion, overjet, overbite, crossbites, and other occlusal charac-
teristics, by observing them intraorally on a patient in centric
occlusion or on nonarticulated study casts (1–21). In addi-
tion, several studies have attempted to incorporate dynamic
criteria, such as nonworking interferences (11–12, 15–17)
and the magnitude and direction of dental slides (1–10, 15),
into the criteria used to determine a patient’s predisposition
to TMD symptoms.
The slide that is referred to in these articles is the tooth
and jaw positional shift that is observed as the patient closes
from a centric relation (CR) position to maximum inter-
cuspation (MIC) of the teeth. Okeson defines CR, or the
musculoskeletally stable position, as the “most orthopedi-
cally stable joint position… when the condyles are in their
most superoanterior position in the articular fossa, resting
the discs properly interposed” (22). According to classical
functional occlusion texts, when the mandible is in CR, only
pure rotational movements of the jaw occur until the lateral
temporomandibular ligament stops the motion and induces
the condyles to move forward (23). Therefore, with the con-
dyles seated in CR and the jaw arcing closed, the patient’s
teeth will eventually contact. This location of the first tooth-
tooth contact is referred to as the primary contact. In most
patients, as Utt et al. (24) have shown, this primary tooth
contact is not likely to be coincident with bilateral equivalent
centric stops as a stable position, and the teeth and jaws will
subsequently slide from this primary contact into the more
stable tooth position of MIC.
As this slide occurs, not only do the tooth relationships
change to accommodate the teeth in MIC, but the condylar po-
sition adjusts from a stable CR position to a new location that is
a slave to the mandibular position of MIC. The direction of the
slide depends on the way the occlusion must be altered to best
accommodate the dentition, irrespective of condylar position.

RWISO Journal | May 2009 33

 Several previous studies on TMD and occlusion have
concluded that signs and symptoms of TMD are seen in
patients who have a larger slide (15), assuming that larger
dental slides correspond to larger condylar shifts from CR
to MIC. Other studies, however, have found no correlation
of TMD symptoms with slides of any magnitude or direction
(6–10). To date, no article has ever proposed a quantifiable
relationship between the amount of observed dental slide
and the corresponding condylar positional change in three
dimensions. This may be the reason for the mixed conclu-
sions of the previous studies. Every study was attempting
to associate joint dysfunction and displacement with what
could be readily observed at the level of the dentition, when
this may or may not be a valid observation. The purpose of
the present study, therefore, was to investigate the magnitude
of dental slides and occlusal changes related to the magni-
tude of the corresponding condylar shift.
Materials and Methods
Population
For this study, we examined 42 orthodontically untreated
children between the ages of 7 and 17 who were seen for
routine treatment in the graduate orthodontic clinic or the
faculty practice at the University of Pennsylvania. No prefer-
ence was given to sex, race, occlusal pattern, skeletal pattern,
number or permanent primary teeth present, or reason for
seeking orthodontic treatment. This population contained
subjects who were included in a larger study on functional
occlusion in orthodontically untreated children and adoles-
cents. The age range of the subjects in the present study was
limited solely to keep this study consistent with future proj-
ects that will use other criteria from this database.
Children who had space maintainers, wore extraoral
or intraoral appliances, had a history of prior orthodontic
treatment, were uncooperative, or had systemic conditions
with craniofacial deformities were excluded from the study.
Records
Maxillary and mandibular impressions were taken on each
child. A CR bite as described by Wood et al. (25), an MIC
bite, and estimated face-bow were also taken on each child.
No attempt was made to prescribe splint therapy for children
who were difficult to manipulate into CR, or who had symp-
tomatic temporomandibular joint (TMJ) or muscle pain at
the time records were taken, nor was any child recalled to
retake the CR bite at a later date. The CR bite obtained on
the initial visit was used as the most accurate bite that could
be obtained on that day.
The maxillary and mandibular impressions were tak-
en with Identic alginate in rim lock alginate trays, poured
34 Tamburrino et al. | Three-Dimensional Condylar and Dental Positional Relationships in CR-to-MIC Shifts
in hand-mixed Vel-mix die stone, and maxillary split cast
mounted with Kerr #2 rapid-set dental plaster on a Panadent
(PCH) semiadjustable articulator in CR. The CR bite was re-
corded using DeLar bite registration wax, and the MIC bite
was recorded using Moyco 10x wax.
Model Examination
The relationships among specific occlusal features of the
models were observed both in MIC, with the MIC wax bite
interposed, and in mounted CR, at the point of the primary
contact. From both of these positions, the following data
were recorded for each patient, using a periodontal probe
for measurement: overjet, overbite, midline position, and po-
sition of the mesiobuccal cusp tip of the maxillary 1st molar
on the buccal surface on the corresponding mandibular 1st
molar. The overbite was defined as the distance in millimeters
from the incisal edge of the mandibular central incisor to the
incisal edge of the maxillary central incisor. In the case of a
height discrepancy between the central incisors, the one mea-
surement with the greater overbite was used. The overjet was
defined as the distance in millimeters from the facial surface
of the mandibular central incisor to the lingual surface of the
maxillary central incisor, tangent to the incisal edge of the
maxillary central incisor. In the case of a buccolingual dis-
crepancy between the central incisors, the one measurement
with the smaller overjet was used. The midline position was
defined as the horizontal difference in millimeters between
the midlines of the maxillary and mandibular dentitions.
The magnitudes of the horizontal change in overjet and
position of the mesiobuccal cusp tip of the maxillary 1st mo-
lar projected on the buccal surface of the mandibular 1st mo-
lar, the vertical change in overbite, and transverse difference
of the midlines were all calculated and recorded.
CPI Recording
The three-dimensional condylar position data for each pa-
tient were collected according to the protocol described by
Crawford (26) and measured with the Panadent Condylar
Position Indicator (CPI).
Results
The results in Figures 1 and 2 show that 21 (50%) of the
patients had posterior condylar movement of the right con-
dyle, and 18 (43%) had posterior condylar movement of the
left condyle. Nineteen of the patients (45%) had mesial right
condyle CR-to-MIC movement, and 23 (55%) had mesial
movement of the left condyle. Thirty-seven patients (88%)
had inferior movement of the right condyle and 33 (79%)
had inferior movement of the left condyle.
 R Condylar CR-MIC Directional Movement
tionship more closely conforms to class II (24, 27). Statisti-
Horizontal Number Percentage
cally, these negative values of the changes in pseudo-class III
Distal 21 50% patients would have falsely represented the data. Therefore,
Mesial 19 45% all positional changes were converted to positive values.
None 2 5% To compare the data, the correlation between dental
Vertical
movements and corresponding condylar movements was
Inferior 37 88%
Superior 5 12% plotted and calculated, as shown in Figure 3. The data were
None 0 0% statistically analyzed by two methods. First, the correlation
coefficient was determined between two variables. Next, the
L Condylar CR-MIC Directional Movement
data for two variables were plotted and a linear “best-fit”
Horizontal Number Percentage
trend line was constructed. The data were correlated to this
Distal 18 43% trend line. The purpose of examining the data in this way
Mesial 23 55% was twofold. First, correlation between two variables was ex-
None 1 2% ecuted to determine whether the CPI-directional and tooth-
Vertical
directional movements were related. Second, the correlation
Inferior 33 79%
Superior 5 12% to the trend line was determined to examine the feasibility
None 4 9% of predicting condylar movement in a certain direction by
observing the dental movement in the same direction.
Figure 1 CPI directional movements.
Dental CR-MIC Movements (mm)
Average Minimum Maximum
CPI R Condyle
Overjet Change 0.74 0.0 3.0
Horizontal Shift
-4.00 Overbite Change 0.99 0.0 3.0
-3.00 L MB6 Movement 0.78 0.0 3.0
-2.00 R MB6 Movement 0.69 0.0 2.5
-1.00 Midline Movement 0.61 0.0 3.0
Vertical Shift

-3.00 -2.00 -1.00 0.00 1.00 2.00 3.00

0.00

1.00 Figure 3 Range of dental movements in millimeters.

2.00

3.00

4.00
For all correlations between pairs of data sets, the R
values were such that no direct relationship between dental
movement and condylar shift in any direction could be made.
CPI L Condyle
In addition, the regression R2 value was determined for each
Horizontal Shift
-4.00 pair of data. For these, too, nearly all of the data sets showed
-3.00
no statistically significant value (R2>0.10). However, for two
-2.00

-1.00
of the data sets, the R2 value was 0.164 and 0.156 for CPI
Vertical Shift

3.00 2.00 1.00 0.00

0.00
-1.00 -2.00 -3.00
left vertical versus overbite and CPI average vertical versus
1.00 overbite, respectively.
2.00
The summary of the correlation statistics is shown in
3.00

4.00
Figure 4, and the dataplots with regression lines are shown
in Figure 5.
Figure 2 Compilation of CPI recordings.

Data concerning dental movements were obtained and

analyzed using Microsoft Excel 2004 software. For all vari-
ables, only the magnitude of the movements was recorded.
This was because several of the subjects had pseudo-class III
functional shifts in which the anterior overjet decreased and
the overbite increased from CR to MIC. Studies have already
described that, in dental movements from CR to MIC, the
overjet increases, the overbite decreases, and the molar rela-
continued on next page...

RWISO Journal | May 2009 35

 Comparison Correlation Coefficient (R) Regression (R2)

CPI L Horizontal/OJ 0.06 0.003

CPI R Horizontal/OJ -0.31 0.094
CPI Avg. Horizontal/OJ -0.15 0.019

CPI L Horizontal/MB6 L -0.14 0.020

CPI R Horizontal/MB6 L -0.17 0.030
CPI Avg. Horizontal/MB6 L -0.09 0.050
CPI L Horizontal/MB6 R -0.14 0.023
CPI R Horizontal/MB6 R -0.23 0.009
CPI Avg. Horizontal/MB6 R -0.09 0.009

CPI L Vertical/OB 0.26 0.164

CPI R Vertical/OB 0.41 0.069
CPI Avg. Vertical/OB 0.39 0.156

CPI Transverse/Midline 0.08 0.005

Figure 4 Data correlation statistics.

OJ change Line Fit Plot

OB change Line Fit Plot
2.5
3

2.5 2

2
ABS Avg. Vert.

1.5
ABS Avg. Horiz.

1.5

0.5 0.5

0
-3 -2 -1 0 1 2 3 4 0
-1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 3
OB change OJ change

MB6 mvmt L Line Fit Plot

MB6 mvmt R Line Fit Plot
2.5
2.5

2
2

1.5
ABS Avg. Horiz.

ABS Avg. Horiz.

1.5

1
1

0.5
0.5

0 0
-2 -1 0 1 2 3 4
-1 -0.5 0 0.5 1 1.5 2 2.5 3
MB6 mvmt L
MB6 mvmt R

CPI Transverse Line Fit Plot

3.5

2.5
Transverse Difference

1.5

0.5

0
0 0.5 1 1.5 2 2.5
CPI Transverse

Figure 5 Data plots of magnitudes of average CPI values vs. dental characteristics, with regression line.

36 Tamburrino et al. | Three-Dimensional Condylar and Dental Positional Relationships in CR-to-MIC Shifts
 Intraoperator reliability testing was performed on a ran-
dom sample of ten patients. The initial data for these patients
were taken during the summer of 2007 or earlier. The data
for these patients were remeasured in May 2008, and the
correlation results shown in Figure 6 indicated good repro-
ducibility of the data.

Comparison Pearson’s Correlation Coefficient

L CPI Horizontal 0.97

L CPI Vertical 0.92
R CPI Horizontal 0.98
R CPI Vertical 0.93
CPI Transverse R 0.94
CPI Transverse L 0.85

CO Overbite 0.98
CR Overbite 0.99
CO Overjet 0.86
CR Overjet 0.98

CO Coincident Midlines 1.00

CR Coincident Midlines 1.00
CO Mandibular Midline L 0.99
CR Mandibular Midline L 1.00
CO Mandibular Midline R 1.00
CR Mandibular Midline R 0.99

MB6 Movement L 1.00

MB6 Movement R 1.00

Figure 6 Reliability testing data for a ten-patient sample.

Discussion to prescribe deprogramming therapy for each patient.

The results obtained in this study are based on first accu-
rately mounting the patient’s casts in CR on a semiadjust-
able articulator. The CR bite registration with a hard an-
terior stop used in this study has been previously validated
as an appropriate technique for recording the CR position
of the mandible (25, 28-30). A basic assumption made for
accurately recording the CR position with this technique is
that the patient’s musculature is relaxed and the joints are
stabilized. An appropriate method for ensuring muscular
relaxation is to use a deprogramming device, such as an oc-
clusal splint or anterior bite plate, for a specified period of
time determined on a case-by-case basis (31-34). However,
the size and time constraints of this study made it impractical
For this study, a modified method of neuromuscular
deprogramming was employed. Following the principles of
simulating a Lucia jig (34, 35), two cotton rolls were placed
between the patient’s maxillary and mandibular incisors,
and patients were instructed to clench and unclench their
teeth onto these rolls intermittently for two minutes before
the centric relation bite registration was taken. While this
method is not ideal, it does interrupt the masticatory muscle
engrams to achieve initial deprogramming of the muscula-
ture and make manipulation of the jaw into CR easier. This
initial recording was sufficient for the purposes of this study.
The CPI data for patients in this study were similar to the re-
sults obtained by Utt et al. (24) and were physiologically sen-

RWISO Journal | May 2009 37

sible, as shown in Figure 7. In addition, Cordray (36) found With a pure dental fulcrum (37), the primary tooth con-
that in 97% his subjects the movement of the condyles was tact in CR is usually on the most posterior teeth in the dental
inferior, with 66.7% of these also having posterior displace- arch. As the patient tries to achieve MIC, this primary con-
ment, while 25.4% had anterior displacement. Only 11.5% tact serves as the point of rotation for the mandible. The por-
of the patients in Cordray’s study had no vertical component tion of the mandible anterior to this contact point will rotate
to their CR-to-MIC condylar shift. Figure 8 compares the counterclockwise upward and forward to close the bite. The
findings of the present study with those of earlier studies on portion posterior to this contact point, which contains the
condylar positional shifts from CR to MIC. condyle, will also rotate counterclockwise, but downward
and backward. Figure 9 illustrates this point with a graphi-
R Condylar CR-MIC Movement
cal representation and a typical CPI recording.
Horizontal Tamburrino, et al Utt, et al15
Distal 21 (50%) 47 (43%)
Mesial 19 (45%) 41 (38%)
None 2 (5%) 19 (18%)
Vertical
Inferior 37 (88%) 80 (75%)
Superior 5 (12%) 9 (8%)
None 0 (0%) 18 (17%)

L Condylar CR-MIC Movement

Horizontal
Distal 18 (43%) 42 (39%)
Mesial 23 (55%) 42 (39%)
None 1 (2%) 23 (32%)
Vertical
Inferior 33 (79%) 80 (75%)
Superior 5 (12%) 7 (7%)
None 4 (9%) 20 (18%)
Figure 9 CPI and graphical representation of a dental fulcrum.
Figure 7 Comparison of percentages of various unidirectional
condylar movements to Utt et al. results. For an anterior displacement, shown in Figure 10, the
Most of the patients in this study also had condylar CPI recording represents what happens when the primary
distractions that were posterior-inferior or anterior-inferior. contact in CR is located on a cuspal incline. As the mandible
This is representative of what happens to the condylar po- closes into MIC, the entire mandible shifts forward along
sitional shift with a dental fulcrum or an anterior displace- the dental inclines. Consequently, the condyle cannot move
ment, respectively. in a direct horizontal fashion, since it is positioned on the

Condylar CR-MIC Movements (Percentage)

Direction Tamburrino, et al. Utt, et al.24 Cordray36 Crawford26

Posterior-Inferior 46 39 66.7 70
Anterior-Inferior 38 29 25.4 Not reported
Posterior-Superior 0 3 Not reported Not reported
Anterior-Superior 8 5 Not reported Not reported
Anterior/Posterior Only 5 18 11.5 Not reported
Inferior/Superior Only 4 6 5.7 Not reported

Figure 8 Comparison of percentages of various multidirectional condylar movements.

38 Tamburrino et al. | Three-Dimensional Condylar and Dental Positional Relationships in CR-to-MIC Shifts
posterior slope of the articular eminence in CR. Therefore, in
order to accommodate the anterior shift of the dentition, it
must move both downward and forward on the eminence.
Figure 10 CPI and graphical representation
of an anterior displacement.
Several of the data points indicated that the condyles
moved upward and forward. This indicates one of two
conditions, both of which present in the same way on the
mounted models and the CPI, as shown in Figure 11. The
primary contact in these cases is usually on a premolar or
anterior tooth, and the mounting in CR commonly has a
posterior open bite. This may signify that the patient’s CR
was not captured accurately due to muscle splinting, or that
the patient postured the mandible forward while CR was
being recorded. However, in the mixed dentition, this condi-
tion is commonly seen even if CR was captured accurately.
Such an occurrence may appear when an erupting perma-
nent tooth causes a slight supereruption of the primary tooth
it is replacing, which subsequently causes this tooth to be
the primary contact. This is the most likely explanation for
these results, since the subjects included many preadolescent
patients.
Figure 11 CPI representation of an anterior primary contact.
No CPI record indicated that either condyle moved in a
posterior-superior direction from CR to MIC on any patient.
This is an anatomically impossible movement, due the defi-
nition of CR and the boundaries of the glenoid fossa. This
observation further supports the biological accuracy of the
data and verifies the other CPI findings for these patients.
When the magnitude of the condylar movements on the
CPI was compared with the magnitude of the dental move-
ments, no correlation was found between horizontal condy-
lar movement and changes in overjet or molar relationship at
the level of the mesiobuccal cusp of the maxillary 1st molar
projected onto the buccal surface of the mandibular 1st mo-
lar. Midline shifts did not correlate with the transverse move-
ment of the condyles. However, two groups of data compar-
ing vertical condylar movements to changes in overbite did
show weak correlations (R2>0.10). This suggests that for
15.6% of the population, there was a reasonable correlation
between the change in overbite and the average bilateral con-
dylar vertical movement; and that for 16.4% of the popula-
tion there was a correlation between the with overbite and
the left vertical condylar movement. While these values may
be statistically significant, they are not clinically relevant.
These findings are illustrated by the fact that several pa-
tients demonstrated large dental movements with minimal
condylar shift, while the converse was true for others. We
will understand why if we study the geometry of the mandi-
ble. As shown previously with the evaluation of the CPI data,
the direction of the condylar shift can vary, depending on
the location of the primary contact. Dental slides from the
primary contact to MIC exhibit different behaviors when the
contact is made on a marginal ridge, on a cuspal incline, or
on an anterior or posterior tooth. One must also remember
that the primary contact, or contacts, can be unilateral or bi-
lateral, and that each contact will affect the direction and the
extent to which each individual condyle will move in three
planes of space. Thus, while the CPI data give a graphic uni-
directional representation of each dimensional movement of
the condyle, the actual movement in the patient is the resul-
tant vector of these three motions. Also, each condyle moves
individually in response to the motion needed to obtain MIC
from CR.
Furthermore, the extent of expression of the dental
movement at the condylar level depends on the distance of
the primary contact from the condyles. Due to the geometry
of the system, the movement of contacts that are closer to
the condyles will be greater than the movement of contacts
that are farther from the condyles. Since each patient’s dental
anatomy is unique, as are the dimensions of the mandible and
the condyles in each patient, the extent of expression of the
dental slide at the condylar level must be different for each
RWISO Journal | May 2009 39
patient. Therefore, since the movement of the condyle de-
pends both on the resultant vector of the dental slide and on
the individual geometry of the patient’s masticatory system,
it is impossible to predict the extent of CR- to-MIC condylar
shift by observing only the intraoral dental slide. Figure 12
illustrates the many variables and geometries that determine
CR-to-MIC shift at both the dental and the condylar levels.
All of these factors must be taken into account.
Figure 12 Illustrations of the complex variables (red), such as
location of tooth contact, mandibular geometry, distance from
the condyle, location of mandibular center of rotation, and
dental shift in three dimensions, that determine the three- di-
mensional condylar positional changes (green).
The clinical importance of this finding is fourfold. First,
it shows that the clinician cannot deduce condyle positional
changes by observing dental movements. Instead, he or she
must measure the positional movements of the temporoman-
dibular joints with instrumentation specifically designed for
this purpose, such as the CPI. Second, in order to determine
the positional changes of the condyle, the clinician needs to
observe the patient’s dentition from models mounted on an
articulator in CR. Otherwise, the instrumentation for mea-
suring the condylar CR-to-MIC positional change cannot be
used, because there is no way to use the CPI or similar in-
strumentation with hand-articulated or heel-trimmed dental
casts. Third, by measuring the CR-to-MIC condylar shift, the
clinician can convert a lateral cephalogram taken in MIC to
one in CR, as Shildkraut et al. (27) have demonstrated. Pre-
vious studies have shown that patients have larger overjets,
shallower overbites, and more closely conform to class II in
the molar and canine region, when they are in CR than when
they are in MIC (24, 27). Since good occlusal function with
good dental health and stability is one of the goals of treat-
ment set forth by the AAO (38), the case should be treatment
planned from CR to allow the clinician to achieve that goal.
Converting the cephalogram helps the clinician to arrive at
an accurate diagnosis. Finally, since the data have shown
that patients with small dental slides can have large condylar
shifts, and patients with large slides can have small condy-
lar shifts, these results suggest that mounting every case and
40 Tamburrino et al. | Three-Dimensional Condylar and Dental Positional Relationships in CR-to-MIC Shifts
observing the condylar position change from CR to MIC in-
creases the likelihood of a correct diagnosis. The clinician
cannot obtain this information, or determine which cases
need articulator mountings, from a patient exam alone.
The results of this study suggest one reason for the dis-
crepancy among studies on TMD and occlusion regarding
the significance of the relationship between the dental slide
and TMD symptoms. If the condylar, rather than the dental,
shift plays a role in the development of these symptoms, this
may partly explain why some patients with gross malocclu-
sions and large dental slides have minimal TMD symptoms,
while other patients with relatively normal occlusions and
small dental slides have severe TMD symptoms. Of course,
this does not take into account the other multifactorial as-
pects of TMD, or the patient’s adaptive capacity—but it does
provide an impetus for further research on this topic to de-
termine the extent of the condylar shift in these subjects.
Conclusions
The data have demonstrated that the magnitude of den-
tal and condylar movement from a CR-to-MIC shift does
not correlate in the horizontal and transverse dimensions,
and that there is an extremely weak correlation in the verti-
cal dimension, which is not clinically significant. The geom-
etry and morphology of each patient’s masticatory system is
unique; this can affect the relationship between the condyles
and the dentition. If the clinician’s objective is to record the
position of the condyles in both CR and MIC so as to under-
stand the direction and magnitude of the condylar shift from
CR to MIC, he or she must use appropriate instrumentation.
Thus, clinically observed dental CR-to-MIC slides in any di-
rection are not valid criteria to associate with joint function
or dysfunction. ■
Notes
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42 Tamburrino et al. | Three-Dimensional Condylar and Dental Positional Relationships in CR-to-MIC Shifts
Contributors
Ryan K. Tamburrino, DDS
■ Clinical Assistant Professor—University of Pennsylvania School
of Dental Medicine, Dept. of Orthodontics
■ Andrews Foundation “Six Elements Philosophy” Course—2007
■ Advanced Education in Orthodontics—Roth-Williams Center
for Functional Occlusion—2008
■ University of Pennsylvania, School of Dental Medicine,
Certificate in Orthodontics—2008
■ University of Pennsylvania, School of Dental Medicine, DMD
—2006
Antonino G. Secchi, DMD, MS
■ Assistant Professor of Orthodontics-Clinician Educator and
Clinical Director, Dept. of Orthodontics, University of Penn.
■ Andrews Foundation “Six Elements Philosophy” Course, USA,
—2005
■ Institute for Comprehensive Oral Diagnosis and Rehabilitation,
OBI Level III—2005
■ Advanced Education in Orthodontics—Roth/Williams Center
for Functional Occlusion USA—2005
■ University of Pennsylvania, MS in Oral Biology—2005
■ University of Pennsylvania, DMD—2005
■ University of Pennsylvania, Certificate in Orthodontics—2003
■ University of Chile—Chile, Certificate in Occlusion, 1998
■ University of Valparaiso—Chile, DDS, 1996
Solomon H. Katz, MA, PhD
■ Professor of Orthodontics—University of Pennsylvania, School
of Dental Medicine
■ Director—Krogman Center for Research in Child Growth and
Development
■ Fellow—Leonard Davis Institute for Health Economics
University of Pennsylvania, PhD—1967
Andres A. Pinto, DMD, MPH
■ Assistant Professor/Clinician Educator and Director of the Oral
Medicine/Medically Complex Patient Care Clinic at the
University of Pennsylvania
■ University of Pennsylvania, MPH, 2007
■ University of Pennsylvania, Certificate, Clinical Research—2005
■ Diplomate, American Board of Oral Medicine—2004
■ University of Pennsylvania, Certificate, Oral Medicine—2001
■ University of Pennsylvania, DMD—1999
■ Universidad Javeriana—Colombia, DDS—1995
Canine Substitution for the Missing Upper Lateral Incisor —
Strategies to Obtain Optimal Dento-Gingival Esthetics and
Functional Occlusion
Straty Righellis, DDS ■ Associate Clinical Professor, UCSF and
Arthur Dugoni School of Dentistry

Straty Righellis, DDS Summary

■ Graduated from UCLA School of While the problem of the missing upper lateral incisor occurs in only 5%
Dentistry, 1971 of the general population, the dental team is challenged to provide optimal
■ Orthodontic certification, UCSF,
1973
treatment outcomes in these cases. This article discusses clinical strategies for
■ Diplomate, American Board of obtaining optimal dento-gingival esthetics and functional occlusion for the
Orthodontics, 1986 substituted-canine solution.
■ Associate Clinical Professor at
UCSF and Arthur Dugoni School of
Dentistry Orthodontic departments
■ Visiting teaching faculty at Roth-
Williams International Teaching
Centers

Introduction
While the problem of the missing upper lateral incisor occurs
in only 5% of the population, the dental team is challenged
to provide optimal treatment outcomes in these cases (1).
When teeth are well proportioned and a complete diagnosis
is made, optimal dento-gingival esthetics and functional oc-
clusion can be readily achieved on a routine basis. However,
when the upper canine is substituted for one or both of the
missing upper lateral incisors, achieving optimal dento-gin- Figure 1 Gingival height of contour of upper central
gival esthetics and functional occlusion is challenging. incisors and upper canines more superior than that
A complete diagnosis and informed consent with the cli- of the upper lateral incisors.
ent produces a treatment plan either to open space to replace
the missing upper lateral incisor with a dental implant or • The long axis of the upper central incisor and the
bridge, or to substitute the maxillary canine for the missing upper canines should be slightly mesial to the gingi-
upper lateral incisor. val height of contour (3) (Figure 2-a).
The scope of this article is limited to strategies to obtain
optimal dento-gingival esthetics and functional occlusion in
the substituted-canine solution.

Optimal Dento-Gingival Esthetics

Objectives. The objectives of optimal dento-gingival esthet-
ics are as follows:
• Gingival height of contour of the upper central inci-
sor and the upper canine should be more superior
Figure 2a Long axis of upper central incisor crown
than the upper lateral incisors (2) (Figure 1). slightly mesial to gingival height of contour.

RWISO Journal | May 2009 43

 • The long axis of the upper lateral incisor should be • Intrude the upper 1st premolar to mimic an upper
coincidental to the gingival height of contour (2) canine relative to the gingival height of contour
(Figure 2-b). (Figure 5).

Figure 5 The upper 1st premolar cemento-

enamel junction position mimics an upper
Figure 2b Long axis of upper lateral incisor
canine cemento-enamel junction.
coincidental to gingival height of contour.

• Dental proportions: The width of well-proportioned
teeth should be approximately 60% to 75% of their
height (4) (Figure 3).
• Apply lingual root torque to better mimic the emer-
gence profile of the lateral incisor. This improves the
emergence profile of the bulky gingival tissue of the
substituted canine. With a preadjusted appliance,
use a lower 2nd premolar bracket on the upper ca-
nine to achieve the best bracket base fit while apply-
ing lingual root torque (Figures 6-a, 6-b, and 6-c).

Figure 3 Width of well-proportioned teeth.

Treatment Strategies
Key tooth positions.
• Angulate the substituted canine to mimic an upper
lateral incisor relative to the gingival height of con-
tour (Figure 4).

Figure 4 The substituted upper canine

mimics upper lateral incisor in angulation
in relation to gingival height of contour.

Figure 6a-c Different case demonstrating

effect of lower premolar bracket on upper
canine (note improved lingual root torque
on upper canine).

44 Righellis | Canine Substitution for the Missing Upper Lateral Incisor

 • Adjust dental proportions as necessary. (Recontour-
ing should be coordinated with a restorative dentist
in advance and at various stages during treatment.)
Often mesiodistal reductions are required on the
upper central incisors to balance adjustments on the
substituted canine (Figures 7, 8, and 9).
Anterior braces removed prior to recontouring

Figure 7 Before recontouring

Figure 8 Immediately after recontouring

Figure 9 After replacement of brackets

Functional Occlusion Treatment strategy. The strategy employed should be as fol-

Objective. The objective of functional occlusion is as follows:
• A mutually protected occlusion should disengage
the posterior teeth during the border movements,
including protrusive and lateral jaw movements, to
provide a healthy masticatory system (5,6,7,8,9,10)
(Figure 10).
lows:
• To achieve this objective, and the objectives listed
above under Optimal Dento-Gingival Esthetics, the
intruded upper 1st premolar requires composite
continued on next page...

Figure 10 Mounted casts demonstrating posterior disclusion during right lateral excursion with composite buildup
to upper 1st premolars to create a mutually protected occlusion.

RWISO Journal | May 2009 45

 buildup to disengage the posterior teeth during man-
dibular jaw movements (Figures 11a and 11b).
With measurable criteria defining optimal dento-gingival
esthetics and occlusal function, and with improved restorative
materials, the dental team can provide improved and stable out-
comes in the canine-substitution solutions when a lateral inci-
sor is missing (11) (Figures 12, 13, and 14). ■

Figure 11a Note interocclusal spaces at

1st premolars postorthodontics.

Figure 11b Note post-1st premolar composite

buildups providing occlusal contact.

Figure 12 Immediate postorthodontics and soft- (laser) and hard-tissue (composite buildup) changes.

Figure 13 Three-year posttreatment.

Notes
1. Graber, Thomas. Orthodontics: Current Principles and Techniques.
2nd ed. St Louis, MO: Mosby; 1994.
2. Janzen E. K. “A Balanced Smile: A Most Important Treatment Ob-
jective.” American Journal of Orthodontics (1977) 72:359.
3. Rufenacht, Claude. “Fundamentals of Esthetics.” Quintessence
Publishing Company: Chicago, IL: 1990
4. Gillen, R. J., Schwartz, R. S., Hilton, T. J., Evans, D.B. “An Analysis
of Selective Tooth Proportions.” International Journal of Prosthodon-
tics (1994) 7:410-417.
5. Ramford, S., and M. Ash, eds. Occlusion. 3rd ed. Philadelphia: W.
Saunders Company; 1983. Figure 14 Before and after smiles.
6. Dawson, Peter. Evaluation, Diagnosis, and Treatment of Occlusal
Problems. 2nd ed. St. Louis, MO: Mosby; 1989:28–33, 41–5, 132.
7. Roth, Ronald H. “The Maintenance System and Occlusal Dynam- and Signs/Symptoms of TM Dysfunction.” Angle Orthodontist (April
ic.” Dental Clinics of North America (1976) 20:761. 1999).
8. Lundeen, Harry. “Centric Relation Records: The Effects of Muscle 10. Okesson, Jeffery. Management of TM Disorders and Occlusion.
Action.” Journal of Prosthetic Dentistry (1974) 31:244. 3rd ed. St. Louis, MO: Mosby; 1983.
9. Crawford, Stan. “The Relationship between Condylar Axis Position 11. Prosthetic work performed by Derric DesMarteau, DDS,
As Determined by the Occlusion and Measured by CPI Instrument Piedmont,CA.

46 Righellis | Canine Substitution for the Missing Upper Lateral Incisor

The Effect of Tooth Wear on a Postorthodontic Pain Patient

Jina Lee Linton DDS, MA, PhD, ABO ■ Woneuk Jung, DDS

Jina Lee Linton, DDS, MA, PhD Summary

■ Graduated from Yonsei University
(DDS, PhD), 1986
■ Graduated from Columbia
University, SDOS, 1988
■ Graduated from Columbia
University Orthodontic Department
(MA), 1991
■ Private Practice at Seoul, Korea,
1991- to present
Woneuk Jung DDS
■ Graduated from Dan Kook
University, 1991
■ Private practice in Seoul, Korea,
1991- to present
Orthodontists have a tendency of ignoring pre-existing dental conditions,
such as wear on tooth material or existing crowns with no anatomic structure.
In the presence of non-chewing side interference, the anterior teeth start to
wear down. As the anterior teeth become shorter, interferences in mandibular
movement increase and the posterior teeth become flatter.
The patient in this article shows that without adequately formed teeth, a
functional occlusion cannot be obtained. Orthodontic treatment should
be detailed and completed with restorative rehabilitation of the lost tooth
material. In order to accomplish functional occlusion with optimal health in
postorthodontic cases, coronaplasty treatment is imperative in most adult
orthodontic cases.

Introduction Dr. Robert Lee, a dentist and a biologist, examined, ob-

Ramfjord and Ash found that individual tolerance level vari-
ations will determine whether or not pain dysfunction symp-
toms will occur in the presence of slight or severe occlusal
interferences. They found, however, that functional occlusal
therapy, if performed with a high degree of accuracy, will
eliminate dysfunctional manifestations in the masticatory
system, by means of splints, equilibration of the occlusion,
restorative dentistry, and orthodontics (1).
In 1972, Dr. Larry Andrews, in “Six Keys of Normal
Occlusion,” proposed static occlusal goals for orthodontic
treatment, thus providing a guideline for the exact position-
ing of each tooth in all three planes of space (2). Dr. Ron
Roth later added keys that relate to occlusal function, and
the orthodontic treatment mechanics that make it possible to
attain gnathologic treatment goals orthodontically (that is,
to attain functional occlusion) (3). Therefore, if one accepts
the treatment goal of coordinated teeth and jaw function,
then diagnosing from, and treating toward, centric relation
(CR) is of paramount importance.
Traditional orthodontic diagnostic armamentaria do
not relate the dentition to joint movement patterns on clo-
sure, or during eccentric excursions. This is probably why
the existence of occlusal interferences that may trigger the
temporomandibular joint (TMJ) pain dysfunction syndrome
has gone largely unnoticed according to Dr. Roth. He also
stated that the symptoms of this syndrome could be created
iatrogenically, by malposition of teeth or a high crown (4).
served, and measured healthy human dentition and soft tis-
sues that showed little or no wear in people over the age
of 30. He noted that such near-perfect natural oral environ-
ments not only exist and function, but are esthetically at-
tractive. It was he who coined the term bioesthetics. Bioes-
thetics is not a technique; rather, it is the observation and
application of the attributes of long-lasting dentitions found
in healthy individuals. Dr. Lee argued that each tooth has a
specific natural form that has a specific function. The length
of the maxillary central incisor, for example, should be be-
tween 11 and 13 millimeters, to provide a separation of at
least 2 to 3 millimeters of clearance at the 2nd molars on the
nonchewing side (5).
To rehabilitate or enhance a human dentition, a healthy
model is required for comparison. Hunt and Turk have de-
scribed this model as having maximization of the anterior
guidance. The maximized anterior guidance allows the reten-
tion or creation of more natural and sharper posterior crown
forms without eccentric occlusal interferences, thereby mini-
mizing the influence of condylar guidance on the morphology
of the posterior teeth. Unworn natural posterior teeth tend
to result in vertical chewing pattern rather than horizontal
chewing, which enhance the established stable physiologic
position of the condyles in CR (6).
RWISO Journal | May 2009 47
 Figure 1 Pre-orthodontic photographs.

Case Report
A female patient initially presented to the authors’ clinic for
resolution of lip protrusion (Figure 1). After clinical and ra-
diographic examination, her study casts were mounted on
a semiadjustable articulator with a centric bite registration,
as described by Dr. Roth. The case was diagnosed as a class
I dentoalveolar protrusion with asymptomatic TMJs. She
was treated orthodontically with fixed straight wire appli-
ances after four first premolar extractions. After 24 months
of orthodontic treatment, the patient was dismissed with re-
movable retainers, which she wore almost every night.

48 Linton, Jung | The Effect of Tooth Wear on a Postorthodontic Pain Patient

 Figure 2 Four-year post-orthodontic photographs

The patient presented to the clinic four years after the
braces were removed, complaining of headaches in the tem-
poral area and right shoulder pain (Figure 2).
Full analysis of functional occlusion was done. Although
her centric occlusion (CO) and CR discrepancy was not
greater than 2 millimeters, the right joint displayed restric-
tion in incisive and lateral border movement during axipath
recording. Upon lateral and protrusive excursions using the
analogue instrumentation introduced by Dr. Lee (7), the pa-
tient displayed inadequate incisal guidance and canine guid-
ance (Figure 3). There were posterior contacts on the non-
chewing side as well as on the chewing side. This lack of
guidance was due to short incisal and canine length, caused
by tooth wear. The upper central incisor was 8 millimeters
long, and the canine was 9 millimeters. The guidelines of the
American Academy of Cosmetic Dentistry (AACD) recom-
mend 12 millimeters for the upper incisor and 12 millimeters
for the upper canine (6).

Figure 3 Mandibular movements

RWISO Journal | May 2009 49

 Given that tooth wear takes place seven times faster in would have become significantly shorter over the years if no
the dentin layer than in enamel, the patient’s entire dentition intervention had taken place.

Figure 4 Measurement of the teeth before additive coronaplasty. The

upper canines and the central incisors were 8.5mm long. (The AACD
recommendation for the upper centrals and the canines is 12mm.)

A CR repositioning splint (8) was used on the patient
for two months, until all of her symptoms disappeared and
a stable condylar position was established. Following splint
therapy, the patient’s true hinge axis points were located, and
her study casts were mounted accordingly. Minimal subtrac-
tive coronaplasty of the posterior teeth was performed to
minimize reduction of her vertical dimension. The lost anat-
omy was added with wax on mounted models. Composite
resin was used to duplicate steep anatomy and redefine cusp
tips (Figure 5). The distance between the upper incisal ce-
mento-enamel junction (CEJ) and the lower incisal CEJ was
maintained (Figure 6). A vertical overlap of 3.5 millimeters,
and a horizontal overlap of 2.5 millimeters were established
(Figure 7). This allowed adequate anterior guidance of the
mandible in excursive movements (Figure 8). As of this writ-
ing, all of the patient’s negative symptoms have disappeared,
and she no longer experiences headaches or muscle discom-
fort. Her bite is stable, and she is pleased with her smile and
with the overall appearance of her face (Figure 9).

Figure 5 Measurement of the teeth after
additive coronaplasty. The upper canine
length was increased from 8.5mm to
10.5mm.
Figure 6 Measurements of the teeth. The Figure 7 Photograph after coronaplasty.
distance from the upper central incisor Front CO intraoral photograph.
cemento-enamel junction (CEJ) to the
lower central incisor CEJ was 14mm in
CO. Upper canines and the central inci-
sors were 8.5mm long. (The AACD recom-
mendation is 18mm.)

50 Linton, Jung | The Effect of Tooth Wear on a Postorthodontic Pain Patient

 Figure 8 Mandibular movement after coronaplasty:
A. Incisive movement of the mandible shows anterior
guidance and 3mm of posterior separation.
B. Right lateral chewing movement shows canine guidance
and 2mm of chewing side separation and 3mm of
non-chewing side separation.
C. Left lateral chewing movement shows canine guidance
and 2mm of chewing side separation and 3mm of
non-chewing side separation.

Figure 9 Comparison before and after coronaplasty:

A. Full smile facial photograph. After bioesthetic coronaplasty, the patient smiles with
less muscle strain on the forehead and around the eyes.
B. Full smile lips. After coronaplasty, the incisal edges follow the lower lip curvature.

continued on next page...

RWISO Journal | May 2009 51

Discussion
The neuromuscular avoidance pattern makes it difficult, if
not impossible, to locate many harmful nonchewing side
interferences intraorally. Many investigators have shown
conclusively that a change in proprioceptive input to the
periodontal proprioceptors caused by a change in occlusion
elicits a change in the neuromuscular response to the lower
motor neuron that can be detected and recorded electromyo-
graphically (3, 9, 10).
Williamson and Lundquist found that when posterior
disclusion is obtained by an appropriate anterior guidance,
the electromyographic activity of the elevating muscles can
be reduced. These authors also found that anterior guidance
will eliminate all lateral forces to the posterior teeth, except
those that are present in the intercuspal position (10). The
anterior guidance allows retention of more natural (sharper)
posterior crown forms without eccentric occlusal interfer-
ence, thereby minimizing the influence of condylar guidance
on the morphology of the posterior teeth. In addition, an-
terior guidance restores comfortable function and prevents
further deterioration (11).
What is the problem posed by existing tooth wear? The
case described in this paper clearly demonstrates that unless
the teeth are adequately formed, adequate function cannot
be obtained. In other words, orthodontic intervention alone
may result in an incomplete occlusion when preexisting
tooth wear is not restored properly. In order to accomplish
functional occlusion with optimal health, we must make use
of the condylar position indicator, neuromuscular depro-
gramming, wax bite techniques, hinge axis registrations, di-
agnostic wax-up, and restoration of the deficient anatomy of
teeth (12). As orthodontists and restorative dentists work to-
gether and continue to improve their knowledge of dynamic
occlusion, the problem of postorthodontic coronaplasty will
no doubt be resolved. Postorthodontic coronaplasty holds
out the most hope for long-range successful solutions to the
problem of adult malocclusion. ■

Notes
1. Ramfjord, Sigurd, and Major Ash.Occlusion. 3rd ed. Philadelphia:
W.B. Saunders; 1983.
2. Andrews, Larry. “The Six Keys to Normal Occlusion.” American
Journal of Orthodontics 62.3 (1972): 296-309.
10. Williamson, Eugene, and D.O. Lundquist. “Anterior Guidance: Its
Effect on Electromyographic Activity of the Temporal and Masseter
Muscles.” Journal of Prosthetic Dentistry 49.6 (1983): 816–23.
11. Hunt, Kenley. “ Full-Mouth Rejuvenation Using the Biologic Ap-
proach: An 11-Year Case Report Follow-up.” Contemporary Esthetic
Restorative Practice 6.6 (2002): 1–6.

3. Thompson, John. “Function: The Neglected Phase of Orthodontics.” 12. Dyer, Eugene. “The Importance of a Stable Maxillomandibular
The Angle Orthodontist 26.3 (1956): 129–43. Relationship.” The Journal of Prosthetic Dentistry 30.3 (1973): 241–5.

4. Roth, Ronald. “Temporomandibular Pain-Dysfunction and Occlusal

Relationships.” The Angle Orthodontist 43.2 (1973): 136–53.

5. Lee, Robert. “Esthetics and Its Relationship to Function.” In: C.R.

Rufenacht, C.R. and Stream, I.L. Carol, eds. Fundamentals of Esthetics.
Chicago, IL: Quintessence; 1990: inclusive page references.

6. Hunt, Kenley, and Mitch Turk. “Correlation of the AACD Accredi-

tation Criteria and the Human Biologic Model.” Journal of Cosmetic
Dentistry 21.3 (2005): 120–31.

7. Lee, Robert. “Jaw Movements Engraved in Solid Plastic for Articu-

lator Controls. Part I: Recording Apparatus.” Journal of Prosthodontic
Dentistry 22.2 (1969): 209–24.

8. Stewart, Hal. “Conservative Full-Mouth Rehabilitation Using the

Principles of Bioesthetic Dentistry.” Contemporary Esthetic Restorative
Practice 10.9 (2006): 46–55.

9. Perry, Harold, Jr. “Functional Electromyography of Temporal and

Masseter Muscles in Class II Division 1 Malocclusion and Excellent
Occlusion.” The Angle Orthodontist 25.1 (1955): 49–58.

52 Linton, Jung | The Effect of Tooth Wear on a Postorthodontic Pain Patient

Hinge Axis — The Need for Accuracy in Precision Mounting

Byungtaek Choi, DDS, MS, PhD ■

Byungtaek Choi, DDS, MS, PhD Summary

■ Graduated from Seoul National The main purpose of using an articulator is to reproduce a patient’s static
University, College of Dentistry and dynamic jaw relationship in order to diagnose and treat occlusal prob-
(DDS), Seoul, Korea, 1981
■ Graduated from Seoul National lems, including temporo-mandibular disorders. Although we may not have to
University, College of Dentistry locate the true hinge axis (THA) in every clinical case, we will have to locate
(MS), Seoul, Korea, 1984 it in those cases where we expect vertical dimension change. Occlusal adjust-
■ Graduated from Seoul National ment, maxillary surgery, and the fabrication of a splint and a tooth positioner
University, College of Dentistry
(PhD), Seoul, Korea, 1990
may change the vertical dimension and these cases need hinge axis mounting.
■ Private Practice, Seoul, Korea In this article, I show the difference between arbitrary hinge axis (AHA) and THA
Chairman of Korean Foundation of mounting and point out the clinical problems that might appear when the casts
Gnatho-Orthodontic Research that are mounted on the AHA do not coincide with the THA.
■ Director of Roth Williams Center,
Korea
■ Attending Professor of Postgraduate
Dental School, Korea University
■ Attending Professor of Medical
School of Hanlim University

Introduction cuspal position (IP) and centric relation (CR). An articula-

Since the early 20th century, dentists have used the articula-
tor. However, orthodontists never really accepted its use in
determining jaw and tooth relations. This holds true even
though dentists in other fields have focused on occlusion
theory, and on the use of the articulator. In the 1960s, Dr.
Ronald H. Roth introduced the concept of functional oc-
clusion into orthodontics, and since then occlusion theory,
together with the use of the articulator, has been taught to
orthodontists who are interested in functional occlusion.
Today’s articulators reproduce mandibular movement
with extreme accuracy. Articulators may be fully adjustable
or semiadjustable. Most dentists prefer the semiadjustable
models, because they are easier to use, although they are less
precise than the fully adjustable models when it comes to
reproducing mandibular movement.
For the diagnosis of orthodontic cases, it is of utmost
importance to observe the occlusion that is related to joints,
and not to the simple digitation of teeth. In the final stage
of treatment, an articulator can be used to make a tooth
positioner for the seating of cusps. It can also be used to
measure the discrepancy of condylar position between inter-
tor is indispensable for occlusal equilibration after appliance
removal. When orthodontists equilibrate the occlusion, they
must locate the hinge axis of the mandible as precisely as
possible. This requires precision mounting of the casts on an
articulator. Additionally, location of the hinge axis is critical
when mounting models for fabrication of a surgical splint
for maxillary orthognathic surgery.
In this paper, Part 1 of a two-part paper, I will define
the hinge axis and discuss the clinical implications, and the
importance of precision mounting from a restorative and
orthodontic standpoint. In Part 2, I will discuss and compare
two systems of condylar path recording, the Axi-Path of the
Panadent articulator, and the Axiograph III of the SAM ar-
ticulator. The purpose of the present study, therefore, was
to investigate the magnitude of dental slides and occlusal
changes related to the magnitude of the corresponding con-
dylar shift.
Hinge Axis and Condylar Position
In order to relate the maxillary model to the articulator, a
face-bow transfer must be made. The purpose of face-bow

RWISO Journal | May 2009 53

transfer is to reproduce the positional relationship of the In 1973, based on clinical investigation, Dr. F. V. Celenza
maxilla with respect to the cranium on the articulator. When concluded that the anterior-superior (AUM) position of the
making a face-bow transfer we use both the right and left condyle in the fossa was the most desirable. (3) This position
mandibular hinge points as posterior references. as well as RUM is independent of tooth positions. The man-
There are two ways to determine these points. One way dible shows a rotational hinge movement around the trans-
is to use the anatomical average value utilizing an ear-bow verse horizontal axis in the AUM position (Figure 3).
type face-bow. The other way is to find the true hinge points
for the individual patient, and to mark these hinge points on
the patient’s skin. The orbital rim is often used as the third
reference point. These three reference points are related to
the articulator with various types of face-bow transfers. The
orbital point along with the two posterior points form the
axis-orbital plane or AOP.
Figure 3 Transverse horizontal axis: The imaginary
axis of the opening-closing movement of mandible
when the condyles are in the AUM position.

The most desirable way to find the transverse horizon-

tal axis is to induce the patient to make an opening-closing
movement in the AUM position. However, we cannot ma-
Figure 1 Arbitrary hinge axis: The imaginary axis nipulate the patient in this position. In order to achieve a
that passes through the estimated hinge points.
reproducible opening and closing movement, the mandible
is manipulated in the RUM position (Figure 4).
Dr. B. B. McCollum (1921), argued that “the mandibu-
lar hinge axis” is the most important factor in dental articu-
lation. He used the term “mandibular centricity” to describe
the positional relationship of the mandibular condyles in
the fossae, and defined it as “the mandible is in centric rela-
tions when both condyles are in their most retruded posi-
tions in the fossae.”(1) In 1969, Dr. C. E. Stuart added the
midmost concept to Dr. McCollum’s idea and later it became
Figure 4 The operator-guided mandibular position
the RUM (rearmost, uppermost and midmost) position.(2)
tends to be the terminal hinge position.
The RUM position, together with the terminal hinge axis
and point centric, were accepted as the basis of mandibular
Terminal Hinge Axis vs. Transverse Horizontal Axis
movement for several decades. But it was argued by many
According to Dr. S. Hobo, if the difference between the two
clinicians that this position might cause unnecessary tension
positions does not exceed 0.3 millimeters, it is not clinically
in the soft tissue of the joint and that therefore it should not
significant. Hobo argues, however, that the stylus for record-
be regarded as physiologic.
ing the rotation of the hinge axis is more stable in the RUM
position, and that the RUM position is preferable for that
reason (Figure 5). (4)

Figure 2 Terminal hinge axis: The imaginary axis

of the opening-closing movement of the mandible
when the condyles are in the RUM position.

Figure 5 The difference between RUM and AUM.

54 Choi | Hinge Axis: The Need for Accuracy in Precision Mounting

 When the bite thickness is less than 3 millimeters, the
difference of 0.3 millimeters between the two positions
causes no significant change in the cuspal path (Figures 6-1
and 6-2).
Figures 6-1, 6-2 The difference between the two positions
causes no significant change in the cuspal path.
Under these conditions, the change of intercuspal posi-
tion does not exceed 25 micrometers. This difference would
have little clinical significance (Figure 7).
Figure 7 The change of intercuspal position is 25µm if the condylar
position changes 0.3 mm when the thickness of the bite is 3 mm.
True Hinge Axis vs. Arbitrary Hinge Axis
Clinical Implications
For convenience, the hinge axis obtained from a hinge axis
recording procedure is called the true hinge axis (THA). It
comprises the transverse horizontal axis and the terminal
hinge axis.
To discuss the difference between THA and arbitrary
hinge axis (AHA) we must define these terms. A THA is the
rotational hinge axis of the mandible created by the rotation-
al opening and closing of the mandible. It can be observed
with an instrument attached to the lower jaw that has an
adjustable stylus approximating the skin lateral to the man-
dibular condyle area. The point of rotation can be found,
recorded on the skin, and with a facebow, transferred to an
articulator. An AHA is an arbitrary rotational axis of the
mandible recorded by an ear-bow type facebow. This type of
face-bow uses anatomical averages to determine the location
of the hinge axis.
A large difference between the THA and the AHA
would be clinically significant because the anteroposterior
cant of the maxillary occlusal plane of a mounted model may
change, depending on the position of the hinge axis.
In the case shown in Figures 8-1 and 8-2, the AHA is
anterior-superior to the THA.
Figures 8-1, 8-2 The AHA is anterior-superior to the THA.
RWISO Journal | May 2009 55
 The arbitrary AOP passes through the AHA. The true
AOP passes through the THA. The true AOP is canted down-
ward posteriorly compared to the arbitrary AOP.
The sagittal condylar inclination is measured by a con-
dylar path recording. Angle A is the sagittal condylar inclina-
tion. If we use the AHA as a posterior reference for face-bow
transfer, the maxillary occlusal plane will become less steep.
When we prepare to do a Le Fort I surgery with man-
dibular autorotation, we need to locate the THA. For both
the surgical treatment objective (STO) and the model sur-
gery, the maxillary position should be assessed on the same
reference plane. If the new maxillary position is not accu-
Figure 9-3 AHA mounting: Vertical excess of the
rately positioned in the model surgery the maxilla will not maxilla will not allow the mandible to rotate.
accept the autorotated mandible in actual surgery. To make
If we try to fit the mandible to the maxilla without changing
the mandible fit the maxilla, the surgeon has no choice but
its position, the condyle must be displaced inferoposteriorly.
to position the maxilla incorrectly.
Very often, maxillomandibular coordination is accomplished
Figure 9-1 shows the upper model mounted on the THA.
at the sacrifice of a correct maxillary position that has been
If we mount the model on the AHA, the maxillary occlusal
determined in STO (Figure 9-4).
plane will rotate clockwise to become less steep (Figure 9-2).

Figure 9-4 AHA mounting: If the maxilla occupies

Figure 9-1 THA mounting.
the connected position, the condyle should move
downward and backward to avoid an open bite.

The large discrepancy between the THA and the AHA

may affect the amount of anterior guidance. Figure 10-1
shows the upper model mounted on the THA.

Figure 9-2 AHA mounting: The occlusal

plane becomes less steep.

When we have determined the new maxillary position, the

next step is to autorotate the mandible. The vertical excess
of the maxilla will not allow the mandible to autorotate as Figure 10-1 THA mounting: Incisal incisor on axial inclination
predicted (Figure 9-3). is 60° and sagittal condylar inclination is 45°.

56 Choi | Hinge Axis: The Need for Accuracy in Precision Mounting

The incisor axial inclination is 60 and the sagittal condylar
guidance is 45°. If the maxilla is mounted on the AHA, the
cant of the upper occlusal plane changes. As a result, the inci-
sor axial inclination changes, and the anterior guidance also
changes (Figure 10-2).
Figure 10-2 AHA mounting: When the cant of the occlusal
plane changes, the incisal incisor on axial inclination and
the anterior guidance also change.
The degree of anterior guidance is directly related to the
amount of posterior disclusion. It may be significant, espe-
cially when the operator sets up the condylar box with a
condylar guidance of average value, because in that case, the
anterior guidance changes, while the condylar guidance does
not.
The large discrepancy between the THA and the AHA
may influence the cuspal inclination of posterior teeth. This
can make a significant difference when occlusal equilibration
or extensive restoration is considered.
U1 to THA is the distance between the upper incisor tip
and the posterior reference point and is measured parallel to
the AOP (Figure 11).
Figure 11 Cuspal inclination may change, depending
on the hinge axis used.
If we use the AHA as the posterior reference point for the
face-bow transfer, the distance between the incisor tip and
the posterior reference point will be U1 to AHA. If we make
a crown on a model that has been mounted on the AHA, the
cuspal inclination will not be the same as it would be on a
THA model.
Two main factors affect the cuspal path. One is the
thickness of the centric bite, and the other is the position of
the hinge axis. Figure 12-1 shows how the deviated hinge
axis affects the cuspal path on the opening movement when
we use a thin bite registration.
Figure 12-1 The deviated hinge axis affects the cuspal
path on the opening movement when the mash bite
(thin bite) is used for interocclusal registration.
When we locate the THA at the accurate posterior reference
point (point C), the cuspal path is represented by line C.
(Figure 12-2).
Figure 12-2 Cuspal path with the THA located at the
accurate posterior reference point T and other points
SB called out on the figures.
If it deviates anterior to the THA, the posterior reference
point changes from C to A, and the cuspal path is repre-
sented by line A (Figure 12-3).
RWISO Journal | May 2009 57
 And if it deviates downward from the THA, the posterior
reference point changes to E, and the cuspal path is repre-
sented by line E (Figure 12-6).

Figure 12-3 Anterior deviation.

If it deviates posterior to the THA, the posterior reference

point changes to B, and the cuspal path is represented by line Figure 12-6 Inferior deviation.
B (Figure 12-4).

When we equilibrate models mounted on the AHA, we

may remove too much or too little tooth material, depending
on the direction of the cuspal path and the degree to which
it deviates from the THA. When we take a centric bite, the
cuspal path is affected both by the amount of deviation and
by the thickness of the bite. Therefore, we should take as thin
a centric bite as possible.

Figure 12-4 Posterior deviation.

If it deviates upward from the THA, the posterior reference

point changes to D, and the cuspal path is represented by line
D (Figure 12-5).

Figure 13 The cuspal path is affected both by the

amount of deviation and by the thickness of the bite.
Here the thickness of the centric bite is 3 mm.

The large discrepancy between the THA and the AHA

may affect the position of the upper mounted model both
vertically and sagittally. This is especially important when
we plan Le Fort I surgery and mandibular autorotation. Fig-
ure 14 shows the upper model mounted on the THA.
Figure 12-5 Superior deviation.

58 Choi | Hinge Axis: The Need for Accuracy in Precision Mounting


Figure 14 THA mounting: The AHA is anterior to the THA.
Note that the AHA is anterior to the THA in Figure 14.
When the upper model is mounted on the AHA instead of
the THA, it will occupy a more posterior position than the
real maxilla does. If we make a surgical splint on a model
that has been mounted on the AHA, the maxilla of the new
position may not fit into the splint of the autorotating man-
dible during surgery. This is especially important in cases of
three-dimensional asymmetries (Figure 15).
Figure 15 AHA mounting. The maxillary cast
occupies a more [posterior?] position.
Figure 16 The difference in cuspal angulation is produced
when the AHA does not coincide with the THA.
Summary
In cases where the AHA deviates greatly from the THA, a sig-
nificant amount of error can be introduced when mounting
a patient’s model on an articulator. When mounting models
on the AHA a thinner occlusal record will help reduce the
amount of error. Conversely, a thicker occlusal record intro-
duces a greater amount of error due to an inaccurate arc
of closure. Since a patient’s initial records are taken on the
AHA and we often diagnose from this mounting, it is impor-
tant that this bite registration be relatively thin. In maxil-
lary surgical cases, occlusal adjustments, splint construction,
and restorative cases it is necessary to mount the case on the
THA. ■
Notes
1. McCollum, B.B. and C.E. Stuart. A Research Report: A Basic Text
for Post-Graduate Courses in Gnathology. Ventura, CA. CE Stuart;
1955: 9–17, 34–46.
2. Stuart, C.E. and I.B. Golden. The History of Gnathology. Ventura,
CA. CE Stuart; Gnathological Instruments 1984:109–114, 139–141.
3. Celenza, F.V. “The Centric Position: Replacement and Character.”
Journal of Prosthetic Dentistry Oct:30(4) (1973):591–598.
4. Cho, Y., S. Hobo, and H. Takahashi. Occlusion. Seoul, Korea.
Kunja; 1996: 47–49, 356–360.
Further Readings
1. Simpson, J.W., R.A. Hesby, D.L. Pfeifer, and G.B. Pelleu. “Arbitrary
Mandibular Hinge Axis Locations.” Journal of Prosthetic Dentistry
Jun:51(6) (1984):819–822
2. Nagy, W.W., T.J. Smithy, and C.G. Wirth. “Accuracy of a Prede-
termined Transverse Horizontal Mandibular Axis Point.” Journal of
Prosthetic Dentistry Apr:87(4) (2002):387–394.
3. Bernhardt, O., N. Küppers, M. Rosin, and G. Meyer. “Compara-
tive Tests of Arbitrary and Kinematic Transverse Horizontal Axis
Recording of Mandibular Movements.” Journal of Prosthetic Dentistry
Feb:89(2) (2003):175–179.
RWISO Journal | May 2009 59