Functional Occlusion for the Orthodontist

RONALD H. ROTH, DDS, MS

In recent years, orthodontists have voiced more and more interest in occlusion and functional
occlusion. There is no doubt that several legal decisions have caught their attention. This, plus the
urgings of colleagues in restorative dentistry and questioning of orthodontic concepts by dentists
interested in occlusion, have caused the orthodontist to seek more knowledge in the area of
functional occlusion and treatment of temporomandibular joint disease. These topics were selected
by 73% of orthodontists responding to a survey of interest in subjects for meeting programs.

Sixteen years ago, I became interested in functional occlusion for several reasons. First, I felt that
the answer to stability of the treated orthodontic case would at least partially rest in the functional
dynamics of occlusion. Secondly, I wanted some assurance that the treatment I had rendered
orthodontically was of benefit to the patient, or at least of no harm to him. And thirdly, I wished to
refute some of the claims made by nonorthodontists, who were also gnathologists, that a good
functioning occlusion could not be obtained if bicuspids had been removed for orthodontic purposes.

Because there was such a myriad of techniques and philosophies to select from, I had no choice
but to learn them all, and then go through a clinical sorting process. This was a task that took a
number of years, a number of courses, and quite an array of instrumentation. In each course, my
"mind set" had to be one in which I was starting from "square one" with an open mind, ready to
learn the clinician’s theory, philosophy, and rationale; and to master his clinical techniques, so that I
could try them and make an evaluation. The good techniques that yielded clinical success were kept,
while those that did not yield a very high percentage of success were reevaluated and then
eliminated.

Since most of the techniques were geared to a general practice or a prosthetics practice and
involved alteration of occlusal morphology either by equilibration or gold work, the next project —
which is still ongoing— was to take the techniques that yielded a high percentage of success and
make them applicable and workable in an orthodontic practice.

Role of Equilibration

At first, I thought that the answer was simply to equilibrate every orthodontic case after the tooth
positions had settled. I later found out, to my dismay, that there is no such thing as a "simple
equilibration", if you wish to establish a stable centric and an excellently functioning occlusion in
eccentric excursions; and I concluded that it is unrealistic to think that equilibration alone will solve
all the problems in orthodontics. In fact, I find it disturbing to see equilibration being pushed upon
the orthodontist as the answer to the functional occlusion problem.

For a case to be equilibratable to a stable centric requires a case that has most of the proper tooth
positions to begin with, and one that is reasonably close to centric.
 The case that is poorly treated and inadequately detailed, or is grossly out of centric, cannot be
equilibrated to a stable centric with the proper anterior guidance in most instances and, in some
instances, it cannot even be restored, but must be retreated orthodontically. So, in my opinion,
continuing to diagnose cases without regard to centric, or the effects of extrusion mechanics on
molars, or without regard to functional detailing of individual tooth positions, will not lend itself to
correction through equilibration. One must utilize a specific set of criteria for a functional occlusion
goal throughout diagnosis, treatment planning, treatment, and retention.

Secondly, performing a correct occlusal adjustment is very time-consuming, if one wishes to

obtain a result that will stay in centric. I do not feel that this is practical for the orthodontist to
pursue on a large majority of his patients, or he would not have time to either earn a living or do
orthodontics.

Thirdly, I do not believe equilibration should be performed until growth has been completed, if at
all possible. The occlusal changes from continued growth would be sufficient to throw a
well-equilibrated case out of centric. Stability of jaws is a prerequisite for a stable equilibration.
Further, I do not believe in a "little bit of equilibration". Many a well-intentioned minor
equilibration has taken an equilibratable case and turned it into a full mouth reconstruction case.

It is my goal to straighten teeth well enough, that I can eliminate having to do equilibration on the
large majority of my cases. On the few cases that need to be equilibrated, I can afford the time to do
it right at the correct time.

Philosophy and Rationale

I think that the large majority of orthodontic cases can be treated to a good functional occlusion,
given a reasonable degree of patient cooperation, but it will take more on the part of the orthodontist
than just thinking about functional occlusion after the appliances are removed.

The literature is replete with articles on functional occlusion, written by orthodontists, which
reach unsatisfactory— if not dangerous— clinical conclusions regarding the application of
functional occlusion concepts to orthodontics. There are also those who are not orthodontists, who
propose to tell the orthodontist how to solve his occlusion problems. Unfortunately, the simpler the
solution, the larger the "bandwagon". The answer to application of functional occlusion concepts
clinically is not a quick and simple task in orthodontics.

There are many who will not agree with my conclusions and concepts. However, I have
documented and demonstrated time and again— to my satisfaction— the clinical workability and
repeatability of these concepts on real live patients. There may, in the future, be a better way to meet
the objective but, as far as I am concerned, the objectives have already stood the test of time.

Treatment Objectives

Perhaps it would be best to start with a list of treatment objectives:

1. Pleasing facial esthetics, evaluated by soft tissue and skeletal measurements cephalometrically.

2. Molar relation and tooth alignment, evaluated by Angle’s description of anatomical occlusion.

3. Functional occlusion, evaluated gnathologically on an articulator.

4. Stability of postreatment tooth positions and alignment.

5. Comfort, efficiency, and longevity of the dentition, supporting structures, and the
temporomandibular joints.

There is no clinical approach or technique in dentistry that has ever been devised that will not
work on someone. What we are dealing with in the reality of clinical practice is to utilize those
approaches that will yield the greatest percentage of clinical success and the lowest percentage of
failure. We want a highly consistent batting average when it comes to day in and day out treatment
of our patients. After all, nobody enjoys failing, especially in a large percentage of his endeavors.
However, the human mind has a tremendous ability to rationalize away our mistakes and failures,
and it is seldom that we really want to "bite the bullet" and take a cold, hard look at what we have
produced. This is particularly true if taking that cold, hard look involves a lot of time and effort.

It is necessary to define some terms and lay down the basic concepts of what functional occlusion
is all about, before proceeding into a discussion of techniques and their clinical application.

Primarily, as we explain to our patients, the lower jaw should be seated all the way up into its
sockets on both sides and be centered, when it is in its most "ideal" or "physiologic" position. When
the jaw is closed from this position to a position of maximum closure, the teeth should "mesh" and
should not cause the jaw to be pulled forward or down out of its socket on either the right or left
side. Not only should the teeth mesh or intercusp upon closure, when the jaw is in its ideal articular
relationship, but the teeth should not interfere with the full extent of movement that the jaw is
capable of making in any possible direction. This very simply explains the concept of "harmony" of
the occlusion with the temporomandibular joints so that anyone, including the patient, can
understand it.

There is an ideal position for the condyles in the glenoid fossae (Fig. 1) and the mandible should
be able to move in any possible direction without the teeth getting in the way of the joint-dictated
movement pattern (Fig. 2). The mandible should also be able to close into maximum intercuspation
without deflecting the condyles from their most "ideal" relationship in the fossae.

Not too many people in dentistry would argue with this explanation. Most concepts or
philosophies would be covered by this definition of harmony of the occlusion with the jaw joints.
Why, then, are there so many seemingly conflicting approaches to the problem to establishing a
good, well-functioning occlusion? The answer to this question lies in four areas:
1. Defining the "ideal" relationship of the condyles in the fossae.
2. The degree of accuracy necessary to record the full extent of jaw movement (border movement)
(Fig. 3).
3. The type of centric contacts (Fig. 4) and the type of excursive occlusal scheme (Fig. 5).
4. The type and accuracy of instrumentation to be used (Fig. 6). The means used to check the
end-of-therapy occlusion will vary from one philosophy to another, so the accuracy of the method
used to assess the occlusion is a factor in determining how reliable a check has been performed.
There is also one other factor to be taken into consideration when one attempts to define or select
a treatment philosophy, and that is— What is your treatment objective? If your goal is to achieve an
occlusion in which centric relation of the mandible and centric occlusion of the teeth are identical,
then you must check to see if you have accomplished this objective after the completion of therapy.
However, if your objective is alleviation of pain by alteration of the occlusion, then it makes little
difference where the mandible is when the teeth occlude, as long as the patient no longer complains
of pain. The latter approach may work for some patients but, in my opinion, not for the majority.

The orthodontist has a different problem than the restorative dentist. The restorative dentist
wishes to build cusps with the greatest cusp height possible. In order to do this, he must follow the
dictates of condylar guidance, and place the cusps properly and construct an anterior guidance that is
in harmony with condylar guidance. The orthodontist already has the cusps and the ridge and groove
directions. He must arrange the teeth and treat the anterior teeth so that they are in harmony with
condylar guidance, and adjust the occlusal plane in relation to the angle of the eminence, so that the
cusps that he already has will clear. The restorative dentist must build cusps into centric, while the
orthodontist must take the cusps he was given and not only fit them into centric, but make them
clear upon movement.

Centric Relation

Centric relation, in my mind, represents an idealized treatment goal.

Centric relation of the mandible is a superior limit position of the condyles in the fossae with the
mandible centered and at its most closed position. On a cephalometric laminagraph of the joint, the
condyle would appear centered anteroposteriorly and there would be little superior joint space in
most instances. There are exceptions to this generality, due to morphologic differences between
individuals and due to the fact that it is not possible to adequately describe a three-dimensional
relationship in a two-dimensional medium. The condyles cannot be retruded from this position
without moving inferiorly in most instances. Centric relation is not found with the condyles
appearing back against the tympanic plates. If this is what is seen on the x-rays then the condyles
are not in centric relation.

In all of my experience, I have yet to see a patient who had a problem because he had a
centrically related occlusion. On the other hand, I have seen many patients who were supposedly
treated to a centrically related occlusion, who were uncomfortable and "wanted to come forward".
But in the final analysis, none— I repeat— none of these patients were found to actually be "in
centric".

The fact that someone’s occlusion is not centrically related is not, by itself, an indication for
treatment. There are people who have occlusal discrepancies and are asymptomatic. Therefore, the
fact that someone’s occlusion deviates from your concept or my concept of an ideal occlusion does
not necessarily give us the right to treat that patient. But, if there is sufficient cause to treat, my
personal preference for a treatment goal would be a centrically related occlusion in which the
intercusping of the teeth takes place with the mandible in centric relation.

To be sure, there are some patients who are not comfortable in centric. These are the same
patients who are not comfortable anywhere. There are some patients on whom occlusal therapy
alone is not successful or where the problem has to be dealt with by means other than the alteration
of the occlusion. However, these represent a small percentage of the patients, in my experience.
Many patients who have had unsuccessful occlusal treatment can usually be corrected by occlusal
therapy, if correctly performed.

Centric relation, contrary to popular opinion, is not a strained position. It is only a strained
position if attempts are made to forcibly retrude the mandible and make the teeth contact where they
do not intercusp. When the teeth fit together with the mandible seated properly in centric relation,
there is no strain. Patients will let you close the mandible where their teeth fit and not where the
teeth do not fit. It is as simple as that.

Electromyographic studies done by Williamson et al at the Medical College of Georgia seem to

indicate that the physiologic positioning of the condyles as determined by the musculature is a
superior-anterior fossa position, where the condyles are seated in the fossae against the
superior-posterior slope of the eminence. Tooth interferences prevent the muscles from seating the
condyles properly.

Stuart defined centric relation as the rearmost, midmost and uppermost position of the condyles
in their respective fossae with the mandible at its most closed position. For years, the emphasis in
describing centric relation of the mandible has been "rearmost" position. This is unfortunate,
because the emphasis should have been placed upon capturing the uppermost or superiormost
position attainable. Dyer and then Dawson have both expressed this opinion in recent years and I am
in total agreement with them. The problem is that when one is dealing with a patient who has
damage to the temporomandibular ligaments, and has excess mobility of the condyles, it is virtually
impossible to push the mandible distally without causing further inferior positioning or subluxation
of the condyles, unless care is taken to support the gonial angles, and even then it is doubtful that
subluxation could be avoided without prior use of a repositioning splint to obtain a stable centric
relation.

Recognizing Occlusal Disharmony

You may wonder at this point what all this discussion about centric relation and repositioning
splints and TMJ problems has to do with the average child’s orthodontic treatment. Even if you have
no intention of treating TMJ patients or using repositioning splints, don’t stop reading just yet.

I have heard so often from so many orthodontists that they are only interested in doing what they
call "standard ortho" and don’t want to get involved in "all this stuff". However, everyone must
realize that to move teeth is to become involved in "all this stuff", like it or not. So, even if you have
no intention of seeking out TMJ cases to treat, it would still behoove every orthodontist to
understand how to avoid triggering or creating an occlusal problem.

Many of our patients are potential problems "just lying in the weeds", waiting for us to come
along and just change something in the occlusion. If we are smart enough to recognize these
potential or existing problems prior to blissfully embarking upon orthodontic treatment, a good deal
of grief for both the orthodontist and the patient could be avoided.

It is first necessary to know the signs and symptoms of occlusal interferences, if we are to
recognize our potential problem cases. The following is a list of signs or symptoms from occlusal
interferences:
1. Occlusal wear.
2. Excessive tooth mobility.
3. Temporomandibular joint sounds.
4. Limitation of opening or movement.
5. Myofascial pain.
6. Contracture of mandibular musculature, making manipulation difficult or impossible.
7. Some types of tongue-thrust swallow.
If a patient has any of these signs or symptoms and the mandible is difficult to manipulate, it
would be wise to pursue a cautious course of action and use a splint to see if the symptoms can be
eliminated or alleviated and what changes occur in mandibular position, before placing orthodontic
appliances.

For whatever reasons, most dentists and orthodontists do not consider most of the above list as
signs of occlusal disharmony. Unless the symptoms are severe, the tendency is to ignore the signs or
symptoms.

It is important to realize that a "little bit of clicking" of the TMJ’s is abnormal. That occlusal wear
is abnormal, unless the patient is chewing whale hides for a living. We must be aware that when
occlusal harmony is present, most of these signs are not present.

We must realize that the patients we are treating, for the most part, are children with
exceptionally high tolerance levels and adaptive capacities. We must also realize that tolerance
levels decrease with age. Therefore, what the child patient can tolerate in terms of occlusal
interferences at the age of 14 or 15, he may not be able to tolerate at age 20 or 25, without
symptoms. Patients do not adapt to occlusal interferences, they tolerate them; but they tolerate them
less well as they get older.

When the patient’s tolerance level and adaptive capacity have been exceeded, the patient will
become symptomatic. Therefore, we must look for signs of occlusal disharmony prior to orthodontic
treatment, if we wish to avoid precipitating symptoms that are severe enough for the patient to
consider them a problem.

It is interesting how most patients will say that they want straight teeth when they are seeking
orthodontic treatment, but how they will say that they went through orthodontic treatment to get a
better "bite" once a functional problem appears.

In terms of their reactions to occlusal interferences, patients could be classified into three
categories:
1. Those with symptomatology.
2. Those that are either psychologically and/or physically predisposed to developing a problem.
3. Those that are neither symptomatic nor predisposed to developing symptoms.
Everyone in our society must live with a certain amount of psychological stress. Some people
vent their stress outwardly and others inwardly. Of those that vent stress inwardly, the two favorite
places are the gut, and the teeth and jaws. If an individual vents his stress by utilizing teeth and jaws
with occlusal interferences, symptomatology will ensue when the tolerance level is physically
surpassed. OCCLUSAL INTERFERENCES TEND TO MAKE TEETH AND JAWS A FOCUS
FOR VENTING PSYCHOLOGICAL STRESS. When the teeth and jaws are stressed by gnashing,
clenching, and grinding, the weakest link or links of the chain will break down. If the patient is
prone to periodontal disease, the working over of occlusal interferences in the presence of plaque
will start periodontal breakdown. If the periodontium and hygiene are good, the patient may
experience occlusal wear. If the joints are the weakest link in the chain, then the patient may
develop temporomandibular joint dysfunction or disease. Patients may develop symptomatology in
any or all of these areas simultaneously.

Aside from the adaptive ability decreasing with age, added psychological stress may precipitate
symptoms, or increasing the size or number of occlusal interferences may also precipitate symptoms.
In many instances, we may have a situation in which the clinical symptomatology is of a minor
nature and the patient is in a delicate balance, accommodating to his existing occlusion, but just
barely. Here is a situation in which he is on the precipice, just waiting for someone or something to
push him over the edge. In could be a traumatic insult, or a sudden stretch of tense mandibular
musculature, or increased psychological stress, or it could be just any change in the occlusion, even
a minor one.

So, the patient with "minor" or subclinical symptomatology could be just waiting for someone to
subject him to orthodontic tooth movement, before the symptoms become overt. Once this has
happened, there is usually no turning back. The orthodontist has now got the ball and he’d better
know which way to run.
 I have had innumerable orthodontic patients referred to my office both after and during
orthodontic treatment, because they had a TMJ problem that suddenly occurred. I have treated my
own postorthodontic TMJ cases and the histories of these patients have led me to believe that many
of the problems could have been avoided or, at the very least, recognized as a problem before
treatment began. Yet, the emphasis today is still being placed, by many clinicians, on what to do
"after the fact".

Examination

On initial examination, the orthodontist should attempt to manipulate the mandible into clinical
centric relation (Fig. 7). This is a skill that must be learned. It is not an inherent capability, as many
seem to think.

The patient must be sure that the operator will not attempt to slam his jaw shut where his teeth do
not fit, if he is going to allow the operator to manipulate his jaw in an attempt to close it. The easiest
way to accomplish this is to place the left thumb and forefinger over the patient’s upper teeth. The
right thumb should be placed on the superior aspect of the pogonion applying downward pressure,
and the right forefinger and second finger placed under the gonial angles applying upward pressure.
The right arm should be stiffened, so that a distal pressure can be applied to the mandible by leaning
from the shoulder, using the weight of the operator’s upper body. The pressure being applied
downward on the chin keeps the patient from closing; and his attempt to close will cause his own
musculature to seat the condyles superiorly, which is exactly what is desired.

As the mandible is manipulated in this fashion, the patient is instructed to "let go" and allow the
jaw to move in the direction that pressure is being applied. The patient is instructed to close until his
lower teeth barely touch your fingers that are covering the upper teeth, and he is assured that you
will not attempt to touch his teeth together at this point.

Once the mandible is back and the condyles seated superiorly, the patient is instructed as follows:
"When I remove my fingers from between your teeth, keep your jaw where it is right now, and very
slowly hinge it closed on this arc until you just begin to feel something touch and then stop. Do not
let your jaw go where your teeth fit." The operator can then remove the fingers from between the
patient’s teeth and see the first centric contact.

If the mandible is easy to manipulate, then what can be seen clinically is usually a fair
representation of the actual discrepancy. If the discrepancy is a large one, a mounting on a simple
anatomical articulator (such as a Whip-Mix or Hanau) is indicated, so that the discrepancy can be
studied and steps for its correction can be integrated into the treatment plan.

If the mandible is difficult to manipulate and upon attempting to hinge the mandible closed a fair
amount of resistance is encountered; and then, once the teeth are contacted, there is no centric
prematurity, do not believe what you are looking at in the mouth. The patient has closed into his
habitual centric occlusion and the musculature is in a state of contracture, to posture or
accommodate the mandible to the existing occlusion. It will require splint therapy to free the
musculature, so that the true discrepancy can be revealed (Fig. 8).

The temporomandibular joints should be palpated for popping or grating sounds. The
musculature should be examined for tenderness. If these signs are present, then splint therapy and
cephalometric TMJ tomograms are indicated, prior to attempting to begin orthodontic treatment.

The occlusion should be inspected for wear facets and checked to see if the patient can contact
these areas of wear or faceting. If he cannot, you cannot accept the occlusion that you are looking at
intraorally as a basis for your orthodontic treatment plan. You, again, will need splint therapy to
unmask the true discrepancy.

The patient should be checked for his ability to execute left and right lateral excursions and
protrusive movements. If the patient cannot execute gliding movement on the anterior teeth in all
excursions, you can rest assured that there are posterior interferences or incorrect anterior coupling,
even though this may not look like the case intraorally. For instance, if the patient cannot keep the
anterior teeth together in a protrusive movement either from centric forward or protrusive back,
there is a severe enough posterior interference present to prevent him from making this movement
without separating his teeth. You may not be able to demonstrate these interferences intraorally, but
with some splint therapy and a simple articulator mounting, the presence of these interferences will
become apparent. This form of intraoral "negative" testing can be employed to check a case all the
way through orthodontic treatment. In other words, you can never determine intraorally that a case is
free from interferences, but it can be determined intraorally when interferences do exist, even
though they cannot be demonstrated intraorally. This is an extremely important concept, but
unfortunately one that people will not accept until it has been demonstrated to them time and again.

The amount of maximum opening should be noted (Fig. 9), as it is an indicator of the state of
contracture of the mandibular musculature. Normal maximum opening from the incisal edge of the
lower incisors to the incisal edge of the upper incisors averages approximately 45 to 50mm.

The patient’s occlusion can also be tested by attempting to tap his teeth together with the
mandible in centric relation position. The patient whose occlusion is close to being in centric
relation will allow his mandible to be opened / of the distance on the hinge-axis and will let the
operator firmly tap his teeth together. If the patient will not allow you to do this, you can be sure he
is posturing his mandible to accommodate to the occlusion and to the tooth intercusping. Some
patients will allow you to tap their teeth together, but will not let you open their mouths more than a
few millimeters. These patients are also posturing the mandible to gain a tooth "fit", and the reason
they will not let you open them any further is because they will not be able to determine
proprioceptively where the mandible belongs to allow the teeth to intercusp. SO DON’T BE
FOOLED.

Diagnosis and Treatment Planning

 If these simple clinical checks are made upon examination, the orthodontist can readily tell
whether or not to be suspicious, and if he should pursue the matter further. Whenever any of the
symptomatology mentioned is found on examination, it is wise to utilize splint therapy to unearth
the true maxillomandibular relationship prior to placing orthodontic appliances. If we have a patient
that has a very sizeable centric discrepancy and the orthodontist is unaware of this situation, then it
is quite unlikely he will select the proper treatment plan to treat the case into centric.

For instance, if a case presents in which the molar relationship is Class I in habitual centric
closure with a normal degree of overbite, but which is crowded, the orthodontist will select a plan to
alleviate the crowding only. However, if the case when mounted on the articulator in centric relation
shows a marked open bite and an anteroposterior discrepancy of 3 to 4mm, a much different
treatment plan would have to be made to deal with the vertical and anteroposterior problems, as well
as the crowding. The open bite and the anteroposterior discrepancy are hidden discrepancies on
intraoral examination. It may require repositioning splint wear to get the patient’s mandible into
centric, to make the true discrepancy apparent. Once the discrepancies are apparent, the orthodontist
will make a treatment plan to deal with all of the discrepancies present in the case; not just one to
cover only those discrepancies he can see intraorally.

The neuromuscular positioning of the mandible to accommodate to occlusal discrepancies will,

many times, hide the true discrepancies from us. We must be aware of what the maxillomandibular
relationship is in centric relation position of the mandible and diagnose the case from this position,
if we are to consistently select treatment plans that will allow us to treat to or very near to centric
relation occlusion.

This means that records must be obtained as close as possible to centric relation. Standard
orthodontic models and cephalometric headfilms have been traditionally taken in habitual centric
occlusion. We must have records taken in centric relation as well, if any significant centric
discrepancy exists in a particular case. This is necessary for us to evaluate how much of the
discrepancy lies in which planes of space, so that we can elect to use the appropriate mechanics that
will deal with each of the discrepancies.

For instance, we may have a case in which there appears to be unilateral Class II molar
relationship, but in centric relation of the mandible there is really a bilateral Class II molar
relationship end-on. If we base our mechanics upon a unilateral Class II relationship and treat
accordingly, we will wind up with a case treated out of centric that is bilateral Class I in habitual
centric closure and unilateral end-on Class II on the side opposite the original habitual centric Class
II in centric relation. If it is bilateral end-on Class II then our mechanics must deal with a bilateral
Class II situation, in order to be able to finish the case in bilateral Class I and in centric relation
occlusion .

When we mount cases on an articulator or look at the case intraorally while it is propped open on
the first centric contacts, we will see an overjet of the incisors. It is not possible to know by looking
at this overjet how much of it is due to the hinging open of the mandible and how much is a true
anteroposterior discrepancy. The only way to find out is to mount models on an articulator
transferred from an accurately located hinge-axis, and then remove the interferences on the models
until the vertical overlap of the incisors is the same as the habitual centric overlap. Now you can
measure the difference in overjet between the habitual centric closure and the hinge-axis centric
closure on the equilibrated models (Fig. 10), and divide the discrepancy into its vertical and
horizontal components.

A template of the mandibular tracing can be superimposed over the original, and the mandibular
template can be slid distally along the occlusal plane the amount of the anteroposterior discrepancy
and then retraced (Fig. 11). When new measurements are taken of this adjusted position of the
mandible, the cephalometric picture of the amount of discrepancy that must be corrected will be a
much truer one.

The difference at the incisal guide pin will give you the vertical discrepancy, and the horizontal
difference can be measured with a Boley gauge or dividers. If the midline relationship is off, it may
be because of asymmetry of maxilla or mandible, or a discrepancy in the transverse plane of space.

In some cases, the discrepancy between centric relation occlusion and habitual centric closure
may be mostly in the vertical dimension. If the condyles are seated superiorly in the fossae and the
mandible hinged closed to the first centric contact, the result is a severe open bite anteriorly. The
treatment efforts then are directed towards closing the open bite by intruding molars, extraction of
teeth and forward sliding of molars, or orthognathic surgical procedures. This may have to be
followed by equilibration and/or restorative procedures. The important point is to be aware that this
"hidden open bite" exists, and then treatment plan accordingly.

In diagnosis and treatment planning, it is necessary to diagnose the case from a mandibular
position of centric relation, if you wish to treat to centric relation occlusion.

In order to begin thinking about fitting of teeth together in centric relation, it is first necessary to
get the jaw relationships correct in all three planes of space (transversely, horizontally, and
vertically). The total dental arches have to be related to each other, so that there is buccolingual
coordination of the basal arches and anteroposterior adjustment so that there is no horizontal overjet,
and there must be sufficient closure of the mandible to provide a vertical overbite. The orthopedic or
surgical requirements of this type of dental arch and overbite correlation are necessary to get to the
point where adjustment of tooth positions becomes meaningful in terms of allowing centric closure
of the mandible and coupling of the anterior teeth. It does little good to position teeth carefully, if
there is a massive discrepancy in the relationship of the dental arches to each other when the
condyles are in a centrically related position in the fossae.

A stable or "true" centric relation can almost never be captured on the first clinical attempt. This
is particularly true if the patient has signs or symptoms of TMJ dysfunction, but it is also true under
almost any circumstances, regardless of symptomatology. The repositioning splint must be used any
time a "true" centric registration is to be obtained. Attempts at mandibular manipulation alone are
not adequate to insure that one has captured a true and stable centric. True centric can be stabilized,
if there are no degenerative joint changes in a nongrowing patient. The cephalometric tomogram of
the TMJ is a good indicator of the state of the bony elements of the joints, but degenerative changes
may be going on in the soft tissues that do not show up on x-ray examination.

Interpreting TMJ Tomograms

It is unfortunate that, for years, those clinicians that have mounted cases did not look at TMJ
films, such as oriented tomograms, and those clinicians that have looked at films have not mounted
cases. It is like blind men trying to describe what an elephant looks like, while one is feeling a leg,
another the trunk, and a third the tail.

To add to the complication, there are different mounting techniques employed at different times
and there are many types of TMJ x-rays from which conclusions have been drawn regarding
condylar positioning. Unless assessments regarding mandibular condylar positioning are done
utilizing both modalities, communication will never be established between the varying
philosophies. There has to be some standardization of methods employed for assessing condylar
position.

Because of anatomical variations between the size and shape of the condyles and fossae and
because centric relation is a three-dimensional relationship, it is virtually impossible to establish an
x-ray definition of centric relation that will hold up in the majority of cases. Besides this, what may
appear to be "normal" positioning in an x-ray, such as a cephalometric tomogram, may be off by a
fair amount from centric relation on an accurate centric mounting. There is no doubt that
cephalometric tomography of the joints is of great diagnostic benefit, but there is also no doubt in
my mind that it will not replace the three-dimensional mounted casts, any more than cephalometrics
will replace orthodontic study models.

Because of the lack of emphasis that has been placed upon the clinical importance of obtaining
the superior position of the condyles in the fossae, there are many patients who were supposedly
corrected to centric relation that are still symptomatic. If one were to obtain a cephalometric
tomogram of the TMJ’s with the teeth in occlusion, it would be evident in most cases that the
condyles are in an inferior distal position near the tympanic plates (Fig. 12). This would be what the
knowledgeable gnathologist would refer to as a "subluxated" and incorrect centric position. The
expert in tomographic interpretation of TMJ films would also say that the condyles are in the wrong
position, as they are not centered in the fossae. The problem is that the expert in tomographic
interpretation has also concluded, since the patient is supposed to be in "centric," that the incorrect
condylar position that he sees on the film is gnathologic centric. Gnathologic centric, in most
instances, will appear to have the condyles in the superior and anterior fossa position that is usually
considered normal by the radiologist. There are, of course, some exceptions, but these are usually
found on patients who have suffered ligament damage and have excess mobility of the TMJ’s.

So, in the large majority of cases, gnathologic centric relation will yield a normal looking position
 on a cephalometric tomogram. But it is important to realize that a normal looking position on a
cephalometric tomogram does not necessarily mean that the patient has a centrically related
occlusion. This is because the three-dimensional relationship of the condyles in the fossae is reduced
to two dimensions on the tomogram. Therefore, slight movement of the condyles, particularly lateral
or vertical axis rotary movements will be difficult, if not impossible, to discern when this type of
movement occurs in small amounts between centric relation and centric occlusion. However, a very
small movement of one or both condyles can incur quite a large occlusal discrepancy, as many who
routinely mount cases can attest.

Although the cephalometric tomogram may be better than most x-rays for diagnosing condylar
position, it is not accurate enough to be able to say that, if the condyles appear to be in a normal
position radiographically, the patient has a centrically related occlusion. The best that can be said for
reading position of the condyles into a cephalometric tomogram, in my opinion, is that if the
condyles appear to be in an abnormal position, you’d better believe it. On the other hand, if the
condyles appear to be in a normal position in the fossae on the tomogram, it does not necessarily
mean that the case is in centric relation. In fact, there could be a considerable occlusal discrepancy
noted if models were to be mounted on an anatomical articulator in centric relation, even though the
condyles appear on the x-ray to be well-related in the glenoid fossae. This is not a rarity, but a rather
common clinical finding.

RONALD H. ROTH

FIGURES
Fig. 1

Fig. 1 Normal condyle-fossa relationship as it appears on a cephalometric tomogram. Norms established by Dr. R.M.
Ricketts.

Fig. 2

Fig. 2 A. Anatomic controls of mandibular envelope of motion with a three-dimensional Posselt diagram. B. Axes ot
rotation d the mandible. C. Projection of the movement of the mandibular hinge-axis. (Photos courtesy of Dr. Niles
Guichet and Denar Corporation.)

Fig. 3

Fig. 3

Guichet and Denar Corporation.)