The Internationai Journai of Periadantics & Restarotive Dentistry

113

Twin-Stage Procedure. Part 1: A New Methiod to Reproduce Precise Eccentric Occiusai Reiations

Sumiya Hobo, DDS, MSD, PhD' Hisao Tai<ayama, PhD"^

The condyiar path, the incisai path, and the cusp angle determine the omount of disocoluslon during eccentric movement. In ptosthodontics, fhe condylar path has been used as the main determinant of aodusion. However, the mefhad fo derive the incisai path and ousp angle ftom the condyior path is not known, and fhus if has been difficult fo scienfifically reproduce fhe amount of disooclusion on a restorafion. This study describes the Twin-Stage Procedure, in which the cusp angie is used as the main determinant af occlusion because of its reilabiilty. if is possible to oocurately control the amount of disocclusibn on fhe restorotion without measuring
candylar path. Ont J Periodont Rest D e n t 1997:17:113-123.)

'Visiting Professor and Pounding Director, University of Caiifornia at Los Angeles, Schooi of Dentistry, Los Angeles, Colifornia: and International Dentai Academy, Tokyo. Japon. "Lecfurer ond Senior Researcher, Kanagawo institute of Technaiogy Japan; and infemationai Dentai Academy Ta l<y a, Japan. Reprint reauests: Dr Sumiya Hobo, 25-18 1-Chme Shohtoh, Shibuya-ku, Tokyo 150-24, Jopan.

The ideai occlusion for eccenfric movements can be classified by three schemes according fo fhe tooth contact condition: mutually protected articulation, group funcfion, and baianced articulation. They are designed to distribute harmtui horizontal occiusai forces evenly between feefh, muscles, and joints. Three factors, the oondyiar path, inoisal path, and cusp angle determine the tooth oontact condition during eccentric movements. When the incisai path is poraiief to the condyior path ond the cusp slope of the maxillary and mandibulor moiors is parailel to both the condylar and incisai paths, balanced articulotion wiii occur (Fig 1), in normol occlusion the incisai poth is steeper than the oondyiar path ond the cusp siope is shallower than the condylar path, in this condition, the molors disccciude during eccentric movements (Fig 2). An increosed steepness of the inoisai path and shallowness of the cusp

Voiume 17.Number2.1997

114

Fig 1 When the condylor path (LI), incisai path (7), and the cusp slope () of maxillary and mandibular molars ore parallei, the moxiiiory ond mandibuiar moiars siide in contact ond disacciusion does not occur.

Fig 2 When the incisai path (7) is steeper thon the candyior path (a) and the cusp angie () is shaliower than the candylar path (a), the maxiilary and mandibuiar moiars disocciude wideiy.

angle increoses the amount of disocclusion. To control the tooth contact condition precisely during eccentric movements, it is neoessary to select one of the three footors as a moin determlnont, ond then the other two factors con be delivered according to the intended tooth confoct condition during eocentric movements. In prosthodontics, the condylor path has been used es the main determinant, and restorations have been made on on orticuiator thot is adjusted to the measured condyiar path. However, the author's research has found that the condylar path is not fixed buf deviates and is influenced greatly by anterior guidance.'-^ Compared with an eccentric condylar path, a returning

condylar path is shailower by a meen of 45%,' in addition, a method of deriving the incisai path end cusp angle from the eondylar path is not known, therefore the use of the condyiar path as the moin determinant for oeciusion hes eaused difficulties. It is well i<nown that the incisai path greatiy influences the tooth contact condition during eccentric movements. The influence of the incisoi poth is calied anterior guidance. The mobility of the anterior teeth ranges from 64 |jm in the canine to 108 |jm in the central incisor,^ it is evident that the incisai path does not deviate independently To investigate whether the incisai path is reliable, the data for incisai path inciination in normai individuals measured

by different reseorchers using an eiectronic measuring system were compared. The standard deviation was 10 degrees both in the protrusive and the iateroi incisai path inclinations. The results indicated thot 32% of the sagittai protrusive incisai path inclination was less thon 35 degrees or greater thon 55 degrees of its mean vaiue (45 degrees). Furthermore, occording to Kelly et al," the occurrence rates of maiocciusion in a randomly seiecfed popuiation t o t a i e d 19,3% and inciuded overbite (6,6%), open bite (2.5%), Angie's Closs li (9,4%), and Angie's Ciass Ili (0,8%), This data showed that one out of five patients did not have an incisai path that refiected an appropriate standdrd.

The Internationai Journal of Periodontics & Restorative Dentistry

115

The above dato indicated that fhere were large variafions in incisai path and thot fhe occurrence rafe of malocciusion was high, if was concluded thaf fhe incisai pafh would nof be valid as fhe main deferminantfor occlusion. The last factor to be considered was fhe cusp angie. Since fhe horizonfai mobiiify of a molar is approximately 70 ijm,^ the cusp path does nof deviafe independenfiy. However, variations may occur among individuis as demonsfrafed wifh fhe incisai pafh. To examine fhis, the data by Sekikawa et al^ and Konazawa et al,* who measured fhe occlusai morphoiogy of study casts of primary school pupils by using a confour iine "moire mefhod," were anaiyzed (Fig 3). As a resuif, ratios af the standard deviations ot distance ond height between cusp and fossa fo fhe mean was 10.9% and 10.2%, respecfiveiy, and overaged 10,6%. The author found that the standard deviation of fhe measuremenf data of cuspal morphology wos very small. On the contrary, the ratios of variafions cf condylar and incisai pafh inclinafions fo the mean was 43% ond 32%, respectively. The data of cuspal morphology had means four times more reiiabie fhan fhose of fhe condylar and incisoi pofhs. The above facfors clarified fhaf fhe cusp ahgie does nof deviafe and was four times more reliable than fhe condylar

path and the incisai path. If was conciuded fhat fhe cusp angle shouid be used as the new determinant ot occiusion.

Disocciusion during eccenfric movements Based on the data of heaifhy individuis, fhe standard amount of disocciusion on moiars for the fhree occiusai schemes when fhe condyle moved 3 mm trom centric reiation was examined (Tobie 1). When the condyle moved 3 mm from cenfric reiation, the incisor and canine reached edge-to-edge position, and eaoh opposing cusp of the posterior teefh was positioned tip-to-fip. iViandibular movement outside of this range was functionaiiy not imporfanf.

Fig 3 An exampie af a moire photograph of the ooclusol surface of o mandlbuiqr first molar for measuring ocdusai morphology. Contour intervoi is 0.2 mm. (Courtesy of Dr M. Sekikowa,^ Reprinted wifh permission).

Table 1 Amounf of disocciusion of molars for each occiusal scheme (mm)

ivlPA Protrusion Nonwori<ing side Wori<ing side 1,0 1.0 D.5 GF 10 0,5 00 BA 0.0 0.0 0.0

Sfandard cusp angie To use cusp ongie as a new determinant for occiusion, it was necessary fo define its vaiue. Since precise three-dimensional data of etfecfive cusp angies were nof avaiiabie in dentistry, fhe measured amounf of disocciusion was used for computation. Although disocciusion had been defined simpiy as the "separation of opposing teeth during eccenfric movements of fhe mandible,"' the definition was nof sufficienf for analyficai purposes.

MPA = Mutually protected articulation; GK = group function: EA = bolonced articulation. Lengtti of condytar path = 3 mm.

Valumel7, Number 2,1997

116

For the present sfudy, fhe authors defined disocclusion as "the superointerior distance between maxiliary ond mondibular opposing cusps during eocentric movements of the mandibie." The verticai and horizontal oomponents of the cusp path can be computed from the average measured vaiues of fhe condylor path and incisai path by fhe modified version of the i<inemofic formuiae for mandibuior movemenf.^ Since a geometric triangle between disocciusion, cusp path, ond cusp angie exists, as shown in Fig 4, if fhe cusp pafh is obfained, the voiue of fhe cusp angie can be esfimated by fhe standard amount of disocciusion using fhe foiiowing trigonomefrio equafion:
Effective cusp ongle of opposing teelh = yerficai component - Amount of of cusp paih disocoiusion Horizon to I oomponent of cusp paHi

centrai incisor toword fhe infroorbitoi margin. Cusp ongle is defined as "fhe angie made by fhe averoge slope of a cusp wifh the cusp piane measured mesiodisfaliy or buoooiingualiy,"' The cusp piane is "fhe piane defermined by the two buccal ousp fips and the highest lingual cusp of a molar,"' The effeotive cusp angle is fhe vaiue fhat refers to the horizontal reference piane, while the cusp angie is the vaiue that refers to the cusp plane formed by the fips of three cusps. The standard cusp ongles cited previousiy are the effective cusp angles formed by the mean ousp slopes and the horizontal referenoe piones.

Twin-Stage procedure in the Twin-Sfage procedure, o sfondard cusp ongie is created on a restoration and the incisai path (anterior guidance) for obtaining the standord amount of disocoiusion is fhen compufed based on the mafhematicol model of mandibuiar movemenf. Thus, by using the sfandord cusp ongle as the main determinant, it is possible to estobiish the standard amount of disocciusion. The onterior guidance created in this manner may oontroi the condylor poth, since the condyiar path is influenced by the anterior guidance.'2 A diagrom comparing the standard prosthetio

Standord cusp angles obfained in fhis monner were os foiiows: 25 degrees for the sagittal protrusive effective cusp angies, 15 degrees for the frontal lateral effective cusp angle on the working side, and 20 degrees for fhe nonworking side. These values refer fo fhe axis piane, which is o horizontal referenoe piane including the transverse horizontal axis and o point 43 mm above the incisai edge of fhe maxiiiary right

procedure and the new procedure is shown in Fig 5, To create a standard cusp angle on the restoration, on articuiator is mondotory. For the Twin-Stage procedure, an ortiouiotor is used as a tool for fhe fobrication of the restorotions. it is important to use the articuiator, not for reproduction but for fhe simuiofion of mandibuior movement to produce certoin conditions. The adjustment vaiue of the arficulator used fo orete the standard cusp angle was cailed "Condition 1." The odjustment volue used to create anterior guidance wos calied "Condition 2." These articuiator adjustment values were determined by computation.^ Since the stondard cusp angies were used as the main determinont of ocoiusion, fhe meosuremenf of the condyiar path was not necessary, and the tooth contaot condition during ecoentric movements wos controlied precisely by every seiected oociusai scheme. The Twin-Hoby Articuiator (3M Dentai) was designed for this purpose (Fig 6),

Fabrication of each occiusai scheme To reproduce the omount of disocciusion for each occiusoi scheme, different adjustment vaiues of an articuiafor were required.

Th9 International Journol of Peiiodontics a Restorative Dentistry

117

Horizontal component ot cusp path Horizontal relere nee plane Cusp patti inclinatior Etieclive cusp angle

Anterior guidance Condyiar guidance Cusp angle Computing-, Cusp angle

controi ,

Cusp patti

i s 0 c 0 1 u s 0 n

Anterior guidance

Condyiar guidance

Amount ot disocclusion

Fig 4 Principle for computing the value af the cusp angle. The cusp path can be determined from the measured vaiues of the candyiar and incisai paths based on the mathematicai model of mandibular mavement. When the cusp path is obtained, the value af fhe cusp angle is estimated by the standard amounf af disocctusian using trigonometry.

fig 5 in file standard prasthetic procedure (upper half), the condyiar guidance is used as the main determinant. Since the methods to derive anterior guidance and cusp angie from the condyiar guidance is nof known, if is not clear haw the standard amount of disocclusion can be created. In the Twin-Stage procedure (lower half), the standard vaiues of the cusp angle are used to create the cusp angle on a restoratian. Anterior guidance is camputed. The restoration fabricated in this manner may controi condyiar guidance. The standard amaunt of disocciusian can be generated.

Mutually protected arficuiotion Mutually protected articuiafion is i<nown as fhe occlusai scheme most suitabie for the natural dentition. For simpiification, the foiiowing wiii be exploined two-dimensionaiiy, aithough the movements of an arficulator occurs fhreedimensionaiiy, 1, Articuiator adjustment vaiues for reproduction of the standard cusp angle. The standard vaiue of fhe sagittal protrusive effective cusp angle was 25 degrees. To create fhe cusp angie an the mounted cast af an articuiator, the cambinations of sagiffai inciinations of the condyiar path and the anterior guide tabie to obtain this cusp

angle are limitiess. For exampie, when the condyiar pafh was set at 10 degrees and the anterior guide fabie was set at 30 degrees, a 25-degree cusp angie was created in the firsf molar. If the oondyiar path was set at 40 degrees and the anterior guide table was set at 20 degrees, a 25-degree cusp angle also was obtained at the first moiar. However, the simpiesf combination was to adjust each inciination to 25 degrees and wax the occiusal morphoiogy to baianced articulation during eccentric movement. A cusp angle of 25 degrees wiii be formed (Fig 7),

Figo The Twin-Hoby Articulator has a rafher simpiified condyiar guide mechanism buf a precise anterior guide mechanism.

Voiume 17. Number 2.1997

118

Fig 7 The combihotian of artiouiator od/ustment vaiues for forming the standard ousp angle (25 degrees) are iimitiess. For example, a combination of 40 degrees for the candylar poth and 20 degrees for the onterior guide table, or the cambinotion of o lO-degree condyiar path and a 30-degree anterior guide table produces fhe same 25-degree cusp angie on the first melar The simpiest combination is ta adjust each ta 25 degrees. A ousp angle of 25 degrees wili be formed uniformiy.

Fig 8 The combination of orticulator adjustment vaiues for generating the standard amount af disocclusion (1.0 mm) are limitless. The disoodusion can be generoted by a combinotion of 40 degrees for the condylar path and 45 degrees for the anterior guide table. Hawever. either a oombination afO degrees for the cohdylarpath and 38 degrees for the anterior guldanoe or another combination cf25 degrees for the former and 50 degrees for the iatter wiii geherate the standard amount of disacdusion. Both combinations create nonphysioiogio movements; therefore, the combination cf 40 degrees and 45 degrees is considered to be the best combination.

If odjustment values for fhe condyiar pafh and anferior guide toble were not the same, o 25-degree cusp angie was obtained oniy on fhe firsf moiar, and o differenf cusp ongie volue was produced on the other cusps. When both condylar path and anterior guide tabie were adjusted fo 25 degrees, a 25-degree cusp angle was created evenly on each cusp of the posferior teefh. This was fhe odjustmenf volue sef fcr fhe orticuiator to achieve Condition 1. During fhe waxing of fhe occiusai morphoiogy under Condition 1. the anterior portion of fhe working cosf became on obstacle because if produced disccclusion during eccenfric

movement. Therefore, when posterior restorations are made, the anterior segment of the working cast must be mode removable using dowel pins. The standord cusp angie con fhen be fabricated under Condition 1 on fhe wori<ing oasf without the anferior segment, 2. Adjustment values for generating disocclusion. Affer the completion of the waxing of the cusps to the standard ongie voiue (25 degrees) the incisai path wos esfablished to reproduce a sfondard omount of disocciusion, for example, 1.0 mm during protrusive movement. Again, there were an infinife number of possible combinotions of odjustmenf values for the condylar path ond anterior

guide tabie of the arficuiotor. However, the computed results shewed a standard amount of disocclusicn was generafed by esfabiishing anterior guidance using a combinotion of 40 degrees for fhe condyiar poth ond 45 degrees for fhe anterior guide table (Fig 8). This combination of adjustment voiues wos not the only one that generated the stondard amaunt of disocclusion. For example, when the condyiar poth wos set at 25 degrees and the onterior guide tabie was set at 50 degrees. 1.0 mm disocclusion was obtained. When the condylar path was set ot 65 degrees and the anterior guide table was set at 38 degrees. 1.0 mm disoociusion was obtained.

The Internotionai Journal of Periodantics a Restorotive Dentistry

119

Table 2 Articulator adjustment values for mutually protected articulation (degrees) Condition Cor^dyiar path Sagittoi condyiar potii inciination Bennett angle Anterior guide to ble Sogittol inciinotion Lateral wing angle

Table 3 Articulator adjustment values for group function (degrees) Condition Condyiar path Sagittoi condyiar poth inciination Bennett ongie Anterior guide tobie Sagittai inoiinotion Loterai wing ongie

Table 4 Articulator adjustment values for balanced articulation (degrees) Condition Condylor poth Sogittol oondylor poth inciinotion Bennett angle Anterior guide table Sagittal molination Laterai wing ongie

25 15 25 10

40 15 45 20

25 15 25 10

40 15 45 0

25 15 25 10

25 15 25 10

i-lowever. if the incisai path was more than 5 degrees steeper thon the condylar path, patients complained of discomfort,^ if the incisai path was shaliower thon the oondylar path, the condyle rotated in a direction opposite to the ordinary direotionduring protrusive movement that is not a physioiogical movement,'" Therefore, it is recommended that the condyiar path be adjusted to 40 degrees ond the anterior guide table be adjusted to 45 degrees to fabricte anterior guidance. This was the adjustment vaiue for the articulatorio achieve Condition 2. Adjustment values for the establishment of mutually protected articulation are shovi/n in Table 2,

Group function Group function was indicated when canine guidance was absent as a result of the ioss ot a cenine. To create group function, articuiator adjustment vaiues for "Condition 2" must be modified from those shown in Table 3, In group function, the omount of disocciusion on the working side during laterai movement must be zero. This can be achieved by ehanging the iateral wing angle of the anterior guide table tor Condition 2 from 20 to 0 degrees. The amount of disocclusien on the nonworking side becomes 0,5 mm. The value for Condition 1 does not need to

be changed. The modified adjustment values for group function are shown in Tabie 3,

Balanoed articuiation Balanced articulation is the occiusai scheme recommended for complete dentures. To create this articuiation. Condition 1 shouid be used to produce both the cusp angle and anterior guidance. Adjustment values for baianced articulation are shovi/n in Table 4, Under the above conditions, the amount of disocciusion during various eccentric movements becomes zero.

Volume 17, Number 2,1997

120

Fig 9a iVIeasurement of the maxiiiary triangie with tacebow.

Fig 9b To examine the cusp angle of the posterior teeth, the sagiftai condyiar path and dnterior guide tabie of the orticuidtor are adjusted Condition I (red moiki'). After the onferior segment of the maxillary cast is removed, the articuiator is moved into vorious eccentric positions. The tip of dnterior guide pin must contact the surfoce of the anterior guide tabie at all times

Fig 9c Aii cuspal interference is removed because of the excessive cusp angie at the eccentric position, which aiiows the maxiiiory and mondiPuior molars even contact.

Advantages of ttie Twin-Stage procedure The Twin-Stage Procedure was deveioped as fhe advanced version of the Twin-Table Technique fhaf was introduced by Hobo in 1991 . ^ i ' ^ The TwinTobie Technique has several disadvantages compared to the Twin-Sfage Procedure, in fhe Twin-Tabie technique, fhe cusp angle was fabricated paraiiel fo fhe measured condyiar pafh, and fhe cusp angle became foo sfeep. To obfain a standard amount of disocciusion wifh such a sfeep cusp angle, fhe incisai path had fo be sef at an angle that was extremely sfeep. This made the pafiehf uncomforfabie. In addifion an anferior guide fable of an arficulafor was fabricated by means of resin molding. It wos technique sensitive.

Fig 9 The anterior segment is repositioned on the maxiiiary cast. To check the anterior guidance, the sagittal condylar pafh ond the onterior guide tabie of the artiouiotor are adjusted to Condition 2 (blue marks), Disocciusion is created eveniy in the posterior region in this case, during the right ioterai movement canine guidance does not exist.

Fig 9e The insufficient amount of footh structure is waxed to reproduce Conine guidance.

The Internatianoi Journal of Periadantics & Restarotive Dentrstry

121

Fig 10a Olose-up of the preparation for an onlay.

Fig lOb For a single-crown restoratian. the die must be removable and isoiated. The mandibular feeth are removed tram the working cast, leaving the die.

Fig 10c The die is ieft on the mandibular cast fhus eliminafing eccenfric interference of the patienfs dentition. A physiologic morphaipgy an fhe occlusal surface is waxed. Far a pasferior single crown restoration, a stondard cusp angle is created under Canditian I. For the anterior single crown restaration. anterior guidance is created under Oandition 2.

Clinical reports
The Twin-Stage procedure is suitoble for a range of procedures including occlusal diagnosis (Figs 9a to 9e), singie crown fabricotion (Figs 10a to lOe), and complete-mouth reconstruction (Figs l i a to l l g ) .

Conclusion
The advantages of the TwinStage procedure are as foiiows, I. Since the meosurement of the condyiar pafh is nof necessary, complicated instruments such as the pantograph and fuily adjustabie articuiator become unneoessory. Therefore, the TwinStage procedure is much simpier than the standard gnathoiogical procedure, yet it follows gnathoiogical principies.

Fig lOd Aer the remaining segments are repiaced on the cast fhe articuiator is moved through eccenfric movement and fhe standard amount of disacdusian wiil appear.

Fig IDs MOD onlay is campiefed cemenf ed intraaraiiy.

and

Volume 17, Number 2,1997

122

Fig l o (ieft) Master casts are mounted on the articulator ie anterior segment is made removabie.

Fig I Ib (right) Prior to the pasteriar waxing, the anterior segment is removed. Fig I Ic (ieft) Posterior teeth are waxed fo meet to Condition i.

Fig ffd (right) ivtaxiilaryand mandibuiar molars under even tooth contact condition. Fig JJe(ieft) Thesagittaicondyiar path and anterior guide tabie adjusted fo Candition 2 to create anterior guidance. The anteriar segment af the maxillary warking cast and wax is replaced. Anferior guidance was created. Fig I I (right) Disacdusian of the finished restorations during lateral movement Fig 1 Ig Frantai view of the finished case.

The Internofionai Journal of Periadantios a Restarotive Dentistry

123

2, The guideline for optimum occlusion is shown clearly by the adjustment values of an articulafor (Conditions 1 ond 2), It is possible to diagnose eccentric occiusai reiations cf the patient precisely and simply, 3, The procedure can be indic a t e d for almost every phase of restorafive ond prosthodontic work including the singie crown, fixed prosthodontics. impiants, complete-mouth reconstructions, and complete dentures. 4, Since fhe condyiar path is not used as the main determinant of occiusion. this procedure is suitable for restorative work fcr fhe fransmandlbuiar disorder patient, especiaiiy after occiusai splint therapy^^ 5, This procedure can be Incorporated easily with commonly used clinical techniques such as facebow transfer, various centric recording methods, and cusp-fossa waxing. Presentiy. the Twin-Stage procedure is controindicated for molocclusion coses that have: (1) on abnormal curve of Speej (2) an abnormol curve of Wiisonj (3) abnormoily rototed teeth: a n d (4) abnormaiiy inclined teeth. The verticai axis of the posferior teeth may hove inclined abnormaiiy in those cases. In such a condition, the

standard effective cusp angle presented in fhe Twin-Stage procedure may not be applicable.

10 kohno S, Anolyse der Kandyien in der Sagittalebene. Dtsh Zohnrzti 1972:27:739-743. 11. Hobo S, Twin-tables technipues for oociusai rehabilitation. Part i. Mechonism of onterior guidance. J Prosthet Dent 1991:66:299-303, 12. Haba S. Twin-tabies techniques tor occlusal rehabilitation. Port ii. Ciinicai procedures. J Prosthet Dent 1991:6:d71-477. 13. Hobo S. Occiusion in temporomondibulor disordersTreotment after occiusai spiint tnerapy. int DentJ 1996:46'146-155.

References 1. Habo S, Takayama H. Re-evaluation of the condylar path as the reference for occlusion. J Snatho 1995:14:31-40. 2. Hobo S, Takayamo iH. Effect of canine guidance on working condyior poth. Inf J Prosthodont 1989:2:73-79. 3. Rudd KD, O'Learry TJ. Stumpf AJ. Horizontai tooth mobiiity in carefuiiy screened subjects. Periodontics 1964:2:05-68. 4. keliy JE, Sanchez ivi. Van Kirk LE. An assessment ot the occiusion of teefh of children. (Data from the Nationol Heaitn Survey: DHEW Pubiication no. CHRA)74-1612 ) National Center tor Heaith Stotistics. U S Pubiio Heaith Service, 1973. 5 Sekikawo M, Ai<ai J, Nonbu A. KanazawG E, Ozaki I Three-dimensionai measurements of fhe ocoiusai surfoce of lower first molars in o madern Jopanese population. Jpn J Oral Bioi 1983:25:737-744. 6. Kanozawa E, Sekikawa M. Ozaki T. Three-dimensional measurements of the ooclusai surface ot upper first moiars in a modern Japonese popuiotion. Acta Anat 1984:116:90-96. 7. Glossary of Prosthodonfic Terms, ed 6. Academy af Prosthodonfics, J Prosthet Dent 1994:71:43-112. 8. Takayoma H, Hobo S. The derivation of kinemotic formuioe for mondibuiar movement. Int J Prosthodont 1989;2285-295. 9. McHorris WH. Ocoiusion with porticuiar emphosis on the functional and parafunctlonai roie ot anterior teetn. Part B, J Clin Orthod 1979; 13:684-701.

Volume 17, Number 2,1997