Twin-tables I-Mechanism

Sumiya

tecthnique for occlusal rehabilitation: of anterior guidance

Tokyo, Japan, and University of California. School of Dentistrv.

Part

Hobo, DDS, MSD, PhD*

International Der;tal Academy, Los Angeles, Cali:.

Anterior guidance and the condylar path have been considered independent factors. In a recent study, it was revealed that the anterior guidance influenced the working co:ndylar path and even changed when the lateral incisal path deviated from the optimal orbit. This supports the hypothesis that anterior guidance and condylar path are dependent factors. When setting anterior guidance, it is recommended to set the working condyle so that it moves straight outward along the transverse horizontal axis. The angle of hinge rotation created by the angular difference between anterior guidance and condylar path assists the posterior disclusion, but is not solely responsible. The anatomy of the cusps is created by establishing the appropriate form of the posterior cusps aligned to the condylar path so that it also contributes to posterior disclusion. Posterior disclusion is crucial in controlling harmful lateral forces. The molars must disclude slightly more than the deviation in the condylar path to avoid occlusal interferences. (J PROSTHET DENT 1991;66:299-303.)

artdlbular movement. has been studied kinematically through advanced research technology.1-3 Consequently, anterior iguidance, which was previously a vague occlusal concept, has heen ana.yzed and it is now possible to compute anterior guidance from the condylar path.4 A computer system developed for this purpose includes the C,yberhoby computer pantograph with the capability to measure the condylar path and produce digital and analog data, the Cyberhoby fully adjustable articulator, and the Anteroputer device, which computes three-dimensional adjustments for the incisal table.5 However, this system is expensive, complicated, and unsuitable for daily practice despite its merit for research. A disparity then exists between advances in research and daily clinical dental practice. Part I of this ar title reviews the mechanism of anterior guidance to provide a foundation for understanding the twin-tables technique. This technique is an uncomplicated practical method to register anterior guidance from the condylar path. Part II presents the procedures of this technique for daily clinical practice.

IMPORTANCE

OF ANTERIOR

GUIDANCE

canines, referred to as canine guidance. The term anterior guidance has replaced the two terms. Although anterior guidance only ranges from 2 to 6 mm, it greatly influences occlusion, In healthy patients, anterior guidance is approximately 5 degrees steeper than the cnndylar path in the sagittal plane.8 Therefore, when a patient protrudes the mandible, the anterior teeth guide it downward, creating space between the posterior teeth referred to as posterior disclusion. The same phenomenon occurs during lateral movement because the lingual inclination of the maxillary canine is steeper than the condylar path. The mandible can be compared to a tripod configuration for discussion purposes.g The posterior legs are represented by right and left condyles whose shape helps to generate the condylar path, and the anterior leg is represented by the incisal point that influences anterior guidance. The threedimensional position of the mandible is determined by these three elements so that if the condylar path alone is measured without consideration of anterior guidance, mandibular movement is not accurately reproduced. Because condylar path and anterior guidance are elements of one anatomic unit, the mandible, they borh affect total mandibular movement.

The orbit of the incisal point during protrusive movement is guided by the lingual surfaces of the maxillary incisors and is termed incisal guidance.j The lateral movements are guided hy the lingual surfaces of the maxillary

ANTERIOR GUIDANCE AS AN INDEPENDENT FACTOR

Early gnathologic concepts focused primarily on the condylar path. The concepts were based on the theory that the condylar path does not change during adulthood and that the determination of anterior guidance is at the discretion of the dentist. McCollum and StuartlO believed that anterior guidance was independent ot the condylar path. In clinical practice, the condylar path is measured

-Presented at .:he Amerir.an Acadc,my of Fixed Prosthodontics meeting, Chicago, 111. aDirector. International Dental Academy; Visiting Professor, Unillersity of California, Sc.hool of Dentistry. 10/l/29420

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HOBO

Fig.

1. Effect of anterior guidance on working condylar

path. Neutral line represents imaginary incisal path (dotted line) when working condyle moves along transverse horizontal axis. Actual incisal path is steeper than neutral line. Working condyle then moves below transverse horizontal axis or detrusion (A). If actual incisal path is flatter than neutral line, working condyle moves above axis or surtrusion (B) . with a mechanical pantograph using clutches without the influence of anterior guidance. When the condylar path is adjusted on the articulator and the diagnostic casts are mounted, both condylar path and anterior guidance are combined to simulate total mandibular movement. Current prosthodontic procedures follow this premise. There are sparse studies that support this concept, and Dawsons statementl is particularly well-known. He stated that the condylar path was not a determination of anterior guidance, and that it does not matter whether the anterior path is flat or curved, concave or convex or parabolic, the rotating condylar sliding down the unchanged condylar path permits the lower anterior teeth to follow any number of path variations without interference. He concluded that anterior guidance could be freely changed by the dentist. To verify whether condylar guidance and anterior guidance were independent factors, the lateral condylar paths in 10 patients were measured with an electronic mandibular recording device.12 The measurements were recorded under two test conditions: tooth-contact, or without clutch condition, and nontooth contact, or with clutch condition. The results demonstrated that the working-side condylar path changed remarkably while the nonworking-side condylar path did not reveal noticeable changes. The working condyle, under the nontooth-contact condition or with a clutch, exhibited small sagittal displacements and showed a tendency to move straight laterally along the transverse horizontal axis. Conversely, under the toothcontact condition, the working condyle moved laterally and deviated sagittally in various directions. From this movement, it was observed that the condylar path was affected by anterior guidance and condylar guidance and anterior guidance were dependent, not independent, factors. 300

Fig. 2. During protrusive movements, condyle rotates along horizontal axis if anterior guidance (/?)is steeper than condylar path ((Y).Angle of hinge rotation compensates for this angular difference.

Takayama and Hobo 13-15 derived kinematic formulae to calculate anterior guidance from the condylar path. Anterior guidance computed from these formulae confirmed a statistical correlation to the data of anterior guidance on the same patients at p < 0.01 level of significance. With the identical formulae, an imaginary incisal orbit was computed for each patient under the assumption that the working condyle translates straight laterally along the transverse horizontal axis. Then this orbit, or the neutral line, and the actual lateral incisal paths under tooth-contact conditions were compared. The results demonstrated that the working condylar path deviated superiorly when the actual lateral incisal path was above the neutral line, and the working condylar path deviated inferiorly when the actual lateral incisal path was below the neutral line (Fig. 1). A similar tendency was noted in the anteroposterior directions. Therefore there was a correlation between deviation of the lateral incisal path from the neutral line and sagittal deviation of the working condylar path at p < 0.01 level of significance.12 Sagittal deviation of the working condylar path-either surtrusion, detrusion, retrusion, or protrusion-is evident when anterior guidance and the condylar path are in discord. This correlation also indicated that anterior guidance and condylar guidance were dependent factors. According to the study of 50 test patients, the mean working condylar path is a straight lateral movement along the transverse horizontal axis.2*3 If this movement is physiologic, then the incisal path deviation from the neutral line may imply that the working condyle compensates for discrepancies by deviating within the sagittal plane. It is then recommended to adjust the anterior guidance so that the working condyle moves straight outward along the transverse horizontal axis during lateral movement. ANGLE OF HINGE ROTATION

Posterior disclusion occurs when anterior guidance is steeper than the condylar path. Early gnathologic concepts
SEPTEMBER 1991 VOLUME 66 NUMBER 3

TWIN-TABLES

TECHKIQI

E: PAHT

Table

I. Degree of disclusion Angle

Me;lSUrlXl

cusp
shape factor (mm)

\ .due ---

of hinge rotation
0.2

Protrusiw Korking Nonworkir~p

.l

-__-.

J.5 I.0 ___

0.5 0.5

0.9 0 0.5

suggested a fully balanced occlusion as the ideal occlusion with anterior guidance paralle. to the condylar path. Anterior guidance was considered an extension of the condylar path. Setting anterior guidance for balanced occlusion was simple because it was parallel to the condylar path. However, when the concept of edisclusion was introduced by I)Amico,7 the relationship between anterior guidance and condylar path was questioned because the degree to which anterior guidance was set, to the condylar path was unknown. The mandible rotates around the intercondylar axis during eccentric movements when anterior guidance is steeper than the condylar path (Fig. 2). The factor that compensates for the difference in steepness is the angle of hinge rotatron. The dentist should determine the influence that the angle of hinge rotation contributes to disclusion to establish an ideal anterior guidance. Takayama and Hobo15 analyzed disclusion relative to the angle cd hinge rotation by using kinematic formulae. The results indicated that the angle of hinge rotation con-tributed to posterior disclusion by approximately 0.2 mm -for protrusive movement and 0.5 mm on average for lateral movement on both working and nonworking sides. According to an investigation of molar disclusion during eccentric movements when the right and left condyle moves 3 mm in protrusive movement and the nonworking condyle moves 3 mm in lateral movement, the amounts of disclusion were 1.1 t 0.6 mm during protrusive movement, and 0.5 i O.:i mm on the working side and 1.0 + 0.6 mm on the nonworking side during lateral movement measured at the mesiobuccal cusp tip of the mandibular first molar.16 The actual disclusion on the working side (0.5 mm) was equal to the amount created by the angle of hinge rotation (0.5 mm). Howlever, t.he actual disclusion during protrusive and lateral movements on the nonworking side differ from the angle of hinge rotation. This leaves residual amounts of disclusion unaccounted for, namely, 0.9 mm in protrusive and 0.5 mm on the nonworking side (Table I), thus suggesting that the angle of hinge rotation was not solely responsible for disclusion. The residual amounts can also be attributed to another determinant of disclusion, the cusp shape factor.

Fig.

3. During protrusive movement, condyle translates without rotation when anterior guidance (~3)and condylar path (fi) are parallel.

Fig. 4. When cusp inclination of molars is parallel to anterior guidance, there is no posterior disclusion despite steeper anterior guidance (fi) than condylar path ((Y).

,/

5. Posterior disclusion is evident when cusp inclination of molars is parallel to condylar path and anterior guidance (8) is steeper than condylar path ((Y).
Fig.

CUSP

SHAFE

FACTOR

When the slopes of posterior cusps are parallel to the condylar path inclination and anterior guidance is parallel to the condylar path, the opposing cusps slide during proTHE JOURPIAL OF PROSTHETIC DENTISTRY

trusive movement without discluding, despite the degree of steepness (Fig. 3). If anterior guidance is steeper than the condylar path, the posterior teeth disclude. However, if the cusp inclination of the molars is parallel to anterior guid301

HOBO

Table II.

Comparison of buffer space with disclusion

Buffer space (mm) Disclusion (mm) 1.1 0.5 1.0

Protrusive Working Nonworking

0.8 0.3 0.8

Fig. 6. Cusp inclination (A) decreases (is more shallow) if it is semicircular (B). Producing a convex cusp diminishes cusp inclination.

ante, there is no posterior disclusion even though anterior guidance is steeper than the condylar path (Fig. 4). The posterior teeth disclude only when the cusp inclination of the molar is parallel to the condylar path and anterior guidance is steeper than the condylar path (Fig. 5). The cusp inclination (A) also becomes more shallow with a semicircular shape (B) as illustrated in Fig. 6. The shape of the cusp has great influence on the disclusion of posterior teeth. To produce fully balanced occlusion, it is then necessary to make the cusp with a straight edge, whereas for disclusion the cusp requires a convex semicircular shape. If the shapes of the posterior cusps are less steep than the condylar path, the posterior teeth disclude even if anterior guidance is parallel to the condylar path. The residual amounts of disclusion that were not accounted for by the angle of hinge rotation can be attributed to this mechanism, regulated by the cusp shape factor. The semicircular shape of the cusps affects posterior disclusion and is the factor contributing to the residual disclusion. This is called the cusp shape face. In practice it is critical that cusp inclination, including the semicircular shape of the cusp, combined with the angle of hinge rotation contributes to posterior disclusion. The molar cusp inclination should be parallel to the condylar path, not parallel to anterior guidance, in establishing posterior disclusion.

optimal function in a fully balanced occlusion. If the condyle deviates slightly, it directly influences the relation between the teeth, resulting in occlusal prematurities and deflective occlusal contacts. McCollum and StuartlO described the condylar path as a fixed entity in an adult. In a recent study, when repetitive lateral movements were compared with the respective condylar paths, no movement traced the same line.17 The deviation in the condylar path during eccentric movements was attributed to the shock-absorbing nature of the articular disk. This study refers to this deviation in condylar path as a buffer space. The average buffer spaces are 0.2 mm in centric relation, 0.3 mm in laterotrusion, and 0.8 mm along the protrusive and nonworking sagittal condylar path. Molar disclusion should be greater than the buffer space to avoid occlusal interferences during eccentric movements. When the average amount of disclusion is compared with buffer space, the amounts closely match (Table II). In protrusive movement, the amount of buffer space is 0.8 mm and disclusion on the nonworking side is 1 mm. The amount of disclusion should be slightly more than the buffer space to prevent deflective occlusal contacts providing separation between the opposing posterior dentition, so that when the condyle is displaced during articular disk compression, harmful occlusal forces can be controlled.

SUMMARY
The mechanism of anterior guidance was reviewed from recent mandibular movement studies to provide a basis for understanding the twin-tables technique, which is a practical method for establishing anterior guidance from the condylar path. Anterior guidance and the condylar path previously were considered independent factors. In a recent study, it was revealed that anterior guidance influences the working condylar path and even changes when the lateral incisal path deviates from the optimal orbit. This supports the hypothesis that anterior guidance and the condylar path are dependent factors. In setting anterior guidance, it is recommended to set the working condyle so that it moves straight outward along the transverse horizontal axis. The angle of hinge rotation produced by the angular difference between anterior guidance and the condylar path assists posterior disclusion but is not solely responsible. The anatomy of the cusps is created by establishing the appropriate form of the posterior cusps aligned to the

FACTORS THAT DISCLUSION

DETERMINE

Molar disclusion during eccentric movements is effective in eliminating harmful lateral occlusal forces. However, a comprehensive theory identifying factors that determine a specific amount of disclusion is unavailable in the literature. Mechanically, the maxillary and mandibular teeth should be in contact during eccentric movements for optimal chewing efficiency. Maximal shear force is observed with a fully balanced occlusion. However, the condyle must follow one orbit precisely during eccentric movements for

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TECHNIQV'?

PART I

condylar path; thus it also con1 ributes to posterior disclusion. Posterior disclusion is crucial in controlling harmful lateral forces but the factors that determine the precise amount of disclusion nave not been established. The diselusions recorded in healthy adults were 1.1 k 0.6 mm in protrusive movement and 0.5 t 0.3 mm on the working side and 1.0 z 0.6 mm on the nonworking side during lat.era1 movement. T hesr number; correlated with the deviation in the condylar path. The molars must disclude slightly more than the deviation in the condylar path to avoid occlusal interferences.

REFERENCES
I. Hobo S. M<lchlzukh S. A kinematic mvestigation of mandibular border mwement by means of an electronw measuring system. Part I. Development of 1he measuring system. . PROWHET DENT 1983:50::368-73. :!. Hobo S. .4 Linemat ic investigation (of mandibular border movemem b) means of an electronic measuring system. Part II. A study of the Eiennett mctvernent. J PHOSTHET DENT 1984;51:642-6. 3. Hobo S. A kinematic investigation e)f mandibular border movement b> means of ar electronic measurmg s!~stem. Part III. Rotational center ot lateral movement. J PHOSTHET DEUT 1984;52:66-72. 4. Hobo S. Taknyamrt H. Kinematic iwestigation of anterior guidance as a basis for ww gnathol,)gical conwpts. J Gnathology 1989;8:14-48. 5. Hobo S, Takayama H. \ new system for measuring condylar path and computing anterior gllidance. Part I. Measuring principles. Int .I Prosthodon t 1988;1:99 06.

A compa:rison gold
Richard Manville

of the abrasiveness

of six ceramic
Jr., DDS,b and

surfaces

and

Jacobi, DDS,a Herbert T. Shillingburg, (G. Duncamon, Jr., DDS, PhDC

University of Oklahoma, College of Dentistry, Oklahoma City, Okla. A type III gold alloy and six different ceramic surfaces were secured in an abrasion machine opposing extracted teeth to determine their relative abrasiveness and resist,ance to wear. The rankings of restorative materials from least abrasive to most abrasive were: gold alloy, polished; cast ceramic, polished; porcelain, polished; cast ceramic, polished and shaded; porcelain, polished and glazed; cast ceramic, cerammed skin shaded; and cast ceramic, cerammed skin unshaded. The ranking of materials from most wear-resistant to least wear-resistant was: gold alloy, cast ceramic cerammed, cast ceramic cerammed and shaded, porcelain polished, porcelain glazed, cast ceramic polished and shaded, and cast ceramic polished. (J PROSTHET DENT 1991;66:303-9.)

Gold has long

rnaterial

been a preferred dental restorative because of biocompstibility, durability, and low

Supported b:f Presbyterian Healt 2 Foundation grant PHF No. 45 BAssociate Professor, Departmen-; of Fixed Prosthodontics. tProfessor and Chairman, Depar ;ment of Fixed Prosthodontics. CProfessor and Chsirman, Department of Dental Materials.
10/l/24177

abrasiveness against natural teeth; however, the primary disadvantage is an unnatural metallic appearance. Porcelain crowns, inlays, and veneers were introduced more than 100 years ago to serve as more natural-appearing restorations. Ceramic materials have become increasingly popular because of improvements in materials and techniques. The excessive wear of natural teeth opposing porcelain has stimulated authors to discourage the use of porcelain

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