Isaac Post, DDS, MSD George L anger, DDS, MSD GNATHOLOGY IN ORTHODONTICS Definition of Gnathology: Why relate gnathology

to orthodontics? Why should we consider gnathological conc epts (generally prosthodontic concepts) in an orthodontic practice? "The most conspicuous lapse of logic is perhaps the statement that the majority of studies show no association between occlusal factors and TMD; therefore they are not causally lin ed. The reiteration of such an obvious error only serves t o misdirect research efforts. Absence of evidence is not evidence of absence." ( Kirves ari, J. Cranio. Bio., 1999) Gnathological Society founded in 1926 by Dr. McCollum, a prosthodontist In the 1970's, Dr. Ronald Roth introduced the use of gnathological principles in orthodontic diagnosis and treatment planning Central to gnathological principles should be: 1. Establish centric Relation Roth's definition: Position of the mandible when the condyle is seated in its mo st superior anterior position against the posterior slope of the eminence with t he thin, central, avascular portion of the disc interposed and centered 2. Coordination of centric relation (CR) and maximal intercuspation (MI) When the teeth are in maximal closure, they should mesh in a "normal" relationsh ip and should not cause the condyle or condyles to be pulled forward or down out of the fossae 3. A harmonious functional scheme The teeth should not interfere with the full extent of movement that the mandibl e is capable of ma ing in all directions Recognizing occlusal disharmony and interferences - signs and symptoms Excessive occlusal wear Excessive tooth mobility Limitations of mouth opening Inability to execute smooth, full lateral and protrusive excursions Myofascial pain TMJ sounds Excessive contracture of musculature Tongue position Mandibular shift upon closure If any of these signs or symptoms are present, it may be wise to fabricate a spl int for the patient To alleviate or lessen symptoms To allow the muscles to deprogram so the mandible can reposition itself Most of our patients are young

Is CR - MI coincidence truly possible? Roth initially thought that it was possible in almost all cases Perfect coincidence of CR - MI is our goal but probably rarely attainable Equilibration should be limited to minor discrepancies - major ones need prostho dontic help or orthodontic retreatment How close is acceptable? Roth (AO, 1973) says maximal acceptable difference between MI (maximal intercusp ation) and CR (centric relation) is 1mm vertically, 1mm anterioposteriorly and .

5 mm transversely Techniques for determining centric relation has long been debated by practitione rs: Roth's isors Power Centric bite registration Patient sits for minimum of 5 minutes with cotton roll or leaf gauge between inc Two piece bite registration Anterior segment Posterior segment Technique:

For patients that are severely muscularly adapted and programmed or have TMD sym ptomology, use a gnathological splint -Unmas s true relationship of maxilla and mandible that is hidden by excessive m uscular contracture Other items to be aware of to maintain centric occlusion 1. Overcorrection must be built into the appliance 2. Second molars are most common teeth to exhibit occlusal interference 3. Adhere to Andrew's Six Keys of Occlusion 4. Beware of creating a molar fulcrum Evidence against the gnathological approach Even the gnathologists agree that the great majority of cases can be successfull y treated without the gnathological approach Roth himself says that in most cases CR - MI is an unrealistic goal of treatment Johnson, J. Prosth Dent, 1988 - CR-MI discrepancies often increase Sadows i et. al., AJO, 1980 - CR-MI discrepencies and non-functional contacts Klar et. al., Semin Ortho, 2003 - 200 ortho cases treated with gnathological tec hniques and guidelines No hard experimental evidence shown lin ing occlusal factors to TMD (although th e gnathologists call these studies "unclear") Many (Phillips, J. Prosth. Dent., 1986) argue that there is greater than .5mm pr ocedural error in measuring CR and MI so these norms are meaningless CPI readings may not always be reproducible (Lavine, et. al., Seminars in Ortho. , June 2003)