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https://doi.org/10.15644/asc49/1/5

Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions

Nikolina HOLEN GALEKOVIĆ ; Health center Zagreb west, Albaharijeva 5, 10000 Zagreb
Vesna Fugošić ; Department of Prosthodontics, Medical Faculty, University of Rijeka, Rijeka, Croatia
Vedrana Braut ; Department of Prosthodontics, Medical Faculty, University of Rijeka, Rijeka, Croatia
Robert Ćelić   ORCID icon orcid.org/0000-0002-5197-3465 ; Department of Removable Prosthodontics, School of Dental Medicine, University of Zagreb, Croatia

Puni tekst: engleski, pdf (278 KB) str. 36-44 preuzimanja: 296* citiraj
APA 6th Edition
HOLEN GALEKOVIĆ, N., Fugošić, V., Braut, V. i Ćelić, R. (2015). Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions. Acta stomatologica Croatica, 49 (1), 36-44. https://doi.org/10.15644/asc49/1/5
MLA 8th Edition
HOLEN GALEKOVIĆ, Nikolina, et al. "Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions." Acta stomatologica Croatica, vol. 49, br. 1, 2015, str. 36-44. https://doi.org/10.15644/asc49/1/5. Citirano 26.10.2020.
Chicago 17th Edition
HOLEN GALEKOVIĆ, Nikolina, Vesna Fugošić, Vedrana Braut i Robert Ćelić. "Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions." Acta stomatologica Croatica 49, br. 1 (2015): 36-44. https://doi.org/10.15644/asc49/1/5
Harvard
HOLEN GALEKOVIĆ, N., et al. (2015). 'Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions', Acta stomatologica Croatica, 49(1), str. 36-44. https://doi.org/10.15644/asc49/1/5
Vancouver
HOLEN GALEKOVIĆ N, Fugošić V, Braut V, Ćelić R. Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions. Acta stomatologica Croatica [Internet]. 2015 [pristupljeno 26.10.2020.];49(1):36-44. https://doi.org/10.15644/asc49/1/5
IEEE
N. HOLEN GALEKOVIĆ, V. Fugošić, V. Braut i R. Ćelić, "Influence of the Hinge Axis Transfer Modality on the Three-Dimensional Condylar Shift Between the Centric Relation and the Maximum Intercuspation Positions", Acta stomatologica Croatica, vol.49, br. 1, str. 36-44, 2015. [Online]. https://doi.org/10.15644/asc49/1/5
Puni tekst: hrvatski, pdf (278 KB) str. 36-44 preuzimanja: 189* citiraj
APA 6th Edition
HOLEN GALEKOVIĆ, N., Fugošić, V., Braut, V. i Ćelić, R. (2015). Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije. Acta stomatologica Croatica, 49 (1), 36-44. https://doi.org/10.15644/asc49/1/5
MLA 8th Edition
HOLEN GALEKOVIĆ, Nikolina, et al. "Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije." Acta stomatologica Croatica, vol. 49, br. 1, 2015, str. 36-44. https://doi.org/10.15644/asc49/1/5. Citirano 26.10.2020.
Chicago 17th Edition
HOLEN GALEKOVIĆ, Nikolina, Vesna Fugošić, Vedrana Braut i Robert Ćelić. "Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije." Acta stomatologica Croatica 49, br. 1 (2015): 36-44. https://doi.org/10.15644/asc49/1/5
Harvard
HOLEN GALEKOVIĆ, N., et al. (2015). 'Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije', Acta stomatologica Croatica, 49(1), str. 36-44. https://doi.org/10.15644/asc49/1/5
Vancouver
HOLEN GALEKOVIĆ N, Fugošić V, Braut V, Ćelić R. Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije. Acta stomatologica Croatica [Internet]. 2015 [pristupljeno 26.10.2020.];49(1):36-44. https://doi.org/10.15644/asc49/1/5
IEEE
N. HOLEN GALEKOVIĆ, V. Fugošić, V. Braut i R. Ćelić, "Utjecaj načina prijenosa šarnirske osi na trodimenzionalni pomak kondila između položaja centrične relacije i maksimalne interkuspidacije", Acta stomatologica Croatica, vol.49, br. 1, str. 36-44, 2015. [Online]. https://doi.org/10.15644/asc49/1/5

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Sažetak
Purpose. The purpose of the study was to determine whether the hinge axis registration and the transfer modality (facebow transfer vs. average mounting) from the subject to the articulator affect the three-dimensional condylar shift between the centric relation (CR) and the maximum intercuspation (MI) position. Material and Methods. The study was comprised of 32 fully dentate subjects (16 male and 16 female). Only the asymptomatic participants with normal occlusal relations (Angle class I) aged 20 - 33 (mean age 22.6 ± 4.7) met the inclusion criteria. Three-dimensional condylar shift (anteroposterior, superoinferior and mediolateral shift) between the centric relation position (CR) and the maximum intercuspation (MI) position was analyzed by means of Mandibular Position Indicator (SAM Prazisionstechnik GmbH, Muenchen, Germany). Results. The average three-dimensional condylar shift was 0.13 ± 0.12 mm for facebow transfer and 0.22 ± 0.23 mm for average mounting. There were no statistically significant differences noted between genders. The results of the Mann-Whitney test showed statistically significant differences for anteroposterior and superoinferior condylar shift (P < 0.001). However, the difference in the mediolateral shift was not statistically significant. Conclusions. In order to find discrepancies within the three-dimensional condylar shift, facebow transfer proved to be more accurate than the average mounting in the semi-adjustable articulator. However, the average value of three-dimensional shifts of
the condyle did not differ from normal values and they did not have clinical significance. Thus, both ways of transfer modalities (facebow transfer and average mounting) in asymptomatic subjects with normal occlusion can be considered reliable.

Ključne riječi
Dental Articulators; Centric Relation; Hinge axis; facebow transfer

Hrčak ID: 136859

URI
https://hrcak.srce.hr/136859

▼ Article Information



Introduction

Centric relation (CR) is defined as the “maxillomandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective discs with condyles in the anterior-superior position against the slopes of the articular eminence. This position is independent of tooth contact and is determined by manipulation of the mandible in a purely rotary movement along the transverse horizontal (hinge) axis (1).” Semi and fully adjustable dental articulators employing facebows have proven invaluable in daily practice when it comes to extended diagnostics, planning and therapy of occlusion and/or masticatory system. Facebow records the position of the transverse hinge axis that passes through the condyles when they are in the CR position. Therefore, a prerequisite for precise determination of hinge axis is repeatable and reliable clinical registration of CR position (1, 2).

Repeatability is one of the main criteria for accepting a CR as a clinically relevant position. Various clinical methods for assessing the repeatability of CR position have been suggested. Many investigators have tested this repeatability by using various instrumentation devices to record condylar changes in all three planes (vertical, horizontal and transverse). These three-dimensional condylar discrepancies are caused by MI-CR displacement at the level of occlusion (3). Wood and Elliot (4) used the condylar position indicator (CPI) to examine the repeatability of Roth’s centric relation method (5). The authors found no significant difference between the condylar position indicator readings, and they concluded that Roth’s centric relation bite registration was highly repeatable. Hobo and Iwata (6) analyzed the repeatability of different clinical CR methods using an electronic mandibular position instrument. The CR methods used in the study were unguided closure, chin point guidance, and bimanual manipulation. The investigation on 10 adults reported that all techniques had 0.2–0.3 mm of condylar displacement. The authors related this displacement to the principle of freedom in centric and did not consider this a drawback to the use of centric records. The most repeatable technique was bimanual manipulation. Chin point guidance positioned the condyles posteriorly, inferiorly, and right laterally. The technique of unguided closure showed a slight lateral displacement in comparison to the other methods. Utt and all. (7) compared the condylar position between MI and CR for 107 patients before orthodontic treatment. The frequency, direction, and magnitude of MI-CR difference were analyzed for possible correlation to the patient's Angle classification, ANB angular measurement, age, or gender. The amount of MI-CR difference was nearly identical for right and left sides and only weak correlations were found between MI-CR displacements of right and left condyles. They concluded that patient's age, ANB angle and Angle classification cannot be used to predict frequency, direction, or magnitude of MI-CR changes at the level of the condyles. Schildkraut and all. (8) examined cephalometric measurements derived from a MI tracing with those of a converted CR tracing. Statistical tests used to compare the MI and CR cephalometric values demonstrated significant differences for the majority of the studied values. However, there were generally no differences between the groups of males and females, or between the skeletal Class I and Class II individuals. The results of this study suggest that to make a correct orthodontic diagnosis, the mandible should be placed in centric relation rather than in the more traditional maximum intercuspation. De Fantini and all. (9) assessed condylar displacement between initial maximum intercuspation and centric relation, recorded after using a deprogramming occlusal splint for an average period of 7.8 ± 2.1 months prior to any orthodontic treatment. The use of occlusal splints results in greater mean condylar displacement values, especially vertically, between MI and CR, which contributed to a more accurate orthodontic diagnosis.

It should be emphasized that the condylar position indicator devices have been shown to be reliable and easy to use (10, 11). Levine and all. (12) assessed the nature and magnitude of method and material-induced error by studying intra- and interoperator variability using the CPI instrument at the levels of the articulator mountings and condylar displacement recordings. Condylar displacement recordings were very accurate and reproducible both among and between operators.

Aim

The difference between the position of CR and MI at level of dental arches causes a shift of articular condyles into articular fossae. The aim of this investigation was to determine whether the transfer modality (anatomic facebow vs. average mounting) from the patient to the articulator affects the three-dimensional condylar shift between the MI and the CR in asymptomatic subjects with normal occlusal relationship (Angle class I). The null hypothesis is that different ways of transferring hinge axis (facebow transfer or average mounting) does not influence on three-dimensional shift of the condyles. The gender differences with respect to the observed variables will be determined on the examined sample. All the data were saved in a data base (Microsoft Office Excel) and statistical analysis was performed using a licenced software package SPSS for Windows 12.0.

Materials and methods

Subjects selection

Study sample consisted of 32 fully dentate subjects (16 male and 16 female) with normal occlusal relations (Angle class I). Participants were dental students aged from 20 to 33 years (male 22.9 ± 5.3; female 22.3 ± 4.1). In order to meet the inclusion criteria, they had to be of good general health, with no clinical signs or symptoms of TMDs, no parafunctional habits and no prosthetic or orthodontic appliances present.

The sample size was calculated with a confidence of 95% and a statistical power of 80%. The number of subjects required in each group to make the comparisons was at least 15.

Procedure and measurement

Alginate (irreversible hydrocolloid) impressions for both dental arches were taken for each subject. The impressions were flushed clear of debris, air blown and were poured in super hard plaster type IV (Elite Rock (Zhermack, Rovigo, Vęneto, Italy)) after 30 min. After trimming the casts, the upper cast was used to prepare CR records. Hard wax was used for preparation (Beauty Pink, extra hard, Moyco Industries, Philadelphia, USA) of the CR record base as well as bite registration wax (Aluwax, Aluwax Dental Products Co., Allendale, USA) for recording impressions of the lower arch in lateral segments. Prior to the CR registration the patient was „deprogrammed“ by biting into a cotton pellet for 5 min. Deprogramming was used to deprive the patient of the proprioceptive sensory feedback and consequently disrupt the programmed neural mechanism that guides the mandible into CR (10-12). Each participant was subjected to four testing visits (first day, the following day, one week after and one month after). The registration of the CR position was done using bimanual manipulation method (Dawson's grasp) (13). For each of four measurements per subject, transfer of the casts to the articulator were randomly mounted twice using average mounting and twice using facebow transfer. Two modalities of transferring the upper cast to the semi-adjustable articulator have been chosen for the present investigation: anatomical facebow transfer and average mounting by means of Occlusal Plane Indicator (SAM Prazisionstechnik GmbH, Muenchen, Germany). Anatomical facebow was positioned onto the patient paralel to the axis-orbital plane. For average mounting, Occlusal Plane Indicator was set to following values: inclination of the occlusal plane 7°, vertical height 7.5 mm and horizontal height 5.5 mm. Prior to the mounting of the lower cast, incisal pin was set to + 7 mm in order to compensate the thickness of the CR record. MPI was calibrated according to manufacturer's recommendations prior to each measurement. All clinical and laboratory phases were completed by all examiners (experienced clinicians).

The determination of the spatial shift of the condyle from its physiological (centric) starting position into the position forced upon it by maximum intercuspation of the teeth is of special interest in the area of temporomandibular joint diagnosis. For metric recording of the condyle, a three-dimensional shift has been developed based on registration of the terminal (transverse) hinge axis. This requires that the selected measuring points lie on the transverse hinge axis. The measuring points exhibit movements analogous to the translation of the condyles. Therefore, the measured shift of the hinge axis points corrected for the intercondylar distance can be interpreted as the shift of the condyles (14).

Condylar position analysis using mounted casts was done by using MPI - Mandibular Position Indicator (SAM Prazisionstechnik GmbH, Muenchen, Germany) (Figure 1) (15). This modular device consists of a modified upper member of the SAM articulator. Sliding measuring cubes were placed on the mounting axis in place of the articulator condyles and an analogue gauge lies in between. Measuring cubes and gauge were used for evaluation of the three-dimensional condylar shift from the MI to the CR. Anteroposterior (ΔX) and superoinferior (ΔZ) shifts were measured relative to defined measuring points on the measuring cubes. Mediolateral shift (ΔY) was evaluated on the analogue gauge.

Figure 1 Mandibular Position Indicator (SAM Prazisionstechnik GmbH, Muenchen, Germany)
ASC_49(1)_36-44-f1

It should be emphasized that the analysis of the condyle position was dependent on the accuracy and quality of centric records.

The measuring procedure was completed for both left and right condyle. It implied placing the articulating paper between the measuring cube equipped with adhesive grids with x,y coordinates and the condyle head of the lower member of the articulator leaving a mark for each hinge axis position. Maximum intercuspation was considered the center of a Cartesian coordinate system and was represented as the starting position of the measurement (set to 0). The obtained marking can match the transverse hinge axis position or denote a difference in horizontal (anteroposterior, (ΔX)) and vertical (superoinferior, ΔZ)) dimensions between MI and CR. For every measuring, markings were made in different color of the articulating paper. Condylar displacements between MI and CR can be placed anteriorly (1)), posteriorly (2), superiorly (3) and inferiorly (4) presenting positive and negative values (Figure 2). The distance between each MI and each of the CR dots on the graph paper was measured, in millimeters, to an accuracy of 0.5 mm.

Figure 2 Measurement of the condylar shift in vertical (ΔZ) and horizontal plane (ΔX)
ASC_49(1)_36-44-f2

At the back of the MPI instrument there is an analogue gauge that registers mediolateral condylar shift. The gauge has a bicolor millimeter scale, red part of the scale representing condylar shift to the right (negative values) and black part representing shift to the left (positive values). Condylar shifts in mediolateral directions were measured, in millimeters, to an accuracy of 0.1 mm. All measurements on the MPI instrument were done by one examiner (RĆ).

Results

Table 1 presents descriptive statistical analysis (frequency and standard deviation) of the tested clinical variables for the condylar shift of the mandible caused by the difference between the MI and CR position. The average three-dimensional condylar shift (anteroposterior (ΔX), superoinferior (ΔZ) and mediolateral (ΔY)) was 0.13 ± 0.12 mm for facebow transfer and 0.22 ± 0.23 mm for average mounting. Kolmogorov-Smirnov test showed that the examined variables were normally distributed (P > 0.05). For this reason, to test the influence of three-dimensional shift of the condyle with respect to the mode of transferring in the semi adjustable articulator, a non-parametric statistical test (Mann-Whitney test) was used. The three-dimensional condylar shift showed no statistical significance with respect to gender (P > 0.05) (Table 2).

Table 1 Descriptive characteristics of the tested three-dimensional condylar shifts between the facebow transfer and average mounting.
Facebow transferAverage mounting
MeanSDMeanSD
Δ Yr
Δ Yl
Δ Xrf
Δ Xrb
Δ Zrd
Δ Zru
Δ Xlf
Δ Xlb
Δ Zld
Δ Zlu
Total
0.16
0.07
0.11
0.12
0.22
0.02
0.32
0.02
0.19
0.12
0.134
0.11
0.14
0.11
0.16
0.16
0.05
0.10
0.04
0.34
0.14
0.124
0.18
0.19
0.10
0.32
0.19
0.39
0.16
0.31
0.26
0.13
0.223
0.12
0.15
0.16
0.33
0.24
0.38
0.19
0.37
0.23
0.16
0.232

ΔYr – mediolateral shift to the right; ΔYl – mediolateral shift to the left; ΔXrf – anteroposterior shift right forwards; ΔXrb – anteroposterior shift right backwards (-); Δ Zrd – superoinferior shift right downwards; Δ Zru – superoinferior shift right upwards (-); ΔXlf – anteroposterior shift left forwards; ΔXlb – anteroposterior shift left backwards (-); Δ Zld – superoinferior shift left downwards; Δ Zlu – superoinferior shift left upwards (-), SD – standard deviation.

Table 2 The results of the Mann-Whitney test for three-dimensional condylar shift with respect to gender (facebow vs. average mounting)
ΔYdΔYlΔXdsΔXdnΔZddΔZdgΔXlsΔXlnΔZldΔZlg
Mann-Whitney U
Wilcoxon W
Z
17513
36549
-0.89
17053
35581
-1.49
17453
35981
-1.18
17588
36116
-0.95
18344
36872
-0.10
16596
35124
-2.17
17587
36115
-0.89
18363
36891
-0.09
17745
36273
-0.80
17835
36363
-0.69
Significance0.3720.1350.2360.3430.9180.1300.3730.9290.4230.486

ΔYr – mediolateral shift to the right; ΔYl – mediolateral shift to the left; ΔXrf – anteroposterior shift right forwards; ΔXrb – anteroposterior shift right backwards (-); Δ Zrd – superoinferior shift right downwards; Δ Zru – superoinferior shift right upwards (-); ΔXlf – anteroposterior shift left forwards; ΔXlb – anteroposterior shift left backwards (-); Δ Zld – superoinferior shift left downwards; Δ Zlu – superoinferior shift left upwards (-).

Comparing the ways of transferring the hinge axis (facebow transfer or average mounting) to the semiadjustable articulator, the results of the Mann-Whitney test showed statistically significant differences for anteroposterior and superoinferior condylar shift (P < 0.001). However, the differences in the mediolateral shift were not statistically significant (Table 3).

Table 3 The results of the Mann-Whitney test for three-dimensional condylar shift in order to the transfer modality (facebow vs. average mounting)
ΔYrΔYlΔXrfΔXrbΔZrdΔZruΔXlfΔXlbΔZldΔZlu
Mann-Whitney U
Wilcoxon W
Z
17568
36096
-0.84
16693
35221
-1.88
16095
34623
-2.83
11979
30507
-7.28
16125
34653
-2.70
14596
33124
-4.54
14026
32554
-4.65
12432
30960
-7.83
17829
36357
-0.70
15821
34349
-3.05
Significance0.4010.0590.0050.0000.0070.0000.0000.0000.4830.002

ΔYr – mediolateral shift to the right; ΔYl – mediolateral shift to the left; ΔXrf – anteroposterior shift right forwards; ΔXrb – anteroposterior shift right backwards (-); Δ Zrd – superoinferior shift right downwards; Δ Zru – superoinferior shift right upwards (-); ΔXlf – anteroposterior shift left forwards; ΔXlb – anteroposterior shift left backwards (-); Δ Zld – superoinferior shift left downwards; Δ Zlu – superoinferior shift left upwards (-).

Discussion

In the study, the bimanual manipulation was used as a method of determining the centric relation. As shown by data from the scientific literature (4-12), it is one of the most reliable and reproducible methods of determining CR in dentistry in spite of the fact that they are asymptomatic subjects, orthodontic patients or patients with temporomandibular disorders. Accordingly, the method of determining the CR in this study did not affect the three-dimensional shift of the condyle since its reliability has been demonstrated (13).

Basically, there are two methods of transferring the relation between the upper and lower dental arch to the base of the skull into the articulator- facebow transfer and average mounting. One can question whether those modalities have an influence on the precision of centric relation registration. From a clinical viewpoint, usage of any facebow type should be more precise than the average mounting. In the present study, the null hypothesis is rejected, indicating that different ways of transferring hinge axis does influence the three-dimensional shift of the condyles among asymptomatic subjects. Besides, the three-dimensional condylar shifts showed no statistically significant difference with respect to gender. The facebow transfer displayed lower values of three-dimensional shifts of the condyle (anteroposterior and superoinferior) compared to the average mounting. This conclusion is the result of the statistical analysis. In other words, the statistically significant differences found in this study do not have significant impact on everyday clinical use of semi-adjustable articulators. These differences of the average three-dimensional condylar shifts between facebow transfer and average mounting were at the level of 0.1 – 0.2 mm that they can be considered a physiological variation of condylar shift of normal temporomandibular joints among asymptomatic subjects with normal occlusion.

In the literature, there are numerous studies with controversial conclusions regarding the use/disuse of the facebow and dental articulators (14-17). In the ones which support the use of facebow, the main criterion is the transfer of hinge axis into articulator. Tuppy et al. (18) tested the position and translation of the hinge axis using an electronic mandibular positioning indicator in 15 symptomatic patients. According to their results, there is great repeatability in the hinge axis positions. Morneburg and Pröschel (19, 20) confirmed the importance of the average or kinematic hinge axis registration as well as its use in prosthetic dentistry. They recommend facebow transfer in order to minimize occlusal mistakes especially for cases that require altering the vertical dimension of the occlusion for more than 4 mm. Padala et al. (21) found that vertical and horizontal condylar shifts were greater for patients with TMD than for asymptomatic subjects. They concluded that discrepancies in condylar shift play a role in the etiopathogenesis of the TMD. Furthermore, they stressed the importance of instrumental-functional analysis, i.e. three-dimensional condylar shift analysis and its use in TMD diagnostics.

On the other hand, some studies have questioned the benefit and reliability of the facebow transfer modality. Scandinavian Prosthodontic Association and its members claim that "although theoretically convincing, there is no strong scientific evidence that proves facebow transfer improves clinical quality of prosthetic restorations in comparison to the average mounting into the articulator " (22, 23).

Conclusion

In the present study, discrepancies in three-dimensional condylar shifts were greater for average mounting than for facebow transfer. In spite of the fact that there were statistically significant differences, from a clinical viewpoint, these differences are not so crucial in everyday practice. This implies that the use of the facebow and/or average mounting are equally reliable clinical procedures to transfer the relationship between upper and lower jaws into dental articulator in asymptomatic subjects with normal occlusion.

Notes

[1] Conflicts of interest The study was approved by Ethics Committee of School of Dental Medicine, University of Zagreb, Croatia. We are grateful to the dental clinic at the Clinical Hospital Center Zagreb for the financial and material support. The authors declare no conflicts of interest.

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