CLINICAL SCIENCE

Reliability of the anterior functional device in recording the

centric relations of patients with posterior tooth loss
Maria C. F. F. Ballastreire,a Giselle G. Carmo,b and Solange M. Fantinic

Obtaining an accurate centric ABSTRACT

relation (CR) record is an Statement of the problem. The recording of centric relations (CRs) in patients with posterior tooth
important step in the diagnosis loss is a process that is subject to inaccuracy. A number of techniques and devices, including the
and planning of orthodontic or anterior functional device (AFD), have been developed in the pursuit of better results.
prosthetic treatment,1 and this
Purpose. The purpose of this in vivo study was to evaluate the reliability of the AFD for the
task might be more complex in recording of the CR in participants with different types of posterior tooth loss.
the presence of posterior tooth
loss. The lack of proper distri- Material and Methods. Two CR records were obtained (CR1, CR2), and 2 maximal intercuspal
position records were obtained (MIP1, MIP2) by a single operator at intervals of 5 minutes. This
butions of simultaneous axial
study included 45 participants of both sexes aged between 18 and 65 years who were divided
and bilateral loads caused by into 3 groups. The first group had intercalated tooth loss (n=19), the second group had distal
tooth loss induces a muscle extensions (n=11), and the third group had no tooth loss (n=15). The distance between the CR
pattern called the engram and and MIP was termed the condylar displacement and was measured in millimeters in the vertical,
makes the proper mandibular horizontal, and transversal planes with a condylar position indicator (CPI). The condylar dis-
manipulation that is frequen- placements between the CR and MIP in both stages of the study (D1 and D2) were compared
tly necessary for the correct with the CPI after mounting the casts on a semiadjustable articulator. Repeated-measures
analyses of variance with one factor were used to compare the records for each group in
recording of the CR difficult or
2
each of the planes: right vertical (RV), left vertical (LV), horizontal right (HR), horizontal left
impossible. (HL), and transverse (T) (a=.05). No significant differences between the records in any of the
Among the clinical tech- planes (RV, LV, HR, HL, or T) were observed; thus, the means of the records of each plane
niques that are used to obtain were used to compare the groups (the intercalated tooth loss, distal extension, and no tooth
reliable CR records, several loss groups). The means of the records of the HR and HL planes were compared by ANOVA
include mandibular manipula- because the data were normally distributed. The means of the records of the RV, LV, and T
tions and recording materials planes were compared by using nonparametric Kruskal-Wallis tests because the data were
non-normally distributed.
that allow for the immediate
mounting of the casts on the Results. No statistically significant difference (P >.05) was found between the condylar displace-
articulator.1,3-6 The chin point ments for any of the studied variables in the 3 considered groups: RV (.512), LV (.690), HR (.179), HL
(.494), and T (.644).
guidance,3 frontal manipula-
4 5
tion, swallowing, bimanual Conclusions. Repeatability of the condylar displacement was observed between the CR and
manipulation,6 and power cen- MIP (D1, D2), which indicates the reliability of this method for recording the CR in participants
tric techniques are among the with posterior tooth loss. The AFD was demonstrated to be a user-friendly tool and permitted the
recording and evaluation of excursive movements with tracings. (J Prosthet Dent 2015;-:---)
manipulation techniques that
are dependent on the oper-
ator.1 Among the techniques that are less dependent on the Lucia anterior programing device,2 the Long leaf
the operator and more dependent on the participant are gauge,7 the Pathfinder,8 the anterior functional device

a
Graduate student, Department of Orthodontics, School of Odontology, University of São Paulo (FOUSP), São Paulo, Brazil.
b
Graduate student, Department of Orthodontics School of Odontology, University of São Paulo (FOUSP), São Paulo, Brazil.
c
Professor, Department of Orthodontics, School of Odontology, University of São Paulo (FOUSP), São Paulo, Brazil.

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Clinical Implications
Although many different methods are available for
CR recording, the reliability of the AFD observed in
this study might contribute to improvements in
clinical practice, particularly in more complex con-
ditions that result from different types of posterior
tooth loss.

(AFD),9 and dynamic and intraoral registration.10 These

techniques can be considered short-term deprogram-
ming techniques rather than occlusal devices, which are
considered long-term deprogrammers. Figure 1. Example image from group with intercalated tooth loss.
In view of discussions regarding the methods best
suited for recording CR11-16 and the ease of use of the
AFD in dental patients,9,11 the purpose of this study was
to evaluate the reliability of this technique as a method of
recording CR in participants with tooth loss compared
with a control group without tooth loss. The absence of
differences between the CR records of the participants
with and without tooth loss was adopted as the null
hypothesis.

MATERIAL AND METHODS

The sample consisted of 45 participants of both sexes
aged between 18 and 65 years who were selected from
the Orthodontic and Prosthodontics Clinics, School of
Dentistry, University of São Paulo. Informed consent was
obtained from all participants and approval from the Figure 2. Example image from group with distal extension.
Ethics Committee of the University of São Paulo (149/
2011) for this study was given.
The participants were divided into the following 3 severe skeletal discrepancies as assessed by clinical and
groups: (1) a group without tooth loss (control, n=15); (2) a photographic examinations, acute temporomandibular
group with intercalated loss (n=19), with 1 or more molars disorders (joint pain and/or muscle pain, severe opening
and premolars absent (Fig. 1), with the exception of the limitations below the 35-mm second research diagnostic
second or third molars, and additional distal extension criteria-temporomandibular disorders) that required im-
(Fig. 2); (3) and a group with no second or third molars mediate treatment or prevented CR recording,14 and
that could also include patients who had lost the first posterior or anterior reverse unilateral or bilateral artic-
maxillary and/or mandibular molars, resulting in unilateral ulation and bruxism.
or bilateral distal extension in 1 or both arches (n=11). Type IV gypsum casts (Durone; Dentsply Brazil) were
The inclusion criteria were good systemic health and obtained from each participant and prepared according to
oral hygiene, anterior horizontal overlap between 1 and the Lauritzen split-cast method.2 The casts were moun-
3 mm, anterior vertical overlap between 1 and 4 mm, and ted on a semiadjustable articulator (Panadent; Panadent
light Class I or Class II and III occlusion according to Corp) with a facebow by following the guidelines out-
the classification scheme proposed by Angle13 while lined in the instruction manual from the manufacturer15
respecting the vertical and horizontal overlap limits. The and fixed with quick-setting plaster (Elite Arti; Zher-
exclusion criteria included ongoing orthodontic treat- mack SpA).
ment, prior neuromuscular deprogramming, active peri- The maximal intercuspal position record (MIP) was
odontal disease, fixed prostheses with more than 1 achieved with extra hard pink wax (Beauty Pink Wax;
element, posterior tooth loss that compromised the cor- Moyco Industries) that had been plasticized in water
rect recording of the CR according to the adopted tech- heated to 58 C and cropped close to the tips of the buccal
nique, anterior vertical and/or horizontal overlaps cusps of the maxillary teeth and coincident with the distal
exceeding the limits established in the inclusion criteria, faces of the last teeth present in the arch in order to

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Figure 3. Tracing anterior function device showing vertex as most ret- Figure 4. Blue Almore wax positioned between posterior teeth with
rusive mandibular position. anterior function device occluding at tracing vertex.

prevent interference with the cheeks. This record was (Fig. 3). The participants were asked to perform open-
made while the participant was seated and after directing ings and closings without protruding the mandible until
the participant to occlude strongly to produce perfora- the operator observed the stylus of the lower device
tions in the wax in the areas corresponding to the coincident with the vertex of the tracing drawn on the
interocclusal contacts. The record was cooled and surface of the upper device. A blue wax sheet with a
removed with air jets, washed in running water, and trapezoidal shape and convenient density was used
dipped into ice water. After cooling, the adaptation was (Almore Intl) to record this position in the dimensions of
confirmed between the mouth and the casts. If there was the upper cast, which was plasticized in a bath at 58 C
any excess, it was removed under running water using a and positioned on the posterior teeth while respecting
sharp scalpel blade. Two records were obtained from the posterior limit of the AFD. The participant was then
each participant (MIP1 and MIP2) according to the instructed to occlude in the defined vertex during the
technique described. The records were identified, dried initial training and relaxation (Fig. 4). The wax record
and stored in hermetically sealed wrappers. was cooled with air jets and then ice water, and the
The CR position was determined with the anterior indentations were smoothed using a sharp scalpel blade
functional device (AFD), which allows for the localiza- under running water. An easy manipulation of the
tion and recording of the maxillary-mandibular rela- mandible using short opening and closing movements
tionship on a tracing that is juxtaposed to an acrylic and the repeatability of the engagement of the teeth in
resin platform that is fixed to the anterior teeth.9 As the indentations helped ensure that the record was
described by Gysi,16 the vertex of the recorded done correctly. Finally, the correct adaptation of the
mandibular trajectory free of dental contact is taken records between the casts was confirmed. The described
as the more retruded position of the mandible in the method was performed twice for each participant (CR1
horizontal plane and assumed to be coincident with and CR2), and the records were dried and stored in
the CR position of the condyles in their respective hermetically sealed plastic wrappers.
mandibular fossa.9 The lower device of the AFD was The maxillary casts were mounted on the articulator
adapted to the incisal edge of the mandibular incisors by with the aid of the facebow. Regarding the mandibular
following the midline of the face, and the upper device casts, the first CR record (CR1) from each participant was
was fixed to the maxillary incisors parallel to the ground used according to the guidelines outlined in the in-
to allow for the smallest possible disocclusion of the struction manual from the manufacturer (Basic).15 The
posterior teeth with a low-fusion compound (Kerr accuracy of the assemblies of both casts were confirmed
Corp). The top was located in the anteroposterior di- by the absence of light between the 2 surfaces of the
rection to allow for recording of the excursive man- split-cast and by verifying that the viewing marks coin-
dibular movements within the limits of the occlusal cided with the center of the graph when transferring the
table and painted with a white dermatographic pencil casts to the condylar position indicator (CPI; Panadent;
(7600 Dematograph; Mitsubishi). The participant was Panadent Corp) (Fig. 5).
instructed to perform protrusive and lateral mandibular With the casts adapted to the CPI and the first CR
movements and subsequently return to the most ret- record adapted between the casts, the first CR position
ruded position. After a few repetitions of these motions, was recorded in the lateral and transversal graphs by
the vertex of the mandibular movements was recorded interposing a sheet of green articular monoface paper

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Table 1. Comparison of RV, LV, HR, HL, and T measures between D1 and
D2 mandibular condylar displacements to assess CR record reliability
Distal Intercalated
Records for Planes Control Extension Loss Total
and Groups (n=15) (n=11) (n=19) (n=45)
RV (D1)
Mean ±SD 0.79 ±0.51 0.14 ±1.5 0.66 ±0.45 0.57 ±0.86
Median (min-max) 0.7 (0-1.6) 0.7 (-3-2.7) 0.7 (-1.6) 0.7 (-3-2.7)
RV (D2)
Mean ±SD 0.75 ±0.57 0.09 ±1.52 0.79 ±0.48 0.61 ±0.9
Median (min-max) 0.7 (0-1.5) 0.7 (-2.8-2.7) 0.8 (0-2) 0.8 (-2.8-2.7)
LV (D1)
Mean ±SD 0.45 ±0.34 -0.16 ±1.81 0.55 ±0.45 0.34 ±0.98
Median (min-max) 0.6 (0-1) 0.3 (-3-3) 0.5 (0-1.5) 0.5 (-3-3)
LV (D2)
Mean ±SD 0.51 ±0.42 -0.22 ±1.92 0.48 ±0.48 0.32 ±1.04
Figure 5. Black point at center of graph during transfer of casts to
Median (min-max) 0.5 (0-1.2) 0.4 (-3.2-3.1) 0.4 (0-1.6) 0.5 (-3.2-3.1)
condylar position indicator corresponds to centric relation position.
HR (D1)
Mean ±SD 0.23 ±0.62 0.68 ±1.04 0.26 ±0.48 0.35 ±0.7
Median (min-max) 0.3 (-1-1.4) 0.5 (-1-2.5) 0.4 (-0.7-1) 0.4 (-1-2.5)
(Bausch; Bausch Articulating Papers) between the styles HR (D2)
and the sheets of the self-adhesive graph paper set in Mean ±SD 0.21 ±0.69 0.65 ±0.96 0.16 ±0.54 0.3 ±0.72
the corresponding surfaces of the instrument. Next, Median (min-max) 0.2 (-1-1.5) 0.7 (-1.1-2.5) 0.2 (-1.2-1) 0.3 (-1.2-2.5)
the CR2 position was recorded from the same 3 CPI HL (D1)
graphics by repeating the steps described and marking Mean ±SD 0.23 ±0.6 0.3 ±1.34 0.02 ±0.58 0.16 ±0.82
the points with red articulating paper. The steps were Median (min-max) 0.1 (-0.8-1.3) 0.3 (-1.6-3.4) 0 (-1.3-1.1) 0.1 (-1.6-3.4)

repeated while inserting the MIP1 and MIP2 records and HL (D2)
Mean ±SD 0.29 ±0.57 0.3 ±1.23 -0.02 ±0.43F 0.16 ±0.74
demarcating the respective positions in blue and black
Median (min-max) 0.3 (-0.9-1.3) 0.2 (-1.7-2.9) 0.1 (-1.1-0.7) 0.1 (-1.7-2.9)
carbon. The distances between the CR and MIP records
T (D1)
represent the offsets of the condyle between the 2
Mean ±SD 0.08 ±0.39 0.02 ±0.78 -0.06 ±0.51 0 ±0.54
mandible positions in the 2 planes of space and were Median (min-max) 0 (-0.5-1) -0.1 (-1.5-1.3) 0 (-1-1) 0 (-1.5-1.3)
measured with a millimeter magnifying glass (Peak Op- T (D2)
tics; Beta Industries) to the nearest tenth of a millimeter. Mean ±SD 0.06 ±0.24 -0.04 ±0.85 -0.1 ±0.4 -0.03 ±0.5
The condylar displacement between CR1 and MIP1 was Median (min-max) 0 (-0.3-0.5) 0 (-1.7-1.4) 0 (-1-0.5) 0 (-1.7-1.4)
defined as D1, and the displacement between CR2 and RV, right vertical; LV, left vertical; HR, horizontal right; HL, horizontal left; T, transverse; D1,
MIP2 was defined as D2. The comparison between the 2 displacement between CR1 and MIP1; D2, displacement between CR2 and MIP2.
measurements (D1 and D2) of each participant is a test of
the reliability of the method in participants with posterior
and T measurements and the results of the ANOVAs of
tooth loss.
the HR and HL measurements.
Repeated-measures analyses of variance with 1 factor
were used to compare the records for each group in each
RESULTS
of the planes: right vertical (RV), left vertical (LV), hori-
zontal right (HR), horizontal left (HL), and transverse (T). The right and left vertical (RV, LV) and horizontal (HR,
Because no significant differences were found between HL), and transverse (T) measurements between the
the records for any of the variables (RV, LV, HR, HL, and condylar displacements (D1 and D2) were compared
T), the average of the records for each of the variables independently of the group (Table 1). No statistically sig-
was calculated for between-group comparisons. nificant differences at the 5% level were found between the
To test the repeatability of the method, the 3 groups D1 and D2 measurements in terms of the studied variables,
were compared in terms of the means of the condylar indicating the reliability of this method (Table 2).
displacements. The nonparametric Kruskal-Wallis test Table 3 shows no significant differences among the 3
was used for the RV, LV, and T variables because they did groups in terms of the means of the D1 and D2 records in
not satisfy the assumption of normality, and ANOVA any of the variables at the significance level of 1% (P
analyses were used for HR and HL because these vari- value) as follows: RV (.512), LV (.690), HR (.179), HL
ables were normally distributed. The calculations of the (.494), and T (.644). According to the results shown in
powers of the samples for each of the RV, LV, HR, HL, Table 4, the power of all of the comparisons of each of the
and T measurements were performed by using the results 5 measurements (RV, LV, HR, HL, and T) was 1.616% at
of the nonparametric Kruskal-Wallis tests of the RV, LV, a significance level of 1%.

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Table 2. Statistical comparisons among the groups tested and their Table 3. Comparison of D1 and D2 records of RV, LV, HR, HL, and T
interactions measures between groups
Comparisons P Distal Intercalated
Right Vertical Variables Control Extension Loss
per Record (n=15) (n=11) (n=19) P
Groups .109
Mean between D1
Records .646 and D2 of RV
Groups×Records .117 Average ±SD 0.77 ±0.53 0.11 ±1.51 0.73 ±0.43 .512*
Left Vertical Median (min-max) 0.7 (0-1.55) 0.7 (-2.9-2.7) 0.65 (0-1.8)
Groups .135 Mean between D1
Records .541 and D2 of LV
Groups×Records .225 Average ±SD 0.48 ±0.37 -0.19 ±1.86 0.52 ±0.45 .690*
Horizontal Right Median (min-max) 0.6 (0-1) 0.3 (-3-3.05) 0.45 (0-1.55)
Groups .179 Mean between D1
and D2 of HR
Records .285
Average ±SD 0.22 ±0.64 0.67 ±0.99 0.21 ±0.49 .179†
Groups×Records .709
Median (min-max) 0.2 (-1-1.45) 0.55 (-1.05-2.5) 0.4 (-0.95-1)
Horizontal Left
Median between D1
Groups .494 and D2 of HL
Records .882 Average ±SD 0.26 ±0.56 0.3 ±1.28 0 ±0.49 .494†
Groups×Records .741 Median (min-max) 0.25 (-0.85-1.2) 0.25 (-1.6-3.15) 0 (-1.2-.75)
Transverse Mean between D1
Groups .696 and D2 of T
Records .380 Average ±SD 0.07 ±0.3 -0.01 ±0.8 -0.08 ±0.44 .644*
Groups×Records .951 Median (min-max) 0 (-0.3-0.65) -0.05 (-1.6-1.2) 0 (-1-0.75)

RV, right vertical; LV, left vertical; HR, horizontal right; HL, horizontal left; T, transverse; D1,
displacement between CR1 and MIP1; D2, displacement between CR2 and MIP2; SD, stan-
dard deviation.
*Nonparametric Kruskal-Wallis test.
†
DISCUSSION ANOVA analyses.

The results of this study support the acceptance of the null

hypothesis because no statistically significant differences Table 4. Results of sample power calculations for each of 5 measure-
were found between the CR records obtained in 2 stages ments (RV, LV, HR, HL, and T)
in participants with 2 different types of posterior tooth loss Average of Level of Sample
Sample Size Measurements Standard Significance Power
or in the control group without such losses; however, Measurement per Group per Group Deviation (a) (b)
sample power was low. Based on these observations, AFD RV nC = 15 x C = 0.77 1.51 5%
= 1% 5.255%
5
should be considered a suitable method for CR registra- nEL = 11 x EL = 0.11
tion regardless of the presence of posterior tooth loss nPI = 19 x PI = 0.73
because the repeatability of a record is essential for it to be LV nC = 15, x C = 0.48 1.86 5%
5 = 1% 4.099%
deemed reliable. The identification of suitable methods for nEL = 11 x EL = -0.19
the registration of maxillomandibular relationships is of nPI = 19 x PI = 0.52
clinical importance in the diagnosis, planning, and HR nC = 15, x C = 0.22 0.99 5%
5 = 1% 6.296%
remediation or rehabilitation of such relationships and nEL = 11 x EL = 0.67

decisively influences the relevant laboratory stages of the nPI = 19 x PI = 0.21

HL nC = 15 x C = 0.26 1.28 5%
= 1% 2.172%
study of casts mounted on an articulator and the func- 5
nEL = 11 x EL = 0.30
tional analyses of temporomandibular joints. Tooth loss
nPI = 19 x PI = 0.0
could hinder the CR recordings adopted by many pro-
T nC = 15 x C = 0.07 0.80 5%
= 1% 1.616%
fessionals as reference positions for various types of 5
nEL = 11 x EL = -0.01
treatment because of changes in maxillomandibular re- nPI = 19 x PI = -0.08
lations and the conditions and relationships of the struc-
RV, right vertical; LV, left vertical; HR, horizontal right; HL, horizontal left; T, transverse.
tures of the TMJ and associated muscle activities.
The search for greater reliability in the localization and
recording of the CR has resulted in a variety of materials have been found by comparing the CR records obtained
and techniques. Comparisons between methods have using the AFD and the Lucia anterior programing de-
failed to identify a single technique that can be consid- vice.11 A comparison of the Lauritzen frontal manipula-
ered definitively better than the others. Less consistent tion with the dynamic and intraoral registration revealed
results have been observed with the swallowing and free- that the registration technique significantly affects the
lock techniques, and greater repeatability has been condylar position and can result in a more anterior and
observed for bimanual manipulation.12 Similar results inferior condylar location.10

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In addition to the repeatability of the CR records, this repeatable, indicating that this method is reliable in
study showed that the AFD, a short-term deprogrammer terms of CR recordings in participants with and
device, could be easily and clinically used in participants without subsequent tooth loss. However, because of
with conditions resulting from the intercalated or distal the low power of the sample, further studies are
extension types of posterior tooth loss. The recording of the necessary to validate this conclusion.
mandibular trajectories (protrusion, retrusion, and later- 2. The AFD was shown to be simple to use and
ality) on the horizontal surface of the maxillary component enabled the graphic evaluation of excursive move-
remained possible, which might contribute to the identi- ments, which may be useful in the diagnosis of any
fication of some types of craniomandibular disorders. functional alterations of the stomatognathic system.
In the control group of participants without tooth loss,
the muscle relaxation time sufficient to achieve the
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pant controls his masticatory force with an analog visual
scale.10 Corresponding author:
Maria Carolina Franco Ferreira Ballastreire
Avenida Dr. Cândido Rodrigues
CONCLUSIONS 115 Centro Piracaia SP 12970-000
BRAZIL
Email: [email protected]
1. The measures of condylar displacement between
the CR and MIP (D1 and D2) were observed to be Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

THE JOURNAL OF PROSTHETIC DENTISTRY Ballastreire et al