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Comparison of condylar guidance setting obtained from a wax record

versus an extraoral tracing: A pilot study


Jose dos Santos Jr, DDS, MSc,a Stanley Nelson, DDS, MSc,b and Thomas Nowlin, DDS, MScc
University of Texas Health Science Center at San Antonio, San Antonio, Texas
Statement of the problem. Protrusive condylar angles can be determined by use of wax protrusive records
(WPR), pantographic tracings (PT), and occlusal wear facets. These methods generate different angles in the
same patient.
Purpose. The purpose of this study was to compare the condylar inclination angles found by use of the WPR in
a Hanau articulator with those found by use of the Whip-Mix PT quick-set recorder. The occlusal wear facet
method was not part of this study.
Material and Methods. Ten subjects were chosen at random from a dental school patient population. All
subjects had a majority of maxillary and mandibular teeth present and according to the examination criteria used
in the schools Division of Occlusion, they were healthy with no signs/symptoms of temporomandibular disorders. The WPR was accepted when it was evident that the patient had protruded straight forward at least 6 mm
anterior to centric relation, as shown on the Hanau articulator by the condylar spheres having moved anteriorly
an equal distance of 6 mm on both sides. The condylar inclination on the articulator was adjusted accordingly.
The PT was used according to the manufacturers directions, which included the use of an intraoral clutch
adapted to the mandibular arch, connected to an extraoral facebow with bilateral inscribing pointers. A holder
frame was adapted to the face with bilateral flags where the inscribing pointers traced the protrusive movement
of the jaw. All the readings were in degrees. No control was used in this project. To test whether there was a
significant difference between the 2 independent samples, a Mann-Whitney U test was performed (P.01).
Results. The mean results for the WPR were as follow: right side (28.1 degrees, SD 8.94); left side (31.50
degrees, SD 9.73). For the PT, results were: right side (41.10 degrees, SD 7.53); left side (35.5 degrees, SD
6.43). When right and left side protrusive condylar angles were combined, the values were: WPR (29.80 degrees,
SD 9.25); PT (38.30 degrees, SD 6.98). The differences on the right condylar values were significant (P.01).
There was no statistical difference on the left side.
Conclusions. Within the limitations of this study, it was concluded that the PT technique yielded greater values
for the protrusive condylar inclination than the WPR. (J Prosthet Dent 2003;89:54-9.)

CLINICAL IMPLICATIONS
Lower condylar angles were recorded from wax records when compared to the extraoral tracing
device. The wax method, although practical, may result in restorations with decreased cusp
height.

hen the subjects casts are mounted in a semiadjustable articulator by use of a facebow and intraoral or
extraoral records to adjust the condylar guidance, a close
approximation of the subjects mandibular movements
and occlusal relationships can be obtained.1,2 This can
facilitate the planning of occlusal adjustment and the
fabrication of restorations and prostheses that subsequently will require less adjustment intraorally.3-5 StudAn abstract of this project was presented in poster format (767)
during the 27th Annual Meeting of the AADR, Minneapolis, MN,
on March 5, 1998.
a
Professor, Division of Occlusion, Department of Restorative Dentistry.
b
Associate Professor, Division of Occlusion, Department of Restorative Dentistry.
c
Professor and Head, Division of Occlusion, Department of Restorative Dentistry.
54 THE JOURNAL OF PROSTHETIC DENTISTRY

ies that compared the pantographic method of measuring condylar inclination angles with the intraoral wax
protrusive method have consistently found higher angles with the pantograph and less variation than with
wax,6,7 with the exception of one study.8
One would assume that the pantographic method is
superior to the wax protrusive interocclusal registration;
however, the method requires skill and the equipment
expense cannot be discounted. In addition, it is difficult
to draw a consistent tangent to the tracings.9,10 This
results in greater angles than mathematical computation
or computer analysis of the tracings and is considered an
unsuitable way to measure the angles.9
It was found7 that protractors supplied by the manufacturers of 2 different pantographic systems were different and that different angles were obtained when one
manufacturers protractor was used to measure a recordVOLUME 89 NUMBER 1

DOS SANTOS, NELSON, AND NOWLIN

ing from the other manufacturers instrument. They did


not expand on the direction of the difference.
Two common methods for setting the sagittal condylar inclination angle in articulators are the use of a
protrusive intraoral record6,7 and the extraoral measurement7,10,11 of the condylar inclination with the pantograph. Since 1905, when Christensen12 advocated use of
the wax registration method to set the sagittal condylar
angle directly on the articulator, there has been controversy over the technique. The various materials used for
the intraoral method have been wax (some supported
with metal11,13) modeling compound, zinc oxide/eugenol paste, and polyether impression materials.6 Although some problems may be encountered with the
use of wax, this study used this material for intraoral
records.
Errors in sagittal condylar angle determination sometimes occur due to cast tipping, which is caused by poor
adaptation of the casts to the wax, deformation or compression of the wax, and frictional inhibition of movement of the condylar components of the articulator.11,14
Posselt and Franzen11 made an extensive study of the
wax protrusive record and used it to set the sagittal
condylar guidance of 3 different articulators. Six different wax records were made on 10 subjects and 2 readings were made from each record. The data for the Dentatus articulator was presented as values in degrees
relative to the Frankfort plane. The plane of reference is
a relevant parameter to consider, because condylar inclination values cannot be compared when obtained with
different planes of reference.15-18
Because of the natural curvature of the condylar path,
we observed that 2 mm of protrusive displacement are
insufficient for the determination of proper condylar
path inclination. The results are inconsistent angular
readings. In reality this may be the steepest portion of
the eminence as viewed on extraoral tracings. Posselt
and Franzen11 used the same wax record with 5 different
examiners at 3 consecutive readings. According to their
readings, there were differences in the angular values
when the same record was used continuously. In agreement with these findings, the authors of this study believed that many manipulations of such a compressible
wax record were a lot for this material to withstand. If an
examiner was last to use the record, then the large differences could be explained by a distorted record. Posselt and Frazen11 believed that the standard deviations
would decrease as the experience of the operator increased. Finally, they concluded that the condylar path
inclination could not be determined without a wide variation by use of the wax protrusive method.
To set the sagittal condylar guidance with less variation, the patient must protrude farther than the functional range of movement of the condyles.11,14 Another
problem noted with the wax protrusive technique was
that patients had a difficult time closing precisely in proJANUARY 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

trusion, which Craddock14 attributed to a lack of voluntary neuromuscular control. In addition, he was concerned that the wax record technique would have
minimum variation because it required the mandible to
be moved anterior to the functional range of movement
of the condyles (only 2 to 3 mm of protrusion) to give
angular readings. In discussing the practical consequences of variations in condylar guidance, he mentioned that the influence of the sagittal condylar guidance was greatest in the second and third molar areas.
He noted that a positive 10-degree change in the condylar guidance from the actual condylar guidance would
bring the molars 0.5 mm farther apart when the mandible was protruded in an end-to-end relationship, which
is approximately a 3-mm movement of the condyle. A
negative 10-degree change would bring the mandible
0.5 mm closer. He concluded that a 5-degree change
would cause a corresponding plus or minus 0.25-mm
change in the molar area. Craddock14 suggested avoiding precise measurements; he stated that the sagittal
condylar guidance should be considered as steep, moderate and somewhat flat rather than in terms of degrees
of angle. The wax protrusive record seems to fulfill
these generic requirements.
Lastly, wax is neither accurate nor reproducible.6
Other problems with the intraoral method, regardless of
the material used, are that the sagittal condylar angle
changes with the degree of protrusion11 and that the
intraoral record represents only one point along the condylar path.1 The purpose of this study was to compare
the sagittal condylar angles set in the Hanau articulator
by use of a method of obtaining an intraoral wax protrusive record to those angles found using the extraoral
method of tracing the condylar path with the Whip-Mix
quick-set recorder.

MATERIAL AND METHODS


Ten subjects, free of signs and symptoms of temporomandibular disorder (judged according to the schools
Division of Occlusion examination forms), were chosen
at random from the Dental School population. Subjects
were informed of the description of the instruments and
procedures to be performed, and a consent form was
signed. All subjects had most of their maxillary and mandibular teeth present, especially at the anterior portion
of the arches. Any absence was recorded to modify the
relationship of the dentition to the metallic clutch.
Stone casts of each subject were obtained by use of irreversible hydrocolloid impression material (Jeltrate Plus;
Dentsply Caulk International Inc, Milford, Del.). The
casts were mounted on an articulator (Hanau articulator
Model Wide-Vue 183 with a springbow; Teledyne/Water Pik, Fort Collins, Colo.) and occlusal wax records
(Shurwax; Heraeus Kulzer, South Bend, Ind.). One investigator made all wax records and completed the
55

THE JOURNAL OF PROSTHETIC DENTISTRY

DOS SANTOS, NELSON, AND NOWLIN

Fig. 1. Protrusive wax record on wax rim.

Fig. 2. Reference line traced on subject face, guided by


upper border of springbow.

Fig. 3. Metallic clutch adapted to lower jaw of subject.

Fig. 4. Whip Mix Quick Set Recorder mounted on subjects


face.

mounting procedures. For all subjects, the protrusive


records were accepted when the mandible moved
straight forward approximately 6 mm (Fig. 1). The wax
records were carefully handled and chilled in tap water.
Excess wax contacting soft tissues in the mouth was
trimmed, and the record was wrapped in a wet towel
before being used to mount and set the articulator. All
procedures for recording, mounting, and setting were
done in the same session.
A second investigator recorded pantographic tracings
(Whip-Mix Quick Set Recorder; Whip-Mix Corp, Louisville, Ky.) for each joint, repeating 2 to 3 times on each
subject on the basis of the manufacturers instructions:
1. With the Hanau springbow in position, guided by
the upper border of the right and left lateral extensions of the instrument, a line approximately 5 cm in
length was scribed with a felt pen on the skin just
anterior to the patients ears (Fig. 2). The springbow was then removed.
2. On both sides of the face, 12 mm were measured
and marked with a felt pen from the posterior bor-

der of the tragus of the ear along the line scribed.


This represented the approximate position of the
patients condylar transverse horizontal axis.
3. An aluminum clutch provided with the Whip-Mix
tracer was used to cover only the mandibular anterior teeth and premolars. A dense and small quantity
of a special plaster (MCG Plaster; Whip Mix Corp)
was placed on the clutch and adapted in the mouth
to set (3 to 5 minutes), maintaining the stem of the
clutch centered in relation to the sagittal plane (Fig.
3). The clutch was carefully removed, cleaned, and
reinserted in the mouth. It was then checked for
possible interferences to the eccentric movements
of the mandible, because the maxillary anterior
teeth should slide freely in contact with the external
surface of the clutch.
4. A metallic frame to hold the flag was adapted to the
subjects head to allow close positioning of the bilateral flags. A nasion piece positioned the lateral
extensions of the frame over the subjects ears. The
attachment of a posterior headband provided a snug

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VOLUME 89 NUMBER 1

DOS SANTOS, NELSON, AND NOWLIN

Fig. 5. Lateral flag of Whip-Mix Quick Set Recorder mounted


on subjects face.

fit of the frame (Fig. 4). Thumbscrews on each flag


were loosened to rotate each one until their horizontal lines were parallel to the lines scribed on the subjects face (Fig. 5).
5. After making sure the horizontal lines of the flags
were parallel to the lines on the subjects face, bilateral pointers were lined up with the crossed lines of
the patients face. Afterward the pointer assembly was
retracted and pieces of recording paper were adapted
to the flag. The paper was aligned with the posterior
edge of the flag, and a sharp graphite lead was
adapted to the pointers. The mandible was guided
into centric relation. With the leads touching the
paper, the subjects were instructed to move the mandible forward and back (Fig. 6). The operator saw
that the maxillary anterior teeth were touching the
plastic piece of the clutch during these displacements.
6. A third investigator used the protractor supplied by
the manufacturer to measure the angle of the tracings. With its respective lines adjusted parallel to the
ruled lines on the recording paper, there was only one
position at which the protractor could be superimposed over the tracings. Readings of the angulations
(in degrees) on the scale were evaluated at the point
where the protrusive tracing started (centric relation).
Because all investigators involved in this project are
members of the Division of Occlusion faculty, several
trials were previously performed to calibrate the team. To
test whether there was a significant difference between
the angles obtained on the condylar guidances of the
articulator and the protractor readings (independent samples), a Mann-Whitney U test was performed (P.01).

RESULTS
On the right side of the head, the pantographic
method gave statistically significant higher higher condyJANUARY 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 6. Pencil tracing produced during protrusive mandibular


movement.

Table I. Angles of condylar guidances measured in the


Hanau articulator (in degrees)
Pantography

Protrusive wax record

Subject

Right side

Left side

Right side

Left side

1
2
3
4
5
6
7
8
9
10
Mean
SD
Mean
SD

46
40
45
30
50
40
40
45
45
30
41.10
7.53

45
35
35
35
45
35
40
30
30
25
35.50
6.43

30
20
25
30
50
22
34
25
25
20
28.10
8.94

25
35
30
35
55
25
25
30
20
35
31.50
9.73

38.30
6.98

29.80
9.25

lar angles (P.01) than the intraoral wax registration


method (Table I). There was no statistical difference on
the left side. The variation was less for the pantograph
than for the wax. When the values were combined, the
mean condylar angles were closer and the variations narrowed but were still larger for the wax (wax 9.25
degrees, pantograph 6.98 degrees). Table I shows the
raw data that demonstrate the overall tendency for the
pantographic method to give greater angles. Interestingly, the angles obtained with wax were higher or equal
in the measurement of 1 condyle in 5 of the 10 subjects.

DISCUSSION
Zamacona et al,18 fully aware of the problems found
by El-Gheriani and Winstanley,9 believed it was possible
to obtain accurate angles of the sagittal condylar path by
drawing a tangent to the tracing and measuring with a
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THE JOURNAL OF PROSTHETIC DENTISTRY

conventional protractor. In their study, 3 investigators


drew tangents on 3 tracings of each side of 56 totally
edentulous patients. Their mean values and standard
deviations were similar on each side and were similar to
the results of the present study. The differences between
the El-Gheriani and Winstanley9 study and the study
presented in this article was that their study used the
ala-tragus line (Campers line) as a reference and that
their subjects were edentulous. The standard deviations
were close to those obtained for the wax protrusive registration for this study (right side 9.25; left side
6.98). The large standard deviations were due to reading
variations from one subject to the other. An interesting
observation by Zamacona et al18 was related to the angular differences between the left and right sides of their
subjects. They found that 44 (78.6%) had a zero- to
10-degree difference, whereas only 12 (21.4%) had
more than a 10-degree difference between right and left
sides.
Preti et al10 used the tangential method of measuring
the graphic registration of the condylar path inclination
(reference occlusal plane) in 390 patients (600 recordings) with 3 investigators and found that the investigators were within 0.788 degrees of each other. There
was a mean error of greater than 5 degrees in only 5
records, which were considered problematic because the
tracings were so short. They combined the right and left
side angles and found a mean of 33 degrees with a range
of 4 to 59 degrees. Because of the large difference in
eminence angles between individuals, they highly recommended measuring the condylar path inclination
when doing extensive restorations.
Craddock14 took triplicate wax records on 3 patients.
He made the statement on the basis of untabulated data
that if 3 separate records of a protrusive jaw relation are
secured and the condylar guidance on an articulator is
adjusted according to them, they will yield 3 different
results. A typical set of readings for 3 presumably identical records would be 20, 25 and 30 degrees. Craddock14 believed it was important to keep the distance of
protrusion the same because the sagittal condylar angle
changes with the amount of protrusion. He further contended that different angles could be obtained with the
same record. He used an articulator with the Frankfort
plane as a reference.
In another study, Posselt and Skytting8 compared
graphic tracings of each of 10 different subjects. They
concluded that the error in the graphic method was
probably due to the difficulty in drawing a tangent to the
curved condylar path and that tests suggest that the
graphic method is much less reliable than the wax method. It appears that they attempted to compare relative
angles measured against 2 different planes of reference.
Ecker et al7 recorded the protrusive condylar pathway
of 16 patients using the wax protrusive method and 2
simplified mandibular motion analyzers, the Whip-Mix
58

DOS SANTOS, NELSON, AND NOWLIN

quick set recorder and the Panadent quick analyzer recorder (Panadent Corp, Colton, Calif.). They combined
left and right sides and found that the wax method produced lower readings with a wider range of angles. The
Whip-Mix analyzer consistently produced higher readings than the Panadent recorder. The authors provided
an explanation for this. The 2 analyzers use slightly different anteroposterior planes. The Panadent uses the
transverse axis and a nosepiece, and the Whip-Mix uses
the average horizontal axis and a nosepiece. The horizontal axis is usually superior by a mean of 4 mm (range
2 to 9 mm) and posterior by an average of 3 mm from
the average horizontal axis. This difference could give a
smaller angle in the Panadent as compared with the
Whip-Mix. Another variable, as previously mentioned, is
the difference in the protractors supplied by each manufacturer. Ecker et al7 results were in degrees, and the
reference was nasion-porion.
Because the sagittal condylar guidance inclination is a
relative value related to a third point of reference, the
Frankfort plane was used as the reference for this study.
This plane was also used for the Whip-Mix quick-set
recorder.1,7,9
It became apparent that protrusive displacement of
the mandible for 6 mm or less may result in decreased
angulation of the condylar path. The readings suggest a
defined limitation of movement during procedures of
wax recording that is not manifested during pantographic movements.
Practical consequences of setting the articulators
condylar guidance higher than the subjects relative angle could possibly result in restorations with protrusive
and lateral interferences. It could also cause some interference to be missed when evaluating the movements
within the articulator. Setting the condylar guidance too
low could avoid development of interferences in restorations but could also indicate interferences in the articulator that are not present in the subject. A higher condylar guidance angle in a patient with dentures may be
better than a lower angle because the posterior teeth
may need adjustment with the higher angle, whereas the
anterior teeth may require adjustment with a lower angle.
Olsson and Posselt15 reviewed the literature, and the
studies they reviewed all agreed that the condylar path
inclination changes with the reference line. Nasion-sella
(porion, clinically) results in the highest angle, Frankfort
results in the next highest angle, and ala-tragus (Campers) results in the lowest angle. The selection of anterior
reference points (nasion or orbitalis, for example) is
more related to the use of a given model of articulator
(nasion for Whip-Mix and orbitalis for Hanau). These
variations do not seem to produce any influence in the
mounting results. Dos Santos et al16 found the same
relationship. The patients eminence angle was relatively
stable over time (changing rapidly only due to disease or
VOLUME 89 NUMBER 1

DOS SANTOS, NELSON, AND NOWLIN

acute trauma). Because all sagittal condylar angles are


relative, and because it is easy to use the Frankfort reference plane with the Hanau springbow facebow,17 the
Hanau system with the wax protrusive record may be the
most practical way to obtain the desired relative angle.
The Whip-Mix quick-set recorder, to date, has consistently given higher angles7,9 than other methods of recording the sagittal condylar guidance angle, even when
the Frankfort reference plane was used (as in this study)
instead of the average axis to the nasion plane.

CONCLUSIONS
Within the limitations of this study, measurement of
the extraoral tracing of the sagittal protrusive condylar
path gave higher values with less variation than the intraoral wax protrusive method. Also, the extraoral recordings appeared to capture a sagittal representation of
the contour of the articular eminence from the most
retruded position forward in straight protrusion. The
first 2 mm of the eminence from the retruded position
(which the wax record did not capture) were the steepest
and appear to be the area from which the usual protractor measurements are made.
Thanks are due to Dr Gerald Re, Associate Professor, The University of Texas Health Science Center at San Antonio Dental School,
for his editing during the preparation of this manuscript.

REFERENCES
1. Donegan SJ, Christensen LV. Sagittal condylar guidance as determined by
protrusion records and wear facets of teeth. J Prosthet Dent 1991;45:46972.
2. Celenza FV. An analysis of articulators. Dent Clin North Am 1979;23:30526.
3. Payne JA. Condylar determinants in a patient: electronic pantographic
assessment. J Oral Rehabil 1997;24:157-63.
4. Bailey JO, Nowlin TP. Evaluation of the third point of reference for
mounting maxillary casts on the Hanau articulator. J Prosthet Dent 1984;
51:199-201.

JANUARY 2003

THE JOURNAL OF PROSTHETIC DENTISTRY

5. Weinberg LA. An evaluation of basic articulators and their concepts: Part


II. Arbitrary, positional, semiadjustable articulators. J Prosthet Dent 1963;
13:645-63.
6. Pelletier LB, Campbell SD. Comparison of condylar control settings using
three methods: a bench study. J Prosthet Dent 1991;66:193-200.
7. Ecker GA, Goodacre CJ, Dykema RW. A comparison of condylar control
settings obtained from wax interocclusal records and simplified mandibular motion analyzers. J Prosthet Dent 1984;51:404-6.
8. Posselt UP, Skytting B. Registration of the condyle path inclination: variations using the Gysi technique. J Prosthet Dent 1960;10:243-7.
9. El-Gheriani AS, Winstanley RB. Graphic tracings of condylar paths and
measurements of condylar angles. J Prosthet Dent 1989;61:77-87.
10. Preti G, Scotti RS, Bruscagin C. A clinical study of graphic registration of
the condylar path inclination. J Prosthet Dent 1982;48:461-6.
11. Posselt UP, Franzen G. Registration of the condyle path inclination by
intraoral wax records: variations in three instruments. J Prosthet Dent
1960;10:441-54.
12. Christensen C. The problem of the bite. Dent Cosmos 1905;47:1184-95.
13. Kinderknecht KE, Wong GK, Billy EJ, Li SH. The effect of a deprogrammer
on the position of the terminal transverse horizontal axis of the mandible.
J Prosthet Dent 1992;68:123-31.
14. Craddock FW. The accuracy and practical value of records of condyle
path inclination. J Am Dent Assoc 1949;38:697-710.
15. Olsson A, Posselt U. Relationship of various skull reference lines. J Prosthet Dent 1961;11:1045-9.
16. dos Santos, Jr J, Nelson, SJ, Nummikoski P. Geometric analysis of occlusal
plane orientation using simulated ear-rod facebow transfer. J Prosthodont
1996;5:172-81.
17. Strohaver RA, Ryan JR. New facebow simplifies routine use and dental
laboratory cooperation. J Prosthet Dent 1988;60:638-41.
18. Zamacona JM, Otaduy E, Aranda E. Study of the sagittal condylar path in
edentulous patients. J Prosthet Dent 1992;68:314-7.
Reprint requests to:
DR JOSE DOS SANTOS JR
DEPARTMENT OF RESTORATIVE DENTISTRY
DIVISION OF OCCLUSION
UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER
7703 FLOYD CURL DRIVE
SAN ANTONIO, TX 78229-3900
TEL: (210) 567-3671
FAX: (210) 567-3669
E-MAIL: santos@uthscsa.edu

AT

SAN ANTONIO

Copyright 2003 by The Editorial Council of The Journal of Prosthetic


Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.11

59