Orthodontic Therapy Using the Roth

Gnathologic Approach
Theodore Freeland and Richard Kulbersh

The purpose of this article is to present the use of the Roth instrument-
assisted gnathological approach in diagnosis and treatment planning of 2
orthodontic cases. In both cases, mounted models were used to assess
maximum intercuspation-centric relation (MI-CR) discrepancy before and
after treatment. MI-CR harmony was used as an end of treatment goal. In
both cases, MI- CR harmony was achieved as indicated by final condylar
position indicator (CPI; Panadent Corp, Grand Terrace, CA) recordings.
(Semin Orthod 2003;9:140-150.) Copyright 2003, Elsevier Science (USA). All
rights reserved.

h r o u g h o u t its more than 100-year history,
T orthodontics has gone through various
stages of development. In the past and continu-
ing to this day, such topics as extraction versus
nonextraction therapy, mixed dentition versus
adult dentition therapeutic approaches, fixed
orthodontic appliance versus functional jaw or-
thopedics, surgical versus nonsurgical treatment
approaches, lower-incisor diagnostic issues and
t e m p o r o m a n d i b u l a r dysfunction considerations,
to name some, have been hotly debated. Al-
though orthodontics, as a health-related science,
has endeavored to, in the current jargon, be
evidence based, therapeutic end results are still a
unique blend of science and art.
No orthodontic diagnostic or treatment
methodology is without potential error because
of growth-related variations and operator abili-
ties. Nonetheless, clinical m a n a g e m e n t of orth-
odontic patients requires the best marriage of
science and art. By using gnathologic principles
in orthodontics and using appropriate instru-
mentation, Roth has attempted to measure as-
pects of orthodontic therapy and evaluate treat-
m e n t results from a gnathology standpoint.
From the private practice of Dr 7: Freeland, Gaylord, MI," and
the University of Detroit Mercy Dental School, Detroit, MI.
Address correspondence to Richard Kulbersh, DMD, MS, Uni-
ve*sity of Detroit Mercy Dental School, 8200 W Outer Drive, PO Box
19900, Box 189, Detroit, MI 48219.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1073-8746/03/0902-0000535.00/0
doi: 10.1053/sodo. 2003.34035
In the Roth technique, a necessary goal con-
sistent with establishing an acceptable gnatho-
logic functional occlusion is achieving maxi-
mum cuspation (MI) and centric relation (CR)
coincidence. In this gnathologic technique, any
existing t e m p o r o m a n d i b u l a r problems that
would prevent the capturing of a valid CR bite
registration are assessed and evaluated, using
appropriate splint therapy, before starting any
orthodontic treatment. After temporomandibu-
lar j o i n t (TMJ) assessment, initial models are
first m o u n t e d on a Panadent articulator and
then evaluated for MI-CR discrepancy on a Pa-
n a d e n t condyle position indicator (CPI; Pana-
dent Corp, Grand Terrace, CA). Any MI-CR dis-
crepancy recorded on the CPI instrument is
then taken into consideration in diagnosis, treat-
m e n t planning, and evaluation of the functional
occlusion at completion of orthodontic treat-
ment. In addition to CPI instrumentation, an
assessment of mandibular m o v e m e n t character-
istics such as Bennett shift, condylar movement
path, and hinge axis are evaluated by a panto-
graphic tracing using Panadent Axiopath instru-
mentation (Panadent Corp). These technique
procedures are d o n e to try and establish har-
m o n y between tooth position and m a n d i b u l a r
motion. This i n f o r m a t i o n is used to evaluate
t r e a t m e n t progress and to construct the gna-
thologic positioner, which is used to finish the
case after debanding.
The following 2 patients are presented to
show the utilization of the Roth gnathologic

140 Seminars in Orthodontics, Vol 9, No 2 ~une), 2003: pp 140-150

 The Roth Gnatholog4cApproach
technique in orthodontics. They represent the
opposite ends of the spectrum in CPI readings.
T h e first patient d o c u m e n t s CPI recordings in
which MI is above CR. This unusual recording,
in which the condyles go up f r o m CR to MI, is
contrm T to the definition of CR as the most
superior condylar position. T h e second patient
d o c u m e n t s CPI recordings that show MI record-
ings below CR. In this instance, the condyles are
distracted down and back f r o m CR to MI. In
both of these patients, using CPI data, a treat-
m e n t plan was f o r m u l a t e d e n c o m p a s s i n g the
central g o a l I t O achieve MI-CR h a r m o n y - - a s
well as to establish a mutually protected func-
tional scheme.
The complete workup of both patients
included an intraoral examination; facial exam-
ination in 3 planes of space; and lateral, postero-
anterior, and submental vertex radiograph eval-
uation of the craniofacial skeleton. Growth
potential, if present, was estimated by a hand-
wrist radiograph. Growth and t r e a t m e n t objec-
tives were assessed and estimated using the Rick-
ett's technique for the visual t r e a t m e n t objective
(VTO). In all instances, cases were treated with
the Roth prescription straight wire appliance
(GAC, Glendora, CA). Space constraints in this
article limit explanation and description of these
t r e a t m e n t aspects. Material presented will con-
centrate only on the CPI aspects of t r e a t m e n t as
they relate to evaluating and working toward
MI-CR coincidence.
Case One
This 14-year, 3-month-old female patient (Fig 1)
presented with a chief c o m p l a i n t of clicking and
pain in the TMJs. O t h e r medical and dental
histo~T considerations were n o n c o n t r i b u t o w
and within normal limits. T h e TMJ clinical ex-
amination revealed a m a x i m u m o p e n i n g of 36
ram, right lateral m o v e m e n t was 6 m m , and left
lateral was 8 m m . Auscultation revealed clicking
in both joints on opening. Palpation of the lat-
eral capsule areas revealed soreness (2 on a 3
point scale) on both sides. T h e Masseter muscle
was sore on both sides (2 on a 3 point scale). A
skeletal assessment was d o n e in 3 planes of space
using lateral, posteroanterior and submental
141
vertex cephalograms. Lateral skeletal character-
istics are shown in the traced cephalogram with
s u p e r i m p o s e d Rothz]arabak analysis (Fig 1C).
Initial records included an estimated facebow
m o u n t i n g that indicated first contact was on the
anterior teeth. The posterior teeth did not touch
(Fig 2). By using this mounting, a CPI recording
was m a d e that indicated that both condyles went
up from centric relation to centric occlusion or
MI was above CR (Fig 3).
T r e a t m e n t considerations were developed us-
ing a 2-year growth forecast and a Rickett's VTO
assessment. This evaluation estimated that the
mandible would probably grow m o r e Class Iil
and that the u p p e r anterior teeth n e e d e d to be
m o v e d forward and torqued, thus allowing the
mandible to autorotate closed. Based on this
patient's TMI problems and resultant inabiliD" to
take a true CR bite, t r e a t m e n t was initiated with
splint therapy (Fig 4).
In this patient, a l t h o u g h not p r o m i s e d be-
fore t r e a t m e n t , the j o i n t p r o b l e m s (pain a n d
clicking) d i s a p p e a r e d a n d the splint therapy
was followed by a true h i n g e axis m o u n t i n g
(Fig 5) to r e d i a g n o s e the occlusion a n d pre-
dict an estimated t r e a t m e n t by using a diag-
nostic setup.
T h e diagnostic setup indicated that an orth-
o d o n t i c only t h e r a p e u t i c a p p r o a c h was possi-
ble. Full appliances were b a n d e d / b o n d e d and
levelling wires placed. Based on the pretreat-
m e n t setup estimations, the u p p e r incisors
were flared and the u p p e r to lower occlusion
was refined with progressive archwires and
(;lass IIi elastics. T h e final o r t h o d o n t i c resuh,
after g n a t h o l o g i c positioner, is indicated in
Figure 6.
Final record assessment, including hinge-
m o u n t e d models (Fig 7), posttreatment lateral
c e p h a l o g r a m with Roth-Jarabak analysis (Fig 8B)
and a p o s t t r e a t m e n t CPI (Fig 8A), indicated that
MI-CR h a r m o n y had not been achieved. Ml was
still above CR.
T h e orthodontic treatment had improved the
MI-CR discrepancy and partially closed the pos-
terior o p e n bite. Refinement of the remaining
MI-CR p r o b l e m was accomplished by splint ther-
apy to stabilize the TM]s.joints, followed by an
occlusal equilibration to gain even centric stops
during centric relation.jaw closure. After equili-
142 Freeland and Kulbersh

bration, a final hinge axis m o u n t i n g was d o n e
and a new MI-CR recording was done, indicating
excellent MI-CR harmony (Fig 9).
Articulator mountings indicated a mutually pro-
tected functional occlusion was also established. In
this patient, gaaathologic technique and principles
were used to diagnose treatment plan and orth-
odontically manage an unusual MI-CR problem.
This technique afforded quantitative assessment to
evaluate occlusal treatment outcome.

Roth-,JarobokAndysis
C
//
f) f/" 7g L~_ /'/

5,, ~-% a\

UL/
ilh <"-"

77 ~J_. /I Figure 1. Initial facial photograph lateral (A). Ini-

tial facial photograph frontal (B). Cephalogram
with superimposed Roth-Jarabak analysis (C).
 The Roth Gnathologic Approach 143

VERTICAL CONDYLAR POSITION

DISTA~
~ i~I........ i
ISTAL
R

LEFT RIGHT

Lt=FT]
~-.® SHIFT
' Panalbnt °°
@1995

.......... ANTEROR
CR

Figure 3. Initial CPI.

F i g u r e 2. A n n a initial m o u n t i n g .
144 Freeland and Kulbersh

Figure 4. Maxillary gnathological splint.

Figure 5. True hinge mounting.

 The Roth Gnatholo~c Aplm)ach 145

Figure 6. Postorthodontic introral photographs.

Figure 7. Postorthodontic hinge mounted models.

146 Freeland and Kulbersh

A VERTICAL CONDYLAR POSITION VERTICAL CONDYLAR POSITION

~IU '~I~'' MI ~ MI
DISTAL DISTAL DISTAL $TAL

LEFT MI RIGHT
LEFT RIGHT

#., SHIFTI i
I1'11h'~R,a.T TRANSVERSE CONDYLAR POSITION
Y3Panadent °°1i CPImm GRAPH LE~ R~GHT
©1995 It~ 1 TRANSVERSE SHI~

ANTERIORI ~! I ~ EDGE ,k:Sru mo CPt

CR 199~ TRANSVERSEmmGRAPH
~MI
ANTERIOR 3GE
B Roth-darabak An~sis
Figure 9. Post-equilibration.
!

77 SL_/i Case Two

57
/ (Fig 12).
Figure 8. Postorthodontic treatment CPI (A). Post-
orthodontic treatment cephalogram (B).
This 13-year, 1-month-old white female patient
(Fig 10) p r e s e n t e d with a chief c o m p l a i n t of
crowded, c r o o k e d teeth and clicking joints.
O t h e r medical and dental history factors were
within n o r m a l limits. T h e TMJ clinical exami-
nation revealed a m a x i m u m o p e n i n g o f 44
mm; right and left lateral m o v e m e n t was 10
mm. A skeletal assessment was d o n e in 3
planes of space using lateral, p o s t e r o a n t e r i o r ,
and submental vertex cephalograms.
Initial records included an estimated facebow
m o u n t i n g that indicated first contact was on the
right second molar. The anterior teeth did not
touch (Fig 11). By using this mounting, a CPI
recording was made that indicated that the left
condyle was distracted posteriorly and inferiorly
Based on this patient's TMJ problems and
resultant inability to take a true CR bite, treat-
m e n t was initiated with splint therapy, using a
maxillary full occlusal coverage gnathological
splint. In this patient, although not a promised
treatment outcome, the j o i n t clicking disap-
peared and the splint therapy was followed by a
true hinge axis mounting (Fig 13) to rediagnose
the occlusion. New CPI measurements indicated
that after splint therapy both the right and left
condyles were distracted further inferiorly and
posteriorly (Fig 14).
T r e a t m e n t considerations were developed by
using a 9-year growth forecast and a Rickett's
VTO assessment. This evaluation estimated that
the mandible would probably have a tendency to
grow more vertically, but an orthodontic only
 The Roth Gnathologic Approach
treatment was potentially possible with the ex-
traction of 4-second bicuspid teeth and antici-
pated autorotation of the mandible subsequent
to molar mesial movement.
Full orthodontic appliances were b a n d e d /
b o n d e d and levelling wires placed. Vertical con-
trol and minimum anchorage mechanics were
initiated. The final orthodontic result, alter gna-
thologic positioner, is indicated in Figure 15A
and B, with cephalometric tracing (Fig 15C).
Final r e c o r d assessment, including hinge-
m o u n t e d models (Fig 16) and a p o s t t r e a t m e n t
CPI (Fig 17), indicated that MI-CR h a r m o n y
had not b e e n achieved. MI was still slightly
inferior and posterior in right and lefl CPI
recordings.
The orthodontic treatment had improved the
MI-CR discrepancy and partially closed the an-
Figure 10. Pre-treatment photographs.
147
terior open bite. Refinement of this remaining
problem was accomplished by splint therapy to
stabilize the temporomandibular joints, fol-
lowed by first a trial occlusal equilibration (Fig
18) and second an intraoral occlusal equilibra-
tion to gain even centric stops during centric
relation jaw closure. After equilibration, a final
hinge axis m o u n t i n g was done and a new MI-CR
recording was done (Fig 19), indicating excel-
lent MI-CR harmony. Articulator mountings in-
dicated a mutually protected functional occlu-
sion was also established.
In this patient, gnathologic technique and
principles were used to diagnose, treatment plan
and orthodontically manage an unusual MI-CR
problem. This technique afforded quantitative
assessment to evaluate occlusal treatment out-
come.
118 Freeland and Kulbersh

VERTICAL CONDYLAR POSITION

A B~
°. Iii:~I 0.
DISTAL ISTAL
., ~I!!
RIGHT LEFT

C l~.., LErrl
SHIFT] I 1 Is"lFr
@Panadent mr"i" }(l mm CPI
© 199~ i I~ TRANSVERSEmmGRAPH
I
ANTERIOR I !\I~OGE MI

Figure 12. Preorthodontic CPl-right recording (A).

Preorthodontic CPI-left recording (B). Preorthodon-
tic cephalogram (C).

Figure 11. Pre-treatment models.

 7"keRoth Cnatholog~cApproach 149

A VERTICAL CONDYLAR POSITION

~+#~: CR
-++"+ ±t+~+u++ CR
DISTAL STAL
.........;::+ +:
MI
MI
RIGHT LEFT
CR

:/1.,o+
i/!!l su,wr

~+ i~!~!! !+ii~ + ~

MI

B Rot.h--darabak Anal~s~
/I

¢J
J

Figure 14. Post-splint CPI r e c o r d i n g (A). Post-splint

( p r e o r t h o d o n t i c ) c e p h a h ) g r a m (B).

Figure 13. T r u e h i n g e m o u n t e d models.

150 Freeland and Kulbersh

C Roth-dorabok Andysis

/ /
77 _ 1
! /
111
\
35

'\,

.// U~
f
(
53 \

-.,,
Bli,
132
/X,' t/
i

~5
'• II
if/t
jz
j . . t<

F i g u r e 15. Post-treatment p h o t o g r a p h s (A). D e b a n d models (B). Post-orthodontic Roth-Jarabak c e p h a l o g r a m

(C).
 The Roth Gnatholoffic Approach 151

VERTICAL CONDYLAR POSITION

DISTAL AL

iI
RIGHT LEFT

*-a~ SHWTI I/v} ;SHIF

°~'i¸~¸¸i'¸!¸¸¸ rmde.~ om y~imm CPI

CR

Figure 17. Post-orthodontic treatment CPI.

:,~ ~'{}!iii15:

Figure 16. Post-treatment records,

Figure 18. Trial occlusal upper cast (A). Trial occlu-

sal lower cast (B).
152 Freeland and Kulbersh

.,-'c./;:iiii:::ili!!! vE
i i li~¸~¸~¸¸Ii~! ii 1
i ~ E" t
RIGHT LEFT

TRANSVERSE CONDYLAR POSITION

LEFT
SHIFT ~,HIF'T
'Q'Panadent too,! mo C P l
! ,,A,O~E.$Em.'O"A~
ANTERIOR EDGE
MI ~ CR

Figure 19. Post-equilibration CPI.