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Numerous factors help to conserve the dentition of elderly patients, such as healthy food habits, a strong physical constitution, and a good quality of life. The aim of this study was to define a model that takes into account the integration of both the structural and functional aspects of a healthy dentition. Twenty-three patients aged at least 75 years were recruited. The patients were required to possess all of their dentition and have no prosthetic rehabilitations and be asymptomatic for temporomandibular joint disorders. Occlusal characteristics were measured and recorded using the criteria adopted by the US National Health and Nutrition Examination Survey: presence or absence of rotation of the upper arches, trend of the occlusal table, and distribution of occlusal contacts during movements. We believe that the following parameters are predictive of a condition of the dental arches’ equilibrium: crowding and disalignment of the teeth, derotated position of the upper arches, absence of the curve of Spee, an occlusal plane trend contrary to spherical theory, and presence of group function on the working side and malocclusion on the nonworking side. We consider that these factors are merely the consequence of correct functioning within the framework of favorable environmental factors.
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Annali di stomatologia
dental geriatrics
Investigation of complete dental arches of 23 patients aged at least 75 years
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Investigation of complete dental arches of 23 patients aged at least 75 years
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                                                                                                              Original article



    Investigation of complete dental arches
    of 23 patients aged at least 75 years




                                                                                                                li
                                                                                                             na
    Beniamino Volpato, MD                                          re is no doubt that several factors contribute to such a for-
    Stefano Di Carlo, MD, DDS                                      tunate event, such as healthy food habits, a strong phy-
    Jorida Shahinas DDS, student                                   sical constitution, and a good quality of life (1-3). In addi-




                                                                                                          io
    Francesca Mencio, DDS, student                                 tion to the general environmental and systemic factors that
    Raimondo Fusco, DDS                                            favor the conservation of complete dental arches, several
    Giorgio Pompa, MD, DDS                                         local factors must also be taken into account (4). In such




                                                                                    az
                                                                   patients, adaptive processes, together with the patient’s
                                                                   behavior, are structured in such a way as to shape the den-
    “Sapienza” University of Rome, Rome, Italy                     tal arches in a particular fashion, in accordance with cer-
    Department of Oral and Maxillofacial Sciences                  tain principles that have yet to be fully elucidated.
    Prosthodontics Unit                                            This study focused on the structural characteristics of the




                                                                                  rn
                                                                   mouths of elderly patients with conserved dentition in the
                                                                   light of current gnathologic, orthodontic, and periodontic
    Corresponding author:                                          thinking (5). The aim of this research was to formulate a
    Prof. Giorgio Pompa                                            hypothesis that would confirm the occlusal and structural




                                                                       te
    Department of Oral and Maxxillofacial Sciences                 requirements for maintaining the integrity of the dental ar-
    Via Caserta, 6 - 00161 Rome, Italy                             ches into old age. To this end, we observed the morpho-
    Phone: +390649976614 - Fax: +390644230811                      logical characteristics of the dental arches of patients aged
    E-mail: giorgio.pompa@uniroma1.it
                                                               In  at least 75 years (6,7) that remain complete and functio-
                                                                   nally efficient, and gathered data systematically whilst eva-
                                                                   luating the contributing factors.
    Summary
                                                   ni
                                                                   Materials and methods
    Numerous factors help to conserve the dentition of eld-
    erly patients, such as healthy food habits, a strong phys-
    ical constitution, and a good quality of life. The aim of      Inclusion criteria
                                            io


    this study was to define a model that takes into account       Twenty-three patients aged at least 75 years were recruited.
    the integration of both the structural and functional as-      These patients possessed all of their dentition (both an-
    pects of a healthy dentition. Twenty-three patients aged       teriorly and posteriorly), no dental mobility, and mandibular
                                   iz



    at least 75 years were recruited. The patients were re-        mobility. In addition, they had no prosthetic rehabilitations
    quired to possess all of their dentition and have no           and were asymptomatic for temporomandibular joint
    prosthetic rehabilitations and be asymptomatic for tem-        (TMJ) disorders and tonic masticatory muscles.
    poromandibular joint disorders. Occlusal characteristics       Data collection (Table 1).
                  Ed




    were measured and recorded using the criteria adopted          The following data collection protocol was applied to each
    by the US National Health and Nutrition Examination            patient:
    Survey: presence or absence of rotation of the upper           Anamnesis collection with special regard to the form–
    arches, trend of the occlusal table, and distribution of       growth–function relationship and the classification of ma-
    occlusal contacts during movements. We believe that the        locclusions.
    following parameters are predictive of a condition of the      Clinical orthognathodontic evaluation (8,9). Occlusal cha-
 IC




    dental arches’ equilibrium: crowding and disalignment          racteristics were measured and recorded using the crite-
    of the teeth, derotated position of the upper arches, ab-
                                                                   ria adopted by the US National Health and Nutrition Exa-
    sence of the curve of Spee, an occlusal plane trend con-
                                                                   mination Survey (NHANES III)(10).
    trary to spherical theory, and presence of group function
    on the working side and malocclusion on the nonwork-
                                                                   In more detail were examined:
C




    ing side. We consider that these factors are merely the        B1. Presence/absence of labiolingual dysfunction;
    consequence of correct functioning within the frame-           B2. Application of the TMJ disorder (TMD) criteria: que-
    work of favorable environmental factors.                       stionnaire on mandibular function and on the chronic pain
                                                                   scale in order to identify their presence and intensity (11);
©




    Key words: occlusion, TMJ disorders, oral rehabilitation,      B3. Angle classes;
    mobile prostheses, dental geriatrics.                          B4. Alignment/disalignment of median lines;
                                                                   B5. Dental crowding. The rating of dental crowding was ba-
                                                                   sed on the irregularity index (12), with a score of betwe-
    Introduction                                                   en 0 and 3 mm considered as anterior disalignment, whi-
                                                                   le one exceeding 3 mm deemed to be crowding (13). The
    Seldom in daily practice does a dentist have the opportunity   perfect alignment between the mesial face of the left ca-
    to observe an elderly patient with conserved dentition. The-   nine and the mesial face of the right canine was scored

    Annali di Stomatologia 2011; II (3-4): 19-24                                                                              19
    B. Volpato et al.


    Table 1 - Data collection Protocol.                             C3. Bondi-Jarabak’s ratio PFH (C-Go)/AFH (N-Gn);
                                                                    C4. Base angle for divergence assessment;
                                                                    C5. ANB angle for skeletal class assessment (this para-
                                                                    meter was considered as a function of point B3 above;
                                                                    Clinical examination of the masticatory apparatus of the
                                                                    soft tissues and hard tissues accompanied by photogra-




                                                                                                                  li
                                                                    phic documentation (20,21);
                                                                    D1. Presence of wear (20);




                                                                                                               na
                                                                    D2. Evaluation of the Prosthodontic Diagnostic Index (22).


                                                                    Results




                                                                                                            io
                                                                    The cohort had a mean age of 79.6 years, and comprised
                                                                    9 males and 14 females.
                                                                    No one presented either hypertonus or pain on palpation




                                                                                     az
                                                                    of the masticatory muscles (temporal medial pterygoid and
                                                                    masseter) and labiolingual dysfunctions.
                                                                    With reference to the possible presence of TMDs, on the
                                                                    Axis I and Axis II questionnaires the patients tested negative




                                                                                   rn
                                                                    in all anamnestic and palpatory examinations of the ma-
                                                                    sticatory muscles and TMJ (23-25).
                                                                    In the examined subjects, 17 cases were found to be an-
                                                                    gle class I, 4 were class II, and 2 were class III.




                                                                        te
                                                                    Interincisive line symmetry was observed in 56.5% of ca-
                                                                    ses and in all cases was present dental crowding with an
                                                                    irregularity index of >5.
                                                                    The presence of rotations of different dentition was ob-
                                                                In  served in 56,5% of cases.
                                                                    Increased overbite was observed in 15 patient and was di-
                                                                    minished in 4.
                                                                    Increased overjet was observed in 7 cases, and reduced
                                                                    in 4 cases.
                                                   ni

                                                                    In all cases the position of the upper arches was distally
                                                                    derotated and there was absence of the curve of Spee and
                                                                    loss the curve of Monson.
                                          io


                                                                    During excentrum movements, such as during the move-
    as zero (5,14);                                                 ment of lower jaw protrusion, wherein the anterior contacts
    B6. Dental anomalies and/or malpositioning;                     are also supported by posterior contacts, a group function
                                 iz



    B7. Overbite/openbite (15);                                     relationship was observed in all cases.
    B8. Overjet (16);                                               Absence of verticalization of movements was observed in
    B9. Position of the first upper molars. Evaluation of the pa-   all patients, everyone exhibited a masticatory angle <25º.
                 Ed




    rallelism between the median raphe of the palate and the        Analysis of Jarabak tracings, modified Bondi, showed that
    mesiodistal diameter of the upper arches, taking the trian-     in all cases the indexes present point to a brachyfacial ty-
    gular fossettes into consideration;                             pology.
    B10. Occlusal plane state observed on the sagittal plane        Dental wear was found in 78.3% of cases. In 14 of these,
    (absence/presence curve of Spee) and on the frontal pla-        the dental wear was observed on both arches, which is a
    ne (absence/presence of curve of Monson);                       sign of adaptation.
    B11. Evaluation of the characteristics of the contacts bet-     In 12 cases was present gum inflammation while in 6 ca-
 IC




    ween structures of antagonistic arches during lower-jaw         ses receding gums.
    movements. We evaluated whether a group function or a           To summarize the results of our study, the following cha-
    canine guidance was present during right and left lateral       racteristics were observed in all of the cases: dental crow-
    movements (15,17);                                              ding, brachyfacial typology, the absence of lingual dy-
C




    B12. Absence or presence of verticalization in lower jaw        sfunctions, the presence of group function during lateral
    movements (masticatory functional angle) (18,19);               movements from the working side and malocclusion on the
    Radiographic assessment of facial typology. X-ray eva-          nonworking side, absence of the curve of Spee, loss of the
    luation was performed on the basis of Jarabak-Bondi’s ce-       curve of Monson, and derotation of the upper arches.
©




    phalometric tracing; this was interpreted “dynamically” to
    obtain an understanding of the mutual relationships bet-
    ween the more important functional units of the face in the     Discussion
    anteroposterior and vertical spatial planes. In particular,
    the following values were consider:                             We were able to observe 23 patients aged at least 75 ye-
    C1. Sum of S+ar+Go angles;                                      ars with dental arches that were complete in both the an-
    C2. Jarabak’s ratio of posterior face height (PFH, S-Go)        terior and posterior sectors. This study focused on the struc-
    to anterior face height (AFH, N-Me);                            tural characteristics of these patients’ mouths; we asses-

    20                                                                                  Annali di Stomatologia 2011; II (3-4): 19-24
    Investigation of complete dental arches of 23 patients aged at least 75 years


    sed them according to the existing diagnosis and data col-           Table 2 - Results.
    lection systems, as well as in the light of current gnatho-
    logic, orthodontic, and periodontic thinking.
    To gain a better appreciation of how correct function af-
    fects the structure of the masticatory organ, we assessed
    the presence or absence of labiolingual dysfunctions, ab-




                                                                                                    li
    sence of any TMD and absence of pain on palpation of the
    craniomandibular muscles. In other words, if it is true that




                                                                                                 na
    the function affects the structure of the organ, throughout
    their lives these patients have somehow maintained fun-
    ctioning that has allowed them in turn to maintain the struc-
    tures of the masticatory organ in a good condition, since




                                                                                              io
    they all displayed the absence of the edentulous condition
    and prosthetic reconstructions in the posterior sectors. Even
    allowing for the existence of favorable genetic and envi-
    ronmental components, we investigated whether observing




                                                                                         az
    the characteristics of these mouths provides any useful in-
    formation. Our aim was to define a preliminary theoreti-
    cal model that takes into account the integration of the fun-
    ctional and structural aspects, which would allow us to pre-




                                                                                       rn
    dict more accurately the consequences of an altered fun-
    ction on the structure of the masticatory organ. For instance,
    by assessing the presence or absence of crowding of den-
    tition, this factor may be considered as a physiological con-




                                                                             te
    sequence of the normal development and adaptive pro-
    cesses involving the mouth. It is likewise possible to view
    the distinction into angle classes not as a functional clas-
    sification, or indeed as a primary objective to be attained,
    but rather a certain kind of evolution that is not necessa-
                                                                     In
    rily pathological or pathogenetic.
    The mechanistic theories of occlusion suggest that the dif-
    ference between ideal occlusion and malocclusion should
    be assessed on the basis of the morphological variations
                                                       ni

    inferred from a comparison with the normal population.
    Once the predefined morphological objectives have been
    attained, a correct system functionality may be conside-
                                            io


    red to have been reached. According to functionalist phi-
    losophy, occlusal rehabilitation is defined as the therapy
    aimed at achieving an excellent morphology integrated with
                                   iz



    the overall equilibrium of the masticatory apparatus. On the
    strength of these concepts, the requirements of an ideal
    occlusion are set out in Table 3 (26-28). Nevertheless, 95%
                  Ed




    of the population display significant morphological varia-
    tions of occlusion (1,4,29). It is possible for even a serious
    malocclusion to exist without having any significant effect
    on the health of the stomatognathic apparatus (19,30).
    These reflections were made with reference to and consi-
    dering all of the stomatognathic factors, and this leads us to
    believe that strictly speaking, not all of the results can be con-
 IC




    sidered as predictive of a pathological condition of the ma-
    sticatory organ, but rather as the consequence of an adap-
    tive physiological process, at least in a general sense.
    With reference to the principles of occlusion contained in
C




    Table 4, the alignment of teeth in the arches is related to
    the mutual relationship between the teeth within the den-
    tal arch, and the resulting imaginary plane is referred to
    as the occlusal plane. This plane is curved, as the teeth
©




    are situated in the dental arch according to different in-
    clinations: the curves of Spee and Monson.
    With reference to the occlusal plane, we found that all of
    the patients had a flat, straight occlusion plane (anti-Spee
    and anti-Monson), mesial inclination of the anterior and po-
    sterior teeth, and vestibular dental cusps, the upper ones
    of which were conserved and the lower ones worn (Figu-
    re 1).

    Annali di Stomatologia 2011; II (3-4): 19-24                                                 21
    B. Volpato et al.


    Table 3 - Ideal occlusion requirements (Okeson JP 1983)(27).

    1.   With the mouth closed the condyles are in their maximum superior position against the curve of the articular hemiarches
    2.   Dental contacts determine an axial loading of occlusal forces.
    3.   In laterality dental contacts are formed (canine guidance) on the working side and disclusion on the non working side.




                                                                                                                         li
    4.   In protrusion suitable contacts of the anterior teeth guide the disclusion of the posterior teeth.
    5.   In a position of food alert waking feeding the posterior contacts are stronger than the anterior contacts.




                                                                                                                      na
    Table 4 - Occlusal evaluation criteria according to NHANES III (7).




                                                                                                                   io
    1. Maximal opening capacity was measured as the distance between the incisal edges of the maxillary and mandibular right
        central incisors.
    2. Relationship between RP and IP. The distance between the retruded contact position and the intercuspal position was




                                                                                           az
        measured as the horizontal, vertical, and lateral distance between the two positions to the nearest half-millimetre.
    3. The side of the first contact on guided hinge closure.
    4. Mediotrusion contacts were recorded during habitual lateral gliding from the intercuspal position up to 3 mm. The presence
        of contact was verified with thin strips for occlusal registration. Mediotrusion contacts inhibiting contact on the laterotrusion
        side were considered to be interferences.




                                                                                         rn
    5. Protrusion contact. The location of the protrusion contact was recorded and then verified with occlusal strips in cases of
        doubt. Contacts of posterior teeth during protrusive movement were considered to be interferences.
    6. The muscles palpated were the insertion of the temporal muscle and the lateral pterigoid muscle. The palpation index was




                                                                              te
        the sum of sites tender to palpation, the maximum thus being 4.
    7. Pain on maximal active opening.
    8. Pain and stiffness on guided hinge closure. In addition, the following variables were recorded at the age of 15:
                                                                    In
    9. TMJ-sounds. Clicking and crepitation during mandibular movements were recorded with a stethoscope.
    10. Tenderness to palpation of the TMJs. The joints were palpated laterally and posteriorly.
    11. Deviation of the mandible during the opening movement was recorded with the aid of a transparent acrylic sheet having
        parallel lines to facilitate recording of lower jaw deviation. Deviation of > 3 mm from the imaginary midline of the upper and
        middle face was recorded.
                                                      ni
    12. Occlusal interferences were used to calculate the interference score (horizontal and vertical distance RP-IP > 1.5 mm, lat-
        eral deviation >0.5 mm, and mediotrusion contact on one side were given 1 point each; horizontal and vertical distance RP
        -IP>2 mm, lateral deviation > 1.0 mm, and mediotrusion contact on both sides were given 2 points each).
                                            io


    13. The clinical CMD index was calculated for statistical testing at the age of 12 as follows: tenderness to palpation of the mus-
        cles of mastication was given 1 point, interincisal distance < 40 mm 1 point, and pain on maximal opening 1 point. At the
        age of 15 some additional variables were included in the index: pain on guided hinge closure 1 point, TMJ-sounds 1 point,
                                  iz



        tenderness to palpation of the TMJs 1 point, and deviation of the mandible during the opening movement >3 mm 1 point.
                  Ed




    As far as the alignment of cusps and upper arch fossae               eth, intercuspal groove of the teeth parallel to the median
    are concerned, the following observations were made: non-            axis of the palate, and staggered alignment of the vesti-
    linear alignment of cusps and lateroposterior maxillary te-          bular surfaces between molars and premolars (Figure 2).
 IC
C
©




    Figure 1 - A) Anti Spee and anti Monson; B) Vestibular cusps: su-    Figure 1 - B) Intercuspal groove of the teeth parallel to the me-
    perior kept and inferior worn.                                       dian axis of the palate, staggered alignment of the vestibular sur-
                                                                         faces between molars and premolars.


    22                                                                                         Annali di Stomatologia 2011; II (3-4): 19-24
    Investigation of complete dental arches of 23 patients aged at least 75 years




                                                                                                                           li
                                                                                                                        na
                                                                                                                     io
    Figure 2 - Intercuspal groove of the teeth parallel to the median      Figure 3 - Important role in stabilizing a group function on the
    axis of the palate, staggered alignment of the vestibular surfaces     working side is the disto-vestibular cusp of the first upper molar,
    between molars and premolars.




                                                                                              az
                                                                           which was found to be mesio-inclined (case studies).




                                                                                            rn
                                                                                 te
                                                                     In
     A                                                                       B
    Figure 4 - Extensive group contacts in the course of mandibular protrusion (A: right side; B: left side).
                                                       ni

    The maxillary and mandibular canines are the teeth best
                                            io

    suited to absorbing and distributing horizontal forces whi-
    le the posterior teeth are in malocclusion. Patients with the-
    se conditions are said to have a canine guidance. The most
                                   iz



    preferable alternative to canine guidance is the so-called
    group function (17,31). Any laterotrusive contact posterior
    to the mesial position of the first molar is counterproduc-
    tive as a result of the increased force that leads to a clo-
                  Ed




    ser approach to the fulcrum and the vector forces (32).
    In 96% of the patients in our study (22 out of 23), an im-
    portant role in stabilizing a group function on the working
    side was the distovestibular cusp of the first upper molar,
                                                                           Figure 5 - Important role in stabilizing a group function on the
    which was found to be mesioinclined (Figure 3). In order               working side is the disto-vestibular cusp of the first upper molar,
    for this cusp to become involved in the group function, the            which was found to be mesio-inclined (case studies).
 IC




    upper molar must be perfectly positioned with its median
    axis parallel to the palatine raphe with respect to the me-
    dian line of the palate, and the intercuspal groove must be
    parallel to the median line of the palate. To achieve ex-              sent in all mouths, decisively contribute to the health of the
C




    tensive group contacts in the course of mandibular pro-                masticatory apparatus in ways and in terms that remain
    trusion (Figure 4), wear of the front teeth must allow po-             to be elucidated. Among the constant contributory factors,
    sterior malocclusion (Figure 5).(33)                                   it was noted that all of our patients are of the brachyfacial
    Angle classes, median line asymmetry, tooth rotation and/or            type, which is a genetic rather than an adaptive factor. This
©




    malpositioning, overbite, overjet, tooth wear and inflamed             factor ensures a certain stability as regards the health of
    and receding gums are all factors that contribute to the gre-          the stomatognathic apparatus.
    at variability in the results observed. Crowding and disa-             It may be concluded that it is impossible to label the fol-
    lignment, derotated positioning of the upper arches, ab-               lowing models that were found to be non predictive as pa-
    sence of the curve of Spee, occlusal plane trend contra-               thological in the strict sense: angle classes, median-line
    ry to spherical theory, presence of group function on the              asymmetry, tooth rotation and/or malpositioning, overbi-
    working side, and malocclusion on the nonworking side                  te, overjet, tooth wear, and inflamed and receding gums.
    seem to suggest that these factors, which are always pre-              In other words, the results seem to indicate that these fac-

    Annali di Stomatologia 2011; II (3-4): 19-24                                                                                           23
    B. Volpato et al.


    tors may more logically be interpreted as the result of an                 Dental Journal. 2001;46(3):183–185.
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                                                                                                                             li
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                                                                                                                          na
                                                                               1989;62(5):505–509.
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                                                                                             az
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                                              io


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                                   iz



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