The Roth-Rinchuse Debate: It's been 25 years

Abstract

It has been a quarter of a century since I found myself at the center of a debate on what I termed “orthodontic gnathology” (ie, centric relation, centric relation records, canine protected occlusion, articulators), with one of the icons in orthodontics, the late Dr Ronald H. Roth.1Utt T.W. Meyers Jr., C.E. Wierzba T.F. Hondrum S.O. A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 298-308Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 2Roth R.H. Point: a three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 315-318Abstract Full Text PDF PubMed Scopus (23) Google Scholar, 3Rinchuse D.J. Counterpoint: a three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 319-328Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar It has been 15 years since the passing of Dr Roth. The debate became known as the “Roth-Rinchuse Debate.” It motivated further debates and discussions in written form, national presentations, and face-to-face expostulates. In this respect, it could be argued that the debate should be called the “Roth-Rinchuse Debate(s).” Before delving into a discussion of the “Roth-Rinchuse Debate,” I want the reader to know I had the highest regard for Dr Ronald Roth. When I was an orthodontic graduate resident at the University of Pittsburgh in the mid-1970s, Drs Ron Roth and Larry Andrews were my idols. Ron and I would always give each other the biggest smile when we saw one another. I remember joking with him about switching positions in our presentations—that I present his view, and he present mine. This 25-year-old debate was initiated by a controversial study published in March 1995 in the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO)1Utt T.W. Meyers Jr., C.E. Wierzba T.F. Hondrum S.O. A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 298-308Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar on the topic of orthodontic gnathology, based on the Roth Gnathology Philosophy. Dr Roth wrote a “Point” article2Roth R.H. Point: a three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 315-318Abstract Full Text PDF PubMed Scopus (23) Google Scholar supporting the paper, and I offered a “Counterpoint”3Rinchuse D.J. Counterpoint: a three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 319-328Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar treatise that detailed the various limitations of the study and paper. Concerning my participation in this debate, I offer this look back. I was approached on several occasions by the AJO-DO editor at the time, Dr Thomas Graber, to opine on a paper submitted for publication. He asked for a critique (not just a commentary) of that manuscript,1Utt T.W. Meyers Jr., C.E. Wierzba T.F. Hondrum S.O. A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 298-308Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar which had an arduous time passing the journal review process. Dr Graber said he wanted to publish the paper, but only if there were “Point” and “Counterpoint” papers to follow. The “Point” view was to support the manuscript and study, and the “Counterpoint” view was to be a critical appraisal of the manuscript and study. He said the manuscript was on a topic I had researched and published. He also pointed out that Dr Ron Roth was writing the “Point” view. Dr Graber convinced me to write the “Counterpoint,” even though I had declined several times. Although the scientific quality of the study was the critical issue, the debate narrowed down to a discourse on Orthodontic Gnathology. That is, considerations of the role of occlusion and condyle position (CR) in the etiology, diagnosis, and treatment of the temporomandibular disorder (TMD), and of course, the value of articulator in orthodontic clinical research (more than just an aid in day-to-day clinical practice). Dr Roth's advocacy for his views go back to the early 1970s, and this was indeed the prevailing view in dentistry at that time, particularly for prosthodontists. So, let it be clear, Dr Roth was not offering an outlandish view on functional occlusion, condyle position, and TMD. Although I believe my view back then, and certainly now, was the most logical and evidence-based perspective, it was the minority view at that time. There is much to learn from a historical and evidence-based perspective from reading the 3 articles. To point, although this debate, and those debates and discussions that followed, were small parts of the annals of orthodontics, they were very significant parts. Every graduate resident should be familiar with these articles and those that followed. Refer to Table I for a summary of the paper by Utt et al from 1995,1Utt T.W. Meyers Jr., C.E. Wierzba T.F. Hondrum S.O. A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 298-308Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar the subject for the debate. Furthermore, in Table II, I have juxtaposed some of Dr Roth's “Point” views with those of my “Counterpoint.” Students of Dr Roth will recognize the witticisms he used in his “Point” paper. For instance, he wrote:If occlusion has nothing to do with TMD, why do they (those people who believe occlusion has nothing to do with TMD) use occlusal splints to treat TMD? Why don't they put the splint on their patient's elbow? p. 315I would like to have the opportunity of placing a high molar restoration with balancing interferences in the mouth of all who believe occlusion has nothing to do with TMD. p. 315Table IOverview of Utt et al 1995 AJO-DO paper1Utt T.W. Meyers Jr., C.E. Wierzba T.F. Hondrum S.O. A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 298-308Abstract Full Text Full Text PDF PubMed Scopus (70) Google ScholarTitle“A three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.”PurposeTo determine the percent and type of possible CO-CR discrepancies there are for a pretreatment orthodontic sample.MethodOne hundred and seven preorthodontic patients, aged 7.75 to 38.17 y, at a U.S. Army orthodontic residency program, were screened for CO-CR discrepancies using power centric bite registrations, SAM articulator with mandibular position indicator. An established profile of what constitutes the “norm” for CO-CR discrepancies in 3-dimensions in space was arbitrarily determined from the records of 250 orthodontic pretreatment patients used in a prior unpublished study. There was no information given on the characteristics of these 250 patients as regard to age, gender, Angle type, and so on, only that they came from a colleague.∗To clarify what the authors meant by CO-CR discrepancies, what they were writing about was the making of centric occlusion (CO) and centric relation occlusion (CRO); the interocclusal position of the teeth when the condyles are in CR) bite registrations at the interocclusal tooth level and then measuring them via the SAM articulator (with mandibular position indicator) at the condyle level (condyles as per an articulator, NOT human condyles).ResultsA total of 19% of the 107 subjects used in this study demonstrated CO-CR sagittal discrepancies in a least 1 direction at the level of the condyles.ConclusionsRecommend using articulate study casts before orthodontics to screen patients for CO-CR discrepancies.CO-CR, Centric occlusion-centric relation; SAM, SAM Dental, Germany. Open table in a new tab Table IIA listing of some of the arguments made by Drs Roth and Rinchuse in their “Point” and “Counterpoint” papersRoth-“Point”Rinchuse-“Counterpoint”•“Orthodontics has assumed by its method of diagnosis in habitual occlusion, that, when the patient bites into occlusion the condyles are approximately in the correct position.”•“Condyle position is important, if not, how did the term ‘Sunday bite’ arise? Without knowing where the condyles belong, you cannot determine how large a Class II malocclusion is.”•“If occlusion has nothing to do with TMD, why do they (those people who believe occlusion has nothing to do with TMD) use occlusal splints to treat TMD? Why don't they put the splint on their patient's elbow?”•“I would like to have the opportunity of placing a high molar restoration with balancing interferences in the mouth of all who believe occlusion has nothing to do with TMD.”•There are an equal number of studies correlating occlusion and TMD.•X-rays are 2-D, so need something to record condyles in 3-D … articulators, with MPI.•“The use of articulators to study occlusion is nothing new and the use of MPI is a valid method.”•“Isn't it odd that orthodontists think they operate under a different set of rules than prosthodontists and oral surgeons?”•“The orthodontist is doing a ‘full mouth reconstruction’ in enamel whenever he undertakes orthodontic treatment.”•“I spent 30 years using the functional occlusion concepts of McCollum and Stuart.”•“…need to return to listening to seasoned clinicians.”•“It is about time we accept some tangible and measureable goals in orthodontics regarding function of occlusion and the joints and condylar position.”•Based on this study a fair percentage of patients (19%) may start orthodontic treatment with a significant false “Sunday bite.”•This study has proposed and substantiated methods to find hidden discrepancies (Sunday bites) before treatment (i.e., Power centric recordings, articulators, MPI).•Mixed and lumped literature/studies from the 70's/early 80's with those from the 90's where CR had changed from a posterior-superior, retruded condyle position to an anterior-superior condyle position.•Should have used a population of healthy versus those with TMD to glean what constitutes “normal” as regards CO-CR discrepancies.•The Utt et al sample was very heterogeneous, i.e., gender, Angle's classes (72 Class II's), etc. Of particular importance, the age range was from 7.75 to 38.17. The results of the study could be due to the age difference.•Authors arbitrary chose 2 mm+ in the sagittal and 0.5 mm in the transverse as indicating CO-CR discrepancies from a chosen “normal.”And, do the instrumentation and methodology used in the study provide for this precision of measurement(s)?•Authors failed to provide evidence of the validity (and to some extent the reliability) for the SAM articulator, MPI, and centric wax bite registration as research investigative instruments and methods…. No reported error.•Many times the written text and tables did not match. Authors mentioned that they did a “t-test” in the text, but in the referenced table there were “F-values” denoting an “ANOVA,”NOT a “t-test.”•Intra-oral telemetry studies of the 1960's have demonstrated that even when patients’ entire dentition were reconstructed into retruded CR (CRO), patient persisted in using habitual CO.•Articulators are based on the faulty and incorrect notion of a “terminal hinge axis;” i.e., even in the initial phase of opening and closing (millimeters) there is both rotation and translation. The “Terminal Hinge Axis” is a theory that believes that in the initial 20 mm or so of opening and closing the TMJ condyles only rotate, no translation.•Importantly, studies have demonstrated that none of the proposed centric bite registrations, including the “Power Bite Registration,” can discern and predicted where human condyles will be placed/located.MPI, Mandibular position indicator; TMJ, temporomandibular joint. Open table in a new tab CO-CR, Centric occlusion-centric relation; SAM, SAM Dental, Germany. MPI, Mandibular position indicator; TMJ, temporomandibular joint. Who won the debate? It is a matter of conjecture and in the proverbial “eyes of the beholder?” The prior convictions the reader had beforehand and which writer's thinking and evidence the reader found most appealing were certainly deciding factors on who one thought won the debate. I do not believe that those who had prior opinions changed their minds. As many know, it is difficult to change a person's beliefs; “A man/woman convinced against his/her will is of the same opinion still.” Nonetheless, with this written debate, the issues involving “orthodontic gnathology” were certainly brought to the forefront. If there was a positive from this discourse, it is likely that those who were undecided on their views on this topic(s) now had a chance to form an opinion. After the publication of these articles, the AJO-DO became inundated by letters-to-the editor concerning the readers’ reactions to the papers by Roth and Rinchuse.4Rinchuse D.J. Williams R.E. Carter R. Chhatwani B. Chubb T. Reader’s forum: comments on Dr. Rinchuse’s counterpoint discussion.Am J Orthod Dentofacial Orthop. 1995; 108: 10A-16AGoogle Scholar After the ADO-DO stopped publishing these letters, which lasted almost a year, the debate started filtering into the Angle Orthodontist.5Rinchuse D.J. The CR-CO discrepancy.Angle Orthod. 1995; 65: 4-8PubMed Google Scholar There were several oral debates and presentations that followed. On December 9, 1997, there was the Roth-Rinchuse Debate at the North East Society of Orthodontists (NESO) meeting in New York City. The title of the debate was “CR/CO Coincidence.” The idea for the event was envisioned by Dr Larry Jerrold. He was assisted in the endeavor by Dr Elliot Moskowitz. Unknown to me, the Roth-Williams Annual Meeting took place there a day before our debate. I thought to myself, am I being set up? The moderators of the program were Drs Larry White and George Cisneros. It was the largest attendance at an orthodontic program that I had ever experienced. I remember seeing several of my former orthodontic residents from the University of Pittsburgh and talked with them after the debate. One mentioned to me that he kept telling the orthodontist seated next to him during my presentation, “Dr Rinchuse was teaching us all this back in the 70s, and he just has more data now.” The day before the debate, Dr Roth informed Dr Moskovitz that I should start the debate, and he wanted the debate to last an additional 20 minutes. This suggestion was eventually agreed on. I used the standard format for orthodontic presentations at that time, which was slides from 2 projectors. One of my opening slides was a caricature of Ron and me boxing each other that I had, drawn by a friend. I thought it would be appropriate because there were many world boxing championships held next door at Madison Square Garden. I had the artist draw both of us with “pumped up” muscles. I looked over at Ron when I showed the slide and saw him smiling. My presentation was a point-by-point discussion of the science and evidence on the change in the definition of CR, reliability and validity of CR records, validity of the “Terminal Hinge Axis,” utility of articulators in orthodontics, and so on. I had each of my points numbered with pictures of various well-known professional football players who wore those same numbers. For number 1, I had the picture of Warren Moon with his jersey number 1 visible. The most salient and poignant comment I made was to point out that the definition and treatment of patients in the 1970s vs the mid-1980s had drastically changed regarding CR. That is, in the 1970s, CR was considered by the dental specialty, and Dr Roth, a retruded, posterior-superior condyle position. The dental corollary was the term, “Centric Relation Occlusion (CRO)” (ie, the interocclusal centric position of the teeth when the condyles were in retruded CR).6Rinchuse D.J. Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective.J Am Dent Assoc. 2006; 137: 494-501Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar The third edition of the Glossary of Prosthodontic Terms defined CR in 1968 as, “The most retruded physiologic relation of the mandible to the maxilla to and from which the individual can make lateral movements.”7Hickey J.C. Glossary of prosthodontic terms. Preface to the third edition.J Prosthet Dent. 1968; 20: 443-480Abstract Full Text PDF PubMed Scopus (13) Google Scholar Dental and orthodontic clinicians (like Dr Roth) treated patients in the 1970s to the then retruded CR position. I, and others, with data to support our view,8Graf H. Zander H.A. Functional tooth contacts in lateral and centric occlusion.J Prosthet Dent. 1963; 13: 1055-1066Abstract Full Text PDF Scopus (59) Google Scholar, 9Pameijer J.H. Glickman I. Roeber F.W. Intraoral occlusal telemetry. 3. Tooth contacts in chewing, swallowing and bruxism.J Periodontol. 1969; 40: 253-258Crossref PubMed Scopus (44) Google Scholar, 10Pameijer J.H. Brion M. Glickman I. Roeber F.W. Intraoral occlusal telemetry. V. Effect of occlusal adjustment upon tooth contacts during chewing and swallowing.J Prosthet Dent. 1970; 24: 492-497Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 11Glickman I, Marigoni M, Haddad A, Roeber FW. Further observations on human occlusion monitored by intraoral telemetry [abstract]. International Association of Dental Research, 201, Abstract 612.Google Scholar, 12Sicher H. DuBrul E.L. Oral Anatomy. CV Mosby, St Louis1970Google Scholar, 13Kydd W.L. Sander A. A study of posterior mandibular movements from intercuspal occlusal position.J Dent Res. 1961; 40: 419-425Crossref Scopus (23) Google Scholar, 14Ingervall B. Retruded contact position of the mandible. A comparison between children and adults.Odonto Rev. 1964; 15: 130-149Google Scholar, 15Sicher H. Positions and movements of the mandible.J Am Dent Assoc. 1954; 48: 620-625Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 16Silverman M.M. Comparative accuracy of the gnathological and neuromuscular concepts.J Am Dent Assoc. 1978; 96: 559-565Abstract Full Text PDF PubMed Scopus (6) Google Scholar, 17Sheppard I.M. The Effect of hinge axis clutches on condyle position.J Prosthet Dent. 1958; 8: 260-263Abstract Full Text PDF Scopus (8) Google Scholar, 18Sheppard I.M. The Bracing position, centric occlusion, and centric relation.J Prosthet Dent. 1959; 9: 11-20Abstract Full Text PDF Scopus (9) Google Scholar, 19Sheppard I.M. Markus N. Condyle versus ramus as articular hinge axis.Dent Prog. 1961; 2: 24-29Google Scholar, 20Shanahan T.E. Alexander L. Mandibular and articular movements.J Prosthet Dent. 1962; 12: 82-86Abstract Full Text PDF Scopus (6) Google Scholar, 21Shanahan T.E. Alexander L. Mandibular and articular movements. Part IV. Concepts of lateral movements and condyle paths.J Prosthet Dent. 1964; 4: 279-289Abstract Full Text PDF Scopus (7) Google Scholar never believe that retruded CR and CRO were natural and physiological positions. The late Dr Tom Graber called, “manipulated CR arbitrary and unphysiologic in contrast to postural rest position.”22Graber T.M. Personal communications.Oct 1994Google Scholar Then in the early 1980s, the thinking about CR began to change toward considering the ideal position to be anterior-superior.6Rinchuse D.J. Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective.J Am Dent Assoc. 2006; 137: 494-501Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar This belief was based mostly on the emerging magnetic resonance imaging temporomandibular joint data showing condyles of patients with temporomandibular joint internal derangements were displaced distally, and the disks displaced anterior-medially.6Rinchuse D.J. Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective.J Am Dent Assoc. 2006; 137: 494-501Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar These data were a signal to change the definition of CR from a posterior-superior, retruded position to an anterior-superior condyle position. In 1987, the fifth edition of the “Glossary of Prosthodontic terms” changed the definition of CR to denote an anterior-superior condyle position. It was written in the Glossary of Prosthodontic Terms in 1987 about the accepted position of CR, “A maxillomandibular relationship in which the condyles articulate with the thinnest avascular position of their respective disks with the complex in the anterior-superior position against the slopes of the articular eminence.”23Glossary of prosthodontic terms.J Prosthet Dent. 1987; 58: 713-762Abstract Full Text PDF PubMed Google Scholar So the supposed ideal CR position in the 1970s was now considered a somewhat pathologic position. An important side note, magnetic resonance imaging studies have confirmed that irrespective of which of the many centric bite registrations proposed and used, including the “Power Bite Registration,”24Kandasamy S. Boeddinghaus R. Kruger E. Condylar position assessed by magnetic resonance imaging after various bite position registrations.Am J Orthod Dentofacial Orthop. 2013; 144: 512-517Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar clinicians cannot discern and then “capture” the exact location of human condyles in the glenoid fossae.24Kandasamy S. Boeddinghaus R. Kruger E. Condylar position assessed by magnetic resonance imaging after various bite position registrations.Am J Orthod Dentofacial Orthop. 2013; 144: 512-517Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar,25Alexander S.R. Moore R.N. DuBois L.M. Mandibular condyle position: comparison of articulator mountings and magnetic resonance imaging.Am J Orthod Dentofacial Orthop. 1993; 104: 230-239Abstract Full Text PDF PubMed Scopus (72) Google Scholar Dr Roth admitted that he treated his orthodontic patients in the 1970s to the retruded CR position but now accepted the current anterior-superior CR position. So I asked Dr Roth during my NESO presentation (and this also applies to the other dental practitioners who treated to retruded CR and CRO in the 1970s) the following question. I asked, “What ever happened to the patients you treated in the 1970s to retruded CR, and you now admit this was an incorrect CR position, and you now treat patients to anterior-superior CR? Did you retreat all those patients to the more current and accepted anterior-superior CR position?” He indicated that his treatments regarding CR have not changed, only that the definition of CR had changed. This argument did not make sense to me, and I believe to others in the audience. When it was Ron's turn to present, instead of using projected slides, he did a PowerPoint (Microsoft Corporation, Redmond, Wash) presentation. He had some trouble getting it going, but it worked out well in the end. This was the first time I had seen a PowerPoint presentation at an orthodontic meeting. Leave it to Ron to be ahead of the game. To be honest, Ron's presentation was not really a debate in the traditional sense. He said at the beginning of his presentation that he does not endorse much of the science and evidence of the day and that of which I presented. He explained that he would rather rely on his own clinical experience and that of the eminent dental clinicians who preceded him. He then said (and to paraphrase), “some of you do not understand gnathology and the Roth philosophy, so I will use my time to teach it to you today.” This was a little puzzling to me, no real debate, and with many in the audience having attended the Roth-Williams meeting a day earlier. Nonetheless, he did an excellent job explaining his philosophy. At the end of our presentations, the moderators had us take questions from the audience. Most of the questions were not related to the topic of the debate but rather focused on clinical aspects of orthodontics. For almost all of our answers, we agreed. I have asked Dr Larry Jerrold on several occasions whether there were any archived recordings of the NESO Roth-Rinchuse Debate of 1997. He answered that he did not know of any. Then on July 19-22, 1999, the College of the Diplomates of the American Board of Orthodontics held their 20th Anniversary Meeting in Aspen, Colorado. The scientific program was titled, “Mounting Models-Myth or Must?”—a reference to using articulators in orthodontics. The advertised subtitle was, “A major controversy in orthodontics today.” There were 3 days of presentations by a half dozen speakers; Drs Roth, Rinchuse, Wooley, Arnett, Mahan, and Gremillion. On the morning of the fourth day, the program speakers were organized into a “Panel Discussion;” Dr Tom Graber was the moderator. The main event of the College of the Diplomates of the American Board of Orthodontics program were the presentations by Ron and me. There were several other articles that followed and several presentations at various venues, including the Annual American Association of Orthodontists Sessions. There are still occasional references to the Roth-Rinchuse Debate(s). As I quoted from Plato in my counterpoint article in 1995, “Wisdom emerges from the clash of contending views.”3Rinchuse D.J. Counterpoint: a three-dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator.Am J Orthod Dentofacial Orthop. 1995; 107: 319-328Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar I remain confident that an examination of the considerations prompted by this debate(s) will foster an appreciation for evidence-based orthodontics.