Interdisciplinary approach to the

mandibular therapeutic position in oral

rehabilitation

Elodie Ehrmann, Markus Greven, Jean-

Philippe Ré & Jean-Daniel Orthlieb

international journal of stomatology

& occlusion medicine

ISSN 1867-2221
Volume 6
Number 4

J. Stomat. Occ. Med. (2013) 6:115-119

DOI 10.1007/s12548-013-0090-y

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 Author's personal copy
J. Stomat. Occ. Med. (2013) 6:115–119
DOI 10.1007/s12548-013-0090-y
Interdisciplinary approach to the mandibular
therapeutic position in oral rehabilitation
Elodie Ehrmann · Markus Greven · Jean-Philippe Ré · Jean-Daniel Orthlieb
Received: 29 April 2013 / Accepted: 12 June 2013 / Published online: 29 October 2013
© Springer-Verlag Wien 2013
Abstract  The following article attempts to summarize
the important elements that were highlighted during the
last congress of the International Academy of Advanced
Interdisciplinary Dentistry. The meeting objectives were
to propose answers to the following practical questions:
why change the maximal intercuspation (mICP) of a pa-
tient? Where should a new mICP be constructed? When
should invasive treatment be used?
Keywords  Malocclusion · Dentistry · Conferences and
proceedings · Temporomandibular joint · Prosthodontic
The following article attempts to summarize the impor-
tant elements that were highlighted during the last
congress of the International Academy of Advanced
Interdisciplinary Dentistry (http://www.iaaidentistry.
com) in association with the “Associazione Italia Gna-
tologia”-. A total of 200 colleagues from 20 countries
participated in the meeting held from 30 November to 2
December 2012 at the faculty of Dentistry Bernhard Got-
tlieb Universitätszahnklinik, Vienna Austria. Talks were
held by R. Slavicek (Austria), J.D. Orthlieb (France), S.
Naretto (Italy), P. Carpentier (France), E. Úry (Hungary),
G. Slavicek (Germany), E. Roshchin (Russia), Xiaohui-
Rausch-Fan (Austria), S. Kulmer (Austria), Xiao-Jiang
J.-D. Orthlieb ()
Faculté d’Odontologie, Aix-Marseille Université,
27, boulevard Jean Moulin, 13355 Marseille, Cedex 5, France
e-mail: jean-daniel.orthlieb@univ-amu.fr
E. Ehrmann
Université de Nice Sophia-Antipolis, Nice, France
M. Greven
Kanagawa Dental College, Bohn, France
J.-P. Ré
Aix-Marseille Université, Marseille, France
Interdisciplinary approach to the mandibular therapeutic position in oral rehabilitation   115
letter to the editor
Yang (China), A. Landry (Canada), M. Greven (Ger-
many), P. Simeone (Italy), N. Bassetti (Italy), G. Reich-
ardt (Germany), S. Cid (Portugal), R. Masnata (Italy), F.
Ravasini, N. Gondoni (Italy), E. Tanteri (Italy), G. Dumi-
nil (France), A. Knaus (Austria), H. Yoshimi (Japan) and
S. Sato (Japan).
To think always means making a selection. To think
about the mandibular therapeutic position means that
there is the possibility of changing the situation of maxi-
mal intercuspation (mICP). The objectives of the meeting
were to propose answers to the following practical ques-
tions: why change the mICP of a patient? Where should
a new mICP be constructed? When should invasive treat-
ment be used? The literature review presented during the
meeting showed a large lack of scientific evidence so the
contents of the following text should only be considered
as proposals.
Why think about a new situation for the mICP?
• I s it to obtain an optimization of condylo-disco-fossa
relationship?
• Is it to facilitate prosthodontic treatment by protruded
anterior repositioning, providing a better anterior oc-
clusal relationship and more posterior space?
• Is it a way to easily obtain a class I during orthodontic
treatment?
Because it is more complicated, strong reasons are
needed to treat a patient “out of his mICP” or sometimes
“out of the centric relation”. It is probably possible to keep
in memory simple principles, indicating to change the
situation of the mICP:
• T
 emporomandibular joint (TMJ): to improve the ca-
pacity to absorb mechanical stress (probably by pro-
viding stability)
 Author's personal copy
letter to the editor
• P rosthesis: to increase the coronal posterior space
• Occlusion: to optimize the anterior occlusal relations
and to obtain better posterior occlusal support and
stability.
Where is the best situation for the mandibular
therapeutic position?
In the case of an unstable TMJ related to a muscular dis-
order, the muscular dysfunction must be treated before
deciding on the condylar position.
If it is decided to change the condylar position the
objectives could probably be to push the mandible
slightly forward (sagittal plane) and to look for a more
median condylar position (coronal plane).
The quantity of the anterior repositioning is depen-
dant on:
• c ondylo-discal relations
• anterior occlusal relations: overjet value
• posterior occlusal relations: one-one or one tooth-two
teeth occlusions.
A new mICP in a protuded mandibular position more
than 2  mm away from the articular reference position
(centric relation) could cause a condylar transversal
instability.
When to decide to change the mandibular
position of maximal intercuspation?
Before answering this question it is necessary to specify
what is meantby invasive treatment?
“Overtreatment” is a more pertinent term than “inva-
sive treatment”.  The most common conclusions in the
literature on temporomandibular disorders (TMD) sug-
gest that invasive treatment is contraindicated because
this is considered to be overtreatment. There is prob-
ably some confusion between invasive treatment and
overtreatment.
• I nvasive treatment changes some anatomical struc-
tures in an irreversible way.
• Overtreatment is unnecessary treatment. If the over-
treatment presents an invasive aspect, from an ana-
tomical or psychological point of view it is a malprac-
tice endangering the patient.
Some detailed literature reviews emphasize that if the
oral condition generates a handicap for mastication this
dental condition can impact the health and the longevity
of the patient.
Even if the evidence is weak correction of dental defi-
ciencies remains indicated in its classical forms (restor-
ative dentistry, prosthetics, orthodontics). The goal of
116   Interdisciplinary approach to the mandibular therapeutic position in oral rehabilitation
treatment is a structural optimization (rather than ideal-
ization) in a low cost individualized way.
In the presence of TMD and altered teeth conven-
tional dental treatment is indicated. This treatment is
invasive but justified by the dental status so there is no
overtreatment.
This dental treatment is necessarily occlusal treatment
which helps to optimize functions and behavior of the
masticatory organ (e.g. correction of unilateral mastica-
tion). This treatment does not constitute a therapeutic
excess cost.
If numerous teeth have to be replaced the occlusion
can be adjustable; however, a risk would be to convince
the patient that dental treatment is indicated only to cor-
rect bruxism, chronic myalgia or a simple click. In the
patient’s mind it is dangerous to reduce the TMD treat-
ment to the occlusal approach.
The notion of occlusal overtreatment concerns sub-
jects with healthy dental arches. With the current level
of evidence in healthy dentition the general rule of TMD
treatment is intangible: no extensive occlusal treatment.
Where are the limits of overtreatment? A very poor
dental status of a patient is an opening way towards an
extensive occlusal treatment and in this case it is not an
overtreatment. Therefore it is permitted to adjust the
mandibular position to optimize occlusal functions, to
improve stability of anatomical structures and to facili-
tate numerous functions of the masticatory organ.
In patients with a perfectly healthy dentition the non-
invasive approach, such as physiotherapy and behavioral
reconditioning, will be the therapeutic approach and
avoiding overtreatment.
For the practitioner the real difficulty is to consider
where are the limits between eufunction (adaptation)
and pathofunction are (structural instability and/or
functional disability). Doubts by the practitioner should
lead to a prudent attitude:
• T
 o take time to analyze the clinical evolution with a
noninvasive approach,
• To analyze the potential of occlusal modifications
(without excess cost) to induce a therapeutic gain.
Reference position: decision-making algorithm
Before deciding which approach to use the current situ-
ation must be assessed. This is the diagnostic phase. To
establish a diagnosis a reference mandibular position is
needed which is characterized by two criteria:
• n on-pathogenic, which means a mandible in its phys-
iological position.
• reproducibility.
Only two mandibular positions can meet these criteria
(Fig. 1). When the mandible is:
 Author's personal copy
Fig. 1  Decision-making
algorithm: mandibular refer-
ence position
• I n maximal intercuspation (mICP) it is in the occlusal
reference position.
• In centric relation it is in the articular reference
position.
The best choice, because it is the simplest one, will be to
conserve the mICP, if the residual mICP is stable enough
(residual means after crown preparations) and not trans-
versally deflected. In this case, the mandibular reference
position will be the occlusal reference position. Other-
wise, a new mICP will be built in a centric relation, the
articular reference position. Sometimes, the TMJ must
be stabilized before by a musculoarticular recondition-
ing phase.
Therapeutic position: decision-making algorithm
Once the reference position is selected, the choice of the
therapeutic position can be made.
• I f the reference position is the occlusal reference posi-
tion, the therapeutic position will necessarily be the
initial mICP of the patient often reinforced by an orth-
odontic or prosthodontic treatment.
• If the reference position is the articular reference posi-
tion a new mICP has to be stabilized in the therapeu-
tic position. There are two possibilities for the sagittal
dimension:
− condyles in centric relation or
− condyles in protruded position (anteposition).
In both cases, then and only then the vertical dimension
must be chosen by rotation around the bicondylar hinge
axis.
Interdisciplinary approach to the mandibular therapeutic position in oral rehabilitation   117
letter to the editor
Because, unlike mathematics, there are often uncer-
tainties in biology, it can be decided to conserve the
initial mICP of the patient despite a lack of stability or a
deflected position (deflected mICP means mICP devi-
ated from occlusion in centric relation).
The decision criterion will be the ratio between the
functional benefits and dental costs (orthodontic or
prosthodontic), induced by the occlusal equilibration in
the therapeutic position initially planned. In this case,
the term used for the therapeutic position, is habitual
mICP to underline its imperfect character (Fig. 2).
Occlusal splint and therapeutic position
The use of a splint phase during the treatment was fre-
quently proposed by the presentations at the meeting
before making modifications to the teeth. The objec-
tives are either to facilitate or induce a musculoarticu-
lar reconditioning or to test a new mandibular position
changed in the sagittal or vertical direction.
A consensus seems to be in favor of a short duration
of the splint phase, generally 2 or 3 months, only during
sleeping time or all day in some cases.
If diagnosis protocols and reconstruction protocols are
widely shared some questions about treatment remained
controversial especially around the splint phase.
• S
 plint adjustments: either frequent adjustments of the
splint are realized to adapt the therapeutic position or
no modification to obtain musculoarticular adapta-
tion to the position induced by the splint.
• Does the splint represent a real functional test for the
therapeutic position? The occlusal morphology, the
thickness, the lack of proprioception, the modification
of the tongue, lip functions and breathing can prob-
ably influence the reactions. It is just a first approach,
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letter to the editor

Fig. 2  Decision-making
algorithm: mandibular
therapeutic position

Fig. 3  Wax impression of

the therapeutic position
directly on the splint

Fig. 4  Clinical case ex-

ample: initial situation dur-
ing splint phase and final
situation after orthodontic
treatment

118   Interdisciplinary approach to the mandibular therapeutic position in oral rehabilitation

 Author's personal copy

letter to the editor

which must be consolidated during the temporary Conflict of interest 

prosthodontic phase. The authors declare that there are no actual or potential
• After the splint phase, how should the obtained man- conflicts of interest in relation to this article.
dibular position be transferred?
• Clearer protocols about these points need to be pro-
posed if the therapeutic position concept is to remain
consistent (Figs. 3 and 4).

Interdisciplinary approach to the mandibular therapeutic position in oral rehabilitation   119