CRANIOMANDIBULAR FUNCTION AND DYSFUNCTION

SECTION EDITOR
GEORGE A. ZARB

Simple application of anterior jig or leaf gauge in

routine clinical practice
W. J. Carroll, D.D.S.,’ J. B. Woelfel, D.D.S.,** and R. W. Huffman, D.D.S.*‘*
The Ohio State University, College of Dentistry, Columbus, Ohio

S everal sophisticated articulating instruments have

been developed’-) and are used to study various aspects of
5. Patients with painful temporomandibular joints
frequently report surprisingly quick relief of their pain
jaw movement and tooth contacts.“” Most restorations and other symptoms after either wearing an occlusal
are made in centric occlusion, not centric relation splint, biting on a leaf gauge (Fig. 1) for several minutes,
occlusion. More information is needed in regard to or after a dentist has removed the tooth or teeth that were
anterior coupling,“-” the relationship of malocclusion to prematurely contacting in the centric relation posi-
immediate side shift canine-protected and group-func- tion.2s.’
tion occlusal relationships,‘5-‘7 and the speculated rela- For a number of years the anterior jig2’-” (Fig. 2) and
tionship of malocclusion to the progression of periodon- more recently the leaf gauge20*27-m have been shown to be
tal disease.” reliable methods for consistently placing and securing
Williamson’8.‘9 defined centric relation as “a position the condyles in a centric relation position.‘9 Both main-
in which both mandibular condyles are simultaneously tain the minimal increased vertical dimension necessary
seated most superiorly on the posterior slopes of the to negate tooth contact.
articular eminences, with the menisci interposed proper- This article acquaints or reminds the reader of
ly between.” The patient’s own healthy closing muscles, characteristics, principles, fabrication, and valuable clin-
contracting evenly on both sides, can best direct the ical applications of an anterior jig and of a leaf gauge.
mandible into centric relation. A terminal hinge arc of
closure occurs only under certain conditions: dentist ANTERIOR JIG CHARACTERISTICS
manipulation, neuromuscularly relaxed and trained The anterior jig (Fig. 2) is quickly made of autopoly-
patient, or when a patient closes properly onto a leaf merized acrylic resin and is therefore rigid.2’.22 It can be
gaugem or an anterior jig21e2’(Figs. 1 and 2). made directly in the mouth or on a maxillary cast. The
The significance and advantages of being able to place jig covers the maxillary central incisors and a small area
the mandibular condyles into the centric relation position of the palate with minimal internal spacing. Its outer
are as follows: surface is adjusted so that a lower central incisor contacts
1. Centric relation is usually an easily reproducible the smooth lingual incline of the jig at only one point.
and not uncomfortable position. The jig’s incline must stop the closure of the mandible
2. When the condyles are retruded, the mandible is before posterior tooth contact, and this lingual slope
capable of repeatedly making a purely rotational move- should be angled 45 to 60 degrees posteriorly and
ment through an incisor separation of 10 to 25 mm,15.24 superiorly from the occlusal plane (Fig. 2).
permitting location and transfer of this axis to an
articulator. PRINCIPLES
3. Patients appear to function comfortably in centric The anterior jig (or appropriate thickness of a leaf
relation after .a centric relation occlusal equilibration, gauge) prevents the posterior teeth from occluding and,
after a full-mouth rehabilitation, during occlusal splint in so doing, appears to modify proprioceptive memo-
therapy, and in wearing complete dentures. ry.5,‘9 Because the anterior jig (or leaf gauge) is rigid,
4. Numerou.s temporomandibular joint disturbances once it is contacted by the lower incisor on retruded
including pathologic changes may occur or are triggered closure, anterior resistance is created (Fig. 3, right) and
when malocclusion exists because of tooth movement, the leverage of the mandible is reversed, creating a
dental restorations, or inadequate orthodontic treat- naturally braced tripod effect with the two condyles
ment 12.13. IS.25 (Fig. 3).3’-”
Contrast the reversal of the class III lever situation

*Private practice, Pcrrysburg, Ohio.

**Professor. Department of Restorative and Prosthetic Dentistry. l McHorris WH. Gnathologic conference presentation. Columbus,
‘**Professor Emeritus, Department of Restorative Dentistry, Ohio, April 25, 1985.

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 CARROLL, WOELFEL, AND HUFFMAN

Fig. 1. Above, left, Patient with head reclined to stretch neck muscles while she closes on
a numbered leaf gauge. Below, left, Close-up shows leaf gauge producing minimal
separation of teeth as it creates anterior resistance (see Fig. 3, right). Above, right,
Numbered plastic leaf gauge. Each leaf is approximately 0.1 mm thick; 55 leaves together
as seen below create an incisal separation of 5.2 mm. Below, right, Side view of numbered
leaf gauge with all 55 leaves stacked and held together by plastic rivit.

that occurs when a patient chews food or bites into an patient’s chin. The patient is instructed to push the
elevated anterior stop preventing further closure (Fig. 3). jaw forward and then backward as the dentist pro-
As the jig or leaf gauge is engaged by the lower incisors vides gentle posterior guidance and decides by his
with the closing muscles continuing to contract, the own tactile sensation whether the condyles are seating
condyles are more likely to become seated in their middle in the glenoid fossa:19,23,26,28,29The dentist’s index and
and most superior positions.‘9*2* It has been suggested middle fingers should be placed under the lower
that protrusion is avoided because a natural reflex border of the mandible near the angle to support the
prevents contraction of the lateral pterygoid muscles as mandible in an upward direction.30s3’
the patient bites firmly on a leaf gauge.“,” 4. Doughy acrylic resin is molded over the maxillary
central incisors and the patient is asked to direct the
CHAIRSIDE FABRICATION OF AN chin forward, then back, and then to close slowly
ANTERIOR JIGZ’ until you say “Stop” (jaw closure into the soft acrylic
1. The patient is positioned in the dental chair with the jig is stopped 3 or 4 mm short of occlusal contact). As
head tipped backward at an angle of approximately the material stiffens it can be removed and placed in
45 degrees to stretch the neck muscles, fascia, and water to dissipate the heat.
skin (Fig. l).z8,29 5. Once the acrylic resin dough has hardened, the
2. The patient is instructed to move the chin forward indentations of the lower anterior teeth are ground
and back several times with the teeth apart and, away so that the lingual surface of the jig becomes
finally, to close slowly. smooth and slopes in an upward posterior direction
3. The dentist’s thumb is held gently against the from the occlusal plane (Fig. 2).

612 MAY 1988 VOLUME 59 NUMBER 5

APPLICATION 01: ANTERIOR JIG OR LEAF GAUGE

Fig. 2. Above, left, Incisal view of Lucia jigzl sufficiently narrow so it covers parts of both
central incisors. It is thickest only on lingual at midline to produce desired jaw
separation. Rest of smooth lingual portion thins to a featheredge toward distal of each
upper central incisor. Below, left, Labial view of Lucia jig adjusted to produce desired
minimal degree of jaw opening to separate all teeth. Mandibular incisor contacts a
smooth lingual incline that guides mandible superiorly and posteriorly as patient taps or
closes firmly. Above, right, Close-up semiside view indicates upward slope of lingual
surface that creates desired anterior resistance. Below, right, Side view of acrylic resin jig
showing its bulk and angle of important lingual surface.

6. Whenever the jig is removed from the mouth, the APPLICATIONS OF PLASTIC ANTERIOR JIG
patient is asked to bite on a cotton roll or leaf gauge, The plastic anterior jig is used routinely in two
or a saliva ejector is placed in the mouth to keep the clinical situations. It is often used in the fabrication of
teeth apart. This will maintain the deprogramming of maxillary centric relation biteplanes or splints. After
the adaptive mandibular closure path (engram).5*‘9 fabrication of a vacuum-formed plastic material onto a
Your instructions to the patient at this time should be maxillary stone cast, an anterior jig is added to the splint
“Chin out and back, and close” (onto the cotton roll, covering the incisive papilla region. It is then adjusted to
leaf gauge, or saliva ejector). the desired minimally opened vertical dimension before
7. Once properly shaped, the jig is replaced in the the addition of ropes of acrylic resin over the entire
mouth. The patient is asked to close in a retruded occlusal and incisal area, including the jig.15a30
position on the jig for a minute or two to allow for The anterior jig is frequently used to make accurate
further muscular relaxation and concomitant reposi- centric relation jaw records (Fig. 4, above), providing the
tioning of the mandibular posture to continue. The muscles of mastication have relaxed before the registra-
retruded tooth contact on the jig is marked with a thin tion. The anterior jig guides and stops the retruded
Mylar-type (DuPont Co., Wilmington, Del.) articu- mandibular closure arc at the preselected vertical dimen-
lating tape. Instructions to the patient for this proce- sion as the recording medium (zinc oxide and eugenol,
dure should be, “Chin forward and back, (Mylar polyether, wax, acrylic resin, or plaster) is interposed
tape is inserted), now close in the back and tap between the posterior teeth.
together several times on this jig.”
8. Completion of the jig is done by removing extraneous ALTERNATIVE METHODS FOR AVOIDING
contacts other than the only one centered lower ADAPTIVE MANDIBULAR CLOSURE
incisor mark that remains, and this small spot of PATTERNS, l9
contact is reduced until the desired vertical dimension Several other methods can be used to assist the dentist
of occlusion is reached (minimal opening but an and patient in recording the terminal hinge position of
assured separation of all opposing teeth). the mandible:

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 CARROLL, WOELFEL, AND HUFFMAN

THE MANDIBLE THE MANDIBLE

ASA ASA
CLASS III LEVER REVERSE CLASS III LEVER

Fig. 3. Top, Class III lever diagram. Below, left, Mandible. as it normally functions in
mastication. Below, right, Reversal of normal class III lever that is created by anterior
resistance such as a Lucia jig, leaf gauge, thin strip of metal, or as incising a carrot.

1. Central bearing screw and opposing table or inclines and record of exact vertical opening between the incisors
(gnathological clutches) used with pantographic tracings (Fig. 1, right). Narrow more firm paper disposable leaf
of mandibular border movements
gauges were described by Woelfel.3’
2. Narrow strip of x-ray foil or relief chamber metal over
the upper incisors32~3’ The leaf gauge is frequently used to obtain diagnostic
3. Impression compound or hard wax anterior stop” centric relation interocclusal records (Fig. 4, belqw), to
4. Biting on a saliva ejector, cotton roll, or popsicle stick” test for existing undetected prematurities”*29 when per-
5. Sliding the teeth with a credit card interposed between forming an occlusal equilibration, and when fitting and
them”
adjusting cast restorations before their cementation.*
6. Patient relaxation with concomitant dentist manipulation
of the mandibleQ 23.25 The leaf gauge may also be used periodically by the
7. Use of a leaf gaugp31-35*36 patient as prescribed by the dentist to relieve painful
Perhaps the most useful and practical alternative to spasms of the lateral pterygoid muscles.‘9~3’,’The leaf
the anterior jig is the leaf gauge.~27-B~3*The leaf gauge gauge is a valuable yet simple device. The general dental
(Fig. 1, right), similar to a “feeler gauge,” consists of practitioner can incorporate it routinely into treatment
multiple sheets of plastic, one or more of which is placed procedures that enhance the quality of professional
between the incisors at an upward angle. The dentist can services to the patient.
then create anterior resistance at any vertical dimension In February 1985, the Committee on Scientific Inves-
by the addition or removal of leaves (Fig. 3). Previously, tigation of the American Academy of Restorative Den-
some leaf gauges were made from unexposed panoramic tistry commented as follows: “The leaf gauge seems to
x-ray film, which was developed to remove the emulsion have gained renewed popularity as a diagnostic aid,
coating, thus providing a clear film. The film was then occlusal adjustment aid, and has been shown to be
cut into 1 cm X 5 cm sections and bound together by helpful in securing centric relation interocclusal registra-
some type of screw-post fasteners. tions.“*’
Recently, a more sophisticated leaf gauge was
described.35pXIt is made out of a thinner, more pliable
plastic. The leaves are a uniform 0.1 mm thick and l McHorris WH. Gnathological confcrcncc prcscntation. Columbus,
sequentially numbered to provide a convenient measure Ohio, April 25, 1985.

614 MAY 1988 VOLUME 59 NUMBER 5

APPLICATION OF ANTERIOR JIG OR LEAF GAUGE

:Fig. 4. Above, Zinc oxide-eugenol interocclusal record supported by fiberglass formula-

tor mesh (wire frame has been removed) with Lucia jig directing mandible posteriorly
and maintaining desired degree of vertical separation of teeth. This type of centric
relation record is used when accuracy is paramount. Notch for jig is seen right. Below left,
Aluwax cloth wafer checkbite is being made with leaf gauge to direct mandible and
maintain vertical dimension. This type of centric relation record is often used for
diagnostic mountings. Notch in wax record accommodates leaf gauge (right).

APPLICATIONS OF THE LEAF GAUGE seated in their respective fossae, and with the lower
The leaf gauge is held by the dentist or assistant with incisors contacting on the underside of the leaves which
an arbitrary number of leaves placed in the oral cavity at slope posteriorly upward.
the maxillary anterior midline parallel to the lingual We presume that using a leaf gauge in this manner
plane of the maxillary central incisors (Fig. 1, left). The eliminates potential operator-guided errors in centric
patient is instructed to close on the back teeth until a relation by permitting the patient’s own neuromuscula-
lower incisor touches the underside of the leaf gauge. ture to seat the condyles in their centric relation posi-
Leaves are added or subtracted as required until the tions. The average number of additional leaves that must
patient can just barely feel a posterior tooth touch while be added to arrive at this final position is six, with a
closing firmly on the leaf gauge. With the addition of a normal range from one to nine.
single leaf the patient initially should not feel any If the leaf gauge is being used for an occlusal
posterior tooth contact. equilibration or to adjust castings to centric relation
As the jaw is held closed with a “half-hard” closing occlusion, the procedure is begun with the mandible in
force for approximately 15 to 20 seconds, often the the tripodized centric relation position6x34 as just
patient again w:ill be able to feel a posterior tooth contact. described. Leaves are gradually removed, one at a time,
The dentist must then add a leaf and the procedure is the prematurity is marked each time with Mylar tape
repeated. Leaves are added one at a time until the patient and the necessary adjustments are made as each leaf is
can close with a half-hard closure force for 2 to 5 removed. A significant advantage is that the patient is
minutes without feeling any posterior tooth contact. At more conscious of biting or tapping on the centrally
this time the mandible is “tripodized.“32+33,37,3*in its located leaf gauge than on the unilaterally placed
centric relation position with the right and left condyles articulating film, thus avoiding the prematurity.

THE JOURNAL OF PROSTHETIC DENTISTRY 615

 CARROLL, WOELFEL, AND HUFFMAN

When using the leaf gauge to make centric relation 4. Gibbs CH, Derda HJ. A new articulator emphasizing centric
interocclusal records (Fig. 4) for mounting diagnostic occlusion and the anterior determinants. J PROSTHETDENT
1977;37:382-93.
casts, the dentist also starts with the mandible in the
5. Lundeen HC, Shryock EF, Gibbs CH. An evaluation of mandib-
tripodized centric relation position32s33,37,38and arbitrari- ular border movements: their character and significance. J
ly adds three or four additional leaves to assure that the PROSTHETDENT 1978;40:442-52.
teeth cannot close completely through the recording 6. Gibbs CH, Lundeen HC, Mahan PE, Fujimoto J. Chewing
material (which would result in an inaccurate record). movements at the first molar. J PR~~THETDENT 1981;46:308-
22.
An anterior cutout is made in the recording-material
7. Clayton JA, Crispin BJ, Shields MJ, Myers GE. A pantograph-
carrier for the leaf gauge (Fig. 4, below right). The ic reproducibility index (PRI) for detection of TM J dysfunction
recording material is positioned onto the maxillary arch [Abstract]. J Dent Res 1976;55:
of teeth, the leaf gauge is properly inserted, and the 8. Beard CC, Clayton JA. Effects of occlusal splint therapy on
patient is instructed to close on the back teeth as before TMJ dysfunction. J PR~~THET DENT 1980;44:324-35.
9. Shotwell JL, Kotowicz WE, Clayton JA. Ability of edentulous
until a mandibular incisor touches the leaf gauge. The
subjects to reproduce mandibular border tracings. J PR~STHET
patient then gently, but firmly, holds the mandible in DENT 1980;44:379-83.
this position until the recording material chills or sets. A 10. Jankelson B, Swain CW, Crane PF, Radke JC. Kinesiometric
recently introduced system uses a carrying wafer with an instrumentation: a new technology. J Am Dent Assoc 1975;
incorporated slot for the leaf gauge.” 90:834-43.
11. Jankelson B. Measurement accuracy of the mandibular kinesio-
Regenos* uses the leaf gauge exclusively when fitting
graph-a computerized study. J PROSTHETDENT 1980;44:656-
and adjusting multiple castings before cementation. 66.
Previously, he remounted the casts to finalize the gold 12. McHorris WH. Occlusion with particular emphasis on the
occlusal contacts on the articulator and found this to be a functional and parafunctional role of anterior teeth; part 1. J
time-consuming and potentially an inaccurate proce- Clin Orthod 1979;13:606.
13. Brose MO, Tanquist RA. The influence of anterior coupling on
dure. In the leaf gauge procedure, the chairside assistant mandibular movement. J PROSTHETDENT 1987;57:345-53.
positions the leaf gauge and one-side articulating film or 14. Schwartz H. Occlusal variations for reconstructing the natural
wax while the dentist, holding the articulating film or dentition. J PROSTHETDENT 1986;55:101-5.
wax on the other side, instructs the patient to concentrate 15. Woelfel JB. Dental anatomy; its correlation with dental health
and close or tap on the leaf gauge. In this manner the service. 3rd ed. Philadelphia: Lea & Febiger, 1984;348-65.
16. O’Leary TJ, Shanley DB, Drake RB. Tooth mobility in
patient is not tempted to bite toward the side of the tooth cuspid-protected and group-function occlusions. J PR~~THET
to be marked. This method avoids any previous adaptive DENT 1972;27:21-5.
closure patterns by the patient.5s’9 17. Goldstein GR. The relationship of canine-protected occlusion to
a periodontal index. J PR~~THET DENT 1979;41:277-83.
SUMMARY 18. Williamson EH. Dr. Eugene H. Williamson on occlusion and
TMJ dysfunction (interview by S Brandt). J Clin Orthod
Utilization of either of the two described methods by 1981;15:333-50.
dentists is recommended as a simple means to routinely 19. Williamson EH. The role of craniomandibular dysfunction in
record or provide centric relation closures. The leaf orthodontic diagnosis and treatment planning. Dent Clin North
gauge (1 to 6 mm thick) can be made from plastic or Am 1983;27:541-60.
20. Long JH. Locating centric relation with a leaf gauge. J
x-ray film or it can be purchased. The anterior acrylic
PROSTHET DENT 1973;29:608-10.
resin jig can be made in a few minutes directly in the 21. Lucia VO. A technique for recording centric relation. J PROS-
mouth by the dentist or an assistant or by a technician THETDENT 1964;114:492-505.
using mounted casts. Both methods avoid adaptive 22. Wise MD. Occlusion and restorative dentistry for the general
mandibular closure patterns and dentist-guided jaw practitioner. London: British Dental Association, 1982;14-6.
23. Dawson PE. Evaluation, diagnosis, and treatment of occlusal
closure as well as other commonly unrecognized errors
problems. 1st ed. St Louis: The CV Mosby Co, 1974;48-70.
in assessing occlusal contacts. 24. Possclt U. The physiology of occlusion and rehabilitation.
Philadelphia: FA Davis Co, 1962;40-8.
25. Roth RH, Rolfs DA. Functional occlusion for the orthodontist-
*Regenos J, Wilkes R. Personal communication, Nov. 1984, Cincin- Part II. J Clin Orthod 1981;15:100-23.
nati, Ohio. 26. Guichet NF. Biologic laws governing functions of muscles that
move the mandible. Part II. condylar position. J PROSTHET
DENT 1977;38:35-41.
27. Phillips RW, Hamilton IA, Jendresen MD, McHorris WH,
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1. Ring ME. Dentistry. An illustrated history. 1st ed. St Lquis: The American Academy of Restorative Dentistry. J PROSTHETDENT
CV Mosby Co, 1970;307-10. 1985;53:844-70.
2. McCollum BB, Stuart CE. A research report. Ventura, Calif: 28. Golsen LF, Shaw AF. Use of leaf gauge in diagnosis and therapy.
Charles E. Sturat, DDS, 1955;62-86. Qunitessence Int 1984;6:61 l-21.
3. McCollum BB. The mandibular hinge axis and a method of 29. Shankland WE, Ralston SJ. The fabrication and use of a leaf
locating it. J PR~~THETDENT 1960;10:428-35. gauge to locate centric relation. Ohio Dent J 1983;57:43-5.

MAY 1988 VOLUME 59 NUMBER 5

APPLICATION OF ANTERIOR JIG OR LEAF GAUGE

30. Huffman RW, Regenos JW. Principles of occlusion laboratory numbered leaves. J PR~STHET DENT 1985;54:652-4.
and clinical teaching manual. 8th ed. Columbus: H and R Press, 36. Huffman R. A numbered leaf gauge (instruction booklet).
1980;VI-A-27. Columbus: Huffman Leaf Gauges, 1984.
31. Woclfel JB. A new device for accurately recording centric 37. McHorris WH. Occlusal adjustment via selective cutting of
relation. J PROSTHETDENT 1987;58:716-27. natural teeth. Part I. Int J Perio Rest Dent 1985;5:9-25.
32. Wirth CG, Aplin AW. An improved interocclusal record for 38. McHorris WH. Occlusal adjustment via selective cutting of
centric relation. J PROSTHETDENT 1971;25:279-85. natural teeth. Part II. Int J Perio Rest Dent 1985;6:9-29.
33. Kornfield M. Mouth rehabilitation clinical and laboratory
procedures. 2nd ed. St Louis: The CV Mosby Co, 1973;14-7. Reprmt requeststo:
34. Strohaver RA. A comparison of articulator mountings made with DR. JULIAN B. WOELFEL
centric relation and myocentric position records. J PROSTHET THE OHIO STATE UNIVERSITY
DENT 1972;28:379-90. COLLEGE OF DENTISTRY
35. Rosenblum RH, Huffman RW. Leaf gauge with consecutively COLUMBUS, OH 43210

Frontal chewing patterns of the incisor point and

their dependence on resistance of food and type of
occlusion
P. Priischel, Dr.Rer.Nat.,* and M. Hofmann, Prof.Dr.Med.Dent.**
Friedrich Alexander UniversitHt, Poliklinik fiir Zahnirztliche Prothetik, Erlangen, West Germany

lhe concern of dental scientists with the recording of movements are confined.5s6 Two patient groups were
masticatory movements is an outgrowth of the conviction studied. One group comprised of 193 young adults (148
that such research would aid in the diagnosis of function- men and 45 women in the age range of 21 to 33 years;
al disorders of the stomatognathic system. Nevertheless, mean age 26 years) was randomly chosen. Criteria for
reports on normal physiologic mastication have revealed inclusion in this study included (1) complete dentition in
large interindividual variations and a multitude of both jaws, no tooth loss except, occasionally, missing
different chewing patterns.’ In the absence of systematic third molars, (2) no dental complaints or functional
methods of classification, only the most commonly disorders, (3) no clinically detectable pathologic findings,
observed forms of movements have been described and and (4) no severe dysgnathia requiring treatment. This
the use of different nonstandardized test foods often led group of test subjects is referred to as the normal group
to contradictory statements. This study used a newly or normal sample. In the second test group, 41 patients
developed procedure for chewing-pattern classifica- (20 men and 21 women in the age range of 16 to 38
tion.2s3 This provided numerical data on frequencies of years; mean age of 24 years) with mandibular progna-
the patterns of normal chewing and their dependence on thism were studied.
the consistency of food and type of occlusion. Winegum and equally sized pieces of soft bread
without crust were assigned as tough and soft consistency
METHODS test food. With each kind of bolus, one trial with chewing
Chewing movements of the incisor point of the lower on the right and one with chewing on the left side were
jaw were recorded by using a Sirognathograph instru- registered. Starting from the habitual intercuspal posi-
ment (Siemens Corp., Bensheim, West Germany) and tion, each chewing action was recorded over a period of
further processed by a connected computer system 20 seconds.
(Hewlett Packard Co., Palo Alto, Calif.). The accuracy
and linearity of the electrognathographic method have EVALUATION
been tested by several researchers, with an accuracy of Evaluation of the data included the classification of
1% achieved in the spatial domain to which chewing chewing patterns and the calculation of parameters
describing the temporal and spatial behavior of the
*Akademischer Rat, Department of Prosthetic Dentistry. masticatory movements. This procedure, which has been
**Professor, Director of the Department of Prosthetic Dentistry. successfully applied23’ includes the following.

THE JOURNAL OF PROSTHETIC DENTISTRY 617