Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : ZC01 - ZC06 Full Version

Clinical, Electromyographical and Radiological Comparison of Dawson’s Bimanual Technique of Guiding the Mandible with Wax Ball Orientation Technique©


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52846.16065
R Sushma , Anand Joshi , Pronob Kumar Sanyal , Pramod Kumar Ramachand Shaha

1. Associate Professor, Department of Prosthodontics, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed To Be University, Satara, Maharashtra, India. 2. Professor and Head, Department of Physiology, Krishna Institute of Medical Sciences, Deemed To Be University, Satara, Maharashtra, India. 3. Professor and Head, Department of Prosthodontics, School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed To Be University, Satara, Maharashtra, India. 4. Professor and Head, Department of Radiodiagnosis, Krishna Institute of Medical Sciences, Deemed To Be University, Satara, Maharastra, India.

Correspondence Address :
Dr. Anand Joshi,
Professor and Head, Department of Physiology, Krishna Institute of Medical
Sciences, Deemed To Be University, Karad, Satara, Maharashtra, India.
E-mail: anandjoshikarad@yahoo.com

Abstract

Introduction: There are numerous methods to guide the mandible into Centric Relation (CR). The Dawson’s bimanual technique is a time tested and established method to guide the mandible into CR. On the other hand the author of the present study also has copyrighted a technique (wax ball orientation technique©) to guide the mandible into CR. Hence, this methodological study was performed to compare the two CR techniques to guide the mandible in CR position using clinical, myographical and radiological assessment methods.

Aim: To compare and assess which amongst the two (Dawson's bimanual techniques, and wax ball orientation technique) CR guiding techniques best guides the mandible to CR position using clinical, electromyographical and radiological assessment methods.

Materials and Methods: This interventional and clinical study was conducted at School of Dental Sciences, KIMSDU, Karad, Maharashtra, India, from May 2019 to May 2020. The study included healthy dentate individuals having Angle's class I malocclusion without any occlusal interferences and an intact dentition except for 3rd molars. Two CR technique to guide the mandible were technique 1-Dawson’s bimanual technique and technique 2- wax ball orientation technique. The study was carried out in three phases: clinical, electromyographical and radiological. Difference between the centric points, workload on elevators, condylar position was statistically analysed. Descriptive statistics was used to analyse the difference between the centric points marked using both the techniques. Independent t-test was applied to compare the gender and the mean centric distribution.

Results: Among the 45 study subjects considered for the study, 32 were females and 13 were males with the mean age of 21 years. No statistically significance difference was observed between the two techniques. Paired t-test showed that workload on elevators of both sides, Right Masseter in technique 1 and 2 had p-value=0.088, left Masseter in technique 1 and 2 had p-value=0.3, Right temporalis in technique 1 and 2 had p-value=0.463, left temporalis in technique 1 and 2 had p-value=0.429. There was difference between the Anteroposterior (AP) and Superoinferior (SI) position of condyle in relation to the fossa. AP measurement in the right side in tech 1 and 2 with p-value=0.448, AP measurement in the left side in tech 1 and 2 with p-value=0.178, SI measurement in the right side in tech 1 and 2 had p-value=0.803, SI measurement in the left side in tech 1 and 2 had p-value=0.259, which were statistically insignificant. Multivariate test showed statistically significant difference between gender and EMG, results whereas it was insignificant in Magnetic Resonance Imaging (MRI).

Conclusion: The wax ball technique has similar accuracy as the Dawson’s Bimanual technique.

Keywords

Centric relation, Condyle, Magnetic resonance imaging, Masseter, Temporalis, Temporomandibular joint

The Centric Relation (CR) is the classic position of the maxillomandibular relationship for the prosthetic rehabilitation. CR position is independent of tooth contact, clinically discernible when the mandible is moved anteriorly and superiorly and is restricted to a purely rotary movement around the transvers horizontal axis (1). CR has a long and substantial history and has been a topic of contention for over a century (2). However, the recent most definition was given by the Glossary of Prosthodontics (GPT) 9 (3) in 2017. Copious literature is available on a variety of guiding techniques to achieve CR each with its own advantages and disadvantages (4),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14),(15),(16),(17),(18),(19). For convenience sake the authors have given a simplified classification of the various methods of guiding the mandible to CR in their systematic review on CR (20) (Table/Fig 1).

Centric relation is a bone-to-bone relationship (21). Various imaging techniques can be used to assess the spatial relationship of condylar disc assembly in CR (22). However, magnetic resonance imaging is undoubtedly the safest, precise and reliable method to identify the exact position of the condyle-fossa relation (23).

More recently, the focus has shifted to CR being described as an anatomic-physiologic relationship (24). Over the last three decades the biological aspects of CR has taken over the mechanical aspect and various authors have contributed to the literature (25),(26). The muscles of mastication play a vital role in a whole quarantine of Temporomandibular Joint (TMJ), occlusion and the elevator muscles, especially the masseter and temporalis. Muscle activity during various jaw positions can be defined by Electromyography (EMG) (25). EMG activities in CR and Maximum Intercuspation (MI) have been described in details by the works of Buxbaum J et al., (26).

Dawson’s bimanual technique: In Dawson’s bimanual technique, the patient is in the reclined position and the patient’s head is cradled by the operator (Table/Fig 2)a-c. With the help of both thumbs on the chin and the fingers resting firmly on the inferior border of the mandible, downward pressure is exerted by the examiners thumb and upwards pressure on the fingers thereby manipulating the condyle-disk assembly in their fully seated positions in the mandibular fossae, after which the mandible is carefully hinged along the arc of terminal hinge closure (20).

Wax ball technique: it is a new technique where in tongue guides the mandible to CR. After establishing the vertical jaw relation, three orientation balls made of modeling wax are placed to the upper record base and along the midline. The wax balls are placed as shown in (Table/Fig 3). The operator gives instruction to the patient as to when they must place their tongue on those fabricated balls. The main advantage of this new technique is that it is easy for the patient to understand and follow the instructions of the operator and simulate the tongue positions on the orientation wax balls thus retruding the mandible posteriorly. This technique is cost-effective and saves time of patients and operators (4).

The authors of the present study in an earlier paper have established that both the Dawson’s bimanual and the wax ball orientation techniques are equally accurate and the time taken by the wax ball orientation technique© is significantly less compared to the Dawson’s technique (4). This finding led the authors to device a study with a purpose to compare and assess which amongst the two CR guiding techniques best guides the mandible to CR position using clinical using clinical, myographical and radiological assessment methods.

Material and Methods

This interventional and clinical study was conducted at School of Dental Sciences, KIMSDU, Karad, Maharashtra, India, from May 2019 to May 2020. Ethical clearance was obtained from Ethical Committee of Krishna Institute (KIMSDU/IEC/01/2018).

Inclusion and Exclusion criteria: Healthy dentate individuals having Angle’s class I malocclusion without any occlusal interferences and intact dentition except for 3rd molars were included in the study. If any decayed, restored and/or missing teeth were found in the subjects, such participants were excluded from the study. Subjects with a history of orthodontic treatment, myofascial pain dysfunction disorder, tenderness in any muscles of mastication, TMJ disorders and with dental implants were also excluded from the study.

The participants had the protocols explained in English, Hindi and Marathi. Informed consent was obtained from each of them. The sample size (N=45) for the study was calculated in G Power Software using α as 0.05, power of the study 80% and medium effect size of 40%.

Three Phases of Methodology

1. Clinical phase: Hydrocolloid impression (3M ESPE alginate impression material, 3M India Ltd., Bangalore, India) of the maxillary and mandibular arches were made to obtain the casts (dental stone, Kalabhai Dental Pvt. Ltd., Mumbai, India). Maxillary casts were mounted onto a semi-adjustable articulator using face bow record (Bio art Semi adjustable articulator, Confident Sales India Pvt. Ltd., Bangalore, India).

Patients’ mandible was guided to CR using technique 1 (Table/Fig 2), dawson’s bimanual technique and technique 2 (Table/Fig 3) Wax ball orientation technique in consecutive appointments (3),(18). CR jigs and interocclusal records were fabricated as follows.

Jigs were fabricated using self-cure acrylic (cold cure, Dental Products of India Ltd., India). After applying petroleum jelly on the upper and the lower anterior teeth approximately 1×1 cm dough was placed on the upper central incisor and the mandible was guided to CR. The patient was hold in the CR position until the material set. Once fabricated, the jigs were cross checked for accuracy and fit, the CR records were made using addition silicone (3M ESPE Imprint, 3M India Ltd., Bangalore, India) with the jig in place. Once set the CR records were stored in a tight pouch for use during articulation, Magnetic Resonance Imaging (MRI) and EMG recordings.

The lower cast was articulated using the CR records fabricated using technique 1. The occlusal points were marked on the casts using 8 μ blue articulating paper (Artifol 8 microns, Bausch, Dr. Jean Bausch GmbH and Co. KG, Germany). The previously mounted lower cast using technique 1 was dismounted and the same lower cast remounted using the set of records fabricated using the technique 2. This time the occlusal points were marked using the 8 red articulating paper (Artifol 8 microns, Bausch, Dr. Jean Bausch GmbH and Co. KG, Germany). The casts were then demounted and preserved for later use. The lower cast now had two occlusal marks at the point of first contact (blue: technique 1 and red: technique 2). In some casts the marks coincided and in some two marks were distinct (Table/Fig 4)a and b.

For standardisation purpose, all the procedures were performed by a single investor. The CR jigs fabricated for both the techniques were stored in a container for later use during recordings of EMG and MRI. The containers were marked with the serial number to identify the study participants it belonged to. The CR jig for technique 1 was coded as 1, for technique 2 as 2 for that particular study participant. EMG and MRI were completed within hours of jig fabrication to avoid any dimensional changes in jigs.

The distance between the blue and red occlusal marking was recorded using the stereo microscope at 45 X (Z4 Zoom systems, Great scopes, High Point, North Caroline, USA). The images and the readings were transferred onto a computer for data analysis.

2. Electromyographic phase: After the clinical procedure, the study participants were subjected to EMG (Clarity EMG Octopus Machine, Clarity medica Pvt. Ltd., India) to record the readings of both the right and left temporalis and masseter muscles in CR positions. The EMG process was explained to the patient in detail. First jig (number 1) was placed in the patient’s mouth, a ground electrode was placed on the forehead, the active electrode was placed on the centre of the maximum girth of the muscle and the third (indifferent electrode) was placed 3 cm away from the active electrode. Five readings of 2 seconds each in amplitude were taken in CR position. The average of the five readings was considered as the average amplitude for the participant. This procedure was repeated with the 2nd jig to record the readings of technique (Table/Fig 5).

3. Radiological phase: Magnetic resonance images were needed of the participants which were incurring by the university itself. The required MRI’s were justified by the ethical committee. With each CR jig in mouth, condylar position against the respective fossae of both the condyles was assessed using same MRI scanner (Siemens Avanto 1.5 Telsa, Siemens Healthcare Pvt. Ltd., Mumbai, India), presumably the most accurate radiation free means of assessing 3-dimensional condyle disc fossa relationship. The detailed procedure of MRI scanning was explained to the study subjects. They were also informed about the chances of accidental discovery of anu orofacial abnormalities or pathologies. However; no pathologies were detected in any of the study subjects. The MRI scans of both the condyles were taken from the sagittal anatomical plane. Both T1 and T2 weighted images were made. The radiologist was blinded to the CR technique that he was assessing. On each side, measurements of the Anteroposterior (AP) and Superoinferior (SI) (Table/Fig 6) of the condyle with respect to the temporal bone was measured using the following cortical bony landmarks: 1) for the AP position, the anterior margin of the condyle and the summit of the articular eminence; 2) for the SI position, the highest point of the condyle and the deepest concavity of the glenoid fossa. The distance from the centre of the condyle to the above landmarks was analysed to check if the condyle positions (right and left) in CR for both techniques had any relation.

Statistical Analysis

Data was entered into excel (Microsoft office, version 10.0) and analysed using IBM Statistical Package for the Social Sciences (SPSS) statistics for window, Version 23.0 Armonk, New York. Independent t-test was applied to compare the gender and the mean centric distribution. Paired t-test was used to analyse the work load on the masseter and temporalis of both right and left side in both the techniques. The AP and SI difference in the position of the condyle was analysed using paired t-test. Multivariate analysis was applied to compare the difference of EMG and MRI status in all groups of both genders.

Results

Among the 45 study subjects considered for the study, 32 were females and 13 were males with the mean age of 21 years. The mandibular casts on which the centric points were marked were visualised under the stereo microscope at 45x magnification. In 26 casts out of the 45, the centric points coincided. The maximum distance detected in one sample was 539.17 μ (Table/Fig 7). Amongst the 19 samples, the mean difference was found to be 174.1075 μ (Table/Fig 8). Independent t-test was applied to compare the gender and the mean centric distribution, which showed no statistical difference with a p-value of 0.699 (Table/Fig 9).

Paired t-test was used to analyse the work load on the masseter and temporalis muscle of right and left side in both the techniques (Table/Fig 10). The workload on both side was statistically insignificant. The p-value for right masseter in technique 1 and 2 was 0.088, for left masseter in technique 1 and 2 was 0.3, right temporalis in technique 1 and 2 was 0.463, left temporalis in technique 1 and 2 was 0.429. This showed that the muscles worked similarly in both the techniques at CR. When the two techniques were compared, technique 1 showed right temporalis having mean amplitude of 51.468. The least load was recorded in left masseter in both the techniques. The left masseter in technique 1 recorded the least workload (mean amplitude of 36.244).

The AP and SI difference in the position of the condyle was analysed using paired t-test. (Table/Fig 11) shows that statistically there was neither a difference between the right and left AP nor in right and left SI positions. The p-value for AP measurement in the right side in technique 1 and 2 was 0.448, AP measurement in the left side in technique 1 and 2 was 0.178, SI measurement in the right side in technique 1 and 2 was 0.803, SI measurement in the left side in technique 1 and 2 was 0.259. The highest distance found in AP on the left side was 6.287 mm in technique 2. The lowest was recorded in right SI positions in technique 2 (4.02 mm).

Further, multivariate test was applied to compare the difference of EMG (Table/Fig 12) and MRI (Table/Fig 13) status in all groups of both genders. Statistically significant results were found between gender and EMG results. Highly significant differences were found in temporalis right muscles in both (p-value=0.009 in technique 1, p-value=0.005 in technique 2) the techniques. However, there was no significant association between gender and MRI data when multivariate analysis was applied.

Discussion

In the present study, there was no significant difference between the Dawson’s bimanual technique and the wax ball orientation technique when compared clinically, electromyographically and radiographically. The Dawson’s bimanual technique is a time tested method whereas the wax ball orientation technique is a newer method of guiding the mandible to CR. Both the techniques and the advantages, disadvantages have been clearly explained in the authors previous comparative study (4). Various studies in literature have compared the Dawson’s bimanual method with other clinical techniques which have showed conflicting results (Table/Fig 14) (1),(2),(9),(11),(12),(16). Many authors have also emphasised on the importance of tongue in registering CR (27),(28),(29).

The EMG integrator-average demonstrates sensitivity to changes in the muscle activity, further; the EMG records are capable of detecting differences in average/μV amplitude levels (25). Buxbaum J et al., indicated that the muscle activity increases in CR position compared to maximum intercuspation. The results of their study demonstrated a significant increase in xVin CR. Average/μV amplitude levels of the masseter and anterior temporalis muscles at CR was higher than MI. When masseter and temporalis was evaluated individually average/μV amplitude levels were higher for temporalis which is in accordance with the results of our study (26). Jeminez ID checked whether the AP changes in various mandibular positions affected the masticatory muscle activity, and showed that the CR position required more muscle activity (temporal and masseter) compared to the other position during mastication, deglutition and respiration (30). Woelfel J et al., and Owens SE et al., separately studied the importance of lateral pterygoid in CR and found that the lateral pterygoid muscle is inactive during the pure hinge movement of the mandible (31),(32).

The EMG reading is result of inhibition of motor neurons in the temporal and masseter muscles. The effect of secondary endings in muscle spindle and Golgi organ is most likely responsible for electrical activity in temporalis muscle and masseter muscle activity. However, the major neural activity takes place in the trigeminal motor neurons (33). Earlier studies have concluded that masseter contributes to isometric force made while cleaning whereas temporalis is a postural muscle which controls mandible during excursive movements and also movements like swallowing and chewing (34),(35),(36).

Carwell ML and McFall WT studied the condylar position using clinical and radiographic (lateral cranial oblique positions) technique. The clinical technique compared was Dawson’s bimanual method, Chin point guidance, anterior guidance, jig. The authors concluded that, centric contact points on the teeth were similar with all the bimanual manipulation on radiographs (37). Velos S et al., compared the condylar position in CBCT after the static and dynamic registration of CR and concluded that dynamic registration was reliable and an accurate method, as there were higher condylar symmetry and the centred position in articular fossa (38). Kandasamy S et al., assessed condylar position by MRI after common bite registration; centric occlusion, retruded CR and Roth-power CR. The study failed to support the claim that certain bite registrations accurately position condyles in specific position in glenoid fossa (23).

Limitation(s)

The sample size taken was small. Use of scanning electron microscope would have been preferable as the stereo microscope had only 45x magnification.

Conclusion

The authors conducting research on this new guiding technique have presented it in a new light with a concrete scientific base and undiscountable evidence. The wax ball technique has similar accuracy as the Dawson’s Bimanual technique and can be used clinically as a new guiding technique for mandible to CR position. The study has a scope to be performed on a large sample to give a more conclusive statement. Use of Scanning electron microscope can be added in the methods performed to obtain more precise measurements.

Author declaration: This paper was presented in the 49th Indian Prosthodontic Society National Conference 2020 by the first author, that is Dr. Sushma R. Hence, the abstract of the same was published as the conference proceedings titled “Clinical, Electromyographical and Radiological comparison of Dawson’s bimanual technique of guiding the mandible with Wax Ball orientation technique©” Volume 20 supplement 1.

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DOI and Others

DOI: 10.7860/JCDR/2022/52846.16065

Date of Submission: Oct 13, 2021
Date of Peer Review: Nov 02, 2021
Date of Acceptance: Jan 03, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 14, 2021
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• iThenticate Software: Feb 02, 2022 (22%)

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