Centric relation: A matter of form and substance.

The recent review article by Zonnenberg, Türp and Greene 'Centric relation critically revisited - What are the clinical implications'? opens an important debate by addressing topics of central relevance in Dentistry, namely the relationship between occlusion and the condyle-to-glenoid-fossa position, and the need for diagnostic assessment and therapeutic alteration of the condylar position in orthodontic patients. Zonnenberg, Türp and Greene concluded that the mandibular condyle is correctly situated in most orthodontic patients. Thus, in their view, orthodontists can disregard this aspect during treatment, and rely on the plastic properties of the masticatory supporting structures, while aiming at finishing the cases in a good occlusal relationship. We think that this approach fails to consider that biological variation of the stomatognathic structures can also be pathological and that, as dental occlusion determines condylar relative position within the glenoid fossa, changes in the occlusion are likely to alter the original condylar-to-glenoid-fossa relation. Hence, we claim that whenever the occlusal relationship must be changed, the clinician should carefully monitor the condyle position and the mandibular function to prevent possible iatrogenic effects. To advance the discourse on the topic, we invite Zonnenberg, Türp and Greene to clarify their definition of 'average patient' and their interpretation of 'full-mouth orthodontic and orthognathic treatment', their understanding of 'biologically acceptable condylar relationship', their justification of maximum intercuspation as reference position, the extent to which they think it is safe to rely on the TMJ resilience, and finally their alternative to centric relation in the treatment of patients needing condylar repositioning.

The dental remains from the Early Upper Paleolithic of Manot Cave, Israel.

This study presents the dental remains discovered at Manot Cave (MC), Western Galilee, Israel. The cave contains evidence for human occupation during the Early Upper Paleolithic period (46-33 ka) mainly of Early Ahmarian (∼46-42 ka) and Levantine Aurignacian (∼38-34 ka) cultural levels. Six teeth (three deciduous and three permanent) were found at the site, of which four could be thoroughly analyzed. The morphology of the teeth was qualitatively described and analyzed using traditional and geometric morphometric methods. A large comparative sample was used in order to assess the morphological affiliation of the Manot specimens with other Homo groups. The results provided equivocal signals: the upper first premolar (MC-9 P3) is probably modern human; the upper deciduous second molar (MC-10 dm2) and the upper second permanent molar (MC-8 M2) might be modern humans; the lower second deciduous molar (MC-7 dm2) might be Neanderthal. Owing to the small sample size and the almost total lack of distinctive characteristics, our outcome could not supply conclusive evidence to address the question of whether Manot Aurignacian population came from Europe or descended from the local Ahmarian population.

Accuracy of transferring analog dental casts to a virtual articulator.

STATEMENT OF PROBLEM: Complex digital workflows have been developed to create virtual dental patients. Direct and indirect digital methods are available for transferring analog patient information to virtual articulators. The direct method consists solely of digital workflows. The indirect method combines analog steps and digital procedures, representing an intermediate solution between the analog and direct digital approach. Studies that have investigated the overall accuracy of the virtual working space are sparse. PURPOSE: The purpose of this clinical study was to investigate the accuracy of the virtual dental space using the indirect digital workflow. MATERIAL AND METHODS: Mounted gypsum casts of 18 patients were used for indirect scanning. The maxillary casts were mounted in their skull-related position with a kinematic facebow. The mandibular casts were mounted in centric relation to the maxillary casts. The obtained digitized casts were transferred to a virtual articulator. An occlusal analysis was performed both in the analog and virtual environments, and the coordinates of matching analog and virtual contact points were measured. The trueness and precision of the indirect transferring procedure were assessed. RESULTS: A total of 194 analog points was considered in the reference. Ninety-three percent of all analog points matched a virtual correspondent, and 96% of the analog first contacts between the casts were also present as first contacts in the virtual space. The trueness of the data transfer, corresponding to the spatial distance between the matching analog and virtual points, was 0.55 ±0.31 mm. The maximum recorded deviation was 1.02 mm. CONCLUSIONS: The correspondence between the number and position of analog and virtual contacts was high. The mean absolute deviation of the matching point-pairs was better than that reported for the direct digital method. Under the conditions described, the virtual dental space created with the indirect digital method can be reliably used for virtual occlusal analysis in clinical practice.

Variation of 3D outer and inner crown morphology in modern human mandibular premolars.

OBJECTIVES: This study explores the outer and inner crown of lower third and fourth premolars (P3 , P4 ) by analyzing the morphological variation among diverse modern human groups. MATERIALS AND METHODS: We studied three-dimensional models of the outer enamel surface and the enamel-dentine junction (EDJ) from µCT datasets of 77 recent humans using both an assessment of seven nonmetric traits and a standard geometric morphometric (GM) analysis. For the latter, the dental crown was represented by four landmarks (dentine horns and fossae), 20 semilandmarks along the EDJ marginal ridge, and pseudolandmarks along the crown and cervical outlines. RESULTS: Certain discrete traits showed significantly different regional frequencies and sexual dimorphism. The GM analyses of both P3 s and P4 s showed extensive overlap in shape variation of the various populations (classification accuracy 15-69%). The first principal components explained about 40% of shape variance with a correlation between 0.59 and 0.87 of the features of P3 s and P4 s. Shape covariation between P3 s and P4 s expressed concordance of high and narrow or low and broad crowns. CONCLUSIONS: Due to marked intragroup and intergroup variation in GM analyses of lower premolars, discrete traits such as the number of lingual cusps and mesiolingual groove expression provide better geographic separation of modern human populations. The greater variability of the lingual region suggests a dominance of functional constraints over geographic provenience or sex. Additional information about functionally relevant aspects of the crown surface and odontogenetic data are needed to unravel the factors underlying dental morphology in modern humans.

Early dispersal of modern humans in Europe and implications for Neanderthal behaviour.

The appearance of anatomically modern humans in Europe and the nature of the transition from the Middle to Upper Palaeolithic are matters of intense debate. Most researchers accept that before the arrival of anatomically modern humans, Neanderthals had adopted several 'transitional' technocomplexes. Two of these, the Uluzzian of southern Europe and the Châtelperronian of western Europe, are key to current interpretations regarding the timing of arrival of anatomically modern humans in the region and their potential interaction with Neanderthal populations. They are also central to current debates regarding the cognitive abilities of Neanderthals and the reasons behind their extinction. However, the actual fossil evidence associated with these assemblages is scant and fragmentary, and recent work has questioned the attribution of the Châtelperronian to Neanderthals on the basis of taphonomic mixing and lithic analysis. Here we reanalyse the deciduous molars from the Grotta del Cavallo (southern Italy), associated with the Uluzzian and originally classified as Neanderthal. Using two independent morphometric methods based on microtomographic data, we show that the Cavallo specimens can be attributed to anatomically modern humans. The secure context of the teeth provides crucial evidence that the makers of the Uluzzian technocomplex were therefore not Neanderthals. In addition, new chronometric data for the Uluzzian layers of Grotta del Cavallo obtained from associated shell beads and included within a Bayesian age model show that the teeth must date to ~45,000-43,000 calendar years before present. The Cavallo human remains are therefore the oldest known European anatomically modern humans, confirming a rapid dispersal of modern humans across the continent before the Aurignacian and the disappearance of Neanderthals.

Variability of Australopithecus second maxillary molars from Sterkfontein Member 4.

The question of how many Australopithecus species lived at Sterkfontein Member 4 and Makapansgat continues to be controversial inasmuch as the fossils are poorly preserved, the stratigraphy is difficult to interpret, and the cranial, dental, and postcranial remains are mostly not associated. To proceed we applied the most intensive modern methods of 3D geometric morphometrics to dental form, specifically the shapes of the upper second molars (M(2)s) in a sample combining 13 Australopithecus, 11 Paranthropus, and 23 Homo. We analyzed outer and inner crown surfaces, as well as crown and cervical outlines both separately and together, using a total of 16 landmarks, 51 curve semilandmarks, and 48 pseudolandmarks over the four structures. Outer and inner enamel surfaces are highly correlated in this dataset, while crown outline is the least informative of the four structures. Homo was easily distinguished from both Australopithecus and Paranthropus by these methods, likewise Homo sapiens from Homo neanderthalensis. There were, however, no stable classes within the Australopithecus sample or between Australopithecus and Paranthropus. Instead, there was a gradient along which Australopithecus prometheus and Australopithecus africanus lie toward the extremes, with Paranthropus overlapping both. If there are indeed different species at this site, then either their M(2) morphologies are uninformative or else the present sample is too small to make an accurate assessment. Our findings suggest that the variability of the Australopithecus specimens will be difficult to interpret authoritatively, independent of the method used.

Enamel thickness variation of deciduous first and second upper molars in modern humans and Neanderthals.

Enamel thickness and dental tissue proportions have been recognized as effective taxonomic discriminators between Neanderthal and modern humans teeth. However, most of the research on this topic focused on permanent teeth, and little information is available for the deciduous dentition. Moreover, although worn teeth are more frequently found than unworn teeth, published data for worn teeth are scarce and methods for the assessment of their enamel thickness need to be developed. Here, we addressed this issue by studying the 2D average enamel thickness (AET) and 2D relative enamel thickness (RET) of Neanderthal and modern humans unworn to moderately worn upper first deciduous molars (dm(1)s) and upper second deciduous molars (dm(2)s). In particular, we used 3D µCT data to investigate the mesial section for dm(1)s and both mesial and buccal sections for dm(2)s. Our results confirmed previous findings of an Neanderthal derived condition of thin enamel, and thinner enamel in dm(1)s than dm(2)s in both Neanderthal and modern humans. We demonstrated that the Neanderthal 2D RET indices are significantly lower than those of modern humans at similar wear stages in both dm(1)s and dm(2)s (p < 0.05). The discriminant analysis showed that using 2D RET from dm(1) and dm(2) sections at different wear stages up to 93% of the individuals are correctly classified. Moreover, we showed that the dm(2) buccal sections, although non-conventionally used, might have an advantage on mesial sections since they distinguish as well as mesial sections but tend to be less worn. Therefore, the 2D analysis of enamel thickness is suggested as a means for taxonomic discrimination between modern humans and Neanderthal unworn to moderately worn upper deciduous molars.

Technical Note: Guidelines for the digital computation of 2D and 3D enamel thickness in hominoid teeth.

The study of enamel thickness has received considerable attention in regard to the taxonomic, phylogenetic and dietary assessment of human and non-human primates. Recent developments based on two-dimensional (2D) and three-dimensional (3D) digital techniques have facilitated accurate analyses, preserving the original object from invasive procedures. Various digital protocols have been proposed. These include several procedures based on manual handling of the virtual models and technical shortcomings, which prevent other scholars from confidently reproducing the entire digital protocol. There is a compelling need for standard, reproducible, and well-tailored protocols for the digital analysis of 2D and 3D dental enamel thickness. In this contribution we provide essential guidelines for the digital computation of 2D and 3D enamel thickness in hominoid molars, premolars, canines and incisors. We modify previous techniques suggested for 2D analysis and we develop a new approach for 3D analysis that can also be applied to premolars and anterior teeth. For each tooth class, the cervical line should be considered as the fundamental morphological feature both to isolate the crown from the root (for 3D analysis) and to define the direction of the cross-sections (for 2D analysis).

Shape variation in modern human upper premolars.

Morphological variation in modern human dentition is still an open field of study. The understanding of dental shape and metrics is relevant for the advancement of human biology and evolution and is thus of interest in the fields of dental anthropology, as well as human anatomy and medicine. Of concern is also the variation of the inner aspects of the crown which can be investigated using the tools and methods of virtual anthropology. In this study, we explored inter- and intra-population morphometric variation of modern humans' upper third and fourth premolars (P3s and P4s, respectively) considering both the inner and outer aspects of the crown, and discrete traits. We worked by means of geometric morphometrics on 3D image data from a geographically balanced sample of human populations from five continents, to analyse the shape of the dentinal crown, and the crown outline in 78 P3s and 76 P4s from 85 individuals. For the study of dental traits, we referred to the Arizona State University Dental Anthropology System integrated with more recent classification systems. The 3D shape variation of upper premolar crowns varied between short and mesio-distally broad, and tall and mesio-distally narrow. The observed shape variation was independent from the geographical origin of the populations, and resulted in extensive overlap. We noted a high pairwise correlation (r1 = 0.83) between upper P3s and P4s. We did not find any significant geographic differences in the analysed non-metric traits. Our outcomes thus suggest that geographical provenance does not play a determinant role in the shaping of the dental crown, whose genesis is under strict genetic control.

Premolar Extraction Affects Mandibular Kinematics.

OBJECTIVES: The practice of premolar extraction in orthodontics is controversial for its potential detrimental effects on the stomatognathic system. However, the ways in which premolar extraction affects mandibular function are still poorly understood. The purpose of this study was to assess the influence of premolar extraction on mandibular kinematics by evaluating axiographic tracings. MATERIALS AND METHODS: Forty-five orthodontically treated patients with premolar teeth extraction were compared with 45 paired untreated controls, selected for the absence of malocclusions. Systematic three-dimensional axiographic recordings of the mandibular movements were performed for protrusive-retrusive movements and speech. The transversal deviations and length of the movements were recorded for both sides along with the rotation angle during speech. STATISTICAL ANALYSIS: Differences between the axiographic variables were analyzed via the permutation test and Wilcoxon rank-sum test. Linear regression was performed to test whether axiographic parameters were predictive of group affiliation. Dot plots were used to explore the distribution of each of the axiographic outcomes, and isometric principal component analysis to assess the differences between the cumulative effects of premolar extraction on jaw motion. RESULTS: The mandibular lateral translation in protrusion-retrusion and speech, the amount of rotation as well as the length of mandibular movements during speech were significantly higher in the treated subjects than in the controls, while retral stability did not differ. The linear regression yielded significant results for the mandibular lateral translation in protrusion-retrusion. The isometric principal component analysis showed higher values of the axiographic variables for 11 out of 45 individuals in the study sample compared with the control group. CONCLUSIONS: Premolar extraction altered mandibular kinematics in at least 25% of the cases within our sample, and the transversal discrepancy between protrusive and retrusive tracings was even predictive of group affiliation. These results support the notion that the routine practice of premolar extraction as part of the orthodontic treatment should be discouraged. It is compelling to perform further studies to assess whether a disrupted kinematics of the mandible is associated to temporomandibular disorders.

Initial therapeutic approaches for orofacial myofascial pain: three pilot studies.

OBJECTIVE: Myofascial pain diminishes the stomatognathic function and hinders clinical diagnosis. Therefore, initial pain reduction is crucial before definitive treatment. Here, the clinical validity of non-pharmaceutical therapies, including the Aqualizer® splint, physiotherapy, and dry-needle acupuncture was comparatively assessed. METHODS: Myofascial pain patients (n = 28; 20-65 years old) were examined through a visual analog scale, and intra- and extra-oral muscle palpation. Mandibular maximum opening and neck mobility were also evaluated. Changes in parameters through time were analyzed via the Kruskal-Wallis test, while the Friedman test and dot-plots were used for comparative therapies assessment. General patient improvement was represented via an isometric Principal Component. RESULTS: The Aqualizer® and physiotherapy resulted in improvement of all parameters except for mouth opening. Acupuncture improved extra-oral muscle pain and neck mobility. CONCLUSION: The Aqualizer®, physiotherapy, and oral acupuncture are effective initial pain therapies. Among all, physiotherapy provided the greatest benefits, followed by the Aqualizer®.

Robert M. Ricketts and Rudolf Slavicek: dentistry by the rules of nature.

The stomatognathic structures act as a complex and integrated system, thereby accomplishing several essential functions of the body. Aside from participating in food digestion, they are key for respiration and swallowing and play a central role in social interaction and stress management. The lifeworks of Robert M. Ricketts (1920-2003), an American orthodontist, and Rudolf Slavicek (1928-2022), an Austrian prosthodontist, were centered on this understanding. Both were educated in the time of gnathology, functional dentistry, and cephalometry and were ready to challenge conventional knowledge and traditions, leading toward innovation. As untiring clinicians, researchers, and mentors, they were fully invested in the study of the stomatognathic system, considering its morphology, dynamics, growth patterns, evolution, and interactions with the body and mind. Based on their extensive knowledge of the masticatory system, they advanced dentistry both with theoretical notions and by implementing new diagnostic and therapeutic concepts, thus reinforcing the idea of dentistry as a medical discipline requiring interdisciplinary effort. Their heritage is represented by numerous publications, discoveries, and inventions that inspire the dental community to follow their exemplary approach to the individualized care of patients. Their knowledge and passion are further passed on through their students. As part of their legacy, they prepared the ground for new research aimed at fostering advancements in occlusion medicine, hence supporting education in oral health.

Cervical and crown outline analysis of worn Neanderthal and modern human lower second deciduous molars.

Despite the general increase in digital techniques for dental morphometric analyses, only a few methods are available to study worn teeth. Moreover, permanent dentitions are studied much more frequently than deciduous teeth. In this study, we address both issues by providing a taxonomic classification of Neanderthal and modern human (MH) lower second deciduous molars (dm(2) s) through the analysis of crown and cervical outlines. Crown and cervical outlines were obtained from a three-dimensional (3D) digital sample of uniformly oriented dm(2) s. Both outlines were centered on the centroid of their area and represented by 16 pseudolandmarks obtained by equiangularly spaced radial vectors out of the centroid. We removed size information from the oriented and centered outlines with a uniform scaling of the pseudolandmark configurations to unit Centroid Size. Group shape variation was evaluated separately for the dm(2) crown and cervical outlines through a shape-space principal component (PC) analysis. Finally, quadratic discriminant analysis of a subset of PCs was used to classify the specimens. Our results demonstrate that both outlines successfully separate the two groups. Neanderthals showed a buccodistal expansion and convex lingual outline shape, whilst MHs have buccodistal reduction and straight lingual outline shape. Therefore, we confirmed that the cervical outline represents an effective parameter for distinguishing between the two taxa when dealing with worn or damaged dm(2) s.

Comparison of dental measurement systems for taxonomic assignment of Neanderthal and modern human lower second deciduous molars.

Traditional morphometric approaches for taxonomic assignment of Neanderthal and modern human dental remains are mainly characterized by caliper measurements of tooth crowns. Several studies have recently described differences in dental tissue proportions and enamel thickness between Neanderthal and modern human teeth. At least for the lower second deciduous molar (dm(2)), a three-dimensional lateral relative enamel thickness index has been proposed for separating the two taxa. This index has the advantage over other measurements of being applicable to worn teeth because it ignores the occlusal aspect of the crown. Nevertheless, a comparative evaluation of traditional crown dimensions and lateral dental tissue proportion measurements for taxonomic assignment of Neanderthal and modern human dm(2)s has not yet been performed. In this study, we compare various parameters gathered from the lateral aspects of the crown. These parameters include crown diameters, height of the lateral wall of the crown (lateral crown height = LCH), lateral enamel thickness, and dentine volume of the lateral wall, including the volume of the coronal pulp chamber (lateral dentine plus pulp volume = LDPV), in a 3D digital sample of Neanderthal and modern human dm(2)s to evaluate their utility in separating the two taxa. The LDPV and the LCH allow us to discriminate between Neanderthals and modern humans with 88.5% and 92.3% accuracy, respectively. Though our results confirm that Neanderthal dm(2)s have lower relative enamel thickness (RET) index compared with modern humans (p = 0.005), only 70% of the specimens were correctly classified on the basis of the RET index. We also emphasize that results of the lateral enamel thickness method depend on the magnitude of the interproximal wear. Accordingly, we suggest using the LCH or the LDPV to discriminate between Neanderthal and modern human dm(2)s. These parameters are more independent of interproximal wear and loss of lateral enamel.

Morphological variation of the deciduous second molars in the Baka Pygmies.

The Baka Pygmies are known for their short stature resulting from a reduced growth rate during infancy. They are peculiar also for their teeth erupt earlier than in any other African population, and their posterior dentition is larger than in non-Pygmy populations. However, the Baka's dental morphology, like several other aspects of their biology, is still understudied. Here, we explore the variation of the Baka's deciduous upper and lower second molars (dm2s) in comparison to a geographically heterogeneous human sample by means of 3D geometric morphometrics and analysis of dental traits. Our results show that the different populations largely overlap based on the shape of their dm2s, especially the lower ones. Their distal region and the height of the dentinal crown differ the most, with the Baka showing the most extreme range of variation. Upper and lower dm2s covary to a great extent (RV = 0.82). The Baka's and South Americans' dm2s were confirmed among the largest in our sample. Despite the Baka's unique growth pattern, long-lasting isolation, and extreme dental variation, it is not possible to distinguish them from other populations based on their dm2s' morphology only.

Response to Comment on "A Middle Pleistocene Homo from Nesher Ramla, Israel".

Marom and Rak claim, on the basis of a few mandibular features, that the Nesher Ramla (NR) Homo is a Neanderthal. Their comments lack substance and contribute little to the debate surrounding the evolution of Middle Pleistocene Homo. Limitations and preconceptions in their study prevented them from achieving resolution beyond a dichotomous interpretation of the NR as either a Neanderthal or a modern human.

The earliest modern humans outside Africa.

To date, the earliest modern human fossils found outside of Africa are dated to around 90,000 to 120,000 years ago at the Levantine sites of Skhul and Qafzeh. A maxilla and associated dentition recently discovered at Misliya Cave, Israel, was dated to 177,000 to 194,000 years ago, suggesting that members of the Homo sapiens clade left Africa earlier than previously thought. This finding changes our view on modern human dispersal and is consistent with recent genetic studies, which have posited the possibility of an earlier dispersal of Homo sapiens around 220,000 years ago. The Misliya maxilla is associated with full-fledged Levallois technology in the Levant, suggesting that the emergence of this technology is linked to the appearance of Homo sapiens in the region, as has been documented in Africa.

Store-operated Ca2+ entry controls ameloblast cell function and enamel development.

Loss-of-function mutations in stromal interaction molecule 1 (STIM1) impair the activation of Ca2+ release-activated Ca2+ (CRAC) channels and store-operated Ca2+ entry (SOCE), resulting in a disease syndrome called CRAC channelopathy that is characterized by severe dental enamel defects. The cause of these enamel defects has remained unclear given a lack of animal models. We generated Stim1/2K14cre mice to delete STIM1 and its homolog STIM2 in enamel cells. These mice showed impaired SOCE in enamel cells. Enamel in Stim1/2K14cre mice was hypomineralized with decreased Ca content, mechanically weak, and thinner. The morphology of SOCE-deficient ameloblasts was altered, showing loss of the typical ruffled border, resulting in mislocalized mitochondria. Global gene expression analysis of SOCE-deficient ameloblasts revealed strong dysregulation of several pathways. ER stress genes associated with the unfolded protein response were increased in Stim1/2-deficient cells, whereas the expression of components of the glutathione system were decreased. Consistent with increased oxidative stress, we found increased ROS production, decreased mitochondrial function, and abnormal mitochondrial morphology in ameloblasts of Stim1/2K14cre mice. Collectively, these data show that loss of SOCE in enamel cells has substantial detrimental effects on gene expression, cell function, and the mineralization of dental enamel.

Dental stigmata and enamel thickness in a probable case of congenital syphilis from XVI century Croatia.

OBJECTIVE: To analyse the dental remains of an individual with signs of congenital syphilis by using macroscopic observation, CBCT and micro-CT images, and the analysis of the enamel thickness. DESIGN: Anthropological analysis of human skeletal remains from the 16th century archaeological site Park Gric in Zagreb, Croatia discovered a female, 17-20 years old at the time of death, with dental signs supportive of congenital syphilis: mulberry molars and canine defects, as well as non-specific hypoplastic changes on incisors. The focus of the analysis was on three aspects: gross morphology, hypoplastic defects of the molars, canines and incisors, as well as enamel thickness of the upper first and second molars. RESULTS: The observed morphology of the first molars corresponds to the typical aspect of mulberry molars, while that of the canines is characterised by hypomineralisation. Hypoplastic grooves were observed on the incisal edges of all incisors. The enamel of the first molars is underdeveloped while in the second molars a thick-enamelled condition is observed. CONCLUSIONS: Our observations for the dental and skeletal evidence are supportive to a diagnosis of congenital syphilis for this specimen from XVI century Croatia. The use of CT imaging helped documenting the diagnostic features and quantifying the effect of the dental stigmata on first molars.