Professional Documents
Culture Documents
1. At the most superior position, the condyle disk assemblies are also braced
medially.
If the condyle disk assembly is properly positioned in the fossa, it can resist
maximum loading without any tension or tenderness.
Comfort under pressure is an important diagnostic criterion for CR
If condyle disk is not properly aligned, elevator muscles will load sensitive
vascular innervated tissues.
Strong contact between articulating bodies is found on all movable joints
because muscles are always arranged to pull across joints.
Medial pole is the predominant stop of upward condylar movement
CR is a functional position that is used repeatedly
CR occurs irrespective of vertical dimension since the mandible hinges on
a fixed axis up to the point of translation. The act of increasing vertical
dimension with a night guard does not require the condyles to move off
centric relation. Even though vertical dimension is increased, the lateral
pterygoid does not have to hold the condyle forward down the eminence
and can release.
CR is not related to aligned midlines
Delicate bimanual manipulation is required to achieve CR.
CR must be verified by firm upward pressure toward the condyles.
If the condyle is not on the disk, we will not achieve CR
If CR manipulation is not comfortable, try to deprogram muscles.
If CR manipulation remains uncomfortable, image the TMJ.
There is no way to evaluate the occlusion until CR is verified.
2. Functioning part of the fossa is the posterior slope of the eminence, not the
depth of the fossa, the roof of the fossa is very thin.
The condyle disk position is determined by muscle action until movement into
maximum intercuspation, the teeth then influence condylar position.
Optimum condylar position is achieved during function.
Myocentric is one of the least reproducible ways to relate the lower jaw to the
cranium, its location is anterior to centric relation.
Anterior and medial displace discs cause the condyle to articulate on the
posterior attachment.
Closed lock- anterior mass of soft tissue prevents the condyle from normal
range of motion.
The patient then bit hard on the leaf gauge while a zinc oxide & eugenol
(ZOE) record as obtained.
A second record as taken in the same fashion after the patient bit half as
hard, as calibrated by electromyography.
A third record as taken with the operator supporting the gonial angles while
the patient closed into wax record that was thick intercanine and lined with
ZOE paste.
The records were analyzed for condylar position with a Denar Vericheck.
CR records with the patient biting hard on the leaf gauge compared to the wax
record caused the mandibular condyles to be forced posteriorly (0.53mm)
and inferiorly (1mm left side and 0.16mm right side), away from the
articulating surface of the eminence.
CR records with the patient biting easy on the leaf gauge compared to the
wax record- condyle was displaced 0.2mm posteriorly each side and
inferiorly 0.067mm left side and 0.1mm right side.
Biting hard on a leaf gauge will cause significantly greater condylar shift
posteriorly than biting easy.
The temporalis muscle is the primary positioner of the condyles until the
posterior teeth touch, at which time the masseter muscles substantially
increase their contraction.
1. Tarantola GJ, Becker IM, Gremillion H. The reproducibility of centric relation: a
clinical approach. JADA 1997;128:1245-51.
2. Lucia VO. A technique for recording centric relation. J Prosthet Dent 1964;
14:492-505.
3. Karl PJ, Foley TF. The use of a deprogramming appliance to obtain centric
relation records. Angle Orthodont 1999;69(2):117-123.
4. Becker I, et al. Effect of a prefabricated anterior bite stop on electromyographic
activity of masticatory muscles. J Prosthet Dent 1999;82:22-6.
5. McKee JR. Comparing condylar position repeatability for standardized versus
nonstandardized methods of achieving centric relation. J Prosthet Dent 1977;
77:280-4.
6. McKee JR. Comparing condylar positions achieved through bimanual
manipulation to condylar positions achieved through masticatory muscle
contraction against an anterior deprogrammer: A pilot study. J Prosthet Dent
2005;94:389-93.
7. Solow, RA. The anterior acrylic resin platform and centric relation verification:
a clinical report. J Prosthet Dent 1999;81:255-7.
8. Williamson EH, et al. Centric relation: a comparison of muscle-determined
position and operator guidance. Am J Orthod 1980;77:133-45.
Electronic Devices and Temporomandibular Disorders (TMD)
Specificity of test for TMD must be high to avoid high cost and unnecessary
or damaging treatment.
ElectromyographyManufacturers claim that EMG devices provide a more objective state of
the muscles than clinical assessment techniques like muscle palpation.
Masseteric silent period occurs after a jaw jerk reflex, and is used to
describe the period of muscle silence caused by electrical stimulation of
sensory inputs. Duration was used as an indicator of muscle dysfunction.
Denture wearers and orthodontic patients also had longer silent periods.
Low specificity- long silent periods in non-TMD patients.
Determining rest positionIt was thought that EMG activity was absent in rest
There is always at least minimal EMG activity in elevator muscles at rest.
Vertical dimension at rest is less than that where EMG activity is minimal
Various muscles are minimally active at different freeway spaces, so it is
not possible to determine a vertical dimension where all muscles are
minimally active.
Large variation in masseter EMG levels between subjects at clinical rest.
Electrical stimulation devices Neuromuscular rest position is not a natural postural position.
Manufacturers suggest dentist pulse the masseter muscles to propel the
mandible from rest position on an isotonic trajectory through the
interocclusal space to a neuromuscularly oriented occlusal position in
space. It is implied that this stimulation will elicit a jaw response that
causes all elevator muscles to contract simultaneously , and result in a
reproducible physiologic jaw position.
Studies show jaw closing reflex is not elicited by stimulation over the
masseter, pulse acts locally in the masseter accounting for the anterior
trajectory of the jaw (myocentric position is anterior to centric occlusion).
Jaw movement analysisRegularity of movement, speed of movement, vertical freeway space,
anterior/ vertical ratio, closure trajectory, chewing movements, and
pantographic reproducibility index studies all showed very low specificitycould not distinguish the TMD patients from normals and were not
diagnostic for TM disorders.
SonographyTMJ pathology doesnt always produce joint sounds.
Sound was not able to distinguish anterior displaced discs with or without
reduction.
Peak spectral frequencies for normal, displaced discs, and degenerative
joint disease have been reported, with a large variability between groups
Anterior displaced disc with or without reduction- 20-1000Hz
Degenerative joint disease225-1000Hz
Normal joint48-200Hz
Diagnosis by spectral analysis cannot distinguish symptomatic from
asymptomatic joints.
4 healthy women were evaluated for the rest position of the mandible
induced by phonetics, transcutaneous electrical stimulation (TES), and
masticatory EMG.
A period of 30 minutes as necessary to produce kinesiographically
reproducible rest positions of the mandible.
Interocclusal dimension at the clinical rest position derived from relaxing
after saying Mississippi (2.5mm) was significantly less than TES (5.2mm)
or EMG activity (5.3mm).
9. Literature review covering rest position, ideal occlusal scheme, diagnosis and
treatment of TMD, and biofeedback.
Conclusion- there is no convincing evidence to support the use of
electromyography in the diagnosis or treatment of dental
patients except in the treatment of parafunction
Studies that have used electromyography to establish rest and occlusal
positions, detection of muscle hyperactivity and hypoactivity, spasm,
fatigue, and muscle imbalance have often failed to include a control group.
When a control group was included, the author usually failed to match the
patients by such variables as age, sex, facial morphology, and history of
bruxism- these variables have a significant influence on the level of EMG
activity.
Rest positionWell accepted that jaw elevator muscles are active in the rest position.
Vertical dimension at rest is less than that at which EMG activity in the
muscles is minimal.
No evidence that clinical rest position can be determined on the basis of
a standard level of postural EMG activity, because of differences between
muscles and between subjects.
Major jaw elevator muscles contain several compartments that differ in
proportion of slow, intermediate, and fast muscle fibers.
This implies that the compartments have different functional roles.
EMG activity generated in standard isometric contraction decreases in
amplitude with age.
Females surface EMG is higher than males lifting the same weight.
Maximal bite force are 2-3 orders of magnitude less in long faced vs. short
faced individuals
Hypothesis that postural EMG activity is higher in TMD patients compared to
normal population is not proven.
Evidence supports the use of biofeedback for the control of bruxism, but
nocturnal bruxism returns when biofeedback is discontinued.
10. Myo-Monitor centric is reached during involuntary, intermittent closure
produced by the instrument.
10 healthy subjects were evaluated for Myo-Monitor centric and CR obtained
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15. 10 subjects free of TMD signs or symptoms were evaluated for the
relationship of jaw muscle activity, rest vertical dimension, and clinical rest
position.
EMG biodfeedback training was used to help the subjects learn to relax.
Subjects were asked to relax at vertical dimensions from 1-16mm in 1mm
steps.
As vertical opening from maximum intercuspation increased, EMG activity
decreased.
Minimal muscle activity ranged from 4.5-12.6mm with an average at 8.6mm
Minimal muscle activity did not correlate with clinical rest position- the
average difference was 6mm.
Clinical rest position of 1-3mm measured phonetically is not one of rest;
certain jaw muscles must be in slight contraction to maintain the jaw in this
position.
1. Okeson JP. The clinical usefulness of surface electromyography in the
diagnosis and treatment of temporomandibular disorders. JADA 2006;
137:763-71.
2. Greene CS. Can technology enhance TM disorder diagnosis? J Calif Dent
Assoc 1990;18:21-4.
3. Widmer CG, Lund JP, Feine JS. Evaluation of diagnostic tests for TMD. J
Calif Dent Assoc 1990;18:53-60.
4. Hudzinski LG, Walters PJ. Use of a portable electromyogram integrator and
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flaw in the literature that shows no relationship between occlusion and TMD.
There are no studies that downplay the role of occlusion in TMD when
condylar position has been defined and verified in relation to maximal
intercuspal position.
Occlusal treatment that does not consider the precise position and condition
of the TMJs is at best guesswork.
Failure to correctly relate the occlusion to a precisely determined condylar
functional positions may make the problem worse.
Common flaws in the literature:
1. Failure to define the type of TMJ disorder being studied.
2. Failure to distinguish between disorders that are intracapsular versus
those that are primarily myalgic.
3. Failure to specify the exact position and condition of the condyle-disk
assemblies when studying the relationship of occlusion to the TMJs.
4. Failure to specify the method used to achieve the selected position of the
TMJs.
5. Failure to verify that the intended joint position was actually achieved
and recorded accurately.
6. Use of Angles classification to describe whether an occlusion is correct
versus malocclusion.
7. Failure to establish definitive criteria for treatment success.
8. Failure to consider signs of progressive damage to collateral structures
when claiming success by treating symptoms only.
9. Failure to define specifically what is meant by terms such as occlusal
correction, or real equilibration.
Concept that patients get better whether they are treated or not is a
generalization that is not consistent with many years of clinical observation
Disappearance of symptoms is not in itself an indication that the patient got
better- i.e. pain from compression of retrodiskal tissue diminishes when
the tissue is perforated, but progressive deformation of the condyle is
almost certain to follow.
6. 99 15 year olds were studied for 3 years to compare the effects of occlusal
adjustment vs mock occlusal adjustment on TMJ dysfunction- # sites
with painful masticatory muscles, pain on opening, TMJ sounds, and a
questionnaire on subjective TMJ dysfunction symptoms.
Interferences were determined clinically
There were only 2 interference free subjects to start.
At 3 years there was a statistically significant association between
interferences and signs of TMJ dysfunction.
It is practically impossible to evaluate the relative significance of the size,
shape, type, location, and number of interferences on the individual level.
Cross sectional studies are theoretically incorrect for a cause-effect analysis,
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because the cause must precede the effect and need not necessarily be
present at the same time as the effect
High frequency of interferences is mistaken for evidence of their normalitythis is not true for caries or periodontal disease.
Absence of interference free subjects in nonselected samples can be the
explanation for the lack of association between occlusal interferences and
craniomandibular symptoms in most studies.
1. Spear FM. Occlusion in the new millennium: the controversy continues.
Signature 2002;7(2)18-21.
2. Schuyler CH. The function and importance of incisal guidance in oral
rehabilitation. J Prosthet Dent 2001; 86:219-32.
3. Schuyler CH. Factors contributing to traumatic occlusion. J Prosthet Dent
1961;11:708-15.
4. Dawson PE. Temporomandibular joint pain-dysfunction problems can be
solved. J Prosthet Dent 1973; 29:100-12.
5. Dawson PE. Position paper regarding diagnosis, management, and treatment
of temporomandibular disorders. J Prosthet Dent 1999;81:174-8.
6. Kirveskarari P, Alanen P, Jamsa T. Association between craniomandibular
disorders and oclusal interferences. J Prosthet Dent 1989;62:66-9.
Occlusion and Teeth
1. To avoid trauma to the periodontium, forces should be directed parallel to the
long axes of the teeth when the opposing teeth come into functional contact.
Any force applied at an angle to the long axis of a tooth may cause trauma to
the periodontium and resorption of the alveolar bone.
If premolars and molars remain in contact in eccentric occlusions with the
protection of the upper cuspids opening the vertical relation, each tooth is
subject to the full magnitude of applied force. Such function contacts at an
angle to the long axes of the opposing teeth can develop kinetic horizontal
vectors of high magnitude.
Functional occlusion of the first permanent molars maintains the vertical and
centric relation of the mandible during the eruption period of the successive
teeth.
Prevention of trauma in the TMJs is equally as important as prevention of
trauma to the periodontium
If the upper cuspids are in the ideal functional relation, attrition of the occlusal
surfaces of premolars and molars is almost completely eliminated.
2. The physiological movement of teeth during simulated mastication (empty
tooth contacting sliding or gliding movements were investigated.
Displacement transducers were placed in paraocclusal splints (no acrylic on
occlusal surfaces).
Elastic deformation of the mandible, even in the absence of occlusion, gives
rise to tooth movement.
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compromised teeth.
Comparison between 20% and 35% periodontal support reduction models
showed higher stress generated at the CEJ for the 35% model.
Restoration reduced stress from buccal cusp loading at the deepest part of
lesion for both models.
3. The occurrence of subgingival cervical lesions lends credence to the
stress induction theory by exclusion of other superimposing factors (acid
attack or abrasive processes).
Pathology of cervical lesion is multifactorial.
The tooth location of the stress tensor dictated the shape of the lesionEccentrically loaded stressed cause asymmetric lesions
Centrally loaded teeth exhibit symmetrical lesions
Initial lesion is a wavelike corrugated pattern corresponding to stress cracks
4. Stress induced cervical lesions are loss of tooth structure that results from
repeated tooth flexure caused by occlusal stresses, also termed abfractions.
Sharp, wedge-like morphology and subgingival location cannot be explained
by toothbrush abrasion or acid erosion.
Lateral occlusal forces from mastication and bruxism cause teeth to bend.
Tensile stress disrupts the chemical bonds of the crystalline structure of
enamel and dentin.
Small molecules can enter the microcracks and prevent reformation of
the chemical bonds.
Acid and abrasion play a secondary role in the development of the lesion.
Enamel has far greater compressive than tensile strength.
Tensile stress from lateral force concentrates at the cervical region.
If occlusion is not corrected, restorations will debond from tensile stress.
Absence of occlusion on the tooth, rounded lesion, and history of forceful
brushing may indicate an abrasion problem.
5. Function as well as parafunction should be given greater clinical significance,
and recognized as a cofactor in the pathogenesis of NCL
Occlusal adjustment and nightguards are recommended to control mechanical
stress factors that contribute to the progress of cervical lesions.
Restoration with bonded composite or glass ionomer is indicated to minimize
stress concentration and the effect of stress corrosion in abfracted areas.
6. When possible, restoration of NCL should be avoided.
Reshaping and smoothing cervical defects with subsequent periodontal root
coverage will avoid bonding to pathological dentin.
Restoration of abfraction lesions only partially relieves the stresses in the
cervical region.
If an eccentric contact is found, occlusal adjustment is recommended to
minimize lateral stresses and possible tooth flexure.
Miller Class I and II recession are predictably (92-99%) covered by grafting
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Lower loading of the lingual cusp of the mandibular molar during mastication
as compared to grinding, caused lower tensile stress.
Decrease of tooth overloads by adjusting the occlusion, eliminating
parafunction, or occlusal splints may limit formation of these lesions.
9. 167 teeth with NCL and 167 teeth 167 teeth with no such lesions were
evaluated for the correlation with premature contacts in CR and
eccentric movements.
Compression forces on the working and nonworking sides cause tooth
flexion at 10-20 times axial forces.
First premolar teeth showed the greatest number of NCL, followed by canines
The second molar teeth had the least number of NCL.
There was a highly significant positive correlation between the incidence of
NCL and premature contacts in CR and the working side, but not in
balancing or protrusion.
1. Pintado MR, et al. Correlation of noncarious cervical lesion size and
occlusal wear in a single adult over a 14-year time span. J Prosthet Dent
2000;84:436-43.
2. Kuroe T, et al. Biomechanical effects of cervical lesions and restoration on
periodontally compromised teeth. Quintessence Int 2001;32:111-8.
3. Braem M, Lambrechts P, Vanherle G. Stress induced cervical lesions. J
Prosthet Dent 1982;67:718-22.
4. Lee WC, Eakle WS. Stress induced cervical lesions: review of advances
in the past 10 years. J Prosthet Dent 1996;75:487-94.
5. Spranger H. Investigation into the genesis of angular lesions at the cervical
region of teeth. Quintessence Int 1995;26(2):149-54.
6. Winter RR, Allen EP. Restorative and periodontal considerations for the
treatment of noncarious cervical lesions. Advanced Esthet and Interdisc Dent
2005,1:24-8.
7. Pegoraro L, et al. Noncarious cervical lesions in adults. Prevalence and
occlusal aspects. JADA 2005;136:1694-1700.
8. Dejak B, Mlotkowski A, Romanowicz M. Finite element analysis of mechanism
of cervical lesion formation in simulated molars during mastication and
parafunction. J Prosthet Dent 2005;94:520-9.
9. Madani AS, Ahmadian-Yazdi A. An investigation into the relationship between
noncarious cervical lesions and premature contacts. J Craniomand Prac
2005;23:10-15.
Occlusion and Masticatory Muscle Function
1. Vector analysis of a 2 dimensional model of the TMJ was developed.
Dynamics of the condyle-disk assembly during muscle loading was analyzed.
The stable equilibrium was found in the superior-anterior position in the fossa.
All other positions of the condyle were less stable and maintained at the
expense of other structures.
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EMG readings were taken at constant bite force at different jaw openings.
Bite force was recorded at constant EMG level at different jaw openings.
Bite force was inversely related to EMG activity.
At constant bite force, EMG activity decreases from 7mm jaw opening to a
minimum at about 15mm jaw opening.
11. 12 subjects with pronounced occlusal wear, group function, and some
balancing interferences were evaluated electromyographically for change in
the occlusion with gold casting augmentation of the canine or acrylic resin
augmentation of the second molar.
The intermaxillary position of the mandible and the dimension, location, and
type of occlusal contacts influenced the activity of the superficial jaw
muscles.
When group function was changed to canine guidance, an overall reduction
of the elevator muscle EMG activity was observed when subjects exerted
full isometric tooth clenching in a lateral mandibular position .
No alteration of the coordination pattern during unilateral chewing was
detected with artificial canine guidance.
Introduction of a hyperbalancing occlusal contact caused significant
alteration in muscle activity and coordination during clenching in a lateral
mandibular position.
Canine protected occlusion doesnt alter muscle activity during mastication,
but reduces muscle activity during parafunction.
Nonworking side contacts dramatically alter muscle activity during
parafunction clenching and this may affect reaction forces at the TMJ.
12. During brisk and forceful clenching an acrylic resin interference, bipolar
surface electromyograms were obtained on right and left masseter
muscles.
On the side of the side opposite the interference, myoelectric clenching
activity was significantly reduced.
Frequently there was significant molar facilitation on the side of the
interference, and significant inhibition on the side opposite the interference
The prescence of a unilateral intercuspal interference, and not its vertical
magnitude was sufficient to distort optimal neuromuscular generation of
well adjusted bilateral clenching forces.
13. When groups of muscle fibers are angled and fan out on either side of a
central tendon, they look like a feather- pinnate arrangement.
Pennation allows muscle to produce power under spatial constraint.
Masseters and medial pterygoid create large forces with relatively small
3 dimensional movement.
Masseter consist of internal aponeuroses that muscle fibers attach at an
angle to, creating diversely angled muscle tension vectors.
Masseter insertion travels anteriorly with incisal function.
Masseter is capable of differential activity in its superficial and deep portions.
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Mobile teeth do not heal from surgical procedures well- role for equilibration.
Trauma from occlusion leads to destruction of periodontal ligament fibers,
which increases the mobility of the tooth.
Occlusion is only 1 factor that can cause mobility in teeth.
Prior to occlusal treatment, the inflammatory component must be controlled.
Equilibration recommendedPrior to splinting for mobility reduction
Reduce mobility and discomfort
To achieve functional relationships in conjunction with restorative treatment,
orthodontics, and orthognathic surgery.
Adjunctive therapy to reduce damage from parafunction
Adjust marginal ridge discrepancies and cusps contributing to food impaction.
3. Animal studies- trauma from occlusion doesnt initate or aggravate gingivitis,
but may favor the progress of attachment and bone loss in periodontitis.
Adjustment of occlusion can reduce tooth mobility significantly.
Tooth mobility will increase with loss of support for the teeth.
50 patients in the study randomly assigned to equilibration or no equilibration
and within each patient modified Widman flap surgery or rootplaning to
each side of the patients mouth.
Occlusal adjustment was done by Ramfjord according to his textbookOcclusion by Ramfjord & Ash 1981.
No difference in mobility between the equilibrated and nonequilibrated groups
Occlusal adjustment in conjunction with conventional periodontal therapy
resulted in a more favorable clinical attachment level after 2 years than in
the nonadjusted patients.
4. Cross sectional study of 4,310 subjects showed a statistically significant
relationship between nonworking contacts and probing depth and
attachment loss.
The magnitude of the increase in probing depth (0.13mm) and attachment
loss (0.14mm) was small.
5. Trauma from occlusion- injury to the supporting structures of the teeth by
the act of bringing the jaws together in a closed position, resulting in
microscopic periodontal membrane injury causing reversible pathologic
mobility.
In addition to its principal fibers, an indifferent fiber plexus forms an
integral part of the periodontal ligament. Thin fibers run in every direction
forming a fine meshed sponge-like structure.
Trauma from occlusion is not a primary etiologic factor in the initiation of
gingival inflammation or loss of connective tissue attachment.
Contrary to normal healthy teeth, periodontitis teeth show no adaptation to
changes in functional demand, instead they remain in a traumatic phase of
progressively increasing mobility.
Trauma from occlusion accelerates attachment loss in progressive
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periodontitis.
The supercrestal connective tissue around hypermobile but otherwise
periodontally normal teeth has significantly less collagen and more vascular
structures than does connective tissue around nonmobile teeth.
Reduced collagen content may result in increased probe depth.
Scaling, rootplaning, and oral hygiene can significantly reduce mobility in
teeth with moderate to severe periodontitis. Further reduction in mobility can
occur after surgical treatment and maintenance therapy.
Excessive force may or may not cause hypermobility.
Characteristics of occlusal forces other than magnitude, such as velocity,
duration, and frequency may be of greater significance for the development
of tooth hypermobility.
Criteria for trauma from occlusion- widened PDL and progressive increasing
mobility.
Recommends equilibration of furcation involved hypermobile teeth to
enhance periodontal treatment.
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unilateral problem
pain is over the joint area
radiographic changes are frequent: flattened joint surfaces
loss of cortical delineation
osteophyte formation
initial stage- clicking, periodic locking
intermediate stage- pain at rest and during function
late stage- normalization of symptoms with radiographic deformation and
disc perforation
mechanical overload is an etiologic factor, frequent clinical association of
compromised dentitions and signs and symptoms of OA
possible relation of disc displacement to OA
treatment- stabilization splint or removable provisional prosthesis to restore
lost posterior dentition
5. Osteoarthritis occurs in joints with and without a meniscus.
Fibrocartilage is completely dependent on synovial fluid for nutrition,
metabolic exchange, phagocytosis, and lubrication.
Impaired lubrication associated with degenerative and inflammatory tissue
changes may alter the frictional character of articular surfaces, which may
impair joint movement capacity and induce gradual stretching of disc
attachments, causing disc displacement.
Conversely, traumatic stretching/rupture of these attachments may allow disc
displacement and direct overload and damge to synovium, fibrocartilage,
and subchondral bone.
Chronic disc displacementanterior band atrophies and folds over the intermediate zone
posterior band becomes flattened and elongated
Degenerationreplacement of original tissue with a tissue structure of inferior quality
Lack of movement may permit adhesions within the capsule and joint to
mature.
6. OsteoarthritisRelates disc displacement and internal derangement to osteoarthritis
Initial stage- clicking with no condylar morphology alteration
Second stage- pain and limited movement
disappearance of cortical plate on anterior-superior surface
causing a flattened condyle
Late stage- no noise, crepitus, or limited opening
least symptoms and greatest radiographic change
condyle considerably decreased in size, ascending ramus
shorter
Without exception small, deformed, and arthrotic condyles were associated
with anterior displaced discs with/without reduction in this arthrographic
study.
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Central third- 5
Medial third- 0
Upper border of the attachment of the capsule in the present material as
most often situated opposite or even above the lateral poles of the condyle
also in adults is remarkable, since in textbooks it is inferior to the poles.
OA change were rare in individual below 40 years old, but common in
individual older than 40 years.
Frequency of OA change higher in females.
Frequency of OA change higher in individual with extensive loss of teeth
OA of the TMJ usually first involves the disc, which is perforated, and then
the temporal bone.
The articular surface of the condyle is damaged last and usually none at all.
13. Perforation of the disc causes progressive remodeling on the condyle and
regressive remodeling on the tubercle at the perforation site.
Articular remodeling merges gradually into osteoarthritis as the articular
tissue breaks down.
Net effect of remodeling that has become uncompensated or pathologic is:
condyle flattened and enlarged, tubercle resorbed, disc perforated, and
articular surface uneven.
If the dentition is not restored or replaced, a high rate of TMJ remodeling
occurs which will probably continue into osteoarthritis.
Progressive remodeling- excess proliferation and deposition of new cartilage
with subsequent conversion into subchondral bone, at a rate sufficient to
add length to the end of the bone.
Regressive remodeling- shortening of the length of the bone by osteoclast
resorbtion of the subchondral plate, the resulting cavities are filled in with
connective tissue which becomes chondrified.
Peripheral remodeling- results in an increased diameter of the chondroosseous junction.
Bundles of collagen fibers travel parallel to the joint surface and interlace with
each other in this plane of articular cartilage.
Cartilage cells generally are limited to the articular tissue on the anterosuperior aspect of the condyle, the area which is in contact with the
articular tubercle during hinge and sliding movements of the joint.
Non articulating part of the jointjunction of the tubercles posterior slope and roof of the mandibular fossa
abrupt thinning of articular tissue into a meager layer of fibrous connective
tissue containing no cartilage cells.
Tissue lining the mandibular fossa is covered with vascular and innervated
synovial tissue.
Collagen fibers in the disc are parallel to the surface of the disc and are
oriented in an antero-posterior direction with little interlacing.
No indication that the thin bone separating the middle cranial fossa and the
mandibular fossa is under mechanical stress.
Degree of remodeling is independent of subject age, and dependent on
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18. Mongini F. Remodelling of the mandibular condyle in the adult and its
relationship to the condition of the dental arches. Acta Anat 1972;822:437-53
19. Mongini F. Condylar remodeling after occlusal therapy. J Prosthet Dent
1980;43:568-77.
Occlusal Equilibration
1. The first requisite is accurate diagnostic casts, accurately mounted on an
articulator, that will reproduce the patients eccentric mandibular movements.
Favorable occlusionEven static contact of the maximum number of teeth in centric relation.
Maximum functional efficiency and distribution of stresses on working tooth
inclines in lateral eccentric positions
No contact on balancing or protrusive inclines
Balancing side contacts- functional stress is upon tooth inclines that are
forcing a separation of the vertical maxillo-mandibular relationship while the
muscles of mastication are contracting to close the vertical relation.
Occlusal disharmony may be a contributing factor to abnormal position of the
condyle in the glenoid fossa and abnormal functional condylar movements.
2. Slide from centric relation to intercuspal position, as seen in a guided closure
pattern, is caused by an interference of the teeth when the mandible is in
the terminal hinge movement.
Horizontal and vertical overlap of anterior teeth in centric relation are marked
with an indelible pen and measured.
Teeth are closed into centric occlusion and the horizontal and vertical overlap
is measured.
The ratio of vertical to horizontal (V/H) movement from CR to centric occlusion
(CO) is calculated.
The author suggests a higher V/H ratio indicates a greater vertical component
in the CR-CO movement and an easier equilibration; a lower V/H ratio
indicates a greater horizontal translation from CR-CO and a more difficult
equilibration.
3. Method of transposing a pre-planned occlusal adjustment, as performed on
articulated casts, to the correct areas in the mouth.
A clear thermoplastic vacuum formed template is prepared on the original cast
and then placed over the adjusted cast.
Areas on the template corresponding to the adjusted areas on the cast are
removed.
The template is placed in the mouth and areas of tooth structure protruding
through the template are removed. After this gross adjustment the
occlusion is refined by intraoral marking and adjustment.
4. Diagnostic casts mounted in CR have dowel pins placed in the bicuspid and
molar areas bilaterally.
Removal of the posterior segments of the model allows evaluation of the
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16. 2 distinct theories are used to explain the rationale behind occlusal
adjustment therapy- traumatic tooth contact theory and avoidance of tooth
contact theory.
Traumatic tooth contact theoryAdjustment of the occlusion to remove forceful contacts from individual
teeth
Adjustment to distribute the tooth contact forces in a stable, interferencefree occlusal scheme
Avoidance of tooth contact theoryBased on the concept that occlusal contact relationships can be perceived
as noxious by the trigeminal neurosensory system.
Mandibular incoordination is the inability to make specific, directed
mandibular movements in a smooth fashion.
Nocturnal bruxism is probably not related to occlusal interferences.
Experimentally induced disruption in the occlusal scheme causes symptoms
at the tooth level (mobility or tooth pain), at the joint level (soreness,
clicking), and at the muscle level (tenderness, changes in chewing cycle,
and postural activity).
Occlusal interferences , usually iatrogenic, that disrupt the existing contact
pattern of maximum intercuspation have an immediate effect on postural
muscle activity. This produces an abnormal asymmetric activity pattern.
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dental changes.
Treatment of primary posterior crossbite is recommended with equilibration,
followed by fixed orthodontics if not effective.
Candidates for equilibration should have unilateral posterior crossbite with
deviation of the midline to the affected side and interferences on the
primary teeth. No significant maxillary narrowing should have occurred
(width of maxillary arch should be similar to width of mandibular arch).
If there is no deviation of the midline, or less maxillary than mandibular
width, crossbite requires orthodontic or orthopedic mechanotherapy.
Primary canine teeth are frequently contribute to a laterally guided centric
occlusion that creates a functional malocclusion.
20.
21. Parafunction is the use of teeth for any function other than chewing,
22. swallowing, and speaking.
Parafunctional activity related to emotional stress and occlusal interferences.
The articular disk divides the TMJ into 2 compartmentsThe upper is a freely movable sliding joint (arthrodial)
The lower functions as a pure hinge joint (ginglymoid)
Nonvascularized articular surfaces of the TMJ are composed of dense
fibrous tissue, rather than hyaline cartilage found in other synovial joints.
Fibrous tissue is less susceptible to aging and more capable of repair than
hyaline cartilage.
Resolution of TMD symptoms recommendations (for 2 weeks):
Avoid sleeping on the jaw, back sleeping is encouraged to allow a rest
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Splint therapy was performed for initial TMD symptoms (pain, clicking,
limited opening, and headaches).
After equilibration most patients reported a marked reduction in perceived
malocclusion, bruxism, tooth sensitivity, and limited lateral excursions.
24. 10 subjects were evaluated for changes in the site and number of
interocclusal contacts 6 weeks after equilibration.
6 of 10 subjects had no slide from centric relation on closure after 6 weeks.
4 of 10 subjects had a relapse and slide after occlusal adjustment, had a
missing tooth. This extraction space hindered stability after equilibration.
Occlusal contact against an incline plane are unstable.
Most stable contacts are cusp against a flat plane.
25. 34 patients with severe bruxism were studied electromyographically before
and after occlusal adjustment.
EMG activity was profoundly reduced for all subjects after occlusal
adjustment (recordings 1 half hour to 1 month later).
Signs of bruxism:
Occlusal wear facets
Occlusal wear with cupping of exposed dentin
Increased muscle tonus and uncontrolled resistance to manipulation of
the mandible
Hypertrophy of the masticatory muscles, especially masseters
Increased mobility of teeth
Dull percussion sound of teeth
Tired feeling muscles in the jaw on waking
Locking of the jaw and tendency to bite cheeks, tongue, and lips
Masticatory muscles tender to palpation
TMJ discomfort or pain
Soreness of the teeth to biting stress
Pulpal sensitivity to cold
Audible sounds from bruxism
Electromyographic rest position did not correlate with clinical rest position,
it was at an increased opening.
Occlusal interferences on the balancing side were accompanied with the
most severe disturbance of muscle function.
It is entirely erroneous to assume that an EMG recording of even and well
synchronized contraction pattern of the masseter and temporalis muscles
in centric occlusion is a reliable indication of an ideal centric relation
between the jaws and teeth.
Discrepancies between CR and centric occlusion were accompanied
invariably by asynchronous contractions or sustained strain in the temporal
and masseter muscles during swallowing.
After equilibration all patients consistently brought their teeth together when
they swallowed and a definite relaxation could be recorded between each
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swallow.
26. 62 dental students were divided randomly into 2 groups, one receiving
occlusal adjustment and the other mock adjustment (polishing fillings)
that left the occlusion unchanged.
2 years later the subjects were reexamined.
The increase in subjective symptoms of TMD was significantly greater in
the placebo control group than the treatment group.
Reappearence of occlusal interferences as expected in the long
observation period and changes in occlusion caused by erupting 3 rd
molars and dental restorations.
Elimination of occlusal interferences in young adults judged not to be in
need of treatment for TMD entails no harmful effects.
27. 20 patients with signs and symptoms of occlusal disharmony were
equilibrated and evaluated over a 2 year period.
History, clinical examination, Panorex and transcranial xrays, mounted
diagnostic casts (CR with intraoral clutches and gothic arch tracing, hinge
axis facebow), and trial equilibration preceded clinical equilibration.
7 patients failed to attend recall
4 patients had relief of all their symptoms
8 patients reported marked improvement in their symptoms
1 patient reported no improvement but teeth come together better
Uneven occlusal plane gave rise to occlusal interferences from 2 nd and 3rd
molars in intact arches.
Tilted 2nd and 3rd molars after loss of 1st molars led to marked occlusal
disharmony in centric closure.
1. Schuyler CH. Equilibration of natural dentition. J Prosthet Dent 1973;30:506-9.
2. Rosner D. A chairside analysis of the feasibility of selective grinding. J
Prosthet Dent 1981;45:30-6.
3. Au AR, Klineberg IJ. A new approach for accurate pre-planned occlusal
adjustment. Australian Dent Journal 1994;39(1):11-14.
4. Williamson EH, Simmons MD. Assessment of anterior tooth coupling and
equilibration using a diagnostic mounting. Quintessence Int 1978(10);61-66.
5. Tarantola GJ, Becker IM, Gremillion H, Pink F. The effectiveness of
equilibration in the improvement of signs and symptoms in the stomatognathic
system. In J Periodont Rest Dent 1998;18:595-603.
6. Kerstein RB, Farrell S. Treatment of myofascial pain-dysfunction syndrome
with occlusal equilibration. J Prosthet Dent 1990;63:695-700.
7. Kerstein RB. A comparison of traditional occlusal equilibration and immediate
complete anterior guidance development. J Craniomandib Prac 1993;11:126139.
8. Shillingburg HT, Grace CS. Thickness of enamel and dentin. J South Calif
Dent Assoc 1973;41:33-52.
9. Scotti R, Villa L, Carossa S. Clinical applicability of the radiographic method for
determining the thickness of calcified crown tissues. J Prosthet Dent
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1991;65:65-7.
10. Wiskott HWA, Belser UC. A rationale for simplified occlusal design in
restorative dentisty: historical review and clinical guidelines. J Prosthet Dent
1995;73:69-83.
11. Magne P, Belser UC. Rationalization of shape and related stress distribution
in posterior teeth: a finite element study using nonlinear contact analysis. Int
J Periodont Rest Dent 2002;22:425-33.
12. Okeson JP, Dickson JL, Kemper JT. The influence of assisted mandibular
movement on the incidence of nonworking contact. J Prosthet Dent
1982;48:174-7.
13. Christensen GJ. The major part of dentistry you may be neglecting. JADA
2005;136:4979.
14. Kerstein RB, Wright NR. Electromyographic and computer analyses of
patients suffering from chronic myofascial pain-dysfunction syndrome:
before and after treatment with immediate complete anterior guidance
development. J Prosthet Dent 1991;66:677-86.
15. Riise C. Rational performance of occlusal adjustment. J Prosthet Dent
1982;48:319-27.
16. Clark GT, Adler RC. A critical evaluation of occlusal therapy: occlusal
adjustment procedures. JADA 1985;110:74317. Agar JR, Weller RN. Occlusal adjustment for initial treatment and prevention
of the cracked tooth syndrome. J Prosthet Dent 1988;60:145-7.
18. Belanger GK. The rationale and indications for equilibration in the primary
dentition. Quintessence Int 1992;23:169-74.
20. Hammad IA, Nassif JA, Salameh ZA. Full-mouth rehabilitation following
treatment of temporomandibular disorders and teeth-related signs and
symptoms. J Craniomand Prac 2005;23:289-96.
21. McHorris WH. Occlusal adjustment via selective cutting of natural teeth.
Part I. Int J Periodont Rest Dent 1985;5:8-25.
22. McHorris WH. Occlusal djustment via selective cutting of natural teeth. Part
II. Int J Periodont Rest Dent 1985;5:8-29.
23. Nassif NJ. Perceived malocclusion and other teeth-associated signs and
symptoms in temporomandibular disorders. Compendium 2001;22:577-84.
24. Ziebert GJ, Donegan SJ. Tooth contacts and stability before and after
occlusal adjustment. J Prosthet Dent 1979;42:276-81.
25. Ramfjord SP. Bruxism, a clinical and electromyographic study. JADA 1961;
62:21-44.
26. Kirveskari P, et al. Effect of elimination of occlusal interferences on signs and
symptoms of craniomandibular disorder in young adults. J Oral Rehabil
1989;16:21-6.
27. Winstanley RB. A retrospective analysis of the treatment of occlusal
disharmony by selective grinding. J Oral Rehabil 1986;13:169-81.
Restoration of Anterior Guidance with Canine Bonding
1. Canine enamel is etched, unfilled resin, and then composite resin bonded
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Nonprecious perforated metal castings were bonded onto the palatal surface
of the maxillary canines to provide centric contact and eccentric guidance.
2 years postoperatively the patient was comfortable with elimination of the
bruxing and clenching habit.
No natural tooth was reduced.
Caries risk is reduced since there are no prepared margins and protective
enamel remains.
Treatment cost is reduced since chair time is reduced
Palatal clearance must be present for restoration thickness.
1. Ford RT, Douglas W. The use of composite resin for creating anterior
guidance during occlusal therapy. Quintessence Int 1988;19:331-7.
2. Colquitt T. The sleep wear syndrome. J Prosthet Dent 1987;57:33-41.
3. Thayer KE, Doukoudakis A. Acid-etch canine riser occlusal treatment.
J Prosthet Dent 1981;46:149-52.
Occlusion and Splint Therapy
1. Suggested regimen is to wear the occlusal device 24 hours a day, otherwise
muscles will slowly adjust to the new vertical dimension of occlusion and
never reach proprioceptive harmony (deprogrammed position).
Adjust the device every 7 days- when no further discernible changes check
every 2 weeks.
There should be at least 1mm between the mandibular teeth and the device
during S sounds.
When the patient functions better with the device than without it, it indicates
the definitive reconstruction will be successful.
2. Orthopedic interocclusal appliance- removable device made of hard acrylic
that is placed between the maxillary and mandibular arches.
Purpose- stabilize and improve function of TMJs
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type occlusal splint, irreversible therapy should be considered only after all
conservative treatment has failed.
15. 8 confirmed bruxist patients were evaluated with portable electromyographic
equipment during sleep, prior to, during, and following splint therapy.
Full arch maxillary stabilization splints were worn during the sleeping hours
for the treatment period.
Nocturnal bruxism was significantly and immediately reduced through
maxillary stabilization splint therapy.
After splint removal, masseter muscle activity returned to pretreatment levels
16. 24 Facial Pain Clinic patients were divided into 2 groups to compare
treatment with a maxillary occlusal splint with a 20 minute tape of
relaxation procedures.
The occlusal splint as worn continuously except during eating and hygiene.
The relaxation tape was listened to daily.
Both groups ere evaluated weekly for 4-6 weeks.
Research design principles used to control variables in this study:
Patients were randomly selected for treatment groups
Objective measurements of symptoms were used to evaluate results
Operators were standardized for recording data and providing treatment
Predetermined treatment periods were used.
The occlusal splint group had a significant decrease in mean observable pain
scores and a significant increase in mean maximal and maximal
comfortable opening.
The relaxation technique had no significant effect on the patients pain,
tenderness, or limited opening.
17. 71 patients with myofascial pain-dyfunction wore a placebo splint with
maxillary full palate coverage only and no acrylic on the occlusal surfaces,
for 1-2 weeks.
If their self reported symptoms did not resolve an anterior canine to canine
platform was added.
If their symptoms did not improve after 2 weeks, posterior platforms were
added to create a maxillary stabilization splint.
35 patients who were not helped sufficiently by the anterior platform splint
did improve with the full coverage splint, confirming the superiority of a full
occlusal coverage appliance for the management of MPD.
The placebo group reported 28/71 improved and 43/71 no change or worse.
The full occlusal coverage group reported 35/44 improved and 9/44 no
change or worse.
Despite the high no change or worse placebo group report and the high
improved full occlusal coverage group, the authors stressed the value of
placebo effect vs. occlusal change.
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retruded position.
Soft splint was not adjusted in any way.
Immediate changes in activity must be due to changes in sensory
information from peripheral receptors, without time for altered
subconscious behaviour or altered reflexes to develop.
Peripheral receptors likely to be involved would be those in the TMJ,
muscles, periodontal ligaments, tongue, lips, and oral mucosa.
Hard splints led to a decrease in EMG activity in relation to activity with no
splint, in both the temporalis and masseter muscles.
Soft splint produced a slight increase in activity in both muscles, particularly
The masseter.
A hard splint is likely to be more effective than a soft splint in reducing the
activity of jaw closing muscles, especially the anterior temporalis.
1. Okeson JP. The effects of hard and soft occlusal splints on nocturnal
bruxism. JADDA 1987;114:788-91.
2. Al Quran FAM, Lyons MF. The immediate effect of hard and soft splints on the
EMG activity of the masseter and temporalis muscles. J Oral Rehabil
1999;26:559-63.
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