Peter E. DawsonFrom J to Smile Design - /http://dentalbooks-drbassam.blogspot.com/http://dentalbooks-drbassam.blogspot.com Contents mony 1 The Concept of Complete Dentistry, 3 Perspectives on Occlusion and “Everyday Dentistry,” 11 Occlusal Disease, 17 The Determinants of Occlusion, 27 The Temporomandibular Joint, 33 The Masticatory Musculature, 45 ‘Centric Relation, 57 Adapted Centric Posture, 69 Determining Centric Relation, 75 Load Testing for Verification of Centric Relation, 85 Recording Centric Relation, 91 Classifi Vertical Dimension, 113 The Neutral Zone, 131 The Envelope of Function, 141 tion of Occlusions, 103 Functional Smile Design, 149 Anterior Guidance and Its Relationship to Smile Design, 159 Restoring Lower Anterior Teeth, 177 Long Centric, 189 The Plane of Occlusion, 199 Posterior Occlusion, 207 Simplifying Instrumentation for Occlusal Analysis and Treatment, 233 Differential Diagnosis of Temporomandibular Disorders, 259 Oceluso-Muscle Disorders, 265. Intracapsular Disorders of the TMJ, 277 Classification of Intracapsular Disorders, 307 Imaging the TMJs, 321 Bruxism, 333 Chapter 30 Chapter 31 Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37 Chapter 38 Chapter 39 Chapter 40 Chapter 41 Chapter 42 Chapter 43 Chapter 44 Chapter 45 Chapter 46 Chapter 47 Requirements for Occluss 345 Solving Occlusal Problems Through Programmed Treatment Planning, 349 The Diagnostic Wax-up, 365 Occlusal Splints, 379 ‘Occlusal Equilibration, 393 Neuromuscular Dentistry Bioelectronic Instrumentat n, 419 Solving Occlusal Wear Problems, 429 Solving Deep Overbite Problems, 453 Solv 467 Solving Anterior Open Bite Problems, 479 Treating End-to-End Occlusions, 493 ¢ Anterior Overjet Problems, Treating Splayed or Separated Anterior Teeth, 501 Treating the Crossbite Patient, 513 Treating Crowded, Irregular, or Interlocking Anterior Teeth, 525 Solving Severe Arch Malrelationship Problems, 547 Using Cephalometries for Occlusal Analysis, 565 Postoperative Care of Occlusal Therapy Patients, 577 The Technological Future for Occlusal Restoration, 582 Lee Culp, CDT Criteria for Success of Occlusal ‘Treatment, 595 xiii/http://dentalbooks-drbassam.blogspot.com Functional Harmony| /http://dentalbooks-drbassam.blogspot.com Chapter ‘The ultimate goal for every patient should be maintainable health for the total mastica- tory system.‘The defining philosophy thal underlies ah honest concern for patients Cun be Summarized im one word: cowiptete, Embracing the concept of complete dentistry always puts the patient first, It-say’s that every patient is entitled te a com plete examinition and a clear understanding of every prob- Jem that should be trealed. It recognizes that almost every dental disorder is, in afl probability, a progressive disorder that will cause increased problems if not detected und treated in a reasonable time frame: ILis axiomatic thar patients cannot perceive a need tor treatment i they do not clearly understand what problems are present. That is the primary purpose of the complete examination, Bur think abour this: patients eannor make @ Imily infurtned decision about treatment unless they also understand the implfeations of aot treating cach problem within uv ceasonable time frame. Practitioners cannot reli- ably predict implications if they don"t have a working knowledge of the totul masticutory system, which includes the interrelationshrps of the teeth, the temporomandibular joints (TMJs), the muscles. and the supporting tissues, i addition to a clear picture of the causes and effects of oc- clusal disease. With an iplication Mindset A key question in every complete dental examination is fun- dhimental to the integrity of the doctor-patient relationship: “Are all the components of the masticatory system imain- taindbly heatthy?® This requires analysis to determine the implications of not treating any parts that are disordered or diseased. Answering these questions is the foundational ba- for the complete examination. I js also the guiding prin- ple for formulating what treatment should be started, what could be deferred, and what may not be required to save teeth but might he desired for improved esthetics Understanding the short and long-term implications of +h type of dental disoner is the basis for establishing pri- ies OF treaument and is the essential informution that is used to establish “phased” tieutment for patients who cannot proceed right away with an extensive treatment plan in its entirety. Examini Typ Every dentist needs 1 develop a clear picture of what a sta- ble, muintainably hi Ithy masticatory system looks like. . . AOL just teeth, but all parts of the system. [na complete ex- eTUnation. exch pari of the system should he analyzed to see if there ane any signs ‘OF syitploms that indicate disease, dix. order, or dysfunciion. 1 imy departure from health is noted IN Lny structure, the key to both diagnosis and (reatmont ree “onimieiidations will he directly related te the Implications of nol eating (hat disorder ina timely manner. Those: implica- ‘ions can be classified into three ¢ typms 1s of implica /http://dentalbooks-drbassam.blogspot.com Iitmediate implications. “These consist of problems tha are in an active stape of progressive disease or deformation, a, disurders that are a causative Factor for pain or discomfort, JF disorders in this category aie not treated ws pricmny, the iniphication is thar delaying treatment will rest in a greater, more complex problem, or au terease of pain, or will ye. quire mare extensive. more complicated, or more expemive Solutions with a possibility tnt delayed’ treatment results, will bot he as good as what could be achieved with Tnimedi~ ile attcntion. Stich decisions cannot rely anly on what x jm tient perceives as “wants.” It requires searching for signs, of which paticnts are ofen not uwure, because signs Of damage lypically occur before symptoms are noticed, Deferrable implications, These consist of problems that will need (0 be treated but could be deferred without caus. ing more complex problems, and delaying treatment for a reasonable lime period Would not result in u less successful Weatinen! outcome. Some problems with inumediate impli cations can be made defernuble by conservative intervention that stops or slows the progression of the disarder so i1 can be effectively treated at a later time, Implications for optional treacment. These are indications Tor treatment that would be nice to have but are not problems that will lead to progressive damage if lefy untreated Cosmetic restorations thal are done solely for the purpe: improving estheties fall into this category. Careful obser tion for signs of stability versus instability is @ critical pan of the decision process before informing a patient that teatincnt is not necessary for long-term health. This does not imply that treauient done solely for esthetics §s inap- Propriate, and experience has shown that being honest with putients about what is optional versus whut is necessary will rarely deter a palicnt from accepting esthetic treatment for Improving appearance. A dental examination is complete if it iennfies all factors thatare capable of causing-or contributing to deterioration wf oral Health or function 11 is incomplete if it does not expose every sign of active deterioration witli the masticatory sys fem. A complete examination does not rely solely on symp toms because signs almost always precede symptoms. It is the responsibility of the examiner to observe signs of deleni- onution before they cause symptoms. In doing so, itis possi ble to develop treatment plans that are aimed at optimum mmtintsinability of the teeth and their supporting structures Seven specific goals should bie the objective for patient care |, Freedom from disease in alll masticatory system steuc- tures Mainiainably healthy periodontium Stable TMJs, Stable ovelusion Sup adChaprer | The Concept of Complete Dentistry == 5 SF) Micijyoaimibly healthy tee ®. Comtormble function 7. Optimum esthetics ‘The establishment of these goals is the foundation for complete dentistry. Ifa goal is clear enough, it can be visual- di and in thet mma be visualized. A good rule is to avoid “suirting any treatment until the desired result ean be clearly visualize. Until the practitioner hus « clear picture of how each type of tissue looks and acts when it is optimally healthy, there will be no frame of reference for knowing whether treat- meni is needed or if itis successful when rendered. Clearly defined goals give purpose to treatment planning and make i possible to be highly objective, When the goals listed above are fulfilled, the consequence will be fulfillment of u further ‘goal that is esse for long-term siabiliiy and comfort, That Js the goal of a peacesfid neimnmusculature. ‘When the entire masticatory system is heallhy and there is harmony of form and function, and the relationships are st ble. the treatment can be said lo be complete. Furthermore, es thefic requirements, including the highest level of functional smile design, can also be fulfilled because all of the guidelines for a naturally beautiful smile are dependent on the same har- mony of form that is necessary for harmony of function. In the analysis: of any oral diagnosis, each of the above goals should be evaluated for fulfillment. This evaluation will full short unless the veasens for form and function relation Ships ure understood along with the cause-and-effect nature Of health versus disease. This type of analysis eliminates de- Pendency on empine treatment or making patients fit aver- ages. There are many stable healthy centitions that do not fit the averages, (hat are not Class L occlusions, and that violate customary guidelines for normalcy. Attempts to “correct” these dentitions often end in failure, and existing harmony of form and function may be disturbed by the treatment. Such omisiskes can be prevented, and a high degree of predictal “ity can be developed if the goals of Inalment are based on a foundation of “why” tather than “how” There is an understandable reasom for every position, “contour, and alignment of every part of the enathostomitic system. There: is always a reason for every incisal edge po- sition, every labial contour, every lingual contour, sind every Susp Up position, There ts always a reason why some teeth Set loose, and others wear away. There is 4 reason why TMJs hurt, why masticatory muscles becarie tender, and teeth vel Sensitive, There is u reason why certain ovclu- Sioms remains stable and ethers diy nol. Treating the effect Without treating the cause is rarely a satisfactory outcome, “aad is almast never necessary. Beery diagnostic or treatment decision should be made ‘the basis of undersminding the reasons for the problem, the reasons for the treatment. Ajl treatment should be et with the goal of providing wed nainnelsing the egret of oral health possible far euch patient, Total ion OF ull causative fictors: to the point of complete HW of deteriorution is not ulways possible. The prob- SOME: PRNSMIS are (90 Severe, OF Have yone on too fong (0 expect a complete return to ideal health, But dhe de gree to which we cun eliminate the causes of deterioration will directly relate to our degree of success yi changing tin- healthy mowths to healthy ones. Causes of Deve ation Denial disease rarely results trom a single entity, It is almost always the result of a combination of factors, The same ausative insult. can produce a variety of responses because of differences in hast resistance. The response can also be altered by variations in inienstty or duration of the insult, sometimes to such an extent that a complelely different set of symptoms may result from inereased intensity of the same causative factor Because similar symptoms may result trom different Causes, and a variety of symptoms may result from the same usative factor, treating swapiomy alone is generally sfiert- ted therapy. It is always advantageous to determune the ‘cause of both signs and symptoms. If the causative insult ean be completely eliminated (such as occlusal overload on a painful, loose tooth with a “high” restoration), the normal adaptive response of (he body should activale a retumy to comfort and reduced hypermobility when the overload on the tooth is eliminated. OF course it may still be necessary to repair damaged tissues, but this can then be done with o greater chance of a long-term successful treatment outcome Much of the confusion about cause-and-effect relation- ships results from failure to differentiate between causative factors and conrributing factors. A contributing factor dees nol by itself cause disease. Rather ivlowers the resistance of the host to the causative factor, or increases the intensity of function or tension. Contributing factors may lower hast re- sistance biochemically or increase intensity biomechani- cally. The resistance muy be lowered in a specific Gssue or In-anentire syst Generally the weakest link breaks down. The greatest susceptibility tw disease oceurs when a causative factor is present (na host with increased stress und lowered resistance, Both causative and contributing factors must be considered when deciding on a path of treatment, but the most effective approach is to give the highest prior ity to dineet causalive factors. Attempts at increasing host r= sistince and decreasing stress levels should be kept in Droper perspective as adjunctive therapy. Let's use a simple illustration to show how a single direct causative factor can produce d variety of signs and symptoms, depending on variations in how different patients respond: Ing healthy patient with w perfect dentition, note the va~ riety of responses that can oceur if u-single bigh restoration with deflective incline imerference is phiced on a second molar. There are many different ways that patients might re- spond tothe sume, specific causative factor (Figure PI): 1. The tooth may become sensitive to hot or cold, ar it muy ache 2. The tooth may become teniler to biling on it 3. ‘The (path may become loose tne/http://dentalbooks-drbassam.blogspot.com FIGURE LI A des in 6, ia 1 17, All of the signs and sympt reet resull of the same . Muscle tension he: Part | Functional Harmony ve Incline interference on a second moku cant be weave factor thal results in. many’ diffenest signs andl symp. ry aystem, ‘The tooth may wear excessively ‘The mandible may be deflected around the interfer- ence into other teeth that become lousenec! Other tecih can be abraded as the mandible is de- flected forward Other teeth can become sore as they arc traumatized at the end of the slide Forced deviation of the mandible can cause mastica- ory muscles to become painfully hyper spastic Trismus may result from the spastic musculature laches may develop The combination of sore teeth, sore muscles, and hreadie hy cl tension Commtint tension and stress may lead to dep The combination of the uncoordinated musculature and the deflected mandible may contribute to a condyle/lisk derangement Eventual displacement of the disk by uncoordinated hypenuctivity may. initi painful compression of cetrodiskal tissues tive arthritic changes in the TMJ 1 low disk displacement and subsequent perfor the retrodiskal issues All ot thes None of the eS Mmuly CUUSe stress 3 ssion masticatory muscle © tole ional Ws listed ubowe cam by actor, Ue oeclasal inter ‘aunsat ference on the second molar None tors that altered the respon: the Causative insult (the deflective occtisal COMLACY),y heen convcted before imeversible damage ucumey SYmptoms would have disappeared without arty changes ing made in host resistance ur emotional stress level Host resistance ts not the only variable, ‘Variations \n tensity of function cag dramatically alter the respon Th. sumnc type of occlusal interference may go completely uh. noticed by a very relaxed patient who has no tenden, clench or brux. The mouth breather or the person wiho 4 with the mouth open will have fewer, if any, of the symptoms because no stress of tooth damage results itt the absence of tooth contact. The same persen under duress may begin to clench or brus, dctivating the muscles intn occlu overload and an avoidance pattem that produces symp in the teeth, muscles, and possibly the joints Despite the complexity of the multicausalily concept, \ is still possible to simplify our approach to diagnosis ana treatment planning if we understand how the mastic Hoy system was designed to function, In the chapters thar fo|- low, you will learn how all parts of the system are interr lated in a functional design that is so logical, ir will parent when there is destructive disequilibrium, |i knowing how the system works, it will be obvious whe wrong when it isn't working properly, causing stress forces to build up within the sysiem. It is not possible completely eliminate stress, but treatment planning shiv: always be directed at reducing stress to a level that destructive. Ensuring that the total system is in. equilibri is a goal of complete dentistry. Iris a very popular concept to blame emotional stress many of the disorders that are, in fact, caused by strict disequilibrium. None of the patient responses listed ab would have occurred if the deffective inelie on the “hig tooth were not present, regardless of the patient’s emotivr state. This is not to Say that emotional stress cannot resul pain or discomfor, What js important 1s that it 1s poss! and practical to isolate structural causes for pain or dy function and correct those causative factors. If treatment limited to covering up symptoms with medications, the str tural disharmony is allowed! to continue its progressive © formation of teeth, joints, or supporting tissues. Expe has also shown that when pain or dysfumetion is eliminate emotional stress is relieved in many patients. [t appets | psychosocial stress is often a result of, rather than 3 & orofacial pain parle lose their tecth in two ways: either the ce! break down, or the supporting structures break down. simplistic as it may sound, if we exclude neoplastic d ders and specific pathological eenditions. alniast every de sraling effeet on the teeth or supporting structures I reel result of one oF bath ef wo cattsative fi (of the centring) Ne Ya. st actually caused the problem, jy abo: usa toms nile 1, Suess from microtauma or physical enjury (mats aa ri os of $e 2. Microorganisms including gingival diseases ic bi viral, or fungal origin‘Suess from microtuuma results From repeated ovclusul verload. Diagnosis und treatment of veelusal dishurmony iit fee discussed in detail throaghoul the remaining chap- As factors of occlusal overload are better understood he destructive evidence of ocelnsal disease is hemer rec penived, there Is sometimes a tendency to downplay other qually important causes of dleterioranion. The role of m= cHmIEANisms must always be given a high priority in every dental cxamination and treatment protocol. The Role of Microorganisms is no doubt that the elimination of hacterial plague and thorough cleaning of gingival sulci are essential for main- microbial waste products not nly cause canes through decalcification of the tooth surface, they ure inflammatory to soft tissues and destructive tothe support, Dentistry cxninnt be called “complete” if io address (he eliniination of this importint causative factor. ‘There is oo such thing as a “healthy” mouth that has Tong-siunding deposits of bacterial plaque. As long as orga- “nized masses of microorganisms are present. prog akdown of the supporting tissues is almost inevitable. i¢ only variable is the rare of deterioration, which may from patient ( patient or even from tooth to tooth in the ¢ mouth, The tissue response to the noxious products of microbial colonies depends both on the general resis- je nf the host and (he resistance of the specific areas that _ Even in a dentition that is unifocraly coated with plaque, destructive effects umy not be unifanm. Periodontal de- Inuction around sone teeth may be severe, whereas other May retain all or most of their bony support. Since the nsity of the sicrobial attack is about the same around ll ech, there must be a woth by tooth difference in resis- ce i the microbial toxins. The difference in resistance ‘one tooth to the next is often directly related to differ- ‘of occlusal stress. [tis a common clinical ding shar the degree of hone breakdown is in direct pro- tion to the and direction of occlusal overload each tooth. Although there docs appear to be # clinical relationship etWeen ooclusal stress and the amount of microbial dam- } Dochusul Sess is NOt a necessary factor in periodontal ‘Severe periodontal disease can occur in an envi- ent of oeclusal perfection. Lis important ty understand hal even the best occlusal treatment cannot prevent deterie- oF supporting structures: if inflamm: W thenipy without contro! of plague is incomplete ?. On the other hand, soft-tissue management, Short-term improvements cum be misleading, The dnt malic results that cun be achieved by ¢7dier occlasal therapy ‘of plaque elimination can be impressive, but years of carefal observation almost always present a different picture of pro- gressive breakdown if either weatment aipprodich is ipnared when a combinauon of periodontal and eeclusal factors ts present A concentrated mouth hygiene program tay transform bleeding. edemilous gingiva into healthy-appearing tissue. In addition, occlusal conection may Breatly improve the comfort of the teeth, and even eliminate hypermobility. Bur such na Heeahl: improvement can be wisteading if, underneath the healthy-looking Ossue, an untreated intrabony lesion remains, No matter how heuthy the gingiva appears, deterioration of the alveolar bone and periodontal structures will continue if the entite sulcus is not cleanable. The healthy appearance on the outside merely produces a false sense of security while de- lerioration continues at the depth of the lesion, No matter how thorough the plaque control. even if eum bined with perfected occlusal therapy. ii is incomplete den tistry if there remain deep lesions that are capable of conun wed deteripration. Despite the exireme mobility pafferns that can be caused by occlusal disharmony, it is doubtful that occlusal traunts can cause an increase in pocket depth Unless inflammation is present within the sulcus, [f the gmgival attachment fs Intact, and there is a sufficient level of supporting bone rensaining. even severely mobile teeth can usually be returned to normal firmness and health by correcting the oeclusion. With metic- ulous hygiene to keep the sulcus free of plaque, inflammu- tion can be prevented. Lindhe anil Nyman! have shown rather conclusively that occlusal trauma of the jiggling wpe, even wiih greatly reduced periodontal support, will not cause further destruction of the uttichment apparatus once the plaque-induced periodontitis has been eliminated. However. the combination of plaque-induced perodontitis and occlusal (rauma causes 4 more progressive loss of con= nective tissue attachment thin in nontraumatived teeth” Recent clinical observations and scientific data have given added credibilily to the relationship of occlusal over- loads to periodontal damage,’ Comparative studies to deter: mine if there is an association between occlusal trauma and periodontitist show that [here appears wo be a definite link. ‘Teeth with a combination of functional mobility and widened periodontal ligament space were found 1 have deeper probing depth, more. elinieal attachment loss, and less radiqgraphic bone support than nonmobile teeth: While this relationship hetween ocelusally induced tooth hypermo- bility and increased levels of periodontitis has been 3 com- man clinical finding for y the actual mechanism for the bone loss was not fully understood. Recent investigations have provided an explanation. Jnterloukin-1 ber 1&4 potent stimulator of bone resory- tion anda known key mediator involved in periodontal dis ease (thas now been determined that interieukinel bet is enproduced by human periodonud ligament cells in response fo mechanical stress Tt has also been shows thut ofder periodontil ligament cells produce an mcreased amount of interleukin-1 bets in response to mechanical Force, and may well be positively related to the acceleration of alveolar bone resorption.” Some authorities have argued that occlusal fuciors play no role in periodontal breakdown becatise inflammation is the essential causative fetor for increased pocket depth. This opinion presents a limited viewpoint of what cuuses periodontal disease. A total picture of periodontal health, and the goal of complete dentistry, involyes alf of the struc tures that support the teeth, not just the gingival uituchment. The way in which bone is destroyed cin he learned from careful clinical observation. The reason why teeth iy) hyper- fametion loosen is becwuse the bone around (he roots breaks: down, The bone breakdown follows a specitie pattem in whieh bone resorption directly relutes to the direction of compressive forces by the root against the bone. The pres- sure stimulation results in thrombosis, hemorrhage, and de struction of collagen in concert with the activation of inter- jeukins tit have been shown to convert fibroblasts into osteaclasts, The osteoclastic activity, im tim, destroys bone in direct proportion to the intensity and directing of the pres- sures exerted, This means then, that totra-alveolar bone breakdown follows a pattern that is definitely related to ac clusal stress patterns Careful clinical observation repeat edly contirms this relationship, which can occur even when the gingival attachment apparatus is intact. Ty the ocelusion is corrected to negate directions! over loads on the teeth before inflammation or injury deepens the sulcus (0 create w Communication through the gingival al- tachment ino the area of bone resorption, osteoblastic ac- livity Will repiir the osteoclastic destmetion and bone will fill back in to its onginal leval. The loose tooth wall tighten and can return to normal health and function If the ovelusal correction is delayed, our clinical exper- ence has Shown thal in time, the sulcus depth very often deepens to eventually communicate with the bone loss area to form a deeper intrabony lesion. Understand that the in- crease in pockel depth requires inflammation or injury to penetute the gingival aflachment, soit theoretically ean be prevented on selective patients whe are willing to follow meticulous liygiene procedures under increased professional supervision. Although possible, successful maintenance on an overloaded, hypermobile (oth is unpredictuble at best, Bone resorption often 1 worst in furcagion areas that are hantest to clean and where communication with the suileus ‘Or pocket is most likely to occur. Once there is any break- through beeen the suleus and the area ot hone breakdown, the pocket |s imniediately deepened to the extentaf the toral infpalveutup defect, More intensive periodontal (reatment is then sequired. but even willt that, the bone level will nn he returned 10 its original Contour. That opporuniy bs lost whenever oeclusal worrection is delayed too long: The repair of (ntraosseans defects 1 more predictable when use teeth ame firen.- Enara almost every viewpoinil of ewe /http://dentalbooks-drbassam.blogspot.com foot than it js arn, Gcelusal stress mast be eonsiderel/as a primary ce supponing. Structure breakidawn around the tweeth. Ci = OF misditected oy excessive forces saiNSL Ue teeth i the essential considerations in maintaining cps fea ofa dentition, and italso has the udded Palin Mure COmfurtible ‘ ne makina le Anatomic Harmon: ‘The most common shortcoming in analyzing or treating ge. clusal relationships is failure to consider ull ate aie | mhasticdtory system. We are prone to: many mistakes if our understanding of occlusion ix limited solely 1 teltisal contacts, The teeth are just pact of the woul system, and Viankly there is a0 way 10 evaluate occlusal relationships snttl we have uscertained that the temporomandibular antic. ulation ism harmony. There is no such thing as a perfects elusion with a disphiced TMJ. ‘That means both the position and the condition of the TMJs must he considered in ls tion to the maximum interculspation of the teeth, The pesce ful function of the masticatory musculature depends on 0 harmonious relationship belween the occlusion and tic ‘TMJs, 0 this relationship 15 always of critical concery | diagnosis and treatment planning. There will always } some price to pay When any part of the masticatory syster is at war with muscle, Thal includes the lips, tongue, ep check musculature. Harmony of form is a prerequisite for harmony of fun ton, and iL is necessary to have a working knowledge of hoy the two interrelate, Every aspect of each twoth"s position an contour can be deternmned on the basis of its harmony wil functional requirements, Asx examples, the upper amtenc teeth must relate to the closing path of the lower Lip as ' moves up toseal contact with the upper fip during every. wal low. The upper incisal edges must relate to a consistent alig’ ment with the lower lip contour for proper phonelics. “The up per lingual contours must relate to the functional paihways« the lower anterior tecth as they move along a repentious Po tem referred as the envelope uf jimetion Both upper ai ower anterior teeth are subject (0 positioaune within a zane © neutralily between the outward forces of the tongue versus th Jnward forces of the lips. There ane other functional rion ships that must be understood to iichieve consistently E> dictable results in occlusal treatment, but the important a to grasp ul this time is that every part of the unasticalory a ; tem Ins an understandable reason for its postimt, cone find alignment. Learning these reasons will take the Lat work out of everything from smile design 1 re ven et facial pain. Not knowing these inter wash a many diagnosis and treativent decisions 1 suet ete If any anwfomue component + mot i Se ak rest of the masticatory some pat onal oF ie ay must adapt We regain equifiium. “Ackaptys ee esis & he evaluaed as responses «a imbalance Such adap" ine not always a problem, Whether te system ik attempts/http://dentalbooks-drbassam.blogspot.com imbalance are beneficial or destructive is dependent response of the altered tissue or part, Astute diagnos s must know the norm and must be able to determine an imbalance exists and whether the tissue or paris successfully adapted to the altered balance. ‘There are many so-called “physiologic malocelusions” are stable and function well. They do so because the cu- ulutive effects of different dynamic factors produce a sta- ble resuli. even though it does not fit the Class I stereotype of a classically correct occlusion. When we get into the sec- ion on weatment planning of different types of occlusul problems, it will be apparent how important it is to under- rand the dynamics of functional and anatomic harmony. It is not possible to adequately evaluate cause and effect influ es in the dentition or the TMJs without knowledge of functional interdependencies, because if we don’t know at causes a malrelationship we will probably fail in our reatment. We may subject our patients to unnecessary vertreatment or inadequate undertreatment if we altempt to ‘irval signs or symptoms without knowing what caused them. Teeth do not simply move out of alignment, become 8c, OF Wear away without a specific underlying cause (or ailment will not be successful unless all currently active Ss for disharmony or deformation are corrected. ‘The goal of functional harmony is a peaceful neuromus- cular system. The masticatory system is capable of high- capacity demands, The system must be free to function to its anatomic limit without mechanical interference, but must not be restricted to function solely at that limit, IUmust fune- tion to the limit when required. It must be at peace when functional demands are reduced, Achieving such functional harmony in an environment of optimally healthy teeth, Joints. periodontium, and musculature, and in combination with the best possible esthetic result, is the essence af come plete dentistry. ” References L. Lindthe J, Nyman S: The role of periodanta disease and the bio. us uctual omtcome HL. The ness of chimical parameters in accurately présicting tooth survival. J Pertodonttal 67:666-674, 1996, 3. Nunn ME, Harrel SK: The effect of occlusal discrepancies on peri- odontitis. 1. Relationship of initial oeclusal discrepancies to initial clinical parameters, J Pevieonral 72:485-494, 2001 4. Harrell SK, Nunn ME; ‘The effect of occlusal discrepancies on periodontitis IT. Relationship of occlusal treatment to the progres sion of periodontal disease, J Periodtansal 72:495-50S, 2001 5. Hallmon WW: Occlusal trauma: effect and impact on pesiodou- lium, Aan Periodontal 4(1):102-108, 1999, 6. Shemizu N, Gaseki T, Yamaguchi ) In vitro cellular aging stimulaies interleukin. | beta production in stretched human peri- odontal ligament denived cells. J Dent Res 76(71:1367-1373, 1997. 7. Pikhstrom BL, Anderson KA, Aeppli D, et al: Association herween signs of trauma from occlusion and periodontitis. J Periadantal 57 1:16, 1986. 8. Woerhang J. The infrabony pocket and its relationship to tauma from occlusion und subgingival plaque, J Pevivdoniat 50:355-8 1979, am asPerspectives on Occlusion and “Everyday Dentistry” Whether general practitioner or specialist, practicing without a comprehensive under- standing of occlusal principles exacts a costly penalty in missed diagnoses, unpredictable treatment results, and lost production time.Al every level of general practice. a dentisi routinely faces Problems of sore teeth, excessive wear, loose teeth, temporo- mandibular joim (TMJ) disorders, and orofacial pain. Patients want correct answers. They want to know if they need orthodontic treatment. or an occlusal splint, or why a joint clicks. or why anterior veneers chip ar erick, A dentist who does not have a working knowledge of occlusal prini ples: must resort to guesswork and time-wasting trial-and- error attempts to solve prohlems that could be contidently solved by understanding cause-and-eftect responses W oe- clusal disharmony. Even achieving predictable function and beauty of smile design is dependent on incorporation of sound occlusal. principles. Those principles are not just for complete mouth prostheties, When principles of occlusal farmony are understood, the entire approach to examination, treatment. and problem solving takes on a new perspective. It | perspective that pays huge dividends of predictability and sed productivity, regardless of the type of practice. There are good reusous why general practitioners should learn principles of occlusal harmony, nd develop skills re~ quired to recognize and treat typical problems associated evlusul disharmony. Descriptions of some of the bene- fits follow, Ltacient Comfort Miamy problems of discomfort are related to occlusal dishar- mony.’ * Teeth thal are sensitive to hot or cold after a restori- tion ix placed are frequently symptomatic because of a de- flective incline interference or a vertical oyerload from a new restoration, Indiseriminate grinding to relieve the inter- fering tooth can trigger new and bigger problems in other tect) and/or the masticatory musculamre. and even the TMJs. Not understanding ocelusul principles is a barrier to solving such everyday problems, and it puts a practitioner in jeopardy of detually casing problems thar are semelinies worse than the original complaint, Biestorarion Longevity Chicks, fractures, and excessive wear on restorations ae ull signs of oevhisal disharmony. Such problems are rare in per fected oeelusions, wil Occlusal Syability Post-treatment shifting of teeth, opening up of contacts, oF creating unestheric p enment are common problems of ‘occlusal mistakes. The use of long-term retainers (0 Mi juin post-orthodantic tooth alignment could be dramatically: reduced if occlusal prineiples were beer understood Freniiis is almost always ur eurly sign of a cortectible ne chal disharmony ame More Accurate Treatment Plannin: Most of the problems that lead to Saat sults could be avoided! Smpromised treutmeny if requirements, for occlusal Were adhered to in the treatment Planning stage, Pn sie freasment planning (see Chapter 29) ix hased an Siete the best treatinent options for fulfilling each Fees, Successful teatment i s planning pays tu i . of the type or level ater: ys huge dividends regards, Improved Esthetics The very best, most naturally beautiful esthetics does Wt Te quire guesswork if the relationship hetween anate ic a mony and functional harmony is understood. The best ‘wie design is automatically achieved when the anterior teeth 23 in harmony with all of the guidelines for occlusal function and stability, Furthermore, these guidelines provide a pre- cise framework for a step-by-step process. [iscreased Productivity . Just imagine how much more productive a practitioner can if all restorations could be placed without necd for “rindi in” high or uncomfortable occlusions. or remaking rest tions that are not correctable: How much Gawe could be pu! better use Ihan trying (o reshape anterior restorations thu: too thick on the lingual. How much wasted time cou! saved if incisul edges weren't too far out, 100 Tong, Woe sh These are the typical everyday problems that mist be fic if principles of ocelusal harmony are not understood used to plan and execute treatment. Ih is unrealistic to expect that every restoration coulil placed without any need for some ae fusul correction. Bu should! be unnecessary 10 do more than mininial eorrest! if the rules for occlusal harmony are faithfully practiced. Decheased Stress Front intecyiews. with more than 200 denusts. (uppes a imyor cause of barmout 15 a tack of predic tability when tempting to satisfy the needs anal desires of patignts. | abilily is especially noted In restorative «i jm attempts to salve tsoue discomfort, Whe being wasted attempting 1» a bite problem by trial and error, the next patient Bs and an alieady full cule pew further janie : up because of “working in” patients to redo. or re : tistry that isn’t quile comfortable, The result is ther 7 ‘cine of these problems ? ire office tain. control procedures, include shortcomings: Bat rs ic fale © e000 ie Lreutnent stress on the en caused by inadequate quality dentist-techniciin commantestion major eause of unacceptable treatment rest! a ‘visualize wetear correct goal [ot the treatinent, This 7 aly accompanied by inadequate Irealment lator fea problew is that unless the requirements: er, wee! Be ri niomy aire understood, there can’ he a clear visionfesult and without a clearly defined goal, wry- ve at a logical treament sequence is Folly. Tt is a that can only be solved by u clear understanding of ments for a stable, comfortable, tmatmtamably Masticalory system though an understanding of occlusal principles has ¢ io every level of dental practice, there is u pervasive ception (hat concepis of dental occlusion are not rele to “everyday dentist [tis important to understand: Shoh a viewpoinl was ever germinated. and why it has so many dentists and educators to regard princi- ‘of occlusal harmony with skepticism. Toa large extent, a negative viewpoint regarding the am mince Of octlusivn bas been by misguided assumptions at disorders of the TMJs und muscles represent the only for oetlusion in dentistry’ A negative view off the iou-TMJ relationship lias permeated the teaching of lusion und has resulted ina profuse amount of literature downplays the role of occlusal therapy™ in general hee. A conceptual belief that oeclusion is unimportant Fis too difficwl) to teach at the dental school fevel has in- lienced a whole cadre of dentists who’ are ill equipped to erly diagnose of treat a broad spectrum of occlusal lems that arc routinely faced in every dental practice.” failure 19 embrace satind occlusal principles hus also to 4 plethora of fringe-type treatment mudalities, unnec: Hy OVerinestment, and denials of responsibility for prob- that are o direct result of occlusal mismanagement. disparagement of oeclusion as an important part of ‘Practice has become so pervasive that the National sof Health (NTH) and the Nations Insitute of tal and Craniofacial Research (NIBCR) published a " to advise the public that occlusal adjustment or Other irreversible occlusal weatwiemt for temporo- bular disorders (TMDs) is “of little value ani may the problem worse!" Further admonitzons that “recent h disputes the view thata bud bite (malocclusion) can TMD” provokes distrust of all forms of acelusal ther- py. A profuse amount of seriously flawed literature sup IS this viewpoint and deniinces all alterations of accly- aS di) Unacceptable choice of treatment. ine judgment of occlusal principles on such a nar as fis effeet on FMD" distorls the true value of Tarmony as a realistic treatment posal for ma iy dif problemas, tm ualeition to its indisputable value in treut- types OF TMDs.\’ including masticatory muscle far the most gommon type of TMD, NIM admonistiment that occlusal tedment “is oF lit. c common denominator of treatment. Hegative view oP occlusal treatinent 1 a msrep- /http://dentalbooks-drbassam.blogspot.com Trying to urrive al sensible answers about the impormee ‘af neelusion fn daily pmetice requires some insight into evallition of the Iderattine. With the growing dependence on lence-ba: reporting, the rules for judving research studies and even clinically based opinions have made #1 eas- ter to evaluate differing dognias. * Rvidence-bused research on occlusion inay nut provide final answers to every ques hon, but 1 pots out when there are serious enough flaws in any research swdy 10 invalidate its conclusions. Since sn much of the negative literature proposes a nonrelalianship of ecelusion to "TMD." an analysis of that literature is in onder: When the NIH position states that “research refutes the view that a hud bite (malocclusion) can wigger TMD? the statement fails the test for a scientifically lie Conelu- sion. A inuly scientific study aust ask. “Whew bind of TMD?" TMD is no « single disorder. [Lis not even a single multifactorial disorder. TMD isan all-inclusive term that includes many different types of disorders, any of which may be multifactorial. A cardinal rule for evidence-based research requires hemo geneity of the disorder being studied. This means that fora proper study of the relationship between occlusion and TMD. the specilic type of TMD must be isoluted and de- fined. An evaluation of the litersiure illustrates that this is rarely done.!*!* This error creates a glaring source of mism formation because (here ate many different disomders of the masticatory system that are typically included in the TMD category. These different disorders have many different eti- ologies, require different treatment strategies. and can result in different treatment ouicomes. A proper choice of treat ment demands specific classitication of the ype and sage of the disorder to be treated! hefore treatment is selected. Any Feported clinical studies that use the term TATD: withour Specifically classifying the exact type of TMD being studied are too scridusly flawed ta be considered valid. This error is found almost universally throughout the literature on both sides of the oaclusi MD debate. Scientific analysis also demunds a much-improved expla- nation that more clearly defines “a bad bite” and requires charscterizution of “malocclusion” in more descriptive terms." The use of Angle 'y Classification of Malocetusian to descnbe arch-to-arch relationships or to define "maloc- clusion” is perhaps (he most consistent and serious flaw in the literature that disparages the idea of a relationship be- tween occlusion and TMD, The cause of confusion is self- evident because Angle's classification dogs not relate maxim occlusal contact (0 either the position or condi- fin of the TMJs. Use of a elissification system that ig- hores any relationship between occlusion and the TMi: can hurdly be considered an analytical model for sunlying the relationship hetween ocelysion and the TMJs, A search of the fiterature confinns that this serious flaw hing been consistent ina profuse amount of reported studies drarave cifed tw disoredit the value of ecehusal hormony aso teal ment objective:/http://dentalbooks-drbassam.blogspot.com Ruling out all rationales for occlusal changes in paticnts with TMD is an indefensible position in light of extensive chrtical experience with conservative occlusal treatment that is close to 100 percent predictable when performed by prop- erly skilled clinicians on properly selected patients. There 15, extensive clinical evidence to support the relationship be- tween deflective occlusal interferences and masteatory muscle sympioms, There is also a proven scientific rationale for establishing occlusal harmony with the TMJs, The ratio- rales for treaiment are pructical. leamable, and appropriate for general practitioners as well as specialists, Atlempting to Festore an ocelusion, correct a bile problem, or even to re shape a high restoration without knowing ihe precisely cor reet maxillo-mandibular relationship. can be a time-wusting, frustrating, and unnecessary experience. Diagnosis of Orofac General Practice jal Pain The dentist of today must become a physician of the total ‘masticatory system. A frequent focus of head, neck, and oro- facial pain is within steuctures that comprise the masticatory sysiem, Analysis of such pain requires a working knowledge ‘of masticatory system structure and function, incliding the intraoral and collateral effects of dysfunction. The variety and vagaries of pain from dental origins are complex enough, but interrelationships beween the TMJs, ihe teeth, and the masticatory musculature require special expertise to evaluate the diversity of signs and symptoms that can tesull from structural disorder within the system, Dentists are the only health protessionals who are trained (or should bei to diagnose problems of the teeth of to un- derstand masticatary sustem fiincting as a baseline for relat- ing orofacial symploms tw variations of dysfunction, This means that the general dentist practitioner is regularly put into the position of “gatekeeper.” responsible for determin- ing Uf a dental or masticatory system disorder is or is Hola factor in head, neck, or orofacial pain, Physicians and other health professionals who do not huve the training to deter- mine if a dental or musticatory system disorder 18 or js nota factor jn head, neck. or orofacial pain must be able to rely on this expertise. Dentists must accept this responsibility and must develop the competence tu fulfill it. Pain from dental origins can combine with sources of pain from outside the masticatory system ta produce con- fusing paiterns of symptoms, so unraveling specific sources of overlapping or referred pain sometimes requires expertise from different specialists. For such a multidisciplinary effort ho succeed, euch specialist must separute out potentials for pain in the specific structures that fall within his or her spe- cially. This puts 4 serious responsibility on the dentist to he inedible resource, capable of determining whether all of the pain, some of the pain, or mune of the jin hus iis source Within mmasticatory system structures, This is why itis so im- portant for dentists to be able to ride ut masticatory system Stmetures as sources of pain, and ta develop sufficient ex- perlise to seleet appropriate medical specialints for evalua tion of signs oF held of expertise, ft is a serious mistake for i ‘any dentist to minimize portance: of understanding the interrelations ene With the rest of the ast sts IhUSHcAtory system struchures, fj, sible 10 understand oxclosion wil ie ‘eclosion without unders re vonstinot Handing the rela. Hionship 0f the teeth Wo the TMMJs, the: muscu. mare funetional patterns of jaw movement, It is equally i “at ry have a realistic understanding of orofacial see ae without a total masticatory system perspective. Failure a derstand these. perspectives is the prinwry season wiwy ya inenbof so many TMD pai Pad bey pain Patents is limited to medicatie, for controlling xymptoms while ignonng suey off - ct i Progressive structural damage, Dentistry can do better than thay Accepting the role of the dentist as a “masticatory system physician” puts the practitioner ona higher level of hues vation, Looking for signs of structural deformation, While the cause of the problem is shill correctable will entighien any Uentist 10 needs that too often go undiagnosed, The destruc. tive factor, that in (he opinion of many clinicians, cuuscs more damage, more lost teeth, more discomfor, and need for extensive dentistry than any other causative [sci is occlusal disease.” Every practitioner should be able recognize il, treat it, and when detected early enough, » vent it front destroying a dentition. Any dentist who docs feel competent to render adequate treatment should, »\ very least, be able to recognize occlusal disease in its ous forms. Patients should be informed of the problem should be referred when a need for treatment is cviden) Occlusal disease can be detected in many forms. The chapter deseribes iissigns and symptoms. SSPIONTS Hut ANE wot sn demi, ' Gi Reterences Riirher DK: Occlusal interferences and terparomanfira function, Generaé Dentistry Jun Feb, 56. 200. Ramfjord SP; Dysfuserions! tenporontandbular joint and pain, J Pmcthed Dent 11:353-374, 2004 Kirveskari P, LeBell ¥; Salonen M, et al: Effecs of eltsniret oclusal interferences on Signs and syroproms of cranium lay disorder in young adults. J Gri Reliohit 1tc21-26, WS" Ash MIM, Ramfjunl SP: Qecfusion. ed, Philtelphis, 1° ‘Saunders, Trolkir P, Maris RW, Preishel HW: Qeclusal adjestmen! ' forerunicmanddibulae disoruers,-a clinica) assessment Py ° thd. Prushet Der GR:957-Met, 199 fs MeNimuara 1A, Seligman DA; Okescat JP: Occlusion. on” Trewunent, and (eraporomandibalar discrsters: aie sfockil Hunn 9-73-80, 1995. : aioe “Institutes of Health Technoloyy Assessment en Sintement, Management of teraporoarandisalar dle Prewt Agsoe 1271595: 1803, 1996. Moh! ND, Orbach Re The ditemuna OF = sus clinical cae ah a Dent 67:1 13% a i Ay Oe Rarnfaan! SP: ection =/http://dentalbooks-drbassam.blogspot.com Fal Tyactiviny of the inferior belly of tle lmeral prer the exmndyles to move wp assembly slides up and down against is lubri- ‘One Of the stipperieést substances (synovial Quid) F-12), Visualize the force thal the lateral pterygoid muscle “it must displace one or both the condyles down ‘and hold it there every time the jaw closes when e defléctive occlusal interfcrn of the mandible, either forward, right, or left felation, always involves the lateral pterygoid e such movements are mace by pulling one or forward and downward. Thus the inferior lat muscle!" has the sole responsibility of for ig Of the mandible to align with maximal inter Whenever centric relation is not coinerdent iniercuspation. This puts the lateral pterypnid HisZONistie jsomettic COMtRACtION in Tesistance (0 force of the triad of Atvang elevalor muscles every ‘elose6, This becomes a more damaging protlem ‘a tendency to clenclr or bru, Chapter 7 Centric Relation I is a nmistake to (hink that there must be a major dite placement of the TMJs to produce a problem, It has heen my consistent expenence thal minute occlusal interferences are often the trigger for sore teeth and masticatory musele pain. In fact, some of the most Severe oceluso- muscle pain ein ne sult from deflective occlusal contacts that slightly move a Joose interfering tooth rather than cause a slide from centric relation to maximum intércuspation. | am convinced thal many less than satisfactory occlusal equilibrations. fail be cause minute interferences are allowed t remain. The key to perfecting any occlusion, however, is complete seating of The condyles up inte centrig relation. What might seem to be an insignificant displacement of the joints from cenirie rela ion ty all that is needed to activate muscle mncoordination and hyperactivity, Clinical experience has shown that 10 be true time ufler tine. Current elegant research into the role of the lateral piery- goid muscle has provided mew insight on why minute oe- clusal interferences: can provoke problematic muscle ne sponses. Murray et al ® have provided evidence that suggests thal a major function of the lateral pterygoid mus- cle is in the generation and fine control of the hortzental component of jaw movement. The isolation of subvomp: ments within the lateral pterygoid and EMG studies of sin- gle motor units (SMUs) indicate (hat a graded activation of internal segments of the muscle is involved in the generation of horizontal force vectors, as would be required in pa functional activily and heavy Measurements of displacement of as litle as 0.) mm were shown to recruit SMUs within the pterygoid muscle. This ev- idence for an association between SMUs and horizontal jaw displacements 1s consistent with predominantly aerobic fihers in the musele that may correlute with fatigue resistance and low forces such as those used in speaking However, Muo et al! found that a significant proportion of fibers within the lateral pterygoid ane predominantly anaerobic and ave therefore: fe ing and fuligue-susceptible, These are the fibers that would most likely be involved in parafune- tioual motor welivities involving protrusive and lateral grind- The fatioue-susceptible ¢ teristics of these fibers seem to correlate with our clinical Hadings of Muscle discomfort from bruxing or clenching when only minnie occlusal interferences were present, This observation is given further potential by findings that the inferior lateral pterygoid muscle was implicated in the development of iso- metic horizontal forces toward the end of the intercuspal phase of chewing.'* Isometric: muscle activity results from the lateral plerygoid muscle’s res to elevator muscle con- uuction . ., exucily what we see inthe presence of deNlecave occlusul interferences. Furthermore, it has been shown that both heads of the luteal pterygoid inuscle are in achve resis- tance"? to prevent the condyle-disk assembly from complete seating during protrusive orcontralateral clenching, More stu are needed in which muscle activity is re~ Jated 10 the relationship of maximum intereuspation (aa pre cisely recorded and verified centric felution. fia the mean time, our clinical observation and consistent, In ustication./http://dentalbooks-drbassam.blogspot.com he absence of’ structural intracapsular disorders, precise oc- clusal correction to eliminate all premature or deflective in- ‘terferences to centric relation is « highly predictable process for eliminating most problems of masticatory muscle pain. At routinely results in comfort for the patient and more sta- bility of the dentition, The key (o success seems to invari- ably be complete release of the inferior lateral pterygoid muscle during closure to maximum intercuspation. This can only be accomplished by eliminating, all defleetive interfer- ences (o centric relation, THE EXTREMELY IMPORTANT SIGNIFICANCE OF TM] SOCKET DESIGN - -. FIGURE 7-13. Direction of movement of the cand yle-disk assembly. — —— J Po a es FIGURE 7-I4 Note the outline of the condyle as comacts the slope af the emincatia. Iris nol in contact vith the thin roof of the Fossa, FIGURE 715 Hinge ax rewoninggs are prc tant he canhelyHEh caro ai on sec AAS ee We've explained why muscle is not ping the upeurd movement of (Fieuie 7-13): Now Sees te EM: the ony anal Ea fossa. Note the triangular shape of the apex is toward the inline to ace; ie! ‘of the medial poles of the condy Meal eos Asem hy referred to us ihe a pl the pure rotstii 1 al a Hes, The Wide par uf y, fossa accommodates the mover f ment of the lateral pole iy. ing rotation. The arrows represent the path of Baan from protrusive to ic relation. The term Centric is an adjective that means “cenicny: ‘The medial poles are centered im the middle of the ma. third of the fossae (Figure 7-15). When the condyles are fully seated, the front of yy. condyle (with disk interposed) contacts against the posi: slope of the eminence. The upward movement is siogpe: py comaet of the medial pole with the heavily buttressed up in the medial third of the fossa (Figure 7-16). \\ point, the condyle-disk assembly cannot move tigh: can rotate in that position, even under strong muscle | IN CENTRIC RELATION, ONLY TH: a POLE ROTATES ON A FIX his i SS" °&° °°” ‘The lateral poles do not align with the fixed axis of so in all opening and closing movements ‘of the mai’ the lateral pole must translate even. when the com!) main on a fixed centric relation axis (see Figure 7-10 is why the glenoid fossae are triangular in shape 9 apex at the medial poles. . The purpose of Jateral pole translanon during con! tation is to provide a sort of windshield wiper el" spreading synovial fluid. back und forth over the entire of the condyle and the bearing surfaces ofthe disk. cular bearing surfaces require this distribution sof ftuid to provide nourishment and Wonca’ ithe condyle fits into # concave disk as a perfect ball un’ the fil under compression. would prevent synovial Howing through the entire interface ‘of the ond o i ‘ties in the surface of the condyle als? 2 indentations for the Mult \o travel i flow hy provid Much confusion has restill aaa jranscranial films ef the TMJ because ol failure A stand the mechanics of lateral pole tavel. I pp ; that the condyle changes: position is the jay eps : From such films, some have concluded that eo * is nota fived avis. But the gnedial pote does ne!” hl it 7 ry) ame fixee prermsercanial files andl it con in fared $14) hi pentric relation. This can be clearly demnoastrate’ rakes ang nem ng a jed from misintenpr:!!)position shown in Figure 7-17 is consistently si- ‘with the uppermost position. This medial pole prevents the lower posterior teeth from moving lly toward the midline, an essential anatomic de- kes anormal curve of occlusion possible. It also s why an immediate side shift is not possible from y seated position of the condyles in centric relation. FAT Medial pole bracing in line with internal pterygoid mus- jom establishes the midmost position at cenisie relation, /http://dentalbooks-drbassam.blogspot.com If the condyle-disk assembly is sliced through the center, it shows the disk on the front of the condyle. It is this per- spective that misleads some to believe the condyle will slip off the back of the disk if it is not “supported” by teeth. This cannot happen if the disk and its ligaments are intact. It is the medial third of the condyle that is well covered by the disk. A slice through this part of the candyle-tlisk assem- bly shows how the normal upward force of the elevator mus- eles is directed through the concavity of the disk and fossa.