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Roger Solow, DDS

Centric Relation (CR)

1. At the most superior position, the condyle disk assemblies are also braced
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.

Only if nonsurgical approaches are unsuccessful should surgery be

TMJ dysfunction- pain to lateral palpation of the joint
pain to palpation of the muscles of mastication
limited range of mandibular movement
joint sounds
3. Goal of occlusal therapy is to eliminate deflection of the condyles from
their functional movement in the glenoid fossa by opposing cuspal inclines
during occlusal function.
Complete seating of TMJs into the fossa in a comfortable relationship is the
most important factor for successful alleviation of pain in the musculature.
2 heads of the lateral pterygoid muscle function reciprocallyinferior head active in opening, inactive on clenching on splint in CR
superior head active in closing
Lateral pterygoid muscle is the only muscle that can protrude the condyle
and is always active in any protruded condylar position.
Potential for muscle hyperactivity and pain is greatest if the deflective tooth
contact is unilateral. If occlusions are examined only in unguided closure
to maximum intercuspation (MI), such discrepancies are missed.
Adapted centric posture- deformed TMJs that have remodeled or adapted to
a conformation that can comfortably accept maximal loading.
Adapted centric posture may not be as stable long term, because deranged,
healed connective tissue remodels more than normal bone and collagen.
Type 1- MI occurs in harmony with a verifiable CR
Type 1A (adapted)- MI occurs in harmony with adapted centric posture.
Type 2- Condyles must displace from a verified CR to MI
Type 2A- Condyles must displace from adapted centric posture to MI
Type 3- CR or adapted CR cannot be verified
Condyles cannot comfortably accept load
Type 4- Pathologic and unstable TMJs with an occlusal relationship in a
stage of progressive disorder.
Progessive anterior open bite, progressive asymmetry, or
progressive mandibular retrusion.
4. If maximum intercuspal (MI) tooth contact is not coincident with the
completely seated position of both condyles, the condyles must be
displaced to achieve closure in MI.
Ligament bracing in centric relation (CR) is not a factor as the condyles can
be displaced down and back from CR before the ligaments reach their
functional limits.
Criteria for CR:
1. Disk if properly aligned on both condyles
2. Condyle-disk assemblies are at the highest point possible against the

posterior slope of the eminentiae.

3. Medial pole of each condyle-disk assembly is braced by bone
4. Inferior lateral pterygoid muscles have released their contraction and are
Adapted centric posture- relationship of mandible to maxilla that is achieved
when deformed temporomandibular joints have adapted to the degree that
they can comfortably accept firm loading when completely seated at the most
superior position against the eminentiae.
Criteria for adapted centric posture1. Condyles are comfortably seated at the highest point against the eminentia
2. Medial pole of each condyle is braced by bone (disk may be partially
3. Inferior lateral pterygoid muscles have released their contraction and are
4. Condyle to fossa relationships occur at a manageable level of stability.
Unstable TMJs result in unstable occlusions.
Lateral pole derangements can be treated as normal joints if the medial pole
disk alignment is acceptable and adapted centric posture can be verified by
load testing.
Common intracapsular problems that permit adapted centric postureLateral pole disk derangement
Complete disk derangement with formation of a pseudo-disk
Complete disk displacement with perforation
Partial disk derangements and asymptomatic clicking TMJs
Treatment positionneither CR or adapted centric posture can be achieved.
objectives in determining treatment positionrelief of pain
eventual stabilization of condyles either in CR or adapted centric posture
5. Central bearing area of articular disc is composed of densely oven collagen
fibrils having no vascularity or innervation- adapted to accept pressure
Thickened posterior band of disc has vascularity and innervation.
Flat plane anterior deprogrammer results in a similar application of force
as bimanual manipulation because of the vectors of action of the elevator
Shape and contour of the articular disc and condyle is variable- resulting in
variation in the joint space on lateral radiographs and tomograms.
Use of radiographs to establish a condylar position should be discouraged
1. Dawson PE. Optimum TMJ condyle position in clinical practice. Int J
Periodont Rest Dent 1985;5:10-31.

2. McNeill C. The optimum temporomandibular joint condyle position in clinical

practice. In J Periodont Rest Dent 1985;5:53-77.
3. Dawson PE. A classification system for occlusions that relates maximal
intercuspation to the position and condition of the temporomandibular joints.
J Prosthet Dent 1996;75:60-6.
4. Dawson PE. Ne definition for relating occlusion to varying conditions of the
temporomandibular joint. J Prosthet Dent 1995;74:619-27.
5. Gilboe DB. Centric relation as the treatment position. J Prosthet Dent
Recording Centric Relation
1. Glossary of Prosthodontic terms- centric relation (CR) is the clinically
determined relationship of the maxilla to the mandible when the condyle-disk
assemblies are positioned in their most superior position in the mandibular
fossa and against the slope of the articular eminence.
CR recorded with bimanual manipulation and wax interocclusal records as
taught as the Pankey Institute.
CR was achieved consistently by a number of dentists on the same patient
within 0.1mm.
Degree of precision in reproducing CR measurements is due to a precise fit of
the condyle within the fossa with the joint braced by the osseous components.
2. Unless the condyles are uppermost, restorations will be made in supraocclusion.
Lucia jig- DuraLay acrylic is polymerized on a model lined with tin foil since
heat is generated. Borders extends 1-2mm beyond the gingival margin
buccal and lingually, covering the 6 anterior teeth.
Jig is retained in mouth with denture adhesive.
Adjustment procedures of jig break the reflex pattern of closure to find CR.
Patient chews forward, back, and sideways creating a gothic arch tracing with
the point at CR.
3. Mounting casts in CR on a semi-adjustable articulator aids in the diagnosis of
the malocclusion and may reveal a malocclusion that is more severe than that
seen with the teeth in maximum intercuspation (MI).
Anterior flat plane deprogramming appliance- Pankey prefabricated bite stop
was lined with orthodontic acrylic.
Wax interocclusal records were obtained with Roth power centric registration
before and after wearing the bite stop during sleep overnight.
Deprogramming appliance provides a CR record with a greater displacement
from MI than a CR record alone.
4. A prefabricated anterior bite stop was relined with red stick impression
Electromyographic (EMG) activity of the anterior and posterior temporalis, and

masseter muscles was recorded during clenching and grinding with or

without the bite stop in place.
The anterior bite stop significantly decreased EMG activity for the anterior and
posterior temporalis, and masseter muscles during clenching and grinding.
If the anterior bite stop is used before or in conjunction with interocclusal
recording, the record may be more accurate because of decreased EMG
5. After 3 hours instruction, a standardized protocol of bimanual manipulation
allowed novice dentists to achieve CR on 106 of 110 first attempts and 4 of
4 second attempts.
The most important criterion for CR is the complete release of the inferior
lateral pterygoid muscle during jaw closure.
6. CR was achieved in 33 out of 33 attempts with bimanual manipulation.
Wearing an anterior deprogrammer for 1 hour followed by unassisted
clenching achieved CR in 43 out of 44 attempts.
When there is no influence from occluding teeth, CR is a physiologic condylar
position to which the contacting masticatory muscles will position the
7. A flat anterior deprogrammer was fabricated with Snap acrylic resin.
Retention on the maxillary incisors by intimate fit from low setting distortion.
The acrylic was shaped so that a single lower incisor would contact when the
patient closed in a consistent arc, as if closing on the posterior teeth.
This contact was marked and observed during bimanual manipulation and
load testing of the TMJs.
BluMousse vinyl polysiloxane CR record was obtained when consistent and
comfortable arc of closure was confirmed on the mark
Patients who were difficult to manipulate were asked to protrude to trace a
gothic arch protrusive pattern- the posterior aspect being CR
After mounting, the soft tissue contact and septae were removed, and the
acrylic platform was placed on the maxillary cast. Lower incisor contact must
close precisely on the intraoral CR mark to verify the accuracy of the
diagnostic casts.
Verification of CR during bimanual manipulation and after mounting, is the
advantage of this technique.
A single operator without an assistant can obtain predictable CR records
The vinyl polysiloxane is accurate and durable
8. 15 subjects were analyzed for the accuracy of achieving CR by biting hard or
easy on a leaf gauge compared with a wax record with the jaw guided by
the operator.
Patients were asked to bite hard on the leaf gauge until they could do so for 5
minutes without the posterior teeth touching, followed by a relaxation period
by closing on cotton rolls. This was designed to deprogram the muscles.

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;
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;
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
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)

1. Surface electromyography does not appear to contribute any additional

information beyond what can be obtained from patient history, clinical
examination, and imaging.
Current gold standard to identify the prescence or absence of TMD, or one
of its subcategories, is a comprehensive history, clinical examination, and
when appropriate, imaging.
Factors influencing the use of surface electromyography (SEMG):
BiologicalPhysiological variability results in confusion between symptomatic and
asymptomatic groups.
Age results in decreased EMG activity in older populations.
Gender results in different SEMG recording.
Skeletal morphology affects SEMG measurements in Class I, II, III patients
Psychological factors, i.e. stress affects SEMG recordings
Skin thickness and body weight distort SEMG activity
TechnicalPlacement, position, and stability of electrodes can cause errors in activity
Cross talk (inadvertent adjacent muscle activity) is a source of error
Head or body movement can lead to inaccurate measurement of activity
Existing pain conditions can affect masticatory muscle SEMG activity
Facial expressions result in an increase of EMG from facial muscles
History of bruxism is associated with muscle hypertrophy and high resting
EMG activity.
Reproducibility and validity are difficult if not impossible for SEMG to achieve
Standards of scientific merit (reliability, validity, sensitivity, and specificity) are
most difficult to attain, placing the diagnostic and treatment utility of SEMG in
2. Only 3 types of technology are clinically valuable and supported by research:
Hard and soft tissue imagingCan give accurate image of TMJ morphology, spatial relationship,
anatomic derangement, and certain pathologies.
None of these findings correlate perfectly with clinical signs or symptoms
Acrylic oral appliances- positive responses in symptomatic patients.
exact reason for these responses is not clear.
Biofeedback training- people can learn to alter their physiologic function
Valid electronic diagnostic machines have not been developed to detect
temporomandibular disorders (TMD)
A reasonable diagnosis can be established in most cases of craniofacial pain
with clinical methods supplemented by imaging techniques.
3. Sensitivity of a test# of patients identified as having the disease / total # patients who actually
have the disease
Specificity of a test# of patients identified as free of disease / total # of disease free people

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
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. 12 patients with severe masticatory dysfunction were evaluated for nocturnal

bruxism changes after using a portable biofeedback unit.
After a 10 night pretreatment recording of masseter muscle activity, each
patient used a portable biofeedback unit for at least 60 nights.
Overall change was measured by a questionnaire and EMG recordings 60
and 90 days after treatment.
Chronic bruxers had clear improvement relative to baseline reports and
For bruxism 41.6% rated the unit very effective, 50% rated it slightly
For facial or head pain 50% rated it very effective, 33% moderately
5. 24 women myofascial pain-dysfunction (MPD) patients were evaluated for the
effect of biofeedback on reduction of symptoms.
3 groups were createdbiofeedback only (15 one minute trials)
biofeedback and instructions to place the jaw in rest position
biofeedback and a prosthetic guide (6.8mm thick metal) to close on to
maintain the open jaw position.
The instruction and prosthesis groups obtained significantly greater EMG
reductions in masseter muscle activity and mandibular range of motion,
compared with biofeedback alone.
Short term biofeedback treatment may be augmented by procedures that
place the mandible in the rest position.
6. Myo-monitor claims to stimulate all of the jaw closing muscles in a
simultaneous and physiologic manner.
Only the distal motoneurons innervating masseter muscle are directly
stimulated, with no evidence of a reflex activated masseter contraction.
Neither jaw closing during mastication nor voluntary biting or clenching are
brought about by the jaw jerk reflex.
It is untenable that reflex activation of the jaw muscles would give and ideal
occlusal position.
7. 10 asymptomatic and 7 symptomatic patients with pain in the masticatory
muscles were evaluated with Myo-Tronics Mandibular Kinesiograph (MKG).
The MKG uses a device containing 3 magnetometers to track the path of a
magnet attached to the lower central incisors.
Mandibular movement of symptomatic patients could not be differentiated
from those of normal subjects during the 4 tests advocated by Myo-Tronicsmeasurent of displacement and velocity, mandibular movement from rest
position to intercuspation, and chewing movements.
The results of this study strongly suggest that the diagnostic criteria that were
tested have no clinical usefulness.
Application of these invalid criteria to diagnose normal and abnormal function

can lead to the classification of normal subjects as dysfunctional.


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
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


by a kinematic facebow and intraoral clutches.

The position of the mandible in Myo-Monitor centric was never found to
coincide with the mandible in CR.
Variability among records of Myo-Monitor centric taken at the same and at
different appointments indicate that this is not a distinct and reproducible
position for each individual.
The axis described by Myo-Monitor centric position was found to be anterior
and inferior to the patients terminal hinge axis.
Myo-Monitor centric tooth contact usually occurs anterior to centric relation
tooth contact.
11. Myo-Monitor manufacturers claim the unit stimulates the mandibular division
of the fifth cranial nerve (motor portion), which conducts impulses to the
muscles of mastication and produces group function of the closing muscles.
5 healthy subjects were evaluated for masseter, medial pterygoid. and
temporalis activity after stimulation by the Myo-Monitor anterior to left and
right tragi.
If electrical stimulus depolarizes a motor nerve, an impulse is initiated which
is rapidly conducted via the nerve to the neuromuscular junction.
If electrical stimulus depolarizes the muscle membrane directly, a muscle
impulse is produced which will slowly propagate over the muscle fibers
leading to contraction.
Contraction of the masseter occurred, while little or no contraction took
place in the other mandibular elevators following stimulation.
From conduction velocity data- the masseter is stimulated directly and not
through its motor nerve.
From lack of consistent contraction in the anterior temporalis, and complete
lack of contraction in the medial pterygoid, it appears that the Myo-Monitor
does not produce group function of the closing muscles.
The Myo-monitor, like any electric shock, excites the masseter directly.
12. 9 asymptomatic subjects were evaluated for differences between models
mounted with a standardized CR records and Myo-Monitor centric records.
CR records were obtained within a range of 0.1mm.
Myo-Monitor centric records varied on the same side on the same patient.
Myo-Monitor centric was anterior to CR.
Myo-Monitor centric was different on the left and right sides of the same
Myo-Monitor centric position is not reproducible with repeated registrations
on the same patient.
13. Far too many instruments and devices gather data that is not of value in
making clinical decisions.
Jaw motion tracking, sonography of the TMJ, occlusal contact recordings,
and EMG recordings of the jaw muscles provide documentation but do
not generate information critical to treatment decisions.


Muscle stimulators reduce elevator muscle tone- this creates an increased

vertical dimension that is not diagnostic of a problem with the patients
existing vertical dimension.
Invalid and artificial criteria of disease with jaw tracking, EMG system in
conjunction with electrical jaw muscle stimulation finding vertical dimension
problems where none existed. Cooper and Rabuzzi. Laryngoscope 1984;
94:68-75. Vertical dimension problem was detected in 21/26 asymptomatic
subjects that exceeded an artificial criteria for correct vertical dimension.

Myo-monitor is designed for stimulation of the motor branches of the 5 th

and 7th cranial nerves, bilaterally using surface electrodes.
Myo-monitor designed to generate a response in all the muscles of
mastication and facial expression.
30-40 minutes of gentle twitch contractions are required prior to any other
use of the Myo-monitor. This is designed to eliminate fatigue spasm or
myostatic contracture.
Rest position is the starting point from which the mandible is carried on a
relaxed trajectory to terminate at the occlusal position compatible with
relaxed musculature.
All measurements should be made with an empty mouth as foreign
objects, especially over the occlusal surfaces alter relational
measurements, noticeable as increased vertical dimension.

15. 10 subjects free of TMD signs or symptoms were evaluated for the
relationship of jaw muscle activity, rest vertical dimension, and clinical rest
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
As vertical opening from maximum intercuspation increased, EMG activity
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
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Dent 1987;58:698-701.
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training of masticatory muscles in myofascial pain-dysfunction patients.
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physiological occlusal position? J Prosthet Dent 1988;60:509-14.
7. Feine JS, Hutchins MO, Lund JP. An evaluation of the criteria used to
diagnose mandibular dysfunction with the mandibular kinesiograph. J
Prosthet Dent 1988;60:374-80.
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induced by phonetic, transcutaneous electrical stimulation, and masticatory
electromyography. J Prosthet Dent 1983;49:100-5.
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the diagnosis, documentation, and treatment of dental patients. J
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1. Goal of creating a new occlusioncontrol the load applied to the TMJs, teeth, and periodontium
ensure muscle comfort and function
2 ways to affect the applied forcealter the occlusion so that the muscles can move the mandible with
less force
redistribute the applied force to more favorable locations: a greater number
of teeth or different teeth.
Which teeth should touch in centric closure?
When only anterior teeth touch 60% of all bite force goes to the TMJ.
If 2nd molars touch, only 5% of the bite force is allowed to reach the TMJ.
The posterior teeth absorb the rest of the force.
Equal posterior tooth contact diminishes force on any single tooth and


reduces the load to the TMJ.

Which teeth should touch in eccentric contact?
Anterior teeth should guide lateral excursions and posterior teeth should not
Anterior guidance reduces elevator muscle activity.
Less force on anterior than posterior teeth, due to Class III lever principle.
Which overbite and posterior anatomy should be used?
A customized anterior guidance should be developed first, then posteriors
with cusps that disclude.
What vertical dimension of occlusion should one use?
Vertical dimension of occlusion (VDO) is an equilibrium between repeated
contraction of the elevator muscles and the eruption force of teeth.
When anterior teeth VDO is increased 2-3mm, the masseter length is
only increased by 1mm.
When the condyle is seated superiorly in the fossa, the masseter muscle
shortens 1:1 by the amount of condylar seating.
Problem with neuromuscular concept is that it is concerned with finding the
amount of electrical activity in the muscles at rest. In all other systems the
concern is creating the lowest level of muscle activity during function to
minimize loads on the teeth.
What condylar position should occlusion be built?
Superior condylar position is usedreproducible
only position with no lateral pterygoid activity
border position- any inferior position will result in posterior interferences
on further condylar seating
Neuromuscular stimulation always produces an inferior and anterior
condylar position because the lateral pterygoid is stimulated.
This creates an occlusal position that requires the pterygoid to be active
everytime the patient closes.
2. The paths of movement of the condyle have little or no influence on the
incisal guidance.
Unlike the resiliency and flexibility in functional movements of the condyle,
the incisal guidance is inflexible; hard surfaces against hard surfaces.
Straight protrusive inclination may be steeper than the lateral guidance,
permitting longer and more esthetic central incisors.
Balancing inclines should be less steep than the incisal guidance and forward
Incline of the glenoid fossa, to avoid traumatic contact.
Mandibular closure paths vary with head posture and muscle tone- so a
slight lateral and antero-posterior freedom in centric occlusion is needed.
Natural dentition- concave incisal guidance with steepness of guiding inclines
diminish as centric occlusion is approached.
Objectives of occlusal rehabilitation:
Static centric occlusion in harmony with centric maxillo-mandibular relation
Even distribution of stress in centric occlusion on the maximum # of teeth


Lateral and anteroposterior freedom of movement in centric occlusion

Masticating efficiency of working inclines coordinated with incisal guidance
and normal condylar movement
Reduction of balancing inclines to avoid traumatic contact
3. Stress on balancing inclines is magnified since they are approximately
perpendicular to the direction of force and concentrated on few teeth.
Steepness of balancing incline related to the forward inclination of the glenoid
fossa and the laterolingual incline of the upper cuspid (or lateral guidance
on other anterior teeth) on the opposite side.
Reduce balancing contacts by reducing the length of the lingual cusp and
steepness of the lingual inclines of upper teeth.
In creating teeth on the articulator, reduce the condylar inclination 10 degrees,
to avoid balancing incline contact in the mouth.
4. Temporomandibular joint pain-dysfunction syndrome can be diagnosed and
treated on a predictable basis.
Muscle becomes fatigued when it must maintain a prolonged contraction.
The source of stimulation causing prolonged contraction is some type of
of interference which requires muscles to hold the mandible in a position
which is not in harmony with normal muscle function.
When the pain of a joint syndrome is related to muscle, there will be a
corresponding deviation that requires abnormal activity of specific painful
Any deviation of the condyle-disc assembly from its braced terminal hinge
starting point, the medial and lateral pterygoid muscles are involved.
Sore right side muscles indicate the slide from first centric occlusal contact
will be toward the left.
If centric relation (CR) interferences are not completely eliminated, the patient
may be less comfortable after occlusal adjustment than he was with his
aquired occlusal position.
The most minute discrepancy can trigger severe muscle imbalance and pain.
The dentist must be able to manipulate the mandible accurately to detect such
minute interferences.
Mandible cannot be forced into CR, forcing causes muscle bracing by the
stretch-reflex mechanism, and the mandible will be held forward of CR.
A discrepancy between firm and light closure marks indicates that the teeth
are being moved by firm closure.
Recommended radiographs for differential diagnosis are periapicals (pulp
disease) and Panorex (cysts, tumors, fractures).
The pain of TMJ syndrome is almost always resolvable in a matter of minutes
once the occlusion has been refined as well as possible.
Multiple adjustments are needed until the teeth reach an equilibrium with their
own periodontal ligaments
5. Use of Angles classification to define malocclusion is a serious, consistent


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
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,


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
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
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.


During simulated mastication or occlusion, every tooth has its own 3

dimensional movement up to 60 microns in every direction.
During canine guidance excursion the upper canines moved up to 60 microns
bucco-mesially and the lower canines up to 50 microns lingual-distally, while
the premolars show no movement.
Following local anesthesia, the upper canines moved up to 120 microns,
demonstrating the role of proprioceptors in the periodontal tissues.
Canine protected occlusion does not produce any excessive tooth
movements of the canines. This is the only type of occlusion which can
prevent undesirable movement of the premolars and molars.
3. 51 patients posterior teeth were analyzed for cracks.
Class I or II restorations put the teeth at 29 times greater risk for cracks.
Excursive interferences caused a 2.3 times greater risk for cracks
Equilibration was recommended to remove the etiologic factors that contribute
to crack propagation.
4. Occlusal disease- the loss of the anatomical parts of occluding tooth surfaces,
resulting in functional impairment, pain, or both.
Bruxism is the cause, occlusal disease is the result.
Most common attrition is laterotrusive.
Adaptive wear- minimally worn anterior teeth from time of eruption through
the loss of mamelons.
Stage I- early occlusal disease, incisal edge and lingual concavity wear
Stage 2- moderate occlusal disease, anterior-posterior group function.
some dentin exposure
Stage 3- advanced occlusal wear, posterior working and nonworking group
function, dentin heavily abraded
Stage 4- total occlusal destruction
Anterior guidance is the major design factor in retarding occlusal disease.
If the lateral incisor wears, the main oppositional teeth are past their initial use.
Occlusal adjustment is no longer elective but mandatory for patients requiring
restorations, for TMJ dysfunctions, or those dentitions that show signs of
occlusal trauma.
Restorative classification- Class I: operative
Class II: crown and bridge
Class III: occlusal reconstruction
Class IV: periodontal prosthesis
5. During the initial exam, the patient should be encouraged to go through all
mandibular movements with the teeth in contact.
Matching wear facets should be communicated to the patient.
Reverse chevron shape of maxillary incisors- specific to movement of
the mandible within the confines of maxillary teeth.
Chevron shape of the incisal edge of maxillary central incisorspathognomonic for crossover position wear.


6. Protrusive crossover (brux-braced) interferences- lower canines and incisors

wearing maxillary incisors.
Occlusal guards must have smooth guidance through crossover positions.
Early occlusal disease may require only nocturnal occlusal guard therapy
and daytime patient control.
Dawson: Excessive anterior wear is often the result of posterior occlusal
Axial loading on implants, without eccentric contacts on posterior teeth,
cannot be overemphasized.
7. Iatrogenically placed high crowns or restorations in maximum intercuspation
can have a local deleterious effect (inflammation and sensory change) on
the investing alveolar tissues and pulp tissue of teeth.
The effect appears to be transient (several days to weeks) because the
traumatized teeth tend to move away from the adverse forces.
These local adverse sensory and periodontal-osseous effects of occlusal
trauma are indications for equilibration.
Asymmetric postural muscle activity resulted from occlusal interferences
(metal overlay) which was not present before the overlay placement.
This asymmetric activity returned to normal upon removal of the overlay.
High amalgam restoration caused pain, tenderness, and fatigue in elevator
One theory of balancing interferences is that canine guidance is protective of
the jaw. This is illogical from the point of view that parafunction causes
canine attrition.
Molar guidance on splints also resulted in reduced muscle force (as in
canine contact only), as subjects were unwilling to clench as hard on one
tooth versus multiple teeth.
Iatrogenic high restorations will likely induce accommodations in postural
and functional jaw patterns. These are greater with interferences to
intercuspal position than lateral occlusal interferences.
Studies on natural teeth with occlusal adjustment or experimental
interferences do not demonstrate that occlusal interferences cause
nocturnal bruxism, or if removed, stop it.
8. 282 patient histories and occlusal analyses were evaluated for occlusal
interferences in centric and eccentric movements, and their relation to pain
in the TMJ, muscles, and adjacent structures.
The presence of the protrusive and lateral component of a slide in centric
was statistically significant for patients with pain and symptoms.
Muscular symptoms were not in proportion to the magnitude of the slide from
Balancing interferences tend to be found on the same side as the
pain/symptoms of TMD.
A slide from CR in combination with balancing interferences was found almost
twice as often in symptomatic as compared to asymptomatic patients.


9. A longitudinal cephalometric study of vertical craniofacial and dentoalveolar

changes during 20 years of adulthood was performed in 30 adults.
Lateral cephalograms at age 25 and 45 years were compared.
Significant changes in craniofacial dimension occur during adult life.
Total anterior face height increased by 1.6mm on average.
4/5 of the increase as in the lower face.
In the dentoalveolar region significant in all dimensions except overjet and
overbite were found, indicating eruptive movement of the teeth and a vertical
development of their investing tissues.
1. DAmico A. Functional occlusion of the natural teeth of man. J Prosthet Dent
2. Siebert G. Recent results concerning physiological tooth movement and
anterior guidance. J Oral Rehabil 1981;8:479-93.
3. Ratcliff S, Becker IM, Quinn L. Type and incidence of cracks in posterior teeth.
J Prosthet Dent 2001;86:168-72.
4. Lytle JD. The clinicians index of occlusal disease: definition, recognition, and
management. Int J Periodont Rest Dent 1990;10(2):103-24.
5. Lytle JD. Occlusal disease revisited: part I- function and parafunction. Int J
Periodont Rest Dent 2001;21:265-71.
6. Lytle JD. Occlusal disease revisited: part II. Int J Periodont Rest Dent
7. Clark GT, et al. Sixty eight years of experimental occlusal interference studies:
what have we learned? J Prosthet Dent 1999;82:704-13.
8. Geering AH. Occlusal interferences and functional disturbances of the
masticatory system. J Clin Periodontol 1974;1:112-9.
9. Forsberg CM, Eliasson S, Westergren H. Face height and tooth eruption in
adults- a 20 year follow-up investigation. Eur J Ortho 1991;13:249-54.
Noncarious Cervical Lesions (NCL)
1. Loss of contour at occlusal and cervical sites on 3 teeth of a single individual
was measured digitally at 3 times over a 14 year span.
1983 casts and 1991, 1994, and 1997 impressions were replicated in epoxy
Finite element analysis and buccal strain gauges show occlusal contact
concentrates stress at the cervical region.
This patient had unilateral canine-guided occlusion at baseline that evolved
into bilateral group function after 14 years.
Both small forces over a large lateral excursion and large forces over a small
lateral excursion could produce similar cervical volume loss.
There was a strong correlation between occlusal wear and cervical volume
loss on the same teeth.
Cervical volume loss as directly proportional to the occlusal force times total
lateral excursion movement.
2. Photoelastic study of cervical root lesions and their restoration in periodontally


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


since there is no loss of interdental bone or soft tissue.

Miller Class III recessions (where there is loss of papillary height because of
bone loss) can expect only partial root coverage.
In most NCL sclerotic dentin (obliteration of dentin tubules) is present and
the tooth is not sensitive.
Difficult to bond to sclerotic dentinZone of resin impregnated sclerotic dentin is thinner than in normal dentin
Tensile bond strength of adhesives to sclerotic dentin is 20-45% lower than
normal dentin.
7. NCL were significantly related to wear facets.
These findings strengthen evidence for the role of occlusal forces as an
etiologic factor for NCL.
Noncarious lesions (NCL) are classified into 3 categoriesAbrasion- loss of tooth structure of mechanical origin.
Attrition- loss of tooth structure by normal or parafunctional contact.
Erosion- loss of tooth structure of chemical or idiopathic origin.
Grippo 1991 introduced a new categoryAbfraction- loss of dentin hard tissue by biomechanical forces (flexing).
Dentin appears stronger than enamel under lateral forces.
Occlusal trauma alone doesnt explain NCL as many teeth show signs of
occlusal trauma but dont develop NCL.
70 patients were clinically evaluated with articulating paper in maximum
intercuspation and lateral and protrusive excursions for NCL and occlusal
The main reason for disagreements in the literature (origin of NCL) is the
large variability of age ranges in the study sample, since prevalence of
NCL increase with age.
Prescence of parafunctional habits did not correlate with presence of NCL.
Lateral chewing forces during chewing and bruxing may cause flexure of
Tensile stress is concentrated at the cervical area close to the tooth fulcrum,
breaking the chemical bond of enamel and dentin crystalline structure. This
allows penetration of small molecules through microfractures that disrupt the
repair of these chemical bonds.
Damaged tooth structure is subsequently lost through secondary factors- acids
and abrasions.
8. Overloading of theoretical teeth by 2D computer simulation resulted in enamel
damage at the CEJ and led to initiation of cervical lesion.
Subsequent overloading resulted in enamel destruction along the CEJ.
The overhanging enamel fragment may be easily chipped.
Alternate tensile and compressive stresses are generated in the cervical
NCL is based on undermining the enamel at the DEJ.
Compressive strength of enamel is 33 times larger than its tensile strength.


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
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
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
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.


2. Elevator muscles demonstrate maximum activity when even bilateral occlusal

contacts occur during clenching in the intercuspal position.
Increasing the number of eccentric tooth contacts increases the muscle
activity during both chewing and clenching.
The inferior head of the lateral pterygoid muscle has a reciprocal role with the
medial pterygoid muscle during chewing.
3. Group function- even tooth contact of the posterior teeth.
Canine guidance- only upper and lower canines contact
Each subject wore a maxillary occlusal splint for 5 days
The splint was cemented with Temp Bond for increased stability
The splint was sectioned at the canines to create 3 pieces- with all 3 pieces in
place group function was recorded in laterotrusion. Canine guidance was
recorded when only the anterior segment was in place.
Canine guidance caused a greater reduction in EMG activity of elevator
muscles compared to group function.
With canine guided occlusion pressure is concentrated in a small periodontal
surface area.
Canine guidance is recommended for full coverage occlusal splints.
4. There is a postural activity in the anterior temporal and sometimes in the
masseter muscles. This is reduced in the supine position.
A 0.5mm high interference of amalgam was placed on a maxillary molar.
EMG recording showed increase muscle activity upon insertion of the
experimental occlusal interference.
5. EMG activity of masseter muscles, anterior and posterior temporalis muscles
were investigated in different vertical and sagittal jaw relations.
The masseter muscle EMG amplitudes were the same for all jaw positions.
The temporalis muscle EMG activity was decreased after the vertical
dimension was raised and further decreased after the mandible was
Function of the masticatory muscles cannot be simply understood form the
direction of their action lines.
Decreased temporalis muscle activity during posture and submaximal
clenching while the splint was worn may relate to the therapeutic effects of
splints for craniomandibular disorder patients.
6. Temporary fixed partial dentures were removed and radio transmitter bridges
were cemented with Opotow cement.
During mastication EMG activity ceases on the muscles of the chewing side
prior to or at the moment of intercuspal tooth contact.
During progressive mastication of the bolus, the amount of EMG activity
The shape of the teeth is determining the last phase of the closing stroke.
Muscular reaction to the experimental incline interference was identical to


the muscular response to any type of tooth contact- a stop or interruption

of the EMG contraction activity. This is the highly sensitive, self-protective
muscular response to prevent possible tissue damage.
The tooth responsible for the interference is not likely to be traumatized during
Possible damaging effect of occlusal interferences during subconscious
movements- bruxism.
7. Full arch maxillary flat plane splint with canine guidance was fabricated, and
electromyographic EMG activity of the temporalis and masseter was
recorded. Canine contact was ground down to allow posterior group function
and the EMG rerecorded.
Only when posterior disclusion is obtained by appropriate anterior guidance
can the elevating activity of the temporalis and masseter muscles be
8. 9 adults were examined electromyographically with electrode insertion in the
superior and inferior bellies of the lateral pterygoid.
The superior and inferior lateral pterygoid muscles demonstrated nearly
reciprocal EMG activity
The superior lateral pterygoid (SLP) active during clenching and moderately
active during ipsilateral movement
The inferior lateral pterygoid (ILP) was active during opening, protrusion, and
contralateral movements.
Clenching in the retruded position- SLP maximal activity
ILP minimal activity
Protrusion against resistance- ILP maximal activity
SLP minimal activity
9. 11 adults were examined electromyographically with electrode insertion in the
superior (SLP) and inferior (ILP) lateral ptergoid, and medial pterygoid
Surface electrodes were taped over the anterior temporalis, masseter, and
anterior digastric muscles.
SLP and ILP demonstrated reciprocal activity.
Jaw appears to have a natural protection from greater force in the retruded
position as evidenced by decreased activity of the superficial masseter,
medial pterygoid, and anterior temporalis during clenching in retruded
SLP active in clenching
ILP active in protrusion, opening, and contralateral positions.
Anterior temporalis active in elevating the condyles and mandible in clenching
Anterior belly of digastric depresses and retrudes mandible
Medial pterygoid and superficial masseter are strong elevators in clenching
10. 8 adults were studied as they bit on an instrument that measured bite force.


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
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
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.


Temporalis muscle tendon inserts into coronoid process and extends

superiorly into the muscle as a central aponeurosis.
Medial pterygoid muscle has 6-8 aponeuroses.
Inferior lateral pterygoid has about twice the cross sectional size of the
superior lateral pterygoid.
No multipennate archictecture in the lateral pterygoid, fibers are suited to
shorten over a longer distance than in the masseter or medial pterygoid.
Digastric consists of 2 bellies separated by an intermediate tendon.
Posterior belly arises from the digastric notch on the medial surface of
the mastoid.
Anterior belly is attached to the digastric fossa of the mandible.
Central tendon is attached to the hyoid.
14. 5 subjects chewed gum before and after an occlusal interference was
introduced by bonding composite to the buccal cusp of an upper premolar.
The interference invariably produced changes in either muscle activity or
displacement of the jaw, or both.
There is no simple and dramatic relationship between malocclusion of the
teeth and many features of muscle activity and jaw displacement.
15. 5 subjects were tested before and 2 weeks after occlusal adjustment.
2 subjects acted as controls.
Tendency for occlusal adjustment to be associated with an increase in the
lateral excursions of the mandible during jaw closure.
It is reasonable to attribute increases in lateral excursions to the removal of
the nonworking side interferences.
All subjects developed maximum muscle effort very close to, or at the
intercuspal position.
If the masticatory system is designed so that high masticatory forces are best
withstood in the intercuspal position, the tendency for peak EMG activity to
move closer to this position following occlusal adjustment is beneficial.
16. 4 subjects had the electrical activity of the anterior and posterior temporalis
and masseter muscles recorded with and without premature unilateral
Celluloid strips 0.05, 0.10, 0.15, and 0.20mm were placed between the first
molars to simulate a premature contact that would activate periodontal
To avoid disguising due to intrusion, the height of the overlay had to exceed
the free vertical movement of opposing teeth (0.02mm)
Unilateral premature contact caused a significant asymmetry of action in
all muscles under study with stronger activity ipsilaterally.
Increased thickness of the overlay decreased the mean voltage bilaterally.
17. With the mandible at rest, EMG recordings were obtained from the anterior
temporalis, lateral pterygoid, and digastric muscles.


10 subjects were recorded in the upright, inclined, and supine positions.

The least activity in all muscles studied was when the subject was in the
supine position.
The supine position is suitable for recording CR.
18. 9 subjects were evaluated for the effect of flat or steep canine guidance or
group function guidance of a maxillary splint on the EMG activity of the
masseter and anterior temporalis muscles.
The flat canine guidance splint separated the 1st molar by 1mm
The steep canine guidance splint separated the 1 st molar by 2.4mm
Higher levels of EMG activity observed with the group function occlusion
suggests that posterior working side contacts during chewing may induce
increased elevator muscle activity.
Canine protected guidance during restoration should be considered to
reduce forces generated to posterior teeth.
During maximum voluntary grinding, EMG activity was lowest when the splint
had a steep canine guidance. Flat guidance as 9% higher and group
function was 38% higher.
19. Muscular resting length corresponds closely to the length developing the
greatest muscular tension.
8 men with normal occlusion and function had EMG recordings of the
masseter and anterior and posterior temporalis muscles at increasing
vertical dimension
EMG activity of the 3 muscles studied decreases when the jaw is depressed
beyond the occlusal position, reaching the minimum as a certain vertical
dimension range specific for each muscle.
Vertical dimension of minimum basal EMGMasseter 10mm
Anterior temporalis 13mm
Posterior temporalis 16mm
Decrease in EMG may be explained by the passive elastic force of the
muscles carrying a larger part of the load on the muscle as is length
20. EMG activity of masticatory muscle during full clenching in the retruded
contact position (RCP) and intercuspal position (IP), with and without a
posterior stabilizing splint was studied.
Clenching in the RCP without the splint and with the presence of an
unstable occlusal contact inhibited masseter muscle activity and reduced
anterior and posterior temporalis muscle activity.
Masticatory muscle activity returned to normal when clenching in RCP with
a splint that permitted stability in the dentition.
Maximum masseter isometric contraction is dependent on the amount of
stability in the dentition rather than jaw position.


If stability is not provided by the dentition (i.e. there is a premature contact)

the jaw muscles must contribute to the stabilization and reduce the
magnitude of maximal contraction to avoid damage to the structures
involved in the compensatory stabilization.
21. 10 subjects with nonreproducible pantographic recordings and 5 subjects
with reproducible pantographic recording formed 2 control groups.
11 subjects with nonreproducible recordings were the experimental group.
A minimum of 20 pantographic recordings were made on each subject
over a minimum of 120 days.
The experimental group had occlusal splint therapy followed by equilibration.
Pantographic reproducibility improved with therapy, controls did not.
Response to occlusal therapy varies with the individual and therapy should
be adjusted to meet individual needs.
1. Radu M, Marandici M, Hottel TL. The effect of clenching on condylar position:
a vector analysis model. J Prosthet Dent 2004;91:171-9.
2. Wood WW. A review of masticatory muscle function. J Prosthet Dent 1987;57:
3. Manns A, Chan C, Miralles R. Influence of group function and canine guidance
on electromyographic activity of elevator muscles. J Prosthet Dent
4. Riise C, Sheikholeslam A. The influence of experimental interfering occlusal
contacts on the postural activity of the anterior temporal and masseter
muscles in young adults. J Oral Rehab 1982;9:419-25.
5. Visser A, McCarroll RS, Naeije M. Masticatory muscle activity in different jaw
relations during submaximal clenching efforts. J Dent Res 1992;71(2):372-8.
6. Schaerer P, Stallard RE, Zander HA. Occlusal interferences and mastication:
an electromyographic study. J Prosthet Dent 1967;17:438-49.
7. Williamson EH, Lundquist DO. Anterior guidance: its effect on
electromyographic activity of the temporal and masseter muscles. J Prosthet
Dent 1983; 49:816-23.
8. Mahan PE, et al. Superior and inferior bellies of the lateral pterygoid muscle
EMG activity at basic jaw positions. J Prosthet Dent 1983;50:710-8.
9. Gibbs CH, et al. EMG activity of the superior belly of the lateral pterygoid
muscle in relation to other jaw muscles. J Prosthet Dent 1984;51:691-702.
10. Manns A, Miralles R, Palazzi C. EMG, bite force, and elongation of the
masseter muscle under isometric voluntary contractions and variations of
vertical dimension. J Prosthet Dent 1979;42:674-82.
11. Belser UC, Hannam AG. The influence of altered working-side occlusal
guidance on masticatory muscles and related jaw movement. J Prosthet
Dent 1985;53:406-13.
12. Christensen LV, Rassouli NM. Experimental occlusal interferences. Part II.
Masseteric EMG responses to an intercuspal interference. J Oral Rehabil
13. Hannam AG. McMillan AS. Internal organization in the human jaw muscles.


Crit Rev Oral Biol Med 1994;5:55-89.

14. Hannam AG, et al. The effects of working-side occlusal interferences on
muscle activity and associated jaw movements in man. Archs Oral Biol
15. Hannam AG, et al. The relationship between dental occlusion, muscle
activity, and associated jaw movement in man. Arch Oral Biol 1977;22:25-32
16. Bakke M, Moller E. Distortion of maximal elevator activity by unilateral
premature tooth contact. Scan J Dent Res 1980;80:67-75.
17. Lund P, Nishiyama T, Moller E. Postural activity in the muscles of mastication
with the subject upright, inclined, and supine. Scan J Dent Res
18. Shupe RJ, et al. Effects of occlusal guidance on jaw muscle activity. J
Prosthet Dent 1984;51:811-8.
19. Manns A, Miralles R, Guerrero F. The changes in electrical activity of the
postural muscles of the mandible upon varying the vertical dimension.
J Prosthet Dent 1981;45:438-45.
20. Jimenez ID. Dental stability and maximal masticatory muscle activity. J
Oral Rehabil 1987;14:591-8.
21. Crispin BJ, Myers GE, Clayton JA. Effects of occlusal therapy on
pantographic reproducibility of mandibular border movements. J Prosthet
Dent 1978;40:29-34.
Occlusion and the Periodontium
1. Acrylic resin stabilized trays that did not touch the occlusal surfaces were
constructed. 3 screws were placed in the mandibular tray and occluded
against acrylic pads added to the maxillary tray. This allowed a reproduction
and measurement of tooth movement on casts that was identical to the
Canine protection, progressive disclusion, and group function were analyzed
In relation to plaque accumulation, inflammation, and pocket depth.
Teeth with canine protected occlusion had significantly lower mean periodontal
disease index scores than teeth with progressive disclusion or group function.
2. Occlusal trauma- injury to the periodontium from occlusal forces in excess of
the reparative capacity of the attachment apparatus.
Primary occlusal trauma- excessive forces on teeth with normal, healthy
supporting structures.
Secondary occlusal trauma- abnormal occlusal forces cause trauma to the
attachment apparatus with inadequate or reduced support.
Jiggling trauma- combination of pressure and tension
periodontal ligament widens and tooth is mobile
supra-alveolar connective tissue is not influenced by occlusal
since it is bordered on one side only by hard tissue (tooth).
Teeth with periodontitis- all trauma from occlusion enhances the rate of
progression of the disease.


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
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


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
Recommends equilibration of furcation involved hypermobile teeth to
enhance periodontal treatment.

33 healthy subjects were divided into 3 groups, 1 control and 2 experimental.

One experimental group had the complete removal of any nonworking side
contact (NWSI).
The other experimental group had the nonworking side contact
reduced to a level harmonious with the occlusion on the working side.
Mobility readings were recorded before and after NWSI occlusal adjustment
Tooth mobility was significantly reduced after complete elimination of
NWSI, as well as after adjusting the NWSI to harmonious contact with the
occlusion on the working side.
Reduction in mobility as significantly greater when occlusal interferences
were completely eliminated than when harmonious contacts were achieved.

1. Goldstein GR. The relationship of canine-protected occlusion to a periodontal

index. J Prosthet Dent 1979;41:277-83.
2. Green MS, Levine DF. Occlusion and the periodontium: a review and rationale
for treatment. J Calif Dent Assoc 1996;24(10):19-27.
3. Burgett FG, et al. A randomized trial of occlusal adjustment in the treatment of
periodontitis patients. J Clin Periodontal 1992;19:381-7.
4. Berhardt O, et al. The influence of dynamic occlusal interferences on probing
depth and attachment level: results of the study of health in Pomerania
(SHIP). J Periodontol 2006;77:506-16.
5. Svanberg G, King GJ, Gibbs CH. Occlusal considerations in periodontology.
Periodontology 2000;9:106-17.
6. Moozeh MB, Suit SR, Bissada NF. Tooth mobility measurements following two
methods of eliminating nonworking side occlusal interferences. J Clin
Periodontol 1981;8:424-30.
Occlusion and the Temporomandibular Joint (TMJ)


1. TMJ pathology is common and may result in significant occlusal changes.

Cadaver studies show that osseous structures undergo remodeling and
morphologic change in response to chronic displacement and deformity of
the TMJ disc.
Inflammation frequently causes swelling of the retrodiscal soft tissues and joint
effusion which puts downward pressure on the condyle and often causes
posterior open bites, crossbites, and pain
In the mandible and TMJ, osseous collapse and subsequent remodeling can
lead to ispsilateral chin deviation, contralateral open bite, and sever occlusal
2. 100 patients with recently aquired, externally visible mandibular deformity and
no history of extraarticular fracture were analyzed.
TMJ degeneration was found in either one or both joints of each patient
Chin deviation was always toward the smaller condyle or more diseased joint.
TMJ degeneration is the principal cause of both aquired facial skeleton
remodeling and unstable occlusion in patients with intact dentition and
without previous mandibular fracture.
Osteoarthritis is the most commonly diagnosed degenerative joint disorder in
radiologic studiesNarrowing or obliteration of articular space
Mandibular condyle flattening
Hypertrophic osteophytes on the articular surface margins
Advanced displacement and degeneration of the meniscus
With loss of articular cartilage, condyle flattening, and degeneration, there
is a progressive loss of vertical dimension resulting in facial contour
changes as the chin moves posteriorly and laterally toward the ipsilateral
degenerated joint.
3. Photoelastic plastic mandibles with opaque plastic teeth attached by a
rubbery liner were stressed with eccentric occlusal load on the teeth.
Canine guidance showed fewer regions of stress concentration within the
condyle and neck compared to group function.
The TMJ is a stress bearing joint but only capable of receiving moderate
Canine guidance with stable posterior occlusal contact in centric relation is the
preferred occlusal scheme to reduce stress to the TMJ.
4. Osteoarthritis (OA)noninflammatory disease of moveable joints
result of time dependent pattern of joint reactions to injury
deterioration and abrasion of articular cartilage and soft tissue surfaces
thickening and remodeling of underlying bone
formation of marginal spurs and subarticular cysts
general health of the individual seldom affected by the disease


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
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
Without exception small, deformed, and arthrotic condyles were associated
with anterior displaced discs with/without reduction in this arthrographic


93% of the deformed or arthritic joints were associated with anterior

displaced discs without reduction.
Ligament attachment of the disc to the lateral pole, and at times the medial
pole, must become elongated for the disc to displace.
Significant limitation of movement associated with anterior displaced disc
without reduction appears not to be permanent, even with no treatment.
7. 14 dry skull were analyzed with tomograms for canine slope angle and
medial glenoid slope.
No relation was found between the palatal slope of the upper canines and
the morphology of the medial wall of the glenoid fossa.
Occlusal hyperfunction modifies the occlusal and glenoid morphologies
in the same way, flattening these surfaces.
8. Osteoarthritis is characterized by deterioration and abrasion of the articular
cartilage, and by simultaneous remodeling processes in the underlying
Internal derangement of the TMJ- displacement or malrelation of the disc to
the condyle and articular eminence
Degenerative changes in the mandibular condyle and articular eminence
were highly correlated partial and complete disc displacement.
Regressive remodeling, with severe resorption activity, was seen in all
osteoarthritic specimens.
A more pronounced articular eminence was highly correlated with partial
anterior disc displacement.
9. Disc provides protection to the underlying tissues and its displacement may
expose these tissues to excessive loads and degenerative changes.
Disc displacement causes joint pain, limited mandibular movement, joint
sounds, and osthoarthrotic change in the TMJ.
The most significant aberration of all suggested processes that terminate in
disc displacement is an increase in joint friction.
Disc is attached firmly to the medial and lateral poles of the condyle, but is
more loosely fused to the capsule anteriorly, and is connected to the
capsule posteriorly by highly innervated and vascular retrodiscal tissue.
On jaw opening- disc pivots posteriorly relative to the anterior rotating condyle
because of the pull of retrodiscal stretched fibers and the lack of opposition
by the relaxed superior lateral pterygoid, thus maintaining its position
between the rotating condyle and eminence.
On jaw closure- because the disc is in a posterior relationship to the condyle, it
needs to pivot back to the original anterior position. Some believe that the
superior lateral pterygoid muscle enables the disc to perform this maneuver.
Osteoarthrosis has been linked with more advanced disc displacement and
changes in disc configuration.
Conversely, it has been established that osteoarthritic changes may precede
the process of disc displacement.
Etiologic events and disc displacement-


Trauma- 1/3 of patients report head and neck trauma

Functional overloading- articular components of TMJ cannot withstand
persistent compressive loading, associated with clenching. Such
overloading can impair the integrity of articular components by generation
of harmful reactive oxidative species (ROS). These can destroy hyaluronic
acid, collagen, and proteoglycans and predispose to disc displacement.
Joint laxity- fails to account for high prevalence of disc displacement.
Degenerative joint disease (osteoarthritis)- changes in articular surface
prohibit smooth gliding of these parts over each other, gradually pushing
the disc forward and causing displacement. Doesnt explain displacement
in nonarthritic joints.
Masticatory muscle spasm- has not been documented during clicking.
Increased friction- collapse of lubrication system plays a pivotal role in the
chain of events leading to disc displacement.
Proposed pathogenesis of disc displacement1. Normal TMJ- Surface active phospholipids are the boundary lubricant.
Hyaluronic acid (HA), a fluid film lubricant, protects the phospholipids
from lysis.
2. Intermittent joint loading- production of oxidative species.
3. Active oxidative species degrade HA, which cant protect the
4. Damage to phospholipids increases friction between disc and fossa.
5. With increased friction, the condyle is pulled forward by the inferior lateral
pterygoid, away from the lagging disc, stretching the disc condyle
6. On continued clenching the mobile disc is dislocated forward and
medially, and during mouth opening the disc is easily pushed forward
down the slope of the eminence by the sliding condyle, creating disc
10. Anchored disc phenomenon (ADP)- integrity of the joint is preserved, but the
disc sticks so tightly to the fossa that it totally prevents condylar sliding.
ADP is characterized by sudden onset, severe limitation of movement (1328mm), and clinical, radiologic evidence of lack of condylar sliding.
When disc displacement is associated with uncontrollable pain and serious
dysfunction, surgical intervention is advised.
General or local anesthesia doesnt improve joint movement.
Differential diagnosis of intraarticular disorders that cause limited range of
Fibrous or bony ankylosisOssified bridge of condyle to fossa on xray from bony ankylosis.
Requires surgical intervention
OsteoarthritisCharacteristic bony changes are evident on radiographs.


Medications and splint effective for 70% of patients, 30% arthrocentesis

Disc displacement without reductionPartial limitation of movement after a history of clicking and intermittent
Antiinflammatory, muscle relaxants, and splint 90%, arthrocentesis 10%
ADPSudden severe limited mouth opening associated with pain on forced
mouth opening.
Physiotherapy is of no value, arthrocentesis is indicated.
11. Parafunctional masticatory activity and its influence on joint loading
contribute to osteoarthritis with adhesions of the TMJ.
Abnormal joint loading is a major factor in cartilage degradation, biochemical
and biomechanical abnormalities, and intra-articular TM pathology.
Clinician must identify and address parafunctional masticatory activity during
Nonsurgical, surgical, and postsurgical treatment regimens.
Bruxism can cause significant damage to every part of the masticatory
apparatus, as well as muscular headache.
Excessive joint loadingproteoglycan degradation
altered synovium
changes in synovial fluid leading to impaired lubrication and nutrition of
generation of free radicals through hypoxia-reperfusion injury that lead to
cartilage matrix degradation
phospholipid catabolism
In this study 83 patients had arthroscopic surgery after detailed history of
parafunctional masticatory activity.
Joints with parafunction had arthroscopically diagnosed osteoarthritis 72%
of the time compared to joints without a history of parafunction 55%.
Biomechanical alterations in the TMJ caused by cartilage degradation can
cause disc hesitation and catching, impaired mobility, and adhesions.
Surgical procedures on the joint do not address those causative factors that
have contributed to the pathogenesis of the disease.
12. Human autopsy study of TMJ components at different ages with different
types of dentition.
Newborn- articular surface of temporal bone was flat.
14-15 years old- tubercle and fossa were well developed and in the sagittal
plane, the surface of the temporal bone was S shaped as in adults.
Below 20 years old all TMJs appeared normal, but with increasing age the
number of joints with local changes in shape (remodeling) or
osteoarthritic (OA) change of the articular surfaces increased.
Frequency of OA change in the disk, condyle , and temporal bone (18
TMJs)- Lateral third- 13


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


functional or mechanical factors.

14. The effect of lateral retrusive vs. lateral protrusive guidance on the
movement of the working condyle was evaluated on 8 patients.
Mandibular splints were fabricated so that the distal of the maxillary canine
was in contact during lateral excursion (retrusive guidance) or the mesial
of the maxillary canine was in contact (protrusive guidance)
Lateral retrusive guidance moved the lateral pole of the working condyle
distally, beyond the normal natural tooth guided mandibular movement.
This posterior deflection of the working condyle may compress or loosen
the posterior band of the disc from its attachment.
15. 103 skulls were evaluated for a correlation between tooth loss or extreme
wear and change of the articular eminence angulation.
Dentition is the significant factor affecting the angle of the eminence.
Natural dentition showed the highest angulation and edentulism the lowest
Osteoarthritic change (roughing, lipping, bony erosion) was seen in skulls
displaying attrition and total edentulism, not in skulls with natural dentition
and high eminence angulations.
Attrition produces osteoarthritic changes in the TMJ with flattening of the
articular eminence- therefore it is deleterious to this joint.
Loss of cusp height and anterior guidance in severe attrition was
accompanied by resorption of the articular eminence, making it shallower.
16. Disk displacement and perforation, condyle and temporal bone remodeling,
and some joint pain may be a result of excessive or misdirected loading.
Minute condylar movements were used to estimate TMJ loading during
clenching on occlusal splints.
5 types of splints were made on each of 5 subjects:
Stabilization splint with uniform anterior and posterior teeth contact
Anterior splint with anterior teeth contacting only, no posterior contact
Anterior repositioning splint 1mm anterior of intercuspal contact, and
uniform contact of anterior and posterior teeth.
Bilateral 2nd molar only contact
Unilateral 2nd molar only contact
Splints with no posterior tooth support resulted in superior condylar movment
during clenching.
Centric stops on posterior protect the TMJ from loading during clenching,
chewing, and swallowing.
Biting on an anterior splint as an effective way to guide the condyles into a
superior position.
Biting on bilateral posterior pivots (2nd molar only contact) did not distract the
17. Clenching on an interocclusal appliance, with no anterior teeth in contact,
reduced intraarticular pressure (IAP) from 20-200 mm Hg to 1-40 mm Hg.
Flow of synovial fluid from synovial capillaries to the joint cavity and from the


joint cavity to into the synovial lymphatic system.

Alternating pressure from opening (negative) to closing (positive) pumps
synovial fluid for lubrication, nutrition, and waste removal- since articular
cartilage has no blood supply.
Traumatized and diseased joints accumulate exudates in the joint space with
an exponential increase in IAP- to the point where blood supply or venous
drainage are compromised, leading to intraarticulaar hypoxia.
Force of closure and clenching loads both the teeth and the TMJ.
The extent of load sharing depends on the length of the resistance arm
relative to the effort arm.
When back teeth only contact on the interocclusal appliance, the vector of bite
force is shifted distally, decreasing the length of the resistance arm relative
to the effort arm, sharply reducing force directed at the TMJ.
Clenching can result in IAP above capillary perfusion pressure, resulting in
occlusion of the synovial capillary bed and hypoxia.
Females generated significantly higher IAP, which may relate to their
predominance of TMJ patients.
18. 100 skulls with complete or partial dentition were analyzed for condylar
remodeling and its relation to the state of the dentition.
Condylar remodeling was shown by partial or total replacement of the
external circumferential lamellae below the joint cartilage by osteons and
their remnants.
Forward movement of the bone front is accompanied by a further laying
down of cartilage, with the result that the external surface undergoes
change in form.
Spongy tissue trabeculae are perpendicular to the most active remodeling
Remodeling of the posterior and anterior portions tends to flatten the upper
Incidence of remodeling increases rapidly between the ages of 18-25.
Remodeling becomes more frequent as partial edentulism increases.
Remodeling of the mandibular condyle is an adaptation of the bone
structure to mechanical stresses derived from functional activity.
19. 22 patients had tomograms before and after occlusal therapy with splints,
equilibration, prosthodontic rehabilitation and orthodontic treatment.
After therapy tomograms were repeated at 9-44 months.
A distinct reshaping of the condyle was seen in 7 patients.
3 patients with degenerative changes showed regression of the lesions.
The significance, aims, and indications of occlusal therapy are probably
more extensive and important than is usually thought.
Reshaping of the condyle due to bone remodeling may take place after
occlusal therapy.
The reshaping affects condyles that were previously flattened as a result of
occlusal alteration, the new shape tends to be rounded.


Degenerative changes may be the consequence of occlusal alterations and

can be treated by occlusal therapy.
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15. Granados JI. The influence of the loss of teeth and attrition on the articular
eminence. J Prosthet Dent 1979;42:78-85.
16. Ito T, et al. Loading on the temporomandibular joints with five occlusal
conditions. J Prosthet Dent 1986;56:478-84.
17. Nitzan DW. Intraarticular pressure in the functioning human
temporomandibular joint and its alteration by uniform elevation of the
occlusal plane. J Oral Maxillofac Surg 1994;52:671-9.


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
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
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
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


anterior relationship upon closure in CR.

If anterior teeth do not contact, but lower incisors impinge on palatal gingival,
equilibration would be contraindicated and orthodontics necessary.
If anterior teeth contact equilibration would be feasible.
5. 30 dentists from the visiting faculty at the Pankey Institute analyzed signs and
symptoms prior to and after equilibration.
Glossary of Prosthodontic terms- interference is any tooth contact interfering
with or hindering harmonious mandibular movement.
Occlusal interferences to the CR arc of closure- cause a displacement of the
condyle from its CR posture.
Occlusal interferences on posterior teeth during excursive movements of the
Both interferences cause hyperactivity of masticatory muscles, inflammation,
and a heightened sensitivity to pain (hyperalgesia).
Muscle pain reported by the patient can be confirmed by muscle palpation.
Forces arising from the occlusal surfaces reach the articular region of the TMJ
causing structural change.
Occlusal interferences can cause tooth mobility, widened periodontal
ligaments, worsened periodontal disease, tooth sensitivity, fractures, and
possible cervical abfraction.
Overall, all signs and/or symptoms of concern improved after equilibration.
6. 53 patients with chronic myofascial pain-dysfunction syndrome were treated
with occlusal equilibration to establish complete anterior guidance.
Common symptoms were pain and fatigue in temporalis and masseter
muscles, nocturnal bruxism, jaw tension on waking, and difficulty chewing
some foods.
Common occlusal element in all patients with chronic muscle pain was the
absence of multidirectional freedom of contact movement of the mandible
as a lack of anterior guidance.
Complete symptom resolution was usually attained within 3 weeks.
4 year followup revealed no recurrence of chronic symptoms after treatment.
Occlusal equilibration can be performed without prior splint therapy after
thorough diagnosis of the occlusion and history of the location and duration
of muscle pain.
Postorthodontic equilibration is indicated as soon as the teeth are stable.
7. Traditional equilibration emphasizes the establishment of a stable centric
relation occlusion which positions the condyle and disk in proper orientation.
Immediate complete anterior guidance development(ICAGD)- focus is
immediate posterior disclusion in right and left excursions and secondarily in
protrusive excursion.
Disclusion time- duration of time that working and nonworking molars and
nonworking premolars are in contact during an excursive movement,
commencing from the habitual closure position through to the contact of


anterior guiding surfaces.

ICAGD initial adjustment step- unguided lateral excursive movements
this is the reverse of traditional equilibration
Lengthy disclusion time- posterior teeth are compressing the periodontal
ligaments as they rub over each other during function.
Primary focus is to reduce pretreatment disclusion time to <0.5 seconds in
any excursion.
All jaw movements are unguided by the operator
There is no effort at eliminating interferences to centric relation
8. 132 maxillary and 127 mandibular teeth were embedded, sectioned, and
Enamel thickness is greatest on the cusp tips of posterior teeth:
Maxillary premolars
Mandibular premolars
Central pit enamel thickness was about 0.5mm on all molars
9. Radiographic investigation can, with the help of a distortion coefficient,
provide a reliable measure of the thickness of calcified crown tissues.
The average relative error was 4.46% or 0.12mm
10. Stability of teeth in the arch depends primarily on eruption from the
periodontium and the balance between resting pressures of the
muscles of the cheeks and tongue.
Occlusal contacts that do not fulfill a justifiable purpose may be eliminated,
and the number of contacts may be reduced to one per tooth.
Occlusal contacts must- counteract eruptive forces of the teeth
provide room necessary for variability in the TMJ
maintain pointed cusps for function and less wear
Simplified occlusal schemeMandibular buccal cusps occlude into the maxillary central fossae
Proximal contacts stabilize the teeth mesial-distally
Anterior guidance discludes the posterior teeth in excursive movements
11. Intact teeth demonstrate cusp flexure because of their morphology and
Nonworking motion generated the most harmful stresses found in the cervical
enamel among all load cases.
Intercuspal position- maximum masticatory force is exerted by closing muscles
in this seemingly motionless state
Enamel, dentin, ceramic, and composite are characterized by their brittle
behavior, so it is important to locate harmful stresses during function.
Vertical loading of the tooth along the main axis did not generate harmful
concentrations of stress.
Supporting cusps are well protected during working and nonworking


loading- mostly subjected to compressive stress

Nonsupporting cusps tend to exhibit more tensile stresses.
Protective mechanismsenamel bridging (vs a deep fissure) reduces stress locally and can protect
distant enamel.
crack-arresting effect of dentin and thick collagen fibers at the DEJ
compensate for the inherently brittle nature of enamel
12. Nonworking or balancing contacts are reported to increase the muscle
activity in the masticatory system.
These contacts are termed initiating factors in parafunctional activity.
147 subjects made 2mm right and left mandibular movements and were
examined for nonworking contacts.
If no contacts were detected, extraoral force was applied to the angle of
the mandible in a medial and superior direction; again the posterior teeth
were examined for nonworking contacts. These forces can be generated
by oral musculature during parafunctional activity.
43.5% of patients had nonworking contacts during voluntary unassisted
lateral excursion.
The incidence of nonworking contact increase to 94.5% of patients when
force was applied to the mandible.
13. Indications for occlusal equilibration:
Prerestorative equilibration- if occlusal prematurities are present
preoperatively, the new restorations must adapt to the incorrect
Postrestorative equilibration- after occlusal refinement at cementation,
another appointment is made at 6 weeks to refine the occlusion.
Postorthodontic equilibration- predictable relapse of the new orthodontic
position if equilibration is not performed within hours of removal of the
orthodontic appliances due to movement of teeth from closing on
occlusal prematurities
Part of treatment for clenching and bruxing- reduces tendency to
aggressively continue their destructive habit.
Esthetic reasons- principles of equilibration can guide the simple reshaping
of malposed teeth
Part of treatment for TMJ dysfunction- direct indication for muscular TMD
Part of periodontal therapymost common sign is widened periodontal ligaments prior to future loss of
maintenance of dentitions with reduced periodontal support by frequent
minimal occlusal equilibration. Decreased mobility seen over time.
14. 7 myofascial pain dysfunction patients were evaluated with a T-Scan
computer to correlate EMG of the masseter and temporalis muscles
with the occlusal interference pattern.


The occlusions were adjusted by removing all lateral and protrusive

excursion interferences prior to refining habitual closure.
Disclusion time (time in seconds, required to disclude the working and
nonworking molar interferences, and nonworking premolar interferences
from the habitual centric closure position to the completion of a
mandibular excursion) was reduced to 0.5 seconds in any lateral
Muscle function and comfort returned to normal in all patients within a
A major etiology of myofascial pain dysfunction syndrome (MPDS) is
excessive molar contact in maximum intercuspation and excursions.

Distance between contact in CR and intercuspal contact is about1mm.

Axial forces on posterior teeth obtained by contacts on a fossa, marginal
ridge, or cusp tip (on a flat plane).
Adjustment first in guided closing position, then free closing movements.
Adjustment then of guided lateral and protrusive excursions, followed
by adjustment in free lateral and protrusive excursion.
All adjustments first laying down, then sitting upright.
All adjustments are performed with light and heavy force to indicate a tooth
touching before the others.
The number of light pressure contacts should equal that of hard pressure.
If occlusal adjustment is done only on 1 arch, more tooth structure on that
arch may have to be sacrificed.

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
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.


Occlusal adjustment therapy has a place in treating problems associated

with the masticatory system, only when the criteria for providing an
occlusal adjustment are based on actual pathologic, clinical, and periodontal
findings directly related to the traumatic occlusal condition.
Occlusal adjustment therapy can redistribute force or load on teeth.
Muscle and joint pain symptoms after iatrogenic interferences can be relieved
with occlusal adjustment that removes these interferences if done in the
short term.
Occlusal interferences (maximum intercuspation and excursive), constantly
contacting in an adverse or forceful manner, may have a traumatic and
potentially harmful effect on the investing periodontal tissues.
Mandibular coordination may be influenced by occlusal interferences and
occlusal adjustment.
17. On diagnosis of a cracked tooth, occlusal adjustment is initiated to reduce
stress and relieve symptoms; followed by restoration covering the cusps.
Wedging effect of cusp-fossa relationship has been proposed as the primary
cause cuspal cracking.
Functional cusps are supported on both the inner and outer inclines of the
opposing teeth.
Cuspal fractures commonly observed on nonworking cusps because they
lack support of the outer inclines.
Wedging effect of the cusp to fossa results in tension in the fossa and
compression on the cusps.
Overcarving or abrasion of the occlusal restoration can cause extrusion of
teeth and alteration of the cusp-fossa relationship and contributes to
fracture of nonfunctional cusps.
With attrition of the functional cusps, more lateral force occurs on the less
worn and unsupported nonfunctional cusps.
Cracked tooth syndrome most frequently involves mandibular molars.
reduction of the height of the lingual cusp.
reduction of the occlusal contact along the inner incline of the lingual
recontour the lingual cusp
Patients with a history of cracked teeth should be provided occlusal
adjustment of susceptible nonfunctional cusps.
18. Most malocclusions in the primary dentition are the result of deleterious oral
habits, such as persistent digit sucking.
The most common malocclusion is anterior open bite.
Primary unilateral crossbite is infrequently caused by dental or skeletal
asymmetry and almost always from a functional slide.
Occlusal interferences are most often responsible or are an aggravating
factor in posterior unilateral crossbite.
Posterior crossbites have been found in 13.2% of 3 year-olds and
require early treatment because they can lead to abnormal growth and


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 patients were treated with a maxillary full arch anterior deprogramming

device that contacted only the lower central incisors in centric relation.
After one week acrylic as added to convert the deprogrammer into a CR
occlusal device. Mutually protected occlusion was established and patients
were instructed to wear it 24 hour a day wear except when eating .
The occlusal device was refined weekly for 8 weeks to eliminate minute
occlusal interferences.
Full mouth restoration was performed 8 weeks after resolution of
Patients discontinued occlusal device therapy no later than 4 weeks after
restorations were completed.
A mental analog scale (MAS) was recorded at all appointments, with teeth
related signs and symptoms graded as percentage improvement.
Symptoms of perceived malocclusion were not resolved during function
unless occlusal equilibration of final restorations as performed.
At 1 month recall patients demonstrated marked reduction in teeth related
signs and symptoms (perceived malocclusion, sensitive teeth, difficulty
moving laterally)
The most prevalent occlusal interferences that inhibited lateral gliding
articulation movements were found in the most posterior tooth area (2 nd
or 3rd molar), both on the working and nonworking sides.

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


position of the mandible.

Apply moist heat to affected TMJ twice a day for 20 minutes
Avoid chewy foods or biting on front teeth
Limit intake of sugar and caffeine
Avoid clenching
Take medication as prescribed
Dowel pins placed in maxillary cast to allow removal of anterior or posterior
segments and evaluate anterior teeth contact with posterior teeth removed.
Basic rules of adjustment:
Adjust depressions instead of elevations.
Adjust shearing cusps (upper buccal and lower lingual) not stamp cusps
(upper palatal and lower buccal).
Adjust opposing stamp cusps equally (to minimize enamel loss)
Adjust the palatal of the upper anteriors instead of the height of the lower
Steps in occlusal adjustment procedure:
If anterior teeth are coupled, perform eccentric adjustments first and centric
adjustment last.
If anterior teeth are not coupled, perform centric adjustments first, obtain
anterior coupling, and perform centric adjustments last.
1. Protrusive and lateroprotrusive adjustment- when anterior teeth are
coupled, adjust any posterior inclines (distal upper, mesial lower) that
prevent anterior teeth from remaining in contact during the entire range
of protrusive excursion. DU ML.
2. Lateral excursion adjustmentworking side- if possible limit adjustment to shearing cusps, buccal
upper and lingual lower.
nonworking side- adjust stamp cusps, palatal upper, buccal lower
3. Centric relation adjustmentprior to adjustment, closure in CR results in distal inclines of lower teeth
when touching upper teeth. This is the anterior component of force that
causes mesial drift and crowding of lower anterior teeth. MU DL
If posterior teeth do not stop the closure of the mandible, anterior teeth must
This results in splaying of the lower anteriors- it is better to treat the etiology
of the pathology, posterior teeth occlusion, than splint the anteriors.
Equilibration should be done in a minimum of 3 appointments
23. Patients were evaluated for teeth associated signs and symptoms of TMD
(perceived malocclusion, self reported bruxism, tooth sensitivity, and
difficulty performing lateral excursions).
59 TMD patients were equilibrated after splint therapy.
Mental analog scale was recorded before and after each treatment phase.
Mental analog scale consisted of patient analysis of each sign or symptom
in terms of percent improvement.


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


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


10. Wiskott HWA, Belser UC. A rationale for simplified occlusal design in
restorative dentisty: historical review and clinical guidelines. J Prosthet Dent
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
13. Christensen GJ. The major part of dentistry you may be neglecting. JADA
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
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;
26. Kirveskari P, et al. Effect of elimination of occlusal interferences on signs and
symptoms of craniomandibular disorder in young adults. J Oral Rehabil
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


to restore contact with the opposing canine.

Acid-etch bond strength of 140 kg/cm3 is sufficient to counter clinical
stresses, no failures at 2 year recall
2. Canine wear due to sleep position occurs on the canine opposite the side
that the patient sleeps on.
Worn canines can be rebuilt with composite to restore disclusion of
nonworking molar contacts on the opposite side.
A protective nightguard can be fabricated if the composite wears or
symptoms persist.
Sleeping on the back with the knees supported by a pillow is the
recommended position. An alternative position is supporting the cranium
with a pillow without exerting pressure on the mandible, with a second
pillow to support the arm and shoulder.

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


improve function of the masticatory motor system and reduce

abnormal muscle activity
protect teeth from attrition
Soft appliance is difficult to adjust accurately
Full arch stabilization appliance controls and maintain tooth position
Partial coverage appliances have significant irreversible complications
With tooth intrusion and eruption
Stabilization splints are 70-90% effective when combined with occlusal
adjustment and prosthetic care.
3. Masticatory muscle pain is by far the symptom that has the best experimental
evidence to support occlusal splints as a highly effective method of
Occlusal splints have been shown to have a distinct influence on improving
mandibular muscle coordination.
4. The thinnest splints were not the most effective in reducing nocturnal
bruxism, reducing resting muscle activity, or relieving symptoms.
Some patients receiving thick (8mm) splints actually did better than patients
using a thinner (1mm) splint.
This study compared canine vs. molar guidance on maxillary flat plane splints
during nocturnal bruxing, clinical examination, and pain diary.
Molar guidance splint provided relief of signs and symptoms and reduced
muscle activity similar to the canine guidance splint.
The well documented alteration of jaw muscle activity through different
occlusal guidance patterns in the alert subject during voluntary clenching
was not the case with nocturnal bruxism.
Electromyographic studies of splint treatment effects on bruxism commonly
find the treatment effects to be immediate, as was found here.
It is common for signs and symptoms to improve significantly in 1-2 weeks.
5. 17 adults with facial pain were evaluated after maxillary splint insertion.
The maxillary splints had simultaneous contact of all mandibular cusp tips
in centric relation. All posterior eccentric contacts were eliminated.
Anterior guiding contacts were maintained with free movement on polished
surfaces in all directions.
Deviation of the mandible to the opposite side of the occlusal interference
Is the most objective symptom of TMJ syndrome.
88% of the muscle involvement and 844% of the TMJ syndrome improved.
6. Occlusal splints were introduced by Karolyi in 1901.
Michigan splintmaxillary flat plane with smooth surface, no indentations
cuspid rise starting 1mm from centric occlusion
always adjusted to centric relation
freedom in centric 0.5-1.0mm on a flat surface


no incisal guidance from centric occlusion (except in deep bite)

easier to develop protrusive and lateral guidance solely on the mandibular
canine than for a whole range of incisal guidance areas
Patients usually free of pain after a few days-weeks with the splint,
sometimes weeks-months.
Large anterior vertical dimension of splint- interferes with lip seal, difficult
speech, excessive salivation, and poor esthetics.
The more pronounced the balancing side contacts and the curve of Spee,
the greater the thickness of the splint or cuspid rise. General rule- increase
the thickness of the splint rather than the cuspid guidance inclination.
Some patients with real or apparent TMJ-muscle pain dysfunction have
dependent tendencies, or may develop these. The requirement of these
patients for attention or treatment is unrelated to the presence or severity
of symptoms. Psychological consultation may be necessary.
7. Neuromuscular incoordination affects mandibular movement.
Reproducibility of pantographic tracings through a pantographic
reproducibility index (PRI) is used to detect muscle incoordination.
Maxillary flat plane splints adjusted to centric relation and immediate canine
disclusion were worn prior to pantographic tracing.
482 pantograms were recorded for 15 experimental subjects and 5 controls
for 3-12 months.
Splint therapy reinstated muscle coordination.
Patients with a longer history or higher initial TMJ dysfunction scores
required a longer period of occlusal splint therapy to become symptom free.
To maintain muscle incoordination obtained by the splint, occlusal adjustment
with removal of occlusal interferences should follow.
8. 33 Facial Pain Clinic patients were evaluated for the effect of occlusion
splints on limited mandibular opening and muscle and joint pain.
Maxillary flat plane splint with even contact of all mandibular cusps in CR,
and immediate canine disclusion, was worn continuously (except eating
and oral hygiene) for 4 weeks.
Acute and chronic pain patients responded similarly to splint therapyPain measured by muscle palpation decreased significantly.
Maximal comfortable interincisal opening increased significantly.
9. 10 adults were evaluated for the masticatory muscle EMG activity when
wearing a maxillary flat plane splint with canine vs. first molar guidance.
EMG activity was recorded during clenching in centric occlusion, clenching
while moving into excursive position, and clenching in excursive position.
EMG activity of the masseter and anterior temporalis as reduced with both
canine and first molar guidance.
Canine guidance was not more effective than first molar guidance in
reducing muscle activity.


10. A CR maxillary flat plane stabilization splint as tested against a nonocclusal

appliance (palatal acrylic only, not touching the occlusal surfaces of the
teeth) in 60 patients.
No details of the occlusal scheme or verification of condylar position were
Patients wore the appliances for 10 weeks at night only.
Signs and symptoms improved more in stabilization splint group than the
nonocclusal control appliance.
11. Myogenous TMD pain patients have significantly higher resting EMG levels
of the anterior temporalis and masseter muscles when compared to normal
asymptomatic subjects.
After treatment with a flat plane centric relation stabilization appliance
(bilateral simultaneous of posterior teeth in centric relation, with anterior
and canine guidance), the EMG activity of all muscles were significantly
reduced with a complete remission of pain.
Most subjects had asymmetric muscle activity.
The highest aymmetry index was seen in myogenous TMJ pain patients.
12. 60 patients were evaluated after Phase I reversible treatment of the
occlusion with a passive occlusal positioning orthotic.
Orthotic was equilibrated so that all teeth made equal contact In centric
relation with canine disclusion in protrusive and lateral excursions.
46% of patients had previous unsuccessful splint therapy.
95% of patients in this study experienced significant pain relief
83% showed marked improvement in joint sounds.
13. 2 groups of 15 subjects were evaluated for the effect of maxillary flat
plane splint versus equilibration on mandibular dysfunction and headache.
Both groups occlusal scheme was bilateral posterior teeth contact in CR and
anterior disclusion in all excursions.
Both groups reduced the subject symptoms of mandibular dysfunction and
headache, but more so in the splint group.
90% of the splint group reported an improvement in the intensity of
dysfunction and the frequency of headache, whereas 50-60% of the
equilibration group did so.
6 subjects (40%) reported increased sensitivity of the teeth after equilibration
14. Study evaluated the short-term effectiveness of stabilization-type occlusal
splint therapy on TMJ dysfunction patients with more than 2 symptoms.
Full arch maxillary flat plane splint with occlusal contact for all opposing teeth
and canine guidance anteriorly and laterally.
After 13 weeks, 87% of patients showed improved TMJ pain, 78% improved
TMJ sounds, 68% improved limitation in movement, and 86% improved
shoulder pain.
Since a high percentage of patients respond favorably to the stabilization-


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.


18. 52 patients returned a questionnaire on headache and mandibular

dysfunction 2 years after the start of treatment. 34 of these patients were
clinically examined.
Range of movement, function of the TMJs, palpation of the masticatory
muscles and TMJs, and pain on movement were measured and a clinical
dysfunction index (Helkimo) was generated.
Clinical and subjective improvement observed after 1 year was maintained in
most patients at 2 years.
Nearly 50% of patients continued to use an occlusal splint, but few continued
use of therapeutic exercises.
Long term prognosis for treatment of mandibular dysfunction is good even
when recurrent headache is considered a symptom of this syndrome.
19. Postural activity of the temporalis and masseter muscles were studied in 31
patients with function disorders, before, during, and after splint therapy.
Signs, symptoms, and postural activity of the temporalis and masseter
muscles were significantly reduced after treatment.
After cessation of splint therapy, signs and symptoms recurred to the
pretreatment level within 1-4 weeks in 80% of patients.
Even if one assumes that bruxism is a central phenomenon, the occlusion
via feedback from periodontal and joint receptors may still influence the
pattern of muscular hyperactivity.
Occlusal splint therapy beneficially affects the stomatognathic system, but
must be regarded mainly as a symptomatic treatment in patients with
nocturnal bruxism.
Splint therapy can eliminate signs and symptoms of functional disorders and
create symmetric and reduced postural activity in the temporalis and
masseter muscles. It may enhance procedures where functional analysis
and occlusal adjustment are involved.
1. Ambard A, Mueninghoff L. Planning restorative treatment for patients with
severe Class II malocclusions. J Prosthet Dent 2002;88:200-7.
2. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy:
design, theory, and overall effectiveness. JADA 1984;108:359-64.
3. Clark GT. A critical evaluation of orthopedic interocclusal appliance therapy:
effectiveness for specific symptoms. JADA 1984;108:364-8.
4. Rugh JD, et al. Effects of canine versus molar occlusal splint guidance on
nocturnal bruxism and craniomandibular symptomatology. J Crandiomandib
Disord Facial Oral Pain 1989;3:203-10.
5. Goharian RK, Neff PA. Effect of occlusal retainers on temporomandibular
joint and facial pain. J Prosthet Dent 1980;44:206-7.
6. Ramfjord SP, Ash MM. Reflections on the Michigan occlusal splint. J Oral
Rehabil 1994;21:491-500.
7. Beard CC, Clayton JA. Effects of occlusal splint therapy on TMJ dysfunction,


J Prosthet Dent 1980;44:324-35.

8. Okeson JP, Kemper JT, Moody PM. A study of the use of occlusion splints in
the treatment of acute and chronic patients with craniomandibular disorders.
J Prosthet Dent 1982;48:708-12.
9. Graham GS, Rugh JD. Maxillary splint occlusal guidance patterns and
electromyographic activity of the jaw-closing muscles. J Prosthet Dent
10. Ekberg EC, Vallon D, Nilner M. The efficacy of appliance therapy in patients
with temporomandibular disorders mainly of myogenous origin. A
randomized, controlled, short term trial. J Orofac Pain 2003;17:133-9.
11. Scopel V, Costa GSA, Urias D. An electromyographic study of masseter
and anterior temporalis muscles in extra-articular myogenous TMJ pain
patients compared to an asymptomatic normal population. J Craniomandib
Prac 2005;23:194-203.
12. Barker DK. Occlusal interferences and temporomandibular dysfunction. Gen
Dent 2004;56-61.
13. Wenneberg B, Nystrom T, Carlsson GE. Occlusal equilibration and other
stomatognathic treatment in patients with mandibular dysfunction and
headache. J Prosthet Dent 1988;59:478-83.
14. Tsuga K, et al. A short-term evaluation of the effectiveness of stabilizationtype occlusal splint therapy for specific symptoms of temporomandibular
joint dysfunction syndrome. J Prosthet Dent 1989;61:610-13.
15. Solberg WK, Clark JT, Rugh JD. Nocturnal electromyographic evaluation of
bruxism patients undergoing short term splint therapy. J Oral Rehabil 1975;
16. Okeson JP, et al. Evaluation of occlusal splint therapy and relaxation
procedures in patients with temporomandibular disorders. JADA
17. Greene CS, Laskin DM. Splint therapy for the myofascial pain-dysfunction
(MPD) syndrome: a comparative study. JADA 1972;84:624-8.
18. Magnusson T, Carlsson GE. A 2 year follow-up of changes in headache
and mandibular dysfunction after stomatognathic treatment. J Prosthet Dent
19. Sheikoleslam A, Holmgren K, Riise C. A clinical and electromyographic study
of the long term effects of an occlusal splint on the temporal and masseter
muscles in patients with functional disorders and nocturnal bruxism. J Oral
Rehabil 1986;13:137-45.
Anterior Repositioning Splints
1. Anterior repositioning splint was fabricated by closing the mouth into an
anterior position so that the closing click did not occur.
Flat occlusal maxillary splint was adjusted to maximum occlusal contact in CR
and group contact in laterotrusion.
The anterior repositioning splint was worn 24 hours a day for 6 weeks.
The flat occlusal splint was worn for nighttime only for 6 weeks.


The anterior repositioning splint eliminated reciprocal clicking and palpatory

tenderness of the TMJ and masticatory muscles as long as it was used; with
decreased pain at rest, chewing, and protrusion.
After removal of the anterior repositioning splint at 6 weeks, symptoms of
pain and clicking returned.
The flat occlusal splint decreased palpatory joint tenderness, but not clicking.
2. 20 patients with reciprocal clicking of the TMJ, elimination of reciprocal
clicking in a protrusive position, and subjective and objective joint pain
were evaluated with splint therapy.
10 patients received maxillary flat plane therapy with the appliance adjusted
to centric relation and anterior guidance in lateral and protrusive excursion
10 patients received a maxillary anterior repositioning appliance followed by
a mandibular occlusal repositioning appliance (MORA) after 6 weeks.
Mandibular repositioning treatment produces significant subjective and
objective improvement in dysfunction of patients with internal joint
derangement, while flat plane splints did not.
Mandibular repositioning treatment may eliminate the reciprocal click of
internal derangement with reduction.
3. The disorder type associated with a dysfunction condyle-disk complex
has been called a disk-interference disorder or internal derangement;
and is commonly associated with anterior and medial displacement/
dislocation of the disk: single episodes of joint sounds (not crepitus)
pain associated with the joint sounds
normal range of movement
After an occlusal splint anterior repositions (AR) the mandiblePermanent repositioning via orthodontics, full mouth reconstruction,
fixed overlay splint, or overlay removable partial denture.
Gradually modify the splint to allow a return or near normal condylar
position without additional treatment or permanent alteration of the
This study evaluated the effects of AR splint therapy, in patients with
internal derangement followed by gradual elimination of the splint without
permanent alteration of the occlusal condition.
Forty patients had diagnosis of disk-interference disorder and wore an AR
splint 24 hours a day for 8 weeks.
Joint sounds are resolved only one third the time when AR splint and stepback adjustment are the sole treatment- suggests that diskal ligaments
do not tighten or shorten during this treatment.
Patients were reevaluated an average of two and a half years later:
Pain continued only 25% of the time.
80% of patients thought the treatment was beneficial.
33% of patients sought additional treatment or continued to have pain.


4. 63 patients with arthrographic diagnosed reciprocal clicking were divided into

3 equal groups: no treatment, flat occlusal splint, and disk repositioning
silver onlays.
The flat plane splint had maximal occlusal contact in CR with group contact
in laterotrusion and anterior guidance in protrusion.
The disk repositioning onlays were fabricated with the lower jaw protruded
to avoid disk clicking on closure.
Both treatment groups were evaluated after 6 months.
The recapture of a displaced disk and maintenance of the normal
relationship between disc and the condyle effectively reduced the pain and
dysfunction associated with TMJ displacement with reduction.
The disk repositioning onlays were significantly better than a flat plane splint
or no treatment.
When the onlays were removed after 6 months the patients symptoms
returned in 6 weeks.
5. 12 patients with reciprocal clicking (suggesting disk displacement with
reduction) and 3 patients with previous clicking that had progressed to
limitation of jaw opening and deviation to the affected side on opening and
protrusion (suggestive of disk displacement without reduction) were
selected for anterior repositioning therapy.
After temporary anterior repositioning with acrylic onlays or a splint, a
permanent change of occlusion to the therapeutic position was performed
by restoration or orthodontics.
All patients felt immediate relief of pain and functional disturbances after
recapturing the disk and insertion of the onlays or splint.
After 3 years the change in the horizontal plane was eliminated and only
half of the change in the vertical plane remained. This relapse as probably
caused by movements of the teeth and mandible.
A double contour on the posterior aspect of a few condyles was interpreted
as a sign of rebuilding and adjustment to the new position.
2 patients with persistent disk displacement had the same improvement at
follow-up as the normal condyle disk relationship. This raises the question
whether correction of the disk position is prerequisite for symptom relief or
whether position of the condyle anterior and inferiorly in the fossa can
reduce the symptoms.
The extent of dental treatment needed to maintain the disk in the correct
position should be relative to the severity of the symptoms.
6. 241 patients were treated with anterior repositioning splint therapy (REPO)
for a clinical diagnosis of anterior disc displacement.
After 3 years only 36 percent were considered successful.
REPO splint therapy for anterior disc displacement should not be lightly
undertaken by the general dental practitioner, but that a more conservative
approach should be adopted for the vast majority of TMJ patients.


16/19 REPO splints were unsuccessful in efforts to recapture and maintain

severely displaced discs with late opening clicks.
If the clinical history and examination suggests the presence of anterior disc
displacement with late reduction or no reduction (chronic closed lock), the
chance that the disc is permanently displace and distorted is extremely high.
The initiation of REPO splint therapy in this group of TMJ patients is both futile
and completely contra-indicated.
A conservative approach with strong emphasis on the use of a CR splint is
more likely to lead to a favorable outcome in at least 70% of the cases.
7. 72 patients were suspected of clicking (reducing meniscus) but only 53 had
arthrographic findings of a reducing meniscus.
Further evaluation revealed that only 41 could be candidates for a protrusive
This represents only 57% (41/72) of patients with clicking who may be
candidates for a protrusive splint.
All joint clicking is not necessarily a manifestation of a reducing meniscus, and
the timing and cause of the sounds are not as clinically diagnostic as one
might expect.
In the absence of pain and major mechanical dysfunction, clicking alone
should not be justification for the initiation of treatment.
8. 74 patients with middle to late opening movement click and closing
movement click near maximum intercuspation were treated with a
mandibular full coverage repositioning splint.
MRI assessment of the TMJ a few weeks after splint therapy started.
Disc displacement was confirmed by scanning first without the splint.
All joints had anterior displaced discs.
About 70% of the discs were recaptured.
9. Ligaments restrict certain movements (border movements) while allowing
other functional movements. If joint movements consistently function against
ligaments, the length of the ligaments can become altered.
Condyle-disc movement can be altered if there is a change in intraarticular
pressure or the morphology of the disc. This is the beginning of discinterference disorders.
If the posterior border of the disc becomes thinned and the inferior retrodiscal
lamina and lateral discal collateral ligament become elongated, the disc can
translate across the articular surface of the condyle.
Disc dislocation without reductionSudden change in condylar movement
Limited mandibular opening to 25-30mm (condyle cannot translate past disc)
Unrestricted ipsilateral eccentric movement (10-12mm)
Loss of joint sounds.
Adhesions can occur in the superior or inferior joint space and alter movement
Once adhesions have developed and the fibrotic tissue matures, nonsurgical


therapy is not likely to be successful.

Studies on anterior repositioning appliances that try to step the condyle back
to the original occlusal position fail to recapture the disc.
Incomplete return of the condyle to its fossa results in a posterior open bite.
Posterior open bite may result from reversible myostatic contracture of the
inferior lateral pterygoid muscle or thickened retrodiscal tissue in the fossa .
After repositioning therapy, the disc doesnt return to the fossa.
As the condyle returns to the fossa, it moves posteriorly and articulates with
adapted retrodiscal tissue while the disc is anteriorly displaced.
Anterior repositioning appliance therapy might lead to dental instability and
require future restoration, therefore it should be used with discretion.
When a stabilization appliance reduces symptoms, it should be used instead of
an anterior repositioning appliance, because it rarely causes irreversible
occlusal change.
All discs do not have to be properly positioned for health.
Therapies for recapturing disc position have for the most part failed.
Reversibe therapy to reduce suffering should be attempted first.
10. Anterior repositioning splint will result in a corresponding change in
occlusion, such as posterior open bite.
For TMJ closed lock, a stabilization splint, manipulation, moist heat, and
exercise should be considered the first choice of treatment, as opposed to
an anterior repositioning splint.
TMJ closed lock occurs when the disk has been abruptly lodged anterior to
the condyle head and blocks normal translation of the condyle through all
phases of jaw function.
TMJ closed lock- limited opening <30mm
deviation on opening toward the affected side
absence of previous clicking
ipsilateral myalgia
Closed lock can progress to degenerative joint disease- patients should be
treated not only for present pain but also for preventing aggravation of problem
1. Lundh H, et al. Anterior repositioning splint in the treatment of
temporomandibular joints reciprocal clicking: comparison with a flat occlusal
splint and an untreated control group. Oral Surg Oral Med Oral Pathol
2. Anderson GC, Schulte JK, Goodkind RJ. Comparative study of to treatment
methods for internal derangement of the temporomandibular joint. J
Prosthet Dent 1985;53:392-7.
3. Okeson JP. Long term treatment of disk-interference disorders of the
temporomandibular joint ith anterior repositioning occlusal splints. J
Prosthet Dent 1988;60:611-6.
4. Lundh H, et al. Disk-repositioning onlays in the treatment of


temporomandibular joint disk displacement: comparison with a flat occlusal

splint and with no treatment. Oral Surg Ora Med Oral Pathol 1988;66:155-6.
5. Lundh H, Westesson PL. Long term follow-up after occlusal treatment to
correct abnormal temporomandibular joint disk position. Oral Surg Oral Med
Oral Pathol 1989;67:2-10.
6. Moloney F, Howard JA. Internal derangements of the temporomandibular joint.
III. Anterior repositioning splint therapy. Aust Dent J 1986;31:30-9.
7. Roberts CA, et al. Clinical and arthrographic evaluation of temporomandibular
joint sounds. Oral Surg Oral Med Oral Pathol 1986;62:373-6.
8. Kurita H, et al. Evaluation of disk capture with a splint repositioning appliance.
Clinical and critical assessment with MR imaging. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1998;85:377-80.
9. Okeson JP. Nonsurgical management of disc-interference disorders. Dent Clin
N Am 1991;35:29-51.
10. Chung SC, Kim HS. The effect of the stabilization splint on the TMJ closed
lock. J Craniomandib Prac 1993;11:95-101.
Vertical Dimension and Splints
1. 52 adults were studied for the effect of an orthotic device on freeway space.
Half of the group was evaluated immediately after placement, half one week
after placement.
The orthotic device was a 3mm acrylic vacuformed appliance. No details of
occlusal scheme or condylar position were given.
Decreased freeway space: immediate 61%, 1 week 50%
Increased freeway space: immediate 35%, 1 week 46%
Conclusion- orthotic thickness does not necessarily increase or decrease
freeway space.
2. Freeway space: difference between the vertical dimension of the face in
intercuspal position and postural position.
Ten adults received maxillary splints, details of thickness and occlusal
scheme or refinement were not given.
Jaw muscle tonus adapts to extreme changes in vertical dimension.
Postural position is maintained by the combined afferent activity from
muscle spindles (length measurers) and periodontal receptors to the
brain stem.
3. 6 subjects with no symptoms of TMD had clear acrylic splints cemented to the
canines and posterior teeth to increase vertical dimension 3.9mm (average)
Cephalograms and EMG recordings were taken before and after splint use
Occlusion was refined to create stability in CR and smooth excursions.
Immediately after placement of the splints, a new interocclusal distance was
Postural position of the mandible varies according to conditions and is not
acceptable as a basis for determining the occlusal vertical dimension.


Vertical relation of occlusion should be estimated from esthetic, phonetic,

comfort, and functional aspects.
4. 3 groups of 25 patients with TMD symptoms wore maxillary full arch occlusal
splints for 3 weeks, continuously at night and 3 hours during the day.
Splints were flat with stable contacts in centric and anterior and canine
Group 1- increased vertical dimension 1mm
Group 2- increased vertical dimension average 4.42mm
Group 3- increased vertical dimension average 8.15mm
Groups 2 and 3 showed a faster and more complete reduction in clinical
symptoms than Group 1.
Groups 2 and 3 had their elevator muscles elongated beyond the clinical rest
position (1-3mm) without exceeding the vertical dimension of least EMG
activity (8-10mm).
Splints adjusted at or near the vertical dimension of least EMG activity are
more effective in promoting neuromuscular relaxation.
1. Lau KU. The effect of orthotic devices on freeway space. J Craniomandib
Prac 2004;22(4):320-4.
2. Hellsing G. Functional adaptation to changes in vertical dimension. J Prosthet
Dent 1984;52:867-70.
3. Carlsson GE, Ingervall B, Kocak G. Effect of increasing vertical dimension on
the masticatory system in subjects with natural teeth. J Prosthet Dent
4. Manns A, et al. Influence of the vertical dimension in the treatment of
myofascial pain-dysfunction syndrome. J Prosthet Dent 1983;59:700-9.
Soft vs. Hard Splints
1. 10 asymptomatic subjects were studied for the effects of hard vs. soft
occlusal splints.
All subjects were tested with both splints
Hard splints were maxillary full arch with even contact on all lower buccal
cusps and incisal edges, with canine disclusion in eccentric excursions.
Soft splints were adjusted so that there as light closure on all teeth,
excursions were not able to be adjusted.
Hard splints significantly reduced nocturnal muscle activity in the
majority of patients.
Soft splints will not significantly reduce bruxism.
A significant number of participants showed and increase in nocturnal
muscle activity when wearing the soft splint.
2. 10 healthy subjects with no symptoms or history of TMD were evaluated for
the effect of hard vs. soft splints on the temporalis and masseter muscles.
Hard splint was adjusted to provide widespread occlusal contacts in the


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