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OCCLUSION AND CLINICAL PRACTICE AN EVIDENCE-BASED APPROACH www.egydental.com

OCCLUSION AND CLINICAL PRACTICE AN EVIDENCE-BASED Edited by APPROACH FICD Iven Klineberg AM RFD BSe MDS PhD FRACDS FDSRCS(Ed) FDSRCS(Eng) Professor of Prosthodontics, Faculty of Dentistry, Westmead Centre for Oral Heal th, Westmead, New South Wales, Australia Rob Jagger BDS MSeD FDSRCS Reader and Consultant in Restorative Dentistry, Department of Adult Dental Healt h, UWCM Dental School, Cardiff, Wales, UK Foreword by Professor Nairn Wilson BDS MSe PhD FDSRCS DRDRCS Dean and Head of School, GKT Dental Institute, King's College, London, UK EDINBURGH lONDON NEW YORK OXFORD PHilADELPHIA ST lOUIS SYDNEY TORONTO 2004

WRIGHT An imprint of Elsevier Limited 2004, Elsevier Limited. All rights reserve d. The right of Iven Klineberg and Rob Jagger to be identified as authors of thi s work has been asserted by them in accordance with the Copyright, Designs and P atents Act 1988 No part of this publication may be reproduced, stored in a retri eval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of th e publishers or a icence permitting restricted copying in the United Kingdom iss ued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WI T 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Depar tment in Philadelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 2382239, e-m ail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com). by selecting 'Customer Supp ort' and then 'Obtaining Permissions'. First published 2004 Reprinted 2005, 2006 ISBN 0 7236 1092 4 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress C ataloging in Publication Data A catalog record for this book is available from t he Library of Congress Notice Medical knowledge is constantly changing. Standard safety precautions mus t be followed, but as new researcl and clinical experience broaden our knowledge , changes in treatment and drug therapy may become necessary as appropriate. Rea ders are advised to check the most current product information provided by the m anufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsi bility of the practitioner, relying on experience and knowledge of the patient, to determine dosages anc the best treatment for each individual patient. Neither tl Publisher nor the editors and contributors assume any liability for any inju ry and/ or damage to persons or property arising from this publication. The Publ isher your source for books, journals and multimedia in the health sciences www.elsevierhealth.com Working together to grow libraries in developing countries www.elsevier.com I www.bookaid.org I www.sabre.org ELSEVIER ~,~?,~,~~~ S"bre Foundation The publisher's policy is to use paper manufactured from sustainable forests Printed in China I

Foreword It is a great honour to be asked to prepare a foreword for an important textbook . The task is made all the more pleasant when the book is one that I have enjoye d reading, wish I had been able to write, and look forward to having available f or subsequent reference. Occlusion is fundamental to the clinical practice of de ntistry, yet many students and practitioners may admit to being uncertain, if no t confused about relevant terminology, approaches to management and appropriate clinical procedures. Setting out the best available evidence on occlusion in a s ystematic, easy to read, authorative style, with chapter synopses, key points an d helpful references, Occlusion and Clinical Practice: An Evidence-Based Approac h enables the reader to build, or restore a solid foundation of knowledge of occ lusion, spanning the complexities of the masticatory system, its assessment and management. This is an elegant, carefully crafted textbook, which more than fulf ils its stated aims and the readers' expectations a most valuable addition to an y dental library or treasured collection of selected texts. What else is special about Occlusion and Clinical Practice: An Evidence-Based Ap proach? Amongst this book's many attributes, it is exceedingly well written and produced in meticulous detail by a truly international team. The style is contem porary and consistent throughout, the illustrations are uniformly of a high qual ity and, despite being a multiauthor volume, the text lends itself to selected r eading - a bonus for those deprived of time and opportunity to read and enjoy th e book from beginning to end. Can I recommend this book to students and establis hed practitioners alike? Yes, most certainly. There is something for everyone, a nd for most a rich resource of new knowledge and understanding of occlusion, tog ether with practical guidance on relevant state-of-the-art clinical procedures. The editors - Iven Klineberg and Rob Jagger, together with the exceptionally wel l qualified cast of contributors, are to be congratulated on a job well done. An outstanding book which is a most welcome and timely addition to existing litera ture. Nairn Wilson London 2003 v

Acknowledgements We wish to acknowledge the support of colleagues who contributed chapters. Each one with their specialised knowledge in their respective field has provided a co mprehensive picture of the biological framework of occlusion for clinical practi ce. We are indebted to our students, both undergraduate and graduate for continu ing to stimulate our interest and challenge our knowledge. This text is dedicated to them. Special appreciation is due for the administrative expertise, personal interest and attention to detail at all stages of this project to Personal Assistant Mrs Tracey Bowerman, and to Ms Pat Skinner for her meticulous editorial support. Without these commitments, this work would not have been possible. vi

Preface and introduction This text book reviews, updates and expands on an earlier work by Klineberg (199 1). During the last decade dentistry has moved further from its mechanical begin ning than ever before and now emphasises - in all disciplines, the biological ba sis of dental practice. Educational programmes of necessity need to reflect thes e fundamental changes in philosophy which were comprehensively presented in Dent al Education at the Crossroads - Challenges and Change (Field 1995).In addition, the recognition of evidence-based dentistry has been a further stimulus to revi ew our core values in education and practice; as has been the case in medicine ( Sackett et aI1996). In recognition of these needs, the authors aim to provide th e reader with the best available evidence on occlusion and its clinical applicat ions. The authors recognise that this is an important requirement of educational programmes and are mindful of the need for applying knowledge of occlusion in c linical practice. Dental occlusion has been described as the way in which teeth contact. This however represents only a limited view and a modern understanding of occlusion includes the relationships of the teeth, jaw muscles and temporoman dibular joints in function and dysfunction. Occlusion is of importance to the pr ovision of comprehensive patient care. It is of relevance to all disciplines in dentistry. Occlusion is of particular relevance to restorative dentistry and pro sthodontics, where tooth restoration requires recognition of the importance of o cclusal form and tooth contact patterns at an appropriate occlusal vertical dime nsion, for optimising jaw function. The occlusion is a focal point for orthodont ic treatment, has a significant bearing on tooth mobility, and is an important c onsideration in treatment planning for maxillofacial reconstruction. In all thes e fields, an understanding of the importance of the occlusion is paramount for e nhancing jaw function, defining lower face height and aesthetic needs, as key is sues in optimising oral health. In addition to facial appearance, orofacial inte grity is a crucial element for psycho-social wellbeing. The text is divided into three parts: Part 1: Biological Considerations of the O cclusion which provides an overview of the functional biology of the jaw muscle system. Tooth relationships are of special importance in restoration and mainten ance of oral function, and with interarch relationships of teeth, form the basis of functional integrity and jaw movement control. Growth and development provid es the framework for understanding the interdependence of form and function, and together with the anatomy and pathophysiology of the temporomandibular joints a nd an understanding of jaw movement, defines the biological basis of occlusion. Dental treatment involving the alteration or replacement of tooth crowns and con tacting surfaces, impacts directly on this biological milieu. Recognition of thi s interaction of form and function confirms the singular importance of careful m anagement of the occlusion in the quest for developing or maintaining optimal or al health. Part 2: Assessment of the Occlusion - summarises a clinical approach for clinical occlusal analysis and for evaluation of study casts as an indispens able part of treatment planning. Part 3: Clinical Practice and the Occlusion - p rovides practical guidelines for clinical management of the occlusion in relatio n to temporomandibular joint and jaw muscles, periodontal health, orthodontic tr eatment, fixed and removable prosthodontic treatment, implant restoration, and d efines the role of occlusal splints and occlusal adjustment. This book has been written for senior dental undergraduates and dentists with a patticular interest in prosthodontics and restorative dentistry. Each chapter contains key referenc es and additional recommended reading, to encourage the reader to pursue further their area of special clinical interest. The text and individual chapters are d esigned to: a) provide an understanding of the framework within which occlusion is required in clinical practice; vii

b) provide clinical research information possible, biological justification for application of occlusion. and where the clinical The authors realise however, that the evidence based on systematic clinical rese arch and long-term clinical studies is weak in many aspects of the role of the o cclusion in biological function and harmony. There is also lack of convincing ev idence for a possible link of the occlusion with functional disorders of the jaw muscle system. Clinical studies have, in general, not adequately addressed the issues of the importance of the occlusion and its pivotal links with form, funct ion and psychosocial wellbeing. It is recognised that there has, in general, bee n no uniformity in clinical study design to allow data comparison. Study design has not consistently addressed issues of patient numbers, long-term follow up, b linding of clinical treatment options, bias and critical assessment of outcome m easures. Carefully designed clinical trials are needed to provide treatment guid elines based on biological research and long-term clinical outcome studies of tr eatment procedures. In the absence of appropriate clinical trials and longterm s tudies on clinical outcomes, clinical practice continues to be primarily based o n clinical experience which is often tempered with clinical convenience (operato r bias). Evidence-based practice is important for medicine and dentistry to opti mise treatment outcomes as the cornerstone of best practice. Evidence-based prac tice is based on the combina tion of: a) high quality scientific and careful lon g-term clinical trials, which provide research evidence to support clinical deci sion making; b) clinical experience is an essential component to allow appropriate interpreta tion of each patient's needs; c) the ability to ask the right questions in searc hing for the appropriate information; d) interpreting that information for appli cation to a particular clinical problem; and e) satisfying each patient's expect ations, rather than providing a predetermined treatment protocol. In the past, c linical experience has directed the path of clinical treatment, and the developi ng acknowledgement of an evidence-based practice approach is a welcome advance f or clinical dentistry; it has already been embraced in clinical medicine. Iven K lineberg Rob Jagger References Klineberg I 1991Occlusion: Principles and assessment. Wright, Oxford Field M J ( ed) 1995 Dental education at the crossroads challenges and change. National Acad emy Press, Institute of Medicine, Washington Sackett D L, Rosenberg W M C, Gray JAM, Haynes R B, Richardson W S, 1996Evidence based medicine: What it is and wha t it isn't: It's about integrating individual clinical expertise and the best ex ternal evidence. British Medical Journal 312: 71-72 viii

Contributors Anthony Au BDs MDSe FRACDS Private Practitioner, Turrarnurra, New South Wales, A ustralia Merete Bakke DDS PhD DrOdont Associate Professor, Department of Oral Fu nction and Physiology, School of Dentistry, Copenhagen, Denmark Gunnar Carlsson LOS OdontDr /PhD DrOdonthc FDSRDS(Eng) Editor-in-chief, International Journal of Prosthodontics; Professor Emeritus, Department of Prosthetic Dentistry, Faculty of Odontology, Coteborg University, Sweden Ali Darendelilar BDS PhD DipOrtho Di scipline of Orthodontics, Faculty of Dentistry, University of Sydney, New South Wales, Australia Annmarie De Boever DDS Department of Fixed Prosthodontics and P eriodontology, Dental School, Universiteit Gent, Belgium Jan De Boever DDS DMD P hD Professor, Department of Fixed Prosthodontics and Periodontology, Dental Scho ol, Universiteit Gent, Belgium John Hobkirk PhD BDS FDSRCS(Ed) FDSRCSEng DrMedHC MIPEM Om Kharbanda BDS MDS MNAMS FICO Head, Orthodontics Department, Westmead Centre f or Oral Health, Westmead, New South Wales, Australia Iven Klineberg AM RFD BSe M DS PhD FRACDS FDSRCS(Eng) F1CD Professor of Prosthodontics, Faculty of Dentistry, Professorial Unit, Westmead C entre for Oral Health, Westmead, New South Wales, Australia Jeremy Knox BDS MSeD PhD FDSRCS(Ed) MOrthRCS(Ed) FDS(Orth) Department of Orthodontics, UWCM Dental School, Cardiff, Wales, UK Greg Murray B DS MDS PhD FRACDS Associate Professor, Faculty of Dentistry, Professorial Unit, Westmead Centre for Oral Health, Westmead, New South Wales, Australia Sandro Pal la Prof Dr med dent Professor, Klinik fur Kaufunktionsstorungen und Totalprothet ik Zentrum fur Zahn-, Mund- und Kieferhelkunde, Universitat Zurich, Switzerland Terry Walton BDS MDSc MS(Mich) Private Practitioner, Sydney, New South Wales, Au stralia Tom Wilkinson BDS MSc MDS Private Practitioner, Adelaide, South Australi a, Australia Professor of Prosthetic Dentistry, Eastman Dental Institute for Oral Health Care Sciences, University College, University of London, UK Rob Jagger BDS MSeD FDSR CS Reader and Consultant in Restorative Dentistry, Department of Adult Dental He alth, UWCM Dental School, Cardiff, Wales, UK ix

Contents SECTION 1 SECTION 3 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION 1. Interarch relationships of teeth I. Klineberg 2. Jaw movement and its control G. Murray 3. Growth and development J. Knox 23 3 CLINICAL PRACTICE AND THE OCCLUSION 7. Temporomandibular joint disorders 67 G. Carlsson 8. Jaw muscle disorders 75 M . Bakke 9. Occlusion and periodontal health 83 J. De Boever; A. De Boever 10. Oc clusion and orthodontics 91 A. Darendelilar; O. Kharbanda 11. Occlusion and fixe d prosthodontics 103 T. Walton 12. Occlusion and removable prosthodontics 111 R. Jagger 13. Occlusion and implant restoration 119 J. Hobkirk 14. Occlusal splint s and management of the occlusion 125 T. Wilkinson 15. The role of occlusal adju stment 133 A. Au, 1 Klineberg 13 4. Anatomy and pathophysiology of the temporomandibular joint 31 S. Palla SECTION 2 ASSESSMENT OF THE OCCLUSION 45 5. Clinical occlusal analysis I. Klineberg 6. Articulators and evaluation of study casts R. Jagger 55 Index 139 xi

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Interarch relationships of teeth I. Klineberg The term 'occlusion' represents a broader concept than the arrangements of teeth . Occlusion is the dynamic biological relationships of components of the mastica tory system that control tooth contacts during function and dysfunction. It is e ssentially the integrated action of the jaw muscles, temporomandibular (TM) join ts and teeth. The essential characteristics of the system morphologically and ph ysiologically are genetically determined (jaw muscle characteristics, jaw shape and size, tooth eruption sequence), and functional relationships mature during g rowth and development. However, once established, continual modification of the jaw muscle system occurs with function and parafunction. Importantly, the influe nce of parafunction on tooth position and wear may be significant, with ongoing remodelling of bone and muscle allowing adaptation to prevailing circumstances, emphasising the dynamic nature of this complex biological system. Synopsis This chapter reviews relationships of teeth that are important in the clinical m anagement of the occlusion. These include an understanding of tooth contact posi tions in the natural dentition and the clinical recordings of jaw position for t reatment purposes. Occlusal relationships are summarised, recognising the prevai ling divergent views in defining optimal jaw and tooth contact relationships. Th e implications of the variations that are described in population studies are co nsidered, and their possible links with jaw muscle pain and temporomandibular di sorders (TMDs) reviewed. A summary statement on occlusal relationships emphasise s the difficulty in defining optimum occlusal features. The border movement diag ram is summarised as an important statement of historical development in the field, and as a useful c onceptual tool for understanding border positions. Anterior and lateral guidance is defined in the light of research evidence, in conjunction with the emerging research evidence on mediotrusive contacts/ interferences. Features of the natur al dentition are distinct from guidelines recommended for restoration of the occ lusion. There is a need for more carefully designed clinical studies, as much of what has been published does not present strong evidence for clarifying issues. It is encouraging, however, that more recently, systemic reviews (Clark et al 1 999, Forssell et al 1999, Marklund & Wanmann 2000, Tsukiyama et al 2001) and con trolled trials (Pullinger & Seligman 2000, Seligman & Pullinger 2000), some of w hich are randomised and blinded, have been reported. It is also recognised that human physiological studies of jaw and condyle position and movement, and electr omyographic (EMG) studies, especially of deep jaw muscles, are technically deman ding, and recruitment of subjects is often difficult. Notwithstanding these chal lenges, progress is being made in moving forward from our mechanical heritage to a recognition of the complexities of the biological system within which occlusa l management is of clinical and psychosocial importance. 3

I BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Key points Occlusion is the dynamic biological relationship of the components of the mastic atory system that determine tooth relationships Intercuspal contact (lC) is the contact between the cusps, fossae and marginal ridges of opposing teeth Intercus pal position (lCP) is the position of the jaw when the teeth are in IC Maximum i ntercuspation (MI) is the contact of the teeth with maximum clenching Centric oc clusion (CO) is the IC when the jaw and condyles are in centric relation ICP and CO are not usually the same tooth contact positions, that is, there is a slide from CO to ICP Median occlusal position (MOP) is a clinically determined tooth c ontact jaw position obtained by a 'snap' jaw closure from a jaw open position Re truded jaw position (RP) is the guided jaw position with the condyles in a physi ologically acceptable position for recording transfer records Retruded contact p osition (RCP) is the tooth contact position when the jaw is in RP Centric relati on (CR) is the guided jaw position where the condyles are located anterosuperior ly, in contact with the central bearing surface of the interarticular disc locat ed against the articular eminence Postural jaw position (PJP) is the jaw positio n determined by the jaw muscles when the subject is standing or sitting upright, with variable space between the teeth Occlusal vertical dimension (OVD) is the vertical height of the lower third of the face with the teeth in ICP Lateral jaw positions: - Mediotrusive (non-working) side contact arises when the jaw is mov ed or guided to the opposite side, and the mediotrusive side moves medially, tha t is, towards the midline - Laterotrusive (working) side contact occurs when the jaw is moved or guided to the side, that is, laterally to the right or left. Th e tooth contacts on that side are termed laterotrusive (or working) contacts Bennett movement is a term that describes lateral movement of the condyle, that is, condyle movement to the laterotrusive (or working) side Bennett angle is the angle of the condyle formed with the sagittal plane on the mediotrusive side as the condyle moves forward downwards and medially Protrusive jaw movement descri bes a forward (straight line) jaw movement, and protrusive tooth contacts includ e incisal tooth contact TOOTH CONTACTS AND JAW POSITIONS The need to describe jaw and tooth positions accurately for treatment planning, writing of clinical reports and for laboratory prescriptions requires an underst anding of the following customarily accepted descriptive terms: Intercuspal cont act (IC) is the contact between the cusps, fossa and marginal ridges of opposing teeth. Iniercuspal position (ICP, IP) is the position of the jaw when the teeth are in intercuspal contact (IC). Light rc occurs with light tooth contact; in t his situation, the number and area of tooth contacts are less than with heavy to oth contact (clenching). rcp is the tooth contact position at the end of the clo sing phase and the beginning of the opening phase of mastication. Most natural o cclusions indicate rcp contacts as a combination of flat and inclined surfaces o r inclined planes with supporting cusp to opposing tooth fossa or marginal ridge . The greatest number of contacts occurs between molar teeth, and this decreases to 67% contacts on first bicuspids and 37% contacts on second bicuspids. Light to heavy biting approximately doubles the number of tooth contacts (Riise & Eric sson 1983). Maximum intercuspation (Mf) occurs with clenching (heavy bite force) , when the number and area of tooth contacts are greatest. The increase in numbe r and area of tooth contacts occurs as a result of tooth compression within the periodontal space, which for individual teeth may be of the order of 100 rm in h ealthy periodontal tissues. With periodontal disease and periodontal bone loss, this may be greater. The distinction between rcp and Ml might appear to be of ac ademic rather than clinical interest; however, the recognition of an increase in the number of tooth contacts is relevant when finalising anatomical tooth form for restorations, to ensure that with clenching the restoration is not too heavi

ly loaded. 4

INTERARCH RELATIONSHIPS OF TEETH Centric occlusion (CO) and ICP may be considered the same for clinical purposes; however, the Glossary of Prosthodontic Terms (Preston et al 1999) defines CO as the tooth contact position when the jaw is in centric relation. CO mayor may no t be the same tooth contact relationship as ICP. Tooth contacts (CO) when the ja w is in centric relation may be more retruded than at ICP. In an epidemiological study, Posselt (1952) determined that CO and ICP coincided in only approximatel y 10% of natural tooth jaw relationships. In clinical practice, complete denture treatment usually requires working casts to be articulated in centric relation (see below). The artificial tooth arrangement and jaw contact position between t he denture teeth is then CO by definition. Median occlusal position (MOP) is a d ynamic tooth contact position that may be determined by a 'snap' (rapid) jaw clo sure from a jaw open position (McNamara 1977). Tooth contacts at MOP have been p roposed as being equivalent to functional tooth contacts. MOP tooth contacts can only be determined clinically and are useful to indicate functional tooth conta cts in clinical occlusal analysis. The use of ultrafine occlusal tape (such as G HM Foil, Gebr. Hansel-Medizinal, Nurtingen, Germany; Ivoclar/ Vivadent, Schaan, Liechtenstein), placed between the teeth (teeth need to be air-dried to allow th e tape to mark tooth contacts), will allow MOP contacts to be identified. It is likely tha t MOP and ICP (with light tooth contact) are equivalent for clinical assessment purposes. Retruded jaw position (RP) is the position of the jaw when the condyle s are in a physiologically acceptable guided position for the recording of trans fer records. This position is a reproducible position for the treatment to be un dertaken. It is not always constant in the long term, as remodelling adaptation of joint components is a feature of biological systems. RP is independent of too th contacts. Retruded contact position (RCP) is the contact position of the teet h when the jaw is in RP. Centric relation (CR) is the jaw relationship (also ter med maxillomandibular relationship) in which the condyles are located in an ante rorsuperior position in contact with the central bearing surface (the thin avasc ular part) of the interarticular disc, against the articular eminence (Preston e t a11999) (Fig. 1.1). This position is independent of tooth contact. RP and CR a re describing similar clinical anatomical relationships. It is the condylar posi tion at RP or CR that is used for clinical recording of the jaw relationship for transfer to an articulator. Postural jaw position (PJP) is the position of the jaw when an individual is sitting or standing upright when relaxed and alert. Th ere is variable space between Articular tubercle Mandibular fossa Ant~erior[;J slope slope Crest ,:/ . s, Bilaminar zone Lateral terygoid p muscle -upper head Lateral terygoid p muscle -lowerhead Fig. 1.1 Mid-sagittal section of the human temporomandibular joint. Note: (1) The ext ent of the central bearing surface of the interarticular disc. (2) The thickness

of articular tissue varies, being thickest in those areas under greatest functi onal shear stress and load. This is illustrated in the lower right of the diagra m where the surface tissues of the articulation are shown varying in thickness i n the condyle, disc and temporal component. The dark areas represent the relativ e thicknesses, confirming that function occurs between condyle and articular tub ercle rather than between condyle and fossa. (3) The anterior thick band (or foo t) of the interarticular disc is bound down on the medial third to the superior surface of the superior lateral pterygoid muscle. Most muscle fibres insert into the condylar fovea. Some muscle fibres insert into a junctional zone between up per and lower heads, which then inserts into the fovea. More laterally, the ante rior thick band attaches to the anterior capsular ligament. 5

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION maxillary and mandibular teeth, termed 'free-way' or speaking space. The PJP is determined by the weight of the jaw and the viscoelastic structural elements of the postural jaw muscles, as well as myotatic reflex contraction. This contracti on is brought about by stretch of muscle spindles that results in activation of alphamotoneurones that innervate the extrafusal muscle fibres of the jaw-closing muscles. PJP is important in the assessment of lower face height (lower third o f the face as a proportion of overall facial proportion) and in determining the occlusal vertical dimension in treatment planning for dentate and edentulous pat ient needs. Occlusal vertical dimension (OVD) is the vertical height of the lowe r third of the face when the teeth contact in ICP. The lower third of the face i s an important component of facial aesthetics and is an essential element of tre atment planning in conjunction with PJP. The 'freeway' or speaking space is a va riable separation of the teeth between PJP and OVD, and is an important determin ant of speech communication. As a result, dental restorations may have a signifi cant influence on speech in both dentate and edentulous treatment. Lateral jaw p ositions - Mediotrusive (or non-working or balancing) side refers to the side of the jaw which moves towards the midline (or medially) in lateral jaw movement. The term 'balancing' may also be understood in functional terms as the 'non-work ing' side, that is, the side opposite the chewing side. Non-working side is cons idered in the analysis of casts on an articulator, or the arrangement of the tee th for complete or partial dentures, in which nonworking tooth contacts may be a desirable arrangement in denture construction. The term is also used in clinica l occlusal analysis to identify the arrangement of teeth and the presence of med iotrusive (or balancing or non-working) tooth contacts or interferences (describ ed in Chapter 5). - Laterotrusive (or working) side refers to the side of the ja w which moves laterally away from the midline in jaw movement. This may also be termed the 'working' or chewing side in function, that is, the side where chewin g occurs. A particular aspect of laterotrusive jaw movement is the number and ar rangement of the teeth which are in contact in lateral or laterotrusive jaw move ment. This is also termed disclusion. Disclusion may involve the anterior teeth only, which may be the canine tooth (canine disclusion), or incisor and canine t eeth (anterior disclusion); or it may involve posterior teeth only - bicuspid an d/ or molar teeth (posterior disclusion); or it may involve both anterior and po sterior teeth (group function). 6 Bennett movement and Bennett angle are terms originally described by Bennett (19 06) as the first clinical study which identified lateral or sidewards movement o f the jaw and differentiated the bilateral features of condyle movement with rem arkable clarity in one subject (Bennett himself). - Bennett movement describes a lateral component of movement of the condyle with laterotrusive jaw movement. B ennett described a lateral horizontal component of movement, which has also been described in relation to the setting of articulator condylar guidance as 'immed iate side shift' (ISS). The latter is strictly an articulator term. There is som e evidence from clinical recordings (Gibbs & Lundeen 1982) that Bennett movement may occur in function, in some individuals, at.the end of the closing path of a chewing movement. - Bennett angle is the angle formed by movement of the contra lateral condyle with the sagittal plane during lateral jaw movement. The contral ateral (or balancing) condyle moves downwards, forwards and medially, forming an angle (Bennett angle) with the sagittal plane when viewed anteriorly (from the front) or superiorly (from above). The articulator term for movement of the cont ralateral (or balancing) condyle is 'progressive side shift' (PSS). OCCLUSAL RELATIONSHIPS Confusion remains concerning optimum occlusal relationships and the association of occlusal variables with TMDs. In attempting to define what is optimum, it is acknowledged that stable occlusal relationships are the norm in the population,

even though there is great variation in structural and functional features. Ther e are no controlled studies on the optimum features of a harmonious natural and/ or restored occlusion. However, studies (Pullinger & Seligman 2000, Seligman & P ullinger 2000, Tsukiyama et al 2001) on the relationship between occlusal variab les and TMDs provide a clue, even though there is a lack of agreement on this in terrelationship (McNamara et a11995, Kirveskari et al 1998). Pullinger and Selig man (2000) and Seligman and Pullinger (2000) studied 12 independent variables to gether with age, and found that there was a significant overlap of occlusal feat ures between asymptomatic control subjects and patients with TMDs. In general, t heir studies indicated that asymptomatic controls were characterised by: a small amount of anterior attrition small or no RCP - ICP slide 1.75 mm)

INTERARCH RELATIONSHIPS OF TEETH absence of extreme overjet 5.25 mm), and absence of unilateral posterior crossbit e. However, sensitivity (61 %) and specificity (51%) did not reach appropriately high enough levels (>75% and >90%, respectively) to provide undisputed evidence of association. In addition, McNamara et al (1995) reported that there is no li nk between changes in the occlusal scheme with orthodontic treatment and the dev elopment of TMDs. In light of the information from these studies, it may be conc luded that those occlusal features that are not associated with TMDs are accepta ble as optimum for the individual. There are no doubt other features needing to be specified from research studies in order to more fully define optimum occlusi on. The recognition of a revised and limited role for occlusal variables in TMDs is significant, as it justifiably questions the historical emphasis given to th e occlusion and its role in dysfunction. In contrast with natural occlusions, in therapeutic restoration it is clinically desirable and practical, even in the a bsence of good research data, to optimise function by taking into account the fo llowing: Establish an appropriate occlusal vertical dimension for aesthetics (lo wer face height), functions of speech, mastication and swallowing, and to increa se interocclusal space where necessary for restorations. Harmonise tooth contact s (maximum intercuspation) with a stable position of the condyles, ideally in an unstrained condylar position with interarticular discs appropriately aligned, t o allow fluent function between condyle and eminence. The specific tooth contact pattern is not defined, but cusp-fossa and cusp-marginal ridge contacts provide stable tooth relationships; the need for tripodised contacts has not been estab lished. Anterior tooth arrangement is crucial for aesthetics and speech. There i s no evidence to support the need for either anterior guidance or group function (Marklund & Wanmann 2000, Yang et al 2000). However, in a consideration of the biomechanics of lateral tooth contact, anterior guidance makes sense, as bite fo rce is reduced as well as the reaction force at the condyles. Smooth lateral and protrusive movements support fluent function, and may be important in optimisin g jaw muscle activity. ICP L i .p R o o L~R RCP Fig. 1.2 A Shows the sagittal (or profile) view of the border diagram with the a nteroposterior relationships of ICP,RCPand ProThe view also shows that the lower incisor tooth movement from ICPto RCPrequires the jaw to be guided into RCP.Low er incisor movement from RCPto H follows a curved path that reflects the initial rotatory movement of the condyles. This is also described as rotation around th e intercondylar or terminal hinge axis, that is, the axis of rotation between th e condyles when they are guided around centric relation. The movement changes fr om rotation to translation (H to 0) after approximately 15-20 mm of jaw opening at the lower incisors. B Shows the frontal view and C the horizontal view of the movement of the lower incisors along the border path. The sagittal view is the most informative. ICP,intercuspal position; RCP,retruded contact position; Pr; p

rotruded jaw position; p. postural jaw position; 0, maximum jaw opening; H, hing e arc of opening. Approximate range of jaw movement in adults: RCP-ICP 0.5-2.0 m m; ICP-O 40-70 mm; RCP-H 15-20 mm; P-ICP 2-4 mm; ICP-Pr 5-10 mm. BORDER MOVEMENT Posselt's border movement diagram Posselt (1952) described the full range of jaw movement in three planes by traci ng the path of the lower incisor teeth as the jaw is guided through the border p aths. The border path is the maximum range of jaw movement which is determined by the jaw muscles, ligaments, movement limitations of the temporomandibular joints, and th e teeth. The teeth define the top of the border diagram which is of particular i nterest in restorative dentistry, as the relationship between ICP (IP) and CO (R CP) is diagrammatically indicated. In the absence of teeth (as in complete edent ulism) the top of the border diagram does not differentiate ICP (IP) and CO (RCP ). The border diagram may be displayed in the sagittal, frontal and horizontal p lanes. The sagittal plane view of the border movement of the jaw in dentate indi viduals, as defined by the movement of the lower incisor teeth, shows features o f particular interest: 7

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION 15 14 13 12 11 10 9 8 7 6 5 4 3 2 A B ,, , ,, , ,, ,, , ,, ,, !-- FAO .---,.', Fig.1.3 A Tracings 1-15 represent individual chewing cycles (or envelopes) obtai ned by monitoring the movements of the lower incisor tooth while chewing gum. Th e movement of the lower incisor was recorded with a Kinesiograph (K5 Myo-tronics Research Inc., Seattle, Washington 98101, USA), via a magnet cemented at the in cisors, and movement of the magnet was detected by an array of sensors (flux-gat e magnetometers) attached to a headframe. Note the individual variations in each chewing cycle. The 15 cycles comprise the functional envelope of movement. (Bar indicates 10 mm.) B Tracings of the lower incisor tooth obtained as in A while chewing gum. The composite envelope of function is composed of the 15 individual chewing cycles shown in A. The relationship of the functional envelope to the i ncisor teeth is shown and the functional angle of occlusion (FAO) represents the approach and departure of the lower incisors from tooth contact. The top of the border path is defined by the position and cuspal inclines of the teeth (Fig. 1.2: K'P to RCP, rcr to Prj. The retruded path is defined by the an atomy of the temporomandibular joints (Fig. 1.2: RCP to H; H to 0). ANTERIOR OR LATERAL GUIDANCE The physical features of tooth guidance vary with tooth arrangement and interarc h relationships. Anterior guidance

is provided by the vertical (overbite) and horizontal or anteroposterior (overje t) relationships of anterior teeth. Posterior guidance is determined by the rela tionships of supporting cusp inclines, particularly of opposing molar teeth. Pos terior guidance may be increased in the presence of missing teeth, with tilting and drifting of teeth, and by the curvature of the occlusal plane anteroposterio rly (curve of Spee) and laterally (curve of Wilson). Tooth guidance varies betwe en individuals and directly influences the approach and departure angle of mandi bular to maxillary 8

INTERARCH RELATIONSHIPS OF TEETH A B Hingeand translatory movementseparated Combinedhingeand translatorymovement c Fig. 1.4 Anterior guidance - functional angle of occlusion. A Anterior guidance on the distal incline of the ipsilateral canine tends to separate the distal hin ge and translatory jaw movements, which may direct the condyle and disc along a more distal path and away from the eminence. B Anterior guidance on the mesial i ncline of the ipsilateral canine tooth tends to provide a combined hinge and tra nslatory movement which may direct the condyle and disc along a more anterior pa th towards the eminence. C The lingual contour of the maxillary canine has a lon gitudinal ridge which divides the lingual surface into a distinct mesial and dis tal fossa. The opposing teeth (ideally the mandibular canine) may contact the di stal or mesial fossa, and lateral jaw guidance will be different in each case. T he distal fossa will tend to direct the jaw along a more distal (posterior) path and the mesial fossa will tend to direct the jaw along a more mesial (anterior) path. teeth, that is, the functional angle of occlusion in chewing. The chewing cycle is also termed the envelope of function, the shape of which is determined by the tooth guidance (Fig. 1.3). The functional loading of teeth and the associated s timulation of periodontal mechanoreceptors provide a reference point for tooth c ontact and establish a beginning and end of jaw movement in mastication and swal lowing (Trulsson & Johansson 1996). mesial or distal guidance, depending on which surface the opposing tooth contact s. Lateral guidance on the distal canine surface may direct the ipsilateral (wor king) jaw distally, while initial tooth contact on the mesial canine incline may direct the jaw mesially. This may influence condyle disc relationships, althoug h this has not been confirmed in clinical studies. This proposal is based on cli nical and geometric assessment (Fig. 1.4). CANINE GUIDANCE The lingual surface of the maxillary canine tooth is ideally contoured, with a p rominent axial ridge that may provide Distal guidance During function or parafunction, if anterior tooth guidance restricts the anteri or component of movement (as is seen in the case of a deep bite), the closing ja w movement 9

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION follows a more distal approach path to tooth contact. The more distal approach t o tooth contact may also arise as a result of distal guidance from the canine th at restricts forward translation in jaw closing. The more distally directed move ment requires a predominance of condyle rotation. It is hypothesised that, with more rotation, the interarticular disc may more readily rotate beyond the poster ior thick band of the disc and become trapped anteromedially. With translation, in contrast to rotation, the disc moves with the condyle, maintaining their rela tionship against the eminence. Mesial guidance Mesial guidance along the mesial canine incline may allow both rotation and tran slation. As a result, the jaw closes along a more anterior path and approaches t ooth contact from a more forward position. It is hypothesised that this combinat ion of rotation and translation encourages approximation of condyle interarticul ar disc with the posterior slope of the articular eminence, maintaining their co ntact relationships. The association between mesial or distal canine guidance in lateral jaw movements, and the effect at the condyle, is complex and is linked with jaw muscle activity and condyle disc relationships. There is some clinical research evidence correlating distal canine guidance with a more posterior condy lar path (Yang et al 2000). Yang et al described a weak correlation between dist al canine guidance (that is, a retrusive laterotrusive path) and a lateral and p osterior movement of the ipsilateral (working) condyle. In contrast, mesial cani ne guidance resulted in lateral and inferior movement of the ipsilateral condyle . It is acknowledged that clinical studies to correlate jaw muscle activity with condyle disc relationships, to determine the influence of canine guidance, are difficult. The sophistication of equipment needed for accurately tracking condyl e movement is a limitation, and the problem of identifying an appropriate point within the condyle for three-dimensional measurement has not been standardised ( Peck et aI1999). Although not necessarily a feature of the natural dentition, wi th clinical restoration of the dentition it is considered desirable to avoid med iotrusive (non-working) and laterotrusive (working) interferences (Wassell & Ste ele 1998, Becker et al 2000). The presence of guidance on canines is also prefer red as a restorative convenience, although group function, where several teeth p rovide simultaneous lateral guidance, has been proposed to lead less readily to muscle fatigue (Moller & Bakke 1998). A number of clinical physiological studies with electromyography and/ or jaw tracking have attempted to determine the feat ures of anterior guidance: 10 Less muscle force is generated with anterior tooth contact only (Manns et al 198 7), and maximum muscle force is developed with molar tooth contact; guidance fro m the anterior part of the jaw results in resolution of muscle force vectors to guide the jaw smoothly into IP. Belser and Hannam (1985) reported that: - There is no scientific evidence to indicate that canine guidance or group function is more desirable. - The steepness of the anterior guidance is not of primary impor tance. - The presence of a dominant canine guidance tends to reduce the opportun ity for generating high interarch forces, and may reduce para functional loads. - Canine guidance does not significantly alter the masticatory stroke. Moller an d colleagues (1988) have reported that: - Maximum occlusal stability and maximum elevator muscle activity occur at IP, suggesting that it is the optimum tooth c ontact position for chewing and swallowing. - Muscle activity is directly relate d to occlusal stability in ICP. - A critical relationship exists between contrac tion time and pause time in jaw-closing muscles and influences susceptibility to fatigue. Short, strong jaw-closing muscle contractions with a relatively long p ause at tooth contact minimise the susceptibility to fatigue. - The relative con traction times of jaw-closing muscles in the chewing cycle were reduced in the p resence of group function contacts for lateral guidance. More recently, Ogawa et

al (1998) have reported that the chewing cycle is influenced by occlusal guidan ce and the occlusal plane inclination. Their studies were based on chewing gum a nd recording three-dimensional movement of jaw and condyle in relation to tooth guidance and occlusal plane orientation. They concluded that: - Both tooth guida nce and occlusal plane orientation influence the form of the chewing cycle. - Oc clusal guidance (overbite and overjet) influences the sagittal and frontal closi ng paths over the final 0.5 mm of jaw movement into tooth contact. - The occlusa l plane angle influences the sagittal and frontal closing paths over the final 2 .0-5.0 mm of jaw movement into tooth contact. MEDIOTRUSIVI; (BALANCING) CONTACTS/INTERFERENCES Canine or anterior guidance is often present in the natural dentition of young i ndividuals; however, tooth orientation in growth and development may result in p osterior guidance. The variation in tooth arrangements and

INTERARCH RELATIONSHIPS OF TEETH contact patterns in healthy adult dentitions is expected, linking form and funct ion. With tooth wear, group function develops as a feature of older natural dent ition. In the process, mediotrusive contacts in lateral jaw movements may arise, as may mediotrusive interferences. A systematic review of the epidemiology of m ediotrusive contacts by Marklund and Wanmann (2000) suggested a median percentag e of the prevalence of mediotrusive contacts of 35% (studies reported 0-97%) and interferences of 16% (studies reported 0-77%). There were no gender differences . Steepness of the condylar inclination may influence the presence of mediotrusi ve contacts or interferences. This inclination changes with age and becomes stee per in adults. It follows that in children with flatter condylar inclinations th ere would be more mediotrusive interferences. This may be the case. However, the clinical significance is whether the presence of these contacts or interference s is associated with increased prevalence of jaw muscle pain and TMDs. There is some reported evidence that jaw muscle tenderness and impaired jaw movement is h igher in children and young adults in association with mediotrusive interference s; however, the evidence is weak. Research evidence suggests that: There is not a direct cause and effect relationship between posterior tooth contact relations hip and either jaw muscle pain or TMDs (Clark et a11999, Pullinger & Seligman 20 00, Seligman & Pullinger 2000). Other factors are involved in the aetiology of T MDs. A biomechanical study of mediotrusive contacts and clenching by Baba et al (2001) reported that canine guidance caused a small displacement at the ipsilate ral molars and the largest displacement at the contralateral molars. A similar e ffect on condyle position is suggested, leading to limited compression of the ip silateral joint and larger compression of the contralateral joint. It is possibl e that TM joint compression arising in this way may alter the biomechanical rela tionships of jaw muscles, condyle and disc and may be a predisposing factor or a possible initiating factor for TMDs. EMG studies have confirmed specific change s in jaw muscles with mediotrusive and/ or laterotrusive contacts, but no direct association with TMDs. Recent studies on the influence of tooth contact interfe rences on jaw and joint position and jaw muscles suggest that: Specific changes in the occlusal scheme, such as placing mediotrusive (balancing) or laterotrusiv e (working) interferences, and canine guidance, cause predictable changes in jaw orientation (or tilt) with clenching (Minagi et al 1997, Baba et al 2001). Biom echanical associations occur as a result: - A mediotrusive interference and heavy bite force or clenching establish a leve r arm with the interference as the fulcrum, leading to greater elevation of the ipsilateral molars and possible compression of the ipsilateral TM joint with a c hange in reaction force (Belser & Hannam 1985, Korioth & Hannam 1994, Baba et a1 2001). It could be hypothesised that in some individuals parafunction in the pre sence of mediotrusive interferences and TM joint increased reaction force may co ntribute to TMD at the ipsilateral joint. - The presence of canine guidance elim inates mediotrusive interferences and changes the biomechanical effects of bite force and clenching on the TMjoint. Baba et al (2001) showed that ipsilateral co ntact from canine to bicuspids to molars (that is, group function) with clenchin g leads to contralateral jaw elevation and joint compression. Canine guidance re sults in least joint compression, while ipsilateral molar contact interference w ith clench leads to greater contralateral joint ,compression. Such biomechanical changes with clenching may also be a possible contributing factor for TMD. - Ba lanced occlusion appears to be protective of the joints and may not lead to an i ncrease in either ipsilateral or contralateral TM joint compression. - In suppor t of the above, Minagi et al (1997) found a positive correlation between the abs ence of contralateral (mediotrusive) tooth contacts and increased prevalence of joint sounds. The corollary from this study is that mediotrusive contacts may ha

ve a protective role for the joint, in association with parafunction. In EMG stu dies, canine guidance results in increased unilateral anterior and posterior tem poral activity. The presence of mediotrusive (balancing side) contacts recruits contralateral jaw muscles and results in bilateral anterior and posterior tempor al activity (Belser & Hannam 1985, Baba et al 1996, Minagi et al 1997). SHORTENED DENTAL ARCH (SDA) It has been shown that individuals may have satisfactory aesthetics and occlusal function with a reduced number of posterior teeth (Kayser 2000). This fact has led to the so-called shortened dental arch concept and the realisation that it i s not always necessary to replace missing posterior teeth. Of particular interes t in the management of the occlusion is the recognition of the concept of the sh ortened dental arch as a viable treatment option. This section 11

I BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION concerns specific tooth contact relationships and the controversial effects of c lenching on the TM joints and describes studies based on the presence of posteri or (bicuspid and molar) teeth. In the absence of the molar and possibly bicuspid teeth, the specific lever arm effects and TM joint reaction forces from loading would not occur to the same extent. Whether or not this is advantageous to the jaw muscle system would depend on remaining tooth distribution and their ability to withstand functional and parafunctionalloading. More importantly, the often claimed association between the lack of posterior teeth predisposing to TM joint loading and the possible development of TMD is not supported. Long-term data on the clinical effects of the shortened dental arch indicates that the absence of molar teeth does not predispose to TMD or orofacial pain, and allows adequate f unction for long-term health of the jaw muscle system. The minimum number of tee th needed for function varies with individuals. The goal of maintaining a comple te dental arch, although theoretically desirable, may not be attainable or neces sary. It has been shown from long-term studies that the anterior and premolar se gments can meet all functional requirements (Kayser 2000). When priorities have to be set, restorative treatment should preserve the most strategic anterior and premolar segments. The need for partial dentures or complex treatment to restor e molar segments (implant, bridgework, endodontics and root/tooth resection) sho uld be questioned and based on individual patient wishes. References Baba K, Yugami K, Yaka T, Ai M 2001 Impact of balancing-side tooth contact on cl enching-induced mandibular displacement in humans. Journal of Oral Rehabilitatio n 28:721-727 Becker C M, Kaiser D A, Schwalm C 2000 Mandibular centricity: centr ic relation. Journal of Prosthetic Dentistry 83:158-160 Belser U C, Hannam A G 1 985 The influence of altering working-side occlusal guidance on masticatory musc les and related jaw movement. Journal of Prosthetic Dentistry 53:406-414 Clark G T, Tsukiyama Y, Baba K, Watanabe T 1999 Sixty-eight years of experimental inter ference studies: what have we learned? Journal of Prosthetic Dentistry 82:704--7 13 Forssell H, Kalso E, Koskela Pet al1999 Occlusal treatments in temporomandibu lar disorders: a qualitative systematic review of randomised controlled trials. Pain 83:549-560 Gibbs C H, Lundeen H C 1982 Jaw movements and forces during chew ing and swallowing and their clinical significance. In: Lundeen H C, Gibbs C H ( eds) Advances in occlusion. Wright, Boston, pp 2-32 Kayser A F 2000 Limited treatment goals - shortened dental arches. Periodontolog y 4:7-14 Kirveskari P, [arnsa T, Alanen P 1998 Occlusal adjustment and the incid ence of demand for temporomandibular disorder treatment. Journal of Prosthetic D entistry 79:433--438 Korioth T W, Hannam A G 1994 Mandibular forces during simul ated tooth clenching. Journal of Orofacial Pain 8:178-189 McNamara D C 1977 The clinical significance of median occlusal position. Journal of Oral Rehabilitatio n 5:173-186 McNamara J A, Seligman D A, Okeson J P 1995 Occlusion, orthodontic t reatment and temporomandibular disorders. A review. Journal of Orofacial Pain 9: 73-90 Manns A, Chan C, Miralles R 1987 Influence of group function and canine gu idance on electromyographic activity of elevator muscles. Journal of Prosthetic Dentistry 57:494--501 Marklund S, Wanmann A 2000 A century of controversy regard ing the benefit or detriment of occlusal contacts on the mediotrusive side. Jour nal of Oral Rehabilitation 27:553-562 Minagi G, Ohtsuki H, Sato T, Ishii A 1997 Effect of balancing-side occlusion on the ipsilateral TMJ dynamics under clenchi ng. Journal of Oral Rehabilitation 24:57--62 Moller E, Bakke M 1988 Occlusal har mony and disharmony: frauds in clinical dentistry. International Dental Journal

38:7-18 Ogawa T, Koyano K, Umemoto G 1998 Inclination of the occlusal plane and occlusal guidance as contributing factors in mastication. Journal of Dentistry 2 6: 641--647 Peck C C, Murray G M, Johnson C W L, Klineberg T J 1999 Trajectories of condylar points during working-side excursive movements of the mandible. Jou rnal of Prosthetic Dentistry 81:444--452 Posselt U 1952 Studies in the mobility of the human mandible. Acta Odontologica Scandinavica 10:1-160 Preston J D, Blat terfein L, South F 1999 Glossary of prosthodontic terms. Journal of Prosthetic D entistry 81:39-110 Pullinger A G, Seligman D A 2000 Quantification and validatio n of predictive values of occlusal variables in temporomandibular disorders usin g a multi-factorial analysis. Journal of Prosthetic Dentistry 83:66-75 Riise C, Ericsson S G 1983 A clinical study of the distribution of occlusal tooth contact s in the intercuspal position in light and hard pressure in adults. Journal of O ral Rehabilitation 10:473--480 Seligman D A, Pullinger A G 2000 Analysis of occl usal variables, dental attrition, and age for distinguishing healthy controls fr om female patients with intra capsular temporomandibular disorders. Journal of P rosthetic Dentistry 83:76-82 Trulsson M, Johansson R S 1996 Encoding of tooth lo ads by human periodontal afferents and their role in jaw motor control. Progress ive Neurobiology 49:267-284 Tsukiyama Y, Baba K, Clark G T 2001 An evidence-base d assessment of occlusal adjustment as a treatment for temporomandibular disorde rs. Journal of Prosthetic Dentistry 86:57--66 Wassell R W, Steele J G 1998 Consi derations when planning occlusal rehabilitatipn: a review of the literature. Int ernational Dental Journal 48:571-581 Yang Y, Yatabe M, Ai M, Soneda K 2000 The r elation of canine guidance with laterotrusive movements at the incisal point and the working-side condyle. Journal of Oral Rehabilitation 27:911-917 12

Jaw movement and its control G. Murray Synopsis The jaw muscles move the jaw in a complex three-dimensional manner during jaw mo vements. There are three jaw-closing muscles (masseter. temporalis and medial pt erygoid) and two jaw-opening muscles (lateral pterygoid and digastric). The basi c functional unit of muscle is the motor unit. The internal architecture of the jaw muscles is complex. with many exhibiting a complex pennate (feather-like) in ternal architecture. Within each of the jaw muscles the central nervous system ( CNS) appears capable of activating separate compartments with specific direction s of muscle fibres. This means that each jaw muscle is capable of generating a r ange of force vectors (magnitude and direction) required for a particular jaw mo vement. The CNS activates single motor units in whatever muscles are required to generate the desired movement. Movements are classified into voluntary. reflex and rhythmical. Many parts of the CNS participate in the generation of jaw movem ents. The face motor cortex is the final output pathway from the cerebral cortex for the generation of voluntary movements. Reflexes demonstrate pathways that a id in the refinement of a movement and can also be used by the higher motor cent res for the generation of more complex movements. Mastication or chewing is a rh ythmical movement that is controlled by a central pattern generator (CPG) in the brainstem. The CPGcan be modified by sensory information from the food bolus an d by voluntary will from higher centres. Simple jaw movements can also be perfor med. such as protrusion and side-to-side movements. At any instant in time. the jaw can be described as rotating around an instantaneous centre of rotation. Many devices have been constructed to describe jaw movements but only sixdegrees-of-freedom devices can accurately describe the complexity of movement . The use of devices that provide single point tracings (for example. pantograph s) may provide misleading information if used for diagnostic purposes or in the evaluation of treatment outcomes. Masticatory movements are complex and consist of jaw. face and tongue movements that are driven by jaw. face and tongue muscle s. Changes to the occlusion appear capable of having significant effects on the activity of the jaw muscles and the movement of the jaw joint. Key points The jaw muscles move the jaw in a complex three-dimensional manner There are thr ee jaw-closing muscles (masseter. temporalis and medial pterygoid) and two jaw-o pening muscles (lateral pterygoid and digastric) The functional unit of muscle i s the motor unit The internal architecture of the jaw muscles is highly complex Jaw muscles generate a range of force vectors (magnitude and direction) required for a particular jaw movement The CNS activates motor units in whatever muscles are required to generate the desired movement Movements are classified into vol untary. reflex and rhythmical Many parts of the CNS participate ir the generatio n of jaw movements 13

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Zygomaticrch a Reflexes demonstrate a pathway that can be used by the higher mot or centres for the generation of more complex movements Mastication is controlle d by a central pattern generator in the brainstem At any instant in time. the ja w can be described as rotating around an instantaneous centre of rotation The us e of devices that provide single point tracings (for example. pantographs) may p rovide misleading information if used for diagnostic purposes or in the evaluati on of treatment outcomes Changes to the occlusion appear capable of having signi ficant effects on the activity of the jaw muscles and the movement of the jaw jo int Lateral Medial Aponeurosis JAW MUSCLES: THE MOTORS FOR JAW MOVEMENT (for reviews, see Hannam & McMillan 1994, van Eiiden & Tu_k_a_w_sk_i_2_0_0_1_). _r _ An understanding of jaw movemen t provides background for Chapter 8 on jaw muscle disorders, which describes cha nges in jaw movement patterns. There are three jaw-closing muscles: masseter, te mporalis and medial pterygoid. There are two jaw-opening muscles: digastric and lateral pterygoid. The contractile element of muscles is the motor unit. Each mo tor unit consists of an alpha-motoneurone plus all the muscle fibres (-600-1000) innervated by (that is, connected to and activated by) that motoneurone. Jaw mu scle motoneurones are mostly located in the trigeminal motor nucleus. There are three physiological types of motor units that contribute to variations in the ma gnitude of force that different motor units generate. Type S motor units are slo w, generate low forces and are fatigue resistant. Type FF motor units are fast, generate the highest forces but fatigue rapidly. Type FR motor units have interm ediate speed and force generating capabilities, and have intermediate fatigue re sistance. Type S motor units are recruited first in a muscle contraction. With l arger forces, Type FR and then type FF motor units are recruited. Further comple xity is added by the fact that each face, jaw or tongue muscle has a complex int ernal architecture in terms of the arrangement of the muscle fibres within each muscle. The masseter muscle, for example, contains muscle fibres arranged in a p ennate manner (that is, a feather-like arrangement). Figure 2.1 illustrates some of the aponeurotic sheaths dividing the Fig. 2.1 Coronal view through the masseter muscle, zygomatic arch and ramus of m andible. Some of the aponeuroses that divide up the masseter have been outlined and are shown in expanded form on the left. The feather-like (pennate) arrangeme nt of the muscle fibres is indicated by the heavy lines. The solid arrow demonst rates the direction of pull if the labelled muscle fibres were to selectively co ntract. The dashed arrow indicates the direction of pull if the muscle fibres hy pothetically passed directly from the zygomatic arch to the mandible. masseter. An expanded view of part of the muscle (left of figure) shows the penn ate arrangement of muscle fibres (heavy lines). When motor units on one side of the aponeurosis contract, they direct forces at an angle (the pennation angle) t o the long axis of the muscle and generate a force vector (that is, magnitude an d direction of force) at an angle (solid arrow in Figure 2.1) to the force vecto r that would be generated if muscle fibres passed directly from the zygomatic ar ch to the ramus without pennation (dashed arrow). These complexities of muscle f ibre architecture provide a wide range of directions with which forces can be ap plied to the jaw. The brain can selectively activate these regions, or sub compa rtments, independently of other regions of the muscle . When generating a partic ular movement of the jaw, the sensorimotor cortical regions that drive voluntary movements (see below) are not organised in terms of specific muscles to activat e. Rather, they send a command signal to the various motor nuclei to activate th ose motor units, in whatever muscles are available, that are biomechanically bes

t suited to generate the force vector required for that particular jaw movement. Thus, for example, a grinding movement of the jaw to the right side with the te eth together might be best achieved by activation 14

JAW MOVEMENT AND ITS CONTROL of some motor units in the inferior head of the left lateral pterygoid, some mot or units in the right posterior temporalis to prevent the right side of the jaw moving forwards, and some units in the right masseter and anterior temporalis to help pull the jaw to the right side and to keep the teeth together while doing so (Miller 1991).The activation of these motor units will produce a force on the jaw that moves the jaw to the right side. Alpha-motoneurones within brainstem motor nuclei. Motor units within muscles. So matosensory system that conveys and processes somatosensory information about th e movement. CLASSIFICATION OF JAW MOVEMENTS CNS COMPONENTS IN THE GENERATION AND CONTROL OF JAW MOVEMENTS (Fig. 2.2) Motor cortex and descending pathways through pyramidal tract to alpha-motoneuron es (drives motor units). Cerebellum (refinement and co-ordination of the movemen t). Basal ganglia (selects and initiates motor programmes). Supplementary motor area (SMA), premo tor cortex (area 6) (contains programmes for movements). Centr al pattern generators for mastication and swallowing (programmes for generating mastication and swallowing). Some important connections of the orofacial motor system Supplementary motor are a (SMA) Premotor cortex (area 6) Face MI (motor cortex) Voluntary movements: for example, playing the piano, speaking, taking an alginat e impression, moving the jaw forwards. Reflex movements: for example, knee-jerk reflex, jaw-jerk reflex, jaw-opening reflex . . Rhythmical movements: for example , chewing, walking, running, breathing. Voluntary movements (for review, see Hannam Sessle 1994) & ( Basal ganglia) Cerebellum Muscle activation Movement of face, jaw, tongue Activation of somatosensory afferents, e.g., muscle spindle, TMJ, periodontal '" Fig.2.2 Some important connections of the orofacial motor system. Arrows indicat e some of the complex linkages in the sequence leading to a motor event. Solid a rrows indicate direction of action potentials conveying information. Dotted arro ws indicate the result of an event. Voluntary movements are driven by the primary motor cortex (termed MI) and highe r motor cortical areas (supplementary motor area (SMA), premo tor cortex). When

patients are asked to move the tongue forwards and open the jaw (as when taking an impression), a set of programmes (much like computer programs) is selected an d activated (via the basal ganglia) and these programmes send signals to the MI, specifically the face region. They contain the details of those motor units tha t must be activated, and the sequence of activation, to produce a particular mov ement. The programmes probably reside in the SMA/ premotor cortical regions. The MI is responsible for activating the various motor units to produce the movemen t required. The face MI consists of specific output zones within the cerebral co rtex that send fibres in the pyramidal tract to synapse directly or indirectly ( via interneurones) onto alpha-motoneurones. Each output zone from the face MI ac tivates a specific elemental movement; for example, movement of the tongue forwa rds or movement of the tongue to the side, or elevation of the corner of the mou th, or jaw opening or jaw movement to the side. The same movement can be produce d at a number of different sites throughout the face MI. The face MI can be cons idered to be the 'keys of a piano' that the higher motor centres 'play' to allow the generation of the required voluntary movement. Combinations of output zones allow the generation of more complex movements (equivalent to the generation of more complex sounds, as when playing chords on a piano). The cerebellum continu ously coordinates movements by controlling the sensory inputs to the motor areas . Corrections to each movement can also occur via shorter pathways that involve fewer neurones and many of these pathways are located entirely at the brainstem level. These pathways can be demonstrated clinically by evoking reflexes. 15

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Reflex movements (for review, see Hannam Sessle 1994) & Reflex movements are largely organised at the brains tern They are stereotyped movements that are involuntary and are oluntary will. The classic reflex is the knee-jerk reflex he knee evokes contraction in the thigh muscles and a brief leg. or spinal cord level. little modified by v where a sharp tap to t lifting of the lower

Other reflexes are the jaw-closing or jaw-jerk reflex, and the jaw-opening refle x. The jaw-closing reflex occurs when the jaw-closing muscles are suddenly stret ched by a rapid downwards tap on the chin. This tap causes stretching of special ised sensory receptors called muscle spindles that are stretchsensitive. They ar e present within all the jaw-closing muscles. When spindles are stretched, a bur st of action potentials travel along the group Ia primary afferent nerve fibres coming from the primary endings within the A R. submand. R. mass. R. post. temp. R. ant. temp. II L. mass. oN', ! "Jill '.', .'1 Ant-post. (x) Med-Iat. (y) Sup-inf (z) 'I '~il '. l\ ~~, j~~1 ~""It jr~,+ L. info lat. ptery. 5mml B a

1 second R. mass. R. post. temp. R. ant. temp. L. mass. L . inf ..lat ptery . '1+ IiiI ,(11, 'i ,. ",,,,, I 1'11\/' 'I H", 1 second Fig, 2.3 Right-sided gum chewing. A Electromyographic (EMG) data from six jaw mu scles (top six traces) and jaw movement data (bottom three traces) during 13 cyc les of chewing of gum. The EMG activity was recorded from the submandibular grou p of muscles (R, submand.; principally the anterior belly of the digastric muscl e), the right and left masseter (R. mass., L. mass.), the right posterior tempor alis (R. post. ternp.), the right anterior temporalis (R. ant. temp.), and the l eft inferior head of the lateral pterygoid (L. info lat. ptery.) muscles. The mo vement traces display the movement of the midincisor point of the mandible in an teroposterior (Ant-post.), mediolateral (Med-Iat.) and superoinferior (Sup-inf.) axes, Thus, for example, the latter shows the amount of vertical displacement o f the midincisor point during the opening phase of each chewing cycle. B Expande d form of the EMG data only from the section labelled 'a' in A. 16

JAW MOVEMENT AND ITS CONTROL spindles. The primary afferents synapse directly onto and cause activation of th e alpha-motoneurones of the same jaw-closing muscle. Thus a stretch of a jaw-clo sing muscle leads to a fast contraction of the same jaw-closing muscle. Reflexes demonstrate a pathway that can be used by the higher motor centres for the gene ration of more complex movements. They also allow fast feedback that adjusts a m ovement to overcome small, unpredicted irregularities in the ongoing movement an d adds smoothness to a movement. The jaw-opening reflex can be evoked by a varie ty of types of orofacial afferents. Activity in orofacial afferents, for example , from mucosal mechanoreceptors, passes along primary afferent nerve fibres to c ontact inhibitory interneurones that then synapse on jaw-closing alphamotoneuron es. The inhibitory interneurones reduce the activity of the jaw-closing motoneur ones. At the same time, primary afferents activate other interneurones that are excitatory to jaw-opening muscles, such as the digastric. The overall effect is an opening of the jaw. Rhythmical movements (for reviews, see Lund 1991, Hannam & Sessle 1994) These movements share features of both voluntary and reflex movements. The refle x features of rhythmical movements arise because we do not have to think about t hese movements for them to occur. For example, we can chew, breathe, swallow and walk without thinking specifically about the task; however, we can at any time voluntarily alter the rate and magnitude of these movements. Rhythmical movement s are generated and controlled by collections of neurones in the brainstem or sp inal cord. Each collection is called a central pattern generator (CPG). The CPG for mastication is located in the pontinemedullary reticular formation. Figure 2 .2 shows some relations of the CPGs. Swallowing is not a rhythmical movement but it is also controlled by a CPG located in the medulla oblongata. The CPG is ess entially equivalent to a computer program. When activated, the CPG for masticati on, for example, sends out appropriately timed impulses of the Alpha-motorneurones Extrafusal musclefibre A Alpha-motorneurones Gamma-motorneurone Ia afferents Intrafusal usclefibre m Output recorded from Ia afferents Restingactivity Gamma-motorneurone Ia afferents B Ia afferentsgo silentwith alpha-motorneuronectivation a Alpha-motorneurones Gamm a-motorneurone Ia afferents c Withalpha-and gamma-motorneurone activation, a firingis maintained I Fig.2.4 Stylised muscle showing extrafusal muscle fibres (thick lines) and intra fusal muscle fibres within the muscle spindle under three conditions. A The rest ing condition, where, in this hypothetical muscle, there is a resting tension on the muscle which comes from, for example, the weight of the mandible at postura l jaw position. The slight stretch to the muscle from the weight of the mandible

results in a slight stretching of the intrafusal muscle fibres and group la aff erent terminals that results in a continuous barrage of action potentials passin g centrally. B In the hypothetical situation where only alpha-motoneurones are f iring, muscle fibres contract and this results in a reduced tension in the muscl e spindle and therefore the spindle la afferent firing ceases for the duration o f the contraction. During this period, the spindle is unable to provide informat ion about unexpected changes in muscle length. C Shows alphamotoneurone activati on accompanied by gamma-motoneurone activation (alpha-gamma coactivation - the u sual situation in any movement) so that the intrafusal muscle fibres contract at the same rate as the extrafusal muscle fibres. This maintains the tension at th e terminals of the Ia afferents so that they maintain their firing and are able to respond to, and signal irregularities in, the movement. 17

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION appropriate magnitude to the various jaw, face and tongue muscle motoneurones so that the rhythmical movement of mastication can occur. We do not have to think about what muscles to activate and the relative timing of activation of the musc les in order to carry out mastication. This is done by the CPG. We can, however, voluntarily start, stop and change the rate and magnitude and shape of the chew ing movements, and these modifications are done through descending commands to t he CPGs from the motor cortical regions. Figure 2.3A shows raw electromyographic (EMG) data from a number of jaw muscles during right-sided chewing of gum. The associated movement of the midincisor point is shown in the lower part. Note the regular bursting pattern of EMG activity that occurs in association with each c ycle of movement. Note also, in the expanded version in Figure 2.3B, that the EM G activity from the inferior head of the lateral pterygoid muscle and the subman dibular group of muscles is out of phase with the jaw-closing muscles. These mus cles are being controlled by the CPG, and many other jaw, face and tongue muscle s, not recorded here, are being activated similarly. Sensory feedback is provide d by mechanoreceptors located within orofacial tissues: for example, periodontal (that signal magnitude and direction of tooth contact), mucosal (that signal fo od contact with mucosa), muscle spindle (that signal muscle length and rate of c hange of muscle length as the jaw closes), Golgi tendon organ (that signal force s generated within muscles) and temporomandibular joint (TM joint) (that signal jaw position) mechanoreceptors . The muscle spindle is a very complicated sensor y receptor. Muscle spindle sensitivity is optimised for all lengths of a muscle. During a muscle contraction, both alpha- and gamma-motoneurones are activated. The alphamotoneurones cause contraction of the main (extrafusal) muscle fibres a nd are responsible for the force produced by muscles (Fig. 2.4A, B). The gamma-m otoneurones are activated at the same time but they cause contraction of the int rafusal muscle fibres within the muscle spindle and thus maintain the sensitivit y of the spindles as the muscle and spindles shorten (Fig. 2.4C). The spindle is therefore always able to detect small changes in muscle length irrespective of the length of the muscle. Sensory information plays a crucial role in modifying mastication (for review, see Lund & Olsson 1983). During chewing, there is a hug e barrage of sensory information that travels into the CNS (Fig. 2.5A). Some of this information travels directly to the cerebral cortex for conscious sensation (Fig. 2.2). - Local reflex effects that assist the masticatory process also occ ur. For example, as food is crushed between the teeth, periodontal mechanorecept ors are activated, and this activity can cause a reflex increase in activity 18 in the jaw-closing muscles to assist in crushing of food. - Many of the orofacia l afferents that are activated by food contact during jaw closing can evoke a ja wopening reflex (see above). This would be counterproductive during the closing phase of mastication. Lund and Olsson (983) have shown that the masticatory CPG depresses the responsiveness of the jaw-opening reflex during the closing phase of the chewing cycle. The low T (that is, threshold) test reflex response shown in Figure 2.5B on the far left is the control jaw-opening reflex response, seen in the digastric muscle, to the activation of orofacial afferents when there is no chewing. During the closing phase of the chewing cycle, the CPG depresses the ability to evoke this reflex. Therefore, in chewing, the excitatory pathway fro m orofacial afferents to jaw-opening motoneurones is depressed, and this allows the jaw to close unhindered. - An analogous effect occurs during the opening pha se of the chewing cycle. During this phase, muscle spindles in jaw-closing muscl es will be stretched and will have a tonic excitatory effect on jaw-closing moto r units. This would resist jaw opening. However, the CPG hyperpolarises jaw-clos ing motoneurones during the opening phase of the chewing cycle (Fig. 2.5B). This hyperpolarisation makes jawclosing motoneurones harder to activate in response to excitatory input from muscle spindles.

BASIC MANDIBULAR MOVEMENTS The jaw can be viewed as being suspended from the skull by muscles, tendons, lig aments, vessels and nerves and is moved in three-dimensional space, with the fix ed points being the teeth and the condyles in their respective condylar fossae. Basic mandibular movements are open, close, rightside jaw movement, left-side ja w movement, protrusion, retrusion. Factors influencing mandibular movements: - c ondylar guidance: the inclination of the pathway travelled by the condyle during a .protrusive or a contralateral jaw movement; these two inclinations will usua lly be slightly different - incisal guidance: determined by anterior tooth relat ionships, that is, the magnitude of overbite (vertical overlap) and overjet (hor izontal overlap) between anterior teeth - posterior guidance: determined by post erior tooth relationships - muscles and ligaments.

JAW MOVEMENT AND ITS CONTROL A Afferent firing B Reflexmodulation Movement Movement Muscle and receptor ctivity a t Testreflex t Opener EMG ~--~---~~-.-~~-~-. CloserEMG Peridontal ~~ Cutaneous ~~ U_I.------IlllIlllllllllllll.: IIIII11 : LowT ~ I~ : H;ghT ~ Membrane potential Digastric Mspindle 1 rmlllllllllllllll: WII I: IIIIII\IIIIIIIIIIIIIIIIIIIIII~ 2 lImlrlllllll I II 1 II r 1IIIIIll1III A B Masseter Fig.2.5 A Some of the patterns of jaw muscle and somatosensory afferent activity during masticatory jaw movements. The movement of the jaw at the midincisor poi nt is at the top. The next two traces show jaw-opener and jaw-closer EMG activit y, respectively. Periodontal and cutaneous mechanoreceptive activity are shown n ext. RA, rapidly adapting, that is, responds only to the dynamic phases of, in t his case, a mechanical stimulus; SA, slowly adapting, that is, responds to dynam ic and static components of a mechanical stimulus. M spindle 1, 2, refers to outpu t from muscle spindle group la (provides information on dynamic changes in muscl e length), and group II (provides information on new muscle lengths) primary aff erents, respectively. Each vertical line in each trace shows the time of occurre nce of an action potential that has been recorded in the primary afferent axon. There is a barrage of sensory information that enters the brain during every che wing cycle. B The jaw-opening reflex is modulated during mastication. The left s hows the type of reflex response that is recorded from the digastric muscle with the jaw at rest (control). Note that the amplitude of this reflex changes durin g mastication. When low-threshold afferents are stimulated (low T, that is, nonp ainful), the mean amplitude is less, especially during the closing and occlusal

phases. In contrast, the response to highthreshold afferents (high T) exceeds th e control during the late closing and occlusal phases. This pathway is facilitat ed during the closing phase of the chewing cycle - it is desirable to stop the c losing phase of chewing should painful stimuli be encountered during this phase. The lower two traces show that the digastric membrane is at its resting level d uring these phases, and masseteric motoneurones are hyperpolarised during the op ening phase to reduce the possibility of these motoneurones firing, particularly under the influence of group la and II muscle spindle afferent barrage arising because muscle spindles are being stretched during the opening phase. (Adapted w ith permission.) 19

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Movements to and from intercuspal position. Of in terest to clinicians are: - gr oup function: defined as an occlusion in which the occlusal load in lateral excu rsion is distributed across at least two pairs of teeth on the working side - mutually protected (-10% of natural dentitions) (or canine-guided) occlusion: only the anterior (or canine) teeth are in contact in any excursive movement of the jaw. Mastication is not a simple open-close jaw movement. Because the condyl es are able to translate forwards as Working side movement of left condyle ca Inferior A Right d c Left B c -5mm D Fig. 2.6 Detail of working side movement of the left condyle. Sagittal (upper pl ots) and horizontal (lower plots) plane views of condylar triangles (upper plots in A) and quadrilaterals (lower plots in A) for the left condyle in a subject p erforming a working-side mandibular movement, that is, the jaw moves to the left side. A superior view of mandible is shown in D and the condylar points are lab elled: a, anterior; b, lateral; c, posterior; d, medial; e, superior (this point was 9.0 mm superior to the other points). The points were determined from compu ter tomography scans of the subject. B shows sagittal (upper) and horizontal (lo wer) squares generated about the origin of the respective axes in A. C shows sag ittal and horizontal squares generated about an origin that was shifted 30 mm fu rther laterally. A square, triangle or quadrilateral is plotted each 300 rns, st arting at the intercuspal position. In each trace, the outgoing movement only is shown from intercuspal position to maximum lateral excursion and the approximat e direction of movement is indicated by a short arrow. The trajectories of indiv idual condylar points have been omitted for clarity. (Adapted with permission.) -Superior outline view of mandible 20

JAW MOVEMENT AND ITS CONTROL well as rotate, there are constantly changing combinations of rotation and trans lation during mastication. Instantaneous centre of rotation of the jaw. At any i nstant in time, the jaw can be described as rotating around a centre of rotation . This centre of rotation is constantly shifting because of constantly changing combinations of translation and rotation during most jaw movements. - A protrusi ve jaw movement with sliding tooth contact consists largely of translation of th e jaw forwards, with a slight downwards translation. With a steeper incisal than condylar guidance, the jaw will also rotate open slightly. The instantaneous ce ntres of rotation will lie well below and posterior to the jaw. - For a left-sid e jaw movement with sliding tooth contact, most of the movement is rotation abou t a constantly moving centre of rotation lying in the vicinity of (usually behin d and lateral to) the left condyle. Figure 2.6A shows sagittal (upper plots) and horizontal (lower plots) plane views of condylar triangles (upper plots in A) a nd quadrilaterals (lower plots in A) for the left condyle in a subject performin g a working-side mandibular movement, that is, the jaw moves to the left side. T he quadrilaterals are formed by joining the points a, b, c and d on the actual o utline of the condyle in the horizontal plane shown in Fig. 2.6D. The triangles are formed by joining the points a, e and c on the condyle; point e is a point 9 mm superior to the other points. A triangle or quadrilateral is plotted each 30 0 ms from intercuspal position (IP). During this working-side movement in the ho rizontal plane, the condyle does not rotate about the centre of the condyle but rather the centre of rotation can be visualised to be behind the condyle. - At e ach successive instant in time during chewing, the centre of rotation shifts in space. For chewing jaw movements, this centre lies between the lower posterior p arts of the jaw and towards the midline. pitch, yaw and roll. This additional information is provided by six-degrees-of-f reedom systems. It has been recently shown that considerable error is introduced to the pathway that condylar-point tracings follow simply because of the select ion of a different point in the vicinity of the condyle (Peck et al1997, 1999). Thus, many of the irregularities in condylar-point tracings that have been ascri bed diagnostic or prognostic significance could simply have occurred because of the location of the condylar point chosen. Figure 2.6B shows the movement of poi nts chosen at equal distances about the coordinate centre in Figure 2.6A. The re sulting squares move in a similar fashion to the quadrilaterals and triangles in A. Figure 2.6C shows the effect on the movement recorded simply by shifting the points 30 mm laterally. The interpretation of the movement of the condyle plott ed in C would be that the condyle has translated posteriorly and laterally, wher eas in fact the condyle has largely translated laterally with some rotation. Sin gle point tracings may therefore provide misleading information if used for diag nostic purposes or in the evaluation of treatment outcomes. Border movements of the jaw are described in Chapter 1. MASTICATORY JAW MOVEMENTS (Lund 1991) Masticatory jaw movements occur well within these border movements e xcept when the jaw approaches or makes tooth contact towards the end of chewing. In the frontal plane, the masticatory cycle is classically described as 'tear-d rop' in shape. At the beginning of opening, the mid-incisor point moves first do wnwards and at the end of opening it moves laterally and upwards towards the wor king side (or chewing side). The midincisor point then moves upwards and mediall y and the food is crushed between the teeth. The masticatory sequence is highly variable from cycle to cycle in a subject chewing the same or different foods an d from subject to subject. Figure 2.3A (lowermost traces) shows that the movemen t of the mid incisor point from cycle to cycle is not identical. Part of this va riability relates to the changing consistency of the food bolus from cycle to cy cle as the food breaks down. The movement of the jaw towards IP is less variable

. The jaw muscles must move the jaw precisely towards the end of the chewing cyc le, so that the teeth glide smoothly along cuspal inclines. Mechanoreceptors (pa rticularly periodon tal) provide a continual source of afferent input to the CNS to ensure the chewing cycle is harmonious with existing tooth guidances (Ch. 1) . 21 HOW TO DESCRIBE JAW MOVEMENT? For over a century, dentists have had a keen interest in the movement of the jaw and have attempted to describe its movement by graphical devices such as pantog raphs and more sophisticated jaw-tracking devices. One of the reasons for doing this has been to make it easier to perform restorative work for patients. These systems usually record the movement of the anterior midline of the lower jaw (fo r example, see Figure 2.3) or the terminal hinge axis or the palpated lateral co ndylar pole in three degrees of freedom, that is, the movement of a single point along anteroposterior, mediolateral and superoinferior axes (Fig. 2.3). They do not provide information about the three rotation vectors:

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Masticatory movements are complex and consist of jaw, face and tongue movements that are driven by jaw, face and tongue muscles. The facial and tongue muscles a re involved because the lips, cheeks and tongue help control the food bolus in t he mouth and keep the food contained over the occlusal table for effective commi nution. It is remarkable that the tongue is largely made of the very substance t hat the teeth commonly break down. The author believes that the face MI strongly inhibits jawclosing muscles before any tongue movements are allowed to occur. T he tongue is most active during the opening phase of the chewing cycle when food is required to be collected and repositioned for effective comminution on the o cclusal table. Different phases of masticatory cycles: - preparatory phase: jaw, tongue, lips and cheeks prepare the bolus for effective food comminution - redu ction phase: period of food comminution associated with salivary flow and mix of food and saliva - preswallowing: food is brought together as a bolus with saliv a, which commences the chemical breakdown process, and is prepared for swallowin g. The shape and duration of the cycle is influenced by the hardness of food: ha rder textured foods are associated with wider chewing cycles that have longer du ration. Softer foods are associated with more up and down chewing cycles (Gibbs & Lundeen 1982). group has also recently proposed that this is so and the implication of these da ta is that whatever we do to the occlusion can have significant effects on jaw a nd jaw-joint movement and the function of the jaw muscles. Recent data suggest t hat the placement of an occlusal interference results in a decrease in activity in most of the jaw muscles, except the lateral pterygoid muscle, where an increa se in activity may be observed .: Thus, restoring teeth, in such a way that resu lts in interferences with the normal pathways of a chewing cycle, can lead to di fferent levels of firing of orofacial afferents (for example, periodontal affere nts). This information will feed back to the CNS and may cause a change to the C PG controlling mastication, or to higher levels of the CNS, for example, face MI . This change will be in the form of changes to the firing of particular motor u nits, in particular subcompartments of muscles, so that the appropriate modifica tion to the chewing cycle can occur. The new chewing cycle will now avoid this i nterference unless the interference is too large and beyond the adaptive capacit y of the CPG and muscles. I~ 'P References CONDYLE AND DISC MOVEMENT The movement of the condyle and disc during normal jaw movements is complex and not well understood (Scapino 1997). The issue is complicated by the fact that th e lateral pterygoid muscle inserts into the TM joint," with the inferior head in serting exclusively into the condylar neck and the superior head inserting large ly into the condylar neck. Some fibres of the superior head do insert into the d isc-capsule complex of the TM joint, but the long-held view (still held by some) that the superior head inserts exclusively into the disc is completely erroneou s! Further, the view that the superior and inferior heads of the lateral pterygo id muscle exhibit reciprocal patterns of activity is also erroneous. Our researc h group has recently proposed that the superior head (and the inferior head) of the muscle is actually like multiple smaller muscles, each able to be independen tly activated and thus able to provide the appropriate force vector onto the con dyle and disc-capsule complex to produce the movement required. Do changes to th e occlusion have any influence on the movement of the jaw and the jaw joint? Our research

Gibbs C H, Lundeen H C 1982 Jaw movements and forces during chewing and swallowi ng and their clinical significance. In: Lundeen H C, Gibbs C H (eds) Advances in occlusion. Wright, Boston, pp 2-32 Hannam A G, McMillan A S 1994 Internal organ ization in the human jaw muscles. Critical Reviews in Oral Biology and Medicine 5:55-89 Hannam A G, Sessle B J 1994 Temporomandibular neurosensory and neuromusc ular physiology. In: Zarb G A, Carlsson G E, Sessle B J, Mohl N D (eds) Temporom andibular joint and masticatory muscle disorders. Munksgaard, Copenhagen, pp 80100 Lund J P 1991 Mastication and its control by the brain stem. Critical Review s in Oral Biology and Medicine 2:33-64 Lund J P, Olsson K A 1983 The importance of reflexes and their control during jaw movement. Trends in Neurosciences 6:458 -463 Miller A J 1991 Craniomandibular muscles: their role in function and form. CRC Press, Boca Raton Peck C, Murray G M, Johnson C W L, Klineberg I J 1997 The variability of condylar point pathways in open-close jaw movements. Journal of P rosthetic Dentistry 77:394-404 Peck C, Murray G M, Johnson C W L, Klineberg I J 1999 Trajectories of condylar points during working-side excursive movements of the mandible. Journal of Prosthetic Dentistry 81:444-452 Scapino R P 1997 Morpho logy and mechanism of the jaw joint. In: McNeill C (ed) Science and practice of occlusion. Quintessence, Chicago, pp 23-40 van Eijden T M G J, Turkawski S J J 2 00] Morphology and physiology of masticatory muscle motor units. Critical Review s in Oral Biology and Medicine 12:76-9] 22

Growth and development J. Knox Synopsis Three-dimensional skeletal proportions are the primary determinant of the relati onship between maxillary and mandibular dental arches. An appreciation of cranio facial growth and development is, therefore, essential in the understanding of t he aetiology of normal and abnormal static and functional occlusal relationships . More detailed descriptions of pre- and postnatal craniofacial development are available elsewhere (Bjork 1968, Enlow 1982). This chapter will provide an overv iew of dentofacial development, focusing on how normal variation and abnormal gr owth and development can influence intra- and interarch relationships. - Transverse - Vertical Abnormal dental development - Aetiology - Interarch rela tionships - Arch length discrepancies - Local factors Late changes - Skeletal Dental Orthodontic solutions NORMAL SKELETAL DEVELOPMENT Key points Skeletal relationships at birth - Prenatal events Normal skeletal development Maxilla - Maxilla relative to cranium - Mandible - Mandible relative to cranium and maxilla Growth rotations - Timing - Prediction Normal dental development - T iming - Space considerations - Interarch relationships Abnormal skeletal develop ment - Aetiology - Anteroposterior The craniofacial relationships present at birth are a product of rapid cell mult iplication, differentiation and migration. The cranial vault is composed of fron tal, parietal, squamous temporal and occipital bones. These bones are formed by intramembranous ossification and are separated by relatively loose connective ti ssues that allow cranial deformation during birth. In contrast, the bones of the base of the skull are formed initially in cartilage. Centres of endochondral os sification appear early in embryonic life, indicating the ultimate location of t he basioccipital, sphenoid and ethmoid bones that form the cranial base. As ossi fication proceeds, bands of cartilage remain as spheno-occipital, sphenoethmoida l .and intersphenoidal synchondroses. The maxilla develops essentially as a memb ranous bone from infraorbital centres of ossification with a small contribution from partial cartilaginous ossification of the nasal capsule. From these centres , frontal, zygomatic, alveolar and palatal areas develop. The mandible is formed , similarly, by intramembranous ossification in fibrocellular condensations alon gside Meckel's cartilage and the inferior dental nerve, and ossification of the secondary condylar cartilage. Postnatal facial growth and development is classic ally described as a downward and forward displacement of the maxillary complex a nd mandible relative to the 23

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION cranial base, involving a process of sutural responses to functional skeletal di splacements and surface remodelling. Apposition of bone at the periphery of the cranial bones rapidly reduces the volume of interposed connective tissue, result ing in the bones being separated by thin periosteum-lined sutures. It is the app osition of bone at these sutures that provides the major mechanism for growth of the cranial vault, with remodelling of the inner and outer surfaces of the bone s providing the means by which recontouring occurs. In the cranial base, cellula r proliferation at the sphenoethmoidal synchondrosis is responsible for growth o f the anterior cranial base until its fusion at about 7 years. The spheno-occipi tal synchondrosis remains patent until the late teen years and contributes to gr owth of the posterior cranial base and anterior displacement of the midface. Gro wth of the maxilla occurs by surface remodelling and by apposition of bone at th e sutures that connect the maxilla to the cranium and cranial base. During norma l facial growth the maxilla is translated downward and forward. During this tran slation bone is laid down in the tuberosity region and at the sutural attachment s of the maxilla to the cranial vault and base, increasing the size of the bone and maintaining sutural dimensions. Interestingly, as the maxilla is translated forward and downward, the anterior surface of the bone is remodelled and bone is removed, resulting in a change in contour due to periosteal activity. During no rmal growth, the mandible is also translated downward and forward relative to th e cranial base. However, in contrast to the maxilla, both endochondral and perio steal activity are important in the growth of the mandible. Vital staining exper iments have shown that bone is primarily deposited on the posterior surfaces of the ramus, coronoid process and condyle, while bone resorption occurs on the ant erior ramal surface and chin as the mandible is translated forward in its soft t issue envelope. In addition to downward and forward translation of the maxilla and mandible desc ribed, longitudinal cephalometric implant studies (Bjork 1968) have demonstrated that there is a rotation of the central core of these bones, the magnitude of w hich is masked by surface changes and tooth eruption (Bjork & Skeiller 1983). Fo r an average individual, the net change during growth is a slight reduction in l ower facial height. However, for patients with longer or shorter faces than aver age, the amount of core (internal) rotation and surface change can vary, resulti ng in significant alterations in vertical facial proportions, interarch relation ships and incisor inclinations during growth. The rate of craniofacial growth is greatest during the first years of life. Thereafter, other than for the small p repubertal and more significant pubertal growth 'spurts', the rate of growth and change in proportions decline to almost zero by 16-18 years of age. It would be incorrect to assume that growth and change in facial proportions ceases in adul thood. Longitudinal cephalometric evaluation of adults involved in the Bolton gr owth study (Broadbent et al 1975) has demonstrated that cumulative changes occur ring in both facial dimensions and proportions continued up to the age of 35-40 years, resulting in altered incisor inclinations and vertical interarch relation ships. NORMAL DENTAL DEVELOPMENT Tooth eruption When a tooth emerges into the mouth, it has a postemergent spurt and erupts rapidly until it approaches the occlusal plane and is subject to the forces of mastication. Eruption then sl ows dramatically as the period of juvenile occlusal equilibrium is reached. Duri

ng this period, teeth that are in function erupt at a rate that parallels the ra te of vertical growth of the mandibular ramus. This is best appreciated by consi dering the relative submergence of ankylosed teeth during growth. During the pub ertal growth, there is a further increase in tooth eruption as the interocclusal space is increased. It would appear that the forces that oppose a tooth's erupt ion, such as occlusal forces and the forces generated by resting soft tissues, a re the rate-limiting factors in postemergent eruption rather than the eruptive f orces themselves. At the end of this circumpubertal eruptive spurt an adult occl usal equilibrium is reached in which tooth eruption may compensate for occlusal wear. CHANGE IN RELATIVE PROPORTIONS The pattern of postnatal growth results in a change in proportions so that the h ead, which at birth contributes 30% of the total body length, in adulthood contr ibutes only 12%. The advanced development of the cranial and uppermost structure s of the body relative to more proximal areas is suggested to represent a 'cepha locaudal gradient of growth'. This gradient is seen in craniofacial development, with the cranial vault being relatively large at birth and the face small and r etrusive. Postnatal growth changes these proportions and the midface becomes les s retrusive, with the mandible being the last of the facial bones to finish ante roposterior development. 24 Eruption of the primary dentition The timing of eruption of the primary dentition is variable and up to 6 months o f acceleration or delay is within the

GROWTH AND DEVELOPMENT Table 3.1 Eruption of primary dentition Calcification begins (weeks in utero) Crown comple te (months) 1.5-3.0 9 6 10-11 Eruption (months) 6-9 18-20 12-15 24-36 Incisors Canines First molars Second molars 13-16 15-18 14-17 16-23 normal range. The eruption sequence is, however, usually preserved and most comm only the mandibular central incisor erupts first, closely followed by the other incisors. Three to four months later, the mandibular and maxillary first molars erupt, followed by the maxillary and mandibular canines 3-4 months after that. T he primary dentition is usually complete by 24-30 months when the second molars erupt (Table 3.1). Spacing is normal throughout the anterior part of the primary dentition but is most noticeable in the primate spaces that lie between canine and lateral incisor in the maxilla and between canine and first molar in the man dible. Generalised spacing of the deciduous teeth is a requirement for correct a lignment of the permanent labial segment. Mixed dentition years The mixed dentition years include dental ages 6-12. Dental age is determined by the teeth that have erupted, the root development of the permanent teeth and the degree of resorption of the primary teeth. The transition from the primary to t he permanent dentition begins at about 6 years with the eruption of the first pe rmanent molars, followed soon thereafter by the permanent incisors. Dental age 7 is characterised by eruption of maxillary central incisors and mandibular later al incisors. The root development of the maxillary lateral incisor is advanced a t this stage and the canines and premolars are completing crown formation. Denta l age 8 is characterised by the eruption of the maxillary lateral incisor and is followed by a period of 2-3 years before any other permanent teeth erupt. There are significant space considerations during the replacement of the deciduous in cisors, as each of the permanent incisors is 2-3 mm larger than its predecessor. Spacing of the primary dentition will usually provide sufficient space to accom modate the larger central incisors and often the lateral incisors, in the upper arch. In the mandible, however, there is on average 1.6 mm less space available than that required for perfect alignment of the lower four perma nent incisors. This space discrepancy, called the 'incisor liability', often res ults in a transitory stage of mandibular incisor crowding at age 8-9 years that remains until eruption of the canines. The larger permanent incisors are therefo re accommodated by using the primate spaces and generalised labial segment spaci ng. In addition, the permanent intercanine width is increased and the incisors e rupt in a more proclined relationship which places them on the arc of a larger c ircle. It is important to note that all of these changes occur without significa nt growth at the front of the jaws. A widely recognised. developmental stage, wh ich not infrequently causes parental concern, is the midline diastema and distal inclination of the maxillary central incisors. The spacing seen in this 'ugly d uckling' stage will invariably reduce as the lateral incisors erupt but may pers ist if the primary canines have been lost or the incisors are flared labially. A s a rule of thumb, a diastema of 2 mm or less will probably close spontaneously when the permanent canines erupt, whereas the diastema may persist when the orig inal dimensions exceed 2 mm. At dental age 9 the root development of mandibular canines and first premolars is 30% complete and the second premolar has started root formation. In the maxilla, however, development is not as advanced and only the first premolar has started root formation. By dental age 10 the root develo

pment of upper canine and upper and lower second premolar is more significant an d the roots of the lower canine and upper and lower first premolars are 50% comp lete. The roots of the incisor teeth are virtually complete at this stage and th e resorption of primary canines and molars is more advanced. At dental age 11-12 the remaining succedaneous teeth erupt and the final phases of the establishmen t of the permanent dentition begin. The space requirements during the replacemen t of the primary canines and molars are extremely important. In contrast to the anterior teeth, the premolars are smaller than the teeth that they replace. The result is a 'leeway space' of 1.5 mm per quadrant in the maxillary arch, while t he space in the mandibular arch measures 2.5 mm per quadrant. The interarch rela tionship of the first permanent molars during the mixed dentition period would b e classified by Angle as half a unit class II, that is, there is a flush termina l plane. The correction of this molar relationship to class I, in the developmen t of normal occlusion, requires that the lower molar move forward by 3.5 mm rela tive to the upper. Approximately half of this distance is provided by the differ ential anteroposterior growth of the mandible during this period and the remaind er is provided by the greater mandibular leeway space. 25

BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Establishment of the secondary dentition Following the eruption of the second permanent molars at 12-13 years, the perman ent dentition is virtually complete, leaving only the third molars to erupt at 1 8-21 years. However, the dentition established during the teenage years often ch anges significantly during the late teens and early twenties. Reduction in the s ize of pulp chambers, apical migration of periodontal attachment and a degree of occlusal and interproximal wear have been recorded as normal maturational chang es in the dental apparatus. In addition, more recent longitudinal studies (Sincl air & Little 1985) have recorded significant changes in dental alignment with ti me, particularly in the mandibular labial segment. There have been a number of t heories proposed to account for the increased lower incisor irregularity with ag e. Pressure from erupting third molars has been suggested as a likely cause, mai nly due to the coincidence of third molar eruption with late lower incisor imbri cation. The force generated by erupting teeth is, however, only 5-10 g and late lower incisor crowding has been recorded in individuals who have congenitally ab sent third molars and in those who have had the third molars removed at a young age (Vasir & Robinson 1991, Harradine e.t aI1998). The reduced interproximal att rition associated with modern diets has been suggested to have a possible aetiol ogic role in the development of late lower incisor crowding, as have alterations in the tone of facial musculature and mesially directed forces of occlusion. Ho wever, contemporary thought considers late incisor crowding to be the result of continued anteroposterior and rotational growth of the mandible during early adu lt life. Therefore, patients who have had ideal alignment of their labial segmen ts during their early teens, whether due to orthodontic treatment or not, will n ot infrequently present with a variable degree of lower incisor imbrication duri ng later life (Sinclair & Little 1985). resulting in anteroposterior, vertical and transverse discrepancies and, dependi ng on the degree of dentoalveolar compensation, abnormal intra- and interarch to oth relationships. Dentoalveolar factors include those conditions in which there is a discrepancy between the sum of the mesiodistal widths of the teeth present in an arch and the space available for the teeth (arch length discrepancies) an d a number of abnormalities that affect an isolated area of dental development ( local factors). Aetiology of skeletal disproportion The determinants of craniofacial growth have been suggested to be the bone itsel f, the cartilaginous components and the soft tissue matrix in which the skeletal elements are embedded. The major difference in the theories is the location at which genetic control is expressed and contemporary thought would suggest that t he truth lies in some synthesis of the second and third theories, that is, growt h is determined by cartilaginous and soft tissue elements. The response of sutur es and periosteal tissues to transplant experiments and environmental influences suggests that these tissues are not primary determinants of growth but instead add or remove bone in response to bony displacement. Similar animal experiments suggest that the mandibular condyle is not a growth centre and instead behaves m ore like a reactive periosteal surface. The cartilage of the nasal septum, howev er, has been suggested to be a pacemaker for other aspects of maxillary growth a nd loss of this cartilage has been seen to result in a maxillary hypoplasia. The functional matrix theory (Moss & Sanlentijn 1969) suggests that the growth of t he face occurs as a response to functional needs and is mediated by the soft tis sues in which the jaws are embedded. Growth of the cranium illustrates this theo ry well. Growth of the brain results in expansion and separation of the bones of the cranial vault, which in turn leads to sutural deposition of bone and increa sed cranial volume. When applied to the growth of the maxilla and mandible, this theory suggests that enlargement of the nasal and oral cavity in response to fu nctional demands results in displacement and growth of the facial skeleton. In f avour of this theory is the reduced growth observed where function is impeded, s

uch as the mandibular hypoplasia associated with condylar ankylosis. The aetiolo gy of a number of skeletal discrepancies is well established. Congenital dentofa cial anomalies, condylar hyperplasia and skeletal disproportion due to trauma ar e good examples. The remainder of the skeletal discrepancies are due to a combin ation of genetic and environmental factors. AETIOLOGY OF MALOCCLUSION An important concept in the study of growth and development is variability. A la rge amount of the available information is derived from cross-sectional studies in which the samples have sometimes been selected on the basis of normal facial proportions and interarch relationships (Riolo et a11974, Broadbent et aI1975). The incidence of malocclusion varies depending on the age and race of the sample and the method of assessment employed. In most instances, malocclusion and dent ofacial deformity result not from some pathological process but from moderate di stortions of normal development. Skeletal disproportion can occur in any of the three dimensions, 26

GROWTH AND DEVELOPMENT Genetic influences on the development of skeletal disproportion have been evalua ted by 'outbreeding' studies and comparison of monozygotic twins. Crossbreeding between genetically different human subgroups could result in the inheritance of discordant dental and facial characteristics. In the early 1970s studies were p erformed on the effects of outbreeding on the indigenous Polynesian population o f the Hawaiian Islands following the influx of Caucasian and Oriental settlers. They found that the prevalence of extreme jaw relationships in the offspring of the various racial crosses was similar to that of the ancestral groups. However, there were some additive effects, that is, if the ancestral Polynesian populati on had 10% crowding, while the Japanese group had 10% class III, there would be approximately a 10% incidence of both characteristics in the offspring. The fact that dental and facial characteristics are not inherited as clearly discernible single gene effects does not mean that there is not a strong hereditary compone nt in the development of dental and facial proportions. Similar facial proportio ns and occlusal traits have been noted in family members but these similarities could be due to a common environment. Differences between genetically identical monozygotic twins can only be accounted for by environmental influences. Some tw in studies have concluded that 50% of occlusal variations could be accounted for on the basis of heritability, leaving 50% due to environmental influences. Howe ver, others argue that if appropriate corrections for similar environment are ma de, the estimate for heritability drops almost to zero. When considering the fun ctional influences on skeletal growth, mouth breathing has been in and out of vo gue as a possible aetiological factor of malocclusion. Respiratory needs are the primary determinant of jaw and head posture and it has been proposed that mouth breathing, by altering these postures, can affect both jaw growth and tooth pos ition. Humans are primarily nasal breathers, but transition to partial oral brea thing occurs at elevated ventilatory exchange rates or increased nasal resistanc e levels. Chronic nasal obstruction results in a lowering of the mandible, downw ard and forward positioning of the tongue and a tipping back of the head. The ty pe of malocclusion associated with mouth breathing is called 'long face syndrome ' and its features are: downward and backward mandibular rotation during growth excessive eruption of posterior teeth a tendency towards maxillary constriction excessive overjet anterior open bite. However, the relationship between mouth breathing, altered posture and the devel opment of malocclusion is not clear-cut. Mouth breathing, in short, can undoubte dly contribute to the development of orthodontic problems, exaggerating existing tendencies for skeletal discrepancy, but partial nasal obstruction is difficult to indict as a major aetiological agent. Dentoalveolar factors When the aetiology of arch length discrepancies and local factors is considered, genetic influences may be evaluated by considering the extent to which malocclu sion was present in early humans as compared to its prevalence under modern cond itions. Crowding and malalignment were not unknown in prehistoric times but the overall perspective is that the prevalence of malocclusion has increased in mode rn times. There are two possible explanations for this increase on genetic groun ds. The first is the additive effect of outbreeding, as discussed earlier; the s econd is the tendency for evolutionary reduction in jaw size. It can be apprecia ted that there would be a tendency for crowding and malalignment to develop if t he rate of reduction of jaw size were faster than the reduction of tooth size or number. The difficulty with this theory is that the increase in the prevalence of malocclusion has occurred too rapidly during the last few hundred years, wher eas evolutionary drift, if this occurs, would take place over a longer time scal e. In addition to skeletal disproportion and arch length discrepancies, a number

of local disturbances of dental development may play an important role in the d evelopment of a malocclusion. Significant disturbances include: abnormalities tooth number abnormalities of tooth size and shape interference with eruption e ctopic eruption improper guidance of eruption early loss of primary teeth premat ure loss of permanent teeth soft tissue factors. Abnormalities of tooth number Congenital absence of teeth results from disturbances during the initiation and proliferation of tooth formation. Anodontia or oligodontia, the absence of all o r most teeth, is often associated with ectodermal dysplasia, but oligodontia may occur in a patient with no apparent systemic problem or congenital syndrome. An odontia and oligodontia are rare, but hypodontia is a relatively common finding with a prevalence of 1.5-3.0%, depending on the sample. 27

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Absence of a deciduous tooth is quite rare but when it occurs the upper 'B' is m ost commonly affected. The permanent teeth most commonly missing are upper later al incisors, lower second premolars, third molars and, less commonly, lower cent ral incisors. Supernumerary teeth result from disturbances during the initiation and proliferation stages of dental development. Supernumerary teeth occur most frequently near the upper midline somewhat palatal to the central incisors, in t he lower premolar region, and distal to the second and third molars. Supernumera ries in the premolar and molar regions generally have little effect on the teeth of the normal series but rotation or delayed eruption of a central incisor, or a large permanent diastema, may accompany a supernumerary in the incisor region. Improper guidance of eruption At one time, the space closure accompanying early loss of primary teeth was attr ibuted entirely to mesial drift of posterior teeth, which was confidently ascrib ed to forces from occlusion. The contemporary view is that mesial drift is inhib ited by, rather than caused by, occlusal forces. However, whatever the cause, me sial drift of the first permanent molar after a primary second molar is prematur ely lost can contribute significantly to posterior arch crowding. Following the premature loss of a primary first molar or canine, space closure results primari ly from distal drift of the incisors due to trans-septal fibre contraction and c heek/lip pressure. Unilateral loss of a primary canine or first molar will lead to an asymmetry of the occlusion and a tendency toward crowding. Abnormalities of tooth size and shape Dental trauma Dental trauma can lead to the development of malocclusion in three ways: damage to permanent tooth buds from an injury to the primary teeth drift of permanent t eeth after premature loss of primary or permanent teeth direct injury to permane nt teeth. Trauma to a primary tooth that displaces an underlying permanent tooth bud can result in defective amelogenesis of the permanent tooth, if enamel form ation is occurring at the time of the injury, or displacement of the crown relat ive to its root, if crown formation is complete. Root formation may stop, leavin g a permanently shortened root or, more frequently, root formation continues at an angle to the displaced crown, resulting in dilaceration. If distortion of the root position is severe enough, it is almost impossible for the crown to assume its correct occlusal position. Traumatic avulsion of primary incisors is unlike ly to lead to significant drift of permanent teeth, but early avulsion is likely to delay the eruption of the permanent successors due to the slow resorption of the layer of compact bone that forms in the edentulous area. If a permanent inc isor is avulsed at an early age, drift of the other permanent teeth may result i n an unsightly space too small for adequate prosthetic replacement. If a posteri or tooth is lost prematurely to trauma, the same patterns of drift will occur as if it had been lost to caries (see later). Abnormalities of tooth size and shape result from disturbances during the morpho differentiation stage of development. The most common abnormality is a variation in size, particularly of maxillary lateral incisors and second premolars. About 5% of the total population has a significant 'tooth size discrepancy' because o f disproportionate sizes of upper and lower teeth. Occasionally, tooth buds may fuse or geminate during their development, making the development of normal occl usion impossible. Interference with eruption

Delays in eruption of permanent teeth contribute to malocclusion, primarily beca use other teeth drift to undesirable positions in the arch. In 10-15% of childre n, at least one primary molar becomes ankylosed before it finally resorbs and ex foliates. This delays the eruption of its successor and malocclusion will result if drift or tilting of surrounding teeth occurs. Occasionally, malposition of a permanent tooth bud can lead to ectopic eruption. The teeth most likely to be a ffected are the maxillary first molars, incisors and canines. If the eruption pa th of the maxillary first molar carries it too far mesially, impaction against t he distal root of the second primary molar, with subsequent loss of this tooth, will result in a reduction of arch length and malocclusion. Ectopic eruption of mandibular lateral incisors, which occurs more frequently than first molars, may lead to transposition of the lateral incisor and canine. Ectopic eruption has b een implicated in the aetiology of the impacted maxillary canine but other consi derations, including arch length discrepancies and physical obstruction of erupt ion, may contribute to this tooth's impaction. Soft-tissue factors The forces contributing to the equilibrium position of the dentition are mastica tory forces, eruptive forces, and the 28

GROWTH AND DEVELOPMENT forces exerted by the lips, cheeks and tongue. Although one might think that for ce magnitude and duration would determine the biological response of the dentiti on, it has been shown that the force duration is by far the most important consi deration, and that heavy intermittent pressures, such as those exerted by mastic atory muscles, have little impact on the long-term position of a tooth (Proffit 1978). Indeed, very light forces are successful in moving teeth, if the force is of long enough duration. The duration threshold seems to be approximately 6 hou rs in humans, a duration exceeded by the lips, cheeks and tongue at rest. It see ms unlikely that the intermittent short-duration pressures, generated when the t ongue and lips contact the teeth during swallowing or speech, would have any sig nificant impact on tooth position. Another possible contributor to the dental eq uilibrium is the periodontal fibre system. A contribution to horizontal equilibr ium is made by the trans-septal fibres, as seen by the tendency of orthodontical ly moved teeth to return toward their pretreatment positions, and a contribution to vertical equilibrium is made by the tooth's eruptive force, which opposes th e intrusive vectors of soft tissue resting pressures. In the absence of space cr eated by extraction or orthodontic tooth movement, the gingival fibre network ap parently has minimal effects on the horizontal dental equilibrium. However, the vertical equilibrium of the dentition is an important consideration in the aetio logy of malocclusion related to function. Although almost all normal children en gage in nonnutritive sucking, prolonged sucking habits can lead to malocclusion if they persist into the mixed dentition years. The malocclusion results from a combination of direct pressure on the teeth and an alteration in the pattern of resting cheek and lip pressures, and is characterised by flared maxillary inciso rs, proclined or retroclined lower incisors, anterior open bite and a constricte d maxillary arch. Direct pressure from the digit is presumably responsible for i ncisor displacement, while interference with normal labial segment eruption and excessive buccal segment eruption are responsible for the anterior open bite. Th e constricted maxillary arch results from the lowered tongue posture and disrupt ion of the force equilibrium experienced by the maxillary posterior teeth. In su mmary, the simple clear-cut explanations of malocclusion on a primary genetic ba sis that were widely accepted in the past have been demonstrated to be incorrect. Skeletal and dentoalveolar orthodontic problems can arise from inheri ted patterns, defects of embryological development and trauma, with a variable c ontribution made by other functional influences. The majority of patients presen ting with malocclusion do so because of a genetic predisposition to their condit ion, an environmental influence that altered their ideal pattern of development, or some combination of genetic predisposition exaggerated by environmental infl uences. The management of malocclusion commonly involves orthodontic, operative and sometimes surgical specialities to normalise intra- and interarch relationsh ips by tooth movement, dentofacial orthopaedics and restorative care. I~ 'P" References Bjork A 1968 The use of metallic implants in the study of facial growth in child ren: method and application. American Journal of Physical Anthropology 29:243-25 0 BjorkA, Skeiller V 1983 Normal and abnormal growth of the mandible: a synthesi s of longitudinal cephalometric implant studies over a period of 25 years. Europ ean Journal of Orthodontics 5:1--46 Broadbent B H Sr, Broadbent B H [r, Golden W H 1975 Bolton standards of dentofacial developmental growth. Mosby, St Louis En low 0 H 1982 Handbook of facial growth. W B Saunders, Philadelphia Harradine N W , Pearson M H, Toth B 1998 The effect of extraction of third molars on late lowe r incisor crowding: a randomised controlled trial. British Journal of Orthodonti cs

25:117-122 Moss M, Sanlentijn L 1969 The primary role of functional matrices in facial grow th. American Journal of Dentofacial Orthopedics 55:566-577 Proffit W R 1978 Equi librium theory revisited. Angle Orthodontist 48:175-186 Riolo M L, Moyers R E, M cNamara J A, Hunter W S 1974 An atlas of craniofacial growth. Monograph 2, Crani ofacial, growth series, University of Michigan, Ann Arbor Sinclair P, Little R M 1985 Dentofacial maturation in untreated normals. American Journal of Orthodont ics 85:146-156 Vasir N S, Robinson R J 1991 The mandibular third molar and late crowding of the mandibular incisors - a review. British Journal of Orthodontics 18:59-66 Further reading Proffit W R, Fields H W 2000 Contemporary orthodontics. Mosby, St Louis, chapter s 2-5 29

Anatomy and pathophysiology of the temporomandibular joint s. Palla Synopsis The temporomandibular (TM) joint is a freely movable articulation between the ma ndibular condyle and the glenoid fossa, with the articular disc interposed. Move ments occur by a combination of rotation (between condyle and disc) and translat ion (between the condyle-disc complex and the fossa). This high degree of mobili ty, in particular of the translatory movement, is reflected in the way in which the disc is attached to the condyle and in the absence of hyaline cartilage. Con dyle and fossa are covered by fibrocartilage and the disc consists of a dense co llagen fibre network oriented in different directions related to functional load . Condylar movements are complex, and during chewing both condyles are loaded, t he working less than the non-working condyle. The TM joint is able to adapt to l oad changes by remodelling. TM joint osteoarthrosis is a primarily non-inflammat ory joint disease characterised by destruction of the cartilage and exposure of the subchondral bone. Central to the osteoarthrotic process is the production of proteolytic enzymes by chondrocytes. Progression is probably determined by the joint-loading condition. This chapter is an overview of the anatomy, the histolo gy of the articular disc and its attachments to the condyle and fossa, condylar movements, joint remodelling and joint osteoarthrosis. Key points Temporomandibular joint anatomy - Temporal component - Mandibular condyle - Arti cular disc - Joint capsule - Disc attachments - Disc position - Joint innervatio n - Joint lubrication Condylar movements - Rotation versus translation Joint loa ding Joint remodelling - Disc remodelling Joint osteoarthrosis TEMPOROMANDIBULAR ANATOMY JOINT The temporomandibular (TM) joint is a freely movable articulation between the co ndyle of the mandible and the glenoid fossa - part of the squamous portion of th e temporal bone. In comparison to other body articulations this joint has some u nique features: Functionally the TM joint is a bilateral joint - the right and l eft joint always function together. The condyle-disc complex has a high degree o f mobility and condylar movements always occur by a combination of rotation and translation. Thus, the TM joint is classified as a ginglymodiarthroidal joint, t hat is, a joint in which both rotatory and gliding (translatory) movements take place. The articulating surfaces are not covered by hyaline but by fibrocartilag e. Condylar movements are controlled not only by the shape of the articulating s urfaces and the contraction patterns of the muscles but also by the dentition. T he 31

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Fig. 4.1 Six positions of the condyle-disc complex during an opening movement. W hile the condyle rotates below the disc, the condyle-disc complex glides anterio rly. Note that at maximum opening the disc lies on top of the posterior part of the condylar head. Fig.4.2 Three-dimensional reconstruction of nine positions of the condyle-disc c omplex during an opening movement. Note that the condyle-disc complex translates less anteriorly than in the sequence shown in Fig. 4.1. As a consequence the de gree of rotation of the condyle is less. dentition also determines the end position as well as the movement of the condyl e-disc complex when jaw movements are performed with the teeth in contact, as at the end of chewing or during tooth grinding. Condyle and fossa are separated by the articular disc, which is attached to both condyle and fossa by means of disc attachments. The condyle articulates against the disc, forming the condyle-disc complex, which articulates with 32

ANATOMY AND PATHOPHYSIOLOGY OF THE TEMPOROMANDIBULAR JOINT A B Magnetic resonance image of disc position in maximum intercuspation (A) and at m aximum opening (B).At maximum intercuspation, the condyle lies behind the disc, whereas at maximum opening it is normally positioned below the disc (for compari son, see Fig. 4.1). In order to reach this position the condyle translates below the disc. Fig.4.3 the temporal bone. The rotatory movements occur mainly between condyle and disc, while translation occurs between the condyle-disc complex and the temporal foss a (Figs 4.1 and 4.2). Under abnormal conditions, for instance when the disc is d isplaced from its normal position, translation may also occur between condyle an d disc (Fig. 4.3). Fig.4.4 Section through a TM joint: 1, pars posterior; 2, pars intermediate; 3, pars anterior; 4 and 5, fibrocartilage covering the condyle and fossa; 6, inferi or lamina of the posterior attachment; 7 and 8, superior and inferior head of th e lateral pterygoid muscle. (From Luder with permission.) Temporal component The temporal component consists of the concave glenoid fossa and the convex arti cular tubercle or eminence. Considering the capsular attachments as its boundary , the temporal component of the joint is slightly wider mediolaterally than ante roposteriorly, on average 23 mm and 19 mm respectively. The depth of the fossa a nd the inclination of the posterior slope of the eminence vary greatly between i ndividuals. Attempts have been made to correlate the inclination of the posterio r slope with occlusal characteristics, for instance the inclination of the incis al guidance, but no such correlations have been found. In the newborn the glenoi d fossa is very shallow (almost flat) and develops rapidly during the first year s of life; it reaches about half its final shape by the time the eruption of the primary dentition is completed. The rate of development of the eminence reduces at about 5 years of age, and slowly diminishes, stopping by the middle to late teens. This early development of the eminence reflects the changes in the direct ion of joint loading. This is due to condylar growth, transition from suckling t o chewing, and variation in the three-dimensional orientation of the musculature caused by growth of the craniofacial complex. Posteriorly the fossa is limited by the postglenoid tubercle of the squamous par t of the temporal bone and lies just in front of the squamotympanic and petrotym panic fissures. The articulating part of the temporal component is covered by a thin layer of soft tissue consisting, from the articular surface down to the bon e of: (1) a fibrous connective tissue zone; (2) a proliferation zone containing undifferentiated mesenchyme cells (not always present); and (3) a cartilage zone . Its thickness varies anteroposteriorly, being thin in the roof of the fossa an d thickest at the articular eminence (Fig. 4.4 - about 0.4 mm at the eminence, 0 .2 mm at the slope and 0.05 mm in the fossa). This reflects the fact that the fu nctionally loaded part of the glenoid fossa is not the roof but the eminence, in particular its posterior slope. Mandibular

condyle The condyle normally has an elliptical shape, and measures on average 20 mm medi olaterally and 10 mm anteroposteriorly. The dimension varies considerably betwee n individuals, with a range of 13-25 mm mediolaterally and 5.5-16 mm anteroposte riorly. The shape of the condyle also presents great interindividual variation. After the age of 3 years, condylar growth occurs mostly in a mediolateral direct ion. The anteroposterior dimension does not change significantly, whereas the me diolateral dimension increases by a factor of 2.5 until adulthood. 33

I BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION and II. Type II collagen is present especially in areas with CLPGs; which are fo und mainly in the posterior band. The collagen fibres have a typical pattern dis tribution: in the intermediate zone the thick collagen bundles are oriented sagi ttally; anteriorly and posteriorly they enter into the anterior and posterior ba nds to become interlaced or continuous with the mainly transversally oriented co llagen fibres of these disc regions. Other fibres pass through the entire bands to continue into the anterior and posterior disc attachments. The transversely o riented fibres are more pronounced in the posterior band. Thus, in the intermedi ate part there is a weaker crosslin king of the collagen bundles, making the cen tral part of the disc less resistant to mediolateral shear stresses. The shape o f the disc is well adapted to the form of the condyle and fossa (see Fig. 4.4), and disc shape varies B greatly between individuals. For instance, the degree of A disc biconcavity depends on the depth of the fossa: in Fig.4.5 Computed tomog raphy of the TM joint. joints with a deep fossa the disc is more concave because A Horizontal and B frontal sections indicate the the posterior part is thick, w hile in joints with a shallow inclination of the condylar long axis in the horiz ontal fossa the disc is less biconcave, that is, it is more even in and frontal planes. thickness. The thickness, and therefore the degree of concavity, also of ten varies mediolaterally (Fig. 4.6); depending on the shape of the fossa the di sc can be thicker medially or laterally. Condylar growth stops in females in the late teens but The disc is avascular and non-innervated, and is may continue in to the twenties in males. flexible in order to: The condyles are not aligned in a transverse axis. On the contrary, their condylar long axes, that is the axis a dapt its shape to the form of condyle and fossa connecting the medial and latera l pole of each condyle, during mandibular movements usually converge in a poster osuperior direction, forming decrease the stress concentrations due to joint an obtuse angle between right and left axes. For imaging incongruencies and therefo re improve load distribution. purposes, there is a tendency to differentiate bet ween the This ability depends on disc thickness: the thicker the disc horizontal and the vertical condylar angle, that is, the angle the better its ability to d istribute the load. Given that the formed by the condylar axis and the frontal a nd horizontal mechanical properties of the disc facilitate its role as a planes, respectively. The horizontal condylar angle varies stress distribution mechanis m, it is reasonable to hypobetween 0 and 30 with a mean of about 15, while the thes ise that the physical condition of the disc determines vertical condylar angle v aries even more (Fig. 4.5). the longevity of the joint structures. Therefore, st resses The condyle is covered by a thin layer of fibrocartilage that cause fatig ue of the disc might ultimately compromise similar to that of the fossa. The sof t tissue layer is thickest the primary stress control mechanism of the joint. su periorly and anteriorly (see Fig. 4.4). Articular disc The disc is a fibrocartilaginous structure. In an anteroposterior direction it c an be subdivided in three zones: an anterior (foot-like) zone Cpes'), an interme diate (thinner) zone Cpars gracilis') and a posterior (thicker) zone Cpars poste rior'). The anterior and posterior zones are also referred to as the anterior an d posterior bands (see Fig. 4.4). The posterior band is usually thicker than the anterior band. The disc is composed of densely organised collagen fibres, carti lage-like proteoglycans (CLPGs), elastic fibres and cells that vary from fibrocy tes to chondrocytes. The collagen consists mainly of types I A Fig.4.6 A Lateral and B medial magnetic resonance images of a TM joint. The po sterior part of the disc can be seen to be thicker medially than laterally. B

34

ANATOMY AND PATHOPHYSIOLOGY OF THE TEMPOROMANDIBULAR JOINT Joint capsule Unlike many other joints, the TM joint does not have a circular capsule. A disti nct capsule exists only laterally and posteriorly, while medially and anteriorly it is absent or so thin that it can hardly be distinguished from the disc attac hments. In these areas, the TM joint wall is formed only by those structures tha t consist of a superior lamina inserting into the periostium of the temporal bon e, and an inferior one inserting into the periostium of the condyle. The lateral joint capsule consists of a prominent inferior disc attachment and a thick caps ule. The capsule is lined with the synovial membrane which continues through a z one of gradual histological transition, i.e. without a distinct boundary, into t he fibrous lining of the articular cartilage of condyle, disc and fossa. The sim ilar structure and continuity of the articular and synovial lining tissues sugge st that they form a continuous tissue system, the 'articular synovial lining tis sue system'. The synovial tissues appear as a folded (areolar) and a smooth (fib rous) membrane. The folded form is at the posterosuperior and anteroinferior att achment, and the smooth form predominates at the anterosuperior and posteroinfer ior attachment. The synovial membrane secretes synovial fluid. This is a transud ate of extravascular fluid from the capillaries in the intermediate layer of the capsule. As with other synovial joints, it provides nutrition for the cartilage and lubrication, and acts as a heat-dissipating mechanism. With joint motion, s ome friction inevitably takes place and generates heat. The heat is dissipated b y the constant flow of fluid across the synovial membrane into the joint cavity and its subsequent resorption by the subsynovial lymphatics located in the loose areolar tissue between the inner border of synovial cells and the outer fibrous ligaments. Fig.4.7 Section through a TM joint. The condyle is in a slightly anterior positi on. The posterior and anterior attachments and the border between the posterior part of the disc and the bilaminar zone are clearly visible. 1 and 2, superior a nd inferior laminae of the anterior attachment; 3 and 4, superior and inferior l aminae of the posterior attachment; 5, border between posterior band and bilamin ar zone. (From Luder with permission.) Disc attachments The attachments that allow the disc to rotate around the condyle and slide anter iorly are particularly important for disc mobility. Fig. 4.8 Histological sectio n of a TM joint with the condyle in a slightly anterior position. Note the diffe rent disc attachments and the folds in the superior lamina of the posterior atta chment. 1, posterosuperior attachment; 2, posteroinferior attachment; 3, anteros uperior attachment; 4, anteroinferior attachment; 5, posterior capsule; PtM, lat eral pterygoid muscle. (From Luder 1991 with permission from Schweiser Monatssch rift fur Zahnmedizin.) Anterior attachments In this area the superior lamina is thicker than the inferior lamina, especially in the lateral and central areas. It consists of dense collagen fibres that ins ert into the periostium of the infratemporal surface in front of the eminence. T he inferior lamina, which inserts into the condyle more superiorly than the post erior attachment, is composed of loose wavy fibres and forms a small recess of t he inferior joint cavity (Figs 4.7 and 4.8). Sparse elastic fibres are found in the inferior lamina. Lateral and medial attachments The lateral disc attachment inserts into the lateral pole and contains, in addit

ion to more or less vertically oriented collagen fibres, fibre bundles that are oriented in 35

 BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION Fig. 4.9 Insertion of the disc to the lateral (L)and medial (M) pole of the cond yle. The medial insertion inserts below the pole. A capsule is only visible late rally (e). PtM, lateral pterygoid muscle. (From luder 1991 with permission from the Schweizer Monatsschrift fur Zahnmedizin.) Fig.4.10 Histological section of a TM joint with the condyle in an anterior posi tion. The superior lamina of the posterior attachment (Sl) begins to become stre tched, and blood vessels (V) in the retrodiscal pad dilate. This tissue is pulle d anteriorly in the retrocondylar space. The opened joint spaces are artefacts. See Fig. 4.11 for comparison in which the posterosuperior lamina is close to the fossa. (From luder with permission.) an almost concentric fashion. These fibres insert into the lateral pole from ant erior and posterior directions. With an opening rotation of the condyle, posteri or fibres are released while the anterior ones are tightened. This allows a firm disc-condyle connection that still permits condylar rotation. The medial capsul e consists of a thin superior and a somewhat thicker inferior disc attachment. U nlike the lateral insertion, the medial attachment inserts below the medial pole and is less firm than the lateral attachment (Fig. 4.9). Posterior attachments The posterior attachment is normally termed the 'bilaminar zone' or 'retrodiscal pad'. The lower lamina inserts into the periostium of the condyle, the insertio n being located more superiorly in the lateral part of the condyle than in the c entral and medial parts, where it is located approximately 8-10 mm below the ver tex of the condyle. The superior lamina inserts into the periostium of the fossa in front of the squamotympanic and petrotympanic fissures. Between these strata lies loose connective tissue with elastic fibres, blood and lymph vessels, nerv es and fat tissue. The inferior lamina consists of thick fibres that originate f rom almost the entire height of the posterior band, and lacks elastic fibres (se e Figs 4.7 and 4.8). It can be easily folded during condylar rotation and is ine lastic. The superior lamina is thinner than the lower one and also has thinner c ollagen fibres. The fibres of both laminae enter the posterior band and become contiguous with the sagittally oriented coll agen fibres. Elastic fibres are visible only in the superior lamina and in the p osterior capsule. The latter extends from the anterior slope of the postglenoid tubercle to the condylar neck below the attachment of the lower lamina. This is made up mainly of condensed fibrous tissue. It has been postulated that the elas ticity of the superior lamina should pull back the disc during closing. The cont ent of elastic fibres in the superior lamina is, however, not sufficient to prov ide this ligament with the elastic force needed to do this. It is more likely th at the elastic fibres of the lamina prevent the loose connective tissue from bec oming trapped between the articular surfaces during jaw movements. In the closed mouth position the collagen fibres of the superior lamina as well as the synovi al lining are extensively folded. During opening or protrusion the superior lami na becomes stretched, allowing the disc to glide anteriorly (Fig. 4.10). Similar ly, the anteroinferior lamina becomes stretched during condylar rotation and mov es the attachment insertion anteriorly in relation to the disc. Thus, the positi on of the disc on the moving condyle is controlled by the lateral, and to a less er extent by the medial as well as by the posteroinferior, disc attachment. The function of the loose tissue between the two strata and the posterior capsule is to compensate for the changes in pressure that arise when the condyle translate s anteriorly. The loose fibroelastic framework allows the 36

ANATOMY AND PATHOPHYSIOLOGY OF THE TEMPOROMANDIBULAR JOINT Fig. 4.11 Magnetic resonance image of the condyle-disc complex at maximum mouth opening. The superior lamina of the posterior attachment (1) is located close to the fossa and the disc (D) lies on top of the posterior part of the condyle (C) . They are continuations of the perimysium that extend into the disc. In the deep masseter and posterior part of the temporal muscle the septa are fine, while at the superior head of the lateral pterygoid muscle the lamellae show an increase in thickness from lateral to medial. In muscular insertions, the tendinous end o f the muscle fibres insert into the disc. This insertion is present only for the fibres of the superior layer of the superior head of the lateral pterygoid musc le in about 60% of joints. These fibres insert medially into the disc. The remai nder of the muscle inserts into the pterygoid fovea above the insertion of the i nferior head with fibrous connections. The remaining 40% of the joints, i.e. of the discs, does not have a muscular but only a fibrous connection. When the fibr es inserting into the disc are pulled, it is possible to stretch the disc but no t to pull it forwards, indicating that an anterior disc displacement cannot be c aused by abnormal activity of the superior head. Further details may be found in Meyenberg et al (1986). Disc position blood vessels to expand, producing an enlargement of the volume of this tissue ( Fig. 4.10); at full mouth opening there is an increase by a factor between four and five. As a consequence, the posterosuperior lamina is pressed against the fo ssa and the posteroinferior lamina becomes folded upwards (Fig. 4.11). The expan sion of this tissue is due to the dilatation of the venous plexus that is connec ted medially to the pterygoid plexus located anteromedially to the condyle. On o pening, this venous blood can be drawn posteriorly and laterally to fill the enl arged space behind the condyle, and on closing it is pushed out. Pressure compen sation is also achieved to a far lesser extent by the inward bulging of the paro tid gland and subcutaneous tissue behind the condyle. The bilaminar zone is thus designed to allow rapid volume changes in the retrocondylar space. Lack of a qu ick pressure compensatory mechanism on opening, closing or translation would pre vent smooth condylar movements. Further details may be found in Luder and Bobst (1991) and Scapino (1997). In maximum intercuspation the posterior band lies abo ve the condyle (see Figs 4.4 and 4.6) and the thin intermediate zone is located in front of the condyle between it and the posterior slope of the eminence (see Fig. 4.4). In magnetic resonance images the border between the posterior band an d the bilaminar zone is seen to be located superiorly in the majority of cases in the socalled '12 o'clock' position (see Figs 4.1 and 4.6). Magnetic resonanc e imaging has also shown that in about one-third of individuals without subjecti ve and objective joint disorders, the posterior band lies anteriorly. Joint innervation The TM joint capsule is richly innervated by branches of the trigeminal nerve: t he auriculotemporal, masseteric and deep posterior temporal nerves. As with othe r joints of the body, branches of the nerves innervating the muscles acting upon it also innervate the joint capsule. Small nerve bundles, from the main nerve t runk innervating the joint capsule, also innervate the most peripheral parts of the disc, especially in the anterior and posterior areas. The capsule and retrod iscal pad also contain perivascular nerve fibres. The trigeminal nerve endings a re either: free nerve endings that are thought to be nociceptors; or mechanorece ptors that are involved in the reflex control of masticatory muscles. 37

Disc attachment to muscles The relationship of the masseter, temporal and in particular of the lateral pter ygoid muscles to the TM joint has been the subject of several investigations. Th ere are two forms of disc-muscle attachment: Fibrous connections consist of fibr ous septa that are perpendicular to the direction of the muscle fibres.

BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION The following receptors have been described: Ruffini endings, Pacinian type endi ngs and Golgi-type endings. Immunohistochemical staining in the rat TM joint ind icated the presence of nerve fibres containing a variety of neuropeptides (neuro peptide Y, vasoactive intestinal peptide, pituitary adenylate cyclase-activating peptide, substance P, calcitonin gene-related peptide) and nitric oxide synthas e, in the synovial membrane, the joint capsule and entering the articular disc. Retrograde transport resulted in the appearance of numerous labelled nerve cell bodies in the trigeminal and superior cervical ganglia, and moderate numbers in the nodose, otic, sphenopalatine, stellate and dorsal root ganglia at levels C2C5. Innervation of the TM joint is therefore complex, and different sensory and autonomic ganglia are involved. Figure 4.12 shows a lateral view of movement of the condyles during the closing phase of a chewing cycle. The first image represents the position at the beginni ng of closing. Three features of the closing stroke may be appreciated: There is a difference in the velocity of the retrusive movement of both condyles: the ip silateral or working condyle moves faster posterosuperiorly and reaches its uppe rmost position in the fossa before the contralateral condyle. In Figure 4.12-4 t he working condyle is almost seated in the fossa, while the contralateral condyl e is still on the posterior slope. This led to the hypothesis that the ipsilater al condyle acts as a stabilising fulcrum during the so-called 'power stroke', th at is, when force is applied to crush food. On opening, both condyles translate approximately the same amount and are located just behind the eminence. As seen in the compound figure (Fig. 4.12, lower right), the condyle rotates about 10, fa r less than during maximum opening (see Fig. 4.1 for comparison). At maximum ope ning the condyle rotates on average by 30; during chewing the rotatory component is about 10. During so small a rotation, only the superior part of the condyle is loaded, and this is the area where the fibrocartilage is thickest. Joint lubrication The frictional coefficient within a joint is very low, and impairment of joint l ubrication has been considered as a possible cause of TM joint disorders. One TM joint disorder considered to be related to impaired joint lubrication is the 'a nchored disc' phenomenon that manifests itself by 'closed lock' (Nitzan et al 20 02). The TM joint is subjected to various loading conditions: lightly loaded mot ion with higher speed (for example, during jaw opening/ closing or speaking) imp act loads (for example, during sudden mandibular accelerations, related either t o fracture of a hard bolus or trauma) fixed steady loads (for example, during su stained clenching). Under all conditions, lubrication by a viscous fluid layer i s essential to protect the articular surfaces. The low friction between the arti culating surfaces is most likely to be provided by a combination of boundary and weeping lubrication. Details may be found in Nickel et al (2001) and Nitzan et al (2002). During light loaded motions, the presence of a synovial fluid film du e to hydrodynamic effects keeps frictional forces very low. During higher loads at slower gliding speeds of articular surfaces, as well as at the beginning of m ovement, the main contribution to joint lubrication appears to be fluid squeezed out from the cartilage matrix (weeping lubrication). During extreme loading con ditions, ultrafiltration, that is, the motion of fluid into the cartilage matrix , produces a viscous gel that separates and protects the articular surfaces. Rotation versus translation As already stated, jaw movements occur by a combination of: rotation of the cond yle against the disc translation of the condyle-disc complex. Both always occur simultaneously during functional movements; that is, opening movements always st art with a combination of rotation and translation. However, there is great intr a- and interindividual variability in the relationship between condylar rotation and anterior translation during empty opening and closing movements. Three patt erns have been described during jaw opening, and four during jaw closing. Openin

g movements are performed most often (75%) by a constant simultaneous increase i n rotation and anterior translation, resulting in a linear relationship between the two components throughout the movement. This means that from the beginning o f opening, both condylar rotation and anterior translation of the condyle-disc c omplex occur together and these two movement components increase constantly thro ughout the movement. A second pattern (16%) is characterised by marked rotation only at the beginning of opening. The third, less frequently observed, pattern ( 9%) has a marked initial and final rotatory component. CONDYLAR MOVEMENTS Examples of condylar movements during various types of movement may be found at http://www.dent.unizh.ch/kfs/ . 38

ANATOMY AND PATHOPHYSIOLOGY OF THE TEMPOROMANDIBULAR JOINT Fig.4.12 Five positions of the ipsilateral and contralateral condyle during the closing phase of a chewing cycle. The lower right figure is a compound image. When the data of all recorded movements are considered together, the relationshi p between rotation and translation in asymptomatic subjects has an almost perfec t linear relationship for both opening and closing. On average, condylar rotatio n increases by approximately 2 per millimetre of anterior translation during open ing, and decreases by approximately the same amount of posterior translation dur ing closing (Salaorni & Palla 1994). The relationship between rotation and trans lation has clinical implications, and explains the decrease in mouth opening whe n anterior condylar translation is reduced, as in the case of an anterior disc d isplacement without reduction. As the degree of mouth opening is mainly determin ed by the amount of condylar rotation, and a decrease in translation causes a de crease in condylar rotation, it follows that mouth opening must decrease. Closin g movements show a greater variability between rotation and translation (for det ails, see Salaorni & Palla 1994). The amount of condylar rotation does not diffe r between males and females, a finding which contrasts with the larger maximum i nterincisal opening of men compared with women. However, this is not surprising, as the degree of opening measured at the incisors depends not only on the degre e of rotation but also on the size of the mandible. Indeed, with the same degree of rotation, the larger the mandible the larger the mouth opening. Consequently , the degree of interincisal opening cannot be considered as a measure of joint mobility or laxity, unless it is corrected for mandibular size. JOINT LOADING A question often raised in dentistry is whether or not the TM joint is loaded du ring function. Computer modelling and recordings in monkeys consistently predict that both joints are loaded during chewing as well as during clenching in eccen tric positions. Theipsilateral (working) condyle can be distracted, i.e. unloade d, only when a subject is biting on the third molar, a finding also confirmed wi th computer simulation and recordings on monkeys. In addition, the measurements of the variation of the minimum condyle-fossa distance in vivo during chewing in dicate that both condyles are loaded during the closing phase. As the decrease o f the minimum condyle-fossa distance during the closing phase of a chewing strok e is generally larger on the contralateral (non-working) than on the ipsilateral (working) side, there must be a larger compression of the disc on the nonworkin g side. This result is in keeping with the models describing a greater load on t he contralateral than on the ipsilateral side during the closing phase of chewin g. For detailed results see Palla et al (1997). JOINT REMODELLING Joint growth stops at about 18-20 years of age (earlier in men than in women). A fter that time soft and hard tissues undergo continuous change, i.e. they are co ntinuously 39

II BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION remodelled. Articular remodelling is considered as normal adaptation of soft and hard tissues to the load changes within the joint. Progressive and regressive r emodelling are described: Progressive remodelling is characterized by tissue pro liferation, i.e. by an increase in the volume of the remodelled tissue with eith er higher cell density and/ or higher number of cells of a certain phenotype. In regressive remodelling there is a decrease in tissue volume and in cell number as well as other signs of tissue degeneration. Joint remodelling leads to change s in the shape of the condyle and fossa which may disturb normal joint biomechan ics. This form change may cause a higher degree of incongruency between condyle and fossa so that the disc tissue may undergo greater stress concentration. parallel to the surface, whereas those inside are parallel or transversally orie nted. These changes emphasise the remodelling of a displaced disc to resist func tional loads. OSTEOARTHROSIS Osteoarthrosis is a degenerative, primarily noninflammatory joint disease, chara cterised macroscopically by cartilage degradation and deterioration that may pro gress to complete cartilage destruction and exposure of subchondral bone. The al teration of the articular surface leads to increased friction during jaw movemen t and crepitation, which is pathognomonic for this disease. Being primarily noninflammatory, osteoarthrosis is usually non-painful, or there may be painful epi sodes that resolve spontaneously. As a result, two forms of os teo arthrosis are described: osteoarthrosis without secondary synovitis and no pain osteoarthriti s with seconday synovitis and pain. The pathophysiology involves secretion of pr oteolytic enzymes (metalloproteinases and cathepsin B) by chondrocytes; both cyt okine-independent and cytokinedependent mechanisms are involved (Fig. 4.13): Cyt okine-independent mechanism. This begins as fibrillation of the articular surfac e, a decrease in the metabolic activity in the most superficial layer and an inc rease in the water content of the cartilage. As a consequence, chondrocytes do n ot receive oxygen and nutrients by slow diffusion from synovial fluid through th e cartilage but directly, so that their metabolic activity changes from anaerobi c to aerobic. This causes a phenotypic alteration of the chondrocytes that dedif ferentiate to form cells that have the characteristics of both fibroblasts (fibr oblastic metaplasia) and hypertrophic chondrocytes (phenotypic modulation). The dedifferentiated chondrocytes synthesise matrix components that are typical for fibroblasts: collagen type I, III and X, and proteoglycans with a higher molecul ar mass. They also proliferate and secrete cathepsin B, an aggressive enzyme tha t leads to degradation of all cartilage components. This enzyme is also capable of inactivating the tissue inhibitors of the matrix metalloproteinases (TIMP-l a nd TIMP-2), which are also proteolytc enzymes. TIMP-l and TIMP-2 also inhibit bl ood vessel formation in the cartilage. Cytokine-dependent mechanism. Chondrocyte s usually secrete proteolytic enzymes in a non-harmful concentration controlled by extracellular inhibitors. In osteoarthrosis the production of proteolytic enz ymes increases. Synovial Disc remodelling Biomechanical stimulus is a primary mechanism for signal transduction between ch ondrocytes and matrix (cellmatrix interactions through integrins) and indirectly between cells and physiological stimuli (cell-molecule interactions through rec eptors). These signalling pathways are associated with biological regulatory eve nts, such as changes in mechanical loads, which influence these pathways and sti mulate remodelling. In anterior disc displacement, there is: an increase in mech anical load in the posterior disc attachment and, depending on the degree of dis placement (partial, total, with or without reduction), a reduction in compressiv e load in the intermediate and anterior disc zones. As a consequence of the post

erior band becoming trapped between condyle and fossa, it undergoes fibrotic cha nge: The collagen fibres bundles become thicker, more rectilinear, and become or iented parallel to the attachment surface. The elastic fibres thin out, vascular ity decreases and the fibrotic attachment may appear hyalinised and may contain cells of cartilage phenotype as well as CLPGs. In the posterior band, the collag en fibres become aligned in all directions and the transverse bundles may increa se in thickness, probably to resist increased tensile stress in the mediolateral direction. In the anterior band, rearrangement of the collagen fibres also occu rs and, with a decrease in compressive load, the CLPGs disappear. The anterior d isc attachment to the condyle becomes stretched and the disc may remain stretche d or become flexed. In the latter case, collagen fibres on the outside of the fl exure are oriented 40

ANATOMY AND PATHOPHYSIOLOGY OF THE TEMPOROMANDIBULAR JOINT Effects on cartilage Metabolism discontinuation in upper layers Cartilage fibril lation Cartilage swelling due to water absorption Cartilage fragments Effects on chondrocytes Increase of the IL-1~,TNFa and iNOS expression Autocrine or paracrine stimulation Cartilage fragments l _ _ Effect on synovial cells Inflammation (moderate, locally limited) Cytokine secre tion IIL-1~,TNFa Exocrine stimulation Chondrocytes Excessive nutrition Excessive oxygen Aerobicmetabolism 5 Chondrocyte activation Secretion of: Metalloendopeptidases Plasminogen activator Prostaglandin E2 'NO Abnormal biosynthesis of proteoglycans and collagen 12 Chondrocytes Phenotypic modulation Active but wrong reparation Proliferation, hy pertrophy Synthesis of type IIcollagen 1 Synthesis of type I, III,X collagen! Sy nthesis of embryonic proteoglycans Increased production and secretion of catheps in B Cathepsin B Chronic collagen destruction Antagonistic of regeneration Disintegra tion of TIMP-1 and TIMP-2 Collagen vascularisation and mineralisation Reinforcem ent of metalloendopeptidases Cathepsin B t J @ Fig.4.13 Cytokine-dependent and cytokine-independent mechanisms. Osteoarthrosis (osteoarthritis) could be determined by the cascade of the events 3, 4, 5, 9, 10 , 11, 12, with the sequence 9, 10, 11, 12 and the mechanical factors 7 determini ng the chronicity of the osteoarthrotic process (From Baici, with permission fro m RC Libri, Milano.) cells are stimulated to secrete cytokines (interleukin (IL-l~) and tumour necros is factor alpha (TNFa, which diffuse into the fibrocartilage and stimulate condro cytes to produce metalloproteinases. These proteolytic enzymes degrade the colla gen matrix, as with cathespin B. Further destructive effects of cytokines involv e suppression of collagen types II and IX, the inhibition of proteoglycan synthe sis and stimulation of prostaglandin 2 synthesis. The free cartilage fragments produced by cartilage degeneration may stimulate synovial cells to further secre te cytokines, producing a vicious circle. This cytokine-induced mechanism result

s in local painful inflammation with prostaglandin 2 secretion. These cytokine-de pendent and cytokine-independent mechanisms may coexist (Fig. 4.13). It is likel y that the cytokine-independent mechanism plays a central role in 41

BIOLOGICAL CONSIDERATIONS OF THE OCCLUSION chronic, non-painful phases of the disease, while the cytokine-dependent mechani sm dominates during painful episodes. The final stages of osteoarthrosis are dom inated by cartilage that is unable to resist functional load. The weakened carti lage loses its biomechanical function, becomes atrophic and the chondrocytes die by apoptosis. As a consequence of vascularisation, osteophytes form and may dis turb joint biomechanics. Histological studies indicate that TM joint osteoarthro sis has a similar pathophysiological mechanism as joints with hyaline cartilage: The first signs are chondrocyte proliferation and an increase in their metaboli c activity. This reparative process allows osteoarthrosis to remain asymptomatic for several years. Later, cartilage volume increases due to an increase in wate r content and the surface becomes irregular. Chondrocytes produce proteolytic en zymes that lead to a disintegration of the collagen matrix. The surface develops deep fissures and loss of cartilage due to intra-articular frictional forces. I slands of chondrocytes become visible near the deep fissures. In the final phase these become larger. As a consequence of the proteolytic destruction of collage n fibres and of proteoglycans, fibrocartilage dis appears, chond rocytes die and the subchondral bone becomes exposed. There are endogenous (age, gender, geneti c disposition and race) and exogenous (joint form and instability, traumatic les ions and overloading) risk factors. The osteoarthrotic process does not necessar ily progress to complete degeneration of fibrocartilage. It is likely that mecha nical factors determine the progression of the disease. Thus, all therapies that decrease TM joint loading (e.g. avoiding parafunction) are important in decreas ing the risk of progression. Nickel J C, Iwasaki L R, Feely D E et al 2001 The effect of disc thickness and t rauma on disc surface friction in the porcine temporomandibular joint. Archives of Oral Biology 46: 155-162 Nitzan D W, Goldfarb A, Gati I et al 2002 Changes in the reducing power of synovial fluid from temporomandibular joints with 'anchor ed disc phenomenon'. Journal of Oral Maxillofacial Surgery 60: 735-740 Palla S, Krebs M, Gallo L M 1997 Jaw tracking and temporomandibular joint animation. In: McNeill C (ed) Science and practice of occlusion. Quintessence Chicago, pp 365-3 78 Salaorni C, Palla S 1994 Condylar rotation and anterior translation in health y human temporomandibular joints. Schweizer Monatsschrift fur Zahnmedizin 104: 4 15-422 Scapino R P 1997 Morphology and mechanism of the jaw joint. Tn: McNeill C (ed) Science and practice of occlusion. Quintessence Chicago, pp 23-40 Further reading Baici A, Lang A, Zwicky R, Muntener K 2003 Cathepsin B in osteoarthritis: uncont rolled proteolysis at the wrong place. Seminars in Arthritis and Rheumatism (in press) Bibb C A, Pullinger A G, Baldioceda F 1992 The relationship of undifferen tiated mesenchymal cells to TMJ articular tissue thickness [published erratum ap pears in Journal of Dental Research 72:881. Journal of Dental Research 71: 18161821 Gallo L M, Nickel J C, Iwasaki L R, Palla S 2000 Stress-field translation i n the healthy human temporomandibular joint. Journal of Dental Research 79: 1740 -1746 Hannam A G 1994 Musculoskeletal biomechanics in the human jaw. Tn: Zarb G A, Carlsson G E, Sessle B J et al (eds) Temporomandibular joint and masticatory muscle disorders. 2nd edn. Munksgaard Copenhagen; pp 101-127 Luder H U 1993 Arti cular degeneration and remodeling in human temporomandibular joints with normal and abnormal disc position. Journal of Orofacial Pain 7: 391-402 Morani V, Previ gliano V, Schierano G M et al 1994 Innervation of the human temporomandibular jo int capsule and disc as revealed by immunohistochemistry for neurospecific marke rs. Journal of Orofacial Pain 8: 36-41 Nickel J C, McLachlan K R 1994 In vitro m easurement of the frictional properties of the temporomandibular joint disc. Arc hives of Oral Biology 39: 323-331 Nickel J C, Iwasaki L R, McLachlan K R 1997 Ef fect of the physical environment on growth of the temporomandibular joint. In: M cNeill C (ed) Science and practice of occlusion. Quintessence Chicago, pp 115-12 4 Scapino R P, Mills D K 1997 Disc displacement internal derangements In: McNeil l C (ed) Science and practice of occlusion. Quintessence Chicago, pp 220-234 Udd

man R, Grunditz T, Kato Jet al1998 Distribution and origin of nerve fibers in th e rat temporomandibular joint capsule. Anatomy and Embryology (Berlin) 197: 273282 Wilkinson T M, Crowley C M 1994 A histologic study of retrodiscal tissues of the human temporomandibular joint in the open and closed position. Journal of O rofacial Pain 8: 7-17 Acknowledgement The author thanks Dr H.D. Luder for providing Figures 4.4, 4.7-4.10. I~ r References Luder H U, Bobst P 1991 Wall architecture and disc attachment of the human tempo romandibular joint. Schweizer Monatsschrift fur Zahmnedizin 101: 557-570 Meyenbe rg K, Kubik S, Palla S 1986 Relationships of the muscles of mastication to the a rticular disc of the temporomandibular joint. Schweizer Monatsschrift fur Zahnme dizin 96: 815-834 42

www.egydental.com 43

Clinical occlusal analysis I. Klineberg Synopsis The assessment of the teeth is an integral part of treatment planning in restora tive dentistry. A broad distribution of tooth contacts disperses vectors of forc e from function and parafunction over many teeth and avoids force concentration on a limited number of teeth. Clinical occlusal analysis allows a detailed asses sment of.tooth contacts in retruded contact position (RCP), median occlusal posi tion (MOP) and lateral and protrusive jaw excursions. Modification of tooth cont acts in these jaw positions may be indicated in restorative care. Occlusal adjus tment and selective grinding are discussed in Chapter 14. Indications of parafun ctional tooth wear are described and the value of provocation tests linked with bruxofacets is discussed. Provocation tests may indicate an association between the particular tooth wear pattern with jaw posture and orofacial symptoms. This information may be of special importance in restorative treatment planning. Provocation tests are described to determine whether they evoke clinical symptom s: - temporomandibular joint provocation test to determine the presence of TM jo int pain or discomfort with clenching on a unilateral posterior support; and - j aw muscle provocation test to determine the effect on jaw muscles of clenching i n intercuspal position (ICP) ('centric bruxing') and clenching with opposing bru xofacets in contact INTRODUCTION In the context of occlusion representing both static and dynamic tooth relations hips and the integrated action of the jaw muscles and TM joints (see Ch. 1), a c omprehensive assessment of the occlusion includes: assessment of the positional relationships of the teeth and interarch tooth contacts in 'centric' and eccentr ic jaw positions jaw mobility measurement to determine TM joint function jaw mus cle palpation following a defined protocol. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) of Dworkin and LeResche (1992) are recogn ised as the international benchmark for TMD assessment (Truelove et al 1992). Th is specific clinical procedure has been accepted as a standard TMD assessment an d follows studies on validation of data collection by clinicians calibrated agai nst a gold standard. This development is an important step in standardising clin ical assessment to justify comparison of clinical studies. One of the shortcomin gs of studies on TMD assessment and management has been the lack of a standardis ed approach to experimental design and clinical assessment (Antczak-Bouckoms 199 5). This has prevented valid data Key points Jaw guidance techniques are described Tooth contacts in MOP and RCP are identifi ed with ultrafine plastic tapes, and their relevance is described Lateral guidan ce, balancing contacts or interferences, and mediotrusive contacts or interferen ces are specified Bruxofacets are identified as evidence of parafunction, and wh ether there is a combination of attrition and erosion 45

 ASSESSMENT OF THE OCCLUSION Table 5.1 Tooth contact identification MOP contacts are marked with red tape to identify functional contacts as distinc t from RCPcontacts (Fig. 5.2D, E). RCPcontacts are marked with black tape follow ing gentle operator jaw guidance (Fig. 5.2A, B) and the distribution of contacts compared with MOP contacts. Optimum jaw support in RCPsuggests bilateral simult aneous contacts on some, or ideally all, posterior teeth. Often only unilateral contacts are present in RCP. A slide from RCPto ICP may be examined (black tape) by having the patient bite after the initial contact in RCP. This will bring th e jaw into ICP and a slide from RCPto !CP,if present, will be observed by the mo vement of the lower incisor teeth. The slide may have anterior, lateral and/or v ertical components; and will be distinctly marked by the black tape. Lateral gui dance is marked with green tape to be distinct from MOP and RCPcontacts, to show which teeth (anterior and/or posterior) provide guidance. If anterior guidance is on the canine teeth, whether the tape marks are on the mesial or distal area of the lingual surface is noted (Fig. 5.2G-J). comparison. It is hoped that the standardised and validated RDC/TMD protocol wil l encourage multicentre studies and, as a result, the development of large datab ases for analysis. This chapter will discuss the details of an assessment of jaw and tooth relationships and will not include the assessment of the TM joints an d jaw muscles. These topics are comprehensively described in Chapters 7 and 8, r espectively. A detailed assessment of the static and dynamic relationships of te eth is important in clinical assessment for all aspects of dental practice. The information obtained will provide an understanding of the specific tooth relatio nships associated with function and parafunction, upon which treatment will be b ased. The number of tooth contacts around the arch relates directly to jaw muscl e activity (Ferrario et aI2002). This is important for prognosis and management of "treatment provided, and allows the clinician to more confidently manage the wishes and expectations of patients. It is recognised that, in the older patient , loss of posterior teeth may nevertheless allow appropriate jaw function (Witte r et aI2001). Table 5.2 Clinical occlusal assessment requirements GHM Foil x 3 (black, red, green) to mark teeth in a specific sequence Miller hol ders x 2 to support GHM Foil for bilateral assessment Gauze to dry teeth to allo w the ultrafine tape to mark the teeth Patient is seated in a dental chair with appropriate lighting Assessment is ideally carried out with patient lying supine ; alternatively it is possible for patients to be seated upright A dental assist ant is helpful for supporting the Miller holders CLINICAL OCCLUSAL ASSESSMENT Clinical assessment of tooth contact details requires operator confidence in det ermining jaw positions with guidance, and the use of high-quality ultra fine mar king tapes (for example, GHM Foil, Gebr. Hansel-Medizinal, Nurtingen, Germany; I voclar /Vivadent, Schaan, Liechtenstein) to accurately determine tooth contact a nd jaw relationships. These ultrafine tapes minimise contact artefacts and clear ly indicate tooth contact details. It is recognised that operator experience is important in consistency of tooth contact markings and that a gold standard appr

oach has not been defined (Millstein & Maya 2001, Harper & SetcheIl2002). A practical approach in clinical assessment is the use of different coloured pla stic tapes (GHM Foils) for identifying specific tooth contacts. For convenience, red, black and green tapes are recommended to allow comparisons to be made, as described in Table 5.1. (See Chapter 1 for revision of jaw and tooth positions.) Table 5.2 lists the requirements for clinical occlusal assessment. Retruded contact position Jaw guidance into RCP may be carried out using chin, chin and jaw, or bilateral jaw guidance. Each clinical approach is satisfactory, but requires practice and experience to gain confidence in the ability to guide the jaw reproducibly. The confidence of the clinician is often challenged by the difficulty that most pati ents have in relaxing the jaw to allow guidance into RCP (Figs 5.1 and Fig. 5.2A -D). 46

CLINICAL OCCLUSAL ANALYSIS A B c D E F Fig. 5.1 Jaw guidance techniques. A, B Jaw guidance obtained by supporting the c hin point with the thumb and the lower border of the jaw bilaterally with the in dex finger and middle finger. The jaw is rotated open and closed with the axis o f rotation at the condyles. The assistant supports the Miller holders and record ing tape. C, D Jaw guidance obtained by supporting the chin point with the thumb and index finger. The same procedure as above is followed in obtaining centric relation tooth contacts. The assistant supports the Miller holders and recording tape. E, F Bilateral jaw guidance with the patient lying supine. The jaw is gui ded with each thumb depressing the chin while the fingertips support the lower b order of the jaw. The head is stabilised by the operator seated at the 10 or 11 o'clock position with the head between the chest and inner surface of the left a rm (for a right-handed operator). Firm bilateral support, with gentle guidance a nd the presence of the sensitive fingerpads along the lower border of the jaw, p rovides an excellent means of accurately recording and testing retruded jaw posi tion or centric relation contacts in the dentate patient. (From Klineberg 1991, with permission.) 47

ASSESSMENT OF THE OCCLUSION c A B F D E G H J 48

CLINICAL OCCLUSAL ANALYSIS Fig.5.2 Clinical recording of jaw positions. A, B Clinical recording of retruded jaw position (RP) with bilateral manual jaw guidance by the clinician. The dent al assistant is supporting Miller holders for right and left quadrant recordings with black foil. C RP contacts marked with tape (arrows). Definite unilateral t ooth contacts are seen on teeth 1.6 (lingual incline of distobuccal cusp), 1.7 ( heaviest contact on distobuccal cusp, also on mesiolingual cusp), lighter contac t on 1.4 (buccal incline of lingual cusp) and 2.6 (anterior fossa). 0, E Clinica l recording of MOP. The clinician holds Miller holders for right and left quadra nt recordings with red foil. MOP contact is obtained by the patient snapping the teeth together (E) sharply from a jaw opened position (D). The tape marks provi de a pattern of functional tooth contacts. F MOP contacts are seen to be distrib uted around the arch in comparison with RP contacts in C. Definite supporting co ntacts are seen on the right: 1.1 (mesial and distal - darker); 1.2 (distal); 1. 3 (distal); 1.4 (lingual incline of buccal cusp - light); 1.6 (lingual incline o f distobuccal cusp - dark, and lingual groove on amalgam); and 1.7 (mesiolingual cusp tip - dark, and lingual incline of distobuccal cusp posterior to the RP co ntact). Contacts on the left: 2.1 (mesial); 2.2 (distal); 2.3 (distal); 2.4 (dis tobuccal cusp incline); 2.6 (mesiolingual and distolingual cusp tips); and 2.7 ( mesiolingual and distolingual cusp tips ). Original RP contacts are arrowed to i ndicate clearly the differences between RP and MOP. G Lateral jaw guidance to th e left. H Lateral jaw guidance to the right. I Lateral guidance to the left prov ided by tooth contacts (arrowed) on 2.3 (mesial - major guidance), 2.2 (distolin gual) and 1.7 (buccal incline of mesiolingual cusp). J Lateral guidance to the r ight provided by tooth contacts (arrowed) on 1.3 (mesiolingual) and 2.7 (buccal incline of mesiolingual cusp). (From Klineberg 1991, with permission.) Median occlusal position Median occlusal position is examined with a different coloured tape (red) to ass ess the distribution of functional contacts and whether this contact distributio n is different from RCP. The optimum tooth arrangement provides multiple bilater al simultaneous contacts, often on all posterior teeth, and, if the anterior too th arrangement allows (depending on degree of overjet), there may be lighter ant erior tooth contacts as well (Fig. 5.2 D-F). lateral tooth guidance The physical features of tooth guidance vary with the intraarch tooth arrangemen t and the interarch relationships of anterior and posterior teeth, and are descr ibed in Chapter 1. Lateral guidance from RCP (gentle operator guidance only) is examined with tape (green) and the presence of mediotrusive and/ or laterotrusiv e contacts or interferences will be identified by tape marks on the teeth concer ned (Fig. 5.2 G-J). muscle contraction has been shown in clinical studies of healthy adults to evoke a dull ache in the face, temple or forehead, similar to the pain described by p atients (Clark et al 1984). In addition, clenching in an eccentric jaw position, that is, not at ICP (centric occlusion, CO), is likely to more readily lead to jaw muscle pain and tenderness to palpation. In eccentric lateroprotrusive or pr otrusive jaw positions, the jaw muscle system has less resistance to loading, es pecially when there are no posterior supporting tooth contacts on laterotrusive (working) and mediotrusive (non-working) sides. In centric bruxism posterior too th support best resists loading, yet muscle pain has been described with centric clenching (see Wanman 1995, for review). Table 5.3 summarises tooth contacts an d nontooth contact parafunction. An occlusal analysis form allows standardised d ocumentation of tooth contact details for restorative treatment planning (Fig. 5 .3). Tooth contacts are indicated by circling the appropriate teeth of the odont ograms. ICP /MOP. For clinical occlusal analysis MOP is recorded (red tape), fol lowed by RCP contacts (black tape). A slide from RCP to ICP (in 90% of individua ls) is identified (black tape) by asking the patient to bite on the teeth once t

he initial RCP contact is determined by clinician guidance. The black tape mark is usually distinct, and the presence of a slide may also be observed through th e movement of the lower incisor teeth with biting from initial RCP contact as th e jaw slides into ICP. The slide dimensions may also be listed on the form. Late rotrusive contacts are identified (green tape), with operator guidance, as the p atient moves the jaw from RCP into right and then left laterotrusion. Initial la teral guidance is also indicated on the form. 49 PARAFUNCTIONAL TOOTH WEAR Parafunctional jaw movements are those movements of the jaw not related to funct ion, that is, not related to mastication, swallowing and speech, facial expressi on, etc., and jaw postures both with and without tooth contact. The most common presenting form of tooth contact parafunction from clinical observation appears to be lateroprotrusive parafunction. This may be destructive to teeth and to art icular tissues. It may in some instances lead to muscle fatigue and myogenic pai n. Sustained jaw

 ASSESSMENT OF THE OCCLUSION local dental factors, that is, there is no association between tooth arrangement or tooth contact interferences (from RCP to ICP, mediotrusive or balancing inte rferences) and the aetiology of parafunction (Seligman et al1988). There is now strong evidence to indicate that parafunction, especially sleep bruxism, is indu ced within the central nervous system and is recognised as a sleep disorder (Lav igne et al 1999, Bader & Lavigne 2000, Lobbezoo & Naeije 2001). Table 5.3 Parafunction Tooth contact parafunction includes: Jaw clenching (centric bruxism) Jaw grindin g (bruxism), which occurs in a lateroprotrusive direction Tapping of teeth Force d postures of the jaw in which teeth may also be inlocked (such as holding the j aw forward in protrusion with the anterior teeth inlocked in a class II relation ship), or in a lateroprotrusive position Non-tooth contact jaw postures include: Holding the jaw in a fixed posture without tooth contact, usually with a varyin g degree of protrusion; which may be a deliberate attempt to improve facial aest hetics Pipe smoking Nail biting, pencil biting Thumb or finger sucking, particul arly in children Clinical signs Clinical signs are summarised in Table 5.4. The most common presenting sign is w ear on teeth, and attritional wear often presents in conjunction with erosion an d abrasion (Bartlett et al1998, Young 2002). The rate of tooth surface loss is u sually of the order of 50 pm per year for posterior teeth (Seligman & Pullinger 1995), and there is a non-linear relationship with age. It was shown by Seligman and Pullinger (1995) that the degree of attrition does not continue to increase in a linear manner with age, and that canine or laterotrusive attrition occurs to a greater degree and more rapidly than posterior attrition. The laterotrusive component of parafunction initially provides some protection of posterior tooth wear. Once reduced anterior guidance develops, the rate of attritional wear inc reases. However, the presence of wear facets (bruxofacets) are clear evidence of parafunction. It has been determined that approximately 75-80% of tooth surface loss (attrition) can be attributed to parafunction and the remainder to functio n (which may include erosion) (Seligman & Pullinger 1995). The facets can usuall y be matched between opposing tooth surfaces. Figure 5.4 shows bruxofacets of va rying severity. During bruxing (particularly sleep bruxism) and centric clenchin g, the customary controls of jaw movement appear to be absent and tooth contact duration may be sustained. Isometric jaw muscle contraction occurs with increase d motor unit contributions, together with the generation of bite forces which ma y be greater than those occurring during mastication and swallowing. Sustained a nd repeated tooth contact results in the development of bruxofacets with progres sive loss of tooth structure. The loss of permanent tooth structure occurring on contact surfaces of opposing teeth is usually clearly evident in adults, and ea rly signs of tooth wear may also be seen in teenagers and young adults as the ca rdinal sign of a parafunctional habit. Since para functional clenching and grind ing usually occur with the jaw eccentrically placed, bruxofacets are readily see n on the contact surfaces of the teeth providing lateral guidance (usually the i ncisor and canine teeth). The loss of tooth structure varies widely in different individuals and is a function of several variables including: Protrusive contacts from RCP to edge-to-edge contacts are identified (green tape ). Bruxofacets are observed with the use of a dental mirror and light reflection from tooth surfaces which show signs of wear; these surfaces are usually highly

reflective with a good light source. Tooth surface loss is graded (see code at base of table) for both attrition and erosion. Vertical dimension is determined in the customary way by observing lower face height proportion and facial aesthe tics. Once the occlusal features are listed, the details may be scored by adding the number of tooth contacts, the RCP-ICP slide dimensions, and the score for t ooth surface loss. Score values are an indication of the degree of tooth contact and surface loss and may be used for comparison for case maintenance in the lon gterm, or for comparison between patients. Parafunction may occur during the day (diurnal parafunction) or may also occur at night (nocturnal parafunction or sl eep bruxism). It is common for people to be unaware of either diurnal or nocturn al parafunction. However, many patients presenting for treatment with signs and symptoms of parafunction are aware of their daytime habit. Night bruxism is ofte n drawn to the attention of the offender by their room-mate or sleeping partner, and parents often observe this habit in children. Bruxism may occur at any age and is often noticed in children by their parents. Bruxism in children has been reported to have a similar aetiology to that occurring in adults. Clinical studi es provide strong evidence that parafunction, and bruxism especially, are not ca used by 50

CLINICAL OCCLUSAL ANALYSIS OCCLUSAL ANALYSIS JAW RELATIONSHIP: ant-post: (Angle molar relationship) vertical: (incisor relationship) transverse: (crossbite) . ICP/MOP (red) RCP (black) SLIDE (black) RCP - ICP distance ant-post vertical lateral displacement mm mm mm 87654321 87654321 1 2 12345678 12345678 4 3 87654321 87654321 1 2 12345678 12345678 4 3 No. R or L INITIAL LATERAL GUIDANCE: (tick box) maxillary tooth mesial distal No. of contracts LATEROTRUSION 0 R (green) 0 L (green) R L LATEROTRUSION DD DD DD 87654321 87654321 1 2 12345678 12345678 4 3 87654321 87654321

1 2 12345678 12345678 4 3 No. TOOTH SURFACE Inc AttritionErosioncan prem mol No. of contracts 0 2 0 DDDD DDDD PROTRUSION (green) 1 BRUXOFACETS 1 2 8765432112345678 87654321 4 No. of contracts 8765432112345678 87654321 12345678 4 3 No. VERTICAL DIMENSION: (tick box) optimal reduced severely reduced open bite anteri or lateral 12345678 3 0 0 D D D D D Scoring the form: RCP........ Lat. R La!. L....... Pro . scoreD scoreD No. of contracts Slide: Ant-Post: Score 0;0 -1.0; -1.5; -2; Vert: 0;0 -1.0; -1.5; -2;Lat: 0;0 -1.0; -1.5; -2; 1.0 1.5 1. 0 1.5 1.0 1.5 01 2301230123 Tooth surface loss Bruxofacets: Erosion: No. of teeth with attrition erosion . . attrition guide ................... erosion guide~~ . Score Score

D D Total D "Tooth surface loss guide: 0- nil; 1 - only enamel; 2 - dentine; Fig. 5.3 3 - dentine extensively; 4 - dentine and secondary dentine; Occlusal analysis form. Clinical occlusal analysis may be standardised by completing an occlusal analysis form. 51

ASSESSMENT OF THE OCCLUSION Table 5.4 Parafunction: clinical signs Teeth Wear on teeth and restorations; degree of wear on teeth depends on: - enam el hardness - interocclusal forces generated and their duration - frequency of h abit Mobility and spreading of teeth Fractured cusps and split teeth Muscles Mus cle fatigue and/or pain Muscle hypertrophy, especially masseter Elevated massete r EMG TM joints Possible overloading Articular sounds (popping, clicking) Intern al derangement - reciprocal click - closed-lock Radiographic changes in condyle contour Jaw mobility as part of TM joint assessment could be regarded as a provocation t est. However, those described in this chapter are associated with bite force for assessment of the teeth, the TM joints and the jaw muscles. TM joint provocation test The patient is asked to bite on a posterior support (for example, cotton roll or wooden spatula - 2 mm thick) placed in the first molar region, separately one s ide at a time, for 30 seconds. Pain or discomfort may be experienced in the cont ralateral joint or joint area from the effects of compression or tension loading of the joint. This occurs as the jaw rotates around the ipsilateral posterior s upport acting as a fulcrum. Symptoms of discomfort may be linked with the patien t's concerns and assist in diagnosis and management. On the other hand, the test may not evoke any symptoms or sensation. Jaw muscle provocation test duration of tooth contact during each episode frequency of parafunctional episod es bite force developed during the habit whether there is static clenching or dy namic grinding of tooth surfaces abrasion resistance of enamel. Functional jaw m ovements of chewing, swallowing and speech comprise a relatively small proportio n of tooth contact duration. However, in addition, para functional clenching occ urs in most, if not all, individuals. It may be diurnal during periods of concen tration, and nocturnal during sleep, and may be provoked by emotional stress, ei ther experienced or anticipated, or as a component of a sleep disorder. Each of these triggers is associated with a change in central nervous system drive to ja w muscle motoneurones, which leads to an increase in: tooth contact time muscle contraction force and duration, and may also lead to increased loading of articu lar tissues in tension or compression. The patient is asked to bite in rcp (CO) - so-called 'centric clenching' for 30 seconds. - Pain, discomfort, muscle fatig ue (weakness or tiredness) may be provoked and may be similar to symptoms that t he patient has experienced in the head, face and/or jaws. This suggests that a p arafunctional clenching habit may be the cause of such symptoms. - On the other hand, this test may not evoke any symptoms. Where there is evidence of para func tional tooth wear, clenching on the bruxofacets for 30 seconds will reproduce th e para functional habit. - Bruxofacets on anterior teeth can usually be matched with the jaw in a protrusive or lateroprotrusive position. - The patient is ofte n unaware of this jaw posture habit, and may be very surprised at the forced and often uncomfortable nature of the jaw position. - The matching of the bruxoface ts in these jaw positions should be carefully explained to the patient: the use of a face mirror is helpful to visually explain the jaw postures that have uncon sciously developed. - A careful explanation of the parafunctional habit, emphasi sing that these specific jaw positions which cause the wear patterns on the teet h are not associated with chewing, swallowing or talking, is an important step i n patient education. - This is a key feature in the conservative management of p arafunctional clenching and its many effects.

PROVOCATION TESTS Provocation tests are a useful component of occlusal assessment. They are used t o provoke a response in the jaw muscles or TM joints, or both, that may match sy mptoms or concerns that a patient has been experiencing and mayor may not have r eported. 52

CLINICAL OCCLUSAL ANALYSIS A B c D E F Fig. 5.4 Parafunction. A, B Parafunctional wear particularly involving tooth 4.2 is also apparent in tooth 1.1. A marked overbite and overjet required lateropro trusive jaw posturing for these tooth contacts to occur. Parafunction was presen t before the inlay was fitted in tooth 1.2, but the presence of the inlay has ca used accelerated wear on tooth 4.2. C, D Parafunctional wear in its earliest sta ges involving tooth 1.3 most clearly. Such wear is unrelated to function, and th e eccentric posturing of the jaw to gain tooth contact causes physical loading o n teeth, TM joints and muscles. The signs on the teeth are obvious; however, det erioration in TM joints and muscles is not obvious and continues until pain or d ysfunction occurs, and the patient then presents for treatment. The patient was an 18-year-old student. E Parafunctional wear indicated by flattening of incisal edges of incisor teeth at a more advanced stage than in A-D. The patient was a 23-year-old dental student and a single parent. F Parafunctional wear of an adva nced nature in a 43-year-old male showing marked destruction of tooth structure. Such wear is unrelated to functional tooth contacts. There are also components of erosion and abrasion. The wear on anterior teeth has been accelerated by coll apse of posterior segments with tooth loss (3.5, 3.6 and 4.5, 4.6) and tilting a nd drifting of teeth adjacent to the spaces. 53

 ASSESSMENT OF THE OCCLUSION The focus on patient education is an important component of the management of pa tient needs. The use of a tailored self-care programme for TMD has been assessed in a randomised controlled trial by Dworkin et al (2002) and shown to be equall y as effective as other treatments in managing TMD. The data indicated that ther e was reduced TMD pain, reduced jaw muscle tenderness, and an enhanced ability t o cope with any residual TMD. I~ References Antczak-Bouckorns AA 1995 Epidemiology of research for temporomandibular disorde rs. Journal of Orofacial Pain 9:226-234 Bader G, Lavigne G 2000 Sleep bruxism; a n overview of an oro-mandibular sleep movement disorder. Sleep Medicine Review 4 :27-43 Bartlett D W, Coward P Y, Nikkah C, Wilson R F 1998 The prevalence of too th wear in a cluster sample of adolescent school children and its relationship w ith potential explanatory factors. British Dental Journal 184:125-129 Clark G T, Beemsterboer P L, Jacobson R 1984 The effect of sustained sub-maximal clenching on maximum biteforce in myofascial pain dysfunction patients. Journal of Oral R ehabilitation 11:387-391 Dworkin S F, LeResche L 1992 Research diagnostic criter ia for temporomandibular disorders: review, criteria, examinations and specifica tions, critique. Journal of Craniomandibular Disorders: Facial and Oral Pain 6:3 01-355 Dworkin SF, Huggins K H, Wilson Let al 2002 A randomised clinical trial u sing research diagnostic criteria for temporomandibular disorders - Axis II to t arget clinical cases for a tailored self-care TMD treatment program. Journal of Orofacial Pain 16:48-63 Ferrario V F, Serrao G, Dellavia C, Caruso E, Sforza C 2002 Relationship between number of occlusal contacts and masticatory muscle activity in healthy young ad ults. Journal of Craniomandibular Practice 20:91-98 Harper K A, Setchell D J 200 2 The use of shimstock to access occlusal contacts: a laboratory study. Internat ional Journal of Prosthodontics; 15:347-352 Klineberg I J 1991 Occlusion: princi ples and assessment. Wright, Bristol Lavigne G J, Goulet J-p, Zuconni M, Morriso n F, Lobbezoo F 1999 Sleep disorders and the dental patient. An overview. Oral S urgery, Oral Medicine and Oral Pathology 88:257-272 Lobbezoo F, Naeije M 2001 Br uxism is mainly regulated centrally not peripherally. Review. Journal of Oral Re habilitation 28:1085-1091 Millstein P, Maya A 2001 An evaluation of occlusal con tact marking indicators. A descriptive quantitative method. Journal of the Ameri can Dental Association 132:1280-1286 Seligman D A, Pullinger A G 1995 The degree to which dental attrition in modern society is a function of age and of canine guidance. Journal of Oro facial Pain 9:266-275 Seligman D A, Pullinger A, Solber g W K 1988 The prevalence of dental attrition and its association with factors o f age, gender, occlusion and TMJ symptomatology. Journal of Dental Research 67:1 323-1333 Truelove E L, Sommers E E, LeResche L, Dworkin S F, von Korf M 1992 Cli nical diagnostic criteria for TMD: new classification permits multiple diagnoses . Journal of the American Dental Association 123:47-54 Wanman A 1995 The relatio nship between muscle tenderness and craniomandibular disorders. A study of 35-ye ar-olds from the general population. Journal of Orofacial Pain 9:235-243 Witter D J, Creugers N H, Kreulen Chiang Mai, de Haan A F 2001 Occlusal stability in sh ortened dental arches. Journal of Dental Research 80:432-436 Young W G 2002 The oral medicine of tooth wear. Australian Dental Journal 46:236-250 54

Articulators and evaluation of study casts R. Jagger Synopsis Articulators are an essential component of restorative dentistry. When casts of a patient's dental arches are placed on an articulator they may be used to asses s the dental occlusion and to allow formation of the occlusal surfaces of dental prostheses and indirect restorations. There are many designs and each, to a gre ater or lesser extent, reproduces the relationship of a patient's maxilla to man dible during jaw movements. This chapter describes the different types of articu lators and describes how they are used to examine the occlusion. ARTICULATORS AND FACEBOW SYSTEMS Articulators An articulator is a hinged mechanical device to which maxillary and mandibular c asts are attached, and which is intended to reproduce, to a greater or lesser ex tent, the relationship of a patient's maxilla to mandible in intercuspal contact position (ICP) and for lateral and protrusive jaw movements. Articulators are u sed to: study the way the teeth occlude for diagnosis and treatment planning all ow the formation of the occlusal surfaces during the laboratory preparation and adjustment of fixed and removable prostheses and indirect dental restorations. T here are many designs but in general there are four different types: simple hing e average value (plane-line) semi-adjustable fully adjustable. Key points Articulators are described under the following headings: - Simple hinge - Averag e value - Semiadjustable - Fully adjustable Facebows and their application are d escribed Occlusal records are an associated component of restorative dentistry. Their relevance to articulator systems is indicated - Retruded jaw position (RP) or centric relation - Intercuspal contact position (ICP) or centric occlusion Lateral and protrusive records - Dynamic records Choosing an articulator Simple hinge articulators are capable of single hinge movement only and do not a llow lateral movements (Fig. 6.1A). They are usually smaller than the patient's jaws and therefore intercuspal position recordings do not allow accurate articul ation. They are consequently of very limited value. Average value articulators h ave their condylar angle fixed at 30. There is usually no provision for an adjust ment for lateral mandibular shift. There is adjustable incisal guidance. These a rticulators represent an improvement on simple hinge articulators and may be con sidered to be sufficiently accurate for reproducing ICP on study casts (Fig.6.1B ). Semi-adjustable articulators allow adjustment of condylar inclination and Ben nett angle and sometimes for Bennett movement. Intercondylar width is usually fi xed at 110mm, but some articulators allow different intercondylar width settings . 55

ASSESSMENT OF THE OCCLUSION A Fig. 6.1 A Hinge articulator. B Average value articulator. B These articulators may be either arcon or non-arcon in design (Fig. 6.2A-C). Arc on describes articulators in which the condylar mechanism is designed with the f ossa box in the upper member "of the articulator and the condylar sphere in the lower member of the articulator. This duplicates the anatomical arrangement of t he temporomandibular (TM) joint. The arrangement allows distraction of the condy les in a similar manner to what is believed to occur in the TM joint. The non-ar con articulators have a ball-and-slot mechanism in which the condylar ball is at tached to the upper member and the slot mechanism to the lower member. Condylar and Bennett angles are obtained from protrusive and lateral occlusal records (se e below) or are set at average values. Incisal guidance, the anterior guiding co mponent of articulation, is simulated on the articulator by alteration of the an gle of inclination of the incisal guidance table. The setting may be made by ref erence to the overbite and overjet relationship of the anterior teeth. If there is no existing guidance (where anterior teeth are absent), an average value can be set. Custom-made incisal guidance tables of an existing incisal scheme can be made on an articulator using study casts. Fully adjustable articulators are com plex but allow closest duplication of the true clinical conditions. These articu lators are designed to duplicate TM joint features by a series of condylar adjustments and also allow curved translation paths (Fig. 6 .2D-F). The condylar settings may be determined by pantographic and stereographi c records (see Figs 6.5 and 6.6). Facebows A facebow is an instrument that records the relationship of the maxilla to the h inge axis of rotation of the mandible. It allows the maxillary cast to be placed in an equivalent relationship on the articulator (Fig. 6.3). In order to precis ely identify the true hinge axis, it is necessary to use a hinge axis locator an d then use a hinge axis facebow. More commonly, facebows are used with an arbitrary hinge axis that is located at a point 12 mm along a line drawn from the upper aspect of the superior border o f the tragus of the ear to the outer canthus of the eye. This point is used to p osition the condylar locator of the facebow. Alternatively, and now more commonl y, the external ear canal is used with an ear facebow which provides an arbitrar y point of reference for each TM joint. The geometric relationship of the ear ca nal to the TM joint is accommodated in the design of the facebow. Facebows also allow transfer of intercondylar distance, which can be adjusted, on some articul ators. In dentate patients the facebow fork is used to locate the occlusal and i ncisal surfaces of the maxillary teeth. Wax or 56

ARTICULATORS AND EVALUATION OF STUDY CASTS A B c E F Fig. 6.2 A-C A Dentatus semi-adjustable articulator. Magnified views of condylar element B, C below show the 'ball and slot' mechanism. In the zero position the condylar sphere (arrowed) contacts the anterior stop; with a right lateral move ment of the articulator the sphere moves distally along the slot (arrowed). This is a 'non-arcon' articulator where the condylar sphere is attached to the upper member. D-F A Denar D5A fully adjustable articulator. The condylar elements (ar rowed) are different from those in A. This is an 'arcon' articulator where the c ondylar sphere is attached to the lower member, similarly to the anatomical arra ngement in the skull. The magnified view (E) shows the superior aspect of the ri ght condylar element, and identifies adjustments for the rear wall of the fossa box (upper arrow), the progressive side shift (middle arrow) and the immediate s ide shift (lower arrow). The magnified view (F) shows the anteroinferior view an d identifies the superior wall of the fossa box (note its contour - upper arrow) , the medial wall (middle arrow) and the intercondylar width adjustment (lower a rrow). (From Klineberg 1991, with permission.) 57

ASSESSMENT OF THE OCCLUSION A B c o E F Fig. 6.3 Facebow transfer. A Ear rod locator for facebow in position in the pati ent's right external ear. B The third point of reference marker attached to a Sl idematic facebow aligned with a mark placed on the side of the nose 43 mm above the incisal edge of tooth 1.1 or 2.1. C Facebow fork in position supported by co tton rolls against the mandibular teeth. D Slidematic facebow, fork and connecti ng jig in position. E A transfer fork, jig, and mounting block assembled on a De nar (Mkll) articulator. F Maxillary cast attached to upper bow of articulator wi th mounting stone. (From Klineberg 1991, with permission.) impression compound attached to the fork must locate the tooth cusps positively, but not extend into undercuts to avoid distortion. In edentulous patients the f ork is attached to a maxillary occlusal rim. Details of a technique using a Denar articulator and facebow that can be recomme nded are shown in Figure 6.3. 58

ARTICULATORS AND EVALUATION OF STUDY CASTS A c B o E Fig. 6.4 Articulating mandibular cast. A Jaw record transfer on maxillary cast . B Jaw record transfer in place between maxillary and mandibular casts followin g trimming of excess wax. C Mandibular cast rigidly supported before mounting st one is added. 0 Mounting of mandibular cast - two-stage technique; first pour fi nishes just short of the mounting ring. E Mounting of mandibular cast completed. (From Klineberg 1991, with permission.) 59

 A ASSESSMENT OF THE OCCLUSION B c o Right Horizontal ~ 0]1' f ! -----.J ! lU: I) -!I [] Left Horizontal Right Vertical Left Vertical -' E Right Anterior Left Anterior F 60

ARTICULATORS AND EVALUATION OF STUDY CASTS Fig.6.5 Patient with a pantograph (Denar) attached to maxillary and mandibular i ntraoral clutches. A Note that the lower assembly (1) supports the two anterior horizontal tables (2) as well as the two posterior horizontal and two vertical t ables (3). The upper assembly (4) contains six scribers which overlay the lower tables. Precut waxed paper recording blanks are placed on the tables. The scribe rs mark the blanks when the pantograph is activated and when the jaw is guided a long the border paths to generate border path tracings. The system is pneumatica lly operated by compressed air and is remotely controlled by an on-off press-but ton switch. To activate the system, the button is depressed, the scribers contac t the recording blanks and trace the movement generated with jaw guidance. B Gen tle manual operator guidance establishing RP. C Gentle guidance while the patien t performs a protrusive movement. Note markings on the anterior tables. D Gentle guidance of the jaw to the right. Note markings on the anterior tables and the position of the scribers. E Gentle guidance of the jaw to the left. Note marking s on anterior tables, and the movement of the scribers in the opposite direction to their movement in D. F Pantographic tracings removed from the pantograph tab les and placed on a storage sheet to be retained with the patient's records. A s econd recording made on another occasion may be compared with these recordings. (From Klineberg 1991, with permission.) OCCLUSAL RECORDS Retruded contact position (RCP) or centric relation (CR) record This relation is used to articulate casts for diagnosis and treatment planning. The relation must be recorded with the teeth slightly apart in order to avoid an y deflection by tooth contacts. RCP or CR is also used for complex, multiple res torations and for complete denture construction. Details of a technique that can be recommended to record centric relation articulate casts are given in Figure 6.4. Lateral and protrusive records These records are used to set the condylar angles of the articula tor. Recording s similar to that for centric relation may be taken but in required lateral or p rotrusive jaw positions. Alternatively, one of a number of graphical analysis sy stems which plot condylar inclination and allow measurement of Bennett movement and Bennett angle may be used. These systems require an upper and lower clutch a ttached to the upper and lower teeth to support and attach an upper and lower bo w. The upper bow holds a grid on which the condylar movement details are marked, and the lower bow contains the measuring and marking rods. Once the system is a ttached, the hinge axis is determined and condylar inclination on jaw opening an d Bennett movement and Bennett angle recorded during lateral border movements wi th gentle operator guidance of the jaw. Accurate study casts (silicone impressions) Trim a metal mesh to fit palatal aspect of the maxillary arch. Adapt mesh with h ard wax to the palatal surfaces. Add two layers of a hard wax (for example, Almi nax). Soften the wax on the mesh in hot water and place on the upper arch and th en guide the mandible around the hinge axis so that the mandibular teeth indent but do not penetrate the wafer. Remove the wax wafer and add a very small amount of registration material (zinc oxide-eugenol paste is probably best). Replace t he mesh and wafer in the mouth. Guide the mandible into the hinge position and a llow the paste to set. Remove the record and verify by placing each cast in turn into its correct position. Dynamic records Tracing plates Single plane Dynamic recordings of mandibular movements in a single plane can be made with tracing plates or acrylic moulding devices attached to intraoral clut

ches which are attached to the teeth. The acrylic clutches are thin plastic plat es that engage undercuts of the teeth. The lower clutch has a central bearing pi n that, during mandibular movements, engages the tracing plate on the inferior s urface of the upper clutch. The tracing made on the plate when the mandible move s from centric relation to lateral border positions is known as the 'Gothic arch ' tracing. The apex of the arch represents centric relation. Pantographic tracin gs The pantograph is a device used in conjunction with fully adjustable articula tors that traces border paths of movement in three planes (Fig. 6.5). 61 Intercuspal contact position (ICP) or centric occlusion record Casts can be articulated (or handheld) in this relationship of maximum tooth int ercuspation for study purposes and if no change to the occlusal scheme is planne d.

 ASSESSMENT OF THE OCCLUSION A B c D E F 62

ARTICULATORS AND EVALUATION OF STUDY CASTS Fig. 6.6 Stereographic TM joint system. The stereographic articulator allows cus tomised condylar fossa mouldings to be prepared individually for each patient. T he mouldings incorporate the specific details of condylar movement. A TM joint f ully adjustable arcon articulator. B Inferior view of the fossa box (metal) with the plastic insert above. The plastic insert supports the acrylic resin dough w hile moulding of fossa details is in progress. C Inferior view of the fossa box incorporating the plastic insert. 0 Inferior view of a moulded fossa. The condyl ar element has been removed to show the details of the fossa moulding (or condyl ar analogue). E Inferior view of the condylar element showing movement of the co ndylar sphere along the moulded fossa into a protrusive jaw position. F Inferior view of the condylar element showing the condylar sphere in the centric referen ce position in the moulded fossa analogue. (From Klineberg 1991, with permission .) These tracings are used to set the articulator guidance mechanisms. Six tracing plates are attached to the mandibular clutch. Six tracing pins are attached to t he maxillary clutch. When the mandible is manipulated to produce border movement s the pins trace both horizontal and vertical tracings on the plates. The traces allow determination of centric relation (from the Gothic arch) and degree and t iming of Bennett movement. Average value articulators These articulators produce an approximation of condylar movements and are freque ntly used to design and prepare complete dentures and simple restorations. Semi-adjustable articulators Stereographic recording Stereographic recordings (Fig. 6.6) are used with the TM joint articulator. They are three-dimensional recordings of mandibular movement that are made by mouldi ng autopolymerising acrylic resin intra orally. In this case the mandibular clut ch has a central bearing screw and the maxillary clutch has four cutting studs. Acrylic resin at the dough stage is placed onto the lower clutch at the location of the studs in the upper clutch. The patient is guided to border movements as the dough sets. Once the acrylic resin has set, the jaw is guided through the bo rder movements and the studs define the mouldings, forcing a precise record. The record may then be transferred to the articulator, and the Gothic arch engraved by the studs allows the dentist/ technician to make customised condylar mouldin gs, also in autopolymerising resin, within the right and left fossa box of the a rticulator. These articulators are recommended for most dental restorations. The maxillary c ast articulation with a facebow relates the maxillary cast to the condylar axis and allows a reasonable approximation of the arc of rotation of the jaw in centr ic relation. This also allows an increase of occlusal vertical dimension (OVD) b y raising the height of the articulator pin, as the hinge axis is the same as th e articulator axis of rotation. Articulating the casts using an RCP (CR) record allows the examination of centric discrepancies. The decision whether to use an arcon or non-arcon articulator is largely a matter of operator preference. All s emi-adjustable articulators are more accurate than plane line or simple hinge ar ticulators but are less accurate than fully adjustable articulators.

Fully adjustable articulators Fully adjustable articulators allow accurate replication of jaw relationships an d lateral and protrusive jaw mandibular movement. They are complex instruments t hat are technique-sensitive. Their use is principally in extensive fixed prostho dontics and restorative dentistry. CHOOSING AN ARTICULATOR OCCLUSAL ASSESSMENT CAST ANALYSIS AND STUDY Simple hinge articulators These articulators are of limited value in restorative dentistry and prosthodont ics but may allow a preliminary evaluation of static tooth arrangement on study casts. Good quality casts must be mounted on a semi-adjustable articulator using a face bow and a centric relation record. Condylar settings may be adjusted using later al and protrusive records. 63

 ASSESSMENT OF THE OCCLUSION 6. Move the casts into protrusive and lateral excursions to determine whether th ere is canine protection (guidance) or group function. 7. Examine whether there are working-side or nonworking interferences. 8. If using an arcon type articula tor, note any condylar displacement from IP to RP. Verification of accuracy of articulation of casts It is important to ensure that the articulated casts accurately reproduce the si tuation in the patient's mouth, as there are several causes of errors in articul ation. Common errors are incorrect occlusal record, inaccurate casts and mountin g errors. Occlusal assessment The following procedure can be recommended for detailed analysis of occlusal con tacts. Using ultrafine GMH foils and Artus shimstock, analyse tooth contacts on articulated casts in the following sequence: 1. Determine RP stops (if RP stops are absent on posterior teeth, use the verification record to check that the art iculation is correct). 2. Locate the position of plunger cusps. 3. Determine the presence of any slide from RP to IP and its dimensions: vertical, lateral, ante roposterior. 4. Check the stability of supporting cusps and intercuspal stops in RP and IP. 5. Examine whether there are marginal ridge discrepancies and whethe r affected teeth have stable opposing contacts. I~ 'fP References Wright, Klineberg I J 1991 Occlusion: principles and assessment. Bristol. Further reading Baetz K, Klineberg I J 1986 An analysis of stereographic jaw recording technique s. Australian Dental Journal 31: 117-123 Cabot L B 1998 Using articulators to en hance clinical practice. British Dental Journal 184: 272-276 Celenza F V 1979 An analysis of articulators. Dental Clinics of North America 23: 305-326 Clayton J A, Kotowicz WE, Zahler J M 1976 Pantographic tracings of mandibular movements a nd occlusion. Journal of Prosthetic Dentistry 25: 389-396 Hobo S, Shillingburg H T, Whitsett L D 1976 Articulation for restorative dentistry. Journal of Prosthe tic Dentistry 36:35-43 Lundeen H C, Shyrock E F Gibbs C H 1978 An evaluation of mandibular border movements: their character and significance. Journal of Prosth etic Dentistry 40: 442-452 64

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Temporomandibular joint disorders G. Carlsson Synopsis This chapter presents a brief review of the most common temporomandibular (TM) j oint disorders, with an emphasis on their association with dental occlusion. The evidence for an occlusal aetiology of TM joint disorders is weak, whereas it is well established that several TM joint disorders can cause occlusal disturbance s. The TM joint disorders presented comprise disc interference and traumatic dis orders, osteoarthritis and rheumatoid arthritis, and other less frequent disorde rs. A careful history and a clinical examination, including imaging of the TM jo int, will in most cases be sufficient for a preliminary diagnosis. Many patients with benign TM joint disorders can be managed in general dental practice, where as others will require specialist and multidisciplinary diagnosis and treatment. Key points Many diseases may involve the TM joints. The most common and the most studied ar e osteoarthrosis and rheumatoid arthritis, as well as disc interference disorder s It is often claimed that occlusal disturbances can cause TM joint disorders, b ut the evidence for that is weak. On the other hand, it is well established that several disorders affecting the TM joints may cause occlusal disturbances (for example, occlusal instability and/or anterior open bite in patients with rheumat oid arthritis) Disc displacement is considered to be the most common TM joint di sorder. It involves a dysfunction of the condyle-disc relation, but the disc position is either not at all or only weakly related to clinical symptoms Disc displacement disorders c an usually be managed with a conservative approach, and more 'aggressive' method s are seldom indicated Several traumatic TM joint disorders are associated with changes in occlusion, which require careful consideration in diagnosis and treat ment Osteoarthrosis is a degeneration of the TM joint but is in general a benign disorder with minor or no symptoms and a good prognosis. In osteoarthritis an i nflammatory component is added to the joint degeneration. Acute inflammatory pha ses associated with pain and dysfunction are usually reversible with simple trea tment A substantial proportion of patients with rheumatoid arthritis may have TM joint involvement. TM joint involvement is related to the severity and duration of the systemic disease. About 10% of patients with rheumatoid arthritis are af flicted with severe occlusal disturbances and dysfunction of the masticatory sys tem There is often a poor correlation between findings from TM joint imaging and clinical signs and symptoms of TM joint disorders Investigation of a patient wi th a possible TM joint disorder may include a history and various clinical, labo ratory and imaging procedures; however, in most cases the history and a clinical examination of the masticatory system focusing on TM joint mobility, sounds and tenderness to palpation may be sufficient for a preliminary diagnosis and initi al treatment 67

 CLINICAL PRACTICE AND THE OCCLUSION INTRODUCTION have been presented over the years but the following classification is probably the most frequently cited: disc displacement with reduction (the displaced disc reduces on opening, usually resulting in a noise, clicking; this is called recip rocal clicking when the noise is heard during both the opening and closing movem ent) disc displacement without reduction, with limited opening disc displacement without reduction, without limited opening. The symptoms described in associati on with such disc interference disorders vary greatly, but usually include pain, tenderness to palpation of joints and/or muscles, joint sounds and reduced mobi lity. There does not appear to be any close correlation between the structural v ariation of the disc-eondyle complex and clinical symptomatology; some patients with verified 'disc displacement' may lack symptoms, and others who have symptom s and disc displacement may improve without change of the structural TM joint fi ndings. The aetiology is not well understood but trauma and general joint hyperm obility are frequently reported in the histories of patients with disc interfere nce disorders. The role played by disorders of the TM joint in producing signs and symptoms in temporomandibular disorders (TMDs) has been much discussed. In the early develop ment of concepts of TMD, TM joint problems were the focus. Interest then turned to the musculature as the most frequent source of pain and dysfunction of the ma sticatory system. During the 1980s many clinicians thought that internal derange ments of the TM joint were the most prevalent factor in TMDs. Today it is genera lly accepted that TMDs include a variety of different disorders involving the TM joint and the muscles of mastication, separately or together (Carlsson & Magnus son 1999). To classify TMDs either as arthrogenous or myogenous is difficult, be cause patients with a primary joint disorder usually have secondary muscle dysfu nction, and patients with a primary muscle disorder may exhibit joint symptoms ( Stegenga 2001). More than 100 different diseases can affect the musculoskeletal system and many of these may also involve the TM joint. Some of these are rare a nd of limited interest for the general dental practitioner, but a few are relati vely common, such as osteoarthrosis/ osteoarthritis (OA) and rheumatoid arthriti s (RA), and the dentist should be familiar with them. In this chapter we will fo cus on TM joint disorders that in various ways may be associated with changes in occlusion. Management During the 1980s there was an enormous increase in interest in disc interference disorders. This resulted in a rapid improvement of diagnostic and therapeutic m ethods, but it also probably led to overdiagnosis and overtreatment (for example , use of magnetic resonance imaging (MRD, anterior positioning appliances follow ed by occlusal therapy, and various surgical methods), higher cost and sometimes increased risk for the patients. It has been repeatedly shown that many patient s with TM joint disc displacement respond well to conservative treatment (Carlss on & Magnusson 1999). It is also well established that painless jaw function is possible with the disc displaced (Stegenga 2001). In the majority of patients di agnosed with disc interference disorders, the simple treatment modalities sugges ted previously for TMD patients should first be tried, that is, counselling/reas surance, medication and physical therapy, often including an interocclusal appli ance. This conservative approach has proven effective according to long-term cli nical follow-up investigations. In a sample of 40 patients with permanent disc d isplacement followed for 2.5 years without treatment, spontaneous improvement wa s observed in about 75% of the cases (Kurita et al 1998). The use of protrusive positioning splints in order to 'capture the disc' is rarely indicated, as it ma y lead to serious changes in the occlusion, requiring extensive

DISC INTERFERENCE DISORDERS Variations from the textbook appearance of the TM joint disc have been termed di sc displacements and they may occur in various directions, anterior displacement s probably being most frequent (Fig. 7.1). Several descriptions B Fig. 7.1 Schematic drawings from arthrographic radiographs of TM joints. A Norma l position of the disc. B Anteriorly displaced disc (arrow). (From Carlsson & Ma gnusson 1999, with permission.) 68

TEMPOROMANDIBULAR JOINT DISORDERS occlusal therapy. Some authors have even maintained that such treatment was wors e than the 'disease' itself. Manipulation techniques to normalise the disc posit ion in patients with disc displacement without reduction may be successful if th e 'closed lock' is acute, that is, of short duration (Carlsson & Magnusson 1999) . A variety of surgical procedures have been applied and maintained to give good results when severe pain and dysfunction continued in association with disc int erference disorders. However, long-term studies are lacking, as are randomised p rospective studies. Surgery is certainly not the first method of choice. It can be concluded that the rapid progress in TM joint imaging techniques made it clea r that internal derangements (mechanical joint disorders of which disc displacem ents are only one) are more prevalent than previously thought. Today it is more and more accepted, however, that visualisation of the disc by methods such as ar thrography and MRI result in an overemphasis on the mechanical aspects of disc d isplacement. Several studies have shown that disc position does not correlate we ll with pain or dysfunction; for example, approximately 30% of asymptomatic subj ects received a radiographic or MRI diagnosis of 'disc displacement' (Stegenga 2 001). The frequently used term 'disc displacement' has therefore been considered 'flawed because it implies the need for treatment'. A careful history and a cli nical examination, without use of sophisticated imaging techniques, and conserva tive management should be adequate for most patients with disc interference diso rders. If severe pain and dysfunction remain after such an approach, the patient is best referred to a specialist clinic. without anaesthesia, by bimanual manipulation of the mandible' from its open loc ked position. A classical description suggests the following procedure: the oper ator stands in front of the patient and use the thumbs to apply pressure to the molar regions in a downward direction; at the same time the chin is raised with the other fingers, after which the mandible is forced backwards. If the dislocat ion occurred a day or days previously, there may be considerable pain and muscul ar tension. In such cases, local anaesthetic blocks of the TM joint areats) are performed before the manipulation, to provide patient comfort and reduction of m uscle guarding. In rare cases, especially after longstanding dislocation, intrav enous sedation or even general anaesthesia may be necessary to enable manipulati on of the dislocated joint. After a successful mandibular reduction the patient should be advised to avoid wide opening movements and heavy chewing for several days to a week. Haemarthrosis A blow to the mandible or extensive stretching of the joint's soft tissues may l ead to oedema or haemorrhage within the joint space. When the trauma has not led to mandibular fracture the patient will usually present with mild swelling and tenderness in the TM joint area, pain TRAUMATIC TM JOINT DISORDERS Injury to the TM joint may result from internal forces (such as from jaw muscles ) or from external forces (such as contact sport or a slamming door) applied to the joint area or along the mandible. Such trauma may produce damage to the soft tissues, the condyle or both. The consequences may be joint dislocation, haemar throsis and condylar fracture. A Acute dislocation Diagnosis and treatment of an acute dislocation should be familiar to all dentis ts: the patient cannot close the mouth and there is an anterior open bite Copen lock'). In front of one or both auditory canals there is a depression, before wh

ich it is usually possible to palpate the condyle positioned anterior to the art icular eminence (Fig. 7.2). When the dislocation is acute, reduction can often b e done B C Acute dislocation of the TM joints. A Panoramic radiograph of a bilateral disloc ation. Both condyles are anterior to the articular eminences. B Transcranial rad iograph of the dislocated right TM joint of the patient in A. C The right TM joi nt after reduction. Fig. 7.2 69

CLINICAL PRACTICE AND THE OCCLUSION c A D B ~ig. 7.3 C~ndyla~ fracture with ~~ inward dislocation of the condyle. A Axial ra diograph. B Tracing of the radiograph In A. C Maximum intercuspal position and D retruded contact position in a patient who had a unilateral condylar fracture a few months previously. on movement and reduced joint mobility. The patient often reports that the teeth on the injured side do not fit, which is the clinical manifestation of the late ral open bite caused by the effusion and haemarthrosis within the joint space. T his can be seen radiographically as an increased distance between the condyle an d the fossa. This condition is sometimes referred to as traumatic arthritis. If the tissue injury is not severe, the acute symptoms usually disappear within one or a few weeks. Ice may be applied intermittently to skin overlying the joint a rea during the first day, after which massage and careful jaw exercises may be i ntroduced gradually to normalise joint mobility. If pain and swelling are severe , drugs with analgesic and antiphlogistic effect may be prescribed. It is import ant to avoid occlusal therapy during the acute phase, as the occlusion will norm aIise when the joint effusion resolves. Condylar fractures Condylar and subcondylar fractures comprise a substantial part of all mandibular fractures. Patients will typically present with an open bite and a slight mandi bular shift toward the affected side. With bilateral condyle fractures there is an anterior open bite. Patients with such fractures usually require specialist e valuation and treatment. However, the sequelae of condylar fractures on the occl usion are of general interest. In children with condyle fractures, the great cap acity for TM joint remodelling results in only minor or no long-term effects on the occlusion. In adults, occlusal instability, including an increased distance between the retruded and the intercuspal jaw positions, is a frequent consequenc e of a previous condylar fracture (Fig. 7.3). This requires special consideratio n in diagnosis of the occlusion for prosthodontic rehabilitation. 70

TEMPOROMANDIBULAR JOINT DISORDERS OSTEOARTHROSIS IOSTEOARTHRITIS Degenerative joint disease is the most common form of rheumatoid disease affecti ng the human body. There are several synonymous terms used for this disease, os teoarthrosis and osteoarthritis being the most frequent. It has been suggested t hat osteoarthritis be used for disorders with clinical symptoms (indicating an o ngoing inflammatory process), and osteoarthrosis where inflammation is absent or minimal and the patient is asymptomatic. Others maintain that this disorder inv olves both degeneration and inflammation and that osteoarthritis is the logical term (Stegenga 2001) . It can be practical to use the abridged form OA for both. OA is primarily non-inflammatory in nature, with initial involvement of the car tilaginous and subchondral layers of the joint. It is defined as a degenerative condition of the joint, characterised by fibrillation and deterioration of the a rticular tissue, and concomitant changes in the form of the articular components (Zarb & Carlsson 1999). The first changes in the articular tissues in OA are ra rely visible radiographically. Radiographic evidence of changes in form will typ ically appear only after considerable time, which can explain the poor correlati on between clinical and radiographic signs of OA. It is often a gradual nonsympt omatic development of OA, but the superimposition of secondary inflammatory chan ges, synovitis, can cause transitory clinical symptoms. The long-term outcome of OA of the TM joint is, in general, good. accumulation of degradative products resulting in an inflammatory response. The often-proposed relationship between disc displacement and OA has recently been q uestioned, as no strong evidence is available. Present research focuses more on the microscopic and molecular level of joint tissues rather than disc displaceme nt (see Ch. 4) (Stegenga 2001). Diagnosis The signs and symptoms are very similar to those of the neuromuscular type of TM D. However, there are some features that might help differential diagnosis: They are almost always unilateral. Symptoms often worsen during the day. Pain is loc ated in the joint itself. Crepitation is a more common joint sound than clicking (but it is a late sign of the disorder). Radiographic changes of the TM joint a re frequent (for example, condyle flattening, osteophytes, sclerosis, decreased joint space). It is important to realise that there is often poor correlation be tween clinical and radiographic findings and many subjects with a radiographic d iagnosis of OA may be asymptomatic or reveal only crepitus (Fig. 7.4). Laborator y findings in synovial fluid have shown promising results in identifying markers of disease activity. The methods offer interesting research possibilities but a re not yet applicable to OA diagnosis in general dental practice (Zarb & Carlsso n 1999). Epidemiology Population studies have shown that OA is an extremely common joint disorder but the prevalence varies in different joints, even if it is strongly correlated wit h increasing age. The reported prevalence of OA in the TM joint varies widely in several studies, probably for methodological reasons. It appears safe to conclu de that TM joint OA increases with age, and it is more frequent in women than in men, for ages above 50 years, as is also the case in other joints of the body ( Zarb & Carlsson 1999). Aetiology Even if overloading has been proposed to be a major aetiologic factor, it is pru dent to recognise that the understanding of the aetiology of OA is far from comp lete. The literature does not contain compelling evidence for an occlusal contri bution to TMDs and this is true also for OA of the TM joint (Zarb & Carlsson 199

9; Pullinger & Seligman 2000). It has been suggested that OA represents an organ failure due to an imbalance between the normal tissue turnover of synthesis and breakdown. A relative increase of breakdown/degenerative activity leads to Fig.7.4 Tomogram of the left TM joint with extensive deformation indicating GA. The patient had a short period of pain and dysfunction but functioned well for m any years both before and after that event. 71

 CLINICAL PRACTICE AND THE OCCLUSION Patients with OA were characterised by a longer slide between the retruded conta ct position (RCP) and intercuspal position (ICP), larger overjet and reduced ove rbite. These occlusal characteristics were interpreted to be the consequence of articular remodelling associated with OA, rather than its cause (Pullinger & Sel igman 2000). OA often has acute and chronic stages. It has been estimated that t he average duration of the acute painful stage is 9-12 months. The disease proce ss tends to 'burn out', and the TM joint often shows extensive osseous changes b ut surprisingly good function. The diagnosis of OA must acknowledge the usually favourable long-term prognosis of this mainly benign disorder. Diagnosis Diagnosing RA of the TM joint will seldom present problems, as the systemic dise ase usually starts in other joints before the TM joint and the diagnosis has mos t probably been established when the TM joint is affected. Symptoms include pain at rest and on chewing, stiffness in the morning, and difficulty in opening the mouth. As the disease process continues, the stability of the occlusion is ofte n destroyed, revealed as an unstable intercuspal position and an increased dista nce between RCP and ICP. Anterior bite opening may occur due to destruction of t he condyles (Fig. 7.5). Radiographic changes include erosion of the cortical con tour of the joint components, reduced joint space, subchondral cysts and gradual ly severe destruction of the bone, eventually leading to complete loss of the co ndyle. Modern diagnostic methods such as analysis of TM joint fluid, laboratory tests, thermologic and arthroscopic techniques have improved our knowledge of th e disease, but they are limited to specialist clinics. There is good evidence th at neuropeptides take part in the modulation of TM joint arthritis and pain (Zar b & Carlsson 1999). Management Because of the current knowledge of the favourable prognosis of OA, the first st ep in treatment is to reassure the patient about the problems associated with th is benign disorder. For patients with only crepitus or mild symptoms, reassuranc e is the only treatment necessary. For patients with more severe symptoms, inclu ding pain and dysfunction, treatment may include one or more of the following: m edication (most frequently non-steroidal anti-inflammatory drugs (NSAIDs) but so metimes, in cases of severe pain, intra-articular injection of glucocorticoid ph ysical therapy (rest and soft diet in the most acute stage, gradually beginning jaw exercises when pain subsides, to promote normal mandibular function) splint therapy - interocclusal stabilisation appliance (to provide reduction of a possi ble overloading of the joint structures). Surgery is very seldom indicated in th e treatment of TM joint OA. Treatment Because RA is a systemic disease, a physician must manage the primary care, whil e the dentist can take part in management of local TM joint signs and symptoms. This usually involves supportive therapy to reduce pain, inflammation and excess ive joint loading (Carlsson & Magnusson 1999). Pain in an acute phase is most pr obably associated with inflammation and therefore analgesics with antiinflammato ry effects should be prescribed, for example, acetylsalicylic acid or NSAIDs suc h as naproxen or ibuprofen. If the pain is severe, intra-articular injection of a glucocorticosteroid often gives rapid relief. When the acute pain has subsided or when there are only minor symptoms, physical exercises are indicated to impr ove joint muscle function and strength. Positive shortand long-term effects of p hysical training in TM joint RApatients have been shown in a comparative study. The role played by occlusal factors in the development of RA of the TM joint is uncertain. From a clinical point of view it is recommended, however, to provide all patients with RA with a stable occlusion, for example, by eliminating gross

occlusal interferences, restoring lost teeth by means of (provisional) prostheti c appliances or temporarily with interocclusal appliances. An anterior open bite caused by RA can often be reduced by simple occlusal adjustment. If the disease has resulted in a very severe malocclusion, orthognathic surgery may be indicat ed. RHEUMATOID ARTHRITIS Rheumatoid arthritis (RA) is a systemic inflammatory disease, that involves peri pheral joints in a symmetric distribution. The aetiology of RA is still largely unknown but immunological mechanisms appear to play an important role. The preva lence of RA has been reported to be about 1-2% of the adult population, with inc idence figures of 0.03-0.1 % per year. RA has shown a 3:1 female predilection. T M joint involvement in patients with RA depends on the duration and severity of the systemic disease, but it can be expected that about half of them will develo p TM joint complaints (Carlsson & Magnusson 1999). Severe forms of the disease w ith significant functional disability, including major occlusal disturbances, oc cur in 10-15% of these patients. 72

TEMPOROMANDIBULAR JOINT DISORDERS A D B E c Fig. 7.5 Patient with rheumatoid arthritis. A Maximum intercuspal position befor e any involvement of the TM joints has occurred. B Panoramic radiograph after ab out 10 years when the TM joints start to be involved. C Panoramic radiograph 3 y ears later when severe destruction of the TM joints has occurred. 0 Part of the radiograph in C showing an almost total loss of the condyle. E Maximum intercusp al position showing an anterior open bite and occlusal instability at the time o f radiographs C and D. A problem in prosthodontic rehabilitation of patients with RA is the continuing joint destruction that may disturb occlusal stability of any reconstruction. A c heck of the disease activity can be obtained from the rheumatologist, and long-t erm provisional prostheses may be necessary if acute phases can still be expecte d. Another problem is the often substantially increased distance between the ret ruded and habitual occlusal positions. The retruded position cannot be used as a reference for transfer records because the disease processes have destroyed the joint structures. A more anterior position that is comfortable for the patient and acceptable to the musculature is chosen. OTHER TM JOINT DISORDERS The TM joint may also be afflicted in many other systemic diseases; for example, psoriatic arthritis, ankylosing spondylitis, gout and acromegaly. The prevalenc e of TM joint involvement in these diseases is not well known but several of the m can lead to changes in the dental occlusion. An example is acromegaly, which i s a chronic disease of adults caused by hypersecretion of growth hormone leading to enlargement of many parts of the skeleton, including the mandible and the TM joints (Fig. 7.6). The importance of including questions on general health in t he patient's history is obvious. 73

I CLINICAL PRACTICE AND THE OCCLUSION temporomandibular disorders using a multifactorial analysis. Journal of Prosthet ic Dentistry 83:66--75 Stegenga B 2001 Osteoarthritis of the temporomandibular j oint organ and its relationship to disc displacement. Journal of Orofacial Pain 15:193-205 Zarb G A, Carlsson G E 1999 Temporomandibular disorders: osteoarthrit is. Journal of Orofacial Pain 13:295-306 Further reading In a patient with acromegaly, the extensive growth of the mandible has led to lo ss of all occlusal contacts. Fig. 7.6 Backe M, Zak M, Jensen B L, Pedersen F K, Kreiborg S 2001 Oro facial pa in, jaw function, and temporomandibular disorders in women with a history of juv enile chronic arthritis or persistent juvenile chronic arthritis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiolology and Endodontics 92:406-414 De Bo ever J A, Carlsson G E 1996 Temporomandibular disorders and the need for prosthe tic treatment. In: Owall B, Kayser A F, Carlsson G E (eds) Prosthodontics: princ iples and management strategies. Mosby-Wolfe, London De Boever J A, Carlsson G E , KIineberg I J 2000 Need for occlusal therapy and prosthodontic treatment in th e management of temporomandibular disorders. Part II: Tooth loss and prosthodont ic treatment. Journal of Oral Rehabilitation 27:647-659 Holmlund A B, Axelsson S , Gynther G W 2001 A comparison of discectomy and arthroscopic lysis and lavage for the treatment of chronic closed lock of the temporomandibular joint: a rando mized outcome study. Journal of Oral and Maxillofacial Surgery 59:972-977 Kopp S 2001 Neuroendocrine, immune, and local responses related to temporomandibular d isorders. Journal of Orofacial Pain 15:9-28 Minakuchi H, Kuboki T, Matsuka Y et al 2001 Randomized controlled evaluation of non-surgical treatments for temporom andibular joint anterior disc displacement without reduction. Journal of Dental Research 80:924-928 Okesson J P (ed) 1996 Orofacial pain. Guidelines for assessm ent, diagnosis and management. Quintessence, Chicago. Svensson B, Adell R, Kopp S 2000 Temporomandibular disorders in juvenile chronic arthritis patients. A cli nical study. Swedish Dental Journal 24:83-92 Zarb G A, Carlsson G E, Sessle B J. Mohl N D 1994 Temporomandibular joint and masticatory muscle disorders. Munksga ard, Copenhagen Neoplasms may be found in the TM joint. Malignant tumours are extremely rare, an d when they occur they are most often metastatic. Since it has been reported tha t they may present with symptoms similar to TMDs, patients with a history of can cer and TM joint dysfunction must be referred for a radiographic examination of the TM joint. More common, but still very rare, are benign neoplasms, which may change the form of the joint components and cause dysfunction and occlusal distu rbances. Although not a neoplasm but a developmental disturbance, unilateral con dylar hyperplasia is associated with similar consequences, due to the enlarged c ondyle, which will also lead to facial asymmetry and malocclusion. I~ <PReferences Carlsson G E, Magnusson T 1999 Management of temporomandibular disorders in the general dental practice. Quintessence, Chicago Kurita K, Westesson P L, Yuasa H et al 1998 Natural course of untreated symptomatic temporomandibular disc displa cement without reduction. Journal of Dental Research 77:361-365 Pullinger A G, S eligman D A 2000 Quantification and validation of predictive values of occlusal variables in 74

Jaw muscle disorders M. Bakke Synopsis This chapter will review the current knowledge of the aetiology and physiology o f jaw muscle disorders, and present an approach for their clinical assessment an d treatment. Jaw muscle disorders are characterised by pain that is usually aqqr avated by function, and by a limited range of jaw movement. They are present in 75% of patients with temporomandibular disorders (TMDs), and women are affected more frequently than men. Several contributing factors must be present for the d evelopment of jaw muscle disorders. No studies have yet fully explained the rela tive importance of potential risk factors. The masseter and medial pterygoid mus cles serve primarily as sources of power, while the temporalis and lateral ptery goid muscles are important for jaw stability. Overuse in terms of sustained acti vity and high-level contractions without rest periods is associated with raised intramuscular pressure, and leads to local ischaemia, increased membrane permeab ility, oedema and eventually cellular damage. Muscle pain is generally described as a continuous deep dull ache or tightness or pressure. The onset is normally gradual, and may vary from a feeling of tiredness to a more severe sharp pain. T he pain may result from trauma, sustained or forceful contractions, stretching o r ischaemia. Local conditions, such as inflammation, increase the receptivity of the pain receptors, lowering their threshold for activation. A comprehensive ev aluation of the jaw muscles includes a systematic history and clinical examinati on. The clinical examination has two main purposes: to assess jaw function, and, if possible, to provoke the patient's pain. The treatment of jaw muscle disorders is directed towards reducing pain and improving function; it sh ould generally be reversible, evidence-based, or at least based on well-establis hed clinical practice. Key points Jaw muscle disorders are a collection of conditions affecting the muscles, prima rily characterised by pain and limited jaw movements; they are part of TMDs The primary masticatory muscles are the temporalis, masseter, and medial and lateral pterygoid muscles. The trigeminal nerve innervates the jaw muscles, and muscle fibres associated with long contraction times and resistance to fatigue predomin ate. The jaw muscles and the bite force adapt to the prevailing level of activit y. There may be fibrosis with overuse The experience of muscle pain is poorly lo calised, but pain provoked by manual palpation more accurately identifies pain l ocation. The intensity may be assessed by visual analogue scales (VASs) and by r ating of the response to the palpation Limited mandibular opening, (less than 40 mm) is assessed by measurement in the incisor region, adding the amount of over bite or subtracting the amount of open bite Chronic localised myalgia in terms o f myofascial pain is the most frequent jaw muscle disorder. Myofascial pain from jaw muscles may also be diagnosed as tensiontype headache, and it may be second ary to disc displacements, osteoarthritis and rheumatoid arthritis of the tempor omandibular (TM) joints 75

CLINICAL PRACTICE AND THE OCCLUSION Counselling, analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), phys ical therapy and intraoral appliances are the main treatments for jaw muscle dis orders EPIDEMIOLOGY AND AETIOLOGY OF JAW MUSCLE DISORDERS Jaw muscle disorders, a collection of muscle conditions, are part of TMDs affect ing TM joints and jaw muscles. Jaw muscle disorders are characterised by pain an d limited jaw movements that are usually aggravated by function. According to st udies using the Research Diagnostic Criteria (RDC) for TMD defined by Dworkin an d LeResche (1992), muscle disorders are frequently found in TMDs, that is, in ab out 75% of the patients, whereas disc displacement disorders and disorders of ar thralgia, arthritis and arthrosis are present in about 30% of the patients. Wome n are affected about twice as frequently as men, and the condition is most preva lent in young to middle-aged adults. Pain in the jaw muscles, experienced as fac ial pain and headache, is the most prominent chronic pain condition in the orofa cial region. Epidemiological studies indicate that about 5% of the population su ffers from jaw muscle pain (myalgia) that is sufficiently severe to require trea tment (Kuttila et aI1998), but there is considerable fluctuation in the presence and intensity of the pain. As in other musculoskeletal conditions, jaw muscle d isorders often run a recurrent or chronic course, and there may be psychological factors that can either produce or influence the pain experience. Depression, w hich has been shown to be present in some TMD patients, as well as multiple pain conditions, increase the risk of the development of persistent pain. However, s ymptoms may also be transient, and spontaneous pain reduction may occur. The aet iology of jaw muscle disorders is considered to be multifactorial, whereby sever al contributing factors must be present for a jaw muscle disorder to develop. No studies have yet fully explained the relative importance of potential risk fact ors, and there is presently no consensus of simple cause-effect relationships, f or example, between occlusal features or specific jaw muscle activities and jaw muscle pain. Based on present information, only anterior open bite represents a true occlusal risk factor for myalgia (Pullinger & Seligman 2000), even if occlu sal parameters have been shown to influence jaw muscle activity. Nocturnal bruxi sm has also been cited as being an important factor for development of myalgia, but in reality a certain amount of nocturnal bruxism is observed in most asympto matic adults. Nocturnal bruxism is now regarded as being a sleep disorder (Lobbezoo & Naeije 2001). Reduced jaw muscle strength (bite force) in patients with TMDs may represent a risk factor, but thi s reduction may also arise as a result of local pain. Because of the unclear aet iology of jaw muscle disorders, there is no objective diagnostic method to easil y differentiate the condition; there is no gold standard (such as tissue biopsy) against which a diagnostic test can be compared with accuracy and reliability. The best approach is a comprehensive medical and dental history and a comprehens ive clinical examination. PHYSIOLOGY AND FUNCTIONAL ANATOMY OF THE JAW MUSCLES Knowledge of the anatomy and function of jaw muscles, as well as their typical f eatures, should help with differential diagnoses of jaw muscle disorders. Physiology This section complements the comprehensive reviews of jaw muscle control and jaw movements in Chapter 2. Jaw function during biting, mastication, swallowing and speech is determined by a complex interaction between jaw muscles, TM joints, t eeth and the nervous system. The primary jaw muscles are the temporalis. massete r, and medial and lateral pterygoids. Branches from the mandibular nerve, extern al carotid artery and internal jugular vein innervate and vascularise the jaw mu scles. The masseter and medial pterygoid muscles serve primarily as sources of p ower, while the temporalis and lateral pterygoid muscles are important for jaw s

tability. The jaw muscles function in concert with the suprahyoid and the infrah yoid muscles, supplemented by the tongue, lip and cheek muscles. The cervical mu scles also have an indirect role through stabilising and changing head posture d uring mandibular movements (Eriksson et al 2000). Muscle bulk is maintained by p hysical activity as well as naturally derived ster~ids and growth hormones. Inac tivity leads to hypotrophy and training to hypertrophy, with changes in the diam eter of muscle fibres. The muscle enzymes responsible for energy release during aerobic and anaerobic muscular effort, and the number of capillaries, adapt to t he prevailing level of activity. Jaw muscles appear to have different tasks and functional activities from limb muscles because the capillary supply is better a nd the muscle fibre characteristics are different. In jaw muscles, fibres associ ated with long contraction times (slow twitch) and resistance to fatigue (type I ) predominate. Overuse in terms of sustained activity and high level contraction s without rest periods is associated with raised intramuscular pressure, and lea ds to local 76

JAW MUSCLE DISORDERS ischaemia, increased membrane permeability, oedema, and eventually cellular dama ge. In addition, slight postexercise oedema and hyperaemia are seen, even after the chewing of gum, in healthy jaw muscles. It has been proposed that low jaw mu scle strength might predispose to overuse. With breakdown of muscle tissue, fibr osis may take place, as well as possible regeneration of muscle fibres from sate llite cells Cresting' myoblasts), which also contribute to muscle growth. The ma ndibular elevators, especially the temporalis and the masseter, are the larger j aw muscles. Their level of activity contributes to bite force, and is influenced by muscle thickness and fibre size and distribution. Bite force is greater in m en than in women, but is also dependent on age and occlusal contacts. There is a correlation between the bite force and facial morphology, as the vertical facia l relationship and jaw angle decrease with increasing strength; thus weak elevat or muscles appear to be associated with long-face morphology, and strong muscles with a more square-faced appearance. If the activity of the elevator muscles de creases due to lower chewing demands, tooth loss or ongoing pain, bite force dec lines and the elevator muscles may become hypo trophic, with visible hollowing o f temples and cheeks. In contrast, excessive use, such as with ongoing nocturnal bruxism, leads to hypertrophy. (Iaterotrusion) involves contraction of the lateral pterygoid muscles on the opp osite (contralateral) side from the excursion, assisted by the posterior tempora lis muscle in the same side (ipsilateral). However, laterotrusion is usually per formed in combination with protrusion of the contralateral side, producing anter olateral jaw movement. JAW MUSCLE PAIN Typical symptoms of jaw muscle disorders Muscle pain is the most common complaint in patients with jaw muscle disorders a nd the intensity is generally moderate. Muscle pain is diffuse; it may be locate d to the source of pain, but may also be referred to other structures. Pain from the temporalis muscle is usually felt as headache in the temple and forehead, f rom the masseter muscle in the jaw and posterior teeth, from the medial pterygoi d muscle deep in the cheek and in front of the ear, and from the lateral pterygo id muscle in the zygomatic area. Muscle pain is described as a continuous 'deep dull ache' or 'tightness' or 'pressure', unpleasant and often exhausting, and it is only rarely associated with a general feeling of illness or with other conco mitant symptoms. The pain normally has a gradual onset, and it may vary from a f eeling of tiredness to a sharper, more severe pain. It may be constant or occur both spontaneously with the jaw at rest, and in response to chewing, stretching, contraction or palpation. Besides pain, a feeling of weakness, stiffness, rigid ity or swelling, and a restriction of jaw opening also often characterise jaw mu scle disorders. Functional anatomy Anatomical details of jaw muscles are found in anatomical texts but aspects of j aw function will be briefly discussed; see Chapter 2 for details of jaw muscle p hysiology. Closing or elevating the mandible is primarily due to bilateral, symm etrical activity of the masseter, temporalis and medial pterygoid muscles, but d uring chewing the activity of the masseter muscle is asymmetric, with greater ac tivity on the chewing side. The effect of gravity on the jaw is counteracted by the positive tone of the temporalis muscle, which is considered to be a signific ant positioner of the jaw. Forceful contraction and tooth contact also involve t he masseter and the medial pterygoid muscle. Jaw opening or depression is accomp lished by the suprahyoid muscles (anterior digastric, geniohyoid and mylohyoid)

with assistance from both lateral pterygoid muscles. The suprahyoid muscles atta ch the mandible to the hyoid bone. When the hyoid bone is fixed by the action of the infrahyoid muscles, the suprahyoid muscles can participate in the lowering of the mandible. Symmetrical protrusion of the jaw is achieved by bilateral acti on of the lateral pterygoid muscles. The posterior temporalis and the suprahyoid muscles support mandibular retrusion, with assistance from the deep masseter mu scles. Moving the mandible to one side Muscle pain and pathophysiology Muscle pain is a form of deep somatic pain capable of causing central excitatory effects. Deep pain inputs also tend to provoke referred pain, hyperalgesia, aut onomic effects and secondary muscle co-contraction, as well as emotional reactio ns. The information leading to the experience of jaw muscle pain is transmitted by free nerve endings, that is, nociceptors (acting as pain receptors), located in muscle, fascia and muscle-tendon complex. Nociceptors relay to the trigeminal subnucleus cauda lis and motor nucleus by small diameter and slowly conducting primary trigeminal afferents. Local reflexes elicit motor responses. Ascending p athways to the sensorimotor cortex are the basis of nociceptive localisation, di scrimination and evaluation, while input to the hypothalamus and limbic system p rovide the autonomic and emotional reactions, all of which constitute the experi ence of pain. Muscle pain may result from trauma, overuse in terms of sustained or forceful contraction, stretching, ischaemia 77

 CLINICAL PRACTICE AND THE OCCLUSION or hyperaemia. Nociceptors respond to mechanical and chemical stimuli from mecha nical forces and endogenous pain-producing substances. Local conditions such as inflammation increase receptivity, so that stimulation becomes more evident at a lowered activation threshold, even by normally innocuous stimuli, and increased spontaneous activity in nociceptors results in soreness and pain. Such sensitis ation processes are most likely peripheral mechanisms for muscle tenderness and hyperalgesia (Graven-Nielsen & Mense 2001).Compression and injury to muscle resu lts in direct activation of nociceptors. This occurs by release of prostaglandin s from damaged cell membranes which sensitise nociceptors, and by the release of inflammatory mediators and neuropep tides such as bradykinin and serotonin (fro m blood vessels), as well as substance P and calcitonin generelated peptide (fro m nerve endings). In ischaemic muscle, the induced decrease in oxygen tension an d pH releases bradykinin and prostaglandin, which sensitise muscle nociceptors, so that they respond to the force of contraction. Different simultaneous stimuli may potentate each other; for example, increased extracellular potassium concen tration, which occurs in prolonged muscular work, increases sensitivity to chemi cal stimulation from hypoxia and to mechanical stimuli, such as increased intram uscular pressure and other effects of muscular contraction. The convergence of t he neurones, processing inputs from muscles, joints, and cutaneous and visceral afferents, is the basis for the poor localisation and poor discrimination of mus cle pain. It is also the cause of referral of pain to other tissues. In second-o rder neurones of the subnucleus caudalis, an altered responsiveness or sensitisa tion may take place after longlasting activity in afferent neurones. A range of ascending and descending modulatory mechanisms influences the transmission in th e central pathways. Central sensitisation and modulation are the main causes of the often poor correlation in musculoskeletal disorders between the pain experie nce and the intensity and the duration of the noxious stimuli; this is also true for chronic tension-type headache. The spread of muscle pain and more generalis ed pain conditions may also be related to central sensitisation, as this phenome non not only comprises increased excitability of neurones of the subnucleus caud alis but also an expansion of their receptive fields. Table 8.1 Evaluation of jaw muscles History Chief complaint (for example, facial pain and headache, jaw stiffness or reduced mandibular opening, difficulty in chewing) General features: Medical pr oblems including medication; social and psychosocial factors Localfeatures: Mand ibular function - mobility, chewing, parafunction Muscle pain - localisation, on set, course, characteristics (quality, intensity, variation, provocation and all eviation), concomitant symptoms Previous examination and treatment Clinical exam ination Orofacial examination: muscles - jaw mobility, and volume facial appearance; jaw tenderness, consistency and dental occlusion (Table 8.l). The use of provocation tests described in Chap ter 5 might also be considered. Supplementary tests may also be helpful, for exa mple, diagnostic injections and chewing tests. The basis of a proper diagnosis i s a thorough identification of symptoms and signs (see also Ch. 7). The patient' s chief complaints should be defined and listed according to their importance to the patient. It should be remembered that jaw muscle disorders often coexist wi th TM joint disorders, or may be a part of a general medical disorder. If a medi cal disorder is suspected as the primary cause of symptoms or a significant cont

ributing factor, the patient should be referred for medical consultation. Anamnesis or history The history-taking of jaw muscle disorders consists ideally of a consultative wr itten questionnaire and an interview. The questionnaire may be mailed to the pat ient for completion before the initial appointment. A questionnaire would cover general medical as well as dental problems, presence of head and face pain, loca tion of the pain on diagrams (Figure 8.1), and information about restricted jaw movements. Besides giving information on the history, the questionnaire provides a basis for a better clinician-patient understanding. During the interview for history-taking, possible variations of facial morphology, expressions of pain, i nvoluntary jaw movements and the patient's attitudes should be noted. Topics for the interview are given above, but further details from the HISTORY-TAKING AND EXAMINATION OF JAW MUSCLES This is required as part of a comprehensive evaluation of jaw muscles, which inc ludes a systematic history, examination (palpation and auscultation) of the TM j oints 78

JAW MUSCLE DISORDERS incisal distance by putting finger pressure between the upper and lower teeth. A chewing test, for example, gum or cotton rolls, may also be used to provoke or aggravate the pain for diagnostic purposes (Farella et aI2001). The patient may not easily localise the site of pain, but pain provoked by manual palpation more accurately identifies pain location. Evaluation of tenderness by palpation is n ormally performed unilaterally with specific pressure by one or two fingers (Fig . 8.1) (Dworkin & LeResche, 1992). The superficial temporalis and masseter muscl es are most easily palpated. Palpation of the pterygoid muscles is far more unce rtain; a combined extraoral and intraoral approach may be used for the medial pt erygoid muscles, and intraoral palpation for the lateral pterygoid muscles. The response to the palpation may be rated from verbal and reflex responses, for exa mple, as: 0 (none - no reflex response) 1 (mild - no reflex response) 2 (moderat e - wincing or grimacing) 3 (severe - aversive movement). A Fig. 8.1 B A A patient's indication of the locations of jaw muscle pain in a self-completed written questionnaire. B Unilateral palpation of the masseter muscle with a fir m pressure by two fingers, rating tenderness according to the verbal and facial expression of the patient. patient depend on the questioning and the clinician's familiarity with the signs and symptoms of jaw muscle disorders. As an aid in assessing the intensity of t he jaw muscle pain, a 100 mm horizontal VAS (left endpoint 'No pain', right endp oint 'Intolerable pain') may be used, both for the initial interview and for mon itoring treatment. The intensity and impact of the pain may also be estimated fr om: medication used changes in the patient's social habits pain diary listing da ys with pain. A total tenderness score may be calculated from the sum of the ratings of indivi dual muscles. The reliability of manual palpation is generally acceptable for te mporalis and masseter muscles only, but the validity has been questioned. Extrao ral manual palpation may be supplemented by pressure algometry to increase relia bility and validity. The reliability and validity of palpation for localisation of tender points and changes of consistency, such as firm bands, are probably du bious. Additional assessments to assist diagnosis include: provocation tests, de scribed in Chapter 5 muscle injections with local anaesthetic to confirm the loc ation of the pain. Clinical examination The examination has two main purposes: to assess jaw function to reproduce the p atient's pain. The assessment is achieved primarily by registration of: jaw mobi lity pain provocation by maximal jaw opening, by chewing and by muscle palpation . Jaw function can be assessed routinely by measuring maximum jaw opening in the incisor region, adding the amount of overbite or subtracting the amount of open bite. The reliability of the measures of the vertical range of motion is excell ent. Generally, a mandibular opening of less than 40 mm is considered moderately restricted, and less than 30 mm severely restricted. During maximum jaw opening , muscle pain may be provoked or aggravated by stretching the elevator muscles, by the active opening itself, or if the clinician attempts to increase the inter CLASSIFICATION DISORDERS

OF JAW MUSCLE On the basis of the duration, muscle pain is described as acute or chronic (Tabl e 8.2). Chronic pain is generally recognised as pain that persists beyond the no rmal healing time. The International Association for the Study of Pain (IASP) re cognises 3 months as a convenient separation of acute and chronic pain. Classifi cations of jaw muscle disorders and associated pain-based signs and symptoms hav e been described by Dworkin and LeResche (1992) - Research Diagnostic Cri teria for Temporomandibular Disorders, Axis I; by Okeson (1996), for the American Acad emy of Orofacial Pain; and by Fricton and Schiffman (2001). 79

CLINICAL PRACTICE AND THE OCCLUSION Table 8.2 Jaw muscle disorders Table 8.3 Tension-type headache Myalgic disorders Acute - Local muscle soreness (postexercise myalgia) - Myositi s Chronic - Myofascial pain - Tension-type headache - Generalised myalgia (for e xample, fibromyalgia and myalgia associated with systematic diseases) Other chro nic disorders Muscle contracture Hypertrophy Disorders associated with myopathie s and neurological disorders (for example, oromandibular dystonia and muscle spa sms) At least two of the following pain characteristics: Pressing or tightening (nonpulsating) quality; mild or moderate intensity (may inhibit but does not prohibi t activities); bilateral location; no aggravation by walking on stairs or simila r routi ne physica I activity Both of the following: No vomiting No more than on e of the following: nausea; photophobia; phonophobia Myalgic disorders The pathophysiology and aetiology of the myalgic jaw muscle disorder subtypes ar e not easily differentiated clinically, however they may be described as follows : Local muscle soreness or postexercise myalgia is believed to arise after signi ficant or acute overuse of jaw muscles. It presents as pain or stiffness and may arise from excessive bruxism, prolonged chewing or other activities that put gr eat demands on the jaw muscles. Myositis is defined as painful inflammation of m uscle and connective tissue that results from local causes, such as infection or trauma. If myositis persists, the inflammation may progress to fibrous scarring , causing muscle contracture. Myofascial pain is the most common local chronic m yalgic disorder of the jaw muscles. Myofascial pain may also be secondary to dis c displacements, osteoarthritis and rheumatoid arthritis of the TM joint. It is characterised by local pain associated with specific sites of local tenderness a nd spread of the pain on palpation. There may be limitation in the range of jaw movement, muscle fatigue and stiffness. Tension-type headache associated with di sorders of pericranial muscles is chronic localised myalgia in terms of myofasci al pain, affecting jaw muscles, especially the temporalis muscles (Table 8.3) (H eadache Classification Committee of the International Headache Society 1988). Th e diagnostic criteria for episodic tension-type headache define this as headache fulfilling the criteria (see Table 8.3) with at least 10 previous headache epis odes lasting from 30 minutes to 7 days, but with less than 15 days with headache per month (IHS 2.1.1). Chronic tension-type headache is defined as headache present for at least 15 days per month for at least 6 months (IHS 2.2.2). Chroni c generalised myalgia in terms of fibromyalgia may also affect the jaw muscles. Fibromyalgia includes widespread, chronic pain, tiredness and stiffness and bila teral symmetrical tenderness corresponding to at least 11 of 18 particular muscl e sites, as well as sleep disturbances and depression. Other chronic disorders The chronic jaw muscle disorder termed 'muscle contracture' that is characterise d by fibrositis and limited range of motion is thought to develop from previous trauma. Jaw muscle 'hypertrophy', characterised by increased strength and volume , arises from prolonged bruxism or other repetitive forceful activities. These c onditions are usually not painful. Myopathies or neurological disorders affectin g the jaw muscles are seldom associated with muscle pain; genetic and acquired m yopathies such as muscle dystrophy, myotonia, polymyositis and dermatomyositis a

re rather characterised by weakness, atrophy and difficulty in chewing. Neurolog ical disorders affecting jaw muscles hamper oral function, and include oromandib ular dystonia with spasmodic episodes of jaw movements, and cerebral palsy with possible daytime bruxism. TREATMENT OF JAW MUSCLE PAIN AND DISORDERS The treatment of jaw muscle disorders is designed to reduce pain and improve jaw function. Ideally, the treatment of jaw muscle disorders should be cost-effecti ve and evidence-based. Where evidence is lacking, treatment 80

JAW MUSCLE DISORDERS should be based on well-established accepted clinical practice (Kuttila et a1199 8, Pullinger & Seligman 2000). As there is no evidence that local myalgic disord ers of jaw muscles are progressive in nature, treatment should also be based on reversible and least-invasive therapies. Such procedures are intended to facilit ate the natural healing capacity of the musculoskeletal system, and to involve t he patient in the management of the disorder. Regional and widespread disorders, as well as suspicion of general medical conditions, need collaboration with pri mary care physicians and other medical specialists. Depending on the type and se verity of the jaw muscle disorders, a combination of several treatments may be a pplied: The first step is always counselling, often carried out together with me dication for alleviation of pain. Analgesics and NSAIDs are normally used for tr eatment for musculoskeletal pain. NSAIDs (ibuprofen) have been shown to have a p ositive effect on ischaemic muscle pain. In postexercise jaw muscle soreness, to pical NSAID gel is more effective than systemic NSAIDs. Muscle relaxants may be used, and 1 month of treatment with diazepam has been shown to reduce chronic ja w muscle myalgia. Tricyclic antidepressants may also have a role in the treatmen t of chronic myofascial pain from jaw muscles. Amitriptyline has a positive effe ct on chronic tensiontype headache, but common side-effects include dry mouth, s edation and constipation. Physical therapy is often used as treatment of jaw mus cle pain in association with TMDs. Symptoms of TMDs and other chronic musculoske letal pain improve during treatment with most forms of physical therapy (Feine & Lund 1997). However, most of the therapies have not been proven to be more effe ctive than placebo. These data support the view that it may be the care of the p atient itself that matters. Passive exercise and stretching are likely to increa se the range of jaw motion but the effect on muscle pain is weak, and there is e vidence from the treatment of other musculoskeletal disorders that active exerci se of the specific painful area strengthens the muscles, improves function, and reduces pain (Feine & Lund 1997). Acupuncture may have a role in treatment of th e jaw muscles. There is little evidence for the use of thermal agents, electrica l stimulation (TENS), ultrasound, and low-intensity laser therapy for chronic mu scle pain and disorders. Intraoral appliances such as occlusal stabilisation spl ints (in hard acrylic resin) have previously been the main treatment for TMDs. H owever, there is controversy regarding their mode of action. The use of stabilis ation splints is supported for localised masticatory myalgia and TMDs, but their effects are partly due to placebo (Forssell et al 1999). Occ lusal factors may contribute to TMDs, but only to a minor extent. Occlusal adjus tment or prosthetic reconstructions as the treatment for jaw muscle disorders ar e not recommended. I~ 'P References Dworkin S F, LeResche L 1992 Research diagnostic criteria for temporomandibular disorders. Journal of Craniornandibular Disorders: Facial and Oral Pain 6:301-35 5 Eriksson PO, Haggman-Henrikson B, Nordh E, Zafar H 2000 Co-ordinated mandibula r and head-neck movements during rhythmic jaw activities in man. Journal of Dent al Research 79:1378-1384 Farella M, Bakke M, Michelotti A, Martina R 2001 Effect s of prolonged gum chewing on pain and fatigue in human jaw muscles. European Jo urnal of Oral Sciences 109:81-85 Feine J S, Lund J P 1997 An assessment of the e fficacy of physical therapy and physical modalities for the control of chronic m usculoskeletal pain (review). Pain 71:5-23 Forssell H, Kalso E, Koskela Pet al19

99 Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomized controlled trials (review). Pain 83:549-560 Fricton J R, Sc hiffman E 2001 Management of masticatory myalgia and arthralgia. In: Lund J P, L avigne G J, Dubner R, Sessle B J (eds) Orofacial pain. From basic science to cli nical management. The transfer of knowledge in pain research to education. Quint essence, Chicago, pp 235-248 Graven-Nielsen T, Mense S 2001 The peripheral appar atus of muscle pain: evidence from animal and human studies (review). Clinical J ournal of Pain 17:2-10 Headache Classification Committee of the International He adache Society 1988. Classification and diagnostic criteria for headache disorde rs, cranial neuralgias and facial pain. Cephalalgia 8(suppl 7):1-96 Kuttila M, N iemi P M, Kuttila S, Alanen P, Le Bell Y 1998 TMD treatment need in relation to age, gender, stress, and diagnostic subgroup. Journal of Orofacial Pain 12:67-74 Lobbezoo F, Naeije M 2001 Bruxism is mainly regulated centrally, not peripheral ly. Journal of Oral Rehabilitation 28:1085-1091 Okeson J P (ed) 1996 Differentia l diagnosis and management considerations of temporomandibular disorders. Orofac ial pain: guidelines for assessment, diagnosis and management. The American Acad emy of Orofacial Pain. Quintessence, Chicago, pp 137-141 Pullinger A G, Seligman D A 2000 Quantification and validation of predictive values of occlusal variabl es in temporomandibular disorders using a multifactorial analysis. Journal of Pr osthetic Dentistry 83:66-75 Further reading Bakke M 1993 Mandibular elevator muscles: physiology, action, and effect of dent al occlusion (review). Scandinavian Journal of Dental Research 101:314-331 Bakke M, Thomsen C E, Vilmann A et al1996 Ultrasonographic assessment of the swelling of the human masseter muscle 81

 CLINICAL PRACTICE AND THE OCCLUSION after static and dynamic activity. Archives of Oral Biology 41:133-140 Bendtsen L, Jensen R 2000 Amitriptyline reduces myofascial tenderness in patients with ch ronic tension type headache. Cephalalgia 20:603--610 Dao T T, Lund J P, Lavigne G J 1994 Pain responses to experimental chewing in myofascial pain patients. Jou rnal of Dental Research 73:1163-1167 Drangsholt M, LeResche L 1994 Temporomandib ular disorder pain. In: Crombie I K, Croft P R, Linton S J, LeResche L, Von Korf f M (eds) Epidemiology of pain. Task force on epidemiology of the International Association for the Study of Pain. IASP Press, Seattle, pp 203-233 Dworkin S F, Huggins K H, LeResche L et al1990 Epidemiology of signs and symptoms in temporom andibular disorders: clinical signs in cases and controls. Journal of the Americ an Dental Association 120:273-281 Dworkin S F, LeResche L, DeRouen T, von Korff M 1990 Assessing clinical signs of temporomandibular disorders: reliability of c linical examiners. Journal of Prosthetic Dentistry 63:574-579 Kreiner M, Betanco r E, Clark G T 2001 Occlusal stabilization appliances. Evidence of their efficac y (review). Journal of the American Dental Association 132:770-777 Layzer R B 19 94 Muscle pain, cramps and fatigue. In: Engel A G, Franzini-Amstrong C (eds) Myo logy. McGraw-Hill, New York, pp 1754-1768 Levine J D 1996 Arthritis and myositis . In: Campbell J N (ed) Pain 1996 - an updated review. rASP Press, Seattle, pp 3 27-337 Lund J P 2001 Pain and movement. In: Lund J P, Lavigne G J, Dubner R, Ses sle B J (eds) Orofacial pain. From basic science to clinical management. The tra nsfer of knowledge in pain research to education. Chicago, Quintessence, pp 151163 Mense S 1993 Nociception from skeletal muscle in relation to clinical muscle pain (review). Pain 54:241-289 Merskey H, Bogduk N (eds) 1994 Classification of chronic pain, description of chronic pain syndromes and definition of pain term s, 2nd edn. Second task force on taxonomy of the International Association for t he Study of Pain. lASP Press, Seattle, pp xi-xiii Meller E 1966 The chewing apparatus. An electromyographic study of the action of the muscles of mastication and its correlation to facial morphology. Acta Physi ologica Scandinavica 69(suppI280):1-229 National Institutes of Health 1996 Manag ement of temporomandibular disorders. National Institutes of Health Technology A ssessment Conference statement. Journal of the American Dental Association 127:1 595-1606 Sacchetti G, Lampugnani R, Battistini C, Mandelli V 1980 Response to pa thological ischaemic muscle pain to analgesics. British Journal of Clinical Phar macology 9:165-190 Salmon S 1995.Muscle. In: Williams P L, Bannister L H, Berry M M et al (eds) Gray's anatomy. The anatomical basis of medicine and surgery, 38 th edn. Churchill Livingstone, Edinburgh, pp 737-900 Scott J, Huskisson E C 1976 Graphic representation of pain. Pain 2:175-184 Sessle B J 1995 Masticatory musc le disorders: basic science perspectives. In: Sessle B J, Bryant P S, Dionne R A (eds) Temporomandibular disorders and related pain. IASP Press, Seattle, pp 47-61 Singer E, Dionne R 1997 A controlled evaluation of ibuprofen and diazepam fo r chronic orofacial muscle pain. Journal of Orofacial Pain 11:139-146 Stal P, Er iksson PO, Thornell L E 1996 Differences in capillary supply between human oro-f acial, masticatory and limb muscles. Journal of Muscle Research and Cell Motilit y 17:183-197 Stockstill J, Gross A, McCall W D 1989 Interrater reliability in ma sticatory muscle palpation. Journal of Craniomandibular Disorders: Facial and Or al Pain 3:143-146 Svensson P, Houe L, Arendt-Nielsen L 1997 Effect of systemic v ersus topical nonsteroidal antiinflammatory drugs on postexercise jaw-muscle sor eness: a placebo-controlled study. Journal of Orofacial Pain 11:353-362 Wolfe F, Smythe H A, Yunus M B et al1990 The American College of Rheuma tology cri teria for the classifica tion of fibromyalgia. Report of a multicenter criteria commi ttee. Arthritis and Rheumatism 33:160-172 82

Occlusion and periodontal health 1. De Boever, A. De Boever Synopsis Periodontal structures depend on functional occlusal forces to activate the peri odontal mechanoreceptors in the neuromuscular physiology of the masticatory syst em. Occlusal forces stimulate the receptors in the periodontal ligament to regul ate jaw movements and the occlusal forces. Without antagonists the periodontal l igament shows some non-functional atrophy. Tooth mobility is the clinical expres sion of the viscoelastic properties of the ligament and the functional response. Tooth mobility can change due to general metabolic influences. a traumatic occl usion and inflammation. Premature contacts between the arches can result in trau ma to the periodontal structures. A traumatic occlusion on a healthy periodontiu m leads to an increased mobility but not to attachment loss. In inflamed periodo ntal structures traumatic occlusion contributes to a further and faster spread o f the inflammation apically and to more bone loss. A traumatic occlusion. as in a deep bite. may cause stripping of the gingival margins. It is not clear if pre maturities or steep occlusal guidance contribute to the occurrence of gingival r ecession. On implants. prematurities may result in breakdown of osseointegration . In some cases occlusal corrections will be necessary to eliminate the traumati c influence of a nonphysiological occlusion. Key points Healthy periodontal structures and occlusal forces Physiology and clinical aspec ts of tooth mobility Tooth mobility Types of occlusal forces Trauma from occlusi on: - Primary trauma in healthy non-inflamed periodontium - Primary trauma in he althy but reduced periodontal structures - Secondary trauma in the progression o f periodontitis Implants and occlusal trauma Gingival recession and occlusal tra uma Clinical consequence and procedures HEALTHY PERIODONTAL STRUCTURES AND OCCLUSAL FORCES The healthy periodontal structures, including root cementum, periodontal ligamen t and alveolar bone, form a functional unit or organ. The periodontal ligament i s a very specialised interface between tooth and the alveolar bone. It serves as a structural, sensory and nutritive unit supporting the normal oral functions o f chewing, swallowing, speaking, etc. It has a very dense network of interconnec ting fibres attached to the bone. The supracrestal fibres are especially importa nt because they maintain the relative position of the teeth in the arch. The col lagen fibres in the periodontal ligament are very dense and represent up to 75% of the volume. These so-called 'Sharpey fibres' are apically oriented and embedd ed both in the alveolar bone and the root cement. The natural dentition has been compared, because of these interconnecting supracrestal fibres, to beads on a s tring. Teeth function together but have their individual mobility in the 83

 CLINICAL PRACTICE AND THE OCCLUSION alveolus. The entire periodontal ligament has viscoelastic characteristics. The ligament provides tooth fixation, and also force absorption. The thickness of th e periodontal ligament is directly related to the forces exerted on it. The peri odontal ligament has a rich and dense vascular and nervous network. The ligament contains proprioceptors for movement and positioning and mechanoreceptors for t ouch, pain and pressure. They regulate muscle function and occlusal forces to av oid overload and damage of the teeth and the alveolar bone. The periodontal liga ment distributes and absorbs forces. Under physiological conditions the occlusal forces are transferred to alveolar bone and further to the mandible, the maxill a and the entire skull. The alveolar process has a pronounced capacity for model ling and remodelling under functional loading. The alveolar process remodels at a rate of 20% per year. The basal bone does not have this capacity. The periodon tal ligament and alveolar bone need the functional stimulus of the occlusion to maintain their physiological, healthy condition. In the vertical direction, the displacement is 0.02 mm by small forces up to 1 N . Under larger vertical forces, the tooth is moved in an apical direction becaus e venous fluid and blood of the periodontal structures is pushed towards the ven ous lacunae and the cancellous bone. It takes 1-2 minutes before the tooth retur ns to its normal position after releasing an applied occlusal force. This explai ns the fact that tooth mobility is decreased after chewing, and the tooth is the n in a more apical position. In healthy conditions, the teeth move in a horizont al plane, under a force of 500 g, as follows (Muhlernann 1960): incisors: 0.1-0. 12mm canines: 0.05-0.09 mm premolars: 0.08-0.1 mm molars: 0.04-0.08 mm. TOOTH MOBILITY Physiological tooth mobility is the result of the histological characteristics o f the periodontal ligament. Physiological tooth mobility, in the horizontal as w ell as in the vertical direction, is different between single root and multiroot ed teeth and is determined by the width, height and quality of the periodontal l igament (Fig. 9.1). Tooth mobility can also be estimated using the Periotest (Siemens AG, Germany), an electronic device that measures the reaction of the periodontium to a defined percussion force. Under higher occlusal loads, the forces are transmitted to th e bone, with slight deformation of the alveolar process as a result. The force i s also transmitted to neighbouring teeth through the interproximal contacts. Evaluation of tooth mobility The exact measurement of individual tooth mobility (periodontometry) is necessar y for research purposes. Clinically, an estimation of tooth mobility is performe d by loading the tooth in an anterolateral direction with two instruments. Four possible grades of tooth mobility are considered: grade 0: physiological mobilit y grade 1: increased mobility but less than 1 mm in total grade 2: pronounced in crease; more than 1 mm in total grade 3: more than 1 mm displacement combined wi th a displacement in vertical direction (tooth can be intruded). Increased mobility can also be observed on radiographs: there is a widening of t he periodontal space without vertical or angular bone resorption and without inc reased probing depth of the periodontal pocket (Figs 9.2 and 9.3). Aetiological factors of hyper- and hypomobility Excessive occlusal forces or premature contacts on teeth are the primary aetiolo gic factors for hypermobility. There is an increased mobility during pregnancy b ecause of the increase in the fluid content of the periodontal structures, an in creased vascularity and a proliferation of

Fig. 9.1 Physiological tooth mobility in a healthy periodontium is determined by the bone height, the form of the root and the magnitude of the applied force, a nd the extent is limited. 84

OCCLUSION AND PERIODONTAL HEALTH Fig. 9.2 Forces applied in one direction on the tooth give a widening of the per iodontal ligament at the bone margin at the other side and in the apical area on the same side of the force. capillaries into the periodontal tissues. Systemic diseases such as non-Hodgkin' s lymphoma, scleroderma and Cushing's syndrome may lead to increased mobility. H ypermobility may be observed in cases of severe periodontal inflammation (period ontitis), teeth with a healthy but reduced periodontal support (that is, in pati ents after successful periodontal treatment), or in the first weeks after period ontal surgery. Normal physiological mobility is decreased in the elderly and in the absence of antagonist teeth. In cases of severe bruxism and clenching the mo bility decreases ('ankylosing effect'). Without antagonists and therefore withou t functional stimulation, teeth will either overerupt or become ankylosed. The p eriodontal ligament becomes thinner and non-functional. Evaluation of the change s in occlusal mobility can be helpful in the diagnosis of occlusal dysfunction, parafunction and in the evaluation of occlusal treatment procedures. TYPES OF OCCLUSAL FORCES The reaction of the bone and ligament depends on the magnitude, duration and dir ection of the forces. Different types of occlusal forces can be recognised: Phys iologically normal occlusal forces in chewing and swallowing: small and rarely e xceeding 5 N. They provide the positive stimulus to maintaining the periodontium and the alveolar bone in a healthy and functional condition. Impact forces: mai nly high but of short duration. The periodontium can sustain high forces during a short period; however, forces exceeding the viscoelastic buffer capacities of the periodontal ligament will result in fracture of tooth and bone. Continuous f orces: very low forces (for example, orthodontic forces), but continuously appli ed in one direction are effective in displacing a tooth by remodelling the alveo lus. Jiggling forces: intermittent forces in two different directions (premature contacts on, for example, crowns, fillings) result in widening of the alveolus and in increased mobility. TRAUMA FROM OCCLUSION Fig. 9.3 Widening of the periodontal space as observed on radiographs. Trauma from occlusion has been defined as structural and functional changes in t he periodontal tissues caused by excessive occlusal forces. Some of these change s are adaptive, while others should be considered pathological. Occlusal trauma can be acute if caused by external impact 85

 A CLINICAL PRACTICE AND THE OCCLUSION B c Fig. 9.4 Clinical example of a primary occlusal trauma in a young girl with a de ep bite and a persistent deciduous canine. A Frontal view showing the deep bite. B Palatal view, with the primary trauma on the palatal mucosa caused by the low er canine. When the patient closes, the lower canine is forced in between the up per canine and the central and lateral incisors. C This traumatic occlusion caus es the widening of the periodontal space, as seen on the radiograph. forces or chronic if caused by internal occlusal factors (premature contacts, gr inding). Chronic occlusal trauma can be understood as primary and secondary trau ma. Occlusal trauma is the overall process by which traumatic occlusion (that is , an occlusion that produces forces that cause injury) produces injury to the at tachment apparatus. develops a normal histological appearance. If the applied forces are too high, r oot resorption occurs in the middle of the hyalinised tissues. This resorption c ontinues for a variable time, resulting in shorter roots, frequently seen after orthodontic treatment. Jiggling forces Primary occlusal trauma Primary occlusal trauma is caused by excessive and nonphysiological forces exert ed on teeth with a normal, healthy and non-inflamed periodontium. The forces may be exerted on the periodontal structures in one direction (orthodontic forces) or as 'jiggling' forces. Jiggling forces, coming from different and opposite dir ections, cause more complex histological changes in the ligament. Theoretically the same events (hyalinisation, resorption) occur, however, they are not clearly separated. There are no distinct zones of pressure and tension. Histologically, there is apposition and resorption on either side of the periodontal ligament, resulting in a widening of the periodontal space (Fig. 9.4). This may be observe d on radiographs. This phenomenon explains the increased mobility without pocket formation, migration and tipping. The clinical phenomena are not only dependent on the magnitude of the forces, but also on the crown-root relationship, the po sition in the arch, the direction of the long axis, and the pressure of tongue a nd cheek musculature (Fig. 9.5). The interarch relationship (for example, deep b ite) influences the extent of the trauma caused by jiggling forces. The hypermob ility is found as long as the forces are exerted on the tooth: there is no adapt ation. Hypermobility is therefore not a sign of an ongoing process, but may be t he result of a previous jiggling force. The long-term prognosis of teeth with in creased mobility is poor, and is a complicating factor if they are used as abutm ent in prosthodontic reconstruction. Successful periodontal treatment leads to h ealthy but reduced periodontal structures. Jiggling forces exerted on the teeth in this condition result in a pronounced increase in tooth mobility because the point of rotation (fulcrum) is closer to the apex than normal. This is uncomfort able for Forces in one direction: orthodontic forces Forces in one direction cause tipping of the tooth in the opposite direction or

tooth displacement parallel to the force resulting in a 'bodily movement'. In th e periodontal ligament, zones of compression and zones of tension are found, ind ucing increased resorption. The clinical result is a (temporary) increased mobil ity. However, there are no changes in the supracrestal fibres, no loss of period ontal attachment, or an increased probing pocket depth. The increased tooth mobi lity is functional adaptation to the forces exerted on that tooth. If the forces are too high and above the adaptation level, an aseptic necrosis in the tension zone of the periodontal ligament occurs, characterised by hyalinisation. In the compression zone, pressure stimulates osteoclasts in the adjacent bone and the alveolar wall is resorbed until a new connection is formed with the hyalinised b one ('undermining resorption'). In the tension zone, bone apposition and rupture of the collagen fibres occur. After removal of the force the periodontal ligame nt is reorganised and after some time 86

OCCLUSION AND PERIODONTAL HEALTH Fig. 9.5 Under jiggling forces in a healthy periodontium, the periodontal ligame nt space is widened, resulting in more tooth mobility but not in marginal bone r esorption or attachment loss. Fig. 9.6 In cases of a healthy but reduced periodontium the tooth mobility (meas ured at the crown level) is increased for the same force, as compared with a too th with a complete periodontium, because of the more apical position of the fulc rum. the patient and might be an indication for splinting of teeth (Fig. 9.6). Secondary occlusal trauma Secondary trauma from occlusion is defined as the trauma caused by excessive and premature occlusal forces on teeth with an inflamed periodontium. A number of a nimal experiments and clinical epidemiological studies investigated the role of occlusion in the pathogenesis of periodontitis. In his original studies in the 1 960s, Glickman (Glickman & Smulow 1967) formulated the hypothesis that premature contacts and excessive occlusal forces could be a co-factor in the progression of periodontal disease by changing the pathway and spread of inflammation into t he deeper periodontal tissues. Glickman hypothesised that the gingival zone was a 'zone for irritation' by the microbial plaque; the supracrestal fibres were th en considered to be a 'zone of co-destruction' under the influence of a faulty o cclusion (Fig. 9.7). Clinically, vertical bone resorption and the formation of i nfrabony defects should be an indication for occlusal trauma. Fig. 9.7 Role of traumatic occlusion in the progression of periodontitis accordi ng to Glickman & Smulow (1967). In the presence of microbial plaque and inflamma tion, A is the 'zone of irritation' and B the 'zone of co-destruction' where the prematurities are co-destructive by changing the inflammatory pathway. Animal experiments Animal experiments investigating the influence of a faulty occlusion on the prog ression of periodontal disease were published by Swedish investigators between 1 970 and 1980 using the beagle dog model, and by American investigators using the squ irrel monkey model. In spite of the many remaining questions and controversies, few animal studies have been published since then. From these studies the follow ing conclusions may be drawn: 87

 CLINICAL PRACTICE AND THE OCCLUSION In the absence of marginal inflammation, jiggling forces do not induce more bone resorption nor a shift of the epithelial attachment in an apical direction. In the case of marginal inflammation (gingivitis), occlusal overload has no influen ce. Jiggling forces on teeth with periodontal disease result in more bone loss a nd more loss of connective tissue attachment (Ericsson & Lindhe 1982). Jiggling forces induce a faster shift of microbial plaque in the apical direction in the pocket (Fig. 9.8). One single trauma does not influence the pathogenesis; the fo rces have to be chronic. Treatment of periodontal inflammation without eliminati on of the premature contacts results in decreased tooth mobility, an increase in bone density, but no change of bone level. After periodontal treatment with sca ling and rootplaning, the presence or absence of prematurities have no influence on the microbial repopulation of the deepened pockets. Fig. 9.8 It must be mentioned that some animal studies did not reach the same definitive conclusions, due to differences in experimental setup and different animal model s. The results of experimental animal studies cannot therefore be directly extra polated to the human situation. In applying jiggling forces on an inflamed, untreated periodontium with existing infrabony pockets (A), the bone destruction is accelerated and the bacteria mov e more apically (8). Clinical epidemiological studies Given the complexity of the occlusal and periodontal interaction and the multifa ctorial aspect of the pathology, very few human studies have been published. Mos t studies have a limited number of subjects and the results are analysed on a su bject basis rather than on a tooth basis. The studies have been recently summari sed by Hallmon (Hallmon 1999). A number of cross-sectional epidemiological studi es found either no relationship between the presence of premature contacts and i ncreased probing depth or bone loss, while others reported that mobility and rad iographic evidence of a widened periodontal ligament were associated with increa sed pocket depth, attachment loss and bone loss (Jin & Cao 1992). More recent lo ngitudinal studies (Harrel & Nunn 2001) found that teeth with premature contacts at initial examination had a deeper probing pocket depth, an increased mobility and a worse prognosis. At the 1 year examination, teeth without premature conta cts originally, or teeth where premature contacts had been removed, showed a 66% reduced chance of a worsening periodontal situation. After a few months, teeth with prematurities showed an increased probing depth compared with the teeth rec eiving occlusal adjustment. It was concluded that premature contacts are a 'cata lyst' in the progression of periodontal disease. It has also been shown that in the same patient more periodontopathogens are fou nd in pockets around hypermobile teeth, than in teeth with normal mobility. This can lead to the hypothesis that the increased mobility changes the ecosystem in the pocket, favouring growth of these bacteria. TRAUMA FROM OCCLUSION AND IMPLANTS

Endosseous implants have no periodontal ligament as an intimate implant-alveolar bone contact exists ('functional ankylosis'). Implant failure can occur not onl y because of bacterial infection (peri-implantitis) but also because of occlusal overload (biomechanical failure) in combination with immunological host factors (Esposito et aI1998). Occlusal overload results in 'osseodisintegration' over t he complete implant surface without clinically detectable pocket formation or si gns of inflammation. Often the implant has no increased mobility in spite of pro nounced bone resorption along its entire surface. Clinical measurement of implan t mobility is not an accurate tool for evaluating osseointegration or disintegra tion of an implant until late in the pathological process. If increased implant mobility occurs, osseointegration is by then usually destroyed. 88

OCCLUSION AND PERIODONTAL HEALTH GINGIVAL TRAUMA FROM OCCLUSION Gingival recession may be provoked by direct contact of the teeth with the gingi va, as in severe overbite, where the upper incisors damage the buccal gingiva of the lower incisors. This problem is not easy to solve and may involve orthodont ic treatment, orthognathic surgery or extensive prosthetic rehabilitation requir ing an increase in vertical dimension. It has been stated that gingival recessio n occurs with functional overload and/ or premature contacts, as in the buccal s urface of upper canines where there is a steep lateral canine guidance. Those ce rvical surfaces also show enamel abfraction. There is still controversy regardin g whether or not overload is an aetiological factor in the recession, and conseq uently whether or not the occlusion and the lateral guidance should be changed. As implant overload leads to bone resorption without the warning signal of infla mmation, deep peri-implantitis pockets or (in the early stage) increased mobilit y, evaluation of the occlusion and radiographs should be included in regular mai ntenance programmes. I~ '?' References PRACTICAL CLINICAL CONCLUSIONS AND GUIDELINES In a healthy non-inflamed dentition, traumatic occlusion leads to hypermobility of some teeth; if hypermobility, radiological widening of periodontal ligament s pace or pronounced cervical abfraction is found, the occlusion should be analyse d and corrected. Simple uncomplicated, non-time-consuming procedures are in most cases adequate to restore a physiological situation and to reduce hypermobility . In cases of a healthy but reduced periodontium, increased mobility may also be reduced by occlusal adjustment; it should be recognised that tooth mobility in such cases, based on the mechanical situation, is nevertheless increased. It may be necessary to splint the teeth to increase the functional comfort and to avoi d direct fracture. This may include very mobile teeth with a healthy but reduced periodontium, but complicates the clinical procedures. In cases of secondary oc clusal trauma, treating the inflammation is of primary importance and should be the first step in treatment planning. From the literature it can be concluded th at prematurities may playa role in the progression of the periodontitis. A simpl e correction of the occlusion, if necessary, should be included in the initial p hase of periodontal treatment. This results in more gain in attachment level dur ing periodontal treatment, and may contribute to better healing of periodontal t issues. There are some indications that removing premature tooth contacts improv es the prognosis of periodontally involved tissues. If some teeth do not react t o conventional periodontal treatment as expected, further investigation should n ot only include periodontal re-examination and microbiological testing, but also more extensive occlusal analysis. Ericsson I, Lindhe J 1982 The effect of long standing jiggling on the experiment al marginal periodontitis in the beagle dog. Journal of Clinical Periodontology 9:495 Esposito M, Hirsch J M, Lekholm U, Thomsen P 1998 Biological factors contr ibuting to failures of osseointegrated implants. II. Etiopathogenesis. European Journal of Oral Sciences 106:721-764 Glickman I, Smulow I B 1967 Further observa tion on the effects of trauma from occlusion. Journal of Periodontology 38:280 H allmon W 1999 Occlusal trauma: effect and impact on the periodontium. Annals of Periodontology 4:102 Harrel S K, Nunn M E 2001 The effect of occlusal discrepanc ies upon periodontitis. II. Relationships of occlusal treatment to the progressi on of periodontal disease. Journal of Periodontology 72:495-505 [in L, Cao C 199

2 Clinical diagnosis of trauma from occlusion and its relation with severity of periodontitis. Journal of Clinical Periodontology 19:92-97 Muhlemann H R 1960 Te n years of tooth mobility measurements. Journal of Periodontology 31:110-122 Further reading Beertsen W, McCulloch C A G, Sodek J 1997 The periodontal ligament: a unique, mu ltifunctional connective tissue. Periodontology 2000 13:20--40 Burgett F G, Ramf jord S P, Nissle R R et al 1992 A randomized trial of occlusal adjustment in the treatment of periodontitis. Journal of Clinical Periodontology 19:381-387 Gher M 1996 Non surgical pocket therapy: dental occlusion. Annals of Periodontology 1 :567-580 Giargia M, Lindhe J 1997 Tooth mobility and periodontal disease. Journa l of Clinical Periodontology 24:785-791 Grant D A, Flynn M J, Slots J 1995 Perio dontal microbiota of mobile and non-mobile teeth. Journal of Periodontology 66:3 86-390 Kaufman H, Carranza F A, Enders B, Neuman M G, Murphy N 1984 Influence of trauma from occlusion on the bacterial re-population of periodontal pockets in dogs. Journal of Periodontology 55:86-92 McCulloch C A G, Kekic P, McKee M D 200 0 Role of physical forces in regulating the form and function of the periodontal ligament. Periodontology 24:56-72 Polson A M II 1974 Co-destructive factors of periodontitis and mechanically produced injury. Journal of Periodontal Research 9:108-113 Schulte W, Hoedt B, Lukas D, Maune M, Steppeler M 1992 Periotest for m easuring periodontal characteristics. Correlation with periodontal bone loss. Jo urnal of Periodontal Research 27:181-190 Wang H, Burgett F G, Shyt Y, Ramfjord S 1994 The influence of molar furcation involvement and mobility on future clinic al periodontal attachment loss. Journal of Periodontology 65:25-29 89

Occlusion and orthodontics A. Darendeliler, O. Kharbanda PART 1: CHILDREN AND YOUNG ADULTS respiration. habits and integrity/maintenance of the deciduous dentition Early r ecognition of malocclusion and its timely interception can minimise or eliminate certain forms of malocclusion Growth modification of growing class II malocclus ion is now a recognised and accepted modality of treatment Growth modification i n growing class III malocclusion is relatively less predictable. yet recommended in certain types of maxillary hypoplasia Full-banded fixed appliance therapy is the most effective mode of treatment of malocclusions of dental origin and some variations of skeletal malocclusions Synopsis An overview of concepts of normal occlusion and malocclusion is presented from a n orthodontic viewpoint. Orthodontists perceive occlusion as tooth alignment and interarch alignment in relation to the underlying skeletal bases and facial sof t tissues. Functional and dynamic aspects of occlusion are now also being incorp orated into objectives of orthodontic treatment. A classification of malocclusio n and its characteristics is presented. Features of postorthodontic optimal occl usion following treatment with fixed appliances are presented. Key points Orthodontics is aimed at providing a well-functioning and anatomically optimal o cclusion that is in harmony with the underlying skeletal base. is aesthetically pleasing and functionally stable with age Malocclusion is not an organic disease but a deviation from normal. that can have infinite variations Malocclusion has aesthetic. functional and superimposed psychological implications Development o f normal occlusion/ malocclusion is the outcome of complex interactions of jaw g rowth. growth of the cranium and face. development of the dentition. eruption ti ming and sequence of eruption. soft-tissue function and maturation. These featur es are governed by the genetic architecture and yet are greatly influenced by en vironmental factors. including nutrition. mode of OPTIMAL OCCLUSION: PHILOSOPHY OF EVIDENCE FOR ORTHODONTICS The concept and philosophy of 'normal' occlusion in orthodontics developed in re lation to the teeth having a 'specific arrangement' in the dental arches (intraarch) and in relation to opposing arches (inter-arch). The wellaligned dental ar ches that have 'normal' labial and buccal overjet, some overbite and have a 'nor mal' anteroposterior relationship between maxillary and mandibular arches consti tute normal occlusion. Historically, cusp-to-fossa relationships of upper and lo wer teeth were regarded as being of special significance. In the late nineteenth and early twentieth centuries, Angle emphasised the relationship of the mesiobu ccal cusp of the maxillary first molar to the buccal groove of the mandibular fi rst molar as the 'key factor' in the establishment of a class I molar 'normal' r elationship. He considered the maxillary first molar to be a stable tooth, which occupied a distinct relationship in the maxillary bone. The position of each de ntal unit in the arch was also described in terms of its unique 'axial inclinati on'. 91

 CLINICAL PRACTICE AND THE OCCLUSION Clinical observations on occlusion were considered both within an arch 'and in r elation to the opposing arches, Within the arch the following were considered: t ight proximal contacts, labiolingual/buccolingual placement, rotation and labiol ingual/mesiodistal inclination. Angle also believed that a full complement of te eth was essential for teeth to be in balance with facial harmony. Following Angl e, clinical research evidence was considered. Studies from the University of Ill inois reported that the maxillary first molar did not always have a distinct rel ationship with the key ridge in the maxilla. The research by Begg on the occlusi on of Australian Aborigines suggested that reduction in tooth substance by proxi mal and occlusal wear was physiological (Begg 1954). Tweed considered the face a nd the occlusion from the perspective of axial inclination of the lower incisors and their relationship with the mandibular plane as a guide for determining nor mal/abnormal relationships of other dental units to their basal bones. His cepha lometric studies provided evidence that in order to achieve a balance of lower i ncisors with basal bone it may be necessary to extract some teeth (Tweed 1946). The advent of cephalometries and studies on 'facial variations' reconfirmed many of the earlier empirical clinical observations that normal occlusion may exist in harmony with skeletal bases only if the skeletal bases and facial bones follo w normal growth and development. Cephalometric studies provided an understanding of how the dentition and the occlusion and underlying skeletal structures grow over time, and differentiated normal and abnormal growing faces and occlusion, I n 1972, Andrews' analysis of dental casts of normal (non-orthodontic normal occl usion/no history of orthodontic treatment) subjects generated a database of occl usal characteristics that have been grouped into 'six keys of occlusion': 1. Mol ar relationships. In addition to the previously described features of the mesiob uccal and mesiolingual cusps of the maxillary first molar with the mandibular fi rst molar, Andrews added that the distal surface of the distobuccal cusp of the maxillary first molar occluded wit h the mesial surface of the mesiobuccal cusp of the mandibular second molar. 2, Crown angulations (mesiodistal tip). Andrews reconfirmed the axial inclination o f the teeth and termed it 'tip'. The crown tip is expressed in degrees and is va riable for each tooth. 3. Crown inclination Oabiolingual or buccolingual). Each tooth crown in the arch has a distinct bucco/labiolingual inclination, designate d as 'torque', which is distinct for each tooth crown, 4. Rotations. In optimal occlusion, there should be no tooth rotation. A rotated molar occupies more spac e in the arch and does not allow optimal occlusion. 5, All teeth in the arch sho uld have tight proximal contact. 6. Flat or mild curve of Spee is a prerequisite of normal occlusion. A deep curve of Spee is suggestive of malocclusion. The 's ix keys' are meaningful for normal occlusion (Fig. 10.1), not because they are c onsistently seen in all cases but because the 'lack of even one' may suggest inc omplete orthodontic treatment. Orthodontic treatment goals should aim to attain Andrews' six keys, Andrews' proposals on tip and torque values have been incorpo rated into orthodontic brackets and tubes of fixed appliances. Such appliances a re generically called 'preadjusted' because they facilitate tooth movement in op timal inclinations and angulations without requiring many adjustments. Tip and t orque values suggested by Andrews are supposedly more suitable for Caucasians. T here are variations in Asians, African-Americans and other races, but they follo w similar features, Roth (1981) suggested that orthodontic treatment goals shoul d also include intercuspal contact position (ICP) or centric occlusion coinciden t with retruded contact position (RCP) or centric relation, In protrusive excurs ions, eight lower anterior teeth should ideally contact six upper anterior teeth and provide smooth lateral and anterior guidance. Fig. 10.1

Normal occlusion: occlusion following non-extraction orthodontic treatment. 92

OCCLUSION AND ORTHODONTICS A ( lass III B Fig. 10.2 A Three types of dental malocclusion: left to right, class I, II and III. B Three types of skeletal malocclusion: left to right, classes I, II and I II. MALOCCLUSION Any significant deviation from normal occlusion may be termed 'malocclusion'. Cu rrent orthodontic understanding of occlusion necessitates that teeth should have normal intra- and interarch relationships, be in harmony with the underlying sk eletal bases, and exhibit a well-balanced face. In addition, deviations in norma l functional relationships suggest malocclusion. Malocclusion may be of dental o r skeletal origin, or both. Deviations could occur in all the dimensions, that i s, anteroposterior, vertical or transverse, in isolation or in combinations of v arying severity. Deviations range from minor, such as slight alterations in arch position, tooth tip or tooth rotation, to more severe forms of crowding, spacin g or abnormal overjet and overbite and their combinations of varying severity. M inor malocclusions may have insignificant functional consequences, yet may gener ate psychosocial concerns for child or adult. While more severe malocclusion in other individuals mayor may not be of any concern, it may be associated with fun ctional problems. Classification of malocclusion In order to standardise description and treatment planning, malocclusion based o n molar relationships was grouped into three classes (Angle 1906), using Roman n umerals (1, II, III) to denote the classes and Arabic numerals (1, 2) to denote divisions. A malocclusion that exists unilaterally is termed a subdivision. Usin g the maxillary first molar as a reference, the classification is: normal mesiod istal (anteroposterior) relationship of the upper and lower first molars (class I); and variations, that is, a distal lower arch (class II), or mesial lower arc h (class III) relationship. Figure 10.2A illustrates dental classes I, II and II I. Class I malocclusion exists when maxillary and mandibular first molar teeth h ave a normal cusp-to-fossa relationship, but there may be deviations in the arra ngement of teeth, intra-arch, interarch or both. The common features of class I malocclusions include: maxillary protrusion crowding/spacing anterior/posterior cross bites 93

 CLINICAL PRACTICE AND THE OCCLUSION deep/open bite midline shift combinations of the above. Class II malocclusion (a lso called distal occlusion) the lower first molar is distal to its normal relat ionship with the maxillary first molar; the mesiobuccal cusp of the maxillary fi rst molar falls mesial to the buccal groove of the mandibular first molar. The u sual features of such malocclusions are: distal positioning of lower canines (cl ass II canine) maxillary protrusion deep bite inter- and/ or intra-arch deviatio ns in teeth. Class II malocclusions associated with proclined maxillary incisors are called division 1 or with retroclined maxillary incisors division 2. Class III malocclusion exists when the lower arch (mandibular first molar) is mesial t o its normal relationship with the maxillary first molar, that is, the mesiobucc al cusp of the maxillary first molar falls distal to the buccal groove of the lo wer first molar. OCCLUSION FOLLOWING ORTHODONTIC TREATMENT Non-extraction era The development of a more scientific approach from the beginning of the twentiet h century was mainly devoted to refinement of 'appliancets)', which could effect ively move teeth into the preconceived concept of 'normal dental relationship'. The treatment by expansion and alignment could provide normal alignment and cusp -to-fossa relationships, but was not always in harmony with the underlying skele tal bases and facial soft tissues. Extraction era: search for the evidence Tweed (1945) reviewed his treated cases that (1) did not result in good facial a esthetics; (2) had relapsed; (3) showed facial balance and a stable occlusion. C linical observations were supported by cephalometric studies; in subjects with a balanced face and good occlusion (orthodontically treated), mandibular incisors were close to 90 to the mandibular plane (IMPA) and their Frankfort mandibular p lane angle (FMA) was about 25. Accordingly, the maxillary arch required alignment to normal overjet with the mandibular incisors. To upright mandibular incisors (bringing close to 90), space was required in the arch, which could be obtained w ith extracting first premolars. Tweed's extraction approach was further supporte d by Begg, who reported that proximal reduction of tooth surfaces was an essenti al part of physiological occlusion (Begg 1954). Similarly, maxillary expansion m ay be insufficient in the correction of large overjet/crowding, and alignment an d extraction of some teeth may be unavoidable. This resulted in extractions bein g performed without the necessary consideration of the remaining growth in child ren and their effect on the adult facial profile. The long-term growth studies w hich are now available need to be considered in orthodontic treatment planning, together with specific racial and ethnic characteristics, which show variations in cephalometric parameters. It has since been realised that extractions should be used with caution following a comprehensive assessment that includes space re quirements, growth trend or anticipated growth, soft-tissue profile and treatmen t mechanics. The advent of cephalometries allowed study of the morphology of the cranium, fac e and jaws, which provided a better understanding of the skeletal and dental com ponents of malocclusion. This allowed classification of skeletal jaw relationshi ps. Figure 10.2B describes three types of skeletal malocclusion. Skeletal class I: Orthognathic or normal - maxillary and mandibular skeletal bas es are in a normal anteroposterior relationship. Skeletal class I jaw relationsh ip does not necessitate a dental class I relationship. A dental class II or clas s III malocclusion may occur on a skeletal class I base. Skeletal class II: Dist al jaw relationship exhibits an anteroposterior discrepancy between the maxillar

y and mandibular bases. A skeletal class II relationship could arise from a smal ler (or posteriorly positioned) mandible or an anteriorly placed (or larger) max illa, or a combination of both. A class I or class II dental malocclusion may be observed on skeletal class II bases, but a dental class III relationship on a s keletal class II base is extremely unusual. Skeletal Class III: Mesial jaw relat ionship exists when the mandibular skeletal base is mesial to the maxillary base in an anteroposterior relationship. Such a relationship could arise when there is a normal maxilla and a large mandible or as a pseudo-class III with a small m axilla and a normal-sized mandible. A varying combination of maxillary deficienc y and mandibular prognathism also occurs. Depending upon the severity and locati on of the skeletal class III dysplasia, a class I or class III dental relationsh ip might exist. Occlusion without extraction The occlusal relationships following non-extraction orthodontic treatment are si milar to that of an occlusion with a full complement of teeth (Fig. 10.3). 94

OCCLUSION AND ORTHODONTICS Fig. 10.3 Occlusion following non-extraction treatment: before (above) and after (below) treatment. Fig. 10.4 Occlusion following extraction of four premolars: before (above) and after (belo w) treatment. of lower molars, to achieve class I molar relationship (Fig. IDA). Occlusion with extraction Four first premolars Class I malocclusion The extraction space achieved following premolar extraction in both arches is utilised for arch alignment and establishment of optimal over jet and overbite. With the use of preadjusted appliances, normal mesiodistal ang ulation (tip) and labiolingual inclinations (torque) of the teeth may be achieve d. However, in some cases proximal contact of the distal surface of the canine w ith that of the mesial surface of the second premolars will be less than ideal, due to the smaller convexity of the mesial surface of the second premolar. The m axillary second premolars are usually smaller than the first premolars. Class /I malocclusion The extraction space in the maxillary arch is used to correct over jet and crowding. The extraction space in the lower arch is used to reduce the c urve of Spee, crowding and mesial movement Maxillary first premolars and mandibular second premolars Lower second premolar extractions provide greater mesial movement of the lower f irst molars for the correction of class II to class I molar relationships where space requirements in the lower anterior segment are small. This approach is com mon in treatment of class II division 1 dental malocclusion. Maxillary first premolars only: therapeutic class II occlusion In certain forms of class II malocclusion, where the lower arch is well aligned, protrusion may be corrected by extraction of first premolars in the upper arch only. The 95

 CLINICAL PRACTICE AND THE OCCLUSION B Fig. 10.5 A Therapeutic class II. B Therapeutic class III. Fig. 10.6 Case of space closure with missing maxillary laterals before (above) and after ( below) treatment. postorthodontic occlusion would have a normal overjet and overbite, with maxilla ry second premolars and molars in a full cusp class II relationship with the man dibular arch. Under these conditions the mesiobuccal cusp of the maxillary first molar articulates in the embrasure between the mandibular first molar and secon d premolar. The dis tobuccal cusp of the maxillary molar articulates with the ma ndibular first molar mesiobuccal groove (Fig. lO.5A). Mandibular first premolars: therapeutic III occlusion class In certain forms of class III malocclusion, treatment might involve alignment of the maxillary arch, proclination of the upper anteriors and retraction of the m andibular incisors, while the molars are maintained in a class III malocclusion. The space for retraction and retroclination of the lower incisors may need to b e obtained by 96

OCCLUSION AND ORTHODONTICS extraction of lower first or second premolars. Postorthodontic occlusion will ha ve a class III molar and premolar relation and class I canine relation with norm al overjet and overbite (Fig. 10.58). Occlusion with missing maxillary laterals Orthodontic treatment with missing maxillary laterals may include regaining spac e and restoration of laterals. In other situations where extraction space may be required for the correction of the malocclusion, the lateral incisor space can be closed by moving the maxillary canines mesially. Postorthodontic (normal) occ lusion in such a case would substitute the first premolars for the maxillary canines and the cani nes for the laterals. Canines need to be modified for aesthetics and would requi re reshaping of the labial surface, cusp tip and proximal surfaces, to more clos ely resemble the laterals. The mesial and distal slopes may be modified with com posite resin. The functional anterior guidance would necessitate some adjustment of the lingual surface. The maxillary first premolar may substitute for the max illary canine, and the intra-arch 'canine' relationship has the mesial slope of the maxillary first premolar with the distal of the lower canine. The maxillary first premolar may need reshaping of the mesiobuccal slope and some reduction of the lingual cusp (Fig. 10.6). PART 2: ADULTS a combined orthodontic and surgical approach (orthognathic surgery). The outcome (s) are rewarding in suitable patients and require careful treatment planning Or thodontic treatment (including surgical orthodontic treatment) shows some relaps e with time The severity of the relapse is governed by many factors, including t he nature of the initial malocclusion, type of treatment, quality of treatment, retention protocol, residual growth of the face, type of face, presence of third molars, soft-tissue behaviour and periodontal health Choice of a retention appl iance and specific retention protocol are governed by the type and severity of t he initial malocclusion, the age of the patient and any individual predisposing factors for relapse Relapse is associated with and may be amplified by the natur al ageing process Synopsis This section provides an overview of the combined orthodontic and orthognathic t reatment options in cases of severe malocclusion with underlying skeletal proble ms. Treatment considerations and objectives of adult orthodontic occlusion are s ummarised. The concepts related to postorthodontic retention - philosophy, metho ds and prevention of relapse - are introduced. Key points The occlusion is in a constant state of biological adaptation, with age changes in the dentition, periodontal tissues and supporting structures Orthodontic trea tment goals in adult occlusion are aimed at achieving a functionally and aesthet ically acceptable occlusion within the limitations of each case. These are impos ed by periodontal health, missing teeth, health of the existing teeth and genera l health of the individual More severe forms of malocclusion, such as severe man dibular retrognathia, maxillary hypoplasia, mandibular prognathism, extreme vert ical dysplasia (long face syndrome), large transverse discrepancies, jaw deviati ons, can only be managed with

 ADULT OCCLUSION Adult occlusion changes continuously throughout and adapts to intrinsic and extr insic factors. life Physiological changes Physiological tooth migration is the lifelong ability for teeth and their suppor ting tissues to adapt to functional 97

II CLINICAL PRACTICE AND THE OCCLUSION demands and, as a result, move through the alveolar process. In humans, teeth in the posterior segments tend to migrate mesially to compensate for wear of inter proximal contact surfaces. Further tooth movement may occur following changes in occlusal equilibrium with loss of a neighbouring or antagonistic tooth. In addi tion to mesial migration, teeth exhibit continued eruption. Studies have demonst rated continuous eruption of upper incisors by 6.0 mm per year between the ages of 19 and 25 (Iseri & Solow 1996). Growth and development of the craniofacial sk eleton is a continuing, long-term process with periods of exuberance and relativ e quiescence, but the biological mechanisms that regulate growth changes remain intact and active throughout life. ORTHODONTIC TREATMENT IN ADULTS In recent years, altered lifestyles and improved dental and orthodontic awarenes s have led to an increased demand for orthodontic treatment by adults. The ideal treatment objectives of aesthetics, function and stability may need to be modif ied for adult patients, and many cases require an interdisciplinary approach. To facilitate placement of fixed or removable prostheses and a healthy periodontal status, parallelism of abutment teeth, intra-arch and interarch space distribut ion, adequate embrasure space and root position, and occlusal vertical dimension change need to be achieved in comprehensive treatment in conjunction with other specialities. Aesthetics of hard and soft tissues are often the main concern fo r adults. The harmony of smile line, gingival level and dental alignment need to be considered as part of interdisciplinary treatment. Adults tend to be anxious about lip competency and support; many adults have a thin upper lip that may be increased in length; changes to the upper lip, with inadequate tooth, bone and soft-tissue support, create an aged appearance. The maintenance of upper lip sup port precludes significant retraction of maxillary incisors, and, in class II di vision 1, advancement of the mandibular dental arch may be the preferred treatme nt objective to develop incisal guidance. Periodontal health is accomplished by improving crown: root ratio in patients who have bone loss and by correcting muc ogingival and osseous defects by repositioning prominent teeth to improve gingiv al topography. The reduction of clinical crown length together with orthodontic extrusion will improve crown: root ratio. Location of gingival margins is determ ined by the axial inclination and alignment of teeth. Clinically there is improv ed self-maintenance of periodontal health when teeth are correctly positioned. T he aim is to level crestal bone between adjacent cementoenamel junctions, as thi s creates a more physiological osseous architecture and the potential to correct o sseous defects. There is a delayed response to mechanical forces in adults as a result of age-related changes of the skeleton and alveolar bone. However, there is no evidence to suggest that teeth move at a slower rate. In a healthy periodo ntium, bone will remodel around a tooth without damage to the supporting tissues . This principle is used to create favourable alveolar bone changes in patients with periodontal defects, for example, the uprighting of molars to reduce pocket depth and improve bone morphology. Extrusion, together with occlusal reduction of clinical crown height, is reported to reduce infrabony defects and reduce poc ket depth. This procedure is advocated for the treatment of isolated periodontal osseous defects, which may be eliminated when marginal bone heights are levelle d. Intrusion of teeth to improve periodontal support has been proposed, but the evidence in the literature is conflicting.

OCCLUSION AFTER TREATMENT WITH COMBINED FIXED APPLIANCE AND ORTHOGNATHIC SURGERY Severe dysplasia of skeletal malocclusion - skeletal class II, class III or extr eme open and deep bite, long face, jaw deviations - can only be corrected in a c ombined approach of orthodontic treatment and orthognathic surgery for surgical correction of the deformity. Where a severe skeletal class III malocclusion pres ents, orthodontic treatment alone is insufficient and treatment requires reducti on in jaw length. A number of surgical lengthening/ shortening procedures of the mandible and relocation of the maxilla are used in clinical practice. Bilateral sagittal split osteotomy (BssO) is the most common for the mandible and Le Fort I and II (fracture of the maxilla and subsequent fixation in the required posit ion) for the maxilla. A number of variations/ combinations of occlusal relations hip are governed by the type and extent of the skeletal and dental malocclusion, and the orthodontic treatment and surgical options. In general, the objectives are to provide a well-balanced harmonious face (skeletal and soft tissue), and a n acceptable functioning occlusion in a class II class 11/or class III molar rel ationship. Ideally, the occlusion at the end of treatment should match specifica tions of a normal occlusion; however, depending on the severity of the discrepan cy, dental compensations are accepted. Dental compensations may camouflage the e xtreme nature of the discrepancy in the sagittal, transverse and vertical planes . In the sagittal plane, upper and/or lower incisors are proclined or retrocline d in class II and class III 98

OCCLUSION AND ORTHODONTICS orthognathic surgery cases to decrease the amount of surgical movement of the ma xilla and/or mandible. In the transverse plane, upper and/ or lower posterior te eth are buccally and/or lingually tipped in posterior crossbite and buccal bite cases to decrease the amount of surgical movement of the maxilla and/or mandible . In the vertical plane, upper and/or lower posterior teeth may be extruded or i ntruded; and upper and/or lower incisors may be extruded or intruded in open-bit e and deep-bite cases to decrease the amount of surgical movement of the maxilla and/ or mandible. Skeletal class 11/ These cases require shortening of the mand ibular base and occasionally maxillary advancement. Skeletal class /I These case s require lengthening of the mandibular base and occasionally maxillary impactio n. width, however, appears to be stable from 13-20 years. Mandibular arch length de creases with time and the lower incisors become increasingly irregular, particul arly in females. These arch changes are observed before 30 years of age; lower i ncisor crowding continues beyond 50 years of age. Periodontal and gingival tissues The stability of tooth position is determined by the principal fibres of the per iodontal ligament and the supra-alveolar gingival fibre network. These fibres co ntribute to a state of equilibrium between the tooth and the soft-tissue envelop e. Orthodontic tooth movement causes disruption of the periodontal ligament and the gingival fibre network, and a period of time is required for reorganisation of these fibres after removal of the appliances: Reorganisation of the collagen fibre bundles in the periodontal ligament occurs over a 3-4 month period; at thi s stage tooth mobility disappears. The gingival fibre network is made up of both collagenous and elastic-like oxytalan fibres. Reorganisation of this network oc curs more slowly than in the periodontal ligament; the collagenous fibres remode l in 4-6 months, while the oxytalan fibres may take up to 6 years to remodel. It is believed that the slow remodelling of the supraalveolar fibres of the gingiv al complex contribute to the relapse of teeth after orthodontic treatment, espec ially in those teeth that were initially rotated. The direction of relapse will tend to be towards the original position of the tooth, thus full-time retention for 3-4 months following removal of orthodontic appliances is required to allow time for reorganisation of the periodontal tissue structures. Retention should b e continued part-time for at least 12 months to allow time for reorganisation of the gingival fibres. To minimise rotational relapse, the following has been sug gested: Early correction of the rotation to allow more time for reorganisa tion. Overcorrection of the rotation if the occlusion allows. In the premolar region overcorrection is possible, especially during early stages of the treatment. How ever, overcorrection at the anterior region, especially towards the achievement of the normal occlusion, when an ideal incisor relationship is obtained, is prac tically impossible. Circumferential supracrestal fibreotomy or pericision at or just before removal of appliances. This procedure involves transection of the su pra-alveolar fibres, allowing reattachment in the corrected position. ORTHODONTIC OCCLUSION IN THE LONG TERM: RELAPSE AND RETENTION Relapse is the tendency for teeth to move from the positions in which they were placed by orthodontics, while retention is 'the holding of teeth following ortho dontic treatment in the treated position for the period of time necessary for th e stability of the result'. Long-term studies of treated cases at the 10-20 year postretention period have shown that orthodontic results are potentially unstab le due to: physiological mesial migration of teeth (age-related changes) periodo ntal and gingival health residual growth neuromuscular influences specific ortho dontic tooth movements developing third molars. A retention phase required to: f ollowing orthodontic treatment is

 allow time for periodontal and gingival reorganisation minimise changes in the o rthodontic result from subsequent growth permit neuromuscular adaptation to the corrected tooth position maintain unstable tooth positions. Normal developmental changes occur in the dentition in both untreated individuals and those who have undergone orthodontic treatment. The changes in the craniofacial structures, in cluding the dental arches, are not simply due to, or the result of, orthodontic and orthopaedic treatment but are also due to ageing. There is an increase in in tercanine width until eruption of the permanent canines, after which this width decreases. The intermolar 99

II CLINICAL PRACTICEAND THE OCCLUSION A Fig. 10.7 B Retention appliances. A Removable maxillary Begg retainer. B Fixed lower lingu al retainer. Neuromuscular influences The soft tissues of the lips, cheeks and tongue at rest contribute to the equili brium and, therefore, stability of tooth position following orthodontic treatmen t. The initial mandibular intercanine and intermolar arch widths are believed to be accurate indicators of the individual's muscle balance between lips, cheeks and tongue. The initial position of the lower incisor has also been shown to be the most stable position for the individual. Permanent retention for the first 3 -4 months is required to allow time for soft tissues of cheeks, lips and tongue to adapt to the new tooth positions. Wherever possible the initial intercanine w idth and lower incisor positions should be maintained. Permanent retention is es sential if advancement of the lower incisors is an objective of treatment. Late mandibular growth has been considered a major cause of relapse of crowding in the mandibular arch in late adulthood. Figure 10.7 illustrates both removable and fixed retention appliances. I~ iP References Effect of residual growth on orthodontic occlusion Skeletal problems will tend to relapse if growth continues beyond completion of orthodontic treatment. In late adolescence, and even adulthood, continued growth in the pattern that caused a class II, class III, deep-bite or open-bite proble m is a major cause of relapse and requires careful management during retention. As a result of the residual mandibular growth, the lower incisors, contained by the upper incisors, cannot accommodate forward movement of the mandible and tend to tip lingually, causing lower incisor crowding. Clinical observation suggests finishing either with a small overjet at the end of treatment, or fixed retaine rs for the lower canine-to-canine area. Some clinicians rotate the mesial side o f the lower canine lingually to prevent mesial movement of the canines after the retention period. 100 Andrews L F 1972 The six keys to normal occlusion. American Journal of Orthodont ics 62:296-309 Angle E H 1906 The upper first molar as a basis of diagnosis in o rthodontics. Dental Items of Interest 28:421-426 Begg P R 1954 Stone age man's d entition. American Journal of Orthodontics 40:298-312, 373-383, 462-475, 517-531 lseri H, Solow B 1996 Continued eruption of maxillary incisors and first molars in girls from 9-25 years, studied by implant method. European Journal of Orthod ontics 18:245-256 Roth R H 1981 Functional occlusion for the orthodontist. Journ al of Clinical Orthodontics 15:32-51 Tweed C H 1945 A philosophy of orthodontic treatment. American Journal of Orthodontics and Oral Surgery 31:74-103 Further reading Behrents R G 1985 An atlas of growth in the aging craniofacial skeleton. Centre for Human Growth and Development, University of Michigan, Ann Arbor, vol 18 Blak

e M, Bibby K 1998 Retention and stability: a review of the literature. American Journal of Orthodontics and Dentofacial Orthopedics 114:299-306 Clark J R, Evans R D 2001 Functional occlusion: a review. Journal of Orthodontics 28:76-81 Grabe r T M, Vanarsdall R L [r (eds) 2000 Orthodontics: current principles and techniq ues, 3rd edn. Mosby, St Louis, pp 29-30 Hellman M 1920 Dental cosmos. In: Strang R H W (ed) (1950) A textbook of orthodontia, 3rd edn. Lea & Febiger, Philadelph ia: p 35

OCCLUSION AND ORTHODONTICS Horowitz S L, Hixon E H 1969 Physiologic recovery following orthodontic treatmen t. American Journal of Orthodontics 55:1-4 Kasrovi P M, Meyer M, Nelson G D 2000 Occlusion: an orthodontic perspective. Journal of the California Dental Associa tion 28:780-790 Little R M, Riedel R A, Artun J 1988 An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. American Journ al of Orthodontics 93:423-428 Moyers R E 1988 Handbook of orthodontics, 4th edn. Chicago, Yearbook Nangia A, Darendeliler M A 2001 Finishing occlusion in class II or class III molar relation: therapeutic class II and III. Australian Orthodo ntics Journal 17:89-94 Proffit W R, White R R [r (eds) 1991 Surgical orthodontic s. Mosby, St Louis, pp 248-263, 264-282 Reitan K 1960 Tissue behavior during ort hodontic tooth movement. American Journal of Orthodontics 46:881-900 Richardson M E 1989 The role of the third molar in the cause of late lower arch crowding: a review. American Journal of Orthodontics and Dentofacial Orthopedics 95:79-83 Richardson M E 1999 Prophylactic extraction of lower third molars: setting the r ecord straight. American Journal of Orthodontics and Dentofacial Orthopedics 115 (1):17A-18A Richardson M E 1999 A review of changes in lower arch alignment from seven to fifty years. Seminars in Orthodontics 5:151-159 Richardson M E, Gormle y J S 1998 Lower arch crowding in the third decade. European Journal of Orthodon tics 20:597-607 Roth R H 1987 The straight wire appliance 17 years later. Journa l of Clinical Orthodontics 21: 632-642 Staley R N 2001 In: Bishara S E (ed) Text book of orthodontics. Saunders, Philadelphia, pp 98-104 Strang R H W 1950 A Tex tbook of orthodontia, 2nd edn. Lea & Febiger, Philadelphia, pp 24-51, 78-106 Thi lander B 2000 Orthodontic relapse versus natural development. American Journal o f Orthodontics and Dentofacial Orthopedics 117:562-563 Vaden J L, Dale J G, Klon tz H A 2000 The Tweed-Merrifield appliance: philosophy, diagnosis and treatment. In: Graber T M, Vanarsdall R L [r (eds) Orthodontics: current principles and te chniques, 3rd edn. Mosby, St Louis, pp 647-707 101

Occlusion and fixed prosthodontics T. Walton Synopsis This chapter presents the rationale for establishing tooth contact patterns duri ng fixed prosthodontic procedures, i.e. for establishing a therapeutic occlusal form. In the absence of scientific data, various 'philosophies of occlusion' hav e evolved in an effort to describe the relationships that should be developed be tween the teeth during restorative procedures or adjustment of the natural denti tion. With little evidence, these philosophies or concepts often involve complic ated and expensive instrumentation and some are promoted with almost religious z eal rather than scientific rigor. Form that supports function is the basis of th e rationale for occlusal form outlined in this chapter. The biological, physiolo gical and mechanical results of an up-to-15-year longitudinal assessment of the outcome of single crowns and fixed partial dentures provides evidence for its ef fectiveness. There is a need for further long-term studies evaluating the outcom e of fixed prosthodontics. It is accepted that prospective, randomised clinical trials with adequate controls and well-defined criteria are very difficult to ca rry out. In addition, clinical studies of less than 5 years have little relevanc e (Cruegers et al 1994) and can lead to incorrect conclusions (Walton 2002). It is therefore imperative that clinicians document and publish information from th eir clinical practice. The resultant collective data would facilitate a more evi dence-based approach to procedures used in fixed prosthodontics. Key points The following are the key points for establishing occlusal form in fixed prostho dontics. Intra-arch stability effected by firm interproximal contacts Interarch stability effected by at least one contact on each opposing tooth in ICP Bilater al synchronised contacts in ICP Absence of posterior contacts during protrusive movements A flat occlusal plane Maintenance of physiological tooth mobility wher e possible Slight clearance (10 urn foil thickness) between the incisors in maxi mum intercuspation (MI) Minimal cusp height and fossa depth Lateral gliding cont acts restricted to the canines or effected as far forward in the arch as possibl e INTRODUCTION Occlusion is the dynamic interplay of various components including the teeth, th eir supporting tissues, the jaw muscles, the temporomandibular joints and the ce ntral pattern generator and other associated cortical interactions. As in any ph ysiological system, a 'normal' state includes a degree of adaptability with a ra nge of form and the absence of pathology. The magnitude of any changes and the d uration over which they occur will influence whether adaptation or pathology ens ues. Slow changes will facilitate adaptation even when the changes eventually le ad to a significant deviation from ideal form. Fixed prosthodontics, however, in volves relatively instantaneous changes in form, thus challenging the adaptive c apacity of the occlusal system. A therapeutic 103

 CLINICAL PRACTICE AND THE OCCLUSION occlusal form that requires minimal adaptation will be less likely to initiate p athology, and the health of the occlusal components will be determined to a grea t extent by the subsequent stability of the teeth. tongue-thrust habit may result in mobility or migration of the tooth even in the absence of any opposing tooth contact. Swallowing Swallowing is also an innate reflex response, that does not necessarily involve the teeth. An important aspect of swallowing involves bracing of the jaw to supp ort the suprahyoid muscles. This is achieved during the infantile swallow patter n by bracing the tongue against the palate. Although the tongue is sometimes use d for jaw bracing by children and adults, for example when drinking, the more co mmon means of jaw bracing during swallowing involves contact between the teeth i n ICP. The forces involved are relatively light. Thus contact between only a few teeth would be unlikely to involve excessive loading leading to symptoms within the teeth or periodontal tissues. Tooth contacts during swallowing will also va ry with head posture. The occlusal form of the teeth and their interarch contact s would seem to have little bearing on swallowing. However, bilateral synchronis ed tooth contacts at ICP may facilitate optimum physiological neuromuscular acti vity during swallowing. TOOTH CONTACTS There has been debate regarding the number and position of contacts required to maintain individual tooth stability. Contacts on natural teeth occur on flat sur faces, marginal ridges, cusp tips, cusp inclines and in fossa. They may be point or plane contacts. Philosophies of occlusion that prescribe specific and multip le point per tooth contact patterns assume a required precision that does not oc cur naturally. It has not been demonstrated that such precision results in any g reater long-term stability of tooth position than that which occurs in the natur al unrestored dentition. Contacts between teeth result in vertical and lateral f orces and significant tipping and rotations may occur if tooth position is unsta ble. Maintaining interproximal contacts facilitates intra-arch stability while i nter-arch tooth stability is facilitated by bilateral contacts between opposing teeth in the intercuspal position (ICP). However, the relatively short time that opposing teeth contact indicates that other forces arising from the tongue and facial musculature, the periodontal ligament and alveolar bone transceptal fibre s may also influence long-term tooth stability. Phonetics The arrangement of the anterior teeth will affect phonetics as well as aesthetic s. The proximity of the upper and lower anterior teeth during protrusive movemen ts, for example, will determine the 'c' , 's' and 't' sounds. The relationship o f the upper anterior teeth and the lip will affect 'f' and 'v' sounds. As well a s facilitating interpersonal communication, there is a social expectation that p honetic patterns will be effected in a specific way. Thus, the absence of anteri or teeth, or any impediment such as posterior contacts that prevent anterior too th approximation when protruding the jaw for speech, can affect self-image as we ll as speech. Excessive lateral deviation or torquing around posterior teeth to develop socially acceptable speech patterns will require adaptation of the jaw n euromuscular system. Exceeding the physiological 'adaptability' of one or more o f these components may result in pain or dysfunction. The length of the incisors , the degree of overbite and overjet, the angle of condylar inclination and the curve of the occlusal plane will influence anterior tooth approximation during p rotrusion. These factors, except condylar inclination, may be modified by restor ative procedures. Tooth form and tooth arrangement should therefore ensure an ab

sence of posterior contacts during protrusive jaw movements and this will be fac ilitated by developing a flat occlusal plane. Thus restorative procedures, which influence phonetics, may also affect the patient's psychological and physiologi cal well-being. FORM THAT SUPPORTS FUNCTION The functions performed by components of the occlusion include suckling, swallow ing, speech, mastication and parafunction. They also contribute to self-image (a esthetics) and emotional expression. Suckling Suckling is an innate reflex that does not involve the teeth. However, in its ma ture form sucking might be considered a parafunction if habits such as finger or tongue sucking become prolonged. The forces involved during such parafunction a nd other habits, such as tongue thrusting, can affect the position and stability of the teeth, especially those with reduced periodontal support, and may be lin ked to specific skeletal jaw morphology. Therefore, although these forces have l ittle bearing on considerations of tooth form in fixed prosthodontics, it is imp ortant to recognise their existence when assessing and effecting long-term follo w-up. For example the overcontoured palatal form of a crowned maxillary central incisor in conjunction with a 104

OCCLUSION AND FIXED PROSTHODONTICS Mastication Mastication usually involves an approximation but not necessarily contact betwee n posterior teeth. It is possible to prepare a food bolus for swallowing without tooth contact. The efficiency of comminution of the food bolus will be influenc ed by the contour of the occlusal surfaces. Steep cuspal inclines mayor may not promote chewing efficiency but will increase lateral loading on the teeth. The n eed for chewing efficiency (and posterior teeth) has decreased significantly wit h modern food-handling techniques. Thus the actual occlusal form provided during restorative procedures would seem to have minimal effect on mastication. The ef fect of lateral loading on teeth may be more significant, especially if the rest ored teeth have reduced periodontal and bony support. In these circumstances low cusp height and shallow fossa depth appear to be beneficial to reduce lateral l oads. rate of wear exceeds the response of the pulp and results in pain can it be cons idered pathological. However, tooth wear and increased tooth mobility may become psychologically debilitating and socially unacceptable. There are cultural diff erences between what is considered acceptable tooth wear, as there are cultural differences in what is considered acceptable tooth colour. Just as commercial ma rketing has promoted the concept that all teeth should be 'white', there is a pe rception that teeth should maintain their adolescent form throughout life. MAINTAINING TOOTH INTEGRITY Parafunction Tooth clenching and grinding (bruxing) are common forms of parafunction involvin g tooth contacts. However, it may be difficult to distinguish between what is no rmal physiological activity and what is parafunctional activity. Clenching durin g power activities such as weight lifting is more likely a normal physiological action than parafunction. Clenching and bruxing during tooth eruption or during stress may also be part of normal physiological activity. It is generally agreed that forces generated during these activities are greater than during other for ms of tooth contact. It is likely that these forms of parafunction are universal . Their amplitude and frequency, however, vary significantly between individuals and result in various forms of adaptability and morphological changes including muscular hyperthrophy, tooth movement, tooth intrusion and wear, periodontal li gament thickening, increased periodontal bone density and temporomandibular join t (TMJ) remodelling. They may possibly also result in pathological changes, incl uding neuromuscular and TMJ dysfunction, tooth and periodontal ligament sensitiv ity and pulpal inflammation. It should be assumed that all patients at some time engage in tooth clenching and grinding, either physiological or parafunctional, and that dental restorations will be subjected to the relatively high magnitude of forces involved. It therefore seems prudent to apply an occlusal scheme that promotes the integrity of the occlusal components assuming the presence of such forces. TOOTH WEAR Tooth wear by itself cannot be considered a pathological consequence of parafunc tional activity. Only when the The periodontal ligament is structured to convert compressive forces to tensile strain between the tooth and supporting bone and does this most efficiently when the forces are applied along the long axes of the teeth. Bone resorbs under com pression, but its structural integrity is stimulated under moderate tensile forc es. The inherent resilience imparted by the periodontal ligament acts as a shock absorber during the application of force, thus lowering the impact loads that h

ave to be sustained by bone, teeth and restorative materials. In addition, movem ent of the teeth away from an applied force can allow other teeth to accept the load. Initial contact in or around ICP is often limited to one or two teeth, but as the biting force increases, more teeth accept the load (Riise & Ericsson 198 3). Thus physiological tooth mobility is a 'protective' mechanism and helps to e nsure tooth and bone integrity. It will also help preserve the mechanical integr ity of restorations. Splinting of teeth may be necessary but maintaining individ ual tooth mobility where possible rather than joining teeth together for restora tive purposes would seem to be a worthwhile goal. The use of non-rigid connectio n in fixed partial dentures may assist in achieving this goal and help maintain the mechanical integrity of any prosthesis (Walton 2003). Excessive lateral load ing can result in structural failure of teeth (fracture) or breakdown of support ing structures. Teeth that are structurally weakened through dental caries and r esultant restorative procedures, or have lost support through periodontal diseas e, are particularly affected by increased lateral loading. Forces applied to the teeth during clenching and grinding will be higher than those applied during an y other function. Thus the loading on tooth form and contacts developed during r estorative treatment will be greatest during parafunction. Lateral loading shoul d be minimised to ensure biological health and mechanical integrity. The maxilla ry anterior teeth are most likely to be subjected to increased lateral loading d uring clenching and chewing because of their inclination (Wiskott & Belser 1995) . This will be further exacerbated following 105

 CLINICAL PRACTICE AND THE OCCLUSION posterior tooth wear (and possibly restoration) and any associated loss in occlu sal vertical dimension (OVD). Excessive contact between the anterior teeth resul ts in fremitus when closing into the intercuspal position. Anterior flaring may also occur if excessive anterior tooth contact prevails over a long period, espe cially if there is associated loss in periodontal support. Splinting of teeth ma y reduce fremitus, but because of its limiting effect on inherent tooth mobility it may also increase tooth fracture. Tooth fracture has been shown to be the mo st common form of failure associated with fixed partial dentures (Walton 2003). Given that it is not possible to measure the intensity of contacts clinically, i t would seem prudent to establish and maintain slight clearance 00 urn foil thic kness) between the anterior teeth in ICP. All teeth are potentially subjected to increased lateral loading during eccentric bruxism. It is assumed that the shal lower the cuspal inclines and fossae, the less lateral loading will be developed during gliding tooth contacts. and result in 'looseness' in the joint. This may affect condylar movements. Deve loping a flat occlusal plane will help to avoid posterior eccentric contacts. SUPPORTING EVIDENCE FROM CLINICAL OUTCOME STUDIES As a result of these considerations, the factors above are proposed recommendati ons for establishing tooth form and contacts during restorative procedures. Ther e are no prospective studies confirming that a particular design promotes physio logical and mechanical stability in fixed prosthodontic treatment. There are few longitudinal outcome studies that detail the occlusal contact pattern used as p art of the study protocol. However, a retrospective 10-year review of single cro wns and fixed partial dentures incorporating the above recommendations into the treatment protocol resulted in only 2% of 344 patients developing temporomandibu lar dysfunction (TMD) subsequent to treatment (Walton 1997). Of these patients, 78% had experienced TMD before treatment and the development of post-treatment s ymptoms may have been part of the cyclical nature of TMD. In addition only 0.5% of 688 metal-ceramic single unit crowns up to 10 years (Walton 1999) and 0.1% of 1208 abutments in 515 metal-ceramic fixed partial dentures up to 15 years (Walt on 2002, 2003) mechanically failed (lost retention, fracture of the materials). These data suggest that the guidelines for occlusal form as described above cont ributed to physiological and mechanical stability. LATERAL TOOTH GUIDANCE FUNCTION DURING Canine teeth are well adapted to accept lateral loading (Ch. 1). They have a fav ourable crown; root ratio; are broad buccolingually; are encased in dense and we ll-buttressed bone; and the cuspal inclination is relatively shallow. In other a nimals the canine is most laterally loaded during tearing of food. This evolutio nary adaptation is redundant in humans for food gathering, but has established t he canine as capable of withstanding lateral forces involved in parafunction. Th is fact can be utilised in restorative procedures. Unless the canine is structur ally weakened, or canine contact is not possible during eccentric movements (Ang le class II division 1 anterior tooth arrangement), it appears to be reasonable to concentrate lateral gliding contacts on the canines during restorative proced ures. When this is not possible it is clinically prudent to distribute lateral f orces over several teeth, but furthest away from the point of application of max imum biting force, that is, as far forward in the arch as possible. When canine guidance is not possible then eccentric gliding contacts may be distributed simu ltaneously over several teeth i.e. 'group function' involving incisors and premo lars to distribute lateral forces on less biomechanically robust teeth. Posterio

r teeth may act as pivoting fulcrum points during gliding movements. This may re sult in distraction and negative pressure within the ipsilateral TMJ in associat ion with tensile stress on capsular attachments, as suggested by Hylander (979). Repeated stress may lead to strain involving stretching or tearing of the attac hments HARM VERSUS BENEFIT Dental treatment involves a degree of iatrogenic injury. The benefits of dental restoration must therefore be weighed against the injury caused. In the absence of signs or symptoms of dysfunction associated with the occlusion, or compromise d tooth structure integrity, or poor aesthetics (teeth or supporting structures) , it is difficult to justify any restorative procedures (or occlusal adjustment) . Cultural demands to restore tooth wear, discoloration or other perceived tooth imperfections and even tooth replacement may result in overtreatment, where the benefits are outweighed by the iatrogenic consequences or financial costs of th e procedures and necessary long-term maintenance. The concept of 'the shortened dental arch' as a viable treatment option had its genesis in the reality that to oth replacement in the posterior segments often results in iatrogenic injury to remaining hard and soft tissues without significant improvement in function. 106

OCCLUSION AND FIXED PROSTHODONTICS THE 'CENTRIC' TREATMENT POSITION There has been much confusion and debate regarding the correct maxillomandibular relationship (MMR) to be utilised during restorative procedures. Initial consid eration of MMR was applied to the construction of complete dentures where there were no naturally occurring interdental relationships. Jaw closure around the TM Js at a specific vertical dimension was the reference point, and instrumentation was developed to simulate this arc of closure. The actual position of the condy le in the glenoid fossa became a controversial topic (Ch. 1). Recording retruded jaw position (RP) or centric relation (CR) has also been a contentious issue. J aw guidance by the dentist to ensure correct condyle-fossa relationships has bee n strongly advocated by some clinicians. However, it is difficult to assess what guidance force should be applied to the resilient TMJs to prevent a strained jo int position. In addition, different operators will inevitably apply different g uiding force. It is difficult to accept that a physiological MMR would be obtain ed. Furthermore, to assess when the condyles are in a 'desired' position in the fossae is not clinically possible. Other clinicians advocate a non-guided closur e, provided that deflective tooth contacts are either absent or eliminated. Howe ver, in this case it is difficult to assess if habitual neuromuscular patterns m ask the optimum physiological closure path and possibly perpetuate recording of a strained TMJ relationship. Interarch recording materials that eliminate tooth contacts can be utilised to relate casts in RP at a given OVD. Further opening o r closure of articulated casts along this arc will only represent the clinical s ituation if the hinge axis has been determined and the orientation of the casts in relation to the hinge axis is identical to that which occurs clinically. Inte rcuspal contact position will be determined in part by biting force and head pos ture. Following initial contact the tooth surfaces may cause a deviation in the arc of closure and individual tooth movement may result in more teeth contacting as bite force increases. Indeed, it is well established (Ch. 1) that only about 10% of the population have an ICP that is coincident with RCP clinically. Maxim um interdigitation of teeth on casts is repeatable for a given set of casts, but will be determined by the position of the teeth recorded in the impressions. In most instances it will very closely simulate the clinical ICP resulting with mo derate biting force. It is a convenient and acceptable reference for indirect re storative procedures, provided that individual teeth have minimal mobility and t here are sufficient tooth contacts to stabilise the casts. Deflective tooth cont acts may result in this reference position being anterior or lateral to the MMR in RP (CR). The recorded maximum interdigitation of teeth on casts should be used for single tooth restorations, fixed partial dentures involving one or unilateral posterio r teeth, or fixed partial dentures involving anterior tooth restoration or repla cement. This assumes an absence of either signs or symptoms of dysfunction or a significant deviation (>2.0 rnrn) from the RCP position, Tooth contact relations hips may be altered by occlusal adjustment or by changes to the contour of provi sional restorations and may result in an area of possible tooth contacts rather than point contacts. The resultant contact area may include the ICP position at the same vertical dimension. There is no scientific evidence to specify that suc h an adjustment is necessary before carrying out restorative procedures. It may be indicated to enhance individual tooth integrity where contacts occur on incli nes of teeth that have become structurally weakened by previous restorative proc edures. Occlusal adjustment (Ch. 15) may then result in a reduction in the later al component of the applied force. ROLE OF INSTRUMENTATION Instruments used in fixed prosthodontics should allow development of a physiolog

ical occlusion and should not require a specific tooth contact pattern. Irrespec tive of the degree of sophistication of the instrumentation, harmony of the vari ous occlusal components must be established. It is prudent to simplify the role and type of any instrumentation employed, given the possibilities for inaccuraci es developing in the many procedures involved (Ch.6). Changes to the occlusal fo rm during restorative procedures may preclude the use of ICP as a treatment posi tion. Prior elimination of deflective tooth contacts by occlusal adjustment or w ith the use of provisional restorations would be likely to unmask any habitual n euromuscular patterns. Subsequently, a patient-directed recording would probably result in a physiological RCP and avoid the variables associated with active ja w guidance by the clinician. Recording the MMR at the anticipated restored OVD t hen eliminates the need to record the hinge axis accurately. It has been claimed , however, that when an arbitrary hinge axis is used, rotational changes of the articulated casts of up to 2 mm (measured at the teeth) will not induce errors a bove clinically tolerable levels (Morneburg & Proschel 2002). Providing the reco rding medium itself does not cause jaw deflection, the subsequently restored too th contact pattern (ICP) will approach CO. The need to record and reproduce late ral jaw movements accurately can be eliminated by restricting lateral gliding co ntact patterns between as few teeth as possible, 107

I CLINICAL PRACTICE AND THE OCCLUSION minimising cusp height and fossa depth, and developing a flat occlusal plane. Av erage value settings on an articulator may be appropriate to ensure adequate cle arance of posterior teeth during lateral movements. A facebow oriented along an arbitrary hinge axis is a convenient method for locating casts relative to the i ntercondylar axis through the condyle spheres of an articulator. Further, this c an closely simulate the actual position of the jaws in the frontal, sagittal and vertical planes relative to the TMJs. A flat occlusal plane indicator may be ju st as effective for some clinical procedures (Shodadai et al 2001). It has been mathematically derived that when average value articulator settings are used the re is a relatively low risk of inducing occlusal errors at premolar and molar re gions during lateral movements (Proschel & Morneburg 2000). Thus, even if group function involving posterior teeth is indicated (e.g. Angle class II division 1 tooth relationships), only minor intraoral adjustment would be necessary to ensu re appropriate tooth contacts. There are no published data validating improved o utcomes in fixed prosthodontics when complex jaw movement recording devices and fully adjustable articula tors are used. On the other hand, use of instrumentati on as described in this chapter for fixed prosthodontic treatment has been found to be appropriate to ensure optimum outcome of prostheses up to 15 years (Walto n 2002). There has also been minimal physiological disharmony of the occlusal co mponents in monitoring patient treatments for up to 10 years (Walton 1999). with an Angle 'class II skeletal pattern and an obtuse gonial angle. A flat curv e is often associated with a more acute gonial angle. Where it is possible to ch ange the orientation of the occlusal plane in fixed prosthodontics. it should be related to aesthetic rather than any perceived functional considerations. LONG TERM MAINTENANCE The recommendations outlined in this chapter are designed to result in relative stability of the dentition to minimise adaptation and/ or the development of pat hology. It is accepted that changes will inevitably occur with time, and minor c hanges in tooth position, even in intact arches, have been demonstrated. Differe ntial wear between anterior and posterior teeth will occur due to the varying fo rces applied. Many dentitions will have several materials (natural and artificia l) forming occlusal contacts, and different toughness, abrasion- and erosion-res istant properties will result in differential wear of these materials. Long-term monitoring of the teeth and supporting structures should include adjustments to maintain the described contact patterns for maximising biological, physiologica l and mechanical stability. I~ 'r' References OCCLUSAL PLANE ORIENTATION Emphasis in the past was given to the orientation of the occlusal plane. Initial consideration related to the stability of complete dentures by minimising the p osterior space between the appliances in eccentric movements. The compensating c urves (curve of Spee and curve of Wilson) facilitated a balanced occlusion for a given anterior overjet and overbite. Other concepts like the Monson curves have been used to orient the occlusal plane in fixed prostheses to develop multiple contacts in eccentric movements such as group function. There is no evidence tha t there is any relationship between occlusal plane orientation and either functi on or outcome of fixed prostheses. In the natural dentition the most significant feature of the occlusal plane relates to aesthetics rather than function. The a nteroposterior cant, measured by reference to the incisal edges and buccal cusp

tips of the maxillary teeth, mostly follows the curve of the lower lip when in t he smile pose and this has an association with a pleasing appearance. Thus a 'st eep' cant will often be associated 108 Creugers N H, Kayser A F, van't Hof M A 1994 A meta-analysis of durability data on conventional fixed bridges. Community Dentistry and Oral Epidemiology 22:448452 Hylander W L 1979 An experimental analysis of temporomandibular joint reacti on force in macaques. American Journal of Physical Anthropology 51:433-456 Morne burg T R , Proschel P A 2002 Predicted incidence of occlusal errors in centric c losing around arbitrary axes. International Journal of Prosthodontics 15:358-364 . Proschel P A, Maul T, Morneburg T R 2000 Predicted incidence of excursive occl usal errors in common modes of articulator adjustment. International Journal of Prosthodontics 13:303-310 Riise C, Ericsson S G 1983 A clinical study of the dis tribution of occlusal tooth contacts in the intercuspal position in light and ha rd pressure in adults. Journal of Oral Rehabilitation 10:473-480 Shodadai S P, T urp J C, Gerds T, Strub J R 2001 Is there a benefit of using an arbitrary facebo w for the fabrication of a stabilization appliance? International Journal of Pro sthodontics 14:517-522 Walton T R 1997 A ten-year longitudinal study of fixed pr osthodontics: 1. Protocol and patient profile. International Journal of Prosthod ontics 10:325-331 Walton T R 1999 A lO-year longitudinal study of fixed prosthod ontics: clinical characteristics and outcome of single-unit metal-ceramic crowns . International Journal of Prosthodontics 12:519-526 Walton T R 2002 An up to 15 -year study of 515 metal-eeramic fixed partial dentures: Part 1. Outcome. Intern ational Journal of Prosthodontics 15:439-445

OCCLUSION AND FIXED PROSTHODONTICS Walton T R 2003 An up to 15-year study of 515 metal-ceramic fixed partial dentur es: Part 2. Modes of failure and influence of various clinical characteristics. International Journal of Prosthodontics (in press) Wiskott H W, Belser U C 1995 A rationale for a simplified occlusal design in restorative dentistry: historica l review and clinical guidelines. Journal of Prosthetic Dentistry 73:169-183 Further reading Beyron H L 1969 Optimal occlusion. Dental Clinics of North America 13:537-554 Helsing G, Helsing E, Eliasson S 1995 The hinge axis concept: a radiographic stu dy of its relevance. Journal of Prosthetic Dentistry 73:60-64 Picton D C 1962 Ti lting movements of teeth during biting. Archives of Oral Biology 7:151-159 Sarve r D M 2001 The importance of incisor positioning in the esthetic smile: the smil e arc. American Journal of Orthodontics and Dentofacial Orthopedics 120:98-111 T radowsky M, Kubicek W F 1981 Method for determining the physiologic equilibrium point of the mandible. Journal of Prosthetic Dentistry 45:558-563 Wood G N 1998 Centric relation and the treatment position in rehabilitating occlusions: a phys iologic approach. Part 2: The treatment position. Journal of Prosthetic Dentistr y 60:15-18 109

Occlusion and removable prosthodontics R. Jagger Synopsis Occlusal considerations for removable prostheses are essentially the same as for fixed restorations. The approach to establishing occlusion for removable partia l dentures is usually conformative. Partial dentures should not transmit excessi ve forces to supporting tissues nor interfere with any contacts in intercuspal p osition or in functional movements. Occasionally a reconstructive approach using onlays is used. Occlusion for complete dentures has three significant differenc es: The absence of natural teeth in edentulous patients may present significant difficulties in determining an acceptable occlusal vertical dimension. Complete denture occlusion is always a reorganised occlusion. Absence of teeth produces p roblems of denture stability (resistance to displacement by lateral forces), par ticularly of the mandibular complete denture. The stability of complete dentures is optimised by a balanced occlusion/articulation. This chapter provides an ove rview of occlusion for partial and complete removable prostheses, including disc ussion of both clinical and laboratory procedures. - Occlusal analysis - Clinical stages - On lay dentures Complete dentures - Occl usion for complete dentures - Occlusal vertical dimension - Artificial teeth - B alanced occlusion - Lingualised occlusion - Occlusion and patient satisfaction Clinical stages Good occlusal practice for removable dentures is very similar to that described for fixed prostheses. Partial dentures should not transmit excessive forces to s upporting tissues nor interfere in intercuspal position or in functional movemen ts. The occlusal form is usually conformative with the natural teeth. Occasional ly a reconstructive approach using onlays is used. Occlusion for complete dentur es, however, has three significant differences: The absence of natural teeth in edentulous patients may present significant difficulties in determining an accep table occlusal vertical dimension (OVD). Complete denture occlusion is always a 'reorganised' occlusion. Absence of teeth produces problems of denture stability (resistance to displacement by lateral forces), particularly of the mandibular complete denture. The stability of complete dentures is optimised by a balanced occlusion. Key points Partial dentures - Occlusion: conformative/reorganised approaches - Treatment pl anning for partial dentures PARTIAL DENTURES Occlusion: conformative / reorganised The usual goal of partial denture treatment (in respect of the occlusion) is to position the artificial teeth so that there is even contact and maximum intercus pation (MI) in the 111

 CLINICAL PRACTICE AND THE OCCLUSION intercuspal position (ICP). For more extensive partial dentures, such as bilater al distal extension saddle dentures, the aim might also be to achieve a balanced occlusion. Occasionally, instead of this conformative approach a reorganised ap proach is used when onlays or an onlay appliance covers some or all of the occlu ding surfaces of the dental arch. Insertion - occlusal correction Minor interferences are often present, as in complete dentures, due to previous clinical or laboratory errors. The dentures must be .adjusted so that the natura l teeth meet in precisely the same way both with and without the dentures in pla ce. Often chairside adjustment by selective grinding is sufficient. Marks produc ed by articulating paper must be interpreted with caution, by visual confirmatio n and by asking the patient for his or her perception of how the teeth contact. The patient should be asked whether the teeth contact evenly or meet on one side first. If aware of a premature contact, can the patient feel which tooth or tee th meet first. Again, this information must be used with caution. When maxillary and mandibular dentures are being inserted, each denture must be checked and co rrected separately. A final correction is done with both dentures in place. Very occasionally the occlusal errors are so large that chairside correction is not possible. In these cases, the artificial teeth causing the interferences should be ground off. Wax can be placed on the base in those regions and CR can be rere corded. If the denture has been returned to the clinic with the casts, a new occ lusal record can be taken, the casts remounted and the occlusion corrected in th e laboratory. Otherwise an overall impression should be taken with the denturels ) in place. The impressions should be cast and the dentures rearticulated, reset and retried. Treatment planning for partial dentures When replacing missing teeth, it is of evident importance that treatment is base d on a comprehensive treatment plan. The treatment plan must be derived from a c areful history, examination and the use of appropriate special investigations. F or the partially dentate patient, special investigations include radiographs, to oth vitality tests and usually articulated, surveyed study casts. The treatment plan for the partially dentate patient must include a detailed design of any pro sthesis. Occlusal analysis During the treatment-planning phase it is important to analyse the occlusion to detect any tooth alignment problems, such as overeruption, that might prevent th e construction of a prosthesis with a satisfactory occlusion. A decision must be made as to whether any preprosthetic occlusal adjustments or alterations are ne cessary; for example, the removal of any tooth cusp interferences along the arc of closure into ICP. Occlusal analysis is done both in the mouth and by the use of articulated study casts. A detailed account of clinical occlusal analysis has been given in Chapter 5. Study casts may be articulated without an occlusal rec ord if intercuspal position is coincident with centric relation (CR) and if ther e are sufficient teeth to provide stable intercuspation of study casts. If there are insufficient teeth, wax occlusal rims are usually used to determine centric jaw relation (CR).

On lay/overlay dentures Whereas complete dentures always have a reorganised occlusion, partial dentures usually have a 'conformative' occlusion. A reorganised approach for partial dent ures may be considered: to correct an overclosed occlusion to improve the occlus ion, for example when there is a gross discrepancy between RCP and the intercusp al position. This approach is achieved by the use of onlays. When a component of the partial denture extends to cover the greater proportion of the occlusal or incisal surface of a tooth it is called an onlay or overlay. Onlays may be used to cover one, many or all of the teeth in the dental arch. They may be made of a crylic resin or castmetal denture base materials. An alternative method is to ad d acrylic resin onto retention tags in metal that has been cast to the fitting s urface of the teeth. This has the advantage that the occlusal surface may be eas ily adjusted. Clinical stages Recording centric jaw relation The working casts also may be articulated without an occlusal record if centric occlusion (CO) is coincident with CR and if there are sufficient teeth to provid e stable ICP of the casts, If there are insufficient teeth, wax occlusal rims ar e used. The wax may be placed on shellac or acrylic base plates, or more commonl y on the metal framework. If the wax rims are to be placed on the framework it i s important to ensure beforehand that the framework fits accurately and does not interfere with the occlusion in retruded contact position (RCP, ICP) or in late ral excursions. 112

OCCLUSION AND REMOVABLE PROSTHODONTICS A B c o Fig. 12.1 A-D A mandibular partial onlay denture. The appliance replaces one of similar design that had been worn for approximately 20 years. Diagnostic or temporary onlays are usually constructed in acrylic resin. The use of an onlay appliance to correct an overclosed occlusion is shown in Figure 12. 1. Extensive coverage of teeth by occlusal onlays can predispose to dental carie s. If clinical conditions allow, fixed restorations are the preferred treatment. 'better' dentures. Nevertheless, it is important to understand the principles of occlusion related to removable prostheses in order to try to provide optimum tr eatment best suited to each individual. The clinician should have a clear pictur e of the occlusion that he or she is trying to achieve for each patient. Recommended occlusion for complete dentures COMPLETE DENTURES Occlusion In a detailed overview of the literature of occlusal considerations in complete dentures, Palla (1997) noted that patients' satisfaction with complete dentures is a complex phenomenon and that the occlusion plays only a minor part. Further, there is little evidence to support commonly held views on the advantages or di sadvantages of tooth form, tooth arrangement or occlusal schemes. Patient satisf action with dentures does not correlate closely with technical quality. For exam ple, patients with greatly decreased vertical dimension and severely worn occlus al surfaces may have no complaint about their dentures. Indeed they may be unabl e to adapt to new Recommended practice is to develop maximum intercuspation of complete dentures to coincide w ith CR at an acceptable aVD. Failure to achieve that can lead to intolerance, usually because of instability of the dentures or because of pain o f the alveolar mucosa as a result of uneven load distribution and high stress co ncentrations. It is also recommended that a balanced occlusion (i.e. harmonious contacts between maxillary and mandibular teeth in all excursive movements) is p rovided in order to help give occlusal stability. Occlusal vertical dimension There is much evidence to show that it is possible to increase avo without adver se consequences, in both the natural dentition and in complete dentures (Palla 1 997). 113

I CLINICAL PRACTICE AND THE OCCLUSION There are limits to an individual's ability to adapt to opening or closing an OV D. The OVD has a great influence on facial appearance. Complete dentures with in sufficient freeway space cause difficulties with speech and may result in pain b eneath the denture. It can be very difficult to determine an acceptable correct OVD once it is lost and many methods have been developed to help establish OVD ( Table 12.1). These are described in detail in standard prosthetic dentistry text s. Perhaps the most commonly used method has been to determine postural jaw posi tion (PJP, 'resting vertical dimension'). OVD is then established 2-4 mm less th an PJP. PJP is not constant, however, and methods used to Table 12.1 Some methods used to determine occlusal vertical dimension measure it generally have poor reproducibility. It varies with, among other thin gs, head posture, the instructions given to the patient to achieve 'rest' and wi th time. It is also known that altering an OVD will lead to the establishment of a new PJP. The clinician must register an OVD and pass that information to the technician. Experienced clinicians usually rely on a combination of methods at t he registration stage; for example, measuring PJP, observing patient appearance at selected OVD and measuring the OVD of previously satisfactory dentures. Clini cians must then try to verify the dimension at try-in stage, again by the use of a similar combination of methods. It is usually possible to provide a patient w ith new dentures with a greater OVD than that of the previous old dentures. It i s wise to test any increase by the progressive addition of autopolymerising acry lic to the occlusal surfaces of the artificial teeth of the old dentures. Postural position (PJp, resting vertical dimension); aVD is approximately 2-4 mm less Measure aVD of satisfactory previous dentures Aesthetics Ridge parallelism : Paralleling the crests of maxillary and mandibular edentulous ridges plus a 50 posterior opening gives an indication of correct vertical dimension. Pre-extrac tion records Lateral skull radiographs Facial measurement Phonetics Patient repo rted position of comfort Intraoral central bearing pin Artificial teeth Artificial teeth are made from either acrylic resin or porcelain. The quality of acrylic teeth has improved greatly in recent years and porcelain teeth are no l onger commonly used. Two types of posterior cusp form are produced by manufactur ers of artificial teeth (Fig. 12.2): Anatomical teeth - may have different cuspa l angulations, e.g. 20, 30 or 40 cuspal angle; 20 cuspal angle teeth are commonly us ed for complete dentures. A B c Fig. 12.2

Artificial posterior teeth. A anatomical teeth; B 10 cusps; C zero degree teeth. 0 114

OCCLUSION AND REMOVABLE PROSTHODONTICS Zero-degree teeth (flat-cusped, cuspless) - are said to be indicated for cases w ith flat alveolar ridges or where there is great difficulty recording CR. Resear ch has not provided evidence to support commonly held views on advantages and di sadvantages of artificial tooth form. For example, while it is possible that sel ection of artificial posterior teeth, such as cusped rather than cuspless, may h ave a marginal effect on chewing efficiency, other factors, in particular retent ion and stability of the dentures, have far more effect. opposing upper teeth. The upper palatal cusps occlude with the fossae of the low er teeth. In a so-called lingualised occlusion, the lower buccal cusps are cut b ack so that there is only contact on the upper palatal cusps. This scheme allows the ease of obtaining a balanced occlusion comparable with the use of zero cusp ed teeth, together with the advantage of retaining poterior tooth cusp form and therefore a pleasing appearance. Clinical considerations relating to occlusion Determining occlusal vertical dime nsion Balanced occlusion Balanced occlusion refers to occlusion with simultaneous contacts of the occlusa l surface of all or some of the teeth on both sides of the arch in all mandibula r positions. A balanced occlusion is developed by the dental technician on the a rticula tor. The five determinants or variables affecting occlusal contacts are known as Hanau's quint: 1. Orientation of occlusal plane. Average-value articula tors have preset distances between the condylar components and the incisal tips. The orientation of the occlusal plane is determined by the clinician when trimm ing the upper occlusal rim. 2. Condylar guidance. Condylar angles of average val ue articulators are also preset, usually at 30. 3. Incisal guidance. Incisal guid ance is commonly set arbitrarily at 10 or 15. 4. Cuspal angle. The cuspal angles of the artificial teeth are produced by the manufacturer. 5. Compensating curve. The dental technician sets the artificial teeth with a compensating curve that allows for a balanced occlusion. The extent to which the balanced occlusion/arti culation developed on an articulator will be present in the mouth will depend on the accuracy of the centric jaw registration used to articulate the casts. It w ill also depend on the degree to which the settings of the articulator replicate the corresponding parameters of the patient's jaws. Use of a semiadjustable art iculator and a facebow record, and lateral and protrusive records to set condyla r angles, will more accurately replicate the mouth than an average value articul ator. In most cases when inserting dentures it will be necessary to adjust the o cclusion, for example using articulating foil in the mouth and specific occlusal adjustment at the chairside, in order to produce a balanced occlusion. As described above, determining an acceptable OVO can be difficult. As discussed , the clinician has, however, to register an OVO and pass that information to th e technician. Experienced clinicians usually rely on a combination of methods at the registration. Recording centric jaw relation Centric jaw relationship is a reproducible position that is used to articulate e dentulous casts. The artificial teeth are set so that maximum intercuspation occ urs at this position. Centric occlusion for complete dentures is the same as IP. Many different methods have been described for recording CR. They may be classi fied as static or functional (Table 12.2). Most methods are capable of giving ac curate results but functional techniques such as 'chew-in' techniques are not co mmonly used. The most common is the use of interocclusal wax occlusal rims. Selecting an articulator for complete denture prosthodontics As discussed previously, an average value articulator can be used with good resu

lts. However, in order to produce dentures with a balanced occlusion/ articulati on that should need minimal adjustment at insertion, a semiadjustable articulato r together with the use of a facebow, and lateral and protrusive transfer record s, should be considered. Table 12.2 relation Static Methods of recording centric jaw Functional Chew-in techniques Swallowing techniques Lingualised occlusion In conventional artificial tooth arrangement the lower artificial buccal cusps o cclude with the fossae of the . . Wax occlusal rims Extraoral tracing (gothic arch) technique Intraoral tracing de vice 115

 CLINICAL PRACTICE AND THE OCCLUSION A B c Fig. 12.3 Precentric check record. A Softened wax on the posterior mandibular te eth. B Patient has closed into the wax in the retruded arc of closure. Closing h as stopped before the artificial teeth contact. C Precentric record removed from the mouth. Setting up complete dentures Setting of teeth requires considerable skill. The determinants of a balanced occ lusion have been described above. Setting procedures for artificial teeth have b een described in detail elsewhere (Zarb et al 1990). bilateral contact. The othe r error is when there is misalignment of cusp-fossa relationships. This is corre cted by first grinding mesial and distal slopes of opposing teeth, until cusp-fo ssa realignment is regained. The opposing fossae can then be deepened until even contact is established. The second objective of occlusal adjustment is to obtai n a balanced occlusion. To readily achieve this the BULL (buccal upper, lingual lower) rule is recommended. It is the contacting surfaces of these cusps (the pa latal surface of the upper buccal cusps and the buccal surfaces of the lower lin gual cusps) that are ground, rather than the cusp tips. If there is misalignment of cusp-fossa relationships, the cusps and their opposing embrasures should be adjusted by grinding mesial and distal cusp slopes of opposing teeth. The adjust ment process should be continued until balanced occlusion is achieved. Precentri c (check) record More extensive errors can be eliminated using a precentric reco rd. To do this, two layers of warm softened baseplate wax are placed on the lowe r premolars and molars. The patient is instructed/ guided to close into the wax (but not to close into tooth contact) in the retruded position. The dentures are then articulated using this record and any errors are removed (Fig. 12.3). When the dentures are inserted, minor errors can be readily corrected as described. Rerecording CR Occasionally the occlusal errors may be so large that chairside a djustment or even a check record could not correct the problem. In these cases, if the appearance of the anterior teeth is satisfactory, the posterior teeth sho uld be ground off, wax can be placed on the base in those regions and CR can be rerecorded. The dentures can then be rearticulated, teeth reset and a denture tr y-in is repeated. Split-cast technique As the acrylic resin cures during the processing of complete dentures, the artif icial teeth can move slightly in the moulds. A split-cast technique is recommend ed to relocate complete dentures on the articulator following processing. This a llows any minor occlusal errors that have occurred during processing to be corre cted. Occlusal correction at insertion There are often occlusal interferences at the insertion stage as a result of ina ccuracy of recording CR and limitations imposed by the articulator. Three method s are used to correct the occlusion: selective grinding, precentric (check) reco rd and rerecording CR. Selective grinding Minor errors are commonly detected wit h the use of articulating foil and corrected at the chairside. Because of the in herent instability of the denture bases, caution must be used when interpreting the marks made by the paper. Some clinicians consider that any adjustments shoul d only be made with the use of a precentric (check) record, as described below. There are two stages to chairside occlusal adjustment: The first objective is to

ensure MI occurs in CR. Two possible errors may be present. One error occurs wh en the cusp-fossa relationships are correct but one or more teeth meet premature ly. To correct this type of error, the opposing fossae should be deepened until there is even 116

OCCLUSION AND REMOVABLE PROSTHODONTICS I~ 'P References Palla S 1997 Occlusal considerations in complete dentures. In: McNeil C (ed) Sci ence and practice of occlusion, Quintessence, Chicago, pp 457-467 Zarb G A, Bole nder C L, Hickey J C, Carlsson G E (eds) 1990 Boucher's prosthodontic treatment for edentulous patients, 10th edn. Mosby, St Louis Further reading Dixon D L 2000 Overview of articulation materials and methods for the prosthodon tic patient. Journal of Prosthetic Dentistry 235-247 Fenlon M R, Sherriff M, Walter J D 1999 Association between the accuracy of inte rmaxillary relations and complete denture usage. Journal of Prosthetic Dentistry 81: 520-525 Freilich M A, Altieri J V, Wahle J J 1992 Principles for selecting interocclusal records for articulation of dentate and partially dentate casts. J ournal of Prosthetic Dentistry 68: 361-367 Murray M C, Smith P W, Watts D C, Wil son N G F 1999 Occlusal registration: science or art? International Dental Journ al 49: 41-46 Rahn A 0, Heartwell C M 1993 Relating inclinations of teeth to conc epts of occlusion. In: Textbook of complete dentures, 5th edn. Lea & Febiger, Ph iladelphia, pp 357-371 Zarb G A, Bergman B, Clayton J A, MacKay H F (eds) 1978 P rosthodontic treatment for partially edentulous patients. Mosby, St Louis 117

Occlusion and implant restoration J. Hobkirk Key points Synopsis Dental implant occlusion has characteristics inherently similar to the natural a nd restored dentitions, and should be designed to mimic nature rather than creat e a purely mechanical system. Its design must therefore follow similar principle s. These need to be modified to allow for the different characteristics of the s upport mechanism, and relate largely to the avoidance of mechanical overload of the patient-implant interface, the implant connecting components and the prosthe tic superstructure. The clinician has freedom to position implants in the most s uitable locations, and these should be selected to minimise non-axial loads on t he implants and reduce torquing as a result of cantilevering of the superstructu re. This can occur both buccally and distally. The occlusal scheme in the partia lly dentate patient should normally be conformative, and avoid localised stress concentration, for example by canine guidance. Where the full arch is reconstruc ted, then so-called 'balanced articulation' is preferred. Shallow cusp angles ar e associated with reduced implant loading. There is little justification for usi ng polymeric occlusal materials solely to minimise loads on implants. Ceramics o r gold alloys perform better, but there may be aesthetic or technical limitation s on their use, especially in larger constructions, when a resin-based aesthetic material may be preferred. Implant occlusion should be designed during treatmen t planning, prior to implant placement. It involves implant location and superst ructure design, as well as occlusal configuration, and is inherent in the treatm ent process. Implant occlusion is inherently similar to the occlusion of any oth er dental prosthesis. Its design relates not only to the occlusal surface, but a lso to its supporting mechanisms Objectives in occlusal design - Maximise occlus al function - Minimise harm to opposing and adjacent teeth - Minimise wear of oc clusal surfaces - Minimise the risk of fracture of the implant superstructure Reduce the risk of fracture of the implant body and its connecting components Protect the implant-host interface; currently this is synonymous with maintainin g osseointegration Particular characteristics of implant occlusion - Location: f reedom potentially to locate implants in optimum locations - Displacability: an osseointegrated implant is displaced very little under load and behaves elastica lly - Immovability: implants cannot be moved by orthodontic forces - Propriocept ion: proprioceptive feedback is reduced - Force transmission: high forces may be generated by a patient with an implantstabilised fixed bridge - Biomechanical o verload: this is thought to be a key factor in the loss of osseointegration - Me chanical linkages: almost all dental implants employ mechanical linkages, many o f which are prone to failure due to overload Force management is principally thr ough the following design features: - implant location - occlusal form and schem e - superstructure design 119

 CLINICAL PRACTICE AND THE OCCLUSION EVIDENCE FROM THE LITERATURE Early studies on dental implant occlusion centred on measurements of masticatory forces and occlusal tactile sensibility. While some of these used force transdu cers placed between the teeth, and were thus of little value in measuring functi onal loads, later studies using miniature intraoral transducers were able to dem onstrate these. Such investigations showed that patients could generate higher o cclusal forces with implant bridges than with conventional removable prostheses. It was also shown that they had a greater ability to detect thin films held bet ween the teeth. Such investigations were intended to show the enhanced performan ce of implant bridges. Subsequently it became evident that excessive occlusal fo rces could result in breakdown of the osseointegrated interface, although, apart from case reports, this work has been based on animal studies, with all the pro blems of their extrapolation to clinical practice. These findings lead to an inc reased interest in the potentially harmful effects of excessive loads, particula rly since meta-analysis had demonstrated that mechanical failure of the implant and its superstructure was a major cause of problems once osseointegration had b een achieved. Such studies were beset by the problem of defining and predicting an excessive load, however this is probably not solely limited to magnitude; fre quency, load rate and duration may all be important, as is thought to be the str ucture of the bone itself. Currently we are lacking any clinically valid enginee ring data that would enable the predictive modelling of bone behaviour and facil itate implant selection, optimal placement and superstructure design. Studies of shimstock perception lead to investigations into the phenomenon of osseopercept ion. These showed that patients with osseointegrated implants were able to detec t applied forces, and that this changed with time. The exact mechanism is unknow n, but is likely to involve nerve endings in the periosteum and mucosa, as well as those associated with the temporomandibular joints and muscles of mastication . Currently we lack detailed knowledge of this phenomenon and its potential diag nostic value. Once there was awareness of the potential affects of force on osse ointegration, both occlusal material and form came under scrutiny. It was postul ated that acrylic resin would provide a shock-absorbing layer as compared with p orcelain; however, while this could be demonstrated in vitro, it has never been shown clinically in a controlled manner. Studies on the effects of occlusal mate rial on masticatory force have failed to demonstrate a linkage, as any possible effects are masked by the large variations between subjects and the moderating i nfluence of the food being masticated. 120 Similarly, studies on occlusal form have tended to be carried out in vitro or in experimental animals, techniques that do not readily translate to the clinical scenario. They do, however, suggest that shallow cusp angles are favourable, and that bilateral occlusal contacts in lateral excursions of the mandible should b e used with large constructions. Nevertheless, there is much advice on occlusal forms and schemes in implant prostheses, that has little if any clinical researc h base. Studies of implant biomechanics lend themselves to physical investigatio ns and modelling techniques, and there have been many such investigations using mechanical or computer-based methods of investigation. While helpful, they lack clinical veracity, a further area where much advice is empirical. CLINICAL PRACTICE Restorative dentistry is concerned with optimising oral function in terms of app earance, speech and mastication. This often, but not inevitably, requires the re placement of missing teeth and their supporting structures. Traditionally the pa rtially dentate were treated with either fixed restorations or removable prosthe ses. The former were stabilised by linking them to the teeth using cemented join ts on tapered tooth preparations, the latter with moveable joints based on clasp

s or precision attachments. Where lack of a suitable dentition or resources made this impossible, recourse had to be made to the alveolar ridges and the vertica l surfaces of the teeth, employing the rather tenuous physical forces of frictio n, adhesion and cohesion. Apart from oral manipulative skills, only the latter t wo were available to the user of complete dentures. The development of reliable implant techniques enabled these to be used as a third dentition, and they are n ow employed to stabilise single crowns, fixed bridges, removable partial denture s and complete overdentures. Restorative dentists have tended to carryover into implant dentistry the precepts and beliefs which sustained them when using these restorative techniques in the natural dentition, often with little justificatio n. This applies equally to the design of the occlusion. While it may be thought that there are quite enough approaches to this topic without adding another laye r of complexity, nevertheless, the host-implant interface, and freedom to potent ially locate implants at will, subject to anatomical constraints, create a diffe rent milieu. What is implant occlusion? In approaching this problem it is necessary to appreciate that we are concerned not solely with the shaping of the

OCCLUSION AND IMPLANT RESTORATION Cantilevered occlusal surfaces result in rotational forces when loaded distally. Fig. 13.2 protect the implant-host interface; currently this is synonymous with maintainin g osseointegration. If we are recognise stabilised occlusion. to achieve these a ims then it is necessary to the differences between tooth and implantprostheses, and their significance for implant Principally these are: Where implants supporting a fixed bridge lie palatal or lingual to the occlusal platform, then vertical forces on the teeth will tend to rotate the bridge aroun d its fixing points on the implants. Fig. 13.1 occlusal surfaces but more importantly with their location, extent and support. These factors will influence both function and, potentially, the integrity of th e reconstruction itself, which extends from the bone around the implant to the l oad-receiving component of the system, the occlusal surface. For the sake of sim plicity the occlusal scheme provided for an implant-stabilised prosthesis is des cribed here as an implant occlusion, that is, an occlusal scheme where a compone nt of the forces applied to the dental prosthesis is transmitted to the orofacia l skeleton by a dental implant. While implant occlusion has similar requirements to that provided by a natural dentition, or one restored by other means, there are also requirements specific to such a situation. Our aims in designing an imp lant occlusion are to: maximise occlusal function minimise harm to opposing and adjacent teeth minimise wear of occlusal surfaces minimise the risk of fracture of the implant superstructure reduce the risk of fracture of the implant body an d its connecting components Location. Freedom to potentially locate implants in optimum locations. Unfortuna tely this is often an illusory freedom due to anatomical constraints. A favourab le relationship between an implant superstructure and its supporting implants ca n result in their being loaded optimally down their long axes, with torquing for ces minimised. Where the relationship between the occlusal table and the implant s is less suitable, then large torquing forces can arise as a result of implant orientation in available bone (e.g. the anterior maxilla), and buccal and distal cantilevering. The latter may also result in extraction forces on implants (Fig s 13.1 and 13.2). Rigidity under load. An osseointegrated implant is displaced v ery little under load compared with a tooth. Osseointegrated implants also move in an essentially linear fashion under load, while teeth and soft tissues move i n a viscoelastic manner. Consequently, if an occlusion made up of tooth- and imp lant-stabilised components has' evenly distributed initial contacts in the inter cuspal position (ICP), then after repeated loading the implant-supported contact s will be higher than those that are tooth-supported. Immovability. Implants can not be moved by orthodontic forces. Occlusal modification by intrusion of an imp lant is not therefore feasible. Proprioception. Implants lack a periodontal memb rane, and, it is thought, conventional proprioceptive feedback. There is some ev idence for perception related to implants, but it is ill understood and less sen sitive than that of a natural tooth. 121

 CLINICAL PRACTICE AND THE OCCLUSION Force transmission. Considerably higher forces may be generated by a patient with an implant-stabilised fixed bridge than with a conve ntional denture. This can result in apparent looseness of the opposing prosthesi s and damage to the underlying tissues as a result of mechanical overload. Biome chanical overload. This is thought to be a key factor in the loss of osseointegr ation, which equates to implant failure. It is considered that transverse loads on dental implants are especially damaging. Values for potentially harmful force s are not known, and may be related not only to their magnitude, but also load r ates and frequency. They may also be dependent on personal variation, bone quali ty, volume and shape, implant design and length, and superstructure design. Mech anical linkages. All dental implants employ mechanical linkages, of which screwe d joints are the most common. These behave differently under load to the cemente d or adhesive joints normally used in restorative dentistry. In particular, over load can result in their failure. While this characteristic is shared with resto rations linked to natural teeth, the small size and mechanical complexity of den tal implants makes fracture of implant superstructures and their retaining screw s a common problem. The absence of engineering data for applied loads makes cons truction an empirical exercise. Undersized components, casting or soldering faul ts, excessive cantilevering and inappropriate occlusal schemes all increase the risk of failure. Fig. 13.3 Loads on a distal cantilever are magnified by leverage effects. These factors have considerable significance when designing an occlusal scheme f or an implant superstructure, the principal function of which is to transmit occ lusal forces to the facial skeleton. Where these are excessive in terms of magni tude, frequency or direction, damage to the prosthesis, implant or supporting ti ssues may ensue. Similarly, occlusal schemes which are not in harmony with their biological environment can give rise to problems, in the same fashion as those stabilised by underlying mucosa or abutment teeth. The principles that apply to these are no different and are described elsewhere in this book (Chs 1, 11 and 1 2). The design of implant occlusion thus hinges around the creation of a functio nally effective masticatory scheme that minimises occlusal loads, especially whe re they are not axial to the implant. Occlusal forces should be axially directed along the length of the implant. In a dentition restored with teeth and implants, initial occlusal contacts in ICP sh ould occur only on the natural teeth. No clinical benefit has yet been shown for a particular occlusal surface material from the viewpoint of implant failure. T ipping forces on implants are harmful. These can arise as a result of cusp angul ation, during lateral excursions of the mandible, and most significantly due to cantilevering of the superstructure (Fig. 13.3). This can be both distal and buc cal, due to attempts to replace posterior teeth, or the need to place maxillary teeth lateral to the residual alveolar ridge in order to provide a natural appea rance and normal relationship with the opposing teeth. Cyclical loads are more d estructive because mechanical components are prone to fatigue failure. Loads on implants in the period after placement and when first loaded should be minimised . This reduces the risk of integration failing to occur due to excessive movemen t of the implant, or being lost in its early stages before it has matured. Impla nt treatment should be used with caution in patients with a bruxing habit. DESIGNING

THE OCCLUSION Force management Given that it is not easy to measure functional occlusal loads clinically or to predict their effects, the clinician must rely on conventional wisdom for guidan ce. This suggests that: Load management is an important dimension of occlusal t, as the scheme chosen will profoundly influence the It covers implant location, extent and design of the material, na ture of the opposing dentition, and the 122 design in implant treatmen forces that are generated. occlusal surfaces, surface type of superstructure.

OCCLUSION AND IMPLANT RESTORATION Fig. 13.4 A linear arrangement of dental implants provides little resistance to rotational forces. Implant location Masticatory forces are largely vertical to the occlusal plane, and higher in the molar region. They also have significant lateral components related to chewing patterns and cuspal angles. Lateral forces will tend to torque implants around t heir apical ends, and are thought to be more harmful to the bone-implant interfa ce than vertical forces. They can also arise as a result of cantilevering of the superstructure both distally and buccally. The extent to which this arises will depend on whether a fixed or removable superstructure is employed. In the latte r situation the linkage between the implant and the prosthesis may permit relati ve rotation, which will minimise torquing. Where implants are linked, horizontal forces will be more widely distributed and torquing reduced, especially if thre e or more implants are linked in a tripod fashion, as opposed to linearly. (Figs 13.4 and 13.5). A further effect of cantilevering is to magnify and reverse the direction of occlusal forces due to leverage effects; it is for this reason tha t cantilever lengths are recommended to be typically 10 mm and no more than 15mm . Fig. 13.5 A triangular orientation of implants, so called tripodisation, will ef fectively resist rotational forces. Where a full arch construction is utilised then 'balanced articulation' should b e provided in order to minimise local loading and maximise stability of the pros thesis. There is some evidence that a degree of horizontal freedom of movement i n K'P is helpful, while in vitro studies have shown that shallow cusp angles may be associated with reduced horizontal loading of an implant during mastication. Occlusal contacts on implant superstructures, which are above the level of the adjacent teeth by 100-250 urn, have been shown in experimental animals to have a negative effect on bone formation adjacent to the implant in the crestal region . Studies on occlusal forces have also shown that loads on cantilevered implant superstructures are reduced significantly when their occlusal surfaces are sligh tly below those of adjacent teeth, whether natural or implant-stabilised. Occlusal material The preferred material for the occlusal surface of implant superstructures is st ill debated. At one time it was believed that acrylic resin would cushion occlus al loads to the benefit of the osseointegrated interface; however, this energy a bsorbing effect appears to be minimal compared with that of the food and individ ual variation in occlusal forces. In these circumstances, other factors need to be considered, such as longevity, abrasion resistance, appearance, ease of fabri cation and ease of repair. Acrylic or other resins, especially those with inorga nic fillers, are often used for their ease of manipulation and flexibility. They also are less prone to mechanical failure 123 Occlusal form and scheme While extensive research on the effects of occlusal design on the outcome of imp lant treatment is limited, a number of general principles are emerging on the ba sis of a small number of studies and clinical experience. Where a single implant is to be restored, or a small implant bridge provided, the occlusal scheme shou ld be conformative. Group function is to be preferred to canine guidance, which should be avoided on an implant superstructure as the high local forces can lead to fracture of the crown, linking components or even the implant.

 CLINICAL PRACTICE AND THE OCCLUSION in bulk, which can be a problem with extensive porcelainfaced metal frameworks. Such polymeric materials have poor wear resistance, and it is not uncommon for t hem to need replacement after 1-3 years, or even less when opposed by a natural dentition, especially if masticatory forces are high. Where this is a problem, g old alloy occlusal surfaces can provide an effective solution in both extensive fixed restorations and implant-stabilised complete dentures, although their appe arance is not acceptable to all patients. The design of the occlusion for implan t prostheses is an integral part of treatment planning and should begin prior to implant insertion. It involves consideration of the occlusal scheme, the extent of the occlusal platform, implant location, control of horizontal forces, the a chievement of axial implant loading where possible, implant location and the opt imisation of appearance. Unfortunately it is often an afterthought, attempted wi th articulating paper and a handpiece, resulting in a suboptimal outcome. Further reading Denissen H W, Kalk W, van Wass M A J, van Os J H 1993 Occlusion for maxillary de ntures opposing osseointegrated mandibular prostheses. International Journal of Prosthodontics 6;446-450 De Pauw G A, Dermaut L, De Bruyn H, Johansson C 1999 St ability of implants as anchorage for orthopedic traction. Angle Orthodontist 69( 5);401-407 Duyck J, Van Oosterwyck H, Vander Sloten J et al2000 Magnitude and distribution of occlusal forces on oral implants supporting fixed prostheses; an in vivo stud y. Clinical Oral Implants Research 11(5);465-475 Duyck J, Ronold H J, Van Ooster wyck H et al 2001 The influence of static and dynamic loading on marginal bone r eactions around osseointegrated implants; an animal experimental study. Clinical Oral Implants Research 12(3);207-218 Kaukinen J A, Edge M J, Lang B R 1966 The influence of occlusal design on simulated masticatory forces transferred to impl antretained prostheses and supporting bone. Journal of Prosthetic Dentistry 76;5 0-55 Klineberg I, Murray G 1999 Osseoperception: sensory function and propriocep tion. Advances in Dental Research 130;120-129 Miyata T, Kobayashi Y, Araki H, Oh to T, Shin K 2000 The influence of controlled overload on peri-implant tissue. P art 3; A histologic study in monkeys. International Journal of Oral and Maxillof acial Implants 15(3);425-431 Richter E-J 1998 In vivo horizontal bending moments on implants. International Journal of Oral and Maxillofacial Implants 13;232-24 4 Stanford C M, Brand R A 1999 Towards an understanding of implant occlusion and strain adaptive bone modelling and remodelling. Journal of Prosthetic Dentistry 81(5);553-561 Van Steenberghe D, Naert I, Jacobs R, Quirynen M 1999 Influence o f inflammatory reactions vs. occlusal loading on peri-implant marginal bone leve l. Advances in Dental Research 13;130-135 Weinberg LA 2001 Therapeutic biomechan ics concepts and clinical procedures to reduce implant loading. Part I. Journal of Oral Implantology 27(6);293-301 124

Occlusal splints and management of the occlusion T. Wilkinson Synopsis Occlusal splints have been used for more than a hundred years to manage jaw dysf unction and they continue to be a common treatment modality. Hypotheses have bee n suggested to explain their action, but lack scientific validation. There is ge neral agreement that splints protect against tooth wear, and are valuable in pre paration for dental treatment especially with complex restorative procedures inc luding change of occlusal vertical dimension or jaw position. However, it has be en difficult to establish the efficacy of splints in the management of temporoma ndibular disorders (TMDs). Although many studies claim that splints reduce noctu rnal bruxism, others have shown that this does not occur, and some patients show increased jaw muscle force while wearing a splint. The use of better study desi gn in recent years has improved our understanding of splint efficacy. Pain reduc tion has been shown to occur in treatment and control groups, suggesting that th is may be due to a placebo effect as well as the natural regression of symptoms with time. Stabilisation (or Michigan) splints and palatal splints (no occlusal coverage, used as a study control) were found to be more effective than using 'i nactive control' splints (worn only during review visits) or 'no splint' control . Trials have also shown that there was no apparent difference between a stabili sation splint and a non-occluding palatal appliance, suggesting that pain reduct ion is not due to a change in mandibular position or sensorimotor feedback, but to a non-specific behavioural response. These recent reviews suggest that there is sufficient evidence to support the use of splints as adjuncts to treatment for localised myalgia or arthralgia. The most c ommon design is the full upper arch, flat plane stabilisation (or Michigan) spli nt (Fig. 14.1). This chapter details the clinical and laboratory stages of prepa ring this appliance and procedures for its adjustment and use. Key points Impression-taking. The splint covers all teeth on the upper arch and opposes all lower teeth. Accurate alginate impressions of both arches are required, and the se can be taken in stock trays Transfer records. A facebow may be used to transf er the relationship of the maxilla to the intercondylar axis and Frankfort horiz ontal. An interocclusal (or maxillomandibular, MMR) record records the relations hip of the mandible to the maxilla in centric relation Mounting casts on the art iculator. A semiadjustable articulator is suitable for splint construction and m ay be set to average condylar values. The maxillary cast is articulated using th e facebow transfer, and the mandibular cast using the occlusal record Block-out undercuts. An ideal path of insertion is determined for the splint, and undesira ble undercuts are blocked out Splint fabrication. Frictional retention is provid ed by the amount of buccal and labial tooth coverage. The flat occlusal table of the splint provides point contact for the buccal cusps of the lower molars and premolars. The tips of the canines and incisors contact a narrower anterior ledg e. An anterior ramp provides guidance for canine or anterior teeth in lateral an d protrusive movements 125

I CLINICAL PRACTICE AND THE OCCLUSION Intraoral adjustment. Adjustment of the inner surface of the splint after proces sing may be required to provide a firm and comfortable fit. The occlusal table i s adjusted to provide even and simultaneous bilateral contact in retruded contac t position (Rep) and then to a 'long centric'. The anterior ramp is then adjuste d to provide anterior guidance without molar contacts Patient instructions. Pati ents are instructed to use the splint while sleeping. Good oral hygiene needs to be emphasised and patients are instructed in the cleaning and storage of their splint Review of splint. Reviews are needed as part of a long-term management st rategy. The splint may need to be adjusted if dental restorations are placed at a later time Laskin (1969) suggested that parafunction and the resultant pain and dysfunction were more related to the central effect of stress than to the peripheral role o f occlusal irregularities. He described this condition as myofascial pain-dysfun ction syndrome (MPD). This theory was reinforced by studies that showed a positi ve correlation between life events, nocturnal electromyographic (EMG) levels and masticatory muscle pain (Rugh & Solberg 1979). Splints have been used to treat the less common muscle conditions described as myositis and myospasm, as well as the more common conditions described as myofascial pain and postexercise muscle soreness associated with bruxism. However, in recent years there has been contr oversy concerning the efficacy of occlusal splints in the treatment of TMDs. A N ational Institute of Health Conference in 1997, on the management of TMDs, repor ted that 'the efficacy of most treatment approaches for TMDs is unknown because most have not been adequately evaluated in long-term studies and virtually none in randomised controlled group trials. Moreover, their superiority to placebo co ntrols or "no treatment" controls remains undetermined' (Lipton & Dionne 1997). SPLINTS AND MUSCLE AND JOINT PAIN Myofascial pain (fulfilling the Research Diagnostic Criteria for Temporomandibul ar Disorders (RDC/TMD) criteria of Dworkin and LeResche, 1992) has been reported in approximately 50% of patients presenting at a facial pain clinic (Fricton et al 1985). It is categorised by muscle tenderness, pain that can be made worse b y function and referral of pain to other regions, and it is found in bruxing and non-bruxing patients. There is currently no convincing research-based evidence to explain the aetiology of myofascial pain. Studies have shown the development of jaw muscle myalgia with voluntary clenching (Arima et al 1999). It has been s uggested that subjects demonstrating intermittent bruxing at times of high stres s may be exhibiting postexercise muscle soreness and that this is more likely to occur on waking. However, the majority of bruxers do not exhibit pain, and it h as been suggested that their muscles may have adapted with time as a training ef fect. Studies of resting EMG levels in bruxers with pain were found to not be si gnificantly different from bruxers without pain (Lund 2001). The poor correlatio n between pain and resting EMG contradicts the earlier 'vicious cycle' theory as sociated with occlusal irregularities. Self-reports of pain among 19 confirmed n octurnal bruxers in a polysomnographic study were compared with 61 patients in a nother study with jaw muscle myofascial pain (RDC/TMD criteria) with no evidence of bruxism (Dao et al 1994a). Only six of the 19 bruxers experienced Extraoral photograph of a stabilising (Michigan) splint seated on the maxillary teeth with the jaw slightly opened. Frictional retention is provided by 25% cove rage of the labial surfaces of the incisors and canines, 33% coverage of the buc cal surfaces of premolars and 50% coverage of the buccal surfaces of molars. Fig. 14.1 LITERATURE REVIEW Early theories of the mode of action of splints were based on the concept that o

cclusal interferences caused masticatory muscle hyperactivity and parafunction, resulting in muscle pain and, in turn, increased hyperactivity (Travell & Rinzle r 1952). This sequence of events was considered to be reduced or eliminated by t he splint, as it provided an ideal occlusal scheme (Posselt 1968). 126

OCCLUSAL SPLINTS AND MANAGEMENT OF THE OCCLUSION pain, and this typically occurred in the morning, whereas the majority of the my ofascial group reported pain in the evening. The authors suggested that bruxism and jaw muscle myofascial pain might be distinct entities with different aetiolo gies. Patients with treated splints for jaw muscle pain may have myositis myospa sm conditions, myofascial pain or postexercise muscle soreness. Research evidenc e is lacking to determine whether these are discrete conditions; their aetiology and natural history and the role of bruxism is unclear. There may also be other conditions causing pain that have not yet been identified. Occlusal splints hav e been shown to reduce nocturnal EMG levels, but their effect is variable and, i n some studies, subjects have shown increases in activity. Clark (1988) reviewed the efficacy of these appliances and concluded that a strong association had be en demonstrated between muscle hyperactivity and the symptoms of jaw pain, and t hat occlusal splints had been used effectively to treat this condition. However, the evidence is weak and care must be taken in drawing the conclusion that ther e is a cause and effect relationship between bruxism and the subgroups of TMDs. Clark also reported on several theories proposed to explain how splints reduce s ymptoms (Clark 1988), including the provision of an interference-free occlusal s cheme, alteration of vertical dimension, correction of the occlusion to centric relation, realignment of the TM joints and increased cognitive awareness. Dao an d Lavigne (1998) reviewed these theories and concluded that the quality of the e vidence was questionable and was based on unsubstantiated aetiologies. The best evidence of therapeutic efficacy comes from systematic reviews of well-designed randomised controlled trials (RCTs). The incorporation of a control group is ess ential, as TMD symptoms fluctuate, there is a high rate of spontaneous remission and placebo effects may significantly contribute to symptom relief. Random assi gnment of patients to groups, and blinded data collection and analysis are essen tial to limit bias. The majority of past studies do not fulfil these requirement s, and hence the true therapeutic value of splint therapy has not been establish ed. Dao et al (1994a) completed an RCT with 61 patients with myofascial pain (RD C/TMD criteria), divided into three groups: a treatment group, using a stabilisa tion (Michigan) splint 24 hours a day; a passive control group who wore a simila r splint but only for 30 minutes at each review appointment; and an active contr ol group who used a non-occluding palatal splint 24 hours a day. The patients' r eport of pain using a visual analogue scale (VAS)reduced significantly with time for all three groups and there was no significant difference between groups. Th ey concluded that this study cast doubts on the therapeutic value of occlusal splints, and felt that the reduction in pain may h ave been due to placebo effects or spontaneous remission. This study caused cons iderable concern among clinicians, particularly as the results were thought to a pply to jaw muscle pain in general. However, the authors failed to indicate that they excluded patients with a history of bruxism. This only became evident when these same patients were reviewed in a subsequent paper (Dao et al 1994b). Henc e the conclusions of the 1994 study for treatment efficacy are only valid for th e TMD subgroup of myofascial pain without bruxism. The outcome of the 1994 study was further analysed by the authors, who compared patients' reports at each vis it of 'pain' (efficacy) with reports of 'pain relief' (effectiveness) (Feine et al 1995). They reported that 'pain relief' scores increased with time for each o f the three groups but increased significantly less for the passive control grou p. They hypothesised that patients in the passive control group may have been in creasingly convinced that they had not received 'true' treatment, which may have explained why they perceived treatment as being less efficacious. It is interes ting to consider that patient satisfaction with treatment depends on factors oth er than pain relief. It would seem that there may have been differences in the s trength of the placebo effect between groups, but this only became obvious when the outcome variable was changed from 'pain' to 'pain relief'. The authors concl

uded that, until the cause of TMDs is known, it was justifiable to provide a tre atment that does not necessarily reduce pain but makes the patient feel better. Ekberg et al (1998) carried out a similar RCT with a patient group with arthralg ia (RDC/TMD criteria) and compared the efficacy of a stabilisation (Michigan) sp lint with a non-occluding but active palatal splint. Patients were not excluded because of a history of bruxism. VAS scores were used to assess pain intensity a nd no statistically significant differences were found between the stabilisation and palatal splint. However, when the outcome measure of 'perceived relief' was considered, the stabilisation splint was statistically superior to the palatal splint. This disagreed with the original study of Dao et al (Dao et aI1994a), bu t the authors considered that this was because the study was of patients with ar throgenous pain, whereas Dads group studied patients with myofascial pain. Sever al studies over the last 5 years have evaluated (meta-analyses) RCTs of splint t herapy. Raphael and Marbach (1997) reviewed the literature on occlusal appliance s for TMDs and reported that 'most controlled studies conclude that appliances a re not effective'. Dao and Lavigne (1998) reviewed similar literature and conclu ded that the true efficacy of splints is still questionable and that the improve ment in pain in most 127

I CLINICAL PRACTICE AND THE OCCLUSION studies may be due to non-specific effects of treatment such as placebo or regre ssion to the mean. They considered that splints might have a place in changing h armful habits and promoting patients' perception of well-being. They concluded t hat until the natural history and aetiology of the different TMDs are determined and more specific treatment regimens are developed for these conditions, splint s should only be used as an adjunct to pain management. Forssell et al (1999) ca rried out a meta-analysis of RCTs of splint therapy and reported that the stabil isation splint was found to be superior to three, and comparable to 12, control treatments, and superior or comparable to four passive controls but expressed co ncern that palatal splints, acupuncture, ultrasound and TENS (transcutaneous ele ctrical nerve stimulation) had been used as controls when these may have affecte d muscle function and the subject's cognitive awareness. They concluded that 'oc clusal splints may be of benefit in the treatment of TMDs'. Kriener et al (2001) reviewed RCTs of splint therapy. They suggested that differences in the TMD pop ulation studied may affect outcomes, with some studies only including myofascial pain patients and others including myogenous and arthrogenous subjects, and out comes might vary between bruxer and non-bruxer populations. They concluded that splints were operating in a similar way to the behavioural interventions of biof eedback and relaxation, and not as a medical device that was producing effects t hrough physical changes in the position of the mandible. They felt that there wa s sufficient evidence to support the use of splints for the management of locali sed myalgia or arthralgia. anterior guidance. It is usually constructed with minimal increase in vertical d imension consistent with providing strength, and is adjusted to even contact of all lower teeth in RCP or centric relation. This is the design that will be desc ribed in this text (Fig. 14.1). Preparation of casts Upper and lower alginate impressions in stock trays provide suitable casts in de ntal stone for splint construction. A facebow may be used to transfer the relati onship of the maxilla to the intercondylar axis and Frankfort horizontal; a maxi llomandibular record is used to record the relationship of the maxillary and man dibular arches to complete the transfer record (Chs 1 and 6). Frictional retenti on for the splint is provided by 25% coverage of the labial surfaces of the inci sors and canines, 33% coverage of the buccal surfaces of premolars and 50% cover age of the buccal surfaces of molars (Fig. 14.1). It is important to block out u ndercuts on maxillary casts to reduce chairside time when fitting the appliance (Fig. 14.2). The appliance extends 5-10 mm into the palate beyond the palatal gi ngival margin. Splint fabrication A 2 mm thick thermosetting blank may be heated and pressure-moulded over the upp er cast. Autopolymerising resin is adapted over the blank, and the articulator i s then closed to determine the vertical dimension of the splint. The resin is sh aped to provide a flat occlusal plane approximately 5 mm in width to be contacte d by the buccal cusps of the lower molar and premolar teeth (Fig. 14.3). The can ine and incisor teeth contact a narrower 2 mm flat anterior ledge. An anterior r amp with a 45 slope extends from this ledge to provide guidance in SPLINT CONSTRUCTION Splint design ----------Design preferences vary widely between clinicians, who may choose upper or lower

appliances, interlocking versus flat plane appliances, appliances with or witho ut anterior guidance, and appliances of various thickness, but these preferences are not supported by outcome studies involving RCTs. There may be differences i n the choice of materials between hard versus soft appliances. Soft appliances m ay be preferred by clinicians because of their perceived comfort and for their e ase of fitting. However, there is evidence to suggest that soft appliances are l ess effective in reducing bruxism (Kuboki et aI1997). The most common appliance used around the world is the stabilisation (Michigan) splint. This is a rigid up per appliance with a flat occlusal plane and a ramp providing 128 Splint outline Fig. 14.2 The outline of splint extensions and lingual undercuts blocked out with plaster.

OCCLUSAL SPLINTS AND MANAGEMENT OF THE OCCLUSION Anterior ramp Fig. 14.3 A frontal section through the upper first molars showing a 2 mm thermo setting blank adapted over the molar surface and palate. The acrylic addition pr ovides a flat plane against which the buccal cusp of the lower molars occludes. A Non-working side contact Thermosetting blank Acrylic Anterior ledge Anterior ramp B Fig. 14.4 A sagittal section through an upper central incisor showing a 2 mm the rmosetting blank adapted over the upper incisor and palate with acrylic resin bu ild-up to provide an anterior ledge and a 45 anterior ramp. 0 Protrusive contact c Fig. 14.5 An occlusal splint. A A horizontal flat plane (white) contacted by the buccal cusps of the lower molar and premolars and the narrower horizontal anter ior ledge (white) contacted by the lower canines and incisors. The 45 anterior r amp (grey) arises immediately from the point of contact of the lower anterior te eth. B The laterotrusive path of the lower right canine tooth against the anteri or ramp during a right-sided lateral excursion. The mediotrusive path of the low er left first molar is shown as a non-working side contact. C The path of the lo wer incisor and canine teeth against the anterior ramp during a protrusive movem ent. The path of the lower left first molar is shown as a protrusive contact. 0 lateral and protrusive mandibular movements (Fig. 14.4). The resin is then proce ssed in a pressure flask to reduce porosity. Laboratory splint adjustment The splint is adjusted on the articulator, with plastic articulating tape, to pr ovide simultaneous RCP contact of incisor and canine tips and premolar and molar buccal cusps in centric relation (Fig. 14.5A). These centric contacts are marke d in one colour and the path of the tips of the lower teeth during lateral and p rotrusive excursions are marked against the anterior ramp in a different colour (Fig. 14.5B, C). The splint is adjusted so that the ipsilaterallower canine tip is the only tooth contacting during lateral excursion and the incisor and canine tips are the only teeth contacting the splint in protrusion eliminating any contralateral or protrusive contacts.on molars or premolars. The splint is then removed from the cast and the palate removed. The labial, buccal and palatal extensions are 129

 CLINICAL PRACTICE AND THE OCCLUSION from time to time but this discomfort will reduce with continued use. Patients a re instructed to monitor their oral hygiene because of the risk of increased pla que accumulation around their teeth and inside the splint. Review of splint Revi'ew appointments assess that occlusal contacts on the splint are stable and are used to reinforce avoidance of daytime parafunction habits. Reviews every 2 months over the first 6 months are desirable to determine when symptoms improve, indicating that patients may start to reduce the frequency of splint wear. Ther e may be a need to return to using the splint if symptoms worsen or if they real ise from their self-monitoring that there has been an increase in clenching, par ticularly during stress. Patients should be informed that teeth might move sligh tly if they cease using the splint for a period and that any initial discomfort or tightness will settle on resuming splint use. Patients using splints on a lon g-term basis should be reviewed every 12 months to ensure there is no occlusal o r periodontal change. Splints may need to be adjusted after new restorations. An intraoral occlusal view of a stabilising (Michigan) splint showing a flat pla ne occlusal surface with an anterior ramp. Articulator tape markings show right and left canine guidance on the anterior ramp and the centric contacts of the lo wer teeth. Fig. 14.6 polished (Fig. 14.6). The occlusal surface is left unpolished so that articulati ng tape leaves clear marks during splint adjustment in the mouth. Intraoral adjustment Judicious blocking out of undercuts during construction reduces chairside time i n fitting the splint. Pressure indicator paste may be used to disclose any point s on the fitting surface that are preventing the splint from fully seating or ca using rocking. The occlusal surface of the splint is then adjusted to even and s imultaneous contact of the tips of all lower anterior teeth and all buccal cusps of molar and premolar teeth in centric relation. Miller holders that support ar ticulating paper assist these adjustments. Some clinicians may allow the patient 'freedom in centric' by adjusting the occlusal surface to even contact of lower teeth at median occlusal position (MOP) - a 'snap jaw closure' that brings the mandible slightly forward from Rep. The anterior ramp is then adjusted to provid e smooth incisal and canine guidance in lateral movement and incisal guidance du ring protrusion. I~ IP References Patient instructions Patients are instructed to use the appliance only during sleep. They are advised that some patients occasionally take splints out during sleep without waking, a nd that splints may increase or decrease salivation during sleep. They may find the splint may be tight on different teeth 130 Arima T, Svensson P, Arendt-Nielsen L 1999 Experimental grinding in healthy subj ects: a cast for postexercise jaw muscle soreness. Journal of Orofacial Pain 13: 104-114 Clark G T 1988 Interocclusal appliance therapy. In: Mohl N D, Zarb G A, Carlsson G E, Rugh I D (eds) A textbook of occlusion. Quintessence, Chicago, pp 271-284 Dao T T, Lavigne G J 1998 Oral splints: the crutches for temporomandibul

ar disorders and bruxism? Critical Reviews in Oral Biology and Medicine 9:345-36 1 Dao T T, Lavigne G J, Charonneau A, Feine J S, Lund J P 1994a The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles; a controlle d clinical trial. Pain 56:85-94 Dao T T, Lund J P, Lavigne G J I994b Comparison of pain and quality of life in bruxers and patients with myofascial pain of the masticatory muscles. Journal of Orofacial Pain 8:350-355 Dworkin S F, LeResche L 1992 Research diagnostic criteria for temporomandibular disorders: review, crit eria, examinations and critique. Journal of Craniomandibular Disorders: Facial a nd Oral Pain 6:301-355 Ekberg E C, Vallon D, Nilner M 1998 Occlusal appliance th erapy in patients with temporomandibular disorders: a double-blind controlled st udy in a short-term perspective. Acta Odontologica Scandinavica 56:122-128 Feine J S, Lavigne G J, Lund J P 1995 Assessment of treatment efficacy for chronic or ofacial pain. In: Morimoto T, Matsuya T, Takada K (eds) Brain and oral functions . Elsevier, Amsterdam, pp 257-264 Forssell H, Kalso E, Koskela Pet al1999 Occlus al treatments in temporomandibular disorders: a qualitative systematic review of randomised controlled trials. Pain 83:549-560

OCCLUSAL SPLINTS AND MANAGEMENT OF THE OCCLUSION Fricton J R, Kroenig R, Haley D, Siegert R 1985 Myofascial pain syndrome to the head and neck: a review of clinical characteristics of 164 patients. Oral Surger y 60:615-623 Kriener M, Betancor E, Clark G T 2001 Occlusal stabilisation applia nces: evidence of their efficacy. Journal of the American Dental Association 132 :770-777 Kuboki T, Azuma Y, Orsini M et al1997 The effect of occlusal appliances and clenching on the temporomandibular joint space. Journal of Orofacial Pain 1 1:67-77 Laskin D M 1969 Etiology of the pain-dysfunction syndrome. Journal of th e American Dental Association 79:147-153 Lipton J A, Dionne R A 1997 National In stitutes of Health technology assessment conference on management of temporomand ibular disorders. Oral Surgery, Oral Medicine, Oral Pathology and Endodontics; 8 3:49-183 Lund J P 2001 Pain and movement. In: Lund J P, Lavigne G J, Dubner R, Sessle B J (eds) Orofacial pain: from basic science to clinical management. Quintessence, Chicago, pp 151-163 Posselt U 1968 Physiology of occlusion and rehabilitation, 2 nd edn. F A Davis, Philadelphia Raphael K, Marbach J J 1997 Evidence-based care of musculoskeletal facial pain. Implications for the clinical science of dentist ry. Journal of the American Dental Association 128:73-79 Rugh J D, Solberg W K 1 979 Psychological implications in temporomandibular pain and dysfunction. In: Za rb G A, Carlsson G E (eds) Temporomandibular joint function and dysfunction. Mun ksgaard, Copenhagen, pp 239-258 Travel! J G, Rinzler S H 1952 The myofascial gen esis of pain. Postgraduate Medicine 11:425-434 131

The role of occlusal adjustment A. Au, I. Klineberg Synopsis Occlusal adjustment is important in prosthodontic pretreatment and has been used for selected cases of temporomandibular disorders (TMDs). The clinical procedur e involves tooth surface reduction and tooth surface addition with an appropriat e restorative material. Occlusal adjustment is distinguished from occlusal equil ibration and selective grinding with clear indications and aims. A systematic pr eclinical and clinical approach has clear advantages for long-term stability of treatment. There is. however. disagreement regarding terminology and the scienti fic justification of this irreversible procedure in the management of TMDs and. in particular. chronic orofacial pain. This chapter aims to clarify definitions and examines research evidence available for the application of occlusal adjustm ent in the management of TMDs and chronic orofacial pain. It is recommended that occlusal adjustment be planned on articulated study casts before being attempted clinically The use of a vacuum-formed template allows ac curate implementation of preplanned occlusal adjustment INTRODUCTIO_N__ Occlusal adjustment is a procedure whereby selected areas of tooth surface, in d entate or partially dentate patients, are modified to provide improved tooth and jaw stability and to direct loading to appropriate teeth during lateral excursi ons. This may involve tooth surface reduction and tooth surface addition with a restorative material. Where tooth surface reduction is required, this is complet ed with minimal adjustment. There is evidence from case-control studies that red uction of tooth contact interferences may reduce specific signs and symptoms of TMDs, such as temporomandibular (TM) joint clicking (Pullinger et al 1993, Au et al 1994). However, these are not prospective controlled studies. Where tooth su rface addition is required, a restorative material may be added to enhance bucco lingual and mesiodistal stability of strategic teeth or to provide more definite guiding inclines for lateral guidance. Occlusal adjustment is distinguished fro m occlusal equilibration and selective grinding. Key points Occlusal adjustment may involve tooth surface reduction and/or tooth surface add ition Occlusal adjustment is different from occlusal equilibration and selective grinding Specific aims and indications are described for occlusal adjustment Oc clusal adjustment should only be used where there is clear and justifiable indic ation There is no strong evidence to indicate that it is more effective than con servative reversible procedures in treatment of TMDs. Nor is there evidence for its use in the management of chronic orofacial pain Occlusal equilibration This is carried out to produce a specific occlusal scheme, generally in severely debilitated dentitions, requiring extensive restorative treatment. It is usuall y designed to achieve: coincidence between retruded contact position (RCP) and i ntercuspal contact position (ICP) precise cusp to fossa or cusp to marginal ridg e contacts 133

I CLINICAL PRACTICE AND THE OCCLUSION anterior guidance resulting in disclusion of posterior teeth with lateral jaw mo vement. Occlusal equilibration may require extensive tooth modification to devel op the prescribed occlusal scheme. Those features may be achieved with fixed res torative procedures. restorations with loss of OVD, extruded teeth and plunger cusps. This has been a traditionally accepted practice in restorative dentistry. Although there appear to be subjective benefits for the patient, these are not verified by controlled clinical trials. Indications for occlusal adjustment Selective grinding This is the reshaping of one or more teeth to reduce or alter specific undesirab le occlusal contacts or tooth inclinations. It may be carried out to reduce plun ger cusps, over-erupted posterior teeth with unopposed contacts, wedging or lock ing effects of restorations or extruded teeth, each of which may prevent freedom of the jaw to move anteriorly and laterally without tooth contact interferences . Selective grinding has also been used as an adjunct treatment in different dis ciplines, including periodontics, orthodontics, general restorative dentistry an d endodontics, but is often incorrectly termed 'occlusal adjustment' in the lite rature. The references listed under Further reading provide examples of its use in different dental disciplines. As a pretreatment in prosthodontics and general restorative care: - to improve jaw relationships and provide stable tooth conta cts for jaw support in ICP - to improve the stability of individual teeth. To en hance function by providing smooth guidance for lateral and protrusive jaw movem ents. This may involve modification of plunger cusps, in-locked cuspal inclines and mediotrusive, laterotrusive and protrusive tooth contact interferences. To m odify a traumatic occlusion where tooth contact interferences are associated wit h excessive tooth loading, such as may occur in parafunctional clenching, result ing in tooth sensitivity, abfractions or fractures and/ or increased tooth mobil ity. Occlusal adjustment will direct loading to appropriate teeth in an optimal direction and where possible, along their long axes. To stabilise orthodontic, r estorative or prosthodontic treatment. In such cases where it is decided that ex isting restorations are to be retained, an occlusal adjustment may be indicated. Alternatively, adjustment in conjunction with occlusal build-up on selected tee th may be required. Occlusal adjustment has been used both as a pretreatment res torative procedure involving fixed and removable prosthodontics, and as adjuncti ve therapy in the treatment of TMDs. Improved neuromuscular harmony as well as s igns and symptoms of TMDs following occlusal adjustment procedures have been des cribed in a randomised controlled study by Forssell et al (1987), but the eviden ce is weakened by the presence of non-homogenous study groups and mixed therapie s. The effect of occlusal adjustment on sleep bruxism has also been investigated in uncontrolled studies (Bailey & Rugh 1980). Clark et al (1999) reviewed artic les that described the effect of experimentally induced occlusal interferences o n healthy, non-TMD subjects. Symptoms including transient tooth pain and mobilit y were reported, and changes in postural muscle tension levels and disruption of smooth jaw movements were noted. Occasional jaw muscle pain and TM joint clicki ng were also observed. However, the data do not strongly support a link between experimentally induced occlusal interferences and TMDs. Tsukiyama et al (2001) p rovided a critical review of published data on occlusal adjustment as a treatmen t for TMDs and Aims of occlusal adjustment To maintain intra-arch stability by providing an occlusal plane with minimal cur vature anteroposteriorly and minimal lateral curve. This minimises the effect of tooth contact interferences. To maintain interarch stability by providing bilat eral synchronous contacts on posterior teeth in RCP and ICP at the correct occlu

sal vertical dimension (OVD). Supporting cusps of posterior teeth are in a stabl e contact relationship with opposing fossae or marginal ridges. To provide guida nce for lateral and protrusive jaw movements on mesially directed inclines of an terior teeth, or as far anteriorly as possible. Posterior guiding contacts are m odified so as not to be a dominant influence in lateral jaw movements. This is a commonly accepted practice in developing a therapeutic occlusion as it is clini cally convenient. However, there is inadequate evidence from controlled studies to justify its routine use in the natural dentition. To allow optimum disc-condy le function along the posterior slope of the eminence, by encouraging smooth tra nslation and rotation of the condyle. To provide freedom of jaw movement anterio rly and laterally. This overcomes a restricted functional angle of occlusion (FA O) caused by in-locked tooth relationships. A restricted FAO arises in the follo wing types of tooth arrangements: deep anterior overbite, undercontoured 134

THE ROLE OF OCCLUSAL ADJUSTMENT concluded that current evidence does not support the use of occlusal adjustment in preference to other conservative therapies in the treatment of bruxism and no n-toothrelated TMDs. This is not surprising as there are no randomised controlle d trials demonstrating a link between tooth contact interferences and aetiology of bruxism or chronic orofacial pain. There is some evidence that tooth contact interferences may be related to jaw muscle pain and TMDs by their effects on dir ectional guidance of teeth in function. However, evidence from current studies i s weak, as direct comparison between the studies is not possible due to: differe nce in philosophy between various researchers regarding mandibular / condylar po sition and the method of achieving RCP during occlusal adjustment difference in philosophy of the occlusal contact scheme lack of a standardised approach to the measurement of the study and outcome factors lack of clearly defined TMD diagno stic subgroups in treatment subjects lack of adequate blinding during the experi ments small sample size with sometimes high subject loss to follow-up short foll ow-up periods non-standardised control treatments poorly defined study bases (ho spital or pain clinic populations) no adjusting for potential confounders or eff ect modifiers. If the efficacy of occlusal adjustment is to be demonstrated, wel l-designed multicentre studies using clearly defined diagnostic subgroups, with large sample sizes and long follow-up periods are necessary. Until then, the rec ommendations of the Neuroscience Group of the International Association for Dent al Research, through its consensus statement on TMDs (2002), should be heeded: ' it is strongly recommended that, unless there are specific and justifiable indic ations to the contrary, treatment should be based on the use of conservative, re versible and preferably evidence-based therapeutic modalities. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing palliative relie f as various forms of invasive treatment, and they present much less risk of pro ducing harm'. Fig. 15.1 Mediotrusive interference on the palatal cusp of the upper second mola r demonstrated on articulated casts. (Fig. 15.1). There are advantages in treatment planning in this way: Clinical ti me is reduced, as treatment planning decisions have been made concerning the opt imum areas of tooth structure to be adjusted, following analysis and adjustment of study casts. It is then relatively easy to follow the pattern of adjustment d etermined on casts when completing an adjustment clinically . Diagnostic occlusa l adjustment on articulated study casts also allows assessment of the amount of tooth surface reduction required. If the diagnostic adjustment indicates that re moval of tooth structure is excessive, other forms of management such as tooth s urface addition, orthodontic treatment or onlay-dentures may be considered. Area s of tooth adjustment are carefully selected, as failure to do so may undermine occlusal stability, leading to further deterioration of the existing disorder. E qually important is the presentation of the diagnostic adjustment to the patient , illustrating the reason for the procedure and the teeth to be modified, to ens ure that informed consent is obtained. This may be of importance in one's defenc e should a dentolegal problem arise. The following text describes an accurate me thod for transposing the preplanned occlusal adjustment, as already performed on articulated casts, to the correct areas of tooth structure in the mouth. CLINICAL PRACTICE Clinical occlusal adjustment is facilitated by carrying out the procedure initia lly on study casts, articulated on an adjustable articulator by accurate transfe r records Preclinical preparation The preclinical sequence to be followed includes verification of the articulatio n of casts when transfer

135

I CLINICAL PRACTICE AND THE OCCLUSION Fig. 15.2 The teeth of the upper and lower duplicate casts painted with die spac er in preparation for preclinical laboratory occlusal adjustment. Clear thermoplastic templates made over unadjusted casts. The centre vent hole i n the casts allows improved adaptation of the thermoplastic material to the cast s. Fig. 15.3 records are taken. Kerr occlusal indicator wax (Kerr, Emeryville, USA) is used t o record RCP contacts. This record is chilled, removed from the mouth and taken to the laboratory, where the perforation points are checked against the initial contact points of the articulated casts. Coincidence of these indicates an accur ate articulation of casts. Tru-fit dye spacer (George Taub Products and Fusion C o. Inc., Jersey City, USA) or a text highlighting pen with a different colour fr om the stone cast may be used to cover contacting surfaces of all upper and lowe r teeth (Fig. 15.2). The occlusal adjustment sequence is carried out on the arti culated casts as follows: RCP contacts are adjusted to provide well-distributed bilateral synchronous contacts, providing optimum jaw support. ICP contacts are adjusted to provide well-distributed bilateral synchronous points of tooth conta ct. The slide between RCP and ICP will be reduced or eliminated; however, routin e elimination of this slide is not an essential requirement. Mediotrusive interf erences are eliminated to allow laterotrusive guidance on canines (canine guidan ce) or canines and bicuspids, or canines, bicuspids and molar teeth (group funct ion). Laterotrusive adjustment is completed when it is possible to move the maxi llary cast in a lateral and lateroprotrusive direction without interference, wit h the canines or canines in conjunction with posterior teeth providing guidance. Protrusive contacts are adjusted to allow canines and incisors to provide protr usive guidance. The adjustment is restricted to regions between cusps where poss ible. Care is taken to preserve supporting cusp tips and to recontour cuspal inc lines, opposing fossae or marginal ridges, thus providing cusp tip to fossa or m arginal ridge contacts. 136 Fig. 15.4 Templates placed over adjusted duplicate casts. Adjusted areas are hig hlighted with ink to allow clear identification. Wax has been added to the palat al surface of tooth 13 to represent the area where composite resin will be place d to provide an occlusal contact. Minimal tooth adjustment is emphasised and adjustments are confined where possib le to the maxillary arch. The adjusted areas of the casts are then marked with i nk to allow clear identification. A clear thermoplastic vacuumformed template (B ego adaptor foils, 0.6 mm thickness) is drawn down over the original cast (Fig. 15.3) and then placed over the adjusted cast (Fig. 15.4). With the use of a shar p scalpel or a flat fissure burr, areas on the template corresponding to the adj usted areas on the cast are carefully removed. The template is trimmed (Fig. 15. 5) around its entire periphery to restrict its extensions to only 2 mm beyond th e gingival margins. The peripheries are smoothed to remove sharp edges that may traumatise intraoral soft tissues.

THE ROLE OF OCCLUSAL ADJUSTMENT Fig. 15.5 Trimmed templates over adjusted casts (palatal view). Perforations in the template correspond to adjusted areas of tooth cusps on the cast. Fig. 15.7 Completed occlusal adjustment is shown; it is a preparatory step for t hree-unit bridgework in the upper posterior quadrants. Diagnostic wax-up of the planned restorations are made on study casts of the adjusted dentition. If no fu rther treatment was required, adjusted tooth areas would be polished and fluorid e applied to complete treatment. diagnostic wax-up. The template can be used clinically to assist the precise pla cement of composite resin in the prepared areas. This represents the initial adj ustment stage. The occlusal adjustment may then be refined and completed. The ad justments are checked repeatedly using plastic articulating tape (GHM foil - Geb r. HanselMedizinal, Nurtingen, Germany; Ivoclar /Vivadent, Schaan, Liechtenstein ) as well as the clinician's tactile sense: Fig. 15.6 Upper template in position on upper teeth. Areas of tooth to be adjust ed protrude through the prepared template perforations and are indicated by the highlighted outlines. Clinical procedures The template is seated over the teeth and examined for accuracy of fit around th e teeth. It should not cause discomfort to the soft tissues. The areas of tooth cusp or marginal ridge to be adjusted are clearly visible protruding through the prepared perforations of the template (Fig. 15.6). A pear-shaped composite fini shing diamond (Komet 8368.204.016) or 12-fluted tungsten carbide burr (Korner H4 6.014) is recommended to adjust the teeth. Areas of tooth structure protruding b eyond the perforations in the template are removed (Fig. 15.6). Where addition o f a restorative material is required, a thermoplastic vacuumformed template can be made over a duplicate of the RCP adjustment is checked to ensure well-distributed bilateral stops on supporti ng cusps. ICP adjustment is checked also for bilateral stops. This may eliminate or reduce the magnitude of an RCP IICP slide. Mediotrusive interferences are re fined to ensure canine or anterior guidance or group function in laterotrusion. Protrusive interferences are refined to allow guidance on canines or canine and incisor teeth. All adjusted tooth surfaces are polished and topical fluoride app lied. Impressions of the adjusted teeth are taken and a diagnostic wax-up of pla nned restorations are made on articulated study casts of the adjusted occlusion (Fig. 15.7). Acknowledgement We would like to express our thanks to Mr Charles Kim for his preparation of the laboratory technical work. 137

I CLINICAL PRACTICE AND THE OCCLUSION I~ '?' References Au A, Ho C, McNeil D W, Klineberg I 1994 Clinical occlusal evaluation of patient s with craniomandibular disorders. Journal of Dental Research 73:739 (abstract) Bailey J 0, Rugh I D 1980 Effect of occlusal adjustment on bruxism as monitored by nocturnal EMG recordings. Journal of Dental Research 59:317 (abstract) Clark G T, Tsukiyama Y, Baba K, Watanabe T 1999 Sixty-eight years of experimental occl usal interference studies: what have we learned? Journal of Prosthetic Dentistry 82:704-713 Forssell H, Kirveskari P, Kangasdniemi P 1987 Response to occlusal t reatment in headache patients previously treated by mock occlusal adjustment. Ac ta Odontologica Scandinavica 45:77-80 Pullinger A G, Seligman D A, Gornbein J A 1993 A multiple logistic regression analysis of the risk and relative odds of te mporomandibular disorders as a function of common occlusal features. Journal of Dental Research 72:968-979 Tsukiyama Y, Baba K, Clark G T 2001 An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorder s. Journal of Prosthetic Dentistry 86:57-66 Further reading Branam S R, Mourino A P 1998 Minimizing otitis media by manipulating the primary dental occlusion: case report. Journal of Clinical Pediatric Dentistry 22:203-2 06 Davies S J, Gray R M J, Smith P W 2001 Good occlusal practice in simple resto rative dentistry. British Dental Journal 191:365-381 Gher M E 1998 Changing concepts. The effects of occlusion on periodontitis. Dent al Clinics of North America 42:285-297 Greene C S, Laskin D M 2000 Temporomandib ular disorders: moving from a dentally based to a medically based model. Journal of Dental Research 79:1736-1739 Hellsing G 1988 Occlusal adjustment and occlusa l stability. Journal of Prosthetic Dentistry 59:696-702 Karjalainen M, Le Bell Y , [amsa T, Karjalainen S 1997 Prevention of temporomandibular disorder-related s igns and symptoms in orthodontically treated adolescents. A 3-year follow-up of a prospective randomized trial. Acta Odontologica Scandinavica 55:319-324 Kopp S , Wenneberg B 1981 Effects of occlusal treatment and intra-articular injections on temporomandibular joint pain and dysfunction. Acta Odontologica Scandinavica 39:87-96 Luther F 1998 Orthodontics and the temporomandibular joint: where are w e now? Part 2. Functional occlusion, malocclusion, and TMD. Angle Orthodontist 6 8:305--316 Marklund S, Wanman A 2000 A century of controversy regarding the bene fit or detriment of occlusal contacts on the mediotrusive side. Review. Journal of Oral Rehabilitation 27:553-562 Minagi S, Ohtsuki H, Sato T, Ishii A 1997 Effe ct of balancing-side occlusion on the ipsilateral TMJ dynamics under clenching. Journal of Oral Rehabilitation 24:57-62 Rosenberg P A, Babick P J, Schertzer L, Leung A 1998 The effect of occlusal reduction on pain after endodontic instrumen tation. Journal of Endodontics 24:492-496 Tsolka P, Morris R W, Preiskel H W 199 2 Occlusal adjustment therapy for craniomandibular disorders: a clinical assessm ent by a double-blind method. Journal of Prosthetic Dentistry 68:957-964 Vallon D, Ekberg E C, Nilner M, Kopp S 1995 Short-term effect of occlusal adjustment on craniomandibular disorders including headaches. Acta Odontologica Scandinavica 53:55-59 138

Index Aborigines (Australia), tooth wear, 92 Acromegaly, 73 Acrylic resin implants, 12 0, 123-124 occlusion records, 62-63 (Fig.), 63 onlays, 112-113 splints, 129 (Fig .) Acute dislocation of temporomandibular joint, 69 Acute pain, chronic pain VS, 79 Adaptor foils, for occlusal adjustment, 136,137 Adjustable articulators, 56, 57 (Pig.), 58 (Fig.),63 Adjustment for balanced occlusion, 116 splints, 126 (Bo x), 129-130 see also Occlusal adjustment Adult orthodontics, 97-100 Aesthetics o cclusal plane, 108 orthodontics, 98 Afferents see Orofacial afferents Ageing, me asurement changes, 99 Alpha-motoneurone activation, 17 (Fig.), 18 Amitriptyline, tension-type headache, 81 Analgesics, 81 rheumatoid arthritis, 72 Analysis form s, occlusal, 49-50, 51 (Fig.) Anamnesis, jaw muscle disorders, 78-79 Anatomical artificial teeth, 114 Anatomy jaw muscle function, 77 temporomandibular joint, 3 1-38 Anchored disc phenomenon, 38 Andrews, L.P., orthodontics, 92 Angle, E.H. cl asses, mixed dentition period, 25 orthodontics, 91-92 Animal experiments, second ary occlusal trauma, 87-88 Ankylosis, 85 primary molars, 28 Anodontia, 27-28 Ant erioposterior cant, occlusal plane, 108 Anterior band, articular disc, 34, 40 An terior disc displacement, 40 Anterior disclusion, 6 Anterior guidance, 7, 8-9, 1 0 Anterior open bite jaw muscle disorders, 76 rheumatoid arthritis, 72 Arcon-desig n articulators, 56 Arthralgia, splints, 127 Arthrography, disadvantages, 69 Arti cular disc (TMJ), 5 (Fig.), 32-33 anatomy, 34-35 attachments, 35-37 displacement , 67 (Box), 76 see also Disc interference disorders movements, 21 position, 37 r emodelling, 39-40 rotation vs translation, 10 Articular tubercle, 33 Articulator s, 55-56, 57 (Fig.), 107-108 adjustable, 56, 57 (Fig.), 58 (Fig.), 63 average va lue, 55, 63, 108, 115 choice, 63, 115 semi-adjustable, 55-56, 57 (Fig.), 63, 115 simple hinge, 55, 56 (Fig.), 63 splint preparation, 125 (Box) Artificial teeth, 114-115 Aseptic necrosis, from orthodontic forces, 86 Attrition (wear), 50, 105 Australian Aborigines, tooth wear, 92 Average value articulators, 55, 63, 108, 115 Avulsion, traumatic, 28 Axial inclination, 92 Bacterial plaque, jiggling for ces on, 88 Balanced occlusion, 115 adjustment for, 116 implants, 119 (Box) Balan cing (mediotrusive) side contacts, 4 (Box), 6, 10-11 Ball-and-slot mechanism, De ntatus semi-adjustable articulator, 57 (Fig.) Begg, P.R. extraction orthodon tic s, 94 retention appliance, 100 (Fig.) on tooth wear, 92 Bego adaptor foils, for occlusal adjustment, 136, 137 Bennett angle, 4 (Box), 6 articulators, 56 Bennett movement, 4 (Box), 6 Bicuspid molars absence, 12 contacts, 4 Bilaminar zone, articular disc, 36-37 Bi lateral sagittal split osteotomy (BssO), 98 Bite force, 77 Block-out undercuts, splints, 125 (Box), 128,130 Blood supply, ja w muscles, 76 Bone loss adult orthodontics, 98 implants, 123 Border movement, 78 Bridges, implants, 120 Bruxism, 50, 105 implants and, 122 pain from, 76, 126-1 27 splints and, 125 (Box) on tooth mobility, 85 see also Sleep bruxism Bruxoface ts, 50 clenching on, 52 BssO (bilateral sagittal split osteotomy), 98 Buccal upper, lingual lower (BULL) rule, 116 Canine guidance, 10, 106 implants, 123 on temporomandibular joint, 11 Canines disclusion, 6 lateral loading, 106 ma xillary, longitudinal ridge, 9 mobility, 84 orthodontics compensation for contin ued growth, 100 lateral missing incisors, 97 Cantilevered surfaces, implants, ro tation forces, 121 (Fig.), 123 Capsule, temporomandibular joint, 35 Cartilage-li ke proteoglycans (CLPGs), articular disc, 34 Casts see Split-cast technique; Stu dy casts Cathepsin B, 41 Central nervous system jaw movement, 13, 14-15 pain pat hways, 77, 78 Central pattern generators, 13, 17-18 Centre of rotation, instanta neous, 20 139

INDEX Centric clenching, provocation test, 52 Centric occlusion (CO), 4 (Box), 5 pain, 49 Centric relation (CR), 4 (Box), 5 occlusal record, 61, 115, 116 for partial d entures, 112 prosthodontics, 107, 115, 116 Cephalocaudal gradient of growth, 24 Cephalometry, 24, 92 Cerebral cortex, 15 Cervical muscles, 76 Check (precentric) records, 116 Chewing cycles, 21-22 occlusal relationships on, 10 traces, 8 (Fig .), 19 (Fig.) Chewing test, pain, 79 Children, orthodontics, 91-97 Chondrocytes, osteoarthrosis, 40-41 Chronic vs acute pain, 79 Circumferential supracrestal fi breotomy, 99 Classifications jaw movements, 13, 15-18 jaw muscle disorders, 79-80 malocclusio n, 93-94 Clenching, 50, 105 centric occlusion, pain, 49 mediotrusive contacts an d, 11 provocation test, 52 on tooth mobility, 85 see also Maximum intercuspation Clicking, temporomandibular joint, 68 Clinical examination, jaw muscle disorder s, 78 (Table), 79 Clinical occlusal analysis, 45-54 Clinical signs, parafunction , 50-52 CLPGs (cartilage-like proteoglycans), articular disc, 34 Clutches, for o cclusion records, 61 CO see Centric occlusion Codestruction, zone of (Glickman h ypothesis),87 Collagen (fibres) articular disc, 34, 40 periodontal ligament, 83, 99 Compensating curve (artificial teeth), 115 Complete dentures, 113-116, 120 c entric occlusion,S maxillomandibular relationship, 107 Concavity, articular disc , 34 Condylar angles, 34 articulators, 56 Condylar fovea,S (Fig.) Condylar guida nce, 18, 115 Condylar inclination, 18 on mediotrusive contacts/interferences, 11 Condylar points, tracing, 20 (Fig.) errors, 21 Condyles, 31 (Box) anatomy, 33-3 4 fractures, 70 movements, 10, 21, 31-32, 31 (Box), 38-39 working side movement, 20 (Fig.) see also Intercondylar axis Conformative occlusion implants, 119 (Box), 123 partial dentures, 111-112 Congen ital absence of teeth, 27-28 Contacts of teeth, 4-6, 104 adjustment for, 136 ass essment, 46-49 implants, 123 mediotrusive,4 (Box), 6,10-11 premature, 83 (Box), 87, 88 see also Interferences Continuous forces, 85 Contraction times, jaw muscl es, 10 Contracture, muscle, 80 Cooling, temporomandibular joint, 35 CR see Centr ic relation Craniofacial development, 23, 24 disproportion, 26 Crepitation, oste oarthrosis, 71 Crowding, incisors, teenage, 26 Crown angulations, 92 Crown incli nations, 92 Crown-root ratios, 98 Crowns (prosthetic), 106 Curve of Spee, 8, 92, 108 Curve of Wilson, 8, 108 Cuspal angles, artificial teeth, 115 Cusp-to-fossa relationships, 91 complete dentures, 116 Cytokines, osteoarthrosis and, 40-42 De ciduous teeth see Primary dentition Denar DSA adjustable articulator, 57 (Fig.), 58 (Fig.) Dental age, 25 Dental compensations, 98 Dental development, normal, 2 4-26 Dentatus semi-adjustable articulator, 57 (Fig.) Dentofacial development, 23 -29 Depression, pain, 76 Development, 23-29 temporomandibular joint, 33 Diagnost ic occlusal adjustment, 135 Diastema, midline, 25 Disc interference disorders, 6 8-{j9 see also under Articular disc Disclusion, 6 Dislocation, temporomandibular joint, Ear canal, as reference point, 56, 58 (Fig.) Ectopic eruption, 28 Edentulism, bo rder movement diagrams, 7 Education of patient, parafunctional habit, 52-54 Effu sions, temporomandibular joint, 70 Elastic fibres, temporomandibular joint, 36-37 Electromyography, 16 (Fig.), 18, 19 (Fig.) anterior guidance, 10 bruxism, 126 splints on, 127 Elevator muscles, 7 7 see also Masseter; Temporalis Endochondral ossification, 23 Epidemiology, seco ndary occlusal trauma, 88 Episodic tension-type headache, 80 Equilibration, occl usal, 133-134 Eruption, 24-25 abnormalities, 28 adults, 98 third molars, 26 Evid ence base fixed prosthodontics and, 103 (Box), 106 implants and, 120 occlusal ad justment, 134-135 splints, 126, 127-128 Evolutionary drift, malocclusion inciden ce, 27 Examination, jaw muscle disorders, 78 (Table), 79 Exercise, for jaw muscl e disorders, 81 Extraction forces, implants, 121 Extractions, orthodontics, 95-9

7 Extrafusal muscle fibres, 17 (Fig.) Extrusion, 98 Fabrication, splints, 128-12 9 Face development, 23-24 disproportion, 26-27 jaw muscle disorders, 77 masticat ion movements, 21 Facebows,56-58,108 splint preparation, 125 (Box) FAa see Funct ional angle of occlusion Fibreotomy, circumferential supracrestal, 69 Displaceability, implants, 119 (Box) Distal drift of incisors, 28 Distal guidanc e, 9-10 mesial guidance with, 10 Distal jaw relationship, skeletal class II malo cclusions, 94 Diurnal parafunction, 50 Divisions, class II malocclusions, 94 Dur ation of force, on dental positions, 99 Fibres, jaw muscles, 76 Fibroblastic metaplasia, osteoarthrosis, 41 Fibromyalgia , 80 Fibrous attachments, articular disc, 37 First molars, relationships, 91 Fix ed appliances, 98-99 Fixed prosthodontics, 103-109, 120 Forces (occlusal), 77,85 ,86-87 duration on dental positions, 29 implants, 119 (Box), 120, 121, 122, 123 Forks, facebows, 56-58 Fossa boxes, articulators, 57 (Fig.) Fovea, condylar,S (F ig.) 29 Dworkin, S.P., LeResche, L. see Research Diagnostic Criteria for Temporomandibul ar Disorders Dye spacer, marking occlusal records, 136 Dynamic occlusal records, 61-{j3 140

INDEX Fractures condyles, 70 implants, 122 teeth, lateral loading, 105-106 Frankfort m andibular plane angles, incisors, 94 'Free-way' (speaking space), 6 Fremitus, 10 6 Frictional retention of splints, 128 Fulcrum function, ipsilateral condyle, 38 Full dentures see Complete dentures Functional angle of occlusion (FAO), 8 (Fig .), 9 (Fig.) occlusal adjustment freeing, 134 Functional ankylosis, implants, 88 Functional matrix theory, facial growth, 26 Functional methods, centric relatio n recording, 115 Gamma-motoneurone activation, 17 (Fig.),18 Genetics, skeletal d isproportion, 27 GHMFoils occlusal adjustment, 137 tooth contact marking, 46 Gin giva, occlusal trauma, 83 (Box), 87, 89 Gingival fibres relapse after orthodonti c therapy, 99 see also Periodontal structures, fibre system Ginglymodiarthrodial joint, 31 Glenoid fossa, 33 Glickman hypothesis, 87 Gold alloy, implants, 124 G olgi tendon organs, 18 'Gothic arch' tracing, 61 Grinding (selective), 134 compl ete dentures, 116 Grinding movement, muscle contraction patterns, 15 Group funct ion, 11, 20 implants, 123 laterotrusive jaw movement, 6 on temporomandibular joi nt, 11 Growth, 23-29 condyles, 34 modification, 91 (Box) relapse after orthodont ic treatment, 100 Guidance, 8-10 anterior, 7, 8-9, 10 clinical occlusal assessme nt, 46-49 condylar, 18, 115 incisal,18 simulation on articulators, 56, 115 later al see Lateral guidance see also Canine guidance Haernarthrosis, 69-70 Hanau's q uint, 115 Hawaiian Islands, outbreeding, 27 Headache, 80, 81 Heat disposal, temp oromandibular joint, 35 Heavy vs light intercuspal contact, 4 High-threshold (T) afferents, traces, 19 (Fig.) Hinge articulators, 55, 56 (Fig. ), 63 Hinge axes, facebows, 56 Histology, temporomandibular joint osteoarthrosis , 42 History-taking, jaw muscle disorders, 78-79 Horizontal condylar angle, 34 H orizontal mobility, teeth, 84 Hyoid bone, 77 Hyperaemia, jaw muscles, 77 Hypermo bility, 84-85, 86--87, 89 Hyperpolarisation, motoneurones, 19 (Fig.) Hypertrophy , jaw muscles, 80 Hypodontia,28 Hypomobility, 85 Iatrogenic injury, 106 ICP see Intercuspal position Immediate side shift (ISS), 6 Impact forces, 85 Implant occ lusion, 120-124 Implants, 119-131 occlusal trauma, 88, 89 premature contact on, 83 (Box) Impressions, for splints, 125 (Box) Incisal guidance, 18 simulation on articulators, 56, 115 Incisor liability, 25 Incisors deciduous and permanent, 25 distal drift, 28 eruption adults, 98 ectopic, 28 lateral loading, 105-106 mandi bular plane angles, 94 missing laterals, orthodontics, 97 mobility, 84 teenage c rowding, 26 Inferior lamina, articular disc, 36 Inflammation pain, 78 secondary occlusal trauma, 87-88 traumatic occlusion, 83 (Box) Insertion of partial dentur es, occlusal correction, 112 Insertions (muscular) see Lateral pterygoid muscle, insertions Instantaneous centre of rotation, 20 Interarch relationships mixed d entition period, 25 occlusal adjustment, 134 Interarticular disc see Articular d isc Intercondylar axis, 7 (Fig.) Intercuspal contact (IC), 4 Intercuspal positio n (ICP), 4,107 articulators, reproduction, 55-56 centric occlusion vs, 5 occlusa l adjustment, 136, 137 occlusion records, 61 slide to RCP contacts marking, 46 ( Table), 49 occlusal adjustment, 136 osteoarthrosis, 72 Interferences protrusive, occlusal adjustment, 137 on temporomandibular disorder s, 135 see also Mediotrusive interferences Interincisal opening, mandible size o n, 39 Interleukin-Ijl, osteoarthrosis, 41 Internal architecture, jaw muscles, 14 , 17 Internal derangements, temporomandibular joint, 69 International Associatio n for Dental Research, Neuroscience Group on occlusal adjustment, 135 Interviewi ng, jaw muscle disorders, 78-79 Intrafusal muscle fibres, 17 (Fig.) Ipsilateral condyle, fulcrum function, 38 Irritation, zone of (Glickman hypothesis),87 Ischa emia, muscle pain, 78 NSAIDs,81 Jaw movement, 13-22 laterotrusive, group functio n, 6 see also Protrusive jaw movement Jaw muscles, 13, 14-15 attachments to arti cular disc, 37 contraction times, 10 disorders, 75-82 internal architecture, 17 physiology, 76-77 provocation test, 52 signs of parafunction, 52 (Table) Jaw tra cking see Tracking of jaw Jaw-closing muscles, 13 Jaw-closing reflex, 16--17 Jaw -opening muscles, 13 Jaw-opening reflex, 17 Jiggling forces, 85, 86-87 Juvenile occlusal equilibrium, 24 Kerr occlusal indicator wax, 136 'Keys of occlusion' (' six keys of occlusion'),92 Kinesiograph tracing, chewing cycles, 8 (Fig.) Knee-j

erk reflex, 16 Laskin, D.M., myofascial paindysfunction syndrome, 126 Lateral gu idance, 8-9, 106 contact marking, 46 (Table), 49 occlusal adjustment, 134 Latera l jaw positions, 4 (Box), 6 Lateral loading fractures of teeth, 105-106 implants , 123 Lateral occlusion records, 61 Lateral pterygoid muscle, 76, 77 insertions, 21 articular disc, 37 pain distribution, 77 Lateroprotrusive contacts, parafunc tion, 49 141

INDEX Laterotrusion,77 Laterotrusive side contacts, 4 (Box), 6 adjustment for, 136 Le Fort 1 and II fractures, maxillary surgery, 98 Leeway space, after secondary den tition eruption, 25 Leverage, occlusal forces, 122, 123 Light vs heavy intercusp al contact, 4 Limited opening, mandible, 75 (Box) Lingualised occlusion, artific ial teeth, 115 Linkages, implants, 119 (Box), 122, 123 Lips, orthodontics, 98 Li terature see Evidence base Loading implants, 122-124 overloading, 119 (Box), 120 , 122 temporomandibular joint, 38, 39-40 see also Lateral loading Local anaesthe sia, temporomandibular joint reduction, 69 Location of implants, 121 Long face s yndrome, 27 Long-term maintenance, prosthodontics, 108 Loose tissue, temporomand ibular joint, Maximum intercuspation (MI), 4 complete dentures, 116 Maximum interdigitation, d etermining treatment position, 107 Mechanical linkages, implants, 119 (Box), 122 , 123 Mechanoreceptors, 18 traces, 19 (Fig.) Medial pterygoid muscle, 75 (Box), 76, Myofascial pain-dysfunction syndrome (Laskin),126 Myositis, 80, 127 Myospasm, 12 7 Myotatic reflex contraction, 6 Nasal obstruction, 27 Nasal septum cartilage, a s growth pacemaker, 26 National Institute of Health, on temporomandibular disord ers, 126 Neoplasms, temporomandibular joints, 77 Median occlusal position (MOP), 4 (Box), 5 contact marking, 46 (Table), 49 splin t adjustment, 130 Mediotrusive interferences, 11 occlusal adjustment for, 136, 1 37 Mediotrusive side contacts, 4 (Box), 6, 10-11 Mesial drift, 28 Mesial guidanc e, 10 Mesial jaw relationship, skeletal class III malocclusions, 94 Mesiodistal tip (crown angulations), 92 Michigan splints (stabilisation splints), 81, 125 (B ox), 128 Microbial plaque, jiggling forces on, 88 Midincisor point, jaw movement tracing, 16 (Fig.) Midline diastema, 25 Miller holders, tooth contact marking, 46-49 Mixed dentition years, 25 Mobility of teeth, 83 (Box), 84--85 adult,97-98 hypermobility, 84--85, 86-87, 89 implants, 121 as protective mechanism, 105 Mola rs absence, 12 contacts, 4 ectopic eruption, 28 mobility, 84 relationships, 91, 92 third, eruption, 26 Monozygotic twins, skeletal disproportion, 27 Monson curv es, 108 MOP (median occlusal position), 4 (Box), 5 contact marking, 46 (Table), 49 splint adjustment, 130 Motor units, 14 Mouth breathing, on jaw development, 74 Nerves pain sensation, 77 to temporomandibular joint, 37-38 Neurological disorde rs, jaw muscles, 80 N europeptides pain, 78 temporomandibular joint innervation, 38 Neuroscience Group, International Association for Dental Research, on occlus al adjustment, 135 Nociceptors, muscle, 77, 78 Nocturnal parafunction, 50 see al so Sleep bruxism Non-arcon-design articulators, 56, 57 (Fig.) Non-rigid connecti ons, fixed partial dentures, 105 Non-steroidal anti-inflammatory drugs (NSAIDs), 81 Non-working (mediotrusive) side contacts,4 (Box), 6, 10-11 Occlusal adjustmen t, 107, 133-138 insertion of complete dentures, 116 Occlusal analysis forms, 4950, 51 (Fig.) Occlusal forces see Forces (occlusal) Occlusal plane indicators, 1 08 occlusal adjustment for, 134 orientation, 108, 115 Occlusal records, 59 (Fig. ), 60-61 (Fig.), 61-63, 107-108 of centric relation, 61, 115, 116 for occlusal a djustment, 135-136 for splinting, 125 (Box) Occlusal tape, ultrafine, 5, 46, 137 Occlusal trauma, 86-88 Occlusal vertical dimension (OVD), 4 (Box),6 complete de ntures, 113-114, 115 Occlusion, defined, 3, 4 Oedema, jaw muscles, 77 Oligodonti a, 27-28 Onlay dentures, 112-113 'Open lock', 69 Optimising occlusal variables, 7 Oral hygiene, splints, 130 Orofacial afferents, 18 jaw-opening reflex, 17 rest oration work on, 21 see also Sensory feedback 37 Low-threshold (T) afferents, traces, 19 (Fig.) Lubrication, temporomandibular jo int, 38 Magnetic resonance imaging articular disc position, 37 temporomandibular

joint, disadvantages, 69 Malocclusion, 91 (Box), 93-94 aetiology, 26-29 skeleta l classes, 94, 98 Mandible development, 23, 24 opening limited, 75 (Box) muscles for, 13 range, 79 reflex, 17 size on interincisal opening, 39 Mandibular casts, 59 (Fig.) Mandibular plane angles, incisors, 94 Manipulation, disc interference disorders, 69 Masseter,75 (Box), 76, 77 internal architecture, 14 pain distribu tion, 77 Mastication, 13 cycles,8 (Fig.), 10, 19 (Fig.) fixed prosthodontics, 10 5 jaw movements, 21-22 muscles of see Jaw muscles occl usal forces, 85 on tooth mobility, 84 Maxilla, development, 23, 24 Maxillary canine, longitudinal ridge, 9 Maxillomandibular relationship (MMR), 107 see also Centric relation 27 MPD (myofascial pain-dysfunction syndrome),126 Mucosal rnechanoreceptors, 18 Mus cle contracture, 80 forces, 10 see also Jaw muscles Muscle spindles, 17 (Fig.), 18 traces, 19 (Fig.) Mutually protected occlusion, 20 Myalgic disorders, 80 Myof ascial pain, 75 (Box), 80, 126-127 142

INDEX Orthodontic forces, 86 on implants, 121 Orthodontics, 91-101 occlusion after tre atment, 94-97 Orthognathic treatment, 97 (Box), 98-99 Osseodisintegration, impla nts, 88 Osseoperception, 120 Ossification, endochondral, 23 Osteoarthritis, temp oromandibular joint, 67 (Box) Osteoarthrosis, temporomandibular joint, 31 (Box), 40-42, 67 (Box), 71-72 Outbreeding, skeletal disproportion, 27 Overcorrection o f rotation, orthodontic therapy, 99 Overlay dentures, 112-113 Overload, implants , 119 (Box), 120, 122 Overuse, jaw muscles, 76-77 Oxytalan fibres, after orthodo ntic treatment, 99 Pacemaker of growth, nasal septum cartilage, 26 Pain muscles, 49, 75 (Box), 76, 77-79 myofascial, 75 (Box), 80, 126--127 osteoarthrosis, 40 r heumatoid arthritis, 72 splints vs, 125 (Box) Palpation, jaw muscle pain, 79 Pan tographs, 13, 60-61 (Fig,), 61-63 Parafunction, 3 fixed prosthodontics and, 104, 105 patient education, 52-54 splints for, 126 tooth wear assessment, 49-52 Pars gracilis, articular disc, 34 Pars posterior, articular disc, 34 Partial denture s, 120 fixed, non-rigid connections, 105 removable, 111-113 Patient education, p arafunctional habit, 52-54 Pennate fibre arrangement, masseter, 14 Pennation ang le, 14 Pericision, 99 Periodontal ligament, 83-84, 83 (Box) collagen fibres, 83, 99 occlusal trauma, 86 Periodontal space widening, 86 Periodontal structures, 8 3-89 adult orthodontics, 98 fibre system after orthodontic treatment, 99 on toot h position, 29 mechanoreceptors, 18 Periodontitis, 87-88 Periodontometry, 84 Per iosteal ossification, 24 Periotest (Siemens AG), 84 Pes, articular disc, 34 Phon etics, 104 Physical examination, jaw muscle disorders, 78 (Table), 79 Physical therapy jaw muscle disorders, 81 osteoarthrosis, 72 Physical training, rheumatoid arthritis, 72 Piano metaphor, jaw movement control, 15 Placebo effect , splints, 125 (Box), 127 Plaque, jiggling forces on, 88 Pockets adult orthodont ics, 98 secondary occlusal trauma, 88 Polynesians, Hawaiian Islands, outbreeding ,27 Porcelain, implants, 124 Posselt's border movement diagram, Questionnaires, jaw muscle disorders, 78 7-8 Postemergent spurt, tooth growth, 24 Posterior band articular disc, 34 trapping, 40 Posterior disclusion, 6 Posterior eccentric contacts, 106 Posterior guidance , 8 Postexercise myalgia, 80 treatment, 81 Postural jaw position (PJP), 4 (Box), 5-6,114 Potassium, pain, 78 Precentric records, 116 Pregnancy, tooth mobility, 84-85 Premature contacts, on periodontal structures, 83 (Box), 87, 88 Premolars deciduous vs permanent, 25 extractions, orthodontics, 95-97 mobility, 84 Premo t or cortex, 15 Preparatory phase, chewing cycle, 21 Preswallowing, chewing cycle, 21 Primary dentition absence of tooth, 28 eruption, 24-25 trauma, 28 Primary mo tor cortex (MI), 15 Primary occlusal trauma, 86--87 Progressive remodelling, tem poromandibular joint, 40 Proprioceptors implants and, 119 (Box), 121 periodontal ligament, 84 see also Osseoperception Prostaglandins, pain, 78 Prosthodontics f ixed, 103-109, 120 removable, 111-117, 120 Protrusive interferences, occlusal ad justment, 137 Protrusive jaw movement, 4 (Box), 20 laterotrusion with, 77 occlus al adjustment for, 134, 136 Protrusive occlusion records, 61 Protrusive position ing splints, 68-69 Provocation tests, 45 (Box), 52-54 Puberty, tooth growth, 24 Radiography osteoarthrosis, 71 rheumatoid arthritis, 72 Ramps, splints, 126 (Box ), 129 Randomised controlled trials, splints, 127-128 Reaction force, temporoman dibular joint, mediotrusive interferences on, 11 Reciprocal clicking, temporoman dibular joint, 68 Reduction, temporomandibular joint dislocation, 69 Reduction p hase, chewing cycle, 21 Reflexes, 13, 16-17 Regressive remodelling, temporomandi bular joint, 40 Relapse, adult orthodontics, 97 (Box),

99 Remodelling alveolar process, 84 temporomandibular joint, 39-40 Removable prosth odontics, 111-117, 120 Reorganised occlusion, partial dentures, 111-112 Rerecord ing centric relation, 116 Research Diagnostic Criteria for Temporomandibular Dis orders (RDC/TMD),45 jaw muscle disorders, 76 Resins implants, 123-124 see also A crylic resin Resting vertical dimension see Occlusal vertical dimension; Postura l jaw position Restriction of functional angle of occlusion, 134 Retention appli ances, protocols, 97 (Box), 99-100 Retrocondylar space, volume changes, 37 Retrodiscal pad (bilaminar zone), articular disc, 36-37 Retruded contact positio n (RCP), 4 (Box), 5 contact marking, 46-49 occlusal adjustment, 136, 137 occlusa l record, 61 rheumatoid arthritis and, 73 Retruded jaw position (RP), 4 (Box), 5 (Fig,) prosthodontics, 107 Retrusive condylar movements, 38 Review, splints, 13 0 Rheumatoid arthritis, 67 (Box), 72-73 Rhythmical jaw movements, 17-18 Rigidity , implants, 121 Root resorption, orthodontic forces, 86 Rotation (developmental) , 24 Rotation (jaw), 20, 21, 31 (Box), 33, 38-39 articular disc, 10 border movem ent, 7 (Fig.) 143

INDEX Rotation (teeth), 92 forces on implants, 121, 123 relapse after orthodontic ther apy, 99 Screws, implants, 122 Secondary occlusal trauma, 87-88 Selective grindin g, 134 complete dentures, 116 Self-care programmes, temporomandibular disorders, 54 Semi-adjustable articulators, 55-56, 57 (Fig.), 63, 115 Sensitisation, muscle pa in, 78 Sensory feedback, 18 traces, 19 (Fig.) see also Orofacial afferents Senso ry receptors muscle nociceptors, 77, 78 temporomandibular joint, 38 see also Pro prioceptors Shape, articular disc, 34-35 Shape abnormalities, teeth, 28 Sharpey fibres, 83 Shimstock perception, 120 Shortened dental arch (SDA), 11-12, 106 Sig nalling pathways, articular disc remodelling, 40 Silicone impressions see Study casts Simple hinge articulators, 55, 56 (Fig.), 63 Single plane tracing plates, dynamic occlusal records, 61 'Six keys of occlusion ', 92 Six-degrees-of-freedom tracking devices, 21 Size abnormalities, teeth, 28 Skeletal classes, malocclusions, 94, 98 Skeletal disproportion, aetiology, 26-27 Sleep, use of splints, 130 Sleep bruxism, 50 occlusal adjustment on, 134 pain f rom, 76, 126-127 Snap jaw closure, median occlusal position, 5 splint adjustment , 130 Soft splints, 128 Soft tissues temporomandibular joint, 33 on tooth positi on, 29,100,104-105 Spasm, muscular, 127 Speaking space, 6 Splints, 125-131 const ruction, 128-130 fabrication, 128--129 osteoarthrosis, 72 protrusive positioning , 68-69 stabilisation splints, 81, 125 (Box), 128 Split-cast technique, 116 Stab ilisation splints, 81, 125 (Box), 128 Static methods, centric relation recording , 115 Stereographic occlusion records, 62-63 (Fig.), 63 Stress articular disc, 35 tens ile, temporomandibular joint, 106 Study casts, 59 (Fig.), 61 determining treatme nt position, 107 occlusal adjustment on, 135 for partial dentures, 112 verifica tion, 64 Subcondylar fractures, 70 Subnucleus caudalis, 77, 78 Sucking ha bits f ixed prosthodontics and, 104 malocclusion, 29 Superior lamina, articular disc, 3 5-36 Supernumerary teeth, 28 Supplementary motor area (SMA), cerebral cortex, 15 Supracrestal fibreotomy, circumferential, 99 Supracrestal fibres Glickman hypot hesis, 87 periodontal ligament, 83 Suprahyoid muscles, 77 Surface loss, teeth, 5 0, 105 Swallowing, 104 Synchondroses, 23,24 Synovial fluid, 35, 38 Synovial memb rane, temporomandibular joint, 35 T (high-threshold) afferents, traces, 19 (Fig. ) Template, for occlusal adjustment, 136,137 Temporalis,76 pain distribution, 77 Temporomandibular disorders assessment, 45-46, 52-54 law muscle disorders and, 75 (Box) rnediotrusive interferences, 11 occlusal adjustment, 133, 134-135 occlu sal variables on, 6-7 physical therapy, 81 splints for, 126-127 treatment, 52-54 see also Temporomandibular joint, disorders Temporomandibular joint, 5 (Fig.), 31-42 canine guidance on, 11 disorders, 67-74 mechanoreceptors, 18 occlusal adju stment for function, 134 provocation test, 52 reproduction in articulators, 56 s igns of parafunction, 52 (Table) tensile stress, 106 see also Articular disc Ten derness, jaw muscle disorders, 79 Tensile stress, temporomandibular joint, 106 Tension-type headache, 80 amitripty line, 81 Terminal hinge axis, 7 (Fig.) Thermoplastic templates, for occlusal adj ustment, 136, 137 Thermosetting resin, splint fabrication, 128, 129 (Fig.) Third molars, eruption, 26 Three-degrees-of-freedom tracking devices, 21 TIMPs (tissu e inhibitors of matrix metalloproteinases),40 Tip, mesiodistal (crown angulation s), 92 Tipping forces, implants, 122 Tissue inhibitors of matrix metalloproteina ses (TIMP-1 and TIMP-2), 40 Tongue, mastication, 21 Tongue-thrusting habit, fixe d prosthodontics and, 104 Torquing, implants, 121, 123 Traces jaw movement, 16 ( Fig.) neurophysiology, 19 (Fig.) Tracing plates, dynamic occlusal records, 61-63 Tracking of jaw, 8 (Fig.), 16 (Fig.), 19 (Fig.), 20 (Fig.) anterior guidance, 1 0 devices, 21 Transducers, force studies, 120 Transfer records see Occlusal reco rds Translation border movement, 7 (Fig.) temporomandibular joint, 31 (Box), 33,

38-39 articular disc, 10 Trans-septal fibres, on tooth position, 29 Trapping, po sterior band, 40 Trauma, 28 temporomandibular joint disorders, 69-70 Traumatic o cclusion, 83 (Box), 85-89, 86 occlusal adjustment for, 134 Tricyclic antidepress ants, jaw muscle pain, 81 Trigeminal nerve, to temporomandibular joint, 37-38 Tu mour necrosis factor (I., osteoarthrosis,41 Tweed, C.H., orthodontics, 92, 94 Tw in studies, skeletal disproportion, 27 Type FF motor units, 14 Type FR motor uni ts, 14 Type S motor units, 14 Ultrafiltration, high-load joint lubrication, 38 U ltrafine occlusal tapes, 5, 46, 137 Undercuts, block-out splint adjustment, 130 splint preparation, 125 (Box), 128 Undermining resorption, 86 144

INDEX Venous plexi, temporomandibular joint, 37 Verification, study casts, 64 Vertical condylar angle, 34 Vertical mobility, teeth, 84 Visual analogue scale (VAS) for pain, 79 splints, 127 Volume changes, retrocondylar space, 37 Voluntary jaw muscles, 15-16 Wax Kerr occlusal indicator wax, 136 making study casts, 61 precentric records, 116 Wax occlusal rims, 112 Wear on teeth, 50, 105 Weeping lubrication, 38 Workin g condyle, fulcrum function, 38 Working side contacts see Laterotrusive side contacts Working side movement, con dyles, 20 (Fig.) Zero-degree artificial teeth, 115 Zone of codestruction, Glickm an hypothesis, 87 Zone of irritation, Glickman hypothesis, 87 145