International Dental Journal ( 1 998)48, 571-581

Considerations when planning occlusal

rehabilitation: A review of the literature
R W Wassell and J G Steele
Newcastle upon Tyne, UK
G Welsh
Edinburgh, UK

Summary

As one of the most demanding tasks facing the restorative dentist, planning and executing
an occlusal rehabilitation should not be undertaken lightly. The stakes are high and
failure is costly. Treatment planning decisions should be undertaken on the basis of
scientific evidence, where this is available, or on the basis of documented experience
where it is not. This review article identifies the major biological and clinical considera-
tions used when planning an occlusal rehabilitation. These include the indications for
reorganising the occlusion, the choice of condylar position and occlusal scheme, the
implications of and indications for increasing the vertical dimension, replacing missing
teeth and the choice of materials. Finally, the literature surrounding the controversial issue
of occlusal rehabilitation as a means to treat temporo-mandibular disorders is also
reviewed.

Planning and executing the restorative rehabilitation of
a decimated occlusion is probably one of the most intel-
lectually and technically demanding tasks facing a
restorative dentist. This review article attempts to
demystify a complex topic by reviewing the scientific
evidence where it is available so that informed treat-
ment decisions can be made.
The term ‘occlusal rehabilitation’ has been defined as
the restoration of the functional integrity of the dental
arches by the use of inlays, crowns, bridges and partial
dentures’. Occlusal rehabilitation therefore involves
restoring the dentate or partially dentate mouth. The
aim is to provide an ordered pattern of occlusal contact
and articulation which will optimise oral function,
occlusal stability and aesthetics. Occlusal adjustment by
grinding may be required as part of the rehabilitation
but does not constitute rehabilitation per se. For the
purposes of this review occlusal rehabilitation is
discussed in the context of cases where restorations are
supported by natural teeth, and does not include the
restoration of the fully edentulous arch or maxillofacial
defects, nor does it include the use of osseo-integrated
implants.
Indications for occlusal rehabilitation
The reasons for undertaking occlusal rehabilitation may
include the restoration of multiple teeth which are
missing, worn, broken down or decayed. Increasingly,
occlusal rehabilitation is also required to replace
improperly designed and executed crown and bridge-
work. In certain circumstances treatment of temporo-
mandibular disorders (TMD) may also be considered an
indication for rehabilitation, but great caution is advis-
able in such cases. Regardless of the clinical reason, the
decision to carry out any treatment should be based
upon achieving oral health, function, aesthetics and
comfort, and treatment should be planned around these,
rather than the technical possibilities. If these goals are
to be achieved certain biological considerations are
necessary when planning and carrying out occlusal
rehabilitation. These considerations form the basis of
this review. They are:
the indications for reorganising the occlusion
the choice of an appropriate occlusal scheme
the occlusal vertical dimension
the need (or otherwise) to replace missing teeth

0 1998 FDlNVorld Dental Press

0020-6539/98/06571-11
572 International Dental Journal (1998) Vol. 48/No.6
the effects of the materials used on occlusal stability
control of parafunction and TMD.
This article will consider each of these in turn and
will examine the scientific evidence, where such
evidence is available, upon which the principles of
occlusal rehabilitation are founded. It is not the inten-
tion of this paper to offer a detailed guide to operative
procedure in this discipline; for this, the reader is
referred e l ~ e w h e r e ~Furthermore,
-~. little reference will
be made to periodontal health as it is assumed that
operators will take steps to ensure that this is optimised
prior to embarking upon advanced restorative
procedures.
Indications for reorganising the occlusion
When undertaking relatively small amounts of restora-
tive treatment, for example up to two or three units of
crown and bridge work, it is often acceptable, and
indeed it is often advisable, to adopt a conformative
approach, that is to construct these restorations to
conform with the patient‘s existing intercuspal position
(IP). The alternative strategy is to reorganise the occlu-
sion by establishing a new occlusal scheme around a
suitable condylar position. The condylar position
usually chosen is termed ‘centric relation’ (CR) and will
be discussed in the following section. It is worth empha-
sising here that the occlusion should not be reorganised
unless there is good reason to do so. The decision to
reorganise a patient’s occlusion may be made on the
grounds either that the existing IP is unacceptable and
needs to be changed, or where a very large amount of
treatment is to be undertaken and the operator has the
opportunity to ’optimise’ the patient’s occlusion. The
decision should (and can) only be made after a detailed
and careful examination of the occlusion, preferably with
the use of accurate study casts mounted in a semi-
adjustable articulator in the retruded arc of closure.
Mounted casts should allow the discrepancy (slide)
between CR and IP to be analysed as vertical, horizontal
and lateral components both at tooth and condylar level.
Moreover, adjustments can be tried and potential resto-
rations waxed allowing the feasibility and difficulty of
reorganisation to be judged properly.
It must be borne in mind that jaw movement will be
simulated only partially by any type of articulator.
Nevertheless, semi-adjustable articulators are an invalu-
able supplement to diagnosis and can save time with
occlusal adjustments when restorations are fitted.
Reorganisation may be considered when the existing
IP is considered unsatisfactory for any of the following
reasons:
Repeated fracture/failure of teeth or restorations:
Clinical experience suggests that persistently failing
restorations (for example a crown or bridge
debonding) are very commonly attributed to
unfavourable occlusal loading which may be
improved by reorganisation.
Bruxism: An optimally constructed occlusion may be
better able to deal with the forces generated by para-
function. The evidence for treating bruxism by reor-
ganising the occlusion is dealt with later.
Lack of interocclusal space for restorations: Reorgan-
ising the occlusion to eliminate a large horizontal
component of slide between CR and IP can create
valuable interocclusal space for the restoration of
worn anterior teeth6. Alternatively, the occlusion may
be reorganised at an increased vertical dimension
necessitating occlusal coverage for at least one arch.
Trauma from the occlusion: This may be soft tissue
trauma (due to teeth impinging on the cheek or
alveolar ridge) or periodontal trauma (due to exces-
sive or aberrantly directed occlusal forces). The latter
may have an accelerating effect on periodontal
disease7 although the evidence is conflicting8.
Reorganisation of the occlusion to direct forces
axially and eliminate interferences and premature
contacts can reduce tooth mobility9. However, the
overall gain in periodontal attachment is marginallo
and should be considered as no more than an
adjunct to periodontal management.
Unacceptable function: Poor tooth to tooth contacts,
with tilting and overeruption of teeth may create
problems with masticatory function, particularly
where large numbers of teeth have been
Unacceptable aesthetics: Alteration in the clinical
crown height may be necessary to improve aesthet-
ics, and this may be made possible by constructing
the restorations to a reorganised occlusion, possibly
at an increased vertical dimension.
The presence of TMD: The link between occlusion
and TMD is controversial and is discussed at the end
of the article.
The condylar position
The condylar position around which a rehabilitation is
constituted must be both comfortable and reproducible.
It must also be recordable and transferable to an articu-
lator and the reference position must not be lost or
altered by the preparation of teeth. For this reason, the
IP which is determined purely by occlusal morphology
is unsuitable as a reference point since it is a learned
position which is rapidly lost following alteration to the
occlusal surfaces of the teeth, for example as a result of
crown preparation. CR has been considered as the opti-
mum condylar position from which to reconstruct an
o c c l ~ s i o n largely
’~ because of its reproducibility. Other
condylar positions based on a downward and forward
position of the condyles15or centrally placed within the
glenoid fossaeI6suffer from poor reproducibility but, as
discussed later, may be indicated on rare occasions for
the management of patients suffering from TMJ disc
displacements.
The definition of CR has changed gradually over the
years, moving away from the concept of a retruded or
 Wassell eta/.:Considerations in occlusal rehabilitation 573

rearmost position, it is now defined as the maxillo-
mandibular relationship in which the mandibular
condyles articulate with the thinnest avascular portion
of their respective discs with the complex in the ante-
rior-superior position against the slope of the articulator
eminence (Glossary of Prosthodontic Terms, 1994). CR
is a stable musculo-skeletal position that occurs in the
healthy TMJ; TMJ dysfunction or derangement can make
locating it difficult or impossible. D a ~ s o n ‘has
~ intro-
duced the concept of ‘adapted centric posture’ which
describes those deformed but adapted joints which may
under certain conditions function with the same degree of
comfort as intact, properly aligned disc assemblies in CR.
For all their detail and precision, definitions of CR
are not terribly helpful to the clinician. The clinical loca-
tion of this position is still usually achieved by using
either chin point guidanceI8 or bimanual manipulation
of the mandible”. Although minor differences in posi-
tion have been reported between the two techniquesZU
they both seem to work in practice. Nevertheless, their
validity has not been fully tested.
Whilst CR is a relatively reproducible position, doubts
have been expressed over how physiological it is. Most
people exhibit a small, usually horizontal, discrepancy
between this position and the position of the condyle
when there is maximum intercuspation of the teethZ1.
Celenzaz2observed that between two and twelve years
following occlusal treatment to make CR and IP coincident,
many patients had re-established the small discrepancy
between the two positions. Similarly, orthodontic treatment
may relapse to recreate a CR-IP di~crepancy~~.
At one time, centric relation contact position (CRCP,
the initial contact on the terminal hinge axis) was
considered an important jaw position which was adopted
routinely in swallowing and chewing, that is, the teeth
were loaded in this position on a regular basis24.For this
reason, it was suggested that occlusal contacts in this
position were important to prevent the teeth being
unfavourably loaded. However, it has been questioned
whether in fact this position is ever really adopted in
functionz5. Electromyographic (EMG) recordings have
shown that CR is not a neutral position but in fact the
muscles are slightly strained with minimum muscle
activity occurring at a point just anterior to this26.This
may account for the relapse reported by Celenza2z.
There is controversy over whether there is an antero-
posterior range of movement with the condyles in their
most superior position. OkesonZ7considers that move-
ment may be possible if the horizontal fibres of the
ligament are elongated, but not in a healthy TMJ. This is
an unsubstantiated clinical observation, but the message
would seem to be that, in patients showing a degree of
freedom posterior to CR, there is a danger that cuspal
inclines on posterior crowns or the lingual surfaces of
anterior crowns may force the mandible backwards into
an uncomfortable and non-physiological position. Care
must therefore be taken not to over-retrude the mandi-
ble during registration. Also the occlusal scheme should
be designed to allow a small amount (approximately
0.5mm) of freedom in centric.
Choice of occlusal scheme
An occlusal scheme is a pattern of occlusal contact used
for reconstruction. For full mouth reconstruction there
are a number of occlusal schemes which are summa-
rised in TubIe 1. All of these schemes stipulate that the

~ ~

Gnathological1l2 CRCP and IP coincident Canine guided lateral excursions, Good for restoring cases without a large
(tripod contacts) posterior disclusion in all excursions. horizontal component of CRCP-IP slide.
Purists will insist on a fully adjustable
articulator.
CRCP and IP coincident As for Gnathological, but designed to Useful where excursive parafunction can-
(tripod contacts) drop into group function if canines not be controlled or canine compromised
wear or move. periodontally.
Pankey-Mann- Area of freedom between Anterior guidance determined Great potential for error with functionally
Schulyer”4J1S CRCP and IP (<0.5mm) functionally on temporaries. Either generated path technique (used to
(morphology functionally canine guided or group function. determine the occlusal morphology of the
generated) posterior teeth).
Area of Freedom in Area of freedom between Either canine guidance or group Useful for cases with large horizontal
Centricllh CRCP and IP (0.5 * 0.3mm) function, but anterior guidance will component of slide, but area of freedom
cusp to fossa occlusion be delayed during posterior contact needs careful adjustment.
in area of freedom.
Balanced occlusionzM Area of freedom between Balanced working and non-working Keeps complete dentures stable during
CRCP and IP contacts in lateral excursions. excusions, but problems seen when used in
Balanced anterior and posterior the natural dentition due to overloading
contacts in protrusive. on the non-working side.
Nyman and L i t ~ d h e ~ ~ CRCP and ICP must have Bilaterally balanced excursive Only for use in cross arch bridges for
even contact contacts determined in temporaries extremely advanced (but controlled)
and copied into definitive periodontitis cases. Balanced contacts give
restorations. stability to an otherwise mobile bridge.
574 International Dental Journal (1998) Vol. 48/No.6
posterior teeth should be loaded axially in IP and CR.
They differ firstly in terms of the relationship between
CR and IP. In the Gnathological Scheme IP and CR are
coincident while in the Freedom in Centric and Pankey
Mann schemes there is a small flat area of function
between IP and CR. There is currently no evidence to
suggest that one pattern of posterior occlusal contact is
superior to another and the choice is made usually on
personal preference or for practical reasons.
The second difference between occlusal schemes
concerns which teeth should provide anterior guidance
(the effect of harmonious tooth contact on jaw move-
ment). At one time, balanced occlusion, with multiple,
bilateral contacts in all excursions was considered to be
the This was reputed to give an harmonious
relationship between the condylar guidance and the tooth
contact guidance but was based on opinion rather than
scientific evidence. However, balanced (non-working
side) contacts in the natural dentition were reportedly
associated with non-axial loading resulting in tooth
mobility, wear, TMJ dysfunction and fracture and
failure of restoration^*^-^^. In addition, non-working
side contacts have been associated with accelerated
periodontal breakdown32 although non-working side
contacts may arise from tooth extrusion due to
periodontal inflammation.
The concept of balanced occlusion was subsequently
replaced by unilateral balanced occlusion or group
function with multiple contacts between maxillary and
mandibular teeth on the working side and disclusion of
all teeth on the non-working side during e x c ~ r s i o n s ~ ~ .
This was considered to distribute stress and to create a
'normal' functional relations hi^^^ and was thought to be
a desirable scheme to reproduce. An alternative school
of thought proposed the concept of canine guidance as
This 'Gnathological concept' was developed
when it was observed that the balanced occlusal scheme
commonly used at the time, often led to clinical failure.
The canine teeth were therefore shaped to ensure
disclusion of the other teeth in mandibular excursions.
Disclusion of posterior teeth is facilitated by progres-
sively reducing the angles of cusp slopes of restorations
sited towards the back of the
Reasons for the superiority of both group function
and canine guided schemes have been presented by
numerous authors, however there is no satisfactory
evidence to say one is more physiological than the otheP.
On balance, canine guidance is often easier to achieve
with the development of group function requiring greater
clinical and technical precision, so for reasons of practi-
cality the former may often be preferable.
However, it may not always be possible to develop
canine guidance, for example due to tooth loss,
malocclusion or marked jaw size d i ~ c r e p a n c y Lindhe
~~.
suggests that in such cases group function be developed
on the premolars and mesial cusp of the first molar
teeth. When this alternative is not possible, he suggests
that a contralateral or balanced occlusion be developed.
This is technically very demanding as extreme precision
is required to ensure harmony with condylar guidance.
Balancing contacts should disclude at exactly the same
time as the working side contacts less the balancing
contacts become occlusal interferences. A balanced
articulation is advocated for the stabilisation of full arch
fixed prostheses supported on a few abutments with
reduced periodontal This complete denture
type of occlusion should only be used where the whole
prosthesis exhibits increased mobility.
Increasing the occlusal vertical dimension
There are cases in which an increase in occlusal vertical
dimension (OVD) will be necessary. Probably the
most common indication for increasing the OVD in
rehabilitation is the need to create interocclusal space to
accommodate restorative materials or to allow an
adequate clinical crown height to restore anterior
aesthetics. Increasing the OVD may also eliminate the
need for occlusal reduction during crown preparation
which may be of critical importance when retention is
compromised by short clinical crown height. However,
such treatment commits the operator to either a full arch
or full mouth restoration in order to establish occlusal
contact on every tooth. There are other methods for
creating interocclusal space for restorations besides
increase vertical dimension. These include crown length-
ening followed by conventional preparation of the teeth,
orthodontics, occlusal adjustment to distalise the
mandible, or the use of localised occlusal s p l i n t ~ ~ , ~ ~ , ~ " .
Research into the effect of altering the occlusal verti-
cal dimension has shown associations with a variety of
problems including clenching, parafunctional habits,
temporomandibular disorders, painful teeth, headaches
and repeated failure of restorations. Costedl proposed
that loss of OVD causing overclosure resulted in the
condyle pressing on the tympanic plate so causing pain.
This 'Costen's syndrome' was therefore treated by
increasing the OVD. However, this treatment was
subsequently found to produce further symptoms of
tooth mobility, clenching, bruxism and myofacial
pain42-44. These observations in turn led to the long held
theory that occlusal height was a fixed dimension and
its alteration resulted in an upset to the jaw m~sculature~~.
There are few recent controlled studies into the effect
on the masticatory system of an increase in the OVD.
C h r i ~ t e n s e nraised
~ ~ the OVD in a group of patients by
means of occlusal onlays on the lower molars and
reported that all patients exhibited signs of headache,
muscle fatigue, sore teeth and parafunction. This added
weight to the view that alteration to OVD should be
avoided. However, C a r l s ~ o npresented
~~ EMG evidence
that the muscles of mastication seemed able to adapt to
an experimental increase in the OVD. A critical differ-
ence between this study and that of Christensen was the
maintenance of stable occlusal contacts on all teeth at
the increased OVD rather than simply increasing the
dimension on pairs of opposing posterior teeth. A
recent review47provides the contemporary view that the
masticatory system is well able to adapt to an increase

in OVD provided this is within moderate limits and
occlusal stability is maintained.
Animal s t ~ d i e s ~of* -increased
~~ OVD demonstrate
changes at a histological and morphological level which
are not representative of collapse or breakdown, but
rather of compensation and adaptation. Problems were
encountered only when extreme changes were made or
if the increased OVD was maintained on only a few
individual teeth.
Studies in human subjects suggest that following an
increase in OVD a new postural position is created with
a decrease in jaw elevator and increase in jaw depressor
muscle a ~ t i v i t y ~ ~These
- ~ * . mechanisms effectively main-
tain the freeway space, despite the increase in OVD.
Conversely, where vertical dimension is lost, as in
severe tooth wear, it has been suggested that there is
compensatory dentoalveolar unless the rate of
wear outstrips the rate of growth when loss of vertical
dimension may occur.
There is little evidence to suggest the how long a
period might be needed to assess tolerance to an
increased OVD. Patients may experience symptoms of
headache, clenching and muscle fatigue for a few days
following an increase in OVD45.Whilst patients show
normal muscle function after one week", this may be
too short a time to allow confident assessmenP7. The
rule of thumb, therefore, is to test the increase in OVD
for at least one months4.Whilst most patients will adapt
to an increase in OVD it is important to identify patients
with psychophsiological factors which may prevent
adaptation before irreversible changes (for example,
crown preparations) are made.
On the basis of the above, a prudent approach to
increasing OVD seems appropriate. An inter-occlusal
splint is usually the treatment of choice. The new verti-
cal dimension is temporarily and reversibly established
on the splint for a trial period during which the devel-
opment of any symptoms of muscle and joint pain can
be observed. The splint used may be a maxillary or a
mandibular appliance constructed to the principles
presented by Nelsonsh. It is important that the splint
maintains occlusal stability during the test period. There
must be even contact on all opposing teeth in order that
no teeth are allowed to intrude or overerupt. Some
authors have been successful in restoring patients to an
increased OVD without an intermediate trial period57.
Such an approach may be appropriate in patients where
only a few standing teeth are to be restored with
adhesively retained restorations and where there has
been no history of TMD.
Replacement of missing teeth
Loss of posterior teeth generally results in a decrease in
masticatory function due to a reduced number of
occluding dental unitss8,". Loss of posterior support has
also been linked with occlusal instability, tipping, drift-
ing, and supra-eruption of teeth with consequent loss of
Wassell eta/.:Considerations in occlusal rehabilitation 575
stable, supporting occlusal contacts and sometimes loss
of occlusal vertical dimensionb0.However, the need to
replace all teeth which have been lost may often be
neither clinically justified, nor economically feasible.
KayseF has investigated the effects of a reduced
number of teeth in each arch, particularly where there is
a continuous but shortened dental arch (SDA). Chewing
function decreases gradually with the loss of teeth, but
remains adequate until fewer than eight opposing teeth
remain in each arch after which there appears to be a
rapid decline in masticatory efficiency. The loss of teeth
distal to the premolars causes few complaints about
aesthetics and only when premolars or anterior teeth are
absent do most patients consider appearance to be
compromised. A number of subsequent cross sectional
studies investigating patients with SDAs have reported
few functional or dental problems, in relation to oral
satisfaction, function and symptoms (including
TMD)11,58,6'-h7. The only negative changes reported were
an increase in attrition in extremely shortened arches
and fewer interdental contacts in the SDA with spacing
of the premolars indicating some drifting of teeth. In
addition Witterh8reported slight but significant increases
in tooth mobility in some SDA patients. This may be an
indication for restoration of the missing units in those
patients with pre-existing periodontal involvement in
order to reduce occlusal loading and prevent increased
mobility.
Based on Kayser's evidence, two pairs of opposing
posterior teeth in each quadrant is consistent with satis-
factory function and aesthetics, but this is undoubtedly
open to huge individual variation. The arch may have
already been reduced below this threshold, but it may
be feasible partially to restore it with fixed restorations.
Some workersh9have considered the restoration of the
SDA using distal cantilever fixed prostheses. Careful
selection of cases, taking into account the number, posi-
tion and periodontal status of the remaining teeth can
lead to satisfactory restorations of the SDA by this
method.
C r o t h e r ~presented
~~ a discussion of the relative
merits of the restoration of bilateral free end saddles
using removable partial dentures (RPDs) and fixed
cantilever bridges. It was suggested that the fixed resto-
ration carries greater patient acceptance and may avoid
the potential for damage to the dentition sometimes
associated with RPDs7'. In addition, L ~ n d g r e nreported
~~
improved chewing efficiency in the dentition restored
with cantilever bridges when compared to Kennedy class
I RPDs. The results of trials of distal extension cantilever
bridges are eagerly awaited to determine whether this
approach provides significant benefits over RPDs.
Material considerations - differential wear
In selecting suitable restorative materials for occlusal
reconstruction, the problem of differential wear must be
borne in mind. Tooth wear is a natural process ongoing
576 International Dental Journal (1998) Vol. 48/No.6
throughout a patient’s life. The rate of wear may vary
depending on factors such as dietary and parafunctional
habits. The process of wear may alter the occlusal rela-
tionship in the long term. However, the process may be
profoundly influenced by the introduction of restorative
materials whose wear characteristics are very different
from those of natural tooth tissue, a process termed
differential wear.
Differential wear has a number of important impli-
cations. Accelerated wear of natural teeth or restora-
tions against more abrasive restorations may affect
occlusal stability, dentine sensitivity, aesthetics and TMD.
plasm an^^^ investigated the nature of occlusal contacts
in natural and restored teeth and concluded that multi-
ple, stable IP occlusal contacts were important for
overall occlusal stability. Differential wear may disrupt
these occlusal contacts leading to occlusal disharmony.
The wear of enamel against various restorative mate-
rials has been extensively investigated and reviewed74.
Amalgam and composite are occasionally used to
restore occlusal surfaces in occlusal rehabilitati~n~~. These
materials have not been associated with excessive wear
of although the wear rate of most composites
may be considered too high to provide reliable results.
Occlusal surfaces are more usually restored using
porcelain or gold. Clinicians commonly employ porce-
lain on occlusal surfaces principally for its aesthetic
advantage^^^, but porcelain has long been recognised as
an abrasive material that can cause considerable wear of
opposing teeth and restorations, particularly where the
surface glaze has been lost during adj~stment’~. Where
porcelain must be employed, because of aesthetic
demands, the correct treatment of the porcelain surface
is essential, particularly following adjustment of occlu-
sal contacts when fitting restorations. Traditionally this
would have involved re-glazing, but Jagger and
Harrison78have reported a very similar wear pattern for
both glazed and unglazed porcelain, and go on to
suggest that surface glaze may be rapidly lost once the
porcelain is in function. They proposed that, after occlu-
sal adjustments, polishing with sandpaper discs and
rubber points rather than reglazing of the porcelain may
in fact be the best means of treating the surface to mini-
mise abrasiveness. Any residual abrasiveness can be
particularly destructive in patients who grind their teeth
(parafunction). Early evaluation of some of the more
recently introduced castable ceramics indicates that they
may be less abrasive than conventional porcelain^^^.
Reports of long term trials are awaited.
Gold alloys have many advantages as restorative
materials including their lack of wear of opposing unitss0.
A polished gold surface appears to be significantly less
abrasive than dental porcelain. The use of noble alloys
to restore occlusal contacts wherever possible will
ensure not only precise development of the occlusion
but also its long term stabilitys1. Alloy surfaces may be
more susceptible to rapid wear by opposing porcelain
than natural tooth enamel as they exert less of a polish-
ing effect on the porcelain in function.
Control of parafunction and
temporomandibular disorders
Parafunction
There is controversy over the link between occlusion
and parafunction. Some clinicians believe that bruxism
(clenching and grinding) may be precipitated by occlu-
sal disharmony8zand relieved by occlusal modificationss3.
Scientific support for such beliefs is not strong but
studies are hampered by the intermittent nature of
bruxism and the lack of awareness in many patients that
they grind their teeths4.
Baileys5 used EMG recordings to investigate the
effect of occlusal adjustment on nocturnal parafunctional
activity and concluded that removal of the occlusal
disharmonies was not effective in controlling the habit.
RughS6investigated the link by introducing occlusal
discrepancies into patients free from occlusal problems
but found that this had no effect on inducing
parafunctional habits in those patients. Current
thinking suggests that the aetiology of parafunction is
multifactorial and occlusal discrepancies alone cannot
be considered responsibles7. Rughas proposed that
nocturnal bruxism is, in fact, a centrally mediated sleep
disorder which affects a large proportion of the popula-
tion. Research has failed to show any lasting harmful
effects in healthy individualss9.For these reasons, occlu-
sal reorganisation should not be routinely undertaken
as a treatment for parafunctional habits. However, it
may be required to treat the resulting wear and to
redirect the heavy loads through the teeth and restora-
tions best suited to receive them.
Temporomandibular disorders
The relationship between occlusal rehabilitation and
TMD is controversial. Many dentists traditionally
ascribe an occlusal aetiology to TMD and strongly
support the notion that TMD can best be treated by
occlusal adjustment and occlusal rehabilitation. Indeed,
at one time a permanent increase in vertical dimension
was considered an essential part of treatment by many
practitioners”. However, there is little in the scientific
literature to support these association^^^^^^.
TMD may cause pain and tenderness either around
the muscles of mastication or the temporomandibular
joints or both. Dentists should be aware of recent work
updating diagnosis and treatment The
subcategories of TMD presenting as painful conditions
of the TMJ are summarised in Table 2. Muscular condi-
tions causing pain have also been sub-categorised,
however, in practice it is difficult to distinguish between
these various subcategories.
Most workers consider TMD to be of multifactorial
a e t i ~ l o g yhaving
~ ~ , ~ ~psychological, traumatic and occlu-
sal components. In the USA especially, many TMD
patients have been treated using invasive or non-revers-
ible modalities such as occlusal adjustment, occlusal
 Wassell eta/.:Considerations in occlusal rehabilitation 577

Table 2 Painful TMJ disorders (derived from International Headache Society Criteria”).

TMT disorder Clinical features

Disc displacement with reduction
Disc displacement without reduction
Osteoarthritis
Polyarthropathies
Reproducibleclick on opening and closing (reciprocalclick)
Previous click disappears, opening limited (closed lock), jaw deviates to affected side, extreme pain
during acute phase
Crepitus, jaw deviates to affected side, point tenderness on palpation, pain with function
Similar to osteoarthritis,but positive serological findings and possible anterior open bite

rehabilitation, orthodontics and surgery. These treat-
ments have often been unsuccessful, and some patients
have been damaged unnecessarily. Moreover, primary
occlusal adjustment (that is, alteration carried out with-
out adjunctive splint therapy) has been reported to be
less effective and more time consuming to perform than
reversible treatments such as full coverage occlusal
splints, physiotherapy and counselling. These have been
shown to be effective for the majority of patients during
long term f o l l o w - ~ p ~It~ ,would
~ ~ . seem to be sound
practice always to use reversible treatments before
embarking on irreversible changes to the occlusion.
There will be a minority of patients who, following
reversible treatment, require some alteration to their
occlusion to maintain their symptoms at an acceptable
Where such occlusal treatment is indicated, the
aim of treatment is to achieve a stable, non-traumatic
occlusal contact relationship in IP and functional excur-
sive positions with the TMJs stable in IP98,y9. There are
several methods to achieve these aims which range from
simple occlusal adjustment to extensive rehabilitation,
surgery or orthodontics. When considering occlusal
rehabilitation for a TMD patient the clinician should
proceed cautiously, using the least invasive procedureslUo.
Where TMD patients require multiple restorations to
repair broken down teeth, restorative treatment can be
complicated by an inconsistent jaw relationship and the
possibility that symptoms may be exacerbated by minor
occlusal changes and prolonged mouth opening. In such
cases restorative procedures should be delayed until the
TMD symptoms have been brought under control. In
this respect, the stabilising splint is particularly useful
as it has been shown to improve co-ordination of jaw
movementlo’.
If restorative treatment is indicated following splint
therapy, a difficult decision has to be made; whether or
not to reorganise the occlusion. Whilst reorganisation
should improve stability and allow forces to be
redistributed, there is also a risk that this may lead to
instability elsewhere in the masticatory An
example of this may be the conversion of a disc
displacement with reduction, which manifests as a
simple reciprocal click, into a displacement without
reduction, which manifests as a, more problematic, closed
lock. This has been described where deflective contacts
have been removed where there is a large horizontal
component of slide4. Until more scientific evidence is
available a pragmatic approach would be to consider
reorganising the occlusion following a period of
successful splint wear. A successful stabilising splint
should stabilise CR. Where pathological changes have
occurred in the TMJs, splint wear has the potential to
allow remodelling and adaptive changes to take place102.
It is therefore a mistake to rush into definitive treatment
and this implies that the splint may need to be worn for
several months or morelo3 to ensure stability and
comfort. If splint therapy has no effect on symptoms or
worsens them, every effort should be made to conform
with the patient’s existing IP.
There is evidence that some patients with a reducible
disc displacement may respond better to an anterior
repositioning splint than a stabilising ~ p l i n t ~ ~The
J~~J~~.
anterior repositioning splint has the effect of bringing
the condyles downwards and forwards. Because there is
a significant risk of producing a posterior open bite
with prolonged wear, current clinical wisdom is to
prescribe full time wear for 6-12 weeksz7 after which
time the inclines on the splint are adjusted to allow the
mandible to return towards its original position. O k e ~ o n ~ ~
reported that after this initial therapy 80 per cent of
patients were free of pain and joint sounds while after
two and a half years 75 per cent of patients had no joint
pain but 66 per cent had had a return of joint sounds.
However, other workers argue that a permanent change
in IP may be necessary to maintain symptom relief106J07.
In its simplest form this can be achieved using a removable
onlay appliance but where crown and bridge or orthodon-
tic appliances are used the cost can be enormous78.
It may be difficult to establish a stable jaw position
in patients who have active condylar erosion due to
osteoarthritis or one of the systemic arthritides (for
example, rheumatoid arthritis). Condylar erosion can
result in an anterior open bitelflaand the occlusion being
propped on the last standing molars. In these cases it is
unwise to attempt occlusal rehabilitation until the
disease can be stabilised, however it may become neces-
sary to consider simple adjustment of the occluding
molars to improve patient comfort.
Patients whose TMD problems have arisen following
the provision of restorations incorporating deflective
contacts and interferences, may also benefit from occlu-
sal adjustment or, more rarely, rehabilitation. However,
it must be emphasised that unless occlusal treatment is
instigated soon after the provision of the offending
restorations, adaptive changes may occur in the TMJs or
neuromuscular system which can prevent resolution of
symptoms by primary occlusal a d j u ~ t m e n t Treatment
~~.
may also be complicated by psychosocial or behavioural
factors93especially if there is a prospect of ‘secondary
gain’ through compensation, from litigation of the
578 International Dental Journal (1 998) Vol. 48/No.6

dentist who provided the defective treatment. Conclusion

The number of TMD patients receiving occlusal
rehabilitation is small in relation to the whole TMD
patient pool and when assessing outcomes it is difficult
to eliminate the undoubted placebo effects of splint
therapy’09J’0and occlusal adjustment”’. Consequently it
is difficult to find definitive scientific evidence for the
efficacy of occlusal rehabilitation in the management of
TMD. Nevertheless, the authors’ experience suggests that
a small minority of TMD patients benefit from occlusal
rehabilitation but further research in this area is required.
Occlusal rehabilitation provides a major challenge for
the dentist, both technically and intellectually. The
authors hope that this review has thrown light on some
of the important biological factors which must be taken
into account to ensure successful treatment. Research
has resulted in some concepts, previously cast in tablets
of stone, being outmoded, whilst in many areas the
scientific evidence is insufficient or conflicting and many
questions remain to be answered.

ConsidCrations pour une planification de la rbhabilitation occlusale. Une Ctude

bibliographique
RCsumC
La planification et l’execution d’une rehabilitation occlusale, Ctant l’une des tsches les plus astreignan-
tes auxquelles est confronte un praticien en chirurgie restauratrice, ne doivent pas 6tre entreprises A la
legere. L’enjeu est considerable et l’echec est onereux. Les decisions en matiere de planification du
traitement doivent 6tre prises en se basant sur des preuves scientifiques, lorsque celles-ci sont disponi-
bles ou en prenant comme base des experiences documentees, lorsque celles-ci ne le sont pas. Cet
article definit les principales considerations biologiques et cliniques utilisees en matiere de planifica-
tion d’une rehabilitation occlusale. Celles-ci comprennent les indications de reorganisation de l’occlu-
sion, le choix de la position du condyle et du schema occlusal, les consequences et les indications de
l’augmentation de la dimension verticale, le remplacement des dents manquantes et le choix des
materiaux. Enfin, est Cgalement analysee la litterature portant sur la controverse de la rehabilitation
occlusale comme un moyen de traiter les troubles de l’articulation temporo-mandibulaire.

Faktoren im Zusammenhang mit der Planung der okklusalen Rehabilitation: ein

Uberblick uber die aktuelle Literatur
Zusammenfassung
Da es sich bei der okklusalen Rehabilitation um eine der schwierigsten und anspruchvollsten Heraus-
forderungen an den Zahnarzt handelt, sollte bei ihrer Planung und Ausfiihrung sehr sorgfaltig verfahren
werden. Es steht eine Menge auf dem Spiel und eine Fehlbehandlung kann enorme finanzielle Auswir-
kungen fur den Behandelnden haben. Entscheidungen im Hinblick auf die Behandlungsplanung soll-
ten auf der Grundlage wissenschaftlicher Erkenntnisse getroffen werden, sofern diese vorliegen.
Andernfalls sollte sich der Zahnarzt auf schriftlich fixierte Erfahrungsberichte stiitzen. Im obenstehen-
den zusammenfassenden Bericht werden die wichtigsten biologischen und klinischen Erwagungen
erarbeitet, die bei der Planung einer okklusalen Rehabilitation unbedingt zu berucksichtigen sind.
Hierzu zahlen die Indikationen fur das neue Okklusionsdesign, die Wahl der Kondylenposition und
des Okklusionsschemas, die Indikationen fur bzw. Implikationen einer Erweiterung der vertikalen
Dimension, der Ersatz fehlender Zahne und die Wahl des verwendeten Materials. AuBerdem erfolgt
zum AbschluB eine Analyse der aktuellen wissenschaftlichen Literatur zum kontroversen Thema
okklusale Rehabilitation als Mittel zur Behandlung von Kiefergelenkstorungen.

Reflexiones en la planificacibn de la rehabilitacih oclusal. Revisibn de la literatura

Resumen
La rehabilitacion oclusal es una de las tareas m6s absorbentes y exigentes del odontologo y, por lo
tanto, su planificacion y ejecuci6n no deben ser emprendidas a la ligera. Los riesgos son muchos y el
fracas0 puede resultar muy caro. Las decisiones con respecto a la planificacion del tratamiento deben
ser tomadas en base a la evidencia cientifica, cuando se disponga de ella, y de no ser asi, de acuerdo
con experiencia documentada. Este estudio identifica las consideraciones biologicas y clinicas m6s

importantes utilizadas en la planificacion de la rehabilitacibn oclusal. Ellas incluyen indicaciones para
reorganizar la oclusion, la eleccion de la posicion condilar y sistema oclusal, las consecuencias de y las
indicaciones para aumentar la dimension vertical, el reemplazo de 10s dientes perdidos y la eleccion de
materiales. Finalmente, se examina tambien la literatura que se ocupa del tema controversial de la
rehabilitacion oclusal como medio para tratar trastornos mandibulares.
References
1. Harty F. Concise illustrated dental dictionary. 2nd ed,. Oxford:
Wright, 1987.
2. Pameijer J H N. Periodontal and Occlusal Factors in Crown and
Bridge Procedures. Amsterdam: Dental Centre for Postgradu-
ate Courses, 1985.
3. Wise M D. Occlusion and Restorative Dentistry for the General
Dental Practitioner. London: BDJ Books, 1986.
4. Wise M D. Failure in the Restored Dentition: Managerirent and
Treatment. London: Quintessence, 1995.
5. Setchell D J. Periodontal diagnosis and occlusal analysis. In:
Rowe AH, Johns RB, (editors). Companion to Dental Studies
pp.497-519. Oxford: Blackwell, 1986.
6. Ibbetson R J, Setchell D J. Treatment of the worn dentition.
Dent Update 1989 1 6 300-307.
7. Lindhe J, Svanberg G. Influence of trauma from occlusion on
progression of experimental periodontitis in the beagle dog.
1 Clin Periodontol 1974 1: 3-14.
8. Polson A M, Meitner S W, Zander H A. Trauma and progres-
sion of marginal periodontitis in squirrel monkeys. IV.
Reversibility of bone loss due to trauma alone and trauma
superimposed on periodontitis. J Periodant Res 1976 11: 290-
298.
9. Fleszar T J, Knowles J, Morrison E. Tooth mobility and peri-
odontal therapy. 1 Clin Periodontol 1980 7: 495-505.
10. Burgett F, Ramfjord S, Nissle R R, et al. A randomized trial of
occlusal adjustment in the treatment of periodontitis patients.
J Clin Periodontol 1992 19: 381-387.
11. Battistuzzi P G F C M, Kayser A F, Kanters N. Partial
edentulism, prosthetic treatment and oral function in a Dutch
population. J Oral Rehabil 1987 14: 549-555.
12. Wayler A H, Muench M E, Kapur K K, et al. Masticatory
performance and food acceptability in persons with remov-
able partial dentures, full dentures and intact natural denti-
tion. J Gerodontol 1984 3 9 284-289.
13. Lappalainen R, Nyyssonnen V. Self-assessed chewing ability
of Finnish adults with removable dentures. Gerodontics 1987
3 238-241.
14. Parker M W. The significance of occlusion in restorative den-
tistry. Dent Clin North A m 1993 37(3): 341-351.
15. Gelb H. Clinical Management of Head, Neck and T M J Pain and
Dysfunction. Philadelphia: W.B. Saunders, 1977.
16. Weinberg L H. Temporomandibular joint function and its
effect on concepts of occlusion. J Prosthet Dent 1976 35: 553-
566.
17. Dawson P E. A classification system for occlusions that
relates maximal intercuspation to the position and condition
of the temporomandibular joints. J Prostket Dent 1996 75: 60-
66.
18. Hellsing G, McWilliams J S. Repeatability of the mandibular
retruded position. J Oral Rehabil 1985 12: 1-8.
Wassell eta/.:Considerations in occlusal rehabilitation 579
19. Dawson P E. Evaluation, Diagnosis and Treatment of Occlusal
Problems. St. Louis.: C.V. Mosby, 1974.
20. Kantor M E, Silverman S I, Garfinkel. Centric relation record-
ing techniques - a comparative investigation. J Prostlzet Dent
1972 28: 593-600.
21. Posselt U. Studies in the mobility of the human mandible.
Acta Odontol Scand 1952 10 (10): 1-160.
22. Celenza F V. The centric position: replacement and character.
1 Prosthet Dent 1973 3 0 591-598.
23. Johnston L E J. Gnathologic assessment of centric slides in
post retention orthodontic patients. J Prostket Dent 1988 60:
71 2-71 5.
24. Graf H, Zander H A. Tooth contacts in mastication. J Prostlief
Dent 1963 13: 1055-1066.
25. Pameijer J, Brion M, Glickman 1,et al. Intraoral telemetry Part
IV. Tooth contact during swallowing. J Prosthet Dent 1970 24:
396-400.
26. Posselt U. Plzysiology of occlusion and rehabilitation. Philadel-
phia: F.A. Davies, 1962.
27. Okeson J P. Long term treatment of disk-interference disor-
ders of the TMJ with anterior repositioning occlusal splints.
J Prosthet Dent 1988 6 0 611-616.
28. D’Amico A. Origin and development of the balanced occlu-
sion theory. J South Callf Dent Assoc 1960 28: 317-318.
29. Schuyler C H. Fundamental principles in the correction of
occlusal disharmony, natural and artificial. J A m Dent Assoc
1935 2 2 1193-1202.
30. Schuyler C H. Correction of occlusal disharmony of the natu-
ral dentition. NY State Dent J 1947 13: 445-462.
31. Schuyler C H. An evaluation of incisal guidance and its influ-
ence in restorative dentistry. J Prostket Dent 1959 9: 374-378.
32. Yuodelis R A, Mann M V. The prevalence and possible role of
non-working contacts in periodontal disease. J Periodontol
1965 3 219-223.
33. Beyron H L. Occlusal changes in adult dentition. J A m Dent
ASSOC 1954 48: 674-686.
34. D’Amico A. The canine teeth - normal functional relation of
the natural teeth of man. J South Calif Dent Assoc 1958 26: 6-
23; 49-60; 127-142; 175-182; 194-208; 239-241.
35. Celar A, Sat0 S , Akimoto S, et al. Sequential guidance with
canine dominance in Japanese and Caucasian samples. B d l of
Kanagawa Dent Col 1994 22: 18-24.
36. Thornton L J. Anterior guidance: group function/canine guid-
ance. A literature review. J Prostket Dent 1990 6 4 479482.
37. Jensen W 0.Alternate occlusal schemes. J Prostlzet Dent 1991
6 5 54-55.
38. Lindhe J. Textbook of Clinical Periodon tology. Copenhagen:
Munksgaard, 1983.
39. Dahl B L, Krogstad D, Karlsen K. An alternative treatment in
cases with advanced localised attrition. J Oral Rehabil 1975 2:
580 International Dental Journal (1998) Vol. 48/No.6
209.
40. Wassell R W. Toothwear: Space creation with the Dahl appli-
ance. In: Barnes IE, Walls AWG, (editors). Gerodontology
pp.103-108. Oxford: Wright, 1994.
41. Costen J B. Syndrome of ear and sinus symptoms dependent
on disturbed function of the temperomandibular joint. A n n
Otol Rhino1 and Laryngol 1934 43: 1-15.
42. Tench R W. Dangers in dental reconstruction involving
increase in the vertical dimension of the lower third of the
human face. J A m Dent Assoc 1938 2 5 566-570.
43. Mershon J V. Bite-opening dangers. J Am Dent Assoc 1939 26:
1972-1979.
44. Schuyler C H. Problems associated with opening the bite
which would contraindicate it as a common practice. J Am
Dent Assoc 1939 26 734-740.
45. Christensen J. Effect of occlusion-raising procedures on the
chewing system. Dent Practitioner 1970 20: 233-238.
46. Carlsson G E, Ingervall B, Kocak G. Effect of increasing
vertical dimension on the masticatory system in subjects with
natural teeth. J Prosthet Dent 1979 41: 284-289.
47. Rivera-Morales W C, Mohl N D. Relationship of the vertical
dimension of occlusion to the health of the masticatory
system,. J Prosthet Dent 1991 6 5 547-553.
48. Ramfjord S P, Blankenship J R. Increased occlusal vertical
dimension in adult monkeys. J Prosthet Dent 1981 4 5 74-83.
49. Gianelly A A, Ruben M P, Risinger R. Effects of experimen-
tally altered occlusal vertical dimension on temporoman-
dibular articulation. J Prosthet Dent 1970 2 4 629-635.
50. Sergl H G, Farmland M. Experiments with unilateral bite
planes in rabbits. Angle Ortkodont 1975 4 5 108-114.
51. Akagawa Y, Nikai H, Tsuru H. Histologic changes in rat
masticatory muscles subsequent to experimental increase of
occlusal vertical dimension. J Prosthet Dent 1983 50: 725-732.
52. Manns A, Miralles R, Gurrero F. The changes in electrical
activity of the postural muscles of the mandible upon vary-
ing the vertical dimension. J Prosthet Dent 1981 45: 438-444.
53. Carr A 8, Christensen L V, Donegan S J, et al. Postural con-
tractile activities of human jaw muscles following use of an
occlusal splint. J Oral Rehabil 1991 18: 185-191.
54. Gross M D, Ormianer Z. A preliminary study on the effect of
occlusal vertical dimension increase on mandibular postural
rest position. Int J Prosthodontics 1994 7(3): 216-226.
55. Berry D C, Poole D F G. Attrition: Possible mechanisms of
compensation. J Oral Rekabil 1976 3 201-206.
56. Nelson S J. Principles of stabilization bite splint therapy.
Dent Clin North Am 1995 39: 403-421.
57. Bishop K, Bell M, Briggs P, et al. Restoration of a worn
dentition using a double-veneer technique. Br Dent J 1996
180 26-29.
58. Witter D J, Cramwinckel A B, van Rossum G M J M, et al.
Shortened dental arches and masticatory ability. J Dent 1990
18: 185-189.
59. Steele J T, Ayatollahi S M T, Walls A W G, et al. Clinical
factors related to reported satisfaction with oral function
amongst older adults in England. Com Dent Oral Epidemiol
1997 2 5 143-149.
60. Stern N, Brayer L. Collapse of the occlusion - aetiology, symp-
tomatology and treatment. J Oral Rehabil 1975 2 1-19.
61. Kayser A F. Shortened dental arches and oral function. J Oral
Rehabil 1981 8: 457-462.
62. Aukes J N S C, Kayser A F, Felling A J A. The subjective
experience of mastication in subjects with shortened dental
arches. J Oral Rehabil 1988 1 5 321-324.
63. Kayser A F, Witter D J. Oral functional needs and its conse-
quences for dentulous older people. Community Dent Health
1985 2 285-291.
64. Witter D J, van Elteren P, Kayser AF, et al. Oral comfort in
shortened dental arches. J Oral Rekabil 1990 17: 137-143.
65. Witter D J, van Eleren P, Kayser A F. Migration of teeth in
shortened dental arches. J Oral Rekabil 1987 1 4 321-329.
66. Witter D J, van Elteren P, Kayser A F. Signs and symptoms of
mandibular dysfunction in shortened dental arches. J Oral
Rehabil 1988 15: 413-420.
67. Witter D J, van Elteren P, Kayser A F, et al. The effect of
removable partial dentures on oral function in shortened
dental arches. J Oral Rehabil 1989 1 6 27-33.
68. Witter D J, de Haan A F J, Kayser A F, et al. Shortened dental
arches and periodontal support. J Oral Rehabil 1991 18: 203-
212.
69. Hedegard 8, Landt H. Cantilever bridges or removable par-
tial dentures in Kennedy class I cases? Quintessence Int 1983
2. 173-182.
70. Crothers A J R, Wassell R W, Jepson N J A, et al. The use of
cantilever bridges. Dent Update 1995 2 2 190-198.
71. Drake C W, Beck J D. The oral status of elderly removable
partial denture wearers. J Oral Rekabil 1993 ZO(1): 53-60.
72. Lundgren D, Laurel1 L. Occlusal force pattern during chew-
ing and biting in dentitions restored with fixed bridges of
cross arch extension. I1 Unilateral posterior two unit canti-
levers. J Oral Rehabil 1986 1 3 191-203.
73. Plasmans P J J M, Kuipers L, Vollenbrock H R, et al. The
occlusal status of molars. J Prosthet Dent 1988 6 0 500-503.
74. Sulong M Z, Aziz R A. Wear of materials used in dentistry:
a review of the literature. J Prosthet Dent 1990 63: 342-349.
75. Roessler D M. Amalgam and composite resin as an alterna-
tive to crown and bridgework in the rehabilitation of an
extensively debilitated dentition. Case report. Aust Dent J
1991 3 6 14.
76. Christensen G J. The use of porcelain fused to metal restora-
tions in current dental practice: a survey. J Prosthet Dent 1986
56 1-3.
77. Monasky G E, Taylor D F. Studies on the wear of porcelain,
enamel and gold. J Prosthet Dent 1971 2 5 299-306.
78. Jagger D C, Harrison A. An in vitro investigation into the
wear effects of unglazed, glazed and polished porcelain o n
human enamel. J Prosthet Dent 1994 72: 320-323.
79. Seghi R R, Rosenstiel S F, Bauer P. Abrasion of human enamel by
different dental ceramics in vitro. J Dent Res 1991 7 0 221-225.
80. Jacobi R, Shillingburg H T J, Duncanson M G. A comparison
of the abrasiveness of six ceramic surfaces and go1d.J Prosthet
Dent 1991 66 (3): 303-309.
81. Wiley M G. Effects of porcelain o n occluding surfaces of
restored teeth. J Prosthet Dent 1989 61: 133-137.
82. Krogh-Poulsen W G, Olsson A. Occlusal disharmonies and
dysfunction of the stomatognathic system. Dent Clin North
Am 1966 11: 627-635.
83. Ramfjord S P. Dysfunctional temporomandibular joint and
muscle pain. J Prosthet Dent 1961 11: 353-374.
84. Wruble M K, Lumley M A, M c G l y F ~ D. Sleep related brux-
ism and sleep variables: a critical review. J Craniomandib

Disord Facial Oral Pain 1989 3: 152-158.
85. Bailey J 0,Rugh J D. Effect of occlusal adjustment on bruxism
as monitored by nocturnal EMG recordings. J Dent Res 1980
59 (1): 317.
86. Rugh J D, Barghi N, Drago C J. Experimental occlusal dis-
crepancies and nocturnal bruxism. J Prosthet Dent 1984 51:
548-553.
87. Attanasio R. Nocturnal bruxism and its clinical management.
Dent Clin North A m 1991 35 (1): 245-252.
88. Rugh J D, Harlan J. Bruxism and temperomandibular disor-
ders. A d v Neurology 1988 4 9 329-341.
89. Seligman D A, Pullinger A G. The role of functional occlusal
relationships in temporomandibular disorders: a review. J
Craniomandib Disord Facial Oral Pain 1991 5 265-279.
90. Campbell J. Distribution and treatment of pain in temporo-
mandibular arthroses. Br Dent J 1958 105 393-407.
91. Wassell R W. Do occlusal factors play a part in temporoman-
dibular dysfunction? J Dent 1989 17: 101-110.
92. Pullinger A G, Seligman D A, Gornbein J A. A multiple logis-
tic regression analysis of the risk and relative odds of tempo-
romandibular disorders as a junctive of common occlusal
features. J Dent Res 1993 7 2 968-979.
93. McNeill C, (editor). Temporomandibular disorders. Chicago:
Quintessence Publishing Co., 1993.
94. Jagger R G, Bates J F, Kopp S. Temporomandibular joint dys-
function, the essentials. Oxford: Wright, 1994.
95. Mejersjo C, Carlsson G E. Long term results for temporoman-
dibular pain dysfunction. J Prosthet Dent 1985 49: 809-815.
96. de Leeuw R, Boering G, Stegenga B,et al. Clinical signs of TMJ
osteoarthrosis and internal derangement 30 years after non-
surgical treatment. J Orofacial Pain 1994 8 18-24.
97. Magnusson T, Carlsson G E. Occlusal adjustment in patients
with residual or recurrent signs of mandibular dysfunction.
J Prostket Dent 1983 4 9 706-710.
98. Clark G T, Adler RC. A critical evaluation of occlusal therapy:
occlusal adjustment procedures. J A m Dent Assoc 1985 110:
743-750.
99. McNeill C. The optimum temporomandibular joint condyle
position in clinical practice. 1985 6 52-76.
100.0keson J P. Management of temporomandibular disorders and
occlusion. Third ed,. St Louis: Mosby, 1993.
101.Clayton J A. A Pantographic reproducibility index for use in
diagnosing temporomandibular joint dysfunction: a report
Correspondence to: Dr. R.W. Wassell, Department of Restorative Dentistry, The Dental School, University of New-
castle upon Tyne, Newcastle upon Tyne NE2 4BW, UK.
Wassell eta/.:Considerations in occlusal rehabilitation 581
on research. J Prosthet Dent 1985 5 4 827-831.
102.Ash M M. Current concepts in the aetiology, diagnosis and
treatment of TMJ and muscle dysfunction. J Oral Rehabill986
13: 1-20.
103.Gausch K. Occlusal therapy of neuromuscular problems in
the orofacial region. Int J Dent 1981 31: 267-272.
104.Lundh H, Westersson P L, Kopp S, et al. Anterior reposition-
ing splint in the treatment of temporomandibular joints with
reciprocal clicking: Comparison with a flat occlusal splint
and an untreated control group. Oral Surg Oral Med Oral Path
1985 6 0 131-136.
105.Anderson G C, Schulte J K, Goodkind R J. Comparative study
for two treatment methods for internal derangement of the
temporomandibular joint. Gerodontics 1985 53: 392-397.
106.Lundh H P L W. Long-term follow-up after occlusal treat-
ment to correct abnormal temporomandibular joint disc
position. Oral Surg Oral Med Oral Path 1988 67: 2-10.
107.Tallents R H. Use of protrusive splint therapy in anterior disk
displacement of the temporomandibular joint: A 1-3 year
follow-up. Prosthet Dent 1990 63: 336-341.
108.Tegelberg A, Kopp S. Clinical findings in the stomatognathic
system for individuals with rheumatoid arthritis and osteo-
arthritis. Acta Odontol Scand 1987 45: 65-75.
109.Greene C S, Laskin D M. Splint therapy for the myofacial
pain dysfunction [MPD] syndrome: a comparative study. J
A m Dent Assoc 1972 8 4 624-628.
11O.Dao T T, Lavigne G J, Charbonneau A, e f al. The efficacy of
oral splints in the treatment of myofascial pain of the jaw
muscles: a controlled clinical trial. Pain 1994 56: 85-94.
1ll.Goodman P, Greene C S, Laskin D M. Response of patients
with myofascial pain-dysfunction syndrome to mock occlu-
sal equilibration. J A m Dent Assoc 1976 9 2 755-758.
112.Stuart C E. Good occlusion for natural teeth. J Prosthet Dent
1964 14 716-724.
113.Schluger S, Yuodelis R A, Page R C. Periodontal Disease. Phila-
delphia: Lea & Febiger, 1977.
114.Schuyler C H. Factors of occlusion applicable to restorative
dentistry. J Prosthet Dent 1953 3: 772-782.
115.Mann A W, Pankey L D. Concepts of occlusion. The PM
philosophy of occlusal rehabilitation. Dent Clin North A m
1963 Nov.: 621-636.
116.Ramfjord S P. Is it really necessary to record jaw movements?
Quintesence Int 1982 13: 187-193.