Occlusal therapy Because of the earlier tendencies to evalu- ate occlusal relationships solely on the basis of how the teeth intercuspate, any occlusion that had the appearance of “proper” intercuspation was considered correct, and any tooth arrange: ment that did not have the textbook version of correct intercuspation was considered a mat. occlusion. Consequently most treatment of oc clusion was designed to make the teeth look like the “correct” version of proper intercuspa: tion, The results were inconsistent, were often unstable, and had an unpredictable effect on problems of muscle dysfunction, tooth hyper: mobility, abrasion, and temporomandibular disorders. Many clinicians reasoned that if a “properly” intercuspated occlusion did not solve problems predictably the problems were unrelated to occlusion. This viewpoint led to a downplay of the role of occlusion and an up- surge of a wide variety of empiric treatment techniques. ‘The indiscriminate use of drugs to treat the symptoms of the disorders has proba bly been the most damaging approach, though many attempts at so-called occlusal therapy were also harmful, even though they may have ved a tentative relief of symptoms. The improper use of bite planes, bite-raising appli- ances, pivots, and mutilative occlusal grinding ‘are common examples of “therapies” that ha been advocated because of claimed successes in relieving symptoms. The claims however could often be disputed under scientific condi- tions, and careful observers often pointed out that it was common for the “successful” results to degenerate into disharmonies that were fre- 14 quently worse than the original problem. Be- cause of the high percentage of bad results from occlusal treatment, many clinicians de- cided it had no value at all. Although some au: thorities were decrying the total concept of occlusal therapy, many practicing clinicians were finding that proper intercuspation was only part of the picture. Ramfjord and Ash! showed that an occlusion should be evaluated more by the way it influenced the function of the stomatognathic system than by the way the teeth intercuspate, Frederick* showed that teeth that were not in harmony with the mus- culature would be moved regardless of how they intercuspated. AS more clinical observations were made and more research was done, it became obvi ‘ous that successful occlusal therapy is not pos: sible if occlusal contacts are not directly re lated to the temporomandibular articulation. ‘The teeth function in direct biomechanical re lationship with the temporomandibular joints and the muscles. Storey’ showed that the oc- clusal interface is not determined by occlusal contacts alone, but also involves the anatomy of the joints, the limiting influence of the liga ments, and the shape and orientation of the oc- clusal plane. These he characterizes as the pas- sive factors. The active parts of the system in- clude not only the muscles themselves but also the reflex responses that arise in and around the teeth, the joints, the muscles, and the mu- cosa and probably in the periosteum and the skin. Storey has suggested that these neuro- muscular reflex responses appear to protectthe teeth and their supporting structures against damage but when they become contin: uously active they lead to pathogenesis. Because of these reflex responses and the intricate interdependencies of the stomatog: nathic system, the alteration of even one tooth incline has the potential for disrupting the bal. ance and thus the stability of the entire system. Such minute incline interferences often occur in occlusions that appear to have ideal inter. cuspation, Our clinical experience has repeatedly dem- onstrated the effect of minute occlusal interfer: ences on muscle harmony and temporoman: dibular function. We have found that even the slight depression of a prematurely contacting tooth is sufficient to activate muscle incoordi- nation and can result in symptoms of a wide range of severity. It is not necessary for the o¢- clusal interference to cause an actual slide or horizontal deviation. The slight vertical over- loading of a single tooth can be the trigger that, keeps the muscles in an incoordinated state of hypercontraction. The detection of such minute interferences requires very careful technique, but it is a practical clinical procedure. Occlusal contacts are marked with two colors of very thin artic- ulating ribbon—one color for very light clos ing contact color, the other for firmer closing contact. If both color marks are not in the same location, it indicates tooth movement on closure. Failure to refine an occlusion so that both the light contacts and the firm contacts are identical can often lead to failure in climi- nating muscle incoordination and the symp- toms that go with it. Many occlusal treatments stop short of achieving equalized axial pres- sures even though the slide is eliminated When symptoms remain, the therapist then of- ten rules out occlusal factors when in fact the occlusal triggers are still activ In the past few years, a considerable amount of excellent research data has confirmed the cause-and-effect relationship between occlusal interferences and muscle incoordination. Re- cent studies have further confirmed the impor- tance of minute occlusal interferences and the positive results achieved by their correction Riise*? has shown through the use of quan- titative electromyography that a single, minor occlusal interference, experimentally induced in the intercuspal position, may change not only the postural muscle activity, but also the Occlusal therapy 15 activity during submaximal and maximal bite. ‘This change in muscle activity also occurs in mastication. Perhaps of most importance is the finding that when the interference is removed, the muscular coordination improves. Bakke and Moller® have documented signifi cant changes in muscular activity from in- duced interferences as thin as 50 jum. Several other research studies have also shown the negative influence on the function of the sto: matognathic system from various types of oc clusal interferences, It is apparent that the periodontal receptors are exquisitely sensitive to slight variations in pressure. It is also apparent and has been doc umented by several investigators that distur- ances of harmonious input to the periodontal receptors caused by occlusal interference can result in functional disorders of the stomatog: nathic system, It has been verified that the cor- rection of the occlusal interferences results in @ return to normal function and harmony of muscle activity Ramfjord and several other investigators have documented the relief of pain and related its timing with the return to symmetric muscle activity when occlusal interferences were re- moved in patients with pain and muscle dys: function, Krogh-Poulsen” has shown the rela- tionship between specific interferences and functional muscle abnormalities. Beyron has shown the relationship of occlusal interfer: ences to asymmetric abrasion of the tooth sur. faces. Graf? showed the relationship of oc- clusal interferences to alterations in the deglu- tition reflex and also concluded that a stable occlusal contact relationship in maximum in- tercuspation seems to be essential for adequate masticatory function. The ample evidence proves rather conclusively the following: 1. Minute occlusal interferences can trigger muscle into hyperactivity, incoordina- tion, and dysfunction, ‘The correction of the interferences elim- inates the muscle dysfunction, relieves the pain, and allows the muscles to re- turn to normal balanced activity. N Why there is lack of agreement regarding the importance of occlusal disharmony as a cause of muscle pain and dysfunction Many authorities have minimized the impor- tance of occlusion as a factor in temporoman- dibular dysfunction and muscle pain, 1 haveate ho hac wa me cor occ clu like tior uns pre mo dis ‘pr sol unt doy tec tre: bly ma imy anc bee in cot tiot tor 14 16 Evaluation, diagnosis, and treatment of occlusal problems: observed repeatedly that the less importance a clinician puts on occlusal factors the more he will advocate the use of drugs or psychologic approaches. The less that occlusal factors are understood, the more there will be the ten- dency to resort to gimmickry, kinesiology, bite raising, and other procedures with question: able scientific rationale, Unfortunately, many of the most common treatments are actually harmful, even though they may provide mo- mentary relief, Since many well intentioned dentists have resorted to these empiric proce- dures because of failure to get results through occlusal treatment, the reason for their disre gard for occlusal therapy should be explained. Three statements could sum up the reasons 1, Dentists distrust occlusal therapy if they fail to get predictive results from its use. 2. Dentists oppose occlusal therapy if the have caused their patients to get wors off from its use. _.3. Predictive occlusal therapy requires more preciseness than most dentists are aware of. If occlusal therapy is not done carefully enough, it will not help, and the altered occlusion may actually intensify the problem or cause new problems of discomfort. There are two extremely important aspects of occlusal treatment that demand preciseness if predictability is to be achieved: 1, Precise position and alignment of the condyle-disk assembly in a physiologi- cally correct relationship to the fossa The condyles need not stay in the centr cally related position, but they must have access to it without interference from the teeth, Preciseness in the elimination of all inter- ferences to the centric relation position of the condyles, Some observations that we (Dawson and Arcan'®) have made through using precise measuring techniques for quantifying occlusal interferences (photocclusion) have shown that the proprioceptive sensitivity is greater than is generally realized and the muscle response to minute discrepancies varies from patient to pa- tient but can reach an exquisite sensitivity in some patients, Some other observations from our photoc- clusion studies follow: 6. From the standpoint of establishing mus- cle harmony, the sumber of tooth cor tacts is less important than the complete climination of deviating inclines or pre ‘mature contacts Two contacts (one on each side) in com: plete harmony with the uppermost condyle-disk position can produce mus cle harmony in some patients. Generally this occurs in combination with tongue- biting habits, . The absence of a slide does not in itself indicate complete symmetry, since un even pressure may result in the move- ‘ment of a tooth or teeth without produc: ing a discernible slide. Such asymmetri pressure is difficult to discern, but it can constitute a potent trigger that activates muscle hyperactivity. Photocclusion methods have enabled us to record not only pressure against deviating inclines, but also variations of intensity of axia! nondeviating pressure. It is not uncommon for the symptoms ‘of occluso-muscle disharmony (such as pain and limitation of function) to re: main even in the absence of a slide, but such symptoms are frequently eliminated only when the axial pressures are equal- ized. The goal is to obtain the maximum number of axtally directed contacts that are equal in intensity. The pressure of even one tooth contact with greater in: tensity is sufficient to destroy the muscle harmony and activate a hyperactivity of the unbalanced muscles. Although it is often necessary to pre: cisely equalize all occlusal contacts to climinate muscle pain and dysfunction, it is not usually necessary to macntain the same degree of occlusal perfection once the muscle activity is normalized. This varies from patient to patient depending on tension levels and some psychologic factors that reduce the normal adaptive capacity of the body. Teeth that have had excessive axial pres sures will almost always rebound after occlusal correction. They may require repeated adjustments before they stabi: lize.REQUIREMENTS FOR SUCCESSFUL OCCLUSAL THERAPY ‘There is, at this time, enough scientific evi dence to logically assume that occlusal treat- ment must be related to both the active and Passive elements of the entire stomatognathic system. The goal of occlusal therapy is to re- duce stresses to a point that is not destructive to any part of the system. This can be accom- plished when one follows a logical sequence for evaluation or treatment of any occlusal problem. The sequence parallels the require- ments for successful treatment, There are three requirements for success when treating problems of occlusal stress or instability, as follows: 1. Comfortable condyles. ‘The temporo- mandibular articulation must be able to function and resist pressure with no dis- comfort. This is the essential starting point for any dental treatment that in volves the occlusal surfaces of the teeth. When we speak of an “occlusal interfer ence,” we are referring to an interference to comfortable mandibular function. U til we have determined the comfortable, Physiologically correct relationship of the condyle-disk assemblies we cannot know the functional mandible-to-maxilla relationship to which the occlusion must be related Anterior teeth in barmony with the en velope of function. Just as the condylar paths determine how the back end of the mandible moves in function, the anterior teeth determine how the front end moves. There are many factors that dic tate correct position and contour of the anterior teeth and that in turn cause the development of the functional pathways that the mandible travels in mastication, speech, swallowing and other functions. The lips, tongue, occlusal plane, and op- timum contracted muscle lengths are some of the determining factors. The an- terior guidance is one of the most impor- tant relationships that determines the character of the entire occlusal arrange- ment Occlusal therapy 17 3. Noninterfering posterior teeth. As al- ready stated, we want to develop the maximum number of axially directed contacts that are equal in intensity, but we do not want any posterior contact to interfere with either the comfortable condyles in the back or the anterior guidance in front. ‘The complexities of occlusion can be sim plified if each of the above requirements is un- derstood, along with its relationship to the other requirements. Each requirement is dis- cu ssed separately, The essential starting point for any understanding of occlusion is a thor- ou; gh knowledge of the anatomy, physiology, and biomechanics of the temporomandibular joints and their relationship to the stomatog- nathic system. REFERENCES, 6 10, Ramfford, S. and Ash, MM: Occlusion, ed. 3, Philadel- Phia, 1983, W.B, Saunders Co. Frederick, $ The buccinator, orbicularis complex Manual prepared for the Florida Prosthodontic Semi< rar, 1987. Storey, AT: Controversies related to temporomandib. lar joint function and dysfunction. In Zarb, G.A., and Carlsson, G.E: Temporomandibular joint function and dysfunction, St. Louis, 1979, The CN. Mosby Co. Riise, C., and Sheikholeslam, A. Influence of experi ‘mental interfering occlusal contacts on the activity of the anterior temporal and masseter muscles during mastication, J. Oral Rehabil. 11:325, 1984 Sheikholeslam, A., and Riise, C: Influence of experi mental interfering cuspal contacts on the activity of the anterior temporal and masseter muscles during submaximal and maximal bite in intercuspal position, J. ral Rehabil. 10:207, 1983. Bakke, M., and Moller, E: Distortion of maximal eleva tor activity by unilateral premature tooth contact, Scand. J. Dent, Res. 88:67, 1980, Krough-Poulson, W.G., and Olsson, As Management of the ocelusion of the teeth: background, definitions, ra fonale. In Schwartz, L, and Chayes, C., editors: Facial Pain and mandibular dysfunction, Philadelphia, 1968, WB. Saunders Co. Beyron, H: Occlusal changes in adult dentition, J. Am. Dent. Assoc, 48:674, 1954 Graf, He Occlusal forces during function. In Rowe, NL, editor: Occlusion: research in form and function, Ann Arbor, Mich. 1975, University of Michigan Press. Dawson, PE., and Arcan, M., Attaining harmonic occlu sion through visualized. strain analysis, J. Prosthet, Dent. 46:615, 1981