The stomatognathic system ate ho hac wa me cor oc clu lik tio un; prc me dis “pt sol un do sur tec tre bly ma we act im anc be in coi tio the to 4 Before we can evaluate dysfunction and dis- ease, we must have a clear picture of normal function and health, ‘The basis for cause- and-effect diagnosis is an understanding of nor mal form and its relation to function. The anat- omist Moffett has observed that “we will not find much of a disturbance in function without having a corresponding degree of alteration in structure.” The healthy interrelationship be: tween form and function provides us with a base line that can be used in distinguishing normal function from pathofunction. Most of the diagnostic procedures de- scribed in this text are designed to fest the var- ious components of the system to determine whether each part is healthy and then to de. cide if that part is in correct position and align: ‘ment to function normally A basic knowledge of the stomatognathic system starts with the temporomandibular joint, since it is the center of structural and functional interrelationships. Some of the most obvious aspects of the temporomandibular joint are often missed. even though they are extremely important. In fact some of the most popular techniques for treating temporomandibular disorders are based on misconceptions of how the joint functions, and many of the procedures that are advocated for restorative or orthodontic treat- ment are either unnecessary or detrimental to longterm stability. To relate each aspect of form to function, it is helpful to separate the 18 various Components of the joint into under: standable segments, starting with the passive structures of articulation and then progressing to an understanding of how the active cle ments make the system function. THE ARTICULATING SURFACES Ifwe examine a dry skull, it is apparent that the articulating surfaces of the condyle and its reciprocal socket merely allow movement to occur. The joint is often described as a univer- sal joint, but that description does not apply because each condyle imposes limitations of movement on the other. One condyle cannot move in any manner without reciprocal move: ment on the opposite side. In opening-closing movements, the two condyles form a common axis and so, in effect, act as one hinge joint Despite the fact that the condyles are rarely symmetric, the axial rotation occurs around a true hinge that is on a fixed axis when the condyles are fully seated. Rotation around a Jixed horizontal axis seems improbable be- cause of the angulation of the condyles in rela- tion to the horizontal axis. Each condyle is normally at about a 90-degree angulation with the plane of the mandibular ramus, which places their axes at an obtuse angle to each other. To understand how the condyles with different axes can rotate around a fixed com: mon axis, we must look to the contour of the ‘medial poles and their relation to the articular fossae, Because of the different angles and the‘The stomatognathic system 19 Horizontal Fig. 3-1. The medial poles of the eondyies are the only rotation points that would permit a fixed axis sripaition because the condyles are not parle wo dhe horizontal axis, This means that the lateral poles of the condyles must translate, even if the medial poles are rotting around a fixed axis (ae nce ap centric relation), asymmetry of the condyles, the medial pole ap- Pears to be the only logical common rotation Point that would permit a true rotation to oc cur on a fixed axis (Fig. 3-1). For the medial pole to serve as a point of ro- tation, the articular fossa must be contoured to receive it, Its triangular shape (Fig. 3-2) serves this mechanical function very well, and in ad. dition the medial part of the fossa is reinforced with thick bone and so it can also serve as a Stop for the upward force of the elevator mus- cles and the inward force of the medial ptery- goid muscles (Fig. 3-3). Other than the strongly braced medial por- tion, the roof of the fossa is always quite thin. Hold a skull up to the light and you will see that the bone in the roof is quite translucent, but notice the density of the medial portion and relate that difference to the relation of form to function. ‘The temporomandibular joint is designed to bear stress and must be ca: Pable of resisting forces that measure into hun- Greds of pounds. The condyles serve as a bilat eral fulcrum for the mandible, and so the joints are always subjected to stress whenever the Powerful elevator muscles contract. The spe- Fig. 3-2. Further evidence that the horizontal axis runs through the medial potes of the condyles is found in the {angular fossae with the apex related to the medial pole. horizontal axis through any part of the condyle other than the medial pole would result in translatory. move. ‘ments of the medial pole during a fixed rotational axis, and this would be incompatible with the V shape of the fossail 20 Evaluation, diagnosis, and treatment of occlusal problems Fig. 3-3. The condyle-disk assemblies are braced at the midmost, uppermost position by compression of the me dial potes against the medial apex of each triangular fossa To resist the inward, upward pressure from the internal pterygoid muscles, the fossae are heavily buttressed with bone in line with the direction of load. The anterior sur: face of each condyle is simultaneously compressed against the posterior slope of the eminentia, Fig. 3-4. Lateral view of cross section through the temporomandibular joint. 1, Posterior slope of the feminentia (notice typical convex contour); 2, condyle; 3, disk (notice biconcave shape to ft both con- vex condyle and convex eminentia); 4, superior lateral ptergoid muscle; 5, inferior lateral pterygoid muscle; 6, synovial tissue; 7, retrodiskal tissue including posterior attachment of disk to temporal bone 8 posterior ligamentous attachment of disk to the condylecific areas of reinforcement of the fossa con: form with the bearing areas for the upward, forward, and inward forces of the musculature. The articular eminence forms the anterior Part of the articular fossa (Fig. 3-4). Because of the slightly forward pull of the elevator mus les, the condyles are always held firmly against the eminence (with the disk inter- Posed). OF great importance is the strongly convex contour of the eminence. Since the an- terior aspect of the condyle is also convex, one can see the purpose and the importance of the biconcave articular disk that fits between the two convex surfaces. Because of its posi- tion between the condyle and the temporal bones, the disk divides the joint into an upper and a lower compartment. The lower compart- ment serves as the socket in which the condyle rotates, whereas the upper compart- ment allows the socket to slide up and down the eminence, Thus the mandible can hinge freely as cither one or both condyles translate forward. ‘The stomatognathic system 21 Since cach condyle serves as a fulcrum and is subjected to a predominantly upward force from the clevator muscles, it is provided with a definite stop to resist those forces. The condyle-disk assembly is able to slide up the eminence until the medial pole is stopped by the reinforced medial part of the fossa. This o¢- curs at the highest point to which the properly aligned condyle-disk assembly can move. It o¢- curs simultaneously with contact still main. tained against the eminence. The uppermost Position is also the position at which the me- dial pole is braced against the medial articular lip (with disk interposed). This relationship stabilizes the midmost position of the mandi. ble in centric relation and prevents any lateral translation from occurring while the condyle- disk assembly is in the uppermost position (Fig. 3-5). Sicher! has stated that “only the fracture of the internal lip or its destruction could permit a medial displacement of the condyle. The presence of the medial articular lip also prevents a lateral displacement of the Fig. 3-5. Medial pote bracing in tine w internal pterygoid muscle contraction establishes the mid. Position at centric relation. This braced position is consistently simultancous with the uppermost Position. This medial Pole stop also prevents the lower posterior teth trom moving horizontally vo ward the midline, an essential anatomic design that makes a normal curve of occlusion possible It alco Blais why an immediate sie sblt ts not possible from the fully seated position ofthe condstes (com tic relation),22 Evaluation, diagnosis, and treatment of occlusal problems condyle, since this could occur only under si- multancous medial displacement of the other condyle.” As further evidence that this is a stress bear- ing joint, all the articular surfaces of the condyle, the fossa, and the eminence are cov- ered with avascular layers of dense fibrous connective tissue. The absence of blood ves- sels is a sure sign that those specific areas are designed to receive considerable pressure. The avascular areas are also devoid of innervation, and this includes the bearing areas of the disk; so if the condyle and the disk are in proper alignment in the fossa they can receive great pressure with no sign of discomfort, since there are no sensory nerves in the bearing ar- eas to report discomfort. ‘The disk itself is a classic example of design for function. It is composed of layers of colla- gen fibers oriented in different directions to re- sist the shearing effect that might occur in a sliding joint. The bearing area is avascular, and so it is nourished by synovial fluids that also lu- bricate the joint for smooth gliding function. The reason for using collagen fibers instead of hyaline cartilage in the temporomandibular joint is that the stiffer cartilage that works well in most other joints would not be pliable enough to change shape as it conforms to the contours of the convex eminence in the slid ing movements. ‘The disk is firmly attached to the medial and lateral poles of the condyle, and such attach- ment is the reason it moves in unison with the condyle. The diskal ligaments, which bind the disk to the poles, allow it to rotate from the front of the condyle to the top and vice versa. In normal function the disk is always posi tioned so that pressure from the condyle is di rected through its central bearing area. Posi tioning of the disk is controlled by the combi- ation of elastic fibers attached to the back of the disk, which keep it under tension against the action of the superior lateral pterygoid muscle that is attached to the front of the disk. So while the diskal ligaments pull the disk along as the condyle moves, its rotation on the condyle is determined by the degree of con: traction or release of the superior lateral ptery: goid muscle. Many of the misconceptions about the disk have resulted from its depiction in illustrations as a little round cap that sits on top of the condyle. It actually wraps around the condyle to the points of attachment medially and later: ally, and its posterior border is quite thick. The steeper the slope of the eminentia, the thicker the distal lip of the disk becomes, a feature that seems to indicate the importance of the disk as one of the structures that combine to determine the uppermost position of the condyle. The functional positioning of the disk is a critical factor in mandibular movements, and several disorders can result from its disco: ordination Although the articulating surfaces allow movement by providing the mechanical frame. work for the sliding hinge, the function of the ligaments is to limit the movements of the mandible. The capsular ligament is not at- tached medially or laterally to the disk, but it is attached to the neck of the condyle below the attachments of the disk. The capsule that appears thin and loose is strongly reinforced laterally as the temporomandibular ligament ‘This has the effect of limiting retrusive and lat eral movement of the condyle without pre- venting its rotation. Me confusion exists regarding how the temporomandibular ligaments can brace the condyle without restricting its function, since in most two-dimensional drawings of the joint it would appear that the ligaments are placed in a position that would simply stop the open- ing of the jaw. This is the function of only one part of the ligament, Its fan shape permits dif- ferent bundles of the ligament to function in different movements of the jaw. The nearly horizontal fibers of the temporomandibular lig. aments limit posterior movement in a manner that permits a pure rotation at the terminal hinge position. This pure rotation is usually limited to a jaw opening of about 15 mm be- fore the opening is stopped by the ligaments at the neck of the condyle. At that point the condyle-disk assembly pivots against the Ii ment and must translate forward to permit fur- ther opening (Fig. 3-6). This is a very inge- nious design that moves the mandible forward as it opens, to keep the floor of the mouth from hinging back into an interference with the airway ‘The strength of the ligaments that limit the rearward movement of the condyles is suffi cient to protect the thin tympanic plate and the soft tissues behind the condyle. The com- bination of the ligaments, the thick distal lip of the disks, and the reinforced areas of the fossae a oeare so protective that even a hard direct blow {fo the.jaw will fracture the mandible rather than drive the condyle back into the tympanic plate or up through the thin roof of the fossa. If one studies the structure and arrange- ‘ment of the temporomandibular articulation, it should become apparent that the joint should be able to hinge freely and resist very strong Pressure with complete comfort if all the parts are bealthy and are in correct align- ‘ment. This is so because all the bearing ar are reinforced for strength and receive all functional pressures on avascular, noninner- vated surfaces. But this occurs only if all the passive parts are in balance with the active forces of the musculature. It has been my con- sistent clinical finding that whenever I find dis- comfort or dysfunction, I will also find muscle incoordination. Since muscle incoordination can so easily start a chain reaction of structural misalignment, it is necessary to determine Whether muscle incoordination is the cause or the result of the structural mairelationship. To do this, we must understand how the muscles function harmoniously. ‘THE MASTICATORY MUSCLES It is helpful to divide the muscles of mast cation into the positioner muscles and the ele- ator muscles. The positioner muscles are re- sponsible for the horizontal position of the ‘mandible. This relationship is determined by the inferior lateral pterygoid muscles that pull ‘The stomatognathic system 23 se 3-6. Positioning of part of the temporomandibular ligament is designed to prevent the mandible from open ing too far on a pure hinge rotation at the uppermost po- sition. As the jaw opens on a fixed axis, the floor of the ‘mouth is directed back into the airway. To prevent this, the ligament reaches its full length at about 15 t© 20 mm ‘of jaw opening, at which point it becomes a pivot that ini- tiates a forward translation of the rotating condyle. This r quires the mandible to move forward away from any air: ‘way obstruction during full opening the condyles forward, and the fibers of the temporal muscles that pull the mandible back. ‘The superior lateral pterygoid muscle is re- sponsible for keeping the disk properly aligned with the condyle during function. ‘The elevator muscles are all positioned di tally to the teeth so that they elevate the condyles and hold them firmly against the em- inence while hinging the jaw. The masseter, in- ternal pterygoid, and the major part of the temporal muscle are responsible for elevation. In the normal resting position of the mandi- ble, the elevator muscles and their antagonistic depressor muscles are in a resting state of pos. tural contraction. The mandible is balanced be- tween. To open the jaw from the resting posi- tion requires the contraction of the depressor muscles and the simultaneous release of the el evator muscles. As the jaw continues to open, the temporomandibular ligament reaches its restricting length at the neck of the condyle to stop the pure hinge rotation of the condyle. At this point, the condyle must translate forward. As the inferior belly of the lateral pterygoid muscle contracts, it pulls the condyle forward down the convex eminentia, and the disk is pulled along with the condyle. As the condyle: disk assembly moves down the steep incline and onto the crest of the eminence, the elastic fibers behind the disk keep tension on it to ro- tate it onto the top of the condyle so that the disk will be maintained in line with the direc: tion of force. To permit the retrodiskal clastic24 Evaluation, diagnosi fibers to rotate the disk to the top of the condyle, the muscle attached to the front of the disk must remain passive, and so the supe rior belly of the lateral pterygoid does not con- tract on opening or protrusive movements of the mandible (Fig. 3-7). ‘The superior stratum of the bilaminar zone is responsible for the positioning of the disk in protrusive movements. The inferior stratum is attached to the condyle, and so as the disk ro- tates back, tension is reduced in those fibers, Increasing tension in the superior stratum oc- curs as the condyle moves forward. ‘As the mandible starts its closure, the mid- dle and posterior fibers of the temporal muscle contract to pull the mandible back while the inferior lateral pterygoid releases its protrusive action. The depre also release as the clevator muscles start their contraction. ‘The combined contraction of the elevator muscles pulls the condyle up the lubricated in- cline until it is stopped by the bracing of the medial pole and the restraining ligaments. The forwardly directed muscle contraction holds the condyle against the eminence ‘The disk, being firmly attached to the poles of the condyle, is pulled up the incline with the condyle, but during that movement it must be rotated from the top of the condyle back to the more anterior relationship; so on closure the superior pterygoid becomes active 10 counteract the pull of the retrodiskal elastic fi bers and, through controlled contraction, holds the disk so that it is rotated to the front of the condyle as it moves back up the incline (Fig, 3-8). When the condyle-disk assembly moves down the eminence, the vacated space above and behind the condyle must be filled rapidly, since the closed system could not tolerate a vacuum, The area must be emptied just as rap- idly when the condyle returns. To accomplish this, a glomus cell arteriovenous shunting sys- tem shunts blood in and out of the area to re place the volume of the condyle as rapidly as it moves forward and to empty the space as rap- idly as the condyle moves back. This shunting, system is called the vascular knee (Fig. 3-9). In order for such rapid reversals in hydraulic pressure to occur, the medium around the are is composed of loose areolar connective tissu which can more readily conform to the unique effects of compression and tension. It is obvious that much of the structural yr muscles and treatment of occlusal problems complexity of the temporomandibular joint is necessary to maintain coordinated function be tween the condyle and the disk. The past few years has brought new insight into condyle: isk function and pathofunction. It has become apparent that condyle-disk discoordination does not occur without the involvement of muscle. One must determine whether incoor: dination of muscle is the cause of the disk mis: alignment and, if so, he must follow the chain of muscle responses back until the originating stimulus for the muscle disharmony is deter: mined. If structural alterations have occurred in the joint, he must determine whether cor- rection of the alignment will allow healing of the affected part, or whether the patient can function at a tolerable comfort level with the damaged part. If the damage is too severe and reparative surgery is the choice, it must be ac- companied by a return to structural and func- tional balance of the entire system or the sur- gery will probably fail. The severing of sensory nerves during surgery may produce a tentative relief of pain, but if balanced function is not achieved, the symptoms will probably reoccur when the sensory nerves regenerate IMPORTANCE OF OCCLUSAL HARMONY Ideal mandibular function results from a harmonious interrelationship of all the muscles that move the jaw. Muscle becomes fatigued if it is not allowed to rest. Muscle should not be forced into prolonged activity with no chance to rest. When teeth are added to the stomatog nathie system, they can exert a unique influ- ence on the entire interbalance of the system because if the intercuspation of the teeth is not in harmony with the joint-ligament-muscle bal ance a stressful and tiresome protective role is forced onto the muscles. When the muscles €l- evate the mandible in the absence of any devi ating interferences, the closing muscles pull the condyle-disk assembly up until it is stopped by bone at the medial pole, If tooth inclines interfere with this uppermost position, the lateral pterygoid muscle is forced into po- sitioning the mandible to accommodate to the teeth, The mandible is thus realigned to make the teeth intercuspate even though to do so requires the lateral pterygoid muscles to take over the bracing function normally assigned (0 the bone and ligaments. ‘The lateral pterygoid muscles are capable of holding the condyles during protrusive funcFig. 3-7. A, When the condyle is at its uppermost position against the steepest part of the posterior slope of the eminentia, the disk is positioned on the front of the condyle in line with the forward diree tion of force. As the condyle is pulled forward by contraction of the inferior literal pterygoid muscle (C+), the superior lateral pterygoid (—) releases contraction. This allows the elastic fibers attached to the back of the disk to rotate it tthe top of the condyle as it moves down the slope. B, As the condyle is pulled down the slope, tension from the retrodiskal elastic fibers increases to rotate the disk toward the top of the condyle and keep it aligned with the changing direction of force. ‘The superior lateral pterygoid must stay released (—) to permit the elastic hers to pall the disk back. Notice the progres: sive slackening of the posterior ligamentous attachment of the disk (PL) to the condyle, C, When the condyle reaches the crest of the eminentia, the direction of force from the elevator muscles is up through the top of the condyle, against the more horizontal surface of the eminentia. The superior lat. ccral pterygoid stays passive through the full protrusive movement to allow the retrodiskal elastic fibers to control the alignment of the disk on opening. Notice that the superior lateral pterygoid muscle at taches to the condyle as well as the disk, thus preventing the disk from being pulled t00 far distallyFig: 3-8. A. As soon as the closing rotation starts, the inferior lateral peerygoid muse (~) releases Contraction to allow the condyle to be pulled back and up the slope by the elevator muscles Samahee neous, the superior lateral pterygoid muscle (+ ) activates its contraction to hold the disk forward. ay Fan ean Pull of the elastic fibers as the condyle starts to move distally. B, As the condyle Orta ee lOhe: the contraction of the superior lateral pterygoid muscle (+) controls the aligament disk, G. The inferior lateral pterygoid (stays passive through the fll range of closure te allen we Condvic 10 slide up the slope of the eminent. The superior lateral pterygoid maintains 1 consolled Convraction (+) 10 hold the disk forward so that itis automatically rotated hack to the front of the ond as the condyle moves back to centric relation. At this point the posterior ligament (PL) i tare Preventing the disk from being rotated too far forward.Fig. 3-9. The space behind the condyle changes rapidly as the condyle moves forward and back. A network of blood vessels, A, with clastic walls allows blood to rush in as the condyle moves forward to fill the space with the expanded vessels, B. As the condyle moves back, the blood is shunted out the vessels: This shunting system is called the ruscwlar kneetion, but in the presence of an occlusal inter ference they can never be relieved of this function without allowing the malatigned teeth to be stressed. ‘The mechanism that forces this prolonged contraction onto the lateral pterygoid muscles is the exquisitely sensitive protective reflex system that guards the teeth and their support ing structures against excessive stress. Proprio: ceptive nerve endings scattered through the Periodontal ligaments are sensitive to evel minute pressures on individual teeth. The proprioceptive system is designed like a glove Of periodontal receptors capable of evaluating the direction and intensity of stresses on the teeth and designed to program the lateral pterygoid muscles to position the jaw so that the elevator muscles can close directly into maximum occlusal contact. If tooth interfer- ences cause the mandible to move left, the right lateral pterygoid must contract to pull that condyle forward. Contraction of the left Pterpgoid moves the jaw to the right. Contrac- tion of both pterygoids moves the jaw forward. There are unlimited variations of timing and degree of muscle contraction to precisely posi- tion the mandible for maximum intercuspation of the teeth, but the lateral pterygoid muscles are always involved in any deviation from cen: tric relation This unique relationship between the lateral pterygoid muscles and the proprioceptive peri odontal receptors is so definite that it even overrides the normal tendency of the muscle to rest when it becomes fatigued. The muscl cannot relax the protective bracing contrac tion as long as the occlusal interference is present. The pattern of deviation is reinforced every time contact is made, and it is retained in the brain's memory bank so that muscular closure into the deviated jaw relationship becomes au tomatic. One important facet of the proprio- ceptive memory, however, is that it fades rap- idly if continual reinforcement of the pattern ation of interfering contacts per- n almost immediate return to normal muscle function, The deviation pattern is for- gotten as soon as it is no longer needed. In the past few years, new research has shown that the effect of occlusal harmony or disharmony is more definitive than had been realized. Many investigators have documented the cause-and-effect relationship between oc- The stomatognathie system 25 clusal interferences and muscle incoordina. tion, but the work of Williamson? has given a new perspective to the importance of precise ‘occlusal harmony and its relationship to physi ologic condyle positioning, Williamson has demonstrated the precise ef: fect of occlusal interferences on muscle coor. dination and normal muscle activity. Using clectromyographic procedures, he showed that interfering contacts on posterior teeth in any eccentric postion caused hyperactivity of the elevator muscles. But if the anterior guid. ance was allowed to disclude all posterior teeth from any contact other than centric rela- tion, the elevator muscles cither stopped ac tive contraction or noticeably reduced it the ‘moment the posterior teeth were discluded. If heavy contact on any posterior tooth in any cecentric position causes a response of muscle hyperactivity, it has the effect of load- ing the tooth or teeth with the occlusal inter- ferences, but the elevator muscle hypercon- traction also loads the joint with the same hy- peractivity. Williamson's research has particular mean- ng to the principles of occlusion outlined in this text because of his agreement with the de scription of centric relation and his meticulous attention to its precise recording. This is the type of research that has been needed because it relates clectromyographic results to a specif. ically described centric relation position that was verified and documented The noticeable reduction in elevator muscle activity at the precise moment of disclusion is ‘one of the most important and clinically useful findings in many An incoordinated musculature rarely exists without some form of adaptive structural change. Because of their tendency to wear, be- come loose, or move, the teeth are the usual site for structural alteration. The temporoman- dibular joint has generally been regarded as the most stable component of the masticatory system, but remodel nge the shape of the disk or the condyles. Mongini* has shown that a direct relationship exists be- tween the shape of the condyle after remodel- ing and the abrasion patterns on the teeth. His findings give strong support to the concept that remodeling of the joint can be considered, to a certain extent, a functional adaptation to a hew occlusal situation, The apex of force positioning of the ears, 1g can ch;26 condyle scems to relate rather consistently with Mongini’s findings regarding the relation- ship between the type of displacement and condylar shape caused by remodeling. He showed that flattening and flaring of the ante: rior surface are the most common changes in condylar shape and are accompanied in most cases by anterior condylar displacement, Re- modeling of the posterior surface of the condyle, leading to flattening or concavities, is frequent in posterior displacement. When all the notable, related research of the past few years is analyzed, it is apparent that the occlusal interface must involve the ar- ticulating surfaces of the temporomandibular joints with equal importance to the occlusal surfaces of the teeth. All the active and passive elements of this interrelationship must be care fully evaluated to make certain that a harmony of parts exists. Signs and symptoms of tem- poromandibular disorders are the effects that occur when some part of this interrclationship goes awry Healing is part of the body's adaptive re- sponse, but for healing to achieve proper re- pair, it must occur in a friendly envionment of balance. Mongini has shown that if the parts of the stomatognathic system can be restored to a balanced relationship even a flattened condyle may regain a normal contour. Occlusal therapy and consequent condylar repositioning led to improved contour of a previous flattened condyle in 7 out of 11 patients, and in 3 of the lesions were also present the lesions were healed. ‘The new insights that so much of the recent research has given us has confirmed what many other clinicians and I have observed clin- ically: successful occlusal treatment is depen- dent on complete harmony of all the passive and active components of a very precise and complex system. It is not possible to have an adequate understanding of occlusion outside faluation, diagnosis, and treatment of occlusal problems of the framework of the total stomatognathic system. Although the problem posed to the occlusal therapist or the restorative dentist is to org nize the dentition in harmony with the muscu- lature, it must first be determined that it is a peaceful neuromuscular system. It is impera- ‘¢ to ascertain that the muscles are not being stimulated into stressful patterns of function that would simply be perpetuated. The muscles must have complete freedom to function with no extended demands on any muscle or group of muscles, Ligaments must be permitted to assume their bracing roles to permit muscles to rest. All tooth inclines should fall outside of nonfunctional jaw move: ments but should be easily reached when func- tional contact is desired. Limiting jaw movements to a terminal hinge are of closure is tolerated by some patients but is restrictive to most because it imposes limita- tions on muscle function that can stimulate an crasure attempt to brux away the interference or move it out of its restricting position. Limit- ing jaw movements to a protruded closure worse because it places continuous demands on the lateral pterygoid muscles by preventing condylar access to the bony stop at centric re- lation. Limiting jaw movements to a distalized joint position is worse yet because it forces the condyle onto a vascular innervated area that not designed to resist pressure and encourages damage and displacement of the disk. The re sulting inflammatory response in« spasm and eventual degenerative changes. ‘A minimal stress occlusion is permissive. It never forces muscles into protective contrac: tion or incites nonfunctional hyperactivity. It permits the entire range of the stomatognathic system to function harmoniously with no ex- cessive demands placed on the joints, the liga ments, the neuromuscular system, or the teeth, es muscle— ee De re peo ccs no Pe carer 2 are gs es cee ean ree nat ies Ie eof nace on emgroennd Bava an wtoen. SUGGESTED READINGS Gibbs, CL, Messerman, T, Reswiek, J.B, tal: Functional moyements of the mandible, J. Prosthet. Dent. 26:608, 197. Main, P.E: The temporomandibular joint in function and ppathofunction, U.CL.A. Symposium on temporomandib: tlar Function and Pathofunction, Chicago, 1980, Quin: {essence Publishing €o., Ine, pp. 35-47. ‘The stomatognathic system 27 Mahan, P.E, Gibbs, CH., and Mauderli, A: Superior and in- ferior lateral pterygoid EMG activity, J. Dent. Res. 61:272, 1982. (Abstenet.) Mahan, P.E: Anatomic, histologic, and physiologic features of TMJ. Chapter 1 in Irby, W.B., editor: Current ad: vances in oral surgery, vol. 3, St. Louis, 1980, The CV. Mosby Co. Posselt, V.: Range of movement of the mandible, J. Am Dent. Assoc. $6:10-13, 1958, Ramfjord, S. and Ash, M.M.: Occlusion, ed. 5, Philadelphia, 1985, W.B. Saunders Co, Sarnat, B,, editor: The temporomandibalar joint, ed. 2, Springfield, I, 1964, Charles C Thomas, Publisher, Sessle, BJ, and Hannam, AG., editors: Mastication and swallowing, Toromo, 1976, University. of Toronto Press. Sicher, H., and DeBrul, ELL: Oral anatomy, ed, 5, St Louis, 1970, The CY. Mosby Ci Zola, A: Morphologie limiting factors in the temporoman: Aibular joint, J. Prosthet, Dent. 13:732-740, 1963.