The concept of complete dentistry A dental examination is complete if it allows jentification of all active factors that are capa- ble of causing or contributing to the deteriora tion of oral health or function. It is izcomplete if it does not provide enough information to develop a total treatment plan aimed at opti mum maintainability of the teeth and their supporting structures, Since there is no effective way to achieve maintainable oral health without a harmony of all parts of the masticatory system, the total system must be evaluated. What affects one part of the system will eventually affect the other parts. The alteration of form or function of teeth, muscle, joints, bone, or ligaments is interrelated and must be understood before any part of the system can be properly ana- lyzed or predictably treated, Deterioration or malfunction of any part should be viewed as an effect that is the direct of indirect result of one or more identifiable causes, The careful diagnostician must first be a careful examiner who observes every delete rious effect in the form of signs or symptoms and then looks for every possible cause for cach observed effect. Both causes and effects must be analyzed carefully so that they can be related to specific goals of treatment. ‘The establishment of definitive goals is the foundation for complete dentistry. If a goal is clear enough, it can be visualized and in fact must be visualized. A good rule is to avoid starting any treatment until the result can be clearly visualized. ‘The ultimate goal of all den- tal treatment is optimum oral health, but until the practitioner can visualize how each type of, tissue looks and acts when healthy, there will be no point of reference for knowing whether treatment is needed or if it is successful when rendered. Clearly defined goals give purpose to treatment planning and make it possible to be highly objective, Complete dentistry has four comprehensive goals: 1. Optimum oral health 2. Anatomic harmony 3. Functional harmony 4. Occlusal stability If cach of these goals is achieved, treatment success is assured. When the entire gnathosto- matic system is healthy, and there is a har- mony of form and function, and the relation- ships are stable, the treatment can be consid- ered “complete.” Furthermore, esthetic re- quirements also be fulfilled, since the appearance of the smile is dependent on the same harmony of form that is necessary for harmony of function. In the analysis of any oral diagnosis prob: lem, cach of the above goals should be evalu. ated for fulfillment. This is practical only if the reasons for form and function relationships are2. Evaluation, diagnosis understood, along with the cause-and-effect na- ture of health versus disease. This type of anal- ysis also eliminates dependency on empiric treatment or making patients fit averages. ‘There are many stable, healthy dentitions that do not fit the averages, are not Class 1 occlu- sion, and seemingly violate all the customary guidelines. Attempts to “correct” these denti- tions often end in failure because the existing harmony of form and function is disturbed by the treatment. Such mistakes can be prevented, and a high degree of predictability can be de- veloped if the goals of treatment are based on a foundation of why rather than how. There is a reason for every position, contour, and align- ment of every part of the gnathostomatic sys- tem, There is a reason for every incisal edge position, every labial contour, every lingual contour, or every cusp tip position. There is a reason why some teeth get loose and others wear away. There is a reason why temporo- mandibular joints get sore, why muscles be- come tender, and teeth get sensitive. There is a reason why certain occlusions remain stable and others do not. Treating the effect without correcting the cause is rarely successful Every diagnostic or treatment decision should be made on the basis of understanding the reasons for the problem and the reasons for the treatment, Planning must then be di- rected at definitive goals by therapeutic use of cause-and-effect relationships. Let us explore each of the four basic goals in detail to show how effectively they can be used to help solve problems of oral diagnosis and treatment. OPTIMUM ORAL HEALTH All treatment should be consistent with the goal of providing and maintaining the highest degree of oral health possible for each patient. In this regard, diagnosis and treatment plan- ning can be condensed into two fundamental objective: 1. Finding all factors that contribute in any way to deterioration of oral health 2. Determining the best method of elimi- nating each factor of deterioration ‘Total climination of all causative factors to the point of complete reversal of deterioration is not always possible. The problems of some patients are too severe or have gone on too long to expect a complete return to ideal health, But the degree to which we can elimi and treatment of occlusal problems nate the causes will directly relate to our de- gree of success in changing unhealthy mouths to healthy ones. Causes of deterioration Dental disease rarely results from a single entity. It is almost always the result of a com: bination of factors. The same causative insult can produce a variety of responses because of differences in host resistance. The response can also be altered by variations in intensity or duration of the insult, sometimes to such an ‘extent that a completely different set of symp- toms may result from increased intensity of the Me Causative factor. Because similar symptoms may result from completely different causes and a variety of symptoms may result from the same causative factor, treating symptoms is generally short sighted therapy. It is always advantagcous to determine the specific cause of both signs and symptoms. If the causative insult can be com- pletely climinated, the normal adaptive re- sponse of the body should activate a return to normalcy. Of course, it may still be necessary to repair damaged tis but this can then be done with a greater chance of a long-term su cessful prognosis. Much of the confusion about cause- and-effect relationships results from failure to differentiate between causative factors and contributing factors. A contributing factor does not by itself luse disease, Rather, it lowers the resistance of the host to the causative factor. Host resis- tance may be lowered biochemically or biome: chanically, and resistance may be lowered in a specific tissue or in an entire system. Gener- ally, the weakest link breaks down. Contribut- ing factors may also work by increasing the in- tensity of function or tension. The greatest sus- ceptibility to disease occurs when a causative factor is present in a host with increased stress and lowered resistance. Both causative and contributing factors must be considered when one is deciding on a course of treatment, but the most direct approach is to give the highest Priority to direct causative factors. Attempts at increasing host resistance and decreasing stress levels should be kept in proper perspec- tive as adjunctive therapy. Let us use a simple illustration to show how a single direct causative factor can produce avariety of signs and symptoms depending on variations in how different patients respond. In a healthy patient with a perfect dentition, let us explore the variety of responses that can occur if a high crown with incline interfer ences is placed on a second molar. There are at least 15 different ways that patients might respond to this specific insult 1, The tooth may become sensitive to hot or cold, or it may ache. ‘The tooth may become tender to touch. . The tooth may become loos The tooth may become worn, ‘The mandible may deviate around the interference, causing the other teeth to be worn down. 6. The deviated jaw function may other teeth to be loosened. 7. The deviated jaw function may cause the masticatory muscles to become hy: peractive, or become spastic. rismus may result from the muscle spasticity 9. Muscle tension headaches may develop. 10. The combination of sore teeth, sore muscles, and headaches may cause ten. sion and str 11, Tension and stress may lead to depres- ion. 12. The combination of the deviated mandi- ble and the spastic musculature may cause a condyle-disk derangement 13. The combination of the disk derange- ment and the elevator muscle spasm may initiate degenerative _ arthritic changes in the —temporomandibular joint. 14, All of the above. 15. None of the above. All the signs and symptoms listed above are a direct result of the same causative factor, the occlusal interference from the high crown. None of the contributing factors that altered the response actually caused the problems. If the causative insult had been corrected before irreversible damage, all symptoms would have disappeared without any changes having to be made in host resistance. Host resistance is not the only variable. Variations in intensity of function can alter re- sponse to the same potentially damaging caus. ative factor. The same type of occlusal interfer ence mentioned above may go completely un- ause The concept of complete dentistry 3 noticed by the very relaxed patient who has no tendency to clench or brux. The mouth breather or the person who sleeps with the mouth open will have fewer if any symptoms because no stress results in the absence of tooth contact. The same patient under duress may begin to clench or brux, activating the trigger that programs the muscles into an avoidance pattern, further complicating the symptoms in the teeth, the muscles, and possi bly the joints. Diagnosis and treatment planning Despite the complexity of the multicausality concept, it is still possible to simplify our ap- Proach to diagnosis and treatment planning, ‘The law of cause and effect is so seldom repu- diated that from a practical standpoint if we find an effect there will always be a cause. Good patient management requires the recog: nition of all causative factors along with an un- derstanding of how and why each factor affects the health or function of any part of the sys- tem, The first step then in achieving complete dentistry is careful diagnosis to observe both causes and effects of disharmony, instabilty, or sease. ‘The method of diagnosis and treatment planning consists in the followin; 1. A careful examination to lyze every factor that is capable of c: ing disease, disharmony, or instability, in other words, finding each detrimental causative factor. 2. An analysis of ost resistance and an evaluation of any other contributing fac- tors. 3. An evaluation of the effects of causative factors. Effects should be related to time, intensity, and host resistance. When you see an effect, search until you find the cause. Is the causative factor still active, or has it already run its course in produc. ing its effect? 4. An analysis of all possible methods that could be used to climinate detrimental causative factors or neutralize their harmful effects, 5. Selection of the best treatment approach. plate and ana: Finding the causative factors Patients lose their teeth in two ways: either the teeth break down, or the supporting struc-4 Evaluation, diagnosis, and treatment of occluss tures break down. As simplistic as it' may sound, if we exclude neoplastic disorders or injury, almost every deteriorating effect on the tecth or supporting structures is a direct result of one or both of two causative factors: 1, Microorganisms 2. Str If the intensity of the causative factors is constant, the degree or rapidity of deteriora- tion is dependent on the contributing factor of host resistance. Patients should understand the role each factor plays, since they must share the responsibility for keeping each factor un- der control. Causative factor 1—microorganisms. There seems to be no doubt that the elimina. tion of bacterial plaque and the thorough cleaning of gingival sulci are essential to oral health. The acid microbial waste products not only cause caries through decalcification of the tooth surfaces, but they are also highly inflam: matory to soft tissues and destructive to the bony support, Any condition that prevents thorough cleaning of any tooth surface or any portion Of the sulcus should be constdered a causative factor that can lead to loss of teeth. There is no such thing as a “healthy” mouth that has long:standing deposits of bacterial plaque. As long as organized masses of microorganisms are present, progressive breakdown of the sup- porting tissues will occur. The only variable is the rate of deterioration, which may vary from patient to patient and even from tooth to tooth in the same mouth. The tissue response to the noxious products of the microbial colonies de- pends both on the general resistance of the host and on the resistance of the specific areas that are being subjected to the microbial tox- ins Even in a dentition that is uniformly coated with plaque, the destructive effects are not uniform. Periodontal destruction around some teeth may be severe, whereas other teeth may retain all or most of their bony support. Since the intensity of the microbial attack is about the same around all the teeth, there must be a tooth-by-tooth difference in resistance to the microbial toxins. The differences in resistance from one tooth to the next most often is di- rectly related to differences in intensity of oc- clusal stress. It is a common clinical finding that the degree of bone breakdown is in direct I problems proportion to the occlusal stress exerted on each tooth. Although there do S appear to be a clinical relationship between the amount of microbial damage and the amount of occlusal stress, oc clusal stress is not a necessary factor. Severe periodontal disease can occur in an environ- ment of occlusal perfection. It is important to understand that the best occlusal treatment ‘cannot prevent deterioration of the supporting structures if inflammation is present. Occlusal therapy without control of plaque is incom- plete dentistry. On the other hand, soft-tissue management, even with exceptional control of plaque, falls short of the long-term maintain. ability that can be achieved when excessive ‘occlusal stresses are also reduced. ‘The short-term improvement that can be ac- complished by efther occlusal therapy or plaque climination can be impressive, but judging results too soon can be misleading. A concentrated mouth hygiene program y transform bleeding, edematous gingivae into healthy-appearing tissue. In addition, oc: clusal correction may dramatically improve the comfort of the teeth and eliminate hyper mobility. But even such noticeable improv ment can be misleading if underneath the healthy-looking tissue an untreated pocket re mains. No matter how healthy the gingiva ap: pears, deterioration of the alveolar bone will continue if the entire sulcus is not cleanable. ‘The healthy appearance on the outside merel produces a false sense of security while deteri: oration continues in the depth of the pocket. No matter how thorough the plaque control program, even if combined with occlusal ther- apy, it is incomplete dentistry if there remain deep lesions that are capable of producing continued deterioration of the periodontal support. Causative factor 2—stress. \yperfunc tion and misdirected occlusal forces can cause of contribute to any or all of the following ef- fects: 1. Hypermobility of teeth . Excessive wear . Hypersensiti Masticatory muscle imbalance 5. Temporomandibular disorders 6, Periodontal breakdown 7. Formation of noxious oral habits 8. Fracture of cusps or split teeth, 3.Since the teeth, their supporting structures, and the entire masticatory apparatus are ad- versely affected by excessive stress, a major goal of treatment is always the reduction of stress to a point that is not destructive. The amount of stress exerted against the dentition is always related in some way to whether the teeth are in harmony with the mechanical movements of the mandible. Because the man- dible is a lever arm with a fulcrum and a power source of strong muscles, it is axiomati that the teeth must not interfere with its pow- erful functional movements. The patterns of mandibular function are definite and are de- pendent on two determinants: 1. The anatomic limits of movement 1 are imposed on the temporomandibular joints by their articulating surfaces and their ligaments The physiologic action of the muscles as they move the mandible within or up to its border limitations If the teeth interfere with the physiologic harmony of muscle-and-joint function, the con. flict produces stress. The stress may result in harm to any or all parts of the mechanism. The damaging effects of such stress can be ob scured by the adaptive responses in the tem, but there is usually a price to pay for ad aptation. The adaptive response may be to wear away the tooth interferences in an at- tempt to regain structural balance between the teeth, the joints, and the musculature. Often, it is easier to loosen the teeth than to wear the hard enamel, whereas in other cases the teeth are just forced out of alignment Muscle activity is almost always affected by occlusal interferences because when the phys: iologic position of the joint is not compatible with the intercuspation of the teeth, muscle will be directed to move the jaw to make the teeth fit even if it requires displacement of the joints. The exquisitely sensitive proprioceptive ervation around the roots directs the mu cles, which can then easily become hyperac- tive by the constant demand to function in the displaced jaw position. If there have been any major shortcomings in the understanding of occlusal diagnosis, the first has been failure to understand how little it takes to throw the system out of balance. The second problem of communication has been disagreement on what constitutes correct posi- The concept of complete dentistry 5 tion and alignment of the condyle-disk assem- bly. Both points must be clarified because when we talk about an occlusal interference we mean that one or more tooth surfaces in- terfere with the physiologic functional pattern of the condyle-disk assembly. The result stress in the mechanism. ‘The proprioceptive nerve endings around the teeth are so exquis- itely sensitive to even minute variations of pressure that the slightest interference by a single tooth is sufficient to change the whole pattern of muscle function. The nature of the myoneural mechanism is to protect the teeth. If the teeth are not in harmony with the joints, the muscles must not only move the mandible into the convenient position, but they are also given the job of bracing the condyles on the slopes of the eminences against the force of an- tagonistic elevator muscle contraction. In other words muscles are forced into the long- term bracing role that is properly the job of bone and ligaments, Although bone and liga- ments in normal function do not become fa- tigued, muscles in abnormal function do. Mus cle fatigue can produce a variety of problems and symptoms. Prolonged contraction of a fa tigued muscle may produce painful spasm of the muscle itself, or it may do the same to its antagonistic muscle by forcing it into an inco- ordinated stretch-reflex contraction, ‘The imbalanced masticatory muscles may affect the postural muscles of the head, neck, and eventually the shoulders, as one system out of harmony disrupts other functional uni All these disruptions produce stress, and stress takes its toll in many different ways from sim- ple acceleration of wear to complex excruciat- ing pain. The pain may masquerade as an car ache, a toothache, or quite often a headache. It is a common occurrence for long-standing headache problems to disappear when muscle harmony is reestablished. A high percentage of headaches are the result of muscle tension. Very often, the trigger for the whole chain of head and neck muscle hyperactivity is from a minute occlusal interference Despite the extreme mobility patterns that can be caused by traumatogenic occlusion, there is no evidence to show that occlusal trauma can cause an increase in pocket depth unless inflammation is present in the region of the gingival attachment. If the gingival attach- ment is intact and there is sufficient level of6 Evaluation, diagnosis, and treatment of occlusal problems supporting bone remaining, even severely mo: bile teeth can be returned to normal firmness and health by correcting the occlusion. With meticulous hygiene to keep the sulci com: pletely free of plaque, inflammation can be pre- vented, even in extremely loose teeth. In the absence of inflammation we do not expect pocket depth to increase, and this is probably so whether the occlusion is correct or faulty. Lindhe and Nyman' have shown rather conclu- sively that occlusal trauma of the jiggling type, even with greatly reduced periodontal sup- port, will not cause further destruction of the attachment apparatus, once the plaque: induced periodontal disease has been cured However, the combination of plaque-induced periodontitis and occlusal trauma causes a more progressive loss of connective tissu tachment than in nontraumatized teeth. Some authorities have argued that occlusal factors play no role in periodontal breakdown because inflammation is the essential causative factor for ihereased pocket depth. This opinion presents a limited viewpoint of what consti- tutes periodontal disease. A total picture of pe- riodontal health should include the health of all the structures that support the teeth, not just the gingival attachment. The way in which bone is destroyed can be learned from carefull clinical observation. The reason why teeth in hyperfunction become loose is that the bone around the roots breaks down. The bone breakdown follows a specific pattern because the bone resorption is a direct result of pres- sure stimulation, which causes thrombosis, hemorrhage, and destruction of collagen. The fibroblasts that are put under excessive pres sure convert into osteoclasts, which in turn de- stroy bone in direct proportion to the intensity and direction of the pressures exerted, This means then that intra-alveolar bone breakdown follows a pattern that is definitively related to occlusal stress patterns. Careful clinical obser- vation repeatedly confirms this relationship. If the occlusion is corrected before inflammation of injury deepens the sulcus to communicate with the area of bone resorption, osteoblastic activity will replace the osteoclastic destruc- tion and bone will complete fill back in to its original levels. The loose tooth will tighten and can return to normal health and function, If the occlusal correction is delayed, our clinical experience has consistently shown that it will eventually communicate with a deep: ened sulcus or pocket. Understand that the in: crease in pocket depth requires bacterial in- flammation or injury and so it theoretically can be prevented. It has in fact been prevented on selective patients who are willing and able to follow extraordinary hygiene procedures un- der increased professional supervision. AL though theoretically possible, it is not gener- ally practical or consistently predictable. Bone resorption often occurs worse in furcation ar- is that are hardest to clean and where com- munication with the pocket is most likely to occur. Once there is any breakthrough be- tween the sulcus and the area of bone break- down, the pocket is immediately deepened to the extent of the intraalveolar defect and a major periodontal lesion results, It is now too late for occlusal correction to resolve the bony defect. Major periodontal therapy will be re- quired, and even then the bone level will not be returned to its original contour. That op- portunity is lost whenever occlusal correction is delayed too long. The repair of intraosseous defects is more predictable when the teeth are firm. From al- most every viewpoint of treatment it is more difficult to keep the supporting tissues healthy around a loose tooth than it is around a firm one, Occlusal stress must be considered as a primary cause of supporting structure break- down around the teeth. Correction of misdi- rected or excessive forces against the teeth is one of the essential considerations in achieving optimum maintainability of any dentit How stress affects the teeth Tooth enamel is the hardest structure in the body. It was designed to last a lifetime of nor- mal function. Even the contour of each crown is designed to maximize the amount of wear it can withstand without harm to its functional capabilities. Electromyographic research has also shown the presence of an energy conser: vation system for the masticatory muscles so that contraction of all three pairs of elevator muscles is reserved by pressure sensors around the roots for when there is a bolus of food between the teeth. The system is de- igned to use minimal muscle contraction when there is no food to penetrate, thereby saving wear and tear on the teeth. The system works well as is evidenced by the number of elderly patients we see with in- tact dentitions that still have enamel surfacesin good function. Whenever you observe such 4 patient with no excessive wear or hypermo- bility in their later years, you will find consis tently that there is a harmony of the occlusal surfaces with the functional movements of the mandible. Whenever the intercuspation is not in har- mony with the physiologic function of the temporomandibular joints, you will find almost, without exception either excessive wear, hy- permobility, or adaptive realignment of the teeth. When a tooth interferes with correct joint position, the pressure sensors around the roots of the prematurely contacting tooth mis interpret the pressure as a bolus and thus acti- vate all the elevator muscles to contract with excessive force against the teeth when it is not needed. The result is acceleration of wear and tear on the dentition. ANATOMIC HARMONY No system works well if its parts are not in their proper place. The masticatory system is no exception. If any part of it becomes mis- aligned, the entire system must adapt. Adapta- tion to misalignment creates stress and ac erates wear. is permissive harmony farting point from which function oc curs. Whether all parts of the system are in a balanced static relationship determines whether there will be a peaceful neuromuscu lar system. This is so because muscle controls all function, and muscle must have a static res ing relationship from which functional activity begins and to which it returns when functional demands are completed. Anything that inter- fers with static harmony of any part alters nor- mal muscle function into an unbalanced rela. tionship of constant demand. Muscle has an optimum length of contraction and an opti mum length at rest, and correct anatomic har- mony depends on allowing muscle to function to its normal limits without interference. ‘The most common shortcoming in analyz: ing or treating occlusal relationships is failure to consider ail the parts of the masticatory sys tem. We are prone to many mistakes if our un- derstanding of occlusion is limited to occlusal contacts alone. The teeth are merely a part of the total system, and frankly there is no way to evaluate occlusal relationships until we have first ascertained that the temporomandibular tion is in harmony. There is no such The concept of complete dentistry 7 thing as a perfected occlusion with a mis- aligned temporomandibular articulation, There can be no occlusal harmony when any part of the masticatory apparatus is at war with mus- cle. That includes the lips, tongue, and cheek musculature A harmony of form is a prerequisite for har- mony of function, and it is necessart to have a working knowledge of how the two interre- late, Every aspect of each tooth’s position and contour can be determined on the basis of its harmony with functional requirements. As ex amples, the upper anterior teeth must relate to the closing path of the lips as they seal for swallowing; the incisal edges must relate to the lower lip contour for proper phonetics and the lingual contours must relate to the tongue in swallowing, Many other functional relation- ships are discussed in other chapters, but the important thing to understand at this point is that every part of the system has an under- standable reason for its position, contour, and alignment. If any anatomic component is not in harmony, the entire system must adapt. Adap- tive changes should always be evaluated as re- sponses to imbalance. Whether the body's at- tempts at correcting imbalance are beneficial or destructive is dependent on the resistance or response of the altered tissue or part. Astute diagnosticians must know the norm and must be able to determine when an imbalance exists and whether the tissue or parts have succe fully adapted to the altered imbalance. If we can achieve anatomic harmony of all parts of the system, we are assured of the best Possible esthetics as well as the comfort of a peaceful neuromuscular system. The best es: thetic result is a natural appearance. Having all parts properly shaped and positioned in total harmony is the formula for a pretty smile and an attractive face, according to the best plan in nature, FUNCTIONAL HARMONY Because it is a dynamic system, organized for performing a variety of functions, each part of the masticatory apparatus has several differ- ent functions. Besides mastication, the same system is also designed to be used for drinking, sucking, swallowing, and breathing, not to mention smiling, kissing, licking, and spitting. The same parts also serve simultaneously as the organ of speech, The total gnathostomatic system is truly a remarkable example of multi-8 Evaluation, diagnosis, and treatment of occlusal problems ple-use bioengineering. To perform such a va- riety of functions, it is obvious that the lips, tongue, cheeks, bone, joints, and muscles must have a highly organized relationship to each other and to the teeth, which must fit into the system without disturbing any of the other functional demands, or vice versa I cannot overstress the importance of un- derstanding the functional interrelationships involved in the masticatory system. It is impos- sible to adequately evaluate cause-and-effect influences in the dentition or the joints with- out knowledge of functional interdependen. cies. If we do not know what causes a malrela- tionship, we will probably fail in our treat- ment. We may subject our patients to unneces- sary treatment or inadquate treatment if we are forced to treat the symptoms without un- derstanding the causes. Functional disharmony usually provokes a chain reaction of responses. A child with en- larged adenoids has difficulty breathing unless he thrusts his tongue forward to increase the size of the airway. The forward tongue thrust overpowers the normal pressure of the lips, and the anterior teeth adapt to the outward Pressure by moving forward until they reach the new position of balance between the tongue and lips. The lower lip may now find it is easier (0 fit behind the upper anterior teeth than to stretch over the protruded arrange: ment The lower lip thus may force the upper an- terior teeth into a more severe protrusion while crowding the lower incisors lingually. If attempts are made to correct the alignment of the teeth, without correcting the cause of the tongue thrust, the treatment will fail. Teeth simply do not move out of alignment, do not get loose, or do not wear away without a specific underlying cause. As already shown, the cause may be at the beginning of a chain reaction, but regardless of when and how the Process was initiated, treatment will not be successful unless all currently active causes for disharmony are corrected, An acceptable analysis of occlusal dishar- mony cannot be made from examination of unmounted diagnostic casts. For an examii n to be considered complete, all functional relationships must be evaluated to determine how the dentition relates to all the other struc- tures that influence anatomic or functional har- mony. This requires a facebow orientation of the casts to the condylar axis. ‘The goal of functional harmony is a peaceful neuromuscular system. The masticatory system is capable of high-capacity demands. The sys. tem must be free to function to its anatomic limit without mechanical interference but must not be restricted to function solely at that limit. It must function to the limit when needed. It must be at peace when functional demands are reduced. OCCLUSAL STABILITY ‘The essence of both anatomic and func tional harmony is balance. Every system in the body (as well as the entire universe) relics on a centered relationship between equal and op- Posite forces. Every cell wall is balanced be- tween the osmotic pressure of intracellular fluids and that of extracellular fluids. ‘The sympathetic nervous sytem is balanced by the parasympathetic system. Every chemi- cal, thermal, or mechanical function in the body responds to antagonistic forces until the opposing forces are equalized. Recognition of this basic law of nature serves as a framework for recognizing when, how, and why each part of the masticatory system is cither in peaceful balance or stressful disharmony. A Class I relationship is not in itself indi tive of occlusal stability. Orthodontic guide- lines and other textbook norms for analyzing ‘occlusal relationships are unquestionably ben- ficial, but there are no rigid standards of tooth alignment that of themselves guarantee stabil- ity or instability. Some of the most perfect Class | occlusions break down, whereas some of the most obvious malocclusions remain sta ble. There is a reason, and the reason is clini cally determinable, The teeth are the most adaptably movable part of the masticatory tem. Their position is rather easily altered, ci- ther vertically or horizontally by the forces ex- erted against them, For any tooth position to be stable it must be in balanced harmony with all forces, both vertical and horizontal, and so it is just as important to have a knowledge of the forces that exert pressures against the teeth as it is to understand classic occlusal re- lationships. A general knowledge of the forces that are critical to occlusal stability will illus- trate the natural law of balance between equal and opposite forces. EEE nnThe concept of complete dentistry 9 Fig. 1-1. The mandible is balanced at a position of equilibrium between the opposing pull of the cle vator versus the depressor muscles. When the opposing muscle the mandible is at its postural rest position, At the rest position, the ‘The resting position of the mandible is the result of balance between the resting length of the elevator muscles and the resting length of the depressor muscles (Fig. 1-1) If either the elevator muscles or the depres- sor muscles contract, the mandible will be moved toward the more powerful contraction. If both the elevator and depressor muscles contract simultaneously, the stronger elevator muscles will usually overpower the depressor muscles and the “resting” position of the man- dible will be more elevated, thus reducing the freeway space. Both sets of antagonistic mus- cles will be stressed by the isometric hyperac- tivity, if the contraction is prolonged. The anteroposterior position of the mandi. ble is determined by the harmonious function of the lateral pterygoid muscles versus the fi: bers of the temporalis (Fig. 1-2). Each condyle is positioned on the slope of the eminence and moved up or down its convex incline by the balanced contraction versus release of these two antagonistic muscles. When the mandible is at rest, the condyle disk assemblies are centered against bone and are in a normal state of resting toni th should be separated, ligament stops so that the positioner muscles can be at peace. ‘The disk itself is balanced between the op- posing forces of the elastic fibers behind the disk and the superior belly of the lateral ptery- goid muscle in front (Fig. 1-3), Because the disk is attached to points on the medial and lateral poles of the condyle, it is free to rotate around those points of attach: ment. Its position on the condyle is thus con: trolled by whether the pull of the retrodiskal elastic fibers is stronger, weaker, or the same as the muscle contraction in front ‘The vertical positioning of the mandible i function is controlled by a dynamic balance of muscle that requires coordinated contraction and release of antagonistic muscles. AS the cle- vator muscles contract, the depressor muscles must release allowing the mandible to be hinged closed around its condylar axis. The ha- bitual closed position of the mandible is a highly repetitious position in relation to the maxilla, The consistency of the mandible-to- maxilla relationship is the result of a physio- logic optimum length of contraction of the el-10 Evaluation, diagnosis, and treatment of occlusal problems Fig. 1-2. ‘The position of the condyles is dependent on a balanced relationship between the protruding ‘muscles (lateral pyerygoids) versus the retrusive muscles (temporalis). In normal function, contraction of one muscle is coordinated with the release of the opposing muscle to allow the condyle to move forward and back. Fig. 1-3. The position of the disk is determined by a balance between the clastic fibers pulling back versus the superior lateral pterygoid! muscle pulling forward, The disk rotates on the condyle to a point of neutrality between the opposing forces,Fig. 1-4. Teeth erupt toward each other as the result of an ever-present eruptive force that stays active throughout life. When the eruptive force of the lower tooth meets an equal opposite force from the upper tooth, the eruptive forces are balanced, The concept of complete dentistry 11 evator muscles balanced to an optimum length of the released stretch of the depressor mus cles. It is this consistent point of dynamic bal ance that determines the vertical dimension of the mandible to the maxilla. The vertical di mension of occlusion is quite naturally deter- mined by this relationship because of the natu- ral law of balance applied to the eruption of the teeth. The law of balanced, equal-and-opposite force consistently applies to the eruption of, teeth. Each tooth has an ever present eruptive force that causes it to continue to erupt until it is met by an opposite force that equals the eruptive force (Fig. 1-4). ‘The ideal stops for eruption are the teeth in the opposing arch. If the opposing force is greater than the eruptive force, the tooth will be intruded. If the resistance is less than the eruptive force, the tooth will continue to erupt ‘until the forces are equal. What determines the precise point of balance? It is the repetitious closed position of the mandible that is deter- mined by the optimum length of contraction of the elevator muscles (Fig. 1-5). Any interfer- ence to this balance of eruptive force versus optimally contracted length of muscle will dis Fig. 1-5. The eruptive forces of the upper and lower teeth meet at the repetitive jaw-to-jaw dimension that is determined by the repetitive contracted length of the elevator muscles, Thus there is x balanced ‘equilibrium between the eruptive force of the teeth versus the contracted length of the elevator mus:12 _ Evaluation, diagnosis, and treatment of occlusal problems Fig. 1-6. The horizontal postion of the posterior tecth is determined by the neutral zone, which is the point of bal ance between the outward force of the tongue versus the inward force of the buccinator bands of mascle rupt the optimum vertical dimension of ocelu- sion. Indiscriminate use of bite planes is one of the most common causes of long-term occlusal harmony because of the chain of damaging events that are initiated by the disruption of the naturally existing harmony. Chapter 5 ex- plains the details of vertical dimension. Horizontal stability of the posterior teeth re- sults from a position of balance between the outward force of the tongue and the inward force of the buccinator muscle (Fig. 1-6). The centerpoint of balance forms the posterior neutral zone, which will be moved by which- ever force is stronger. See Chapter 6 regarding the neutral zone. To have long-term stability of the anterior teeth, one must position them in a balanced relationship between the forward pressure of the tongue and the inward pressure of the lips. As teeth erupt, they are guided into this bal- anced position of neutrality between opposing forces (Fig, 1-7). The precise location of this anterior neutral zone is one of the most critical determinations that must be made as it affects the entire pattern of masticatory function (see Chapter 16, Anterior Guidance). ‘The interrelationships previously described are just a few examples of the balance that must exist between all functional components Fig. 1-7. The anterior teeth erupt into a balance between the forward pressure from the tongue versus the inward pressure from the lips. The point at which the oppo: forces are balanced is called the mevtral zone of the entire gnathostomatic system if we are to achieve long-term stability of the system. There are many other less obvious examples that could be used to illustrate this basic law of nature. Even the quality of speech requires a balance between oral and nasal resonance that an be disturbed by improper positioning of teeth because of the forced alteration of tongue position. When the need for balance in all aspects of the masticatory system is understood, it will be obvious that knowledge of the anatomy and physiology of the system is also a requirement for proficiency in diagnosis and treatment plan- ning. Without this knowledge, the practitioner will be prone to accept far too many of the ‘empiric approaches, including harmful proce dures, gimmickry, and a general tendency to overtreat. But if the interrelationships and in- terdependencies of the parts of the system are understood, along with knowledge of physio- logic principles, diagnosis becomes a logical routine of finding a cause for every deleterious effect, Treatment then evolves from the deter- mination of what is the best way to restore the system to functional harmony and optimum, maintainable health. That is the concept of complete dentistry.EXPLAINING THE TREATMENT RATIONALE TO THE PATIENT An oversimplified but effective way to relate the treatment requirements to patients is to explain, as follow: If we are to make your mouth healthy and keep it that way, we must accomplish two things. 1. We must leave no place in your mouth that is not completely cleanable. 2 We must reduce all the stresses in your mouth to a point where they are not destruc: tive, ‘These two are my responsibility. Your responsi- bility is to keep your mouth spotlessly clean and to Feport any uneven stresses that may occur so that they can be corrected. It is also your responsibility to maintain your best level of general health through proper diet and exercise. If we both do a complete job of fulfilling our responsibilities, you should have your teeth as long as you need them. Hygiene appointments should be scheduled after diagnosis and treatment planning, It should be part of the treatment prescribed by the dentist to help cach patient learn the Proper way to care for the mouth. Mouth hy- giene is a very important part of the prelimi- nary mouth preparation, which is usually nec- essary before one starts restorative procedures. Ivis also ideal for the hygienist to record di- etary habits and to counsel patients on proper nutrition for prevention of future dental dis- case ‘The cones of complete dentistry 13 REFERENCE 4. Lindhe, J, and Nyman, $: The role of oeclusion in peri- odontal disease and the biological rationale for splinting in treatment of periodontitis, Oral Sciences Rev. 10: iva SUGGESTED READINGS Arnim, SS: The connective tissue fibers of the marginal ‘gingiva, J. Am, Dent, Assoc. 47: Amim, SS: Microcosms of the mouth—role in periodontal disease, Texas Dent. J. 82:4, March 1964, Cheraskin, E., Ringsdorf, WM., Jr and Clark, J.W. Diet and. disease, Emmaus, Pa, 1977, Rodale Books. Lindhe, J., and Svanberg, G: Influence of trauma from oc: clusion on progression of experimental periodontitis in the beagle dog, J. Clin, Periodontol. 1:3, 1974. Ramfjord, 5. and Ash, MM: Ocelusion, ed. 3, 1983, WB, Saunders Co, Rocabado, M.: Biomechanical relationship of the cranial, cervical, and hyoid regions, J. Criniomandibular Pract 1983. Rudd, KD, O'Leary, TJ,, and Stumpf, Aj, Jr: Horizontal tooth mobility in carefully screened subjects, Period. ontics 2:65, March 1964, Sicher, H.: Functional anatomy of the temporomandibular joint. In Samat, B., editor: The temporomandibular joint, ed. 2, Springiield, IIL, 1964, Charles © Thomas, Publisher,