THE MASTICATORY ORGAN

Functions and Dysfunctions

Rudolf Slavicek
First english edition 2002

Slavicek, Rudolf:
The Masticatory Organ: Functions and Dysfunctions / Rudolf Slavicek. - Klosterneuburg: Gamma Med.-wiss. Fortbildungs-AG,
2002
ISBN 3-9501261-1-2

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 Contents

Contents
Introduction 11
Chapter 1: EVOLUTION 17
Evolution of mankind and the masticatory organ 18
The scientific discussion 19
The new species "Homo" 22
Evolutionary hypothesis regarding hominization, relative to the masticatory organ 27
Oral communication in hominid evolution 31
Expression and Signaling 32
Communication, Information 32
Description 33
Evolution of the psyche - the limbic system 34
Effects of evolution - an overall view 38
Evolution of the masticatory organ from the viewpoint of tooth morphology 48
The new organ- a cybernetic feedback control mechanism 50
Thinking in terms of a feedback control mechanism 51
The organism and its so-called masticatory organ - definition 56
Chapter 2: STRUCTURES 59
The Cranio-Mandibular System (CMS) 60
Structures of the cranio-mandibular system in detail (CMS=TMJ) 62
Bony structures 62
Ligamentary structures 65
The articular disk 66
Retro-articular structures 66
The system-immanent musculature of the mandibular joints 71
Caput profundum masseteris 71
Musculus pterygoideus lateralis caput superius 74
The frontal head of the Musculus temporalis 75
The synovial apparatus 84
Extended ligamentary attachments 84
Ligamentum sphenomandibulare 84
Ligamentum stylomandibulare 86
Ligamentum stylohyoideum 86
Ligamentum pterygospinale 86
The so-called "alpha"ligament 86
Summary 89
The neuromuscular system (NMS)- muscles of the masticatory organ 90
Musculus temporalis 96
Musculus masseter 97
Musculus pterygoideus medialis 98
Musculus pterygoideus lateralis caput inferius 99
Musculus mylohyoideus 101
Musculus digastricus 103
Musculus stylohyoideus 106
Musculus geniohyoideus 106
Musculus genioglossus 108
Musculus hyoglossus 108
Musculus styloglossus 109

5
R. Slavicek • The Masticatory Organ

Musculus linguae (the tongue) 109

The musculature of the soft palate, the pharyngeal vestibule and the pharynx 110
Musculus levator veli palatini 111
Musculus levator uvulae 112
Musculus glossopalatinus 112
Musculus palatopharyngicus 112
Musculus tensor veli palatini 112
The pharynx - pharyngeal head - throat 113
Epipharynx 113
Mesopharynx 113
Hypopharynx 114
Muscles of the larynx 116
Muscles related to the posture of the head, the throat, neck and thoracic girdle 118
The pre-vertebral muscles 125
Musculus rectus capitis ventralis 125
Musculus longus capitis 125
Musculus longus colli 125
Musculi scaleni 127
The infrahyoid muscles 127
Musculus sternohyoideus 127
Musculus omohyoideus 129
Musculus sternothyreoideus 129
Musculus thyreohyoideus 129
Musculus sternocleidomastoideus 131
Musculus trapezius 132
Musculus levator scapulae 134
Summary 134
Occlusion - Articulation 136
Ontogenesis of the masticatory organ 137
The postnatal period 140
The developmental period of deciduous dentition 156
The first developments in speech 158
Problems relating to the sleeping position 158
Respiratory problems 159
The functional period of mature deciduous dentition 159
Summary of the functional period of "deciduous dentition" 160
The first functional period of changing dentition 161
The second functional period of changing dentition 172
The third functional period of changing dentition 178
The discussion on changing dentition 183
Mature, complete dentition 187
Compensation mechanisms 188
Dento-alveolar compensation 189
Vertical compensation 189
Articular compensation 189
So-called occlusion concepts 192
The functional areas of occlusion 193
The functional area of the frontal dental arch 193
The frontal lateral dentition area 197
Functional areas of the premolars 197
The morphology of the premolars 199
The occlusal planes 202
Definitions 202
Spheres of occlusion 207
The behavior of the occlusal plane and spheres in comparative research 207
Functional lines of occlusion 210
Normal dentition and malocclusions 212

6
 Contents

The characteristics of "ideal" dentition (Class I) 212

So-called dysgnathias 212
The morphological syndrome of Class II/1 213
The morphological syndrome of Class II/2 216
The morphological syndrome of Class III 217
Chapter 3: FUNCTIONS 219
Mastication 220
The "eating tools" or "guzzling tools" 220
Reptiles 220
Carnivores 221
Herbivores 225
The phylogenetic changes from Hominoids to Hominids to Homo sapiens 226
The Pongids 226
Homo sapiens 230
Mastication- definitions, scientific discussion 234
Speech 258
On the physiology and pathophysiology of speech in a non-abraded dentition 260
Occlusion and speech 263
Posture - On the physiology and pathophysiology of body- and head posture in
modern humans 265
Body posture of healthy humans 267
The lateral view 267
Anterior view 268
Posterior view 268
Esthetics"- the human appearance as a function 271
Objective and subjective esthetics 272
Harmony - Symmetry - Proportion 274
Cephalometry and Esthetics 275
General theories of proportion in human esthetics 276
The function of stress management 281
Functional patterns in clenching and bruxism 291
The role of so-called occlusion concepts in the parafunctionne 294
Occlusion concepts 296
The concept of balanced occlusiona 296
The concept of group function on the laterotrusion side 298
The concept of canine-guided occlusion 298
The sequential concept 298
Malocclusions 300
Summary and final observations 301
The CMD patient with primary psychological disease 302
The psyche, the masticatory organ and environmental factors 302
Chapter 4: DIAGNOSTICS 305
Clinical functional diagnostics 306
Diagnostics 311
The patient's main concern 313
The complete medical anamnesis 313
The dental anamnesis 314
The pain anamnesis 315
The actual clinical functional analysis (Physio-diagnostics) 315
The comparative muscle analysis 316
Clinical procedures 317
Palpation 320
The shoulder-neck region 320

7
R. Slavicek • The Masticatory Organ

The atlanto-occipital connector 323

Musculus temporalis 323
The cranio-mandibular system (mandibular joints) 325
Musculus pterygoideus medialis 330
Musculus masseter 330
The floor of the mouth 330
The tongue 332
The infrahyoid musculature 336
Examination of the movements of antagonistic muscle groups 337
Free mobility of the atlanto-occipital joints and the cervical spine 343
Analysis of mandibular movement 343
The clinical examination of mandibular movement - manipulative techniques 345
Preliminary neurological findings 345
Clinical diagnostics of occlusion and articulation (dental status) 349
The periodontal examination 350
Clinical functional analysis with the aid of instrumental devices 352
Condylography 352
The principle of joint track recording, relative to the hinge axis 359
Mechanical graphic recording of joint movement 359
Electronic condylography: procedures for using the devices 360
Diagnostics using clinical recordings of mandibular movement 372
Creating standards of evaluation 373
Systematic evaluation of the eight basic recordingsli 373
Introduction to practical descriptive diagnostics 374
Terminology of quantification 374
Quantity 377
Limitation 377
Acute inflammation in the CMS 378
Acute inflammation outside of the CMS 378
Acute trauma 378
Effects of trauma (ankylosis) 379
Adhesions 379
Pseudo-adhesions (synovial problems) 380
Joint capsule (scars, systemic disease) 380
Problems of the ligamentary apparatus of the CMS 380
Functional problems of the articular disk 381
Luxation to anterior 382
Mechanical hindrances 382
Degenerative changes in the joint (arthrosis) 383
Problems of the facial soft tissue 383
Limitation of movement in the mandibular joint 383
Pain and muscular inhibition 383
Ligamentary problems in the CMS 384
Avoidance mechanisms 388
Discussion of limitations 391
Hypermobility 391
The quality of the recording 396
The characteristics of the recording 396
Side comparisons (symmetry) of the recordings 397
Temporal course of the recordings 397
Speed phenomena of the recordings 398
So-called joint noisei 398
Causes of joint noise 399
Reduction cracking and luxation cracking (according to Farrar) 399
So-called reciprocal cracking in the six basic movements 400
Protrusion 400
Retrusion 401

8
 Contents

Mediotrusion 401
Medioretrusion 401
Opening 401
Closing 404
Guided movements 404
Pressure directed to cranial 404
Luxation-reduction anterior cracking 405
Patho-morphological cracking 406
Ligamentary cracking 408
Synovial noise 408
Observing function 409
Masticatione 409
Speech 410
Stress management 413
Deglutition 413
Conclusions 415
Instrumental functional analysis with the Cadiax Compact 416
Instrumental functional analysis 423
Instrumental Functional Analysis- a definition 424
Procedures (list of work procedures 424
Creating exact jaw models 425
Verification of the retral physiological position
(or pathophysiological position) of the mandibular joints 429
Open questions and discussions 434
Generating a coordinate-system appropriate to the reference
position (appropriate to the joint) 436
Attaching the jaw models in the articulator 437
Analysis of mandibular position 437
Analysis of tooth position 442
Analysis of the dynamics of mandibular movement 442
Additional diagnostics 447
Lateral X-ray 447
Procedure for obtaining a lateral X-ray 448
Patient instructions 449
Fixing and adjusting the patient in the head-fixing device;
removal of ear plugs; taking the image 449
Developing the film and control (not applicable for digital imaging) 450
Tracing 450
Evaluation of the lateral X-ray 450
Evaluation of the skeleton 451
Assessment of the vertical 454
Dental analysis and the assessment of the occlusal plane 455
Esthetic evaluation and assessment 456
Static diagnostic analysis 456
Dynamic (functional) analysis 456
The introduction of front tooth control into the lateral X-ray 457
Radiological and imaging procedures 458
Panoramic overview recording and other slice techniques 458
Lateral-transcranial joint X-rays 459
Mandibular joint tomography 459
Computed tomography of mandibular joints 459
Arthrography 460
Magnet resonance imaging of the mandibular joints 460
Additional diagnostic measures in the articulator 461
Diagnostic equilibration 461
Procedures 461
Diagnostic wax-up 462

9
R. Slavicek • The Masticatory Organ

Orthodontic and surgical set-up 462

Summing up ideas about diagnostics and diagnosis 463
The masticatory organ as a feedback control mechanism - the human being
as a feedback control mechanism 463
Principles of correlation diagnostics 465
Streamlining the results of diagnostic procedures 465
The form of a correlation scheme 465
Entering data into a correlation scheme 466
Evaluation of the validity of individual findings 466
Arranging individual findings according to their significance 466
Synopsis and diagnosis (verbal summary) 466
Determining the therapeutic value 467
Planning therapy 467
Implementing the therapy and control 467
Setting up a maintenance program 468
Thoughts on the current situation regarding the application of diagnostic measures 469
Chapter 5: THERAPY 471
A few thoughts regarding the treatment of functional disorders of the masticatory organ 472
Symptomatic therapy for acute pain 473
Causal initial therapy of the dysfunctional masticatory organ 474
Therapy of predominantly muscular causes 474
Therapy of causes predominantly located in the joint area 474
Therapy of predominantly occlusal causes 475
Therapy of predominantly psychological causes 475
Therapy of predominantly neural causes 476
The treatment of somatic causes or systemic diseases with involvement
of the masticatory organ 476
Therapy in cases of predominantly environmental factors 477
Capitolo 6: THE DYNAMIC FUNCTIONAL ANATOMY OF
CRANIOFACIAL COMPLEX AND ITS RELATION TO
THE ARTICULATION OF THE DENTITIONS – S. SATO 482
Introduction 484
Evolutionary aspects of craniofacial bones 486
Craniofacial bone connection 487
Sphenoid bone 487
Occipital bone 488
Vomer bone 488
Temporal bone 488
Craniofacial bone dynamicss 490
Occiput-spheno-maxillary complex with the vomer bone 491
Maxillary bone growth according to the dynamics of the cranial base 492
Temporo-mandibular complex 494
The importance of the function of occlusion for mandibular growth 495
Craniofacial growth and development with special focus on the occlusal plane 496
Cephalometric evaluation of the denture frame (denture frame analysis) 498
Implications for dental practice - Developmental mechanism of growth abnormality 502
References 514
Concluding remarks 516
Bibliography and literature for further study 522
Glossary 535
Acknowledgements 542

10
 Introduction

Introduction

Functions and
dysfunctions of the
so-called
"masticatory organ"

The human masticatory organ is unique in its struc-

ture and functions. I open with this simple state-
ment because it reflects my deepest convictions and
motivation, based on my knowledge and experi-
ences.
In an extremely short and therefore dramatic peri-
od of evolution, the simple primate masticatory
organ developed into a complicated and fascinating The development of the human masticatory
multi-functional system. organ, from embryonic development to a
In fact, the term "masticatory organ" is inappropri- morphologically complete functional unit of
ate, as the function which gives the name, is cer- mature permanent dentition and related
tainly not its most important one. Recognizing and structures, is fascinatingly logical, and an
understanding the phylogeny and characteristic
extremely unpredictable event. Function and
changes to Homo sapiens sapiens is important in
order to properly appreciate the brilliant variety as dysfunction are very closely related but not
well as vulnerability of this fascinating organ. connected with the concepts of eugnathia and
Our knowledge of the repetitive phylogenic steps dysgnathia.
during ontogenesis highlights the problematic areas
brought about by overlapping new functional areas
and the resultant susceptibility to impairment. All
epidemiological studies in adolescents have demon-
strated temporary "crashes" to signs and symptoms
of dysfunction. This is because form is constantly
and rapidly changing, and function must continu-
ally adapt during development.
One of the most important ideological and concep-
tual errors in dentistry is based on the dogmatic
declaration of a fictitious goal, namely an ideal eug- One of the most important ideological and
nathia, which is exalted to the Holy Grail of dental
conceptual errors in dentistry is based on the
medicine. This dangerous stigma, branded in the
young dental student's brain, influences a dentist dogmatic declaration of a fictitious goal,
throughout his/her professional life. The vision of namely an ideal eugnathia, which is exalted
eugnathia may be used as a teaching aid for better to the Holy Grail of dental medicine.

11
R. Slavicek • The Masticatory Organ
"Speech makes the brain; the brain makes
speech".
"Man created himself through his descriptive
speech."
The rather polar balance of the limbic
system, up to this point, was brought into
imbalance by the "fall of man" into anthropo-
genesis.
The anatomy of the human cranium, and
especially the viscerocranium, distinguished
by the masticatory organ, displays a very high
degree of variability and individuality in
terms of skeletal structure.
Popper, K. R., Lorenz, K.: Die Zukunft ist offen
(Das Altenberger Gespräch). Serie Piper, München 1985
Popper, K. R., Eccles, J. C.: Das Ich und sein Gehirn. Serie
Piper, München 1982
12
comprehension of dysgnathias which, in most
cases, function "in spite of the abnormality". Life is
not interested in form but in function.
The central role of the masticatory organ in the
evolution of an individual, in abstract communica-
tion and in the development of the brain connec-
ted with it, is worthy of note.
"Speech makes the brain; the brain makes speech".
This statement of Popper, expressed during a dia-
logue with Lorenz, indicates the importance of oral
communication in anthropogenesis. Popper, an
avowed agnostic, relentlessly continued in this vein.
Referring to the concept of Creation in a dialogue
with Eccles he said, "Man created himself through
his descriptive speech."
The masticatory organ is known for its close somat-
ic connection with the development of the brain.
Its connection with the brain has a psychic
facet as well. The emotional assessments resulting
from ethical values associated with anthropogene-
sis, the appearance of "self-consciousness" and the
conscious recognition of the difference between
self-protecting egoism and the altruism necessary
for survival of the species, are brain developments
markedly associated with the masticatory organ.
The rather polar balance of the limbic system, up to
this point, was brought into imbalance by the "fall
of man" into anthropogenesis. In the somatic area,
the process of "standing up" and using bipedal
locomotion created both new responsibilities and
inherent new strategic phylogenic and ontogenetic
problems for the masticatory organ. There followed
an unprecedented dramatic change in the anatomy
of the base of the skull, resulting in a considerably
accentuated development of the maxillo-mandibu-
lar structures, including the dentition. All of these
morphological changes occurred in an extremely
brief period during the phylogenesis of the human
species, and is repeated in the ontology of the first
two years of the life of every human being. Posture
and the masticatory organ have existed in an insep-
arable interdependence since the origin of
mankind.
The anatomy of the human cranium, and especial-
ly the viscerocranium, distinguished by the masti-
catory organ, displays a very high degree of vari-
ability and individuality in terms of skeletal struc-
tures. The positions of the jaw bones relative to the
cranium on the one hand, and the dental arches
within these jaw bones relative to each other on the
 Introduction

other, are characterized by marked differences

between races, as well as, by remarkable differences
between individuals within these races.
This semantic repetition of individuality in the last
sentence is used to emphasize its importance.
Individuality (the individual is irreproducible, in-
comparable, unique, and therefore different from
anybody else) places a huge question mark behind
the validity of epidemiological studies, which large-
ly ignore the subject of individual differences. This
predisposition of current natural science to reduc-
tionism in the field of medical research for epi-
demiological evidence is challenged, and refuted,
by the existence of the individual.
The concept of "human races" and their differences
deserve emphasis as well as immediate qualifica-
tion. There is only one human "species"! The There is only one human "species"!
human race has a series of ethnic groups within the
one species, characterized by phenotypic differ-
ences.
Everything about the masticatory organ changed
through the genesis of mankind: Its structures,
functions, and its relation to the brain and therefore
to the psyche, and, above all, its assumption of a
central position in the hierarchy of the human
organism. The so-called masticatory organ is, in The so-called masticatory organ is, in conjun-
conjunction with the brain, the most human of ction with the brain, the most human of
organs, in terms of construction as well as signifi- organs, in terms of construction as well as
cance. The human masticatory organ has no com-
significance.
parison in the long process of evolution, from a
functional point of view. Because of the masticato-
ry organ and the brain, human beings were able to
create an ecological niche, which resulted in their
being in a position to create their own new world.
The dangers and responsibilities associated with
this ability have been covered by various authors.
The masticatory organ, its functions and dysfunc- The masticatory organ, its functions and dys-
tions and their diagnosis and therapy is a fascinat- functions and their diagnosis and therapy is a
ing field and a challenge for the modern dentist. fascinating field and a challenge for the
This organ deserves to be admired and highly
modern dentist.
esteemed by "its" dentists. It requires going back
in his/her mind, turning to and reflecting on the
holistic concept of medicine. It also means turning
away from mechanistic thought without neglecting
the mechanical elements of dental medicine. The
modern dentist must master his/her craft and at the
same time understand the importance of the mas-
ticatory organ for the entire field of medicine. Lorenz, K.: Die acht Todsünden der zivilisierten
Menschheit. 18. Aufl., Piper Verlag, München 1985.
This book is dedicated to diagnostics and contains Földy R.: Das Arche Noah Syndrom. Nicht alle haben Platz.
diagnostic information, but let me warn the reader Wirtschaftsverlag Langen Müller/Herbig, München 1997

13
R. Slavicek • The Masticatory Organ
Formulating a diagnosis is not the task of
some apparatus or, even more dangerous,
some seemingly logical computer program,
but a deeply human decision, replete with
responsibility.
What modern medicine frequently lacks, at
the end of this seemingly complete chain of
diagnostic efforts, is the synopsis.
... apply only indirectly to the masticatory
organ itself. The latter has become a plat-
form for more complex medical problems.
14
and emphasize that collecting diagnostic informa-
tion cannot be an end in itself; it only constitutes
the preliminary step of a diagnosis. Formulating a
diagnosis is not the task of some apparatus or, even
more dangerous, some seemingly logical computer
program, but a deeply human decision, replete
with responsibility.
The purpose of diagnosis is to identify the "disease"
and "cure" it. With this seemingly unpretentious
definition, I am attempting to illustrate the main
problem dealt with in this book, as well as high-
light the erroneous direction of progress in modern
medicine. Diagnosis must necessarily lead to a ther-
apeutic decision, to a "yes or no" regarding therapy.
Thus the diagnosis itself, being a human responsi-
bility, is subject to human fallibility. One of the
weaknesses of currently prevalent opinion within
our social structure is to disregard physician's falli-
bility. More often than not, this leads to a kind of
risk-free, alibi medicine, based on a fear of legal con-
sequences for human fallibility.
For this and other reasons, the path of medicine at
the end of the twentieth century tends to favor
exaggerated diagnostics. The resulting problems of
coordination have led to the dangerous iatrogenic
diagnostic procedures of our times.
The human being experiences his organism as a
biological puzzle. He discovers "deviations" from
so-called "norms" and considers these, and therefore
himself, to be abnormal. As a logical result thereof,
the individual, in his "self-consciousness", considers
himself to be ill. What modern medicine frequent-
ly lacks, at the end of this seemingly complete
chain of diagnostic efforts, is the synopsis, which is
the conclusion and the guiding hand of a responsi-
ble person. This constitutes the most important
factor, i.e. the care and resulting human relation-
ship between the physician and the patient.
Paradoxically, a part of this lack of communication
in medicine has shifted to dental practice, causing
the contemporary dentist to be confronted with
new responsibilities. The dentist becomes the
patient's confidante and recipient of information
concerning problems, many of which apply only
indirectly to the masticatory organ itself. The latter
has become a platform for more complex medical
problems. This often alienates the purists and
mechanists of our profession, who would like to see
strict limitations being imposed on the authority of
the practicing professional.
 Introduction

At this point it would be appropriate to cite an inci-

dent from a recent conference of the EACD
(European Academy of Cranio-Mandibular Disorders).
The chairman of the "round-table" asked a lecturer,
who had advocated a personal discussion with the
patient before starting therapy, the astounding
question as to whether the dentist was authorized
to carry out such a discussion, as he/she surely
lacked the qualification to do so! Such implied
muzzling should cause modern dentists to recon-
sider their ranking in the medical field by their own
senior experts and by other medical professions.
While doing so, dentists should keep in mind the Without an intensely medical approach, it is
fact that, from a functional point of view, they are impossible to appreciate and understand this
taking active responsibility for the "most human" complex organ.
and most complex of all organs.
It is time for a change in medicine and this is espe-
cially true for dental medicine. Dentistry is one of
the most invasive fields in the medical profession.
Without an intensely medical approach, it is
impossible to appreciate and understand this com-
plex system. It is hoped and, in fact, demanded that
dentists be made aware of their responsibility with
regard to the masticatory organ.
This book is written very subjectively. It reflects my This book is written very subjectively.
ideas and opinions about the profession, without a
tendency or intention to list so-called objective
points of view, in consecutive order, as has been
done in the past in carefully prepared literary jour-
nals governed by a certain reserve and scientific
lack of emotion. This contemporary method of sci-
entific "contemplation of one's navel" concurs nei-
ther with my emotionality nor with my self-regard.
I reflect here the high values of those who have I reflect here the high values of those who
taught me, including all of those whose historical have taught me.
works I have read and whose ideas have earned my
respect. I reflect here also the spirit of my friends I reflect here also the spirit of my friends
and colleagues and, above all, my students, who and colleagues and, above all, my students.
were able to impart to me a fund of most valuable
ideas during open discussions.
This book is dedicated to my wife, Luise, and to my
children, who have accompanied me along the road
of dentistry, or perhaps more accurately, dental
medicine.

Capra, F.: Die Wendezeit – Bausteine für ein neues

Weltbild. Scherz Verlag, Bern, München 1983

15
 Chapter 1

Evolution

The controversial discussion of mankind's

genesis has been in full swing since
Darwin's provocative "Origin of the
Species", often overshadowed by dogmatic
antiquation, and full of a fascinating variety
of hypothetical trains of thought. The pre-
sent book is governed by a strong belief in
the central importance of the stomatogna-
thic system. "Man created himself through
his descriptive speech", said Popper, indi-
cating the central importance of the "organ
of speech" - which we falsely term the
masticatory organ - for the development
of the brain, in our own emergence as a
species. The stomatognathic system of the
new race is a highly refined cybernetic
system of great significance for the orga-
nism. Knowledge of the evolution of the
so-called masticatory organ is absolutely
essential in order to understand its com-
plex functions and developments of the
brain associated with them.
R. Slavicek • The Masticatory Organ
Evolution
"Nothing in biology makes sense, unless one
regards it in the light of evolution."
Th. Dobzhansky
Dobzhansky, Th., Ayala, F. J., Stebbins, G. L.,
Valentine, J. W.: Evolution. San Francisco 1977
18
Evolution of mankind
and the masticatory
organ
In my many years of clinical activity concerning
the functions and functional disorders of the
masticatory organ along with the scientific pro-
cessing of results and experience, I have been con-
stantly confronted with questions that can only be
answered from the viewpoint of anthropogenesis.
In the course of several years, I have arrived at a
practical mosaic, a framework, for understanding
the significance of the masticatory organ in the
history of our race. I would like to present my
subjective point of view regarding the phylogeny
of the masticatory organ and its functions. I first
coordinated these ideas while preparing a lecture
on the subject of "Creation" for the Arge
Prosthetic Gnathology conference in Gastein in
1994. The subsequent work-up of these ideas and
the resulting conclusions opened new doors with
regard to my comprehension of the masticatory
organ. At this point I would like to cite
Theodosius Dobzansky, whose words are especial-
ly apt for the masticatory organ. ("Nothing in
biology makes sense, unless one regards it in the
light of evolution." Th. Dobzhansky)
This chapter uses an evolutionary, phylogenic and
ontogenetic viewpoint to examine an organ that
was originally concerned with obtaining,
ingesting and processing food into a bolus, and its
transformation into a multi-functional organ,
whose continued designation as the "masticatory
organ" is not only misleading, but also false from
 Evolution

the viewpoint of the functional hierarchy of

human organs. It is for this reason that I will
attempt to define and illustrate the various func-
tions of this organ, unique to and reserved for, the
human species. A presentation of the current fun-
ctions of the human "masticatory organ" and their
rapid emergence will show that, in this period of Emergence
mankind's evolution, the organ's development
was by no means a slow, gradual or continuous
one in the Darwinian sense (Phyletic Gradualism).
The concept of the "emergence" of new functions
is absolutely correct when applied to the mastica-
tory organ because we are, in fact, referring to
functionally unique and unprecedented creations.
Emergence means the "sudden appearance" of Emergence means the "sudden appearance" of
something principally new and unprecedented. something principally new and unprecedented.
From the point of view of emergence philosophy,
new qualities emerge in higher "levels of being",
in contrast to those that preceded them. It is
impossible to access former qualities. The entirely The entirely new features of mankind are
new features of mankind are intimately connected intimately connected to the masticatory organ
to the masticatory organ and its unique interrela- and its unique interrelationship with the
tionship with the more highly developed brain, more highly developed brain, now in concert.
now in concert.

The Scientific Discussion

Charles Darwin left a strong impression on biolo-
gy in the nineteenth and twentieth centuries, with
his evolutionary theory of adaptive progress up
the ladder of racial development. This is especial- Sympatry
ly evident in discussions on human phylogeny.
Purist insistence on exclusivity in the develop-
ment of the species, as in Phyletic Gradualism,
assumes that different species populating the
same territory, according to sympatric continuity,
underwent slow and adaptive evolution in the ... according to sympatric continuity, under-
classical Darwinian sense. Hybridization and went slow and adaptive evolution in the clas-
interbreeding among similar species did not take sical Darwinian sense.
place. Each species is considered to be a distinct
population and a specific genetic system. In the
Darwin-Wallace scheme, biological species are
regarded as "evolutionary units".
The recognition and occupation of available
niches through adaptive behavior, as defined by E.
Mayr, is the ideological foundation of the concept Darwin, Ch.: On the Origin of Species by Means of Natural
of "Phyletic Gradualism" in the development of a Selection. London 1859 (dt.: Die Entstehung der Arten
species. From this point of view, regarding the durch natürliche Zuchtwahl. Stuttgart 1867)

19
R. Slavicek • The Masticatory Organ
Every species is a finely integrated genetic sys-
tem, which has been selected, over a period of
many generations to fit into a particular niche
within its environment. (E. Mayr)
The evolutionist is fully convinced that he has
found an entirely satisfactory solution to the
basic problem of evolution in Darwin's theory.
(E. Mayr)
There is a paucity of evidence to indicate a
step-by-step continuity leading up to "Homo".
Phyletic Gradualism
Mayr, E.: Animal Species and Evolution. 1963
(dt.: Artbegriff und Evolution. 1967)
Mayr, E.: aus Wuketits, F. M.: Evolutionstheorien/
Dimensionen der modernen Biologie 7, Evolutionstheorien.
S. 171, Darmstadt 1988
Mayr, E.: ... und Darwin hat doch recht. Piper Verlag,
München 1994
Eldredge, N., Gould, S. J.: Punctuated Equilibria: An
Alternative to Phyletic Gradualism. In: Schopf, T. J. M.
(ed.): Models in Paleobiology. S. 82–115, Freeman, Cooper,
San Francisco 1972
20
emergence of differing alleles in a homologous
chromosome array, sub-populations with minor
phenotypic differences emerged and were able to
establish themselves, in isolation, over a long peri-
od of time. Mayr also recognized the advantage of
the isolation of such a sub-population, because
isolates were removed from the gene flow of the
general population, which can result in more
rapid and efficient speciation; however, he insists
on the principle of gradualism. Under the pressu-
re of external selection mechanisms (the Synthetic
Theory views "selection" as the determining force
in evolution), these sub-populations represented a
preliminary stage of speciation, provided they
were able to persist and gradually adapt. These
kinds of sub-populations tended to exist in homi-
nid development, but all of the branches were
characterized by unusually static evolutionary
behavior, although, at the time, the exceptionally
low population density would have favored the
principle of isolation, or at least increased its like-
lihood. There is a paucity of evidence to indicate a
step-by-step continuity leading up to "Homo". In
actuality, a great number of these preliminary sta-
ges in the gradual evolution from Australopithecus
were unsuccessful.
The dogmatism of representatives of classic
Darwinism and its derivatives (Neo-Darwinism
and Synthetism) could not alter the fact that the
principle of secondary adaptation to altered con-
ditions left many questions unanswered. Above
all, the time factor involved in the assumption of
a purely adaptive form failed to provide answers
to existing questions and even raised new pro-
blems. Because of these contradictions and open
questions, new evolutionary theories disputing
the Darwin-Wallace hypotheses appeared.
Apparently, nature is liable to discard the gradual,
risk-free path of gene-point mutation in phyletic
development, which is subject to adaptive control,
in favor of a very risky "more active" path in gene
regulation and chromosome mutation. For various
reasons, Eldredge and Gould dispute the "soft"
biological model of phyletic gradualism as the
"norm" in the development of a species and postu-
late instead their hypothesis of "punctuated equi-
librium". According to this hypothesis, erratic dis-
continuities in speciation followed long periods of
evolutionary "near stagnation". This abrupt clado-
genesis leap within an existing species was an
 Evolution

exceptionally rapid one in comparison to normal Myths throughout mankind's history are
evolutionary time periods. The probability of such replete with examples.
rapid change was due to the possibility of strong
imbalances, based on the formation of peripheral
isolates and the resulting allopatric speciation. Cladogenics
The formation of such isolated groups was favor-
ed by the exceptionally low population density at Allopatry
the time. Because of their special characteristics,
peripheral isolates had the opportunity to esta-
blish themselves genetically. Allopatry in this con-
text means that there was no similar or very simi- "Life forms without initiative, curiosity, fanta-
lar species in the territory. This provided an sy, must fight for ecological niches that are
opportunity to develop, test and reproduce new already occupied. However, those with initia-
characteristics, functions and structures in a prac- tive have created new ecological niches for
tically "non-competitive" environment. After a
period of consolidation, upon renewed contact themselves. And, the interesting thing is that,
with the original species, they would have the pos- from the beginning, ecological niches have
sibility to preserve their genetic continuity, even been made by life forms." Dialogue between
to the extent of becoming competitors of the ori- Popper and Lorenz (Altenberg)
ginal species. If one of these types of isolated
populations actively took advantage of the oppor-
tunity, it would not have been occupying an avai-
lable niche through adaptation, but would have
been creating one of its own!
Being expelled from the horde because of their …it is altogether possible that the processes
"different-ness" might have signified death for the (leading to) the development of a species
outcasts - but might also have meant a new could be initiated by a series of random, cata-
opportunity. Myths throughout mankind's history
strophic genetic processes, as a result of
are replete with examples. This activity of life is
not an adaptive fight for survival, but a striving forced reorganization of disorganized epistat-
towards something new and higher. Here I would ic super-genes.
like to refer to Popper's statement to Lorenz
during their discussions in Altenberg. The possi-
bility of rapid speciation, described above, is
named "Punctualism" by its authors. An additio-
nal possibility of speciation would be the comple- Punctualism
te abandonment of adaptive control mechanisms,
as postulated in Saltationism. In this case, causal
large-scale mutations took place, and allowed
evolutionary leaps to occur. In a hypothetical way,
Carson points to such an extremely risky approach
to speciation. A promising "hopeful monster" that Ontogenesis
came into being this way would not choose the
road of adaptive examination; he would "reprodu-
ce" and subject himself to the merciless control of
his own ontogenesis. Popper, K. R., Lorenz, K.: Die Zukunft ist offen (Das
Altenberger Gespräch). Serie Piper, München 1985
Lorenz, K.: Die acht Todsünden der zivilisierten Menschheit.
Piper Verlag (18. Auflage), München 1985
Carson, H. L.: The Genetics of Speciation at the Diploid
Level. In: Amer Nat 109, S. 83–92, 1985

21
R. Slavicek • The Masticatory Organ
Ill. 1: The short "flat-faced" terrestrial Australopithecus
africanus was the gene carrier of the human race for millions
of years.
Species-Homoid-Hominid
Ill. 2: The brain weight of the Australopithecus africanus in
relation to the brain weight of modern humans.
Homo habilus-phylogenesis
Ill. 3a and 3b: The angle of separation of the lower jaw in
chimpanzees is parallel to slightly negative, but distinctly
positive in Australopithecus, because of the condylar distance.
The form of their jaws is entirely different.
22
The new species "Homo"
Returning to human development, we find that,
in an extremely short time span in relation to the
entire history of development, an unprecedented
change in favor of morphological "different-ness"
took place. A new species emerged. A significant
portion of the morphological differentiation of
this species affected the masticatory organ. The
evolutionary functional adaptation of the hominid
masticatory organ into a communicative organ on
a higher level required preparation of the appro-
priate brain functions. The evolution of the masti-
catory organ is closely linked to brain develop-
ment. It is possible that the brain had sections
that were prepared in an anticipatory fashion. In
other words, during hominid evolution, cortical
areas of the brain were "recruited" and "prepared".
Hominid speciation did not lead to immediate
further development, but to a long period of evo-
lutionary stagnation. The Australopithecus africa-
nus (see ill. 1, 2, 3a, 3b, left) survived as the gene-
carrying species for millions of years, with just a
few slight ramifications in terms of phenotypes
(see ill. 4, p. 23). To exaggerate, according to
Dawkins, the hominid, as a species, functioned as
the gene survival machine in the contest for gene-
tic survival.
Suddenly, after millions of years, a dramatic gene-
tic change took place and Homo habilis crossed
the line from hominid to Homo. This may be
regarded as an explicit example of "punctuation"
(see ill. 5-7, p. 23).
Returning to the masticatory organ, the path
towards the new species "human" means that,
because of the complete readjustment of functions
within a very short period of phylogenic time, we
may use the morphological concept described by
Goethe and Burdach, which is the conceptual unit
of "form and function", and apply it in its full
scope to the "new" masticatory organ". Of special
note in this case is the fact that a patently new or
expanded function emerged as a result of the spe-
cies actively making use of an altered organic
morph to build up a different expanded "commu-
nication". This new function leads to speciation
and to its own establishment.
Further development of the "speech" function
confirms the altered form of the masticatory
 Evolution

Ill. 4: As the latest findings show, there were no or only minimal regional changes over a period of millions of years.

Ill. 5: Homo habilis, the "skillful one", Ill. 6: The relative brain weight of Homo Ill. 7: … with varying brain volumes.
the "handy one", ends the evolutionary habilis is markedly increased …
stagnation with his special characteristics.
He successfully makes use of his "quali-
ties" : the hand, brain, and communica-
tion.

23
R. Slavicek • The Masticatory Organ

organ and leads to further modifications through

structural changes in the skull associated with the
brain. The concept of evolution, the creation of
something new, the "concept of creation", can be
justifiably applied here. This is the beginning of
an extremely active period in the "creation" of an
ecological niche for "Homo".
The prepared areas of the brain, mentioned above,
were initiated and developed rapidly and dramati-
cally through the evolution of communicative
speech. Verbal communication created the higher
level of the Buehler-Popper speech model. Brain
volume increased rapidly and consistently from
this point onward. Other ramifications of the
hominid species stagnated and became extinct.
Ill. 8: Note the vertical position of the foreface of the orang- Even the gene-carrying Hominids, Dawkins'
utan when he walks on the ground. "gene survival machine", ceased to exist at this
point and eventually died out.
It was the descriptive and argumentative func-
tions of this new speech that exponentially accele-
Organisms are machines for (the purpose of) rated the dramatic development. In a later chap-
gene survival. (R. Dawkins) ter we will elucidate a hypothesis regarding the
enormous influence of the masticatory organ
through its speaking ability being advanced, and
the evolution of the brain as a result of the gro-
wing ability to communicate.
Even the gene-carrying Hominids, Dawkins' An evolutionary "rapid" change to upright postu-
"gene survival machine", ceased to exist at this re and to bipedal locomotion took place at the
point and eventually died out. time when the new form of communication deve-
loped. The altered posture had already been intro-
duced by Australopithecus and was certainly faci-
litated by the modified viscerocranium. Common
illustrations of the cranium of pongids and
Viscerocranium Australopithecus are both false and misleading, as
they do not represent the actual body-head postu-
re of living individuals, but are based on traditio-
nal, incorrect comparisons (see ill. 9-11, p. 25).
Homo stood up and became a two-legged being.
At first, this process affected the pelvic girdle, the
spinal column and the proportions of the extremi-
ties. Upright posture had lasting effects on the
Prognathia entire postural apparatus, especially on the head
(see ill. 12-14, p. 26). In a physiological position,
Verticognathia terrestrial primates are not "pro-", but "vertigo-
gnathic", because of the field of vision they requi-
re (see ill. 8, left). The forehead of an adult chim-
panzee or a gorilla hangs down to a certain extent.
Dawkins, R.: The Selfish Gene. Oxford University Press, Therefore, dramatic requirements for upright
Oxford 1976 (dt.: Das egoistische Gen. Springer Verlag, posture affected the entire cranial skeleton, espe-
New York 1978) cially the sphenoid, temporal and occipital bones,

24
 Evolution

Ill. 9: This prognathic depic-

tion of a primate skull does
not correspond to the reality of
optionally or primarily terres-
trial anthropoids. The field of
vision, in the shown position,
would not allow the individual
to view the ground.

Ill. 10: This comparative illus-

tration of a gorilla skull with
that of Australopithecus is
false and needs to be corrected
(see illustration below).

Ill. 11: Accurate comparison of

skulls; the short foreface of the
hominid allows for distinct
backward rotation of the crani-
um, as an expression of the
cladogenic change in posture.

25
R. Slavicek • The Masticatory Organ

Ill. 12: The term “Homo erectus“ expresses the breakthrough to becoming a Ill. 13: Simultaneously, the volume of the
true biped. brain increases. It comprises approximately
70% of that in modern humans.
Homo erectus

Ill. 14: The process of standing upright affects the pelvic girdle, the spinal column and proportions of the extremities. The "freeing"
of the hands is an important evolutionary process. The ligamentary attachment of the primate skull is modified to afford the "bal-
anced head" of humans.

26
 Evolution

which deserve special attention. This point will be

dealt with in greater detail later by viewing struc-
tures during the dramatic ontogenesis of children,
who eventually attain upright posture (compare
ill. 15, right).

Evolutionary hypothesis regarding

hominization, relative to the
masticatory organ
Ill. 15: The muscular balance of the human skull on its artic-
The hypothesis presented and discussed here may ular surfaces. The increases in brain volume are fully achieved
in the Neanderthal. There is no further change.
be formulated as follows: One of the most impor-
tant pre-conditions for hominization was the exi-
stence of morphological prerequisites for oral
communication. The prerequisites were achieved
by means of a cladogenic alteration in the form of
the dental arch, probably a random evolutionary
occurrence. At the same time, the recession of the
viscerocranium resulting from retention of the
"child-like" arch form, and the concurrent increa-
singly upright posture simplified laryngeal control
of the highly refined, ventral muscle group of the
throat.
A specific change in the functional range of the
upper cervical spine took place, relative to control
of the head and head posture. The respiratory pas- The respiratory passages and, most likely, the
sages and, most likely, the prepared areas of the prepared areas of the hominid brain, attained
hominid brain, attained "the ability of speech". "the ability of speech".
The dominant pongid canine which, especially in
males, was prominent and separate, dominating
the upper arch, remained integrated in the dental
arch, and the primate gap between the upper
canine and the front teeth did not develop during
growth. Gender-related differences in dental
arches became minimal. The masticatory organ
became more suitable as an organ for speech
because of changes in the architecture of the den-
tal arcade and the reduction of canine dominance.
This capability was utilized and the value of more This capability was utilized and the value of
abstract communication was appreciated. The more abstract communication was appreciated.
increasing ability to express one's knowledge,
developed on the basis of the available language,
created the possibility of "articulating" and pas-
sing on one's knowledge. This led to being able to
add others' experiences to one's own and vice
versa, and thus create, exchange and pass on know-
ledge. This permitted consistent development of

27
R. Slavicek • The Masticatory Organ
"Speech is brain - Brain is speech"
This led to being able to add others' experi-
ences to one's own and vice versa, and thus
create, exchange and pass on knowledge.
Because of their isolation, these "aliens" had
an opportunity to develop and consolidate
their new characteristics with no competition.
Phenotype
Eldredge, N., Gould, S. J.: Punctuated Equilibria: An
Alternative to Phyletic Gradualism. In: Schopf, T. J. M.
(ed.): Models in Paleobiology. Freeman, Cooper, San Francisco
1972
Eccles, J. C.: Die Evolution des Gehirns – die Erschaffung
des Selbst. Piper Verlag, München 1989
Popper, K. R., Eccles, J. C.: Das Ich und sein Gehirn.
Piper Verlag, München 1982
28
the brain, leading to the evolution of Homo into
Homo sapiens. Such development of the brain
may have already been prepared in anticipation,
through preformed but unused centers. Using the
symbols of a transmitter and receiver, the deve-
lopment of speech (transmitter) must lead to con-
current functional adaptation of hearing (receiver)
and the new function, namely understanding.
This hypothesis postulates that the "capability"
(not the ability) of speech, that is, the morpholo-
gy of the masticatory organ for speech, is the pre-
mise for brain development. The development of
a new species and its cladogenic determination
were rendered possible by "punctuated equilibria"
and probably by the emergence of so-called peri-
pheral isolates, as indicated by Eldredge and
Gould. Thus, the human masticatory organ did
not emerge as a result of the slow, adaptive pro-
cess and the secondary effects of selection mecha-
nisms in the sense of phyletic gradualism. The for-
mation of peripheral isolates caused an allopatric
principle to emerge, possibly based on stochastic
individuals, i.e., "random" phenotypes of a few
individuals. Because of their isolation, these "ali-
ens" had an opportunity to develop and consoli-
date their new characteristics with no competiti-
on, and they took advantage of the opportunity.
The most important modifications affected the
brain and the masticatory organ, including the
development of communicative speech.
At this point we must compare the stochastic
"Non-Concept" of the Trial and Error Principle
and the "Random" concept of creation, as attemp-
ted by Eccles in his work "The Evolution of the
Brain - the Creation of Self", and in his dialogue
with Popper. Comparing the two possibilities
would give rise to a discussion concerning the dif-
ferent paths toward hominization. From the point
of view of the proposed hypotheses, the second
possibility appears both, more active and more
probable. "Speech is brain - Brain is speech", as
Popper said!
In contrast to Darwin, the involution of the canine
is not a result of an intelligence-based capability to
trade off bodily weapons for tooled ones, but rather
the formation of random peripheral isolates equip-
ped with variations, possibly with a somewhat dif-
ferent masticatory organ including retrognathic
jaws with smaller canines and a more erect posture,
compelled by their smaller size, along with additio-
 Evolution

nal intelligence, which enabled them to take ... also provided with additional intelligence,
advantage of their opportunities. Their different which enabled them to take advantage of their
appearance caused them to be rejected by the horde opportunities.
and possibly led to their expulsion. This was a
requirement for the establishment of an intelligent,
peripheral isolate capable of survival, and was a pre-
requisite for speciation. This contradicts Darwin's retrognathic
thesis insofar that it was not the making and using
of tools that changed the morphology of the masti-
catory organ, but that the modified, "weaker" phe-
notype could only survive the selection mechanism Speciation
because it possessed sufficient creative desires to
make tools that would compensate for physical
deficiencies. The concurrent development of diffe- The concurrent development of differentiated
rentiated communication, together with a more communication, together with a more capable
capable masticatory organ and a suitable brain, was masticatory organ and a suitable brain, was a
a conditio sine qua non (see ill. 16 and 17, p. 30).
conditio sine qua non.
The freeing of hands through the attainment of an
upright posture was also an important contributory
factor.
This clearly shows that the process of hominizati-
on was an extremely active and formative one and
may be termed "creative" in the true sense of the
emergence of something new. Unsuccessful
attempts by hominids to continue their evolutio- The freeing of hands through the attainment
nary development by returning to physical attri- of an upright posture was also an important
butes, as was the case with Australopithecus ro- contributory factor.
bustus and boisei, underline the significance of
brain development secondary to communication.
The return to physicality was unsuccessful. These
branches of the hominid disappeared from the Hominization
world.
The development of abstract, communicative
speech necessarily led to the functional polarizati-
on of the brain and subsequently to that of the
eyes and ears (comp. Popper). The development of
two different brains, based on speech, is indirectly
connected to human "one-handedness". Thus, Sense-organ communication with the environ-
sense-organ communication with the environ- ment through the eyes and ears also became
ment through the eyes and ears also became polar. polar.

29
R. Slavicek • The Masticatory Organ

Ill.. 16 (above): This

old illustration shows
the dramatic differ-
ences between the
dentition of primates
and the human mas-
ticatory organ.

Ill. 17 (left): The

reintegration of the
canine was not a
result of "substitut-
ing" the tooled
weapon for the bodi-
ly one, but a sign, at
the beginning of
hominid evolution, of
the different con-
struction of the visce-
rocranium.

30
 Evolution

The idiomatic expression "I've got an eye on you" "I've got an eye on you"
reflects the differential dominance in sensory per-
ception. Interestingly, the German equivalent of "Lend me your ears"
"lend me your ears" is "lend me your ear". Thus,
the German idiom reflects differential dominance
while the English one fails to do so. The evalua- The evaluation of sensory impressions is also
tion of sensory impressions is also polar. Therefore, polar.
in order to understand the human stomatognathic
system, it is especially important to investigate
the morphological readjustment of the organ and
the demands made on it by the complex function
of speech. Speech is inseparably linked to hearing.
The development of the transmitting mechanism
known as speech requires extreme morphological
differentiation of the masticatory organ, in order
that it be able to accomplish the entire spectrum
of the new function.
The so-called production of speech is of utmost
morphological interest. Comparisons of the
speech-producing apparatus of great apes or pri-
mates, especially chimpanzees, with that of
humans, reveal a continuous lowering of the
sound-producing apparatus. All studies carried
out indicate that the larynx of the chimpanzee is
sufficiently developed to bring forth speaking
sounds (comp. Tobias). The most important diffe-
rence appears to be that they do not possess the
cerebral qualifications or "readiness" that is nee-
Tobias, P. V.: Recent Advances in the Evolution of the
ded to take advantage of this possibility. In con- Hominids with Special Reference to Brain and Speech. In:
trast, the hominid apparently took advantage of Chagas, C. (ed.): Recent Advances in the Evolution of
the opportunity at this time, under specific condi- Primates. Pontificiae Academiae Scientiarum. Vatican City
tions. Scripta Varia 50, S. 85–140, 1983

Oral communication in Speech (Bühler/Popper)

hominid evolution Functions Values
Expressive function triggered /
Bühler formulates several levels for the concept of non-triggered
speech, including "animal speech" and "human Signaling function effectiveness /
speech". Bühler's scheme was expanded upon and non-effectiveness
improved by Popper. Speech is an abstract means
of communication; it develops symbols and com- Descriptive function falsity / truth
binations of symbols that permit a "transmitter" Argumentative validity / non-validity
to communicate with a "receiver". Speech should function
be regarded as a semiotic system. The Bühler-
Popper scheme is arranged in four functional Bühler, K.: Sprachtheorie: Die Darstellungsfunktion der
groups. Sprache. Gustav Fischer, Jena 1934

31
R. Slavicek • The Masticatory Organ
The two lower levels in the scheme are pre-
sent in the newborn.
The transition that leads to the formation of
abstract communication takes place through
intensive verbal imitation by the infant of
what is heard.
32
Expression and Signaling
These two lower levels of communicative expres-
sion are already present in the animal world. Both
levels are utilized by the newborn human being
immediately after birth. However, viewing
human development from an ontogenetic view-
point, certain inferences regarding the evolutio-
nary development of speech may be made.
The two lower levels in the scheme are present in
the newborn. Here the function employed is the
expression of vowels that signify or express fee-
lings. The "conditioned" ear (usually the mother)
quickly learns to distinguish between hunger,
pain, comfort and anger. Initial communication
takes place and, when successfully employed and
confirmed by the receiver, triggers a characteristic
learning process.
The transition that leads to the formation of
abstract communication takes place through
intensive verbal imitation by the infant of what is
heard. Thus, hearing is an absolute prerequisite
for this process. Oral imitation contains the pri-
mary attempts to enrich expression by intersper-
sing the originally purely vowel expressions with
consonants. The "babbling" baby is actually a
learning and striving human being. Initially suc-
cessful communication, signaled by the doubling
of syllables, consists purely of soft tissue-suppor-
ted consonants, because of the absence of dentiti-
on. Repetition of syllables (e.g., "ma-ma", "pa-pa",
"da-da", etc.) is the first of this kind of communi-
cation, and the same throughout the world.
Primates, especially chimpanzees, have been
tested in intensive programs for their ability to
cross the threshold to abstract oral communicati-
on. In spite of these ongoing efforts, results show
no crossover to the third level of oral communica-
tion and there seems to be no readiness to "pass
on" the results of their hard labor.
Communication, Information
This limitation in the development of progressive
oral communication was no longer apparent in
hominids. Preparing areas of the brain and impro-
 Evolution

ving "speech capabilities" in the masticatory organ In the beginning was the Word, and the
appear to have been prerequisites for the rapid Word was with God, and the Word was God.
speciation of one or more small, "random" sub- The same was in the beginning with God.
populations. Extensive sharing of information
All things were made by him; and without
made it possible to impart one's knowledge to
others. This development in oral communication him was not any thing made that was made.
at the next higher level probably took place with In him was life; and the life was the light of
Homo habilus. This is indicated by a marked men.
increase in brain volume whereby, the increase in (John 1, 1-4)
frontal and dorsal speech centers is noteworthy.
Finally, the absolute breakthrough came about in
Homo erectus, who represented ultimate and suc-
cessful genetic progress. Humans rose and stood
erect. Brain volume and the regions of speech
were decidedly enlarged. This success is evidenced
by the rapid propagation of the species, along
with its high rate of reproduction.
The improved ability to reproduce had several The "word" is the physical connection
roots. One of these is the development of the so- between myself and others. (Tarouca)
called "nuclear family", contingent on communi-
cation and characterized by social unity and
mutual solicitude. This behavior pattern already
existed in more highly developed animals, gover-
ned by instinct. Based on the difference in brain
development, altruistic components were mar-
kedly increased as hominization progressed. In
conjunction with the development of speech at a
higher level, progressive maturation into a social
being was one of the major steps towards homi-
nization.

Description
The development of descriptive, abstract speech is
most certainly the foremost step. The importance
of speech is recognized by religions of the world as
a central one. In the Bible, the creative force is
known as the Word. A superb quotation from
Tarouca underscores the importance of speech in
human relations.
From this point in time, the development of … development of speech as a means of "data
speech as a means of "data transfer" of accrued transfer" of accrued knowledge …
knowledge was the main impetus behind the
extremely rapid evolutionary process in anthropo-
genesis. The possibility of verbal expression cer-
tainly was a major contributor to the establish-
ment of social behavior and social structures. The

33
R. Slavicek • The Masticatory Organ
Hypothesis
The new levels include the formulation of
hypotheses and also, of course, the possibility
of the misleading lie.
The limbic system is closely associated with
emotion.
MacLean, P. D.: Evolution of the Psychoencephalon.
Zygon 17, S. 187–211, 1982
34
new levels of speech abilities extended far beyond
communication and expression, as they included
other novel possibilities: the ability to ask, under-
stand and answer questions, and the capability to
formulate a solidly based line of reasoning and its
individual interpretation. These created new and
truly incredible opportunities between the trans-
mitter and the receiver. The new levels include the
formulation of hypotheses and also, of course, the
possibility of the misleading lie.
Evolution of the psyche
- the limbic system
Concurrent with the physical "difference" on the
road to becoming Homo, a remarkable mental
change occurred. In addition to important
modifications in posture and communicative
capability, the "fall" of anthropogenesis led to
emotional imbalance. The originally polar balance
in the limbic system became increasingly imba-
lanced through hominization (see ill. 18, p. 35).
The limbic system may be briefly described as a
phylogenetically ancient functional system belon-
ging to the Archipallium. Topographically, it lies
between the brainstem and the neo-cortex. It con-
sists of the limbic cortex, a slightly layered gray
cortex, with the hippocampus, indusium griseum,
Gyrus cinguli and Gyrus parahippocampalis. Sub-
cortical areas of the Nucleus amygdalae and the
Area pyriformis and septalis, and the so-called
limbic middle-brain with median cell groups, are
also important.
The limbic system is closely associated with emo-
tion. Stimulation of its centers is liable to trigger
emotional reactions (positive and negative). A
simplified hypothesis of the limbic system separa-
tes it into two main components, which approxi-
mate pleasant and unpleasant emotions (comp.
McLean). These include fear and defensive reac-
tions as well as pleasant experiences such as hap-
piness, desire and sexual arousal.
In the course of evolution, a shift in emphasis in
favor of pleasant and enjoyable experiences occur-
 Evolution

Ill. 18: The limbic system:

-topography between the brainstem and the neo-cortex,
-limbic cortex with the hippocampus, indusium griseum, Gyrus cinguli, Gyrus hippocampalis,
-sub-cortical area with the Nucleus amygdalae, Area pyriformi and septalis,
-limbic middle-brain with medial cell groups.

35
R. Slavicek • The Masticatory Organ
Aggression
Controlled aggression is what keeps the indi-
vidual alive. It is a self-protective mechanism
necessary for self-preservation.
Egoism
Altruism
Modern human behavior still demonstrates
the ancient patterns of pack and clan mental-
ity.
The relationship between the psyche and the
masticatory organ must now be analyzed,
from the viewpoint of subconscious problem
solving, at the organic level.
36
red. The so-called pleasure centers of the limbic
system increased at a proportionally greater rate
than did the "aggressive" ones. The cortico-baso-
lateral (neo-cortical) areas now amounted to 81%
in humans, the centro-median (archeo-cortical)
areas to no more than 19%. This signifies a consi-
derable reduction in the components associated
with anger and aggression and greatly influences
the capability of aggressive behavior.
The "aggressive" centro-medial centers of the lim-
bic system did not continue to develop, probably
due to the enhancement of social (familial) beha-
vior patterns necessary for preservation of the spe-
cies. If you will; altruistic behavior was promoted
at the cost of egoistic principles. However, con-
trolled aggression is what keeps the individual
alive. It is a self-protective mechanism necessary
for self-preservation.
It follows that the evolution to human beings cau-
sed fundamental emotional changes. The altruistic
element, is the foundation of protective preservati-
on of the species, which developed disproportiona-
tely to the disadvantage of self-protective egoism,
allowing for and effecting the social structures of
communal living. Interestingly, altruism was evi-
dently subject to (territorial) limits. Modern human
behavior still demonstrates the ancient patterns of
pack and clan mentality.
The significant changes in the limbic system had
major consequences for the masticatory organ,
which could now be recruited as one of the poten-
tial organic levels for processing problems of a
psychological nature. Personal development was
permanently inhibited and the individual was for-
ced to "adjust", according to ethical, religious,
familial and legal rules of the social structure.
According to these rules, the free development of
self-preserving egoism was inhibited and conside-
red "sinful". Direct, immediate problem solving
became ever more difficult, or impossible. The
relationship between the psyche and the mastica-
tory organ must now be analyzed, from the view-
point of subconscious problem solving, at the
organic level. Life is a constant challenge and the-
refore creates constant stress. From the viewpoint
of maintaining adaptation, this inherent stress is
required as a perpetual stimulant for all vital pro-
cesses. Stress is countered by a positive aggressive
reaction from the organism for the purpose of sur-
vival (note here the absurd negative connotation
 Evolution

of the word "aggression" in current jargon). Life is

a constant struggle to come to terms with exter-
nal and internal problems; but "coming to terms" ... but "coming to terms" means resolving
means resolving and/or eliminating the problem. and/or eliminating the problem.
The relationship between the psyche and soma, in
the context of the problem of the mind and the
brain, plays a central role in human evolution.
Following the emergence of consciousness, the
emergence of self-consciousness, which is unique
to humans, became very important. The new self- The new self-consciousness includes the real-
consciousness includes the realization of death, ization of death,
with all its spiritual possibilities, and the question
of confronting the cessation of one's own existen- Emotion
ce. This awareness is already evidenced, to a great
extent, in the demise of the Neanderthal culture,
Homo sapiens neanderthalis.
A definite shift in the emotional-aggressive beha-
vioral pattern may be seen in pongids, above all,
in the highly developed chimpanzee, the most clo-
sely anthropoid of all the apes. The only chim- The only optionally meat-eating chimpanzees
panzees with the option to eat meat are by no are by no means predatory and are not
means predatory, and are not equipped for the equipped for the role.
role. Nevertheless, at intervals they display an
aggressive urge to hunt. They will either fulfill
this need at the expense of gibbons, with whom
they usually live in peaceful co-existence, or (what
an ominous sign for the future!) they hunt other
bands of chimpanzees. During these intervals, the
altered emotional behavior of the pack is conspi-
cuous, especially that of male adolescents, the The "young toughs" of the pack who are the
"young toughs" of the pack who are the initiators. initiators.
Their unprofessional killing is in contrast to true
predatory behavior and is often interrupted by
absurd mental behavior, such as sympathetic
actions towards the victim. Vogel correctly Vogel correctly describes this behavior as the
describes this behavior as the crossover point from crossover point from killing to murder.
killing to murder.
A further change in emotional behavior concerns
sexual activity and reproduction. The polarization
in the limbic system and its "promotion" of plea-
sure centers, the upright posture of the body, and
the concomitant "overt presentation of erogenous
zones", are altered in Homo's sexual behavior
compared to that of hominids.

Vogel, Ch.: Vom Töten zum Mord. Carl Hanser Verlag,

München, Wien 1989

37
R. Slavicek • The Masticatory Organ
- the development of communicative
speech
- the development of functional
asymmetry in the brain
- the expansion of consciousness and
the emergence of self-consciousness
- the psychological imbalance resul-
ting from evolutional changes in the
limbic system
The canine, the symbolic weapon of Primates
(especially in males), disintegrated in the buc-
cal-labial aspect. However, it is still regarded
as an aggressive tooth and the focal point for
external and internal aggression
38
Effects of evolution -
an overall view
In summary, the evolutionary effects of human
brain development may be listed as follows:
- the development of communicative
speech
- the development of functional asymme-
try in the brain
- the expansion of consciousness and the
emergence of self-consciousness
- the psychological imbalance resulting
from evolutional changes in the limbic
system
The importance of teeth in the management of
emotions should be reemphasized. Semantically,
we may state graphically that Homo "bares his
teeth to the world". This emotional aspect of den-
tition is by no means solely a human privilege, but
a traditional symbol of strength and a threatening
device in other species. However, the display of
teeth also emphatically reflects emotions by way
of expressing friendliness, laughter and smiling.
Facial expression is strongly governed by the
teeth, among other factors.
Even after the evolution to human beings, the cani-
ne, the symbolic weapon of Primates (especially in
males), disintegrated in the buccal-labial aspect.
However, it is still regarded as an aggressive tooth
and the focal point for external and internal
aggression (see ill. 19-20, p. 39). Except for the
brain and its development, the extremely rapid
phase of evolutionary hominization affected no
other organ as emphatically as it did the organ
which, in consideration of its multiple functions, is
still falsely referred to as the "masticatory organ".
If we attempt to identify the main reason for the
enormously successful human creation and popu-
lation of an ecological niche, it certainly would be
the development of the complex and abstract
form of communication which we call "speech".
The development of speech as a highly specialized
form of breathing and the resultant explosive deve-
lopment of the brain associated with the exponen-
tial enhancement of communicative capacity, are
certainly the most striking events in hominization.
 Evolution

Ill.. 19: The

non-integrated
(separate) canine
in pongids
(males) is to be
interpreted as a
sign of domi-
nance, strength
and aggression.
It is a "symbolic
weapon" and
should be dis-
tinguished, for
instance, from
the tiger's
canine which is
a true instru-
ment for killing.

Ill. 20: The human canine reintegrated

into the maxillary arch in its functionality.

39
R. Slavicek • The Masticatory Organ
Humans created themselves through their
descriptive speech.
Therefore, the form of the recent Homo sapi-
ens dental arches became, simultaneously,
both cause and effect of anthropogenesis
The entire spinal column underwent major
modifications, conditioned by stress.
Kyphosis
Lordosis
At birth, the fetal posture of the spine and
head is the same in primates and Homo sapi-
ens.
40
"Hand in hand" with these developments, the
hand was modified to become a highly-differen-
tiated "grasping" organ. "Handedness" first beca-
me possible when humans became bipeds.
Conversion of speech into an additional and more
abstract form of communication, namely writing,
accelerated the emergence of Homo sapiens. The
development of speech had structural prerequisi-
tes and the result of these major formative impul-
ses was the modification of the entire viscerocra-
nium. In turn, the ensuing brain development
necessarily brought about a further structural
change in the stomatognathic region because of
the enormous increase in volume. Therefore, the
form of the recent Homo sapiens dental arches
became, simultaneously, both the cause and effect
of anthropogenesis (see ill. 21-23, p. 41).
Concurrently, the additional phylogenic step of
"standing erect" took place. Although this chan-
ge in posture had the advantage of freeing the
hands for important tasks, it also significantly
extended the functional duties of the stomato-
gnathic system. The head with its increasingly
altered proportions, due to the brain, was no lon-
ger leaning far to the front, hanging from the
nuchal ligament and carried by strong neck
muscles, but muscularly tensed and balanced on
the relatively small articular surface of the atlan-
to-occipital connector, similar to the rig of a sai-
ling ship. Dorsally, the change took place through
the atlanto-occipital attachment, ventrally
through the complex system of the infrahyoid
and suprahyoid muscles which, through their
attachment to the mandible, indirectly assumed
the responsibility of head posture with the assi-
stance of the true masticatory muscles.
The entire spinal column underwent major modi-
fications, conditioned by stress. The kyphotic
situation of the primate cervical vertebrae under-
went a phylogenic modification and developed a
complex, alternating lordotic, architecture (see ill.
24, p. 42). Of great interest to us is the fact that,
at the time of birth, the human spine corresponds
to that of a newborn primate. At birth, the fetal
posture of the spine and head is the same in pri-
mates and Homo sapiens (see ill. 25-26, p. 42, 43).
The spinal column was restructured over millions
of years of phylogenic time. Ontogenetically it
occurs after birth during the short period the
infant strives to attain an upright position.
 Evolution

Ill.. 21: The human dental arch in

intercuspation.

Ill. 22: The sketch shows the strong

transversal development in the posteri-
or area and the reintegration of the
canine into the arch. The arched form
could be a result of the enormous
development of the brain.

Ill. 23: The entirely different architec-

ture of the spinal column of a semi-ter-
restrial primate in comparison to the
bipedal human.

41
R. Slavicek • The Masticatory Organ

Ill. 24: A comparison between humans and primates shows the approximately identical cranial-spinal architecture. The position of
the foramen occipitale magnum is displayed in red. The dramatic change in adults is clearly seen. The major alterations in inclina-
tion of the foramen occipitale magnum are illustrated here, i.e., posterior rotation in humans and ventral rotation in pongids.

Ill. 25: The fossa are positioned in a wide fashion laterally and not overlapped by the neo-cranium.

42
 Evolution

Ill. 26: The small braincase with a ridge for insertion of postural musculature.

Ill. 27: Overlays of development of the cranial base and on the palatinate plane in chimpanzees prove that there are no noticeable
directional changes during growth.

43
R. Slavicek • The Masticatory Organ
Ill. 28: During the ontogenetic process of attaining the
upright position, the horizontal semicircular canals must
remain horizontal. For this reason, alterations are made in
the system.
Tilscher, H.: Die Kopfgelenke – ein zusätzliches Sinnesorgan?
Sonderdruck aus: Reinhardt, B. (Hrsg.): Das Bewegungsseg-
ment der Wirbelsäule im Blickfeld der orthopädischen
Rückenschule. Med. Lit. VerlagsgesmbH., Uelzen 1993
44
Standing upright and the enormous demands of
restructuring and modification made on the func-
tional areas associated with it take place within a
few months of life (see ill. 28, left).
Phylogenetically, this change in structure strongly
affects the structure of the pelvis and, conse-
quently, the female birth canal. This aggravated
the problem resulting from the increasing volume
of the neurocranium and, due to the development
of the infant, made it necessary for the infant to be
born "prematurely". This strategic and complete
modification of the spinal column and pelvic gird-
le also explains, in a very broad sense, the relati-
onship between problems in posture on the one
hand, and functions and dysfunctions within the
masticatory organ on the other. This subject will
be discussed in detail later.
In the evolution to Homo sapiens, the complex
muscular structures of the primate cranium and
the masticatory organ were completely altered in
terms of concept. This was accomplished on the
one hand by posture, and on the other hand
through the new, additional and important func-
tions of the human masticatory organ. Just the
stabilization of the mandible against the functio-
nal surface of the articular eminence during
upright motion requires an entirely new system.
The evolutionary development of "head balance"
appears to assign the atlanto-occipital joints a spe-
cific function, which includes their adopting the
role of an additional sense organ (compare
Tilscher).
Upright posture also necessitated a major change
in the respiratory apparatus. Respiration and the
development of speech had a great influence on
evolutionary phylogenic development. The respi-
ratory passages sank more dorsally and the see-
mingly illogically conceived intersection of respi-
ratory passages with the digestive tract became
even more problematic, as the epiglottis mecha-
nism was compromised in its function.
Constrictions in the respiratory passages are often
compensated for by modifications in posture.
The stress-related modification of the pelvic gird-
le and the brain-related increase in cranial volume
necessitated a strategically "premature" birth
among humans. Post-natal development of the
human brain nearly triples its volume, in contrast
to post-natal brain development in pongids,
among which only the chimpanzee, the most
 Evolution

developed of the great apes, exhibits a minimal

amount of post-natal (brain) growth. The neu-
rocranium increasingly overlapped the viscerocra-
nium, affecting, above all, the relative position of
the temporo-mandibular joints to the cranium.
Phylogenetically, upright posture necessitated
complete restructuring of the cranial base, especi-
ally the position of the foramen magnum. By
means of counter-rotation, the vestibular appara-
tus must compensate for the dorsally rotating
components of upright posture (see ill. 29 and 30,
right; ill. 31 and 32, p. 46).
In ontogenesis, this slow, evolutionary develop-
ment is represented in a dramatic time lapse
sequence. The ontogenetic change in posture in
the first post-natal year in humans compels a rota-
tion of approximately 45 degrees in the foramen
magnum. This ontogenetic change to the upright
position, which takes place at the end of the first Ill. 29: The infant primate develops further with no signifi-
post-natal year, and the changes in the dynamic cant changes in anterior and vertical growth.
architecture of the spinal column associated with
it, cause a structural change in the entire cranial
base. The temporal and sphenoid bone are especi-
ally affected by the corrections that take place in
the position of the organs responsible for equili-
brium (horizontal semicircular canals). The fora- 40 – 45°
men magnum inflects about 45 degrees posterior-
ly during this development. This extreme rotation
influences the entire cranial base and thereby,
above all, the structures of the temporal bone, as
the vestibular organ with its horizontal semi-cir-
cular canals must necessarily duplicate the
upright posture.
The shifts in structure might be related to indivi-
dual flexion of the spheno-occipital syndesmosis.
The change in the relationship appears to have a
Ill. 30: This overlay clearly illustrates the difference in onto-
major influence on the growth and the direction genetic development. The position of the foramen magnum,
of growth of maxillary structures (see ill. 33 and after attaining the upright position, is 35-45 degrees. In
34, p. 46). This would indicate (comp. Sato) that chimpanzees, none of these alterations takes place
the individual behavior of the cranial base (flexion (see ill. 27, p. 43).
or extension) during ontogenetic development
determines the variable position and relation of Flexion
the jaw. The vehement and dramatic development
Extension
of the neurocranium and the increasingly compli-
cated birth canals, associated with upright postu-
re, gave rise to even more premature birth during Delattre, A.: Du Crane Animal au Crane Humain. Masson
edit., S. 104, Paris 1951
hominization (see ill. 35, p. 46). The evolutionary
Sato, S.: Alteration of Occlusal Plane due to Posterior Dis-
development in the breadth of the neurocranium crepancy Related to Development of Malocclusion –
compelled concurrent development of the vis- Introduction to Denture Frame Analysis. Bulletin of
cerocranium. The sutures reacted to the increa- Kanagawa Dent. Col., Vol. 15, No. 2, S. 115–123, 1987

45
R. Slavicek • The Masticatory Organ

Ill. 31: This sketch from Delattre and Fenart shows the extent Ill. 32: Rotation and counter-rotation - upright posture and
of movements that take place. the vestibular system.

Ill. 33: The structure of the cranial base is of great signifi- Ill. 34: Example of a cephalometric overlay.
cance in cephalometric analysis.

Ill. 35: This graph of post-natal brain development illustrates

the dramatic increase in humans in comparison with hominoids.

46
 Evolution

Ill. 36: The occlusal scheme from Selenka's historical work

illustrates the practically identical morphology of molar con-
tours, relative to modern humans. However, in the overlays
one notes a tendency towards mesioclusion.

Ill. 37: The distinct "herbivorous", transversal abrasion in the Ill. 38: In humans, the masticatory loop is asymmetrical from
adult chimpanzee is evident. the frontal view, in contrast to the masticatory loop in apes.

TEST OF SIGNIFIANCE FOR ASYMMETRY OF ANGLE AOI DURING

MASTICATION OF CARROT BY Homo sapiens AND
Macaca fascicularis

No. of No. of Chews Mean Angle AOI

Individuals Left Right Left Right T-Value

Macaca
fascicularis 3 60 60 87.33 ± .30° 87.93 ± .26° 1.504
(d.f.=118)
Homo Sapiens 5 60 60 88.70 ± 1.11° 83.01 ± .89 4.01*
(d.f.=118)

*p<0.01

Ill. 39: An index contrasting the AOI in apes and humans.

47
R. Slavicek • The Masticatory Organ
Remodeling processes continue throughout
life and should be regarded as adaptive mech-
anisms.
The morphology of the primate dentition,
especially the molars, approximates that of
humans.
48
sing volume (resulting from the increasing size of
the brain) in terms of reactive growth. From this
point of view, the sutures were not growing struc-
tures, but reactive ones.
The mandible had to undergo remodeling proces-
ses in order to adjust appropriately to transversal
growth. Special conditions applied to the area of
the cranio-mandibular attachments, as the man-
dibular joint grows interstitially and appositional-
ly on the condylar process, and is also subject to
the effects of the remodeling process. Remodeling
processes continue throughout life and should be
regarded as adaptive mechanisms. The glenoid
fossa of the temporomandibular joint in pongids,
still located widely lateral outside the neurocrani-
al area, is increasingly "covered up" by the homi-
nization of the cranium. At the end of the evolu-
tionary process, the joint fossa lies beneath the
cranial vault. The dorsal limitation caused by a
post-glenoidal process is no longer apparent.
Evolution of the masticatory organ
from the viewpoint of tooth
morphology
The morphology of the primate dentition, especi-
ally the molars, approximates that of humans.
The disposition of the teeth to each other, howe-
ver, is different.
The dentition of primates is characterized by par-
allel, sometimes posteriorly converging lateral
teeth (molars and pre-molars), by the exposed
canine which, in male apes, continues to grow
with an open apical foramen long after puberty,
and four front teeth, which are protruded and
separated from the remaining teeth by a so-called
"primate gap".
The anterior arch and the morphology of front
teeth also differ from those in humans. The arran-
gement of the front teeth in primates is more
protrusive and transversal, and in no way domi-
nantly limiting. Behind the four front teeth, there
is a clear gap to the canine.
Mastication in hominoids is strongly transversal;
it rather resembles the herbivores and causes early,
 Evolution

strong abrasion (see ill. 37, p. 47). From the ante-

rior view, the masticatory loop is symmetrical.
Asymmetrical masticatory loops should be regar-
ded as a result of brain-polarization. The denti-
tion approximates that of humans, a tendency
towards mesioclusion is seen. The role of the four
front teeth is apparently an unimportant one. The
molars abrade early. The abrasion model is similar
to the basic model in herbivores.
Dental arches in modern humans are characteri-
zed by the buccal-labial overbite of the maxillary
teeth. During the last 150 years, a new human During the last 150 years, a new human phe-
phenotype has emerged as a result of the altered notype has emerged as a result of the altered
eating habits of our western industrial society. eating habits of our western industrial society.
Human beings tend to live much longer, the
masticatory organ is not subject to food-related
abrasion, and the developmental grooves are
retained to a large extent. This induces changes in
the functional model of the masticatory organ.
Because of changes in the environment and in
social structures, exogenous pressures at the
somatic as well as psychic level are significantly
increasing. As a result of the incredibly numerous
and increasing forms of communication in recent
times, it is quite possible that the human brain Alt K. W. Türp J. C.: Die Evolution der Zähne. Phylogenie
will be greatly modified in the future. – Ontogenie – Variation. Quintessenz Verlag, Berlin 1997

49
R. Slavicek • The Masticatory Organ
Cybernetics
This unique and extremely successful
evolutionary development of the new species
was characterized by the function of the
human mind.
... the "face", whose individuality and expres-
sion are substantially influenced by the masti-
catory organ.
... created a backdrop for the management of
stress, which was brought about by new areas
of social conflict.
50
The new organ -
a cybernetic feedback
control mechanism
The result of all these changes, which took place
during hominid evolution, was a new race, name-
ly the human race. This unique and extremely
successful evolutionary development of the new
species was characterized by the function of the
human mind. The most important milestone in
human brain development was the emergence of
"self-consciousness". The new functions of the
masticatory organ were intimately connected with
the extremely expansive functional development
of the brain. In addition to its nominal function,
viz. mastication, it was also distinguished by the
function of speech. In order to stand upright and
become a true biped, major contributions were
required from the neuromuscular structures asso-
ciated with head and body posture.
Becoming conscious of one's identity and the
resulting emergence of an individual, i.e. esthetic
consciousness, created the "face", whose individu-
ality and expression are substantially influenced
by the masticatory organ. The loss of a balanced
psychological polarity extended the functional
range of the organ and created a backdrop for the
management of stress, which was brought about
by new areas of social conflict. These new tasks
could only be fulfilled by effecting drastic changes
in structural areas.
With the purpose of instigating clearly defined
approaches of thought, I feel justified in regarding
the masticatory organ as a separate feedback con-
trol system in the overall control organism, and in
 Evolution

classifying it within the dynamic hierarchy of the The theoretical conclusion of this thought
overall system with its ever-changing priorities. process must lead to a relocation of the
The theoretical conclusion of this thought process organism into its own individual environ-
must lead to a relocation of the organism into its ment, created by its self-consciousness.
own individual environment, created by its self-
consciousness. With the help of this theory of a
feedback control mechanism, it should be possible
to more easily follow, and better understand, diag-
nostic steps and therapeutic approaches with
regard to the masticatory organ.

Thinking in terms of a
feedback control system
The concept "Feedback control mechanism cyber-
netics" was introduced in science in 1948 by
Norbert Wiener, although a general "automatic
regulation" concept had previously been propa-
gated by H. Schmidt (1941). Cybernetics derives
from the Greek word for the "helmsman" who, by
his decisions, determines the course and also, in
the sense of a closed system, causes reactive changes
to occur in all of the dependent inner sub-systems.
The simple example of a well-trimmed sailing
ship makes this evident and comprehensible: if
the helmsman alters the course, the entire system
is forced to adjust. External influences are altered
relative to the ship, although they actually may
remain the same. The "true" wind remains
unchanged, the virtual wind changes. The posi-
tion of sails needs to be modified, and this alters
both the speed and position of the ship. All of the
dynamic parameters must adapt, although the
environment has not changed. On the other hand, When the ship loses its ability to adapt, a
if there is an alteration in environmental condi- shipwreck is imminent.
tions, e.g., in the force or direction of the wind,
then naturally the entire dynamics of the ship i.e.,
the system "ship" and all of its sub-systems, must
adapt. This example can be detailed in a variety of
ways, but it suffices to indicate the compactness of
a feedback control system which, within itself, is
subject to permanent modification and, simulta-
neously, to external influences. The function of a
"helmsman" is not, however, a rigid, hierarchical-
Wiener, N.: Cybernetics or Control and Communication in
ly static function, but rather can be utilized the Animal and the Machine. Hermann Verlag, Paris 1948
dynamically in other positions. When the ship Fasching, G.: Kaleidoskop der Wirklichkeiten. Springer
loses its ability to adapt, a shipwreck is imminent. Verlag, Wien 1999

51
R. Slavicek • The Masticatory Organ
Ill. 40: This sketch, according to Uexkuell, illustrates the
theoretical scheme of any arbitrary organism (animal or
human) as a unit of the psyche and soma, within its skin.
Ill. 41: When the organism is confronted with a problem in
its environment, it recognizes the problem and assigns it a
degree of importance. Its reaction results in a solution to the
problem. The reaction again flows automatically into the
environment as reality; a direct, cognitive solution is applied
to the problem and the problem is solved.
Psychosomatics
Uexkuell, Th. v. (Hg.): Lehrbuch der psychosomatischen
Medizin. Urban und Schwarzenberg Verlag, München 1986
Eccles, J. C.: Die Evolution des Gehirns – die Erschaffung
des Selbst. In: Eccles, J. C.: Die Mikrolokalisations-
hypothese. Piper Verlag, New York, Heidelberg, Berlin 1989
Eccles, J. C.: Do Mental Events Cause Neural Events
Analogously to the Probability Field of Quantum
Mechanics? 227: 411–28, Proc. R. Soc. Lond. (Biol.) 1986
52
The concept of feedback control can be applied to
organisms. For the living organism, it may be
applied and considered from both a somatic
and psychic point of view and, naturally, from a
psychosomatic viewpoint as well.
We will use two examples from the literature to
learn to think in terms of feedback control. The
following will consider the position of the orga-
nism in its environment from two fields of influ-
ence: from the field of "reception", which per-
ceives the environment, and the field of "reaction",
which responds to the environment. This can be
illustrated by using a simplified scheme from
Uexkuell (see ill. 40, left). If a problem appears in
the vicinity (environment) of the organism and is
judged to be important, the organism reacts
immediately by offering a solution to the problem
(see ill. 41, left). This simple feedback control
mechanism shows the direct possibility of prob-
lem solving without an undue length of process-
ing time.
This may also be illustrated by a further simple
example: an organism, e.g., an animal living in
open nature, perceives another organism in its
environment. This effects an "assessment of signif-
icance" and possibly, depending on previous expe-
rience, an "assignment of significance". The result-
ing reaction might, for example, call for "escape".
If this is carried out, problem solving has taken
place which, if successful, gives rise to an imprint
in the sensory area of "experiences". From the
viewpoint of modern brain physiology, the word
"experience" may be interpreted as the structuring
of virtual psychons.
The brain researcher Eccles formulated this thesis
regarding the interaction of the mind and brain,
based on theories of quantum physics, in his
micro-localization hypothesis. In this hypothesis,
he compares the smallest functional unit of the
neural system, the neuron, with the smallest func-
tional unit of the mind, the psychon. The psy-
chon, the postulated "mental" unit, is assigned to
the dendron (neural unit), and can induce a men-
tally instigated neural event. This learning capa-
bility, the building up of experiences, leads to the
said reaction when the typical event occurs, but
may also lead to the reactive solution in the event
of less specific similar incidents. Most environ-
mentally related processes are much more compli-
cated in humans, whose psychosomatic structure
 Evolution

is differentiated from that of organisms by "self-

consciousness". In contrast to the "System:
Organism", the human being may be regarded as
the "Supra-system: the Individual", who builds his
own individual environment. This cybernetic
scheme is much more complex than that of an
organism without "self-consciousness" (see ill. 42,
right).
The human, as a supra-system, receives and
processes events through the sub-system, the psy-
che (see ill. 43, right). From this viewpoint, the
Ill. 42: Because of "self-consciousness", unique to humans, a
distinction between conscious, unconscious and
so-called supra-system is created, possessing its own individ-
pre-conscious processes in this scheme deserves ual reality.
attention. The area of the unconscious and pre-
conscious, for subsequent processing of psychic
stresses, is an important element of the mental
approach to functions of the masticatory organ,
which serves as a platform for stress management.
When considering approaches and successful
attempts to view the masticatory organ as a feed-
back control mechanism, Stallard's scheme of
"organic occlusion" and the much more dynamic
one proposed by Fröhlich deserve investigation
(see ill. 44 and 45, p. 54).
In my lectures and publications, I frequently Ill. 43: The reception system psyche processes incoming
introduced an expanded scheme of the position of problems and transposes them into emotions in the somatic
the human masticatory organ in the overall area if they cannot be resolved immediately.
organism (see ill. 46, p. 54). In this scheme, the
somatic areas of the main structures are compared
with the functions of the masticatory organ, but
the somatic and psychic areas of the central
nervous system are also integrated into the same
feedback control system in order to document the
absolute interdependence of the brain and the
masticatory organ (see ill. 47, p. 55). Worthy of
note are the functions in the center, which
emerged through evolutionary functional expan-
sion (see ill. 48 and 49, p. 55). Speech was one of
the main functions (see ill. 50 and 51, p. 55). The
postural function of the head, because of the
attainment of upright position and becoming a
biped, is a part of the overall human posture (see
ill. 52, p. 55). Esthetic consciousness is listed as a
function of the masticatory organ because the face
is molded by the viscerocranium (see ill. 53, p.
55). One of the significant new functions is stress Fröhlich, F.: Die okklusionsbedingten Schmerzen im Kiefer-
Gesichts-Bereich. Schweiz. Mschr. Zahnheilkunde 76,
management, which is considered to be closely
S. 764–776, 1966
associated with the psychic aspect, but also with Stallard, H.: Oral Rehabilitation and Occlusion.
the environment. Dentition provides a somatic Postgraduate Education School of Dentistry. University of
backdrop for stress management. Clenching and California S. F.

53
R. Slavicek • The Masticatory Organ

Ill. 44: The system of dependence of three basic structures, Ill. 45: Fröhlich refined the dependencies and emphasized
postulated by Stallard, was the basis of the gnathological the direct influence of occlusion on the jaw joints.
concept of "organic occlusion".

Ill. 46: The cybernetic scheme "masticatory organ", occupying a central position in the organism, which is surrounded by its indi-
vidual environment. Structures and functions are detailed and interrelationships with somatic and psychic areas of the CNS are indi-
cated.

54
 Evolution

Ill. 47: The central nervous system is Ill. 48: The list of functions to be per- Ill. 49: Mastication is the function
divided, schematically, into a psychic formed and shared by the human mas- which gives the name, but certainly
and a somatic region. ticatory organ. not the most important one

Ill. 50: Speech, the most important Ill. 51: Speech and respiration are an Ill. 52: The posture of the head, from
medium of communication, is its main indivisible unit. the viewpoint of the overall function
function. of the organ, is one of the main
aspects of phylogenesis.

Ill. 53: The human face is the center Ill. 54: Bruxism and pressing, as
of perception and self-perception. somatically required zones, serve the
purpose of reducing stress.

55
R. Slavicek • The Masticatory Organ
Many, if not most, functional disorders
should be investigated in regard to causal
environmental influences.
"Organ" derives from the Greek word
"organon", which means "tool".
According to cybernetic thinking, the entire
organism is a dynamic feedback control sys-
tem.
56
bruxing are legitimate functions of the masticato-
ry organ (see ill. 54, p. 55).
The position of the masticatory organ in relation
to the entire organism and its role within its indi-
vidual environment are clearly described in the
cybernetic scheme. Many, if not most, functional
disorders should be investigated in regard to
causal environmental influences. Of course, from
this point of view the entire organism is regarded
as a feedback control system that must constantly
react to internal and external changes.
The organism and its so-called
masticatory organ - definition
As one is apt to use the simplified term "mastica-
tory organ", it would be appropriate to first con-
sider the word "organic": "organ" derives from the
Greek word "organon", which means "tool". The
organ is defined as a morphological unit com-
posed of cells and tissues, which fulfills one or
more functions. It is perfectly justified and practi-
cal to apply Burdach's and Goethe's morphologi-
cal concept, in its original sense, namely a "com-
prehensively dynamic" one. This concept not only
applies to the limited viewpoint of anatomy, but
also to other dynamic forms, e.g., in fine arts.
Organs are parts of entire organisms, structurally
and functionally different but subjugated to
orderly, hierarchical principles. According to
cybernetic thinking, the entire organism is a
dynamic feedback control system. As we have
mentioned, the hierarchical order in this system
should by no means be regarded as a static one.
Rather, it is unprecedented and dynamic, depend-
ing on circumstances. The organism organizes its
hierarchy according to the priority principle, i.e.,
according to the functions required at the
moment. This means that the functions required
for life determine the importance and dominance
of the organs at any particular time. As an exam-
ple, we cite the banal but apropos statement,
"plenus venter non studet libenter": supplying the
necessary amount of blood for digestion reduces
brain activity to a lower level of priority.
 Evolution

The principle of the organism may be defined as

follows:
• An organism is a self-regulating, self-orga-
nizing and self-reproducing dynamic system.
• The organism reacts to the environment
and is permanently subject to its demands.
• The organism must continuously adapt in
order to cope with these demands and
requirements.
• Constant adaptation is necessary for life Adaption
support and is therefore the only means of
survival.
• All organs are involved in this process.
• The organism uses these organic functions The organism uses these organic functions
indiscriminately for the purpse of living and indiscriminately for the purpose of living and
surviving. surviving.

For the "individual" human being, the environ-

ment is to be regarded as an individual reality.
This means that there is no objective environment
for the individual; every human builds his/her
own subjective stage of observation, from which
he/she experiences the individual environment.
Cognizance of this viewpoint is especially impor-
tant for the dentist when he or she is handling a
patient.
• The functions of the masticatory organ are • The functions of the masticatory organ are
intimately connected with functions of the intimately connected with functions of the
brain, both somatically and psychically. brain, both somatically and psychically.
• Along with its functions, the masticatory • Along with its functions, the masticatory
organ has assumed a central position in the organ has assumed a central position in the
organism.
organism.
• Contact with the environment is established
• Contact with the environment is estab-
and maintained through the masticatory
organ. lished and maintained through the masti-
catory organ.
• Therefore, environmental factors are very
important in the evaluation of causality with • Therefore, environmental factors are very
regard to functional disorders in the mastica- important in the evaluation of causality
tory organ. with regard to functional disorders in the
• The masticatory organ is also a backdrop for masticatory organ.
the psyche, for conscious and unconscious • The masticatory organ is also a backdrop
processing of problems. for the psyche, for conscious and uncon-
scious processing of problems.
The concept of a feedback control mechanism is
the main theme of this book. Learning about basic
structures is a prerequisite for better comprehen-
sion of the functions.

57
 Chapter 2

Structures

The structures of the masticatory organ

became characteristics of evolutionary
adaptation to entirely altered conditions.
The most drastic modification was requi-
red in the mandibular attachment to the
skull, brought about by the dramatic chan-
ge in the posture of the head along with
the position of the occlusal plane, relative
to gravity. This modification applies to
bony structures as well as to ligaments and
muscles that posture the mandible relative
to the skull. The dentition in humans is
made up of closed arches, i.e., all teeth are
contacting, possessing an entirely new fun-
ctional make-up and entrusted with new
responsibilities. The neuromuscular system
had to assume very different functions. It is
important for the dentist to realize that
minimizing the importance of extensive
knowledge, especially on the subject of
occlusion, as is currently being practiced
by scientific "trendsetters", may have dele-
terious consequences.
R. Slavicek • The Masticatory Organ
Synovia
A synovial gliding joint with a moveable sock-
et.
Under normal ligamentary conditions in the
inner capsular structures, translation takes
place mainly in the upper articular cavity and
rotation in the lower articular cavity.
Sicher, H.: Zur Mechanik des Kiefergelenkes. 27: 27–33, Z.
Stomatol. 1929
Sicher, H.: Functional Anatomy of the Temporomandibular
Articulation. Austral. J. Dent. 55: 73–85, Apr.–Oct. 1951,
Austral. J. Dent. 24: Jan.–Feb, 1952
Sicher, H.: Functional Anatomy of the Temporomandibular
Joint. In: Sarnat, B. C.: The Temporomandibular Joint.
2nd ed. 28–58, III, Springfield 1964
Gerber, A., Steinhardt, G.: Kiefergelenkstörungen –
Diagnostik und Therapie. Quintessenz Verlags GmbH,
Berlin 1989
Weinberg, L. A.: Correlations of Temporomandibular
Dysfunction with Radiographic Findings. J. Prost. Dent. 28:
519, 1972
Weinberg, L. A.: Evaluation of the Duplicability of TMJ
Radiographs. J. Prost. Dent. 24: 512–514, 1970
60
The cranio-mandibular
system (CMS)
Viewpoints concerning the physiology and patho-
physiology of the temporo-mandibular joints have
undergone frequent change over the last few
decades. The classical definition by Harry Sicher, a
dentist from Vienna, describes the temporo-
mandibular joint very clearly and simply as a syn-
ovial gliding joint with a moveable socket. Instead
of the rather absurd, antiquated anatomical defin-
ition that refers to the articular fovea on the tem-
poral bone, Sicher proposes the notion of a practi-
cal, functional, moveable socket, namely the artic-
ular disk. In addition, this definition clearly points
to the fact that the gliding function of the "condy-
lar disk" unit is in the foreground, and that rota-
tion in the lower joint compartment only supports
the physiology of "gliding" joint movement.
This is especially important in view of the fact
that in diagnostics, until the present time, the
bony relation between the temporal bone and the
condylar process has been overestimated. The
cranio-mandibular system itself can and may only
be viewed from its dynamics; static, bony rela-
tionships are relatively inconsequential. This point
of view is provocative and uncomfortable for some
dogmatic diagnosticians however, and it but should
give them substantial food for thought.
Under normal ligamentary conditions in the inner
capsular structures, translation takes place mainly
in the upper articular compartment and rotation
in the lower articular compartment. The articular
disk, a moveable socket, is "passively" carried
along during translatory lower jaw movement by
 Structures

ligamentary attachments. Muscular control in this

passive role is supplied by muscles near the joint,
which are inserted in the capsule, in structures of
the articular disk, and (the majority of fibers) in
the condylar process. Supported by gross and Supported by gross and micro-morphological
micro-morphological research from recent litera- research from recent literature and based on
ture and based on the results of other studies, I the results of other studies, I have postulated
have postulated a cranio-mandibular system, the
a cranio-mandibular system, the CMS, and
CMS, and replaced the expression "temporo-
mandibular joints" with the structural unit "CMS" replaced the expression "temporo-mandibular
in the cybernetic schematic view of the masticato- joints" with the structural unit "CMS" in the
ry organ. This cranio-mandibular system encom- cybernetic schematic view of the masticatory
passes the bony structures of the jaw, the (exten- organ.
ded) connecting and passive centering ligaments,
and the system's active centering muscles (see ill.
1, p. 63).
Under physiological conditions, the condyle of the
condylar process lies permanently in the lower
compartment of the articular disk. The position of
the condyle in the disk is secured by an ingenious Luxation
ligamentary apparatus, which dynamically stabi-
lizes the relation between the articular head and Reduction
the mobile socket. These stabilizing ligaments
allow for a great degree of rotation. The possibili-
ty of translatory movement in the lower articula-
tion is, as a rule minimal, but may be substantial
in the presence of a loose (individual phenotype or
pathophysiologically altered) ligamentary system.
Under pathological conditions and permanent or Under pathological conditions and perma-
semi-permanent luxation (derangement), the nent or semi-permanent luxation (derange-
condyle, or a part of the condyle, is not located in ment), the condyle, or a part of the condyle,
a proper anatomical relationship to the articular is not located in a proper anatomical relation-
disk. Nevertheless, in most cases, satisfactory
ship to the articular disk. Nevertheless, in
compensating function can be achieved.
most cases, satisfactory compensating func-
In addition, the ligaments that connect the
mandible and hyoid to the cranial structure are tion can be achieved.
classified within the cranio-mandibular system.
These attachments tend to be disregarded from
the viewpoint of function and dysfunction. The
ligaments and also the entire fascia apparatus in
the cranio-cervical region should be evaluated
with regard to their practical relationship with the
"stomatognathic system". The extended ligaments
were an absolute evolutionary necessity for stabi-
lizing the mandible against gravity given the
altered cranial posture.
All of the structural areas within the CMS under-
go lifelong adaptation. The adaptation is con-
fined, under physiological conditions, to minimal All of the structural areas within the CMS
and continuous processes. undergo lifelong adaptation.

61
R. Slavicek • The Masticatory Organ
The impression of an "articular cavity" first
emerges during maturation through the func-
tionally dependent articular eminence
This morphological description of bony struc-
tures indicates a strong dependence on the
dental morphology of both dental arches
Steinhardt, G.: Die Bedeutung funktioneller Einflüsse für die
Entwicklung und Formung des Kiefergelenkes. Deutsche
Zahn-, Mund- und Kieferheilkunde 2, 1935
62
Structures of the
cranio-mandibular system
in detail (CMS = TMJ)
• Bony structures
• Ligamentary structures, including the
temporomandibular ligament
• The articular disk
• Retro-articular structures (bilaminar zone)
• The system-immanent musculature system
for the temporo-mandibular joints
• The synovial-capsule apparatus
• Extended ligamentary attachments
Bony structures
The bony structures consist of the condylar
process of the mandible and the temporal bone.
The impression of an "articular cavity" first
emerges during maturation through the function-
ally dependent articular eminence located in front
of the small articular capitulum and individually
formed as an arch-shaped wall. The articular emi-
nence is developed during growth, by the func-
tional influence of a dynamic occlusion. It
responds to functional influences throughout life.
The condylar process develops a trochlear head,
whose longitudinal axis leads towards the great
occipital foramen in different ways, depending on
the individual. The form of the trochlea is gener-
ally characterized by individual, arch-shaped flex-
ion from the axial view. The articular eminence
and condylar process are often developed slightly
asymmetrically. Occasionally, they are markedly
asymmetrical. This morphological description of
bony structures indicates a strong dependence on
the dental morphology of both dental arches (see
ill. 2 and 3, p. 63 and ill. 4 and 5, p. 64).
Important muscles for articular function in
humans are inserted in the condylar process. The
surfaces of the temporo mandibular joints are cov-
ered with fibrous cartilage. The structures of the
human temporo mandibular joint have no defined
post-glenoidal region. A post-glenoidal process is
entirely absent.
 Structures

Ill. 1: This symbolic illustration depicts the complete interdependent unity of the system. It consists not only of the joints as such,
but also of the entirety of structures, including the ligaments and the immanent musculature system near the joints.

Ill. 2: In this inferior view, we see the articular cavity result- Ill. 3: In the lateral side view, a sagittal perspective, the
ing from the anteriorly positioned articular eminence. condylar process is positioned behind the articular eminence.
The intercuspating teeth stabilize and determine the position.

63
R. Slavicek • The Masticatory Organ

Ill. 4: The mandible, seen from above, shows the arrangement Ill. 5: In this cross-section from a sagittal view, the convergence
of both condyles with their oblique longitudinal axes, converg- of structures with convex-convex characteristics becomes evi-
ing towards the back, or posteriorly. dent.

Ill. 6: The mandible is connected to the cranium by the articular capsule on the condylar process. The capsular cavity allows rela-
tively unlimited movement.

64
 Structures

The two bony elements of the right and left tem-

poro-mandibular joints, the condylar process and
the temporal bone, are connected to each other by
a loose (because of functional demands) joint cap-
sule, and are by no means held tightly together.

Ligamentous structures (of the joint)

The joint capsule (see ill. 6, p. 64) is, in general, a
loose sac-like connector. However, it displays ele-
ments that may be regarded as ligamentary rein-
forcement. The "looseness" of the capsular struc-
ture - it is also characterized and distinguished by
the individual phenotype - allows for extensive
physiological mobility of the temporo-mandibular
joint.
Significant reinforcement of the capsule is
achieved by a special construction of fibers that
extend from anterior-superior to the temporal
bone, posteriorly and inferiorly to the ascending
branch and the condylar process of the mandible.
This capsular support is known as the ligamen-
tum temporo-mandibulare or the temporo-
mandibular ligament.
Some fibers extend horizontally to the condyle
itself (see ill. 7, right). Upon closer inspection it is
found that the principle vector of these fibers
repeats itself in the pterygoid-masseter loop. This
strengthening of the capsule serves as a protective
mechanism for the ligament against trauma in
posterior direction. For instance, in the event of a
shove or push or posterior pressure at the chin, the
energy is re-routed in a cranial direction through
this practical attachment. In cases of extreme Ill. 7: The illustration shows the scheme of fiber patterns.
trauma, the extension of the ligament at the neck These are by no means outwardly distinct at the joint.
of the condylar process is frequently a "calculated Rather, they are subject to numerous anatomical variations.
breaking point" of the mandible, especially in
infants and adolescents.
In addition, the temporo-mandibular ligament is
one of the practical attachments, which aids the
"bipedal" human in centering the mandible
against the forces of gravity.

The temporo-mandibular ligament is one of

the practical attachments, which aids the
"bipedal" human in centering the mandible
against the forces of gravity.

65
R. Slavicek • The Masticatory Organ
Ill. 8: The illustration clearly shows the functional rotational
freedom of joints in the lower compartment, in spite of their
taut attachment to the disk.
Ill. 9: The illustration demonstrates the practicality of collat-
eral ligaments. The lateral one is generally more substantially
formed than the medial one.
Zenker, W.: Über die mediale Portion des M. temporalis und
deren Funktion. Österr. Zschr. für Stomatol. 51: 550–554,
1954
Zenker, W., Zenker, A.: Die Tätigkeit der Kiefermuskeln
und ihre elektromyographische Analyse. Zschr. für Anatomie
und Entw. Geschichte 119, 1955
Rees, A., Leonard, A., The Structure and Function of the
Mandibular Joint. J. of the British Dental Association Vol.
XCVI, No 6, March 16: 125–133, 1954
Bumann, A., Groot-Landeweer, G.: Zur Diagnostik und
Therapie des Kompressionsgelenkes. Dtsch. Zahnärzt. Zschr.
Jul. 45 (7 Spec No): 4–6, 1990
Special thanks to the Royal Dental College in
Aarhus/Denmark, for providing pictures (Ill. 10, 11, 14,
15)
66
The articular disk
The articular disk is attached (beneath the actual
capsular structure) to the joint trochlea by a medi-
an and a more substantially formed lateral liga-
ment. The ligaments are attached so as not to hin-
der rotation of the joint head in the lower portion
of the disk. The ligamentary structures are known
as medial and lateral collateral ligaments (see ill. 8
and 9, left; ill 10 and 11, p. 67).
The articular disk is also secured by two further
ligaments, namely the disco-temporal and disco-
condylar ligaments.
The disco-temporal ligament extends from the
petro-tympanic groove to the disk, and forms the
upper plate of the bilaminar zone. With the
mandible in a retral position it is loose and relaxed.
The disco-condylar ligament is larger and lies, in
a retral position, tautly on the condyle, thereby
tightening the connection between the articular
disk and the articular head. In a protrusive posi-
tion this ligament relaxes. The temporo-condylar
ligament, on the other hand, tenses by an extreme
open movement and pulls the articular disk some-
what posteriorly (see ill. 12 and 13, p. 68). The
ligaments are also subject to variations, dependent
on the phenotype, as well as to pathophysiological
changes. The site of origin in the petro-tympanic
groove occupies a certain role in the discussion of
functional joint pathology (comp. Bumann).
Retro-articular structures
Between the two lamellae described above is a
highly vascularized pad (see ill. 14 and 15, p. 68,
69) known as retro-articular structures (hydrody-
namic retral pad). The latter ensures hydrody-
namic pressure adjustment in translatory articular
movements, serves as a hydrodynamic placement
mechanism for determining the functional posi-
tion of the temporo-mandibular joints, and also
serves as a hydrodynamic protective mechanism
against posteriorly oriented trauma (see ill. 16-18,
pages 69, 70). The function of this pad has been
described on several occasions, the best functional
description being provided by Zenker, an
anatomist from Vienna.
 Structures

Ill. 10: In this posterior view, the firm attachment of the articular disk to the poles is shown.

Ill. 11: This preparation shows the confluence of fibers to the condylar process.

67
R. Slavicek • The Masticatory Organ

Ill. 12: The illustration is a sagittal view. Red: the sturdy
disco-condylar layer of the bilaminar zone. Blue: the slender
disco-temporal ligament, relaxed in retral position. In retral
position, the disk is positioned on the joint head by the disco-
condylar layer.
Ill. 13: In a protrusive position, the disco-temporal ligament
is taut and the lower layer relaxed. The retral joint area of
the bilaminar zone is filled with veins.

Ill. 14: This picture shows the sagittal section, in which the inter-relationships are clearly seen. The bilaminar zone is evident.

68
 Structures

Ill. 15: In this specimen, the disk and retral spaces are raised and unfolded from the condylar process.

Ill. 16: This sketch shows the extension of the bilaminar zone during average inclination of the articular eminence. The disk ends in
the zenith of the joint head, with upright head posture. The blue line passing through the condyle shows the extension of the bilam-
inar zone medially.

69
R. Slavicek • The Masticatory Organ

Ill. 17: With a rather flat eminence, the disk ends somewhat more posteriorly; the bilaminar zone has adequate possibility to
position the condyle anteriorly.

Ill. 18: With a steep eminence, the disk clearly lies in a functional anterior position, the bilaminar region extends over the zenith to
the front. This also allows the vascular apparatus to be positioned vertically.

70
 Structures

The immanent musculature system of the

temporo-mandibular joints
The position of the mandible in relation to the
articular eminence, the distance of the mandible
to the maxilla and the isometrically precise steer-
ing of dental arches to each other, are strongly
dependent on and controlled by the immanent
musculature system. I believe that the CMS mus-
cles, in view of their responsibilities, should not be
grouped together with the true masticatory mus-
cles. The muscles involved in this region are the
upper head of the lateral pterygoid, the "deep
head" of the masseter and, in approximately 30%
to 40% of cases, the fourth "frontal head" of the
temporal muscle, as described by Zenker.

Caput profundum masseteris

The so-called "deep head" of the masseter, the Ill. 19: This sketch clearly shows the differentiation of vec-
tors within the heads of the masseter muscle.
Caput profundum masseteris of modern anatomi-
cal nomenclature, requires further explanation
(see ill. 19, right).
This muscle is not a single unit. Rather, it is com-
posed of two layers which, because they are
attached to each other in their front margins,
form an open "sac" at the back. The upper layer
originates with strong bundles of tendons at the
lower edge of the zygomatic bone, extending to
the temporal zygomatic suture, and is inserted in
the outer side of the mandible. The deep layer also
inserts in the outer side of the mandible and
extends to the zygomatic arch, whereby portions
of the fibers extend under it and are inserted in
the temporal fascia. A portion of the fibers also
extend to the lateral capsule and the lateral third In Pernkopf's original terminology of topo-
of the joint trochlea. graphic anatomy, the two muscle plates have
In Pernkopf's original terminology of topographic been termed the Musculi zygomatico-
anatomy, the two muscle plates have been termed mandibulares and are thereby distinguished
the Musculi zygomatico-mandibulares and are from the true masseter.
thereby distinguished from the true masseter (see
ill. 20-23, pages. 72-73). The so-called deep head
of the masseter is also a term originating from the ... an "intelligent tendon" between the upper
new anatomical nomenclature. Nevertheless, this and lower jaw.
muscle should be described as it was originally -
namely as an independent, two-headed muscle,
because its tasks are significantly different from those Wilkinson, T.: personal communication
of the true masseter. In a personal discussion with me, Pernkopf, E.: Atlas der topographischen und angewandten
Tom Wilkinson once described it as an "intelligent Anatomie des Menschen. Platzer, W. (Hrsg.), Urban &
tendon" between the upper and lower jaw. Schwarzenberg Verlag, München 1957

71
R. Slavicek • The Masticatory Organ

Ill. 20: In this specimen, the proximity to the joint of the deep head is clearly seen.

Ill. 21: The picture shows that the mass of the superior head covers the main portion of the heads lying inferior to it.

72
 Structures

Ill. 22: Only after removal do the dimensions of the inferiorly located muscles become evident.

Ill. 23: The deep head itself consists of two heads, with somewhat different functions.

73
R. Slavicek • The Masticatory Organ
Ill. 24: This sketch of vectors is an attempt to illustrate the
differences. The posterior portions are functionally related to
the temporal fascia and the lateral portion of the joint.
Ill. 25: The distinct vector of the inferior head of the lateral
pterygoid muscle establishes this powerful muscle as the
"protractor" of the mandible.
Kunzl, G.: Makroskopische Untersuchungen der Kau-
muskulatur und ihre Beziehungen zum Kiefergelenksdiscus.
Dissertation a. d. Med. Fakultät Univ. Wien, 1994
Juniper, R. P.: Temporomandibular Joint Dysfunction: A
Theory Based upon Electromyographic Studies of the Lateral
Pterygoid Muscle. Br. J. Oral Maxillofac. Surg. Feb. 22 (1). P.
1–8, 1984
Juniper, R. P.: Electromyography of the Two Heads of
External Pterygoid Muscle via the Intra-Oral Route.
Electromyogr. Clin. Neurophysiol. Jan.–Feb. 23 (1–2). P.
21–33, 1983
Juniper, R. P.: The Superior Pterygoid Muscle?
Br. J. Oral Surg. Jun. 19 (2). P. 121–8, 1981
74
The description "intelligent tendon" implies the
possibility that maintenance of variable translato-
ry distance can be programmed during function,
in order to maintain perfect functional translation,
appropriate to the bolus. The fibers inserting in
the condyle, the capsule and the disk are liable to
laterally contract the capsule and, thereby, the disk.
Again, the anatomist Pernkopf refers to both
heads as the zygomatic-mandibular muscles
(Caput superficialis et profundum), thereby dis-
tinguishing them from the true masseter.
Observations from Kunzl's dissertation, initiated
by myself, confirm and expand on this view.
In addition, they differ with regard to their vec-
tors as well as from the viewpoint of muscle phy-
siology and their innnervation. They provide sta-
bility for the mouth (intelligent tendon), and also
serve as an active, muscular "jumping sheet", sta-
bilizing the lateral open space. Contraction during
the closing phase of mastication induces a median
centralizing movement of the condyles (see ill. 24
and 25, left). In a new scientific study by Kunz et.
al., the insertion of fibers on the temporal fascia
has been given a new meaning and functional
interpretation.
Musculus pterygoideus lateralis
caput superius
This muscle has been a subject of controversy over
the last two decades. Originally it was thought to
be the synergist of its counterpart, the inferior
head, and was thus described in the old anatomy
literature as the active "protractor" of the articular
disk. Electromyographic studies have proven,
however, that it normally works asynchronously
to the inferior head, which may be described as
the protractor of the mandible in symmetric or
asymmetric function (see ill. 26, p. 75). The supe-
rior head of the lateral pterygoid extends from its
origin at the sphenoid bone in the skull, posteri-
orly and inferiorly, and inserts in the median half
of the condyle, using the eminence as a hypo-
mochlion. Portions of the fibers also insert direct-
ly or indirectly on the articular capsule and on the
articular disk. The direct insertion in the articular
disk is more noticeable in fetal, infant and adoles-
cent articulations than in temporo-mandibular
joint specimens of older individuals. This may
have led to the numerous discussions in the last
few years, in which the direct insertion at the

articular disk has been disputed (comp. Juniper,
et. al.). The function of the muscle has been
described by several authors and has been repea-
tedly investigated by electromyography. Like the
deep head of the masseter, it is active during clos-
ing. It centers the condyle against the eminence
and is slightly active in a non-occlusally support-
ed "resting position", the so-called floating rest
position. This indicates its importance as an anti-
gravitational centering system (see ill. 27, p. 76).
Its connection to the capsule and, directly or indi-
rectly, to the disk, may function as a tight stabi-
lizer of these areas during rapid movement.
Hollmann once described the function of the
articular disk as an "active jumping sheet for the
condyle" (see ill. 28, p. 76).
The frontal head of the Musculus temporalis
In approximately 30% of the cases (comp.
Zenker, Kunzl), this portion of the temporal mus-
cle inserts between the masseter and the pterygoid
in the condylar process, the capsule and the disk.
It is also active during closing and is therefore
involved in "centering".
All muscles of the immanent musculature system
have an anteriorly oriented vector. Thus, contact
with the eminence is maintained through a nearly
"passive" state of readiness. One of the main res-
ponsibilities of this articular musculature appears to
be muscular centering of the mandible against the
cranium, made necessary by the evolutionary
change to the upright position. The numerous
fibers to the capsule may be interpreted as capsule
tensors. There is no doubt about the fact that mus-
cle fibers of the immanent musculature system also
extend to the articular disk. This is especially evi-
dent in the articulation of infants and adolescents
(see ill. 29-36, pages. 77-79). In the preparatory
access from above, the practicality of the cranio-
mandibular musculature becomes most evident.
The vectors establish the postural area of responsi-
bility, anteriorly against the eminence (see ill. 37-
42, pages. 80-81). From this viewpoint, the entire
ventral portion of the condylar process is a large
muscular cavity, offering possibilities of insertion
for muscles of the CMS (see ill. 43, p.82).
Electromyographically, the asynchronous functions
of both heads of the lateral pterygoid can be
proven under physiological conditions (comp.
Tauber), (see ill. 44-48, pps. 82-83).
Structures
Ill. 26: In humans, the function of the superior head of the
lateral pterygoid muscle is asynchronous to that of the inferi-
or head and inserts in the condyle itself, as well as, in the
capsule and the articular disk.
Wilkinson, T.: The Relationship between the Disc and
Lateral Pterygoid Muscle in the Human
Temporomandibular Joint. J. Prosthet. Dent. 60: 715, 1988
Wilkinson, T. M., Mahan, P. E., Gibbs, C. H., Mauderli, A.,
Bronnon, L. S.: Superior and Inferior Bellies of the Lateral
Pterygoid Muscle EMG Activity at Basic Jaw Positions.
J. Prosth. Dent. 50: 710, 1983
Wilkinson, T., Chan, E. K.: The Anatomic Relationship of
the Insertion of the Superior Lateral Pterygoid Muscle to
the Articular Disc in the Temporomandibular Joint of
Human Cadavers. Aust. Dent. J. Aug. 34 (4): 315–22, 1989
Wilkinson, T., Crowley, C., Piehslinger, E., Wilson, D.,
Czerny, C.: Correlations between Anatomic and MRI
Sections of Human Cadaver Temporomandibular Joints in
the Coronal and Sagittal Planes. J. Orofac. Pain. 10 (3):
199–216, 1996
Fukuda, Y., Yoshida, K., Inoue, H., Suwa, F., Ohta, Y.:
An Experimental Study on Inserting an EMG Electrode to
the Superior Head of the Human Lateral Pterygoid Muscle.
J. Jpn. Prosthodont. Soc. 34: 902, 1990
Yoshida, K., Fukuda, Y., Takahashi, R., Nishiura, K., Inoue, H.:
A Method for Insertion the EMG Elektrode into the
Superior Head of the Human Lateral Pterygoid Muscle.
J. Jpn. Prosthodont. Soc. 36: 88, 1992
Meyenberg, K., Kubik, S., Palla, S.: Relationship of the
Muscles of Mastication to the Articular Disc of the
Temporomandibular Joint. Schweiz. Monatsschr. Zahnmed.
96: 815, 1986
Yoshida, K., Inoue, H.: An Electromyographic Study on the
Lateral Pterygoid Muscle during Mastication in Patients
with Internal Derangement of TMJ. J. Jpn. Prosthodont.
Soc. 36: 1261–1272, 1992
Dauber, W.: Die Nachbarschaftsbeziehungen des Discus
articularis des Kiefergelenkes und ihre funktionelle
Deutung. Schweiz. Mschr. Zahnmed. 97: 427, 1987
75
R. Slavicek • The Masticatory Organ

Ill. 27: An electromyographic recording in a non-occlusally supported, so-called floating rest, shows the activity of the superior head,
establishing its function as a postural muscle. When active, it holds the condyle against the disk, and disk to the eminence.

Ill. 28: A symbolic photograph showing the "jumping-sheet" nature (Hollmann) of the system.

76
 Structures

Ill. 29: This sketch makes it clear that the superior head may Ill. 30: The joint trochlea of a newborn shows the distinct attach-
also consist of several heads , or if you will, one head with ments of muscles to the disk. The main portion of the superior
two different anatomical insertions (Wilkinson). head, however, inserts in the condylar process.

Ill. 31: This picture makes it clear that the muscle bundles are in direct contact with the capsular collagen tissue and with the mar-
ginal region of the disk.

77
R. Slavicek • The Masticatory Organ

Ill. 32, 33: Direct insertion is seen under strong magnification.

78
 Structures

Ill. 34: In the polarization

microscope, the brightly lit
musculature can be clearly dis-
tinguished from the slightly
undulating structure of colla-
gen fibers.

Ill. 35: Noticeable, in this

purely sagittally oriented sec-
tion, is the larger quantity of
"transversally intersected"
bundles, relative to the anteri-
orly arranged bundles, which
cannot possibly correspond to
the sagittal vector of the
pterygoid muscle.

Ill. 36: In a view created by a

lateral access, it is difficult to
display the spatial arrange-
ment of muscles according to
their vectors. Green: portions
of the deep head of the mas-
seter muscle.
White: the disk.
Red: the superior head of the
lateral pterygoid muscle.
Yellow: the head of the tempo-
ral muscle.

79
R. Slavicek • The Masticatory Organ

Ill. 37: The picture shows the entry from

the middle cranial fossa.

Ill. 38: A representation of the

entry area.

Ill. 39: Removal of the bony

covering.

80
 Structures

Ill. 40: The morphology of the

structures from cranial view.
White: the articular disk.
Green: the deep masseter.
Red: the superior head of the
pterygoid muscle.
Black: the masseter nerve.

Ill. 41: This picture shows a

specimen with a clearly distin-
guishable temporal portion
(yellow).

Ill. 42: A representation of

vectors with a receding tempo-
ralis.

81
R. Slavicek • The Masticatory Organ

Ill. 43: This spatial representation of a computerized tomograph establishes

the anterior portions of the joint cavity as actual muscular fovea.

Ill. 44: Only the inferior heads of the lateral pterygoid muscles are active when the mouth remains continuously open.

Ill. 45: If the test subject bites onto the incisal edges, simultaneous activity in the midle temporal muscle and in the inferior head of
the pterygoid muscle is seen.

82
 Structures

Ill. 46: A comparison of a

functionally normal test sub-
ject with a functionally
abnormal patient shows that
in the former, the tap-open
action proceeds asynchro-
nously in the superior and
inferior heads, but synchro-
nously in the abnormal
patient.

Ill. 47: This is also the case

in rapid execution.

Ill. 48: In a patient with a

strong functional disorder,
permanent activity is seen in
both heads of the lateral
pterygoid muscle.

83
R. Slavicek • The Masticatory Organ
Ill. 49: An average protrusive movement creates positive out-
ward pressure to the vector of the inferior head of the lateral
pterygoid muscle, causing synovia to be expelled.
Ill. 50: An incursive movement reduces the pressure, and
synovia is sucked in.
• Ligamentum sphenomandibulare
• Ligamentum stylomandibulare
• Ligamentum stylohyoideum
• Ligamentum pterygospinale
84
The synovial apparatus
The predominantly translatory function of
mandibular movement requires maximum fric-
tion-free gliding of the condyle-disk assembly on
the eminence. Because of the vector of the inferi-
or head of the lateral pterygoid, a positive anteri-
orly directed inter-capsular pressure results from
protrusive movement, whereby synovial fluid is
expelled. In the recovery phase, a low-pressure si-
tuation occurs, i.e., a potential vacuum, which
causes the synovia to be sucked back into the
complex. This is the physiological basis for joint
metabolism (see ill. 49 and 50, left). In all cases of
functional disturbances of the condyle-disk assem-
bly, joint metabolism is jeopardized, due to an
innate absence of a vascular supply system.
Extended ligamentous attachments
The mandible and the hyoid in Homo sapiens are
ligamentously self-centering, fixed to (or rather
suspended from) the skull by three ligaments (see
ill. 51, p.85). Because of their course and their
detailed fiber distribution, they are ideally suited
for centering the mandible "non-muscularly,
involving minimal activity on the part of the pos-
tural musculature. The following ligaments exist
(see ill. 52-57, pages. 87-88):
• Ligamentum sphenomandibulare
• Ligamentum stylomandibulare
• Ligamentum stylohyoideum
• Ligamentum pterygospinale
Ligamentum sphenomandibulare
This ligament extends from the angular process of
the sphenoid to the lingula of the mandible in the
entry area of the bundle of mandibular neural
fibers, and lies between the inferior head of the
lateral pterygoid and the medial pterygoid.
Practically, it has approximately the same vector
as these muscles and approximates their passive
extended position. As a ligament, it holds the
ascending branch between the two muscles and
centers the mandible simultaneously to the mid-
dle and anteriorly against the eminence, without
having to utilize the strength of the two mastica-
tory muscles.
 Structures

Ill. 51: A clear display of the cranio-mandibular suspension by a self-centering ligamentary apparatus (posterior view).

85
R. Slavicek • The Masticatory Organ
Details of cross-meshing, which affords the
ligament the ability of active recovery from
the medio-eccentric position.
Platzer, W., Pomaroli, A.: personal communication
Platzer, W., Pomaroli, A.: Zur Anatomie der Kiefergelenke.
Fortschr. Kiefer-Gesichtschir., 25: 1–2, 1980
Rocabado, M.: Physical Therapy for the Postsurgical TMJ
Patient. J. Craniomandib. Disord., 3 (2): 75–82, 1989
Rocabado, M.: The Importance of Soft Tissue Mechanics in
Stability and Instability of the Cervical Spine: A
Functional Diagnosis for Treatment Planning. Cranio., Apr.
5 (2): 130–8, 1987
Rocabado, M.: Biomechanical Relationship of the Cranial,
Cervical and Hyoid Regions. J. Craniomandibul. Pract.,
Jun.–Aug. 1 (3): 61–6, 1983
86
Ligamentum stylomandibulare
It extends from the styloid process to the inner
side of the angle of mandible, where it expands
fan-like, and meshes in the fascia of the medial
pterygoid. This fan-shaped structure displays details
that are histomorphologically interesting regard-
ing cross-meshing, which afford the ligament the
ability of active recovery from the medio-eccentric
position.
Ligamentum stylohyoideum
This ligament also extends, along with the stylo-
mandibular ligament, from the styloid internally,
anteriorly and inferiorly, and subsequently also
meshes with intermediate fibers. Here again, the
result is tension within the intermediate fibers
during eccentric movement to the mediotrusive
side. Median muscular movement is followed by a
"ligamentary" return of the mandible to the mid-
dle (comp. Platzer). These ligaments are impor-
tant from the viewpoint of both function and dys-
function, and must be given due consideration
during diagnostic procedures.
Ligamentum pterygospinale
An additional aspect of the significance of the lig-
amentary structures is seen in the pterygospinal
ligament. This short but powerful attachment
might have been involved in ontogenetic vertical-
ization in the transfer of tension from the sphe-
nooccipital syndesmosis in the viscerocranium. Its
insertion in the posterior margin of the pterygoid
process would be suitable for effecting an indirect
transfer of tension onto the vomer bone during
the rotation and expansion phase in the ontoge-
netic process towards bipedal locomotion, and a
simultaneous expansion in breadth of the neuro-
cranium. This influence on the action of the
vomer might be important for Dr. Sato's growth
prognosis, which I will refer to later in the discus-
sion of cranial structures.
The so-called "alpha" ligament
Rocabado postulates a ligamentary loop, which
connects the hyoid and the cervical spine. From
this viewpoint, alterations in flexion of the cervi-
cal spine have a direct effect on the position of the
hyoid and thereby also on the position of the
mandible. In Rocabado's diagnostics, this liga-
ment’s status is considered highly significant and
influences his therapeutic approach.
 Structures

Ill. 52: The stylohyoid ligament and the stylomandibular ligament from a posterior view.

Ill. 53: The temporo-mandibular ligament, the stylomandibu- Ill. 54: This illustration shows the pterygomandibular liga-
lar ligament and the stylohyoid ligament from a lateral view. ment and the stylomandibular ligament from a medial view.

87
R. Slavicek • The Masticatory Organ

Ill. 55, 56: This illustration is an attempt to illustrate the detailed structure of the stylomandibular ligament on the inner side of the
mandible.

Ill. 57: Tension and relaxation in eccentric movement.

88
 Structures

Summary
H. Sicher's description of the temporo-mandibular
joint as a synovial, gliding joint with a moveable
socket is undisputed. The joint capsule is spacious,
allowing for a high degree of translation. The
temporo-mandibular ligament is a practical rein-
forcement of the capsule, and serves as a diverter
in cases of rapid retral movement towards the cra-
nium. Strong loads are placed on the temporo-
mandibular ligament in cases of high vertical loss
(anodontism, sunken total prosthesis), necessita-
ting a forward shift of the mandible. It influences
the course of mandibular marginal movements in
Posselt's scheme.
The retral vascular pad offers protection against The human temporo-mandibular joints have
trauma directed posteriorly, but also functions as assumed responsibility for a significantly
an elastic, hydrodynamic buttress during mastica- expanded functional area. They are not joints
tion and speech and as a three-dimensional place-
in the true sense of the word, but rather con-
ment mechanism for interference-free recovery
into the normal occlusal position without sub- stitute a new system in conjunction with
stantial guidance from muscles. other structures. The system may be termed
The musculature of the CMS centers the condyle the cranio-mandibular system or CMS.
against the articular eminence. This immanent
musculature system is active in non-occlusally
supported maintenance of functional readiness
(the "floating rest"), and in activities involving the
closing muscles.
It is not active in eccentric dynamics in function-
ally healthy individuals.
The so-called "deep head" (actually two heads) of
the masseter (Musculus zygomaticomandibulare)
functions both as a positioning mechanism for the
vertical distance of occlusion and as a lateral bor-
der (jumping sheet) for condylar movement. Its
contraction at the end of the mastication loop cen-
ters the mandible from a lateral position as a mus-
cular "jumping sheet" in a medial direction ("in-
shift"). The closing muscles (adductors) move the
mandible cranially and anteriorly to reach the
occlusal position. In this setting, the muscles of
the CMS take over the fine tuning of articular
structures and centering to the eminence.
During protrusive translation, a positive pressure
is created in the synovial joint and synovial fluid is
expelled. When the retractor muscles pull the
mandible back from the protruded position, the
pressure is reduced and the synovial fluid is
sucked in. Joint metabolism is maintained
through these movements.

89
R. Slavicek • The Masticatory Organ
The neuromuscular system adds dynamics to
the remaining structures of the masticatory
organ.
The human, standing or sitting upright, car-
ries or "balances" the head on two relatively
small articular surfaces of the atlanto-occipital
joint between the cranium and cervical spine.
90
The Neuromuscular
System (NMS) -
muscles of the
masticatory organ
The neuromuscular system adds dynamics to the
remaining structures of the masticatory organ. It
assumes the responsibility of determining func-
tionally appropriate processes in so-called move-
ment patterns. The required information is pro-
vided by proprioceptive signals from other struc-
tures and internal system controls.
The previously described modifications and exten-
sions of the functional range in the human masti-
catory organ apply to a great extent to muscles, in
which there are also considerable overlapping
areas of responsibility to be mastered. Two illus-
trative examples are the functions of head posture
and speech. The human, standing or sitting
upright, carries or "balances" the head on two re-
latively small articular surfaces of the atlanto-
occipital joint between the cranium and cervical
spine. This task is performed in humans in a com-
plicated way, through an evolutionarily practical
restructuring of the muscle groups. Posteriorly,
the muscles are able to achieve a kind of "flexible"
dynamic balance by means of the widely project-
ing atlas and the phylogenetically and ontogene-
tically prepared cervical spine, in order to afford
the receptor systems, the eyes and ears, optimal
contact with the environment, whereby the
mobile pectoral girdle has a stabilizing effect. The
eyes will always strive to seek a horizontal neutral
position with the horizon. Ventrally, postural con-
trol is anchored in the sternum and clavicle and
extends to the mandible by means of the move-
able hyoid.
 Structures - the Neuromuscular System

The mandible itself is, in turn, muscularly

attached to the cranium. This interrupted and
therefore indirect attachment serves to maintain
postural balance, but is also required to perform
other important functional tasks. One of these is One of these is communicative speech, the
communicative speech, the "transmitter" for "transmitter" for establishing contact with
establishing contact with others in the environ- others in the environment.
ment. Dynamic head posture and speech, a high-
precision motoric feat, need to be carried out
simultaneously, and are a small example of the
extensive additional responsibilities that the neu-
romuscular system must carry out as a result of
man's evolution to Homo. Naturally, the condi- Naturally, the condition of the "receiving sys-
tion of the "receiving system", the sensory organs, tem", the sensory organs, is of great impor-
is of great importance to the muscles. Optical or tance to the muscles.
acoustic stimuli are especially important for the
mobile overall posture of the head (see ill. 58-66,
p. 92-93). The NMS requires paramount consid-
eration in the diagnostics of the functions and dys-
functions of the masticatory organ, as the adapta-
tion and compensation mechanisms for maintain-
ing undisturbed functionality are mainly per-
formed here. For this reason, problems in the
NMS are disorders that are recognized by the
patient and cause him/her to report for regular
check-ups or for physiotherapy. Often, these prob-
lems affect the cervical spine and overlap into
functional areas of the stomatognathic system. It
would be a great error in judgment to regard
these problems only from the viewpoint of the
complex joint mechanics of the cervical spine and
the atlanto-occipital attachment and not from the
standpoint of the musculature. In the sequence of
examining the functional state of the masticatory
organ, a careful, standardized investigation of the
NMS must be given first priority. This is not pos-
sible, however, without basic knowledge of the
morphology of the muscular system. The mor-
phological concept mentioned here is meant to
denote its original meaning, namely the "form
and dynamics of structural units". The NMS of
the masticatory organ may in no way be viewed in
isolation during the examination. Associations
with problems of overall physical posture must be
considered, especially those between special groups
of the NMS and the temporo-mandibular joints. In
addition, other areas are also very important e.g.,
it is essential to study the overall functions of the
masticatory organ. Knowledge of the anatomical
makeup and functions of the NMS is a prerequi-
site for understanding function and dysfunction.

91
R. Slavicek • The Masticatory Organ

Ill. 58-66: The human head with its face is distinguished by the sensory organs.
Mobility of the head is a precondition for the receptor systems of the eyes, ears
and nose. Tilscher describes the cervical spine as an additional sensory organ. The
masticatory organ, head and neck are a functional unit of the bipedal human
being.

Ill. 59 Ill. 60

92
 Structures - the Neuromuscular System

Ill. 61 Ill. 62

Ill. 63 Ill. 64

Ill. 65 Ill. 66

93
R. Slavicek • The Masticatory Organ
Dynamic registration of mandibular move-
ment, which a part of this book is devoted to,
is not at all simple (and is almost derogatorily
referred to as "jaw-tracking" in current jar-
gon) but indicates, in complex form, the rela-
tionship between muscle and joint.
94
The morphology and responsibilities of the mus-
culature are described in the following section.
Knowledge of these aspects is necessary in order
to understand the dynamic processes of mandibu-
lar movements and the functional responsibilities
associated with them. Dynamic registration of
mandibular movement, which a part of this book
is devoted to, is not at all simple (and is almost
derogatorily referred to as "jaw-tracking" in cur-
rent jargon) but indicates, in complex form, the
relationship between muscle and joint.
Morphology, functions, innervation and basic vec-
tor principles must be described in detail, as this
information is needed for sufficient comprehen-
sion of the subject. The central functions overlap
other functional areas to a great extent. Within
the scope of dental medicine, it is necessary to
have profound knowledge of these crucial areas.
The musculature of the
masticatory organ
• Innervation by the Nervus trigeminus
V/3, portio minor
• Musculus temporalis
• Musculus masseter
• Musculus pterygoideus medialis
• Musculus pterygoideus lateralis
• (Musculus tensor tympani)
• Innervation by the Nervus facialis
• Musculus biventer, venter mastoideus
• Musculus stylohyoideus
• (Musculus stapedius)
• Musculus levator veli palatini
• Musculus uvulae
• The mimic musculature
• Musculi epicranii
• Musculus depressor glabellae – muscles
around the palpebral fissure
• Musculus corrugator glabellae
 Structures - the Neuromuscular System

• Musculus orbicularis oculi

• Platysma
• Musculus quadratus labii inferius
• Musculus mentalis
• Musculus triangularis
• Musculus risorius
• Musculus zygomaticus major
• Musculus zygomaticus minor
• Musculus infraorbitalis
• Musculus angularis
• Musculus caninus
• Musculus buccinator
• Musculus orbicularis oris
• Musculus nasalis - muscle on the
auditory aperture
• Musculus auricularis temporalis
• Musculus auricularis nuchalis

• Innervation by Nervi glossopharyngicus

and vagus (muscle in the rhomboid fossa)
• Musculus tensor veli palatini
• Muscles of the pharynx

• Innervation by Nervus vagus (Nucleus

ambiguus, Nucleus laryngicus in the
rhomboid fossa)
• Muscles of the larynx

• Innervation by Nervus accessorius

(muscle core in the cervical cord)
• Musculus sternocleidomastoideus
• Musculus trapezius

• Innervation by Nervus hypoglossus

(muscle core in the rhomboid fossa)
• Musculus geniohyoideus
• Musculi linguae (tongue)

95
R. Slavicek • The Masticatory Organ
Ill. 67: The converging fibers insert in the coronoid process of
the mandible.
It is an adductor, retractor, laterorotator and,
in a case of a frontal head, a muscle of the
CMS, with the task of centering the condyle
against the eminence.
Zenker, W.: Über die mediale Portion des M. temporalis und
deren Funktion. Österr. Zschr. f. Stomatol., 51: 550–554, 1954
Zenker, W., Zenker, A.: Zur funktionellen Anatomie des
M. temporalis. Dt. Zahn-, Mund- und Kieferheilkunde, 24:
368–375, 1956
96
Musculus temporalis
The temporal muscle (see ill. 67, left) is a muscle
plate resembling the sector of a circle, filling the
temporal fossa and covering the bone forming the
temporal plane with its field of insertion. In the
skull of a newborn, it extends up to the superior
border of the squamous part of the temporal bone.
With the eruption of teeth, its insertion is shifted
higher on the lateral surface of the cranium.
Along with its rough fibers it forms the two tem-
poral lines on the lateral wall of the skull. Its vari-
able and individual origin in bone extends forward
to the zygomatic process of the frontal bone,
backwards behind the auricle to the supramastoid
ridge and down to the infratemporal ridge. The
temporal fascia serves as its origin. The fibers of
the temporal muscle converge to the inferior exit
of the temporal fossa. The outer side of the mus-
cle indicates an individually proportional tendon
arrangement. The muscle forms a very strong ter-
minal tendon, which extends under the zygoma-
tic arch and inserts in the coronoid process of
the mandible. The most anterior portions of the
muscle frequently (30%) form a frontal section
(comp. Zenker), which is inserted in both, the
coronoid and (with receding fibers) into the
condylar process. The functional details of this
variation are described in the section dealing with
the CMS musculature.
Functions of the Musculus temporalis
It is an adductor, retractor, laterorotator and, in a
case of a frontal head, a muscle of the CMS, with
the task of centering the condyle against the emi-
nence.
The temporal muscle is assigned to the group of
adductors and raises the mandible in closing
movement. Because of its differential fibrous
arrangement and its slightly anteriorly conver-
ging overall vector, it is not only an adductor but
also a retractor, and can rotate the mandible
somewhat laterally. Its posterior portions, which
extend anteriorly almost horizontally, induce
retraction of the protruded lower jaw. This part of
the muscle is an antagonist of the inferior head of
the lateral pterygoid muscle.
As mentioned earlier, approximately one third of
all humans have a frontal head with receding
 Structures - the Neuromuscular System

fibers leading to the condyle, which is involved in

the immanent musculature system of the CMS.
Its insertion in the coronoid process (processus
muscularis), which it encompasses in a variable
fashion both directly and with tendons, permits
precise control of intercuspation (see ill. 68, right).

Innervation of the Musculus temporalis

V/3 pars. mot., Nn. temporalis prof. 2-3

Musculus masseter
The true masseter muscle (ill. 69, right) is a some-
what rectangular, powerful muscle plate, extend- Ill. 68: The vectors of the muscle that executes closing and
ing obliquely from inferior-posterior to anterior- retraction functions. In a bald individual, the sequence of
contraction during mastication can be seen very clearly.
superior, attaching the mandible to the cranium.
Underneath are two additional flat muscle plates,
which are combined in the accepted modern ter-
minology and designated the deep head of the
masseter muscle. No distinction is made between
the two; together they are known as the deep
head. As the two muscles cannot be assigned to
the masseter, either with regard to their vector,
function or characteristics, from a diagnostic
standpoint they must be distinguished from the
true masseter in the stomatognathic system.
They consist of two layers hanging together in the
anterior margin and forming a sac, which opens at
the back. The surface layer originates in the infe-
rior border of the zygomatic bone in powerful
bundles of tendons, extends back to the temporal
zygomatic suture and inserts in the process of
mandible. The inferior layer also inserts in the
outer side of the mandible and extends to the
arcus zygomaticus, whereby, parts of the fibers Ill. 69: In the above illustration, one mainly sees the superior
head, with its vector progressing to anterior-superiorly. The
extend underneath and are inserted in the tempo-
so-called deep head is detectable very close to the joint and
ral fascia. However, some of the fibers also extend can be distinguished by its fiber arrangement.
medially to the lateral pole of the condylar
process.
In the original terminology of topographic anato-
my, Pernkopf termed these two muscle plates the
Musculi zygomatico mandibulares, thereby distin-
guishing them from the true masseter.
Pernkopf, E.: Atlas der topographischen und angewandten
Anatomie des Menschen. Platzer, W. (Hrsg.), Urban &
Schwarzenberg Verlag, München 1957

97
R. Slavicek • The Masticatory Organ
Ill. 70: The vector of the superior head shows the direction of
closing and centering movements.
Ill. 71: Illustrating the vector is an attempt to show the vari-
ous tasks of the deep heads and their significance for the
CMS. In protrusion, the muscle plate secures the joint head
in a lateral direction.
Dauber, W.: Die Nachbarschaftsbeziehungen des Discus
articularis des Kiefergelenkes und ihre funktionelle Deutung.
Schweiz. Mschr. Zahnmed., 97: 427, 1987
98
Functions of the Musculus masseter
It is an adductor, laterotractor and laterorotator.
The masseter is the "lifter" (adductor) of the lower
jaw (see ill. 70, left). Its anterior-superior vector
centers the mandible and thereby the condylar
process against the articular eminence of the tem-
poral bone. In conjunction with the medial ptery-
goid (comp. Dauber) it forms a functional unit
known as the pterygoid-masseter loop. Vector
analysis shows that, in addition to the closing
function, this unit also has the ability to shift the
mandible laterally and to rotate it a little.
Innervation of the Musculus masseter
Innervation is provided by the masseteric nerve
(V/3 pars motorica). The masseteric nerve extends
from anterior to the condyloid process of
mandible, laterally and posteriorly to the mas-
seter. It belongs to the motoric portion of the
trigeminus nerve.
The so-called "deep head" of the masseter and its
functions will be discussed in the description of
the immanent musculature system of the CMS
(see ill. 71, left).
Musculus pterygoideus medialis
This muscle (see ill. 72, p. 99) is a synergist to the
masseter, located on the inner side of the
mandible and linked with the masseter through a
strip of tendon, so that together they form a
strong loop around the angle of the mandible.
The loop encompasses not only the posterior por-
tion of the horizontal branch of the mandible but,
like a sac, also the posterior border of the ascend-
ing branch. The medial pterygoid is at approxi-
mately the same level as the masseter, only half as
wide but twice as thick and, in contrast to the
sagittal arrangement of the masseter, is located
somewhat towards the front. Its short but power-
ful traction originates in the pterygoid fossa and
the pyramidal process of the palatal bone and
pulls obliquely posteriorly, inferiorly and laterally,
finally inserting in the inner side of the angle of
the mandible and the pterygoid tuberosity. Its
fibers often intertwine with those of the inferior
head of the lateral pterygoid.
 Structures - the Neuromuscular System

Functions of the Musculus

pterygoideus medialis
It is an adductor and mediotractor. The medial
pterygoid is the powerful closer (adductor) of the
mandible. It belongs to the group of jaw eleva-
tors, along with the masseter and temporalis
muscles. Unilaterally innervated, it is a powerful
mediotractor that is frequently involved in the
occurrence of bruxism. Its vector extends from
inferior-posterior-external to anterior-internal-
superior (see ill. 73, right).
Innervation is supplied from V/3 pars. mot., by
the medial pterygoid nerve.

Musculus pterygoideus lateralis caput Ill. 72: The morphological units of the medial pterygoid
inferius muscle with the masseter and the inferior head of the lateral
pterygoid muscle are illustrated here. The sac-like enveloping
of the angle of the mandible as a loop is clearly seen. (person-
This powerful muscle (see ill. 74, p. 100) is shaped
al communication Prof. Dauber)
like an obliquely lying pyramid, approximately
5 cm in length, with a base measuring approxi-
mately 4x2 cm. The muscle lies in the infratem-
poral fossa of the sphenoid and originates in the
outer surface of the wide lateral lamina of the
pterygoid process and in the infratemporal fascia
of the maxilla. In terms of function it is to be
strictly distinguished in humans from the superi-
or head of the same name. The muscle inserts in
the pterygoid fovea on the anterior side of the
condylar process. At the site of origin its fibers fre-
quently interweave with those of the medial
pterygoid.

Functions of the Musculus

pterygoideus lateralis caput inferius
It is a protractor and, in case of unilateral action,
a mediotractor. The vector of this muscle (see ill.
75, p. 100) is nearly horizontal; its origin is ante- Ill. 73: The vector of the medial pterygoid muscle is directed
rior-median. Its insertion in the condylar process superiorly, anteriorly and, above all, inward.
lies posteriorly and laterally, so its fibers extend
from the insertion anteriorly and internally. It is a
protractor of the mandible and initiates every
muscular function of the masticatory organ, from
the relative or absolute retral position of the
mandible, in resting position.
Because of its horizontal-oblique vector, it is an
efficient mediotractor with unilateral innervation .

99
R. Slavicek • The Masticatory Organ

Ill. 74: The inferior head of the lateral pterygoid muscle and the medial
pterygoid muscle are functional "partners". The superior head, also shown
(green), is assigned to the CMS-specific musculature.

Ill. 75: This illustration of the vector of the inferior head Ill. 76: The superior head, active in closing, centers the
makes its protrusive function clear. condyle against the eminence.

100
 Structures - the Neuromuscular System

In protrusion, the vector causes positive physio- The Musculus pterygoideus lateralis caput
logical pressure in the joint during the preliminary inferius is innervated from V/3 pars. mot.
gliding movement against the articular eminence
(see ill 76, p. 100), and is angled obliquely in the
opposite direction. The increase in pressure causes
synovial fluid to be expelled. This function is
important for joint metabolism. The function of
the superior head is independent of the inferior head.
The Musculus pterygoideus lateralis caput inferius
is innervated from V/3 pars. mot.

Musculus mylohyoideus
This muscle (see ill. 77, right) forms a parallel-
fibered plate, which originates with short, tendi-
nous fibers on both sides along the mylohyoid line
in the inner side of the mandible and extends pos-
teriorly to the medial pterygoid. The right and
left muscles converge to a raphe, which extends
from the symphysis of the chin to the body of the Ill. 77: The mylohyoid muscle forms the flexible floor of the
hyoid. The posterior margin of the muscle inserts mouth.
in the body of the hyoid. At approximately half
the distance the muscle forms a gap, which allows
for vessels and also a process of the sub-mandibu-
lar gland to pass through. It forms a so-called oris
diaphragm.

Functions of the Musculus mylohyoideus

This muscle is responsible for an "active floor of This muscle is responsible for an "active floor
the mouth". Both mylohyoids support the tongue of the mouth".
like an "adjustable jumping sheet" and allow it to
function. In deglutition, they raise the hyoid, with
the dental arches supporting the mandible against
the skull. However, if the hyoid is isometrically
stabilized downwards, these muscles have the
potential to depress the mandible. The floor of the
mouth is most significantly involved in the func-
tion of speech, as the high-precision motor move-
ments of the tongue require total functional coor-
dination with the floor of the mouth.

Innervation of the Musculus mylohyoideus

From V/3 pars mot. by a branch of the inferior
alveolar nerve. In the floor of the oral cavity the In the floor of the oral cavity the so-called
so-called trigeminus musculature is layered trigeminus musculature is layered beneath the
beneath the tongue's hypoglossus musculature. tongue's hypoglossus musculature.

101
R. Slavicek • The Masticatory Organ

Ill. 78: This illustration shows the origin, progress and insertion
of this complex muscle, which is involved in nearly all functions.

Ill. 79: The anterior belly, which inserts in the inner men-
tosymphysis, is supplied from the motor part of the trigemi-
nus nerve.
Ill. 80: The posterior belly originates in the mastoid notch of
the temporal bone, inferior to the longissimus muscle and the
splenius capitis muscle. Note the open angle between the sty-
lohyoid muscle and the posterior belly of the digastric muscle.
Here, the lifters and retractors of the hyoid are clearly recog-
nizable and distinguishable in terms of function.

102
 Structures - the Neuromuscular System

Musculus digastricus
This muscle (see ill. 78-80, p. 102) consists of two
muscle bellies that differ completely with regard to
their origin and are usually connected by a cylin-
drical intermediate tendon, although a large num-
ber of anatomical variations exist (comp. Platzer,
Pomeroli). The muscle extends through a fascia
loop at the hyoid and the greater horn of the hyoid.
The anterior belly originates immediately adjacent
to its counterpart in the mandible, in the digastric
fossa, and lies on the middle portion of the oris
diaphragm. Sometimes the anterior belly lies fan-
shaped on the oris diaphragm, the direction of its
fibers following those of the mylohyoid, so that the
floor of the oral cavity appears doubled. This varia-
tion and innervation of the anterior belly by the Ill. 81: The complexity of the suprahyoid muscular connec-
mylohyoid nerve indicates that both muscles origi- tions can be surmised from this illustration. The stylohyoid
nate from a common structure. muscle with its functional connection to the digastric muscle
is seen.
The posterior belly of the digastric muscle origi-
nates in the mastoid notch of the temporal bone
and resembles a cone, with its sides pressed toge-
ther. It lies inferior to the origin of the longissimus
and splenius capitis muscles, extends behind the
parotis anteriorly and inferiorly and continues to
the anterior border of the sternocleidomastoid to
the intermediate tendon of the hyoid. It is general-
ly surrounded by the stylohyoid, which forms a
genetic unit along with the posterior belly of the
digastric muscle, as indicated by the mutual inner-
vation via the facial nerve (see ill. 81, right).

Functions of the Musculus digastricus

When the hyoid is fixed, this muscle serves as a
mouth opener. After an initial protraction move-
ment by the inferior head of the Musculus ptery-
goideus lateralis caput inferius, its contraction
rotates the mandible to an extreme mouth open
position. In cases of a loose ligament structure, this
may occasionally result in anterior over-rotation. In
a case of an anatomically shorter articular eminence,
this may lead to an open mouth lock (habitual lux-
ation) (see ill. 82-86, p. 104).
When the dental arches are stabilized in a position
from the occlusion, this muscle is an efficient raiser
of the hyoid, working synergistically with the mylo-
hyoid. If the mandible is in protruding position, the Platzer, W., Pomaroli, A.: Zur Anatomie der Kiefergelenke.
muscle can carry out a symmetric or asymmetric Fortschr. Kiefer-Gesichtschir. 25: 1–2, 1980
recovery movement. Platzer, W.: personal communication

103
R. Slavicek • The Masticatory Organ

Ill. 82 Ill. 83

Ill. 84 Ill. 85

Ill. 82: Origin and insertion of the digastric muscle and

its vectors.
Ill. 83: After initial protrusion from the lateral pterygoid
muscle, the digastric muscle may serve as an extreme
opener.
Ill. 84: With cranial support, the digastric muscle acts as
a hyoid lifter.
Ill. 85: From a protrusive position, the digastric muscle is
an efficient retractor during symmetric or asymmetric
movement.
Ill. 86 (right): This sketch shows the exceptionally effi-
cient steering potential of the digastric muscle, via the
hyoid, to the mandible. Ill. 86

104
 Structures - the Neuromuscular System

Ill. 87: The total supra- and infrahyoidal complex is illustrated. The central role of the hyoid as the control point and changeover
point becomes evident.

105
R. Slavicek • The Masticatory Organ
Ill. 88: The steep, superiorly directed vector of the stylohyoid
muscle allows for retraction and lifting of the hyoid, plus the
"tightening of the loop", permitting better gliding of the
connecting tendons of the digastric muscle.
Its insertion in the loop of the fascia might
serve to promote friction-free gliding move-
ment of the digastric muscle.
The stylohyoid is innervated by the Nervus
facialis.
106
The digastric muscle is one of the most versatile
muscles of the stomatognathic system. It plays an
important role in most functions of the masticato-
ry organ, but is often neglected in diagnostics (see
ill. 81, p. 103).
Innervation of the Musculus digastricus
The mandibular belly is supplied from the third
branch of the motor portion of the trigeminal
nerve. The mastoid belly is supplied by the facial
nerve.
Musculus stylohyoideus
The stylohyoid (see ill. 88, left) is a rounded mus-
cle originating from and around the styloid
process. Near the hyoid, it mainly surrounds the
tendons of the digastric muscle and inserts in the
loop of its tendon and the body of the hyoid. The
muscle lies posterior to the Musculus styloglossus
and superior to the Musculus stylopharyngicus.
Functions of the Musculus stylohyoideus
The stylohyoid retracts the hyoid to a posterior-
superior position during deglutition. Its insertion
in the loop of the fascia might serve to promote
a friction-free gliding movement of the digastric
muscle.
Innervation of the Musculus stylohyoideus
The stylohyoid is innervated by the Nervus facialis.
Musculus geniohyoideus
This short, powerful muscle (see ill. 89 and 90, p.
107) lies on the oris diaphragm and supports the
floor of the oral cavity. It originates in the crest of
the geniohyoids and its muscle fibers join those of
the Musculus genioglossus. It inserts in a wide
ridged area on the outer side of the body of the
hyoid.
 Structures - the Neuromuscular System

Ill. 89: The origin and insertion of the geniohyoid muscle shows that it is an efficient elevator of the hyoid, and
is also a powerful jaw opener when the hyoid is fixed. Along with the mylohyoid muscle, it is substantially
involved in deglutition.

Ill. 90: The geniohyoid muscle is illustrated from a superior view. This picture shows its position relative to the
mylohyoid muscle.

107
R. Slavicek • The Masticatory Organ

Functions of the Musculus geniohyoideus

This muscle pulls the hyoid anteriorly and raises it
superiorly. When the hyoid is fixed, it lowers the
mandible. The geniohyoids, mylohyoids and
digastric muscles raise the tongue during degluti-
tion like a plunger, to a superior-anterior position,
so that the bolus is forced against the isthmus of
fauces when the lips are closed.

Innervation of the Musculus geniohyoideus

The geniohyoid is innervated by the Nervus
hypoglossus.

Musculus genioglossus
This tendinous muscle originates in the double-
cusped spine of the genioglossi (Spina muscularis)
along with its contralateral counterpart, and is the
most powerful of the lingual muscles. The fibers
of both Musculi genioglossi extend radially to the
tip, the back, and into the floor of the tongue.
They form the lingual aponeurosis and simultane-
ously the main body of the vertically ascending
fibers.

Function of the Musculus genioglossus

This muscle lowers the back of the tongue and
effects an outward extension of the tongue. In
cases of unilateral paralysis, the tongue is inclined
to move to the non-affected side, whereas the
opposite may happen in unilateral hyperactivity.
The tendons are liable to initially calcify and after-
wards ossify with advancing age, especially in
edentulous patients with severe atrophy.

Musculus hyoglossus
This muscle originates in the greater horn of the
hyoid and extends to superior-anterior, where it is
inserted in the outer aspect of the M. genioglossus,
separated by the inferior longitudinal muscle. The
M. genioglossus and M. hyoglossus form a channel,
called the lateral lingual groove, in which the supe-
rior lingual aponeurosis extends to the tongue.

108
 Structures - the Neuromuscular System

Functions of the Musculus hyoglossus

The Musculus hyoglossus also belongs to the ver-
tical-fiber group. It extends to the lingual aponeu-
rosis and acts as a retractor of the tongue. Several
bundles of the Musculus chondroglossus, which
originate in the lesser Corno minus, lie on the
inner side.

Musculus styloglossus
It originates in the Processus styloideus and the
Ligamentum stylomandibulare, passes through
the body of the tongue from behind and joins the
fibers of the superior longitudinal muscle. It
extends to the tip of the tongue and "meets" there
with its counterpart.

Function of the Musculus styloglossus

The function of the Musculus styloglossus is to
change the shape of the tip of the tongue and the
anterior margin.

Musculi linguae (the tongue)

Because of the several finely bundled muscle spin-
dles in the lingual musculature, the tongue is
exceptionally mobile. It is involved in the "milk- It is involved in the "milking action" of infant
ing action" of infant mammals. This first instinc- mammals.
tive behavior pattern is simplified and falsely
described as "suckling". This implies that the
mother's milk is "sucked out" by active sucking
from a vacuum created by the diaphram through
the pulmonary system. This is incorrect. This
mechanism should be termed a milking action,
because the mother's mammary papilla, including
the areola, is grasped by the mandible in a pro-
trusive position and milked out incursively. The
milking action is also supported by a mechanically The milking action is also supported by a
developed vacuum, which is caused by a channel- mechanically developed vacuum, which is
shaped cavity of the tongue on one hand, and the caused by a channel-shaped cavity of the
incursive movement of Bichat's fat pad on the
tongue on one hand, and the incursive
other. This negative pressure may amount to 100-
200 mm Hg. The milking action sequence is com- movement of Bichat's fat pad on the other.
pleted by completing the incursive movement fol- This negative pressure may amount to 100-
lowed by deglutition. 200 mm Hg.

109
R. Slavicek • The Masticatory Organ
After infancy, the tongue is substantially
involved in mastication.
The abundantly available muscle spindles
allow for the tongue's excellent proprioceptiv-
ity, making it an excellent sensory organ.
Parafunctions and hyperactivities.
Innervation of the lingual musculature is sup-
plied from the Nervus hypoglossus.
110
After infancy, the tongue is substantially involved
in mastication. It forms and then transports the
bolus by transfering it during swallowing to the
isthmus musculature. The tongue is also a main
prerequisite for speech, as it is necessary for the
formation of lingual, dental and palatal sounds.
The abundantly available muscle spindles allow for
the tongue's excellent proprioceptivity, making it an
excellent sensory organ. The tongue is a focal point
in the masticatory organ due to it giving rise to the
sense of taste, along with related psychological ram-
ifications. The internal muscles of the tongue origi-
nate and insert in the aponeurosis and the lingual
septum. The direction of the muscle fibers gives rise
to their respective names, as follows:
• Musculus verticalis linguae
• Musculus transversus linguae
• Musculus longitudinalis linguae superius
• Musculus longitudinalis linguae inferius
Functions of the tongue
The tongue is involved in all important functions of
the masticatory organ. This also applies to para-
functions and hyperactivities. In diagnostics, special
attention must be given to the lingual surface, the
lingual borders, and the tongue's behavior in
regards to mobility and motility. The internal mus-
cles serve the high precission-motor action of form-
ing the tongue during this function.
Innervation of the lingual musculature
Innervation of the lingual musculature is supplied
from the Nervus hypoglossus.
The musculature of the soft palate,
the pharyngeal vestibule and the
pharynx
The muscles of this region are involved in all func-
tions of the masticatory organ. The functional areas
formed by these muscles are involved in respiration
and speech. These areas must be given important
consideration in diagnostics, with regard to both
function and dysfunction. Their association with
the pathology of the superior respiratory passages
 Structures - the Neuromuscular System

requires a good understanding of this portion of the

muscular apparatus on the part of the dentist. For
this reason, we need to have complete knowledge
of the morphology of this region.

Musculus levator veli palatini

Its thick, parallel-fibered muscle belly originates
in a narrow, rounded form, from the basal surface
of the temporal bone pyramid. It lies medial to
the thin plate of the tensor of the palatine velum
on the lateral wall of the pharynx and forms the
main mass of the soft palate. The levator muscle
of the palatine velum lies on the tube, medial
from the tube's canal, anterior to the entrance of
the carotid canal, forming a duct in the lower cir-
cumference of the tube. Its fibers interweave with
those of its contra-lateral partner and with those
of the Musculus palato-pharyngicus.

Function of the Musculus levator

veli palatini
The two levators allow the soft palate to contract
and, as parallel-fibered muscles, to raise the poste-
rior pharyngeal wall extensively, so that the pha-
ryngeal nasal cavity is closed against the intrusion
of food. The levator of palatine velum causes a dis-
tinct bulge in the mucous membrane in the lower
circumference of the tube aperture and forms a so-
called levator bulge, which narrows the entrance to
the canal.
Regarding the tube itself, the levator muscle of
palatine velum acts synergistically with the tensor
muscle of the palatine velum to dilate, as it forces
the auditory cartilage posteriorly and superiorly. Myon
After the synergetic action of the two muscles, the
elastic cartilage returns to its neutral position, the
tube narrows and Ostmann's fat pad pushes later-
ally against the cartilaginous medial wall.
In further consideration of phonation, the network
of muscles in the soft palate makes for a finely
adjustable accommodation apparatus, which is
involved in the phonation of vowels and the tone of
the voice. This region is therefore of great interest
in phonology.

111
R. Slavicek • The Masticatory Organ

Innervation of the Musculus levator veli pala- Innervation of the Musculus levator veli
tini is supplied from the facial nerve. palatini
is supplied from the facial nerve.

Musculus levator uvulae

This rounded pair of muscles originates in the pos-
terior nasal spine and extends between the various
mucous glands of the uvula as a united body of
muscle.

Function of the Musculus levator uvulae

Bilaterally innervated, this muscle raises the
uvula. Unilaterally innervated, it pulls the uvula
laterally. Interestingly, in cases of strong unilate-
ral contraction of the retro-maxillary muscles and
through the involvement of soft palatal muscles
during phonetic activity, the uvula is diverted to
the side under tension (see ill. 91, p. 115).

Innervation of the Musculus levator uvulae

Innervation of the levator muscle of the uvula is
supplied from the facial nerve.

Musculus glossopalatinus
In conjunction with the transverse lingual muscle,
this muscle can narrow the pharyngeal opening.
Innervation of the transverse lingual is supplied
from the glossopharyngeal nerve.

Musculus palatopharyngicus
This muscle can raise the larynx and also shorten
the pharyngeal head. It is actually a palatal pha-
ryngeal larynx. Innervation is supplied from the
glossopharyngeal nerve and the vagus nerve.

Musculus tensor veli palatini

This muscle is a powerful contractor of the soft
palate and, together with the levator of the pala-
tine velum, a dilator of the tube (Musculus dilata-
tor tubae), whereby ventilation of the middle ear
takes place. The result can sometimes be heard as

112
 Structures - the Neuromuscular System

a (clacking) sound during "empty" deglutition. In

cases of dysfunction in the stomatognathic sys-
tem, these topographic and functional areas
should not be underestimated. The symptomato-
logy regarding the relationship with the auditory
region has not yet been amply researched, but
should nevertheless be considered carefully from
the viewpoint of functions of muscles related to
the tube. Worthy of special note is the close prox-
imity to the medial pterygoid, the main muscle
involved in parafunction.
Somatomotoric innervation of the tensor of the
palatine velum is supplied from the glossopharyn-
geal nerve from the otic ganglion via Jacobson's
anastomosis.

The pharynx - throat

The respiratory passages and alimentary canals
share a large vestibule posterior to the oral and
nasal cavities, namely the pharynx (throat). It
extends from the roof of the pharynx, the pharyn-
geal fornix, to the entrance of the esophagus. The
pharyngeal head is a flatly pressed choana
attached on its wider side to the skull and open-
ing into the esophagus.
The pharyngeal cavity consists of three levels:
• The upper: epipharynx (Pars nasalis pharyn-
gis, nasopharynx)
• The middle: mesopharynx (Pars oralis pharyn-
gis)
• The lower: hypopharynx (Pars laryngica)

Epipharynx
In the lateral region of the epipharynx behind the
choanae, there is an elongated opening in the
extension of the inferior nasal cavity - the pharyn-
geal opening of the auditory tube, measuring
approximately 6 mm in length. It leads into the
tube and further into the spaces of the middle ear,
which can thus be ventilated by the pharynx. In
children, the pharyngeal opening to the tube is
surrounded by lymphatic tissue (tonsilla tubalis).
The epipharynx extends superiorly to the cranial
base where its roof, the pharyngeal fornix, is firm-
ly united with the body of the sphenoid bone, the
pyramids of the temporal bone and the basal por-
tion of the occipital bone.

113
R. Slavicek • The Masticatory Organ
Linder-Aronson, S., Behfelt, K., Neander, P.: Posture of the
Head, the Hyoid Bone and the Tongue in Children with and
without Enlarged Tonsils. Eur. J. Orthod. Mov. 12 (4):
458–67, 1990
Hellsing, E., Forsberg, C. M., Linder-Aronson, S.,
Sheikholeslam, A.: Changes in Postural EMG Activity in the
Neck and Masticatory Muscles Following Obstruction of the
Nasal Airways. Eur. J. Orthod. Mov. 8 (4): 247–53, 1986
Fränkel, Ch., Fränkel, R.: Der Funktionsregler in der
orofazialen Orthopädie. Verlag Hüthig, Heidelberg 1992
Björk, A.: The Face in Profile. Svensk Tidskr. 40
(Suppl 5 B), 1947
114
Mesopharynx
The respiratory and alimentary passages intersect
in the oral part of the pharynx. During degluti-
tion, the soft palate and posterior pharyngeal
wall- Passavant's ridge - close the access from the
mesopharynx into the epipharynx. The mesopha-
rynx is visible in the region of the faucal isthmus,
where the floor of the tongue lies with the lingual
tonsils on the posterior pharyngeal wall. The lym-
phatic tissue of the lingual floor overhangs the
right and left palatal and tubular tonsils, together
with tonsillar tissue from the epipharynx, and
forms the lympho-reticular pharyngeal ring. In
cases of strong hypertrophy of lymphatic tissue in
growing children, the respiratory passages may be
constricted. This is compensated for by a postural
change, i.e. by moving the head to the front.
According to several authors, this postural modi-
fication and the tendency towards oral respiration,
commonly associated with it, influence the
growth of the viscerocranium (comp. Linder-
Aronson, Fränkel, Björk).
Hypopharynx
In the laryngeal portion, the pharynx is even more
constricted. On its anterior wall the larynx bulges
with annular and arytenoid cartilage and their
musculature. By pressing the raised larynx against
the base of the tongue, the respiratory passage is
closed against the hypopharynx (see ill. 92, p. 115).
The entire pharyngeal posterior wall lies on the
spinal column. The elongated furrows of the
esophageal mucous membrane start at the level of
the lower third of the annular cartilage plate. The
passage of the pharynx into the alimentary canal
is known as the mouth of the esophagus. It lies at
the level of the 6th cervical vertebra. The right
and left muscle appendages of the longus muscle
and cervical rectus push the posterior pharyngeal
wall and its line of origin to the spheno-occipital
syndesmosis convexly forward, so that a recess is
formed between the two insertion arches, filled
with lymphatic tissue from the pharyngeal tonsil.
The musculature of the most cranial portion of
the pharyngeal opening is of significance to the
dentist because the anterior regions are connected
with the mandible.
 Structures - the Neuromuscular System

Ill. 91: Clinical picture of a unilaterally "tensed" patient showing the distinct asymmetric entrance to the phar-
ynx during tension.

Ill. 92: The laryngeal portion of the hypopharynx with the epiglot-
tis, which is raised muscularly to cover the laryngeal entrance during
deglutition. Thus, a complex switchblade between the respiratory
and the digestive canal was achieved - an equally necessary new
function from an evolutionary point of view.

115
R. Slavicek • The Masticatory Organ
The dentist concerned with functional diag-
nostics must have a basic knowledge of the
laryngeal musculature in order to determine
the differential diagnosis of the rather fre-
quently occurring ailments in this region.
116
Musculus constrictor pharyngis superius
It originates in a long line from the angle of
mandible, upwards up to the pterygoid process of
the sphenoid. Four areas can be distinguished in
the muscle:
• The Pars mylopharyngica, whose fibers origi-
nate from the angle of mandible behind the
last molar posterior to the mylohyoid line.
• The Pars glossopharyngica, as a direct exten-
sion of the transverse lingual muscle in the
pharyngeal wall.
• The Pars buccopharyngica, whose Raphe
pterygomandibulare forms a tendinous con-
nection to the Musculus buccinator in the pha-
ryngeal wall.
• The Pars pterygopharyngica are the most
superior, its fibers leading from the hamulus
and from the medial lamella of the pterygoid
process, and passing between the levator and
tensor of the palatine velum.
Innervation of the pharynx
The motor nerves originate in the pharyngeal
plexus formed by the 9th and 10th cranial nerves
and the sympathicus, and extend onto the poste-
rior pharyngeal wall. The 9th and 10th cranial
nerves supply the mucous membrane with senso-
ry and parasympathetic nerves. The mucous
membrane nerve of the piriform recess is the
internal recess of the superior laryngeal nerve.
Muscles of the larynx
The dentist concerned with functional diagnostics
must have a basic knowledge of the laryngeal
musculature in order to determine the differential
diagnosis of the rather frequently occurring ail-
ments in this region. Patients may develop cramps
in the cervical region, a choking feeling, and occa-
sionally spontaneous hoarseness. It is necessary for
the dentist to work in cooperation with otolaryn-
gologists and logopedists.
The larynx hanging on the hyoid, the trachea, and
the thyroid gland connected with it, are all
involved in movements of the hyoid, which in turn
depend on the antagonism of the superior and
inferior hyoid musculature. Pharyngeal muscles
attached to the larynx and the palatopharyngeal
 Structures - the Neuromuscular System

larynx, leading from the soft palate, not only

move the larynx but can also fix it at various
heights, so that the vocal cords supported by the
laryngeal cartilage are able to make sounds
according to the position of the attachment tube.
Because the pharyngeal opening and its muscula-
ture work in conjunction with lingual muscles and
those of the floor of the mouth, function-based
tension understandably influences the functioning
of the larynx. Evolution in humans brought about
entirely new high-precision tasks for the NMS.
For many humans in current times, the most
important function is that of "speech". It is there-
fore illogical that so little attention is given to the
stomatognathic aspect when studying the causes
of dysfunction in the larynx.
In addition to muscles that raise and lower the
entire respiratory tract, the larynx has its own
muscles with which it dynamically controls the
(true) glottis. The movement of laryngeal carti-
lages against each other (in respiration and phona-
tion) is rendered possible by specific obliquely stri-
ated muscles. The laryngeal muscles consist of five
paired muscles and one unpaired muscle.

The paired muscles are as follows:

• Musculus cricothyreoideus (innervation:
Recessus externus of the Nervus laryngicus
superius)
• Musculus cricoarytaenoideus posterius
• Musculus cricoarytaenoideus lateralis
• Musculus thyreoarytaenoideus (innervation:
Nervus recurrens)
• Musculus vocalis (innervation: Nervus laryn-
gicus inferius)

The unpaired muscle is:

• Musculus arytaenoideus

Innervation
Laryngeal muscles are innervated from the right
and left vagus nerves. The nerve fibers originate in
the ganglion cells of the laryngeal core in the
medulla oblongata, the nucleus ambigus and
reach the larynx through the superior and inferior
laryngeal nerves.
In the formation of sound, three mechanisms are
at work: the respiratory apparatus, the phonation
apparatus and the articulation apparatus in the

117
R. Slavicek • The Masticatory Organ
... has become important for the diagnosis of
functional disorders of the masticatory organ,
as the prevalence of postural problems in
humans is increasing.
The head and trunk are connected to each
other posteriorly by the neck and anteriorly
by the throat.
The supra- and infrahyoid muscles join on
the moveable hyoid.
Tilscher, H.: Das Bewegungssegment der Wirbelsäule im
Blickpunkt der orthopädischen Rückenschule. Medizinisch-
literarische Verlagsgesellschaft, Uelzen 1993
118
pharynx. Of course, not only the formation of
sound, but also its translation into "speech" are of
interest. This complex concept of speech involves
all structures of the masticatory organ under the
supervision of specific brain centers.
Muscles related to the posture of the
head, the throat, neck and scapular
girdle
As discussed in the chapter dealing with evolu-
tion, evolutionary phylogenetic modifications in
posture led to an upright and walking being, and
to subsequent phylogenic developments. This
region has become important for the diagnosis of
functional disorders of the masticatory organ, as
the prevalence of postural problems in humans is
increasing. Studies performed on schoolchildren
indicated dysfunctional body posture in nearly
100% of the cases (comp. Tilscher). From running
to walking to squatting, human beings have
become static sedentary individuals, whose
dynamics primarily take place in the brain i.e., in
the intellect. Because of the integration of essen-
tial portions of the cervical musculature
(neck/throat) in the stomatognathic system, prob-
lems frequently arise in this area. A causal classifi-
cation of these problems is, however, most difficult
to make.
For exactly this reason, diagnostic and therapeutic
interdisciplinary cooperation is essential.
The head and trunk are connected to each other
posteriorly by the neck and anteriorly by the
throat. Posteriorly the cervical spine is supported
and protected on both sides by the covering pro-
jections of neck muscles. In the caudal region, the
cervical spine is overlaid by the function-based,
migrated scapular girdle (Levator scapulae,
rhomboideus, trapezius) (see ill. 93, p.119). The
anterior lateral trunk muscles insert directly in the
skeleton of the visceral tract, the sternum, the
clavicle and the first rib (see ill. 94-95, p. 120-
121). The supra- and infrahyoid muscles join on
the moveable hyoid, which assumes a significant
role here as the center of the entire vector system
of this complex muscle apparatus. The muscles
also simultaneously cover and support the thyroid
gland and the larynx. The pre-vertebral group
forms a soft pad for the visceral tract in front of
and lying on the cervical spine. The scalenus group
 Structures - the Neuromuscular System

Ill. 93: The complexity of the trunk-neck-head connection is clearly seen in this illustration. The muscles have to ensure perfect pos-
ture, balance, and especially mobility. Several cumulative problems emerge in this region because of man's evolutionary "regression"
to a predominantly static, sedentary being.

119
R. Slavicek • The Masticatory Organ

Ill. 94: The problems of posture and mobility are more complex and more susceptible to dysfunction, because of the intermediate
location of the hyoid and its expanded area of responsibility, especially the "positioning function" in speech.

120
 Structures - the Neuromuscular System

Ill. 95: This illustration shows that ventral and dorsal functions are extended by the task of having to provide muscular connec-
tions.

121
R. Slavicek • The Masticatory Organ
The inferior belly of the omohyoid crosses
here; vessels and nerves to the upper extremi-
ties also extend through this point.
122
covers the upper thoracic aperture and also the tips
of the lungs from the side.
Above the previously mentioned muscle groups
lies the incomplete muscular layer of the trapezius
and sternocleidomastoid muscles, extending from
the sternum and clavicle to the cranium. The
muscles are innervated by the accessory nerve and
both originate at the skull. The trapezius pushes
against the thoracic girdle and extends down the
spinal vertebrae to the 12th thoracic vertebra (see
ill. 96, p. 123). M. sternocleidomastoideus inserts at
the sternum and the clavicle (see ill. 97, p. 124).
The entire muscle layer has three large windows.
Two triangular windows (one right, one left), are
demarcated by the trapezius and sternocleidomas-
toid, which is also designated the Trigonum colli
laterale (dexter et sinister). A third medial window
formed by the two sternocleidomastoid muscles is
the ventral cervix of the trigonum.
The lateral cervical triangles are formed at their
base by the clavicle, their apexes extend posterior-
ly to the angle of the mandible. The floors of the
cavities are formed by the splenius muscle, the
levator of the scapula and the scalenus muscle.
The most inferior portion forms the greater supra-
clavicular fossa. The inferior belly of the omohy-
oid crosses here; vessels and nerves to the upper
extremities also extend through this point.
The middle triangle of the neck contains muscles
innervated from the vagus nerve, as well as the
overlying musculature innervated from the
hypoglossus nerve. The base of the triangle is
formed by the hyoid bone. The skin of the throat
shows a retraction here, the "hyoid groove". The
apex of the anterior triangle forms the "jugular
fossa" (Fossa jugularis) above the episternum.
Superiorly, the retromandibular fossa is formed
between the angle of the mandible and the ante-
rior margin of the sternocleidomastoid, extending
to the lateral wall of the pharynx. In the retro-
mandibular fossa, three thin muscles originate on
the styloid process: the M. styloglossus, the M.
stylohyoideus and the M. stylopharyngicus.
Innervation
The muscles receive their neural supply from va-
rious sources. A considerable portion of the liga-
mentary attachment apparatus of the hyoid also
originates in the styloid, namely the stylohyoid
ligament. This phylogenetically modified, concep-
tually new self-centering ligamentary attachment
 Structures - the Neuromuscular System

Ill. 96: The covering in the posterior and anterior areas is incomplete.

123
R. Slavicek • The Masticatory Organ

Ill. 97: The anterior covering is also incomplete.

124
 Structures - the Neuromuscular System

is of systemic-diagnostic significance and should

not be neglected in cases of dysfunction. In the
anterior regions, the throat is overlaid by the
platysma (see ill. 98-99, right).
The neural supply to the various layers is an out-
come of the complicated phylogenic development
of this region extending from the pharyngeal arch
and primitive vertebrae surrounding the cervical
spine and cervical viscera.

The pre-vertebral muscles

Musculus rectus capitis ventralis
The short ventral rectus capiti extends obliquely
from the lateral massa of the atlas towards the
basal portion of the occipital bone, to immediate- Ill. 98: The platysma covers the anterior neck-visceral tract
ly before the foramen magnum. It forms a tena- to a varying extent.
cious connection between the atlas and the skull
and is, as a rule, involved in posture-related ten-
sion.

Musculus longus capitis

This powerful, elongated muscle plate originates
from the carotic tubercle (CV 6) and the three to
four superiorly and anteriorly positioned oblique
cusp processes, and extends to the basal portion of
the occipital bone. It causes a bulge in the poste-
rior pharyngeal wall and inserts in a flat pit on the
occipital bone.
The longus capitis muscle causes a forward tilting
of the head and simultaneously forms a soft cush-
ion, where the loose gliding tissue in the
retropharynx is located, whereby the visceral tract
remains mobile in front of the spine during speech
and deglutition. It can compensate for strong ver-
tical loss by inversely bending the cervical spine,
thus reducing tension in the anterior cervical Ill. 99: Because of its width in the mandibular insertion, the
region (see ill. 100-101, p. 126). platysma is involved in the functional placement mechanism.
In cases of respiratory distress, expansion of the respiratory
passages and dilation of the efferent vessels are effected by
Musculus longus colli means of external contraction.
This long neck muscle is also an elongated three-
sided muscle plate. The function of this muscle is
to serve as a lateral benderof the body. When
bilaterally innervated, it stretches the lordosis of
the cervical spine.
At this point it would be appropriate to mention
the Musculus rectus capitis lateralis, belonging to
the intercostal muscles. It is an efficient lateral body
bender and connects the lateral portions of the atlas
to the cranial base. It is frequently involved in
problems of the atlanto-occipital region.

125
R. Slavicek • The Masticatory Organ

Ill. 100: Computerized tomogram of a patient with a severe dysfunction and a greatly reduced distance
between the maxilla and the mandible. Note the inverse flexion of the cervical spine and the strong retraction
of the hyoid.

Ill. 101: The patient's X-ray shows the extreme skeletal relationship and dental deep bite.

126
 Structures - the Neuromuscular System

Musculi scaleni
The scalenus muscles are relics of intermediate rib
muscles, rising to cranial from the superior tho-
racic ribs to the costal elements of the cervical
spine. Together they form a deep muscular cone,
attached on the wide 1st rib, which protects the
cervical pleura and helps to keep the lungs warm.
The tips of these muscles extend to the oblique
processes of the superior cervical vertebra and
their base extends, with two peaks, onto the 1st
rib and the third peak on the 2nd rib. The mus-
cles are known as step muscles (scala=step).

Function and innervation

Unilaterally innervated, the scalenus muscles are
responsible for lateral bending of the cervical spine.
Bilaterally innervated, they raise the 1st rib and Ill. 102: The vector illustrations above and below demon-
thereby also the superior portion of the thorax. strate the significance of the interplay between supra- and
They are very powerful inhalation muscles during infrahyoid muscles.
thoracic respiration, especially when the neck and
head are tilted back. In tense or anxious individu-
als, they contribute to inefficient and shallow tho-
racic respiration. At the same time, in cases of
improper and tense sitting posture, they are involved
in functional shortening of the cervical spine. They
may also be involved in phonetic problems.

The infrahyoid muscles

In the angle between the inferior facial area and
the anterior cervical area, one can clinically pal-
pate the body of the hyoid. Three band-shaped
muscles descend from it and cover the ligaments
protecting the visceral tract. One of these muscles
is divided obliquely into two parts by a narrow,
tendinous attachment (Inscriptio tendinea) on the
thyroid cartilage. Above it lie the sternohyoid and Ill. 103: The force of combined functions also shows the
direct connection with the sternoclavicular joint and the two
omohyoid muscles; below these two lies the ster-
temporo-mandibular joints. The function of the anterior
nothyroid muscle with its extension to the hyoid, mimic muscles, as powerful occluders, demonstrates the
and the thyrohyoid muscle (see ill. 102 and 103, complex interplay of several muscle components.
right).

Musculus sternohyoideus
This thin, long band of muscle originates from the
posterior side of the sternoclavicular joint and
extends upwards from the superior thoracic aper-
ture, covering the thyroid, to the superior border
of the body of the hyoid. This muscle stabilizes
the hyoid.

127
R. Slavicek • The Masticatory Organ

Ill. 104: First of all, the infrahyoid group connects the hyoid directly or indirectly in a relatively straight line with the sternum and
the clavicle. More complex is the omohyoid muscle, extending from the scapula and inserting in the hyoid. This attempt to illus-
trate its vector shows an "intermediate insertion" in the cervical fascia.

128
 Structures - the Neuromuscular System

Musculus omohyoideus
This muscle (see ill. 104, p. 128 and ill. 105, right)
lies lateral to the sternohyoid and is frequently sep-
arated into two band-shaped muscle bellies by a
ligament-like, intermediate tendon, joining again
at a nearly perpendicular angle. The inferior belly
leads from the scapula. It originates medially from
the superior notch of the scapula on its upper mar-
gin, is of variable width, fixed to the clavicle with
the sturdy cervical aponeurosis (Fascia omoclavicu-
laris), and extends over the scalenus gap. The liga-
ment-like intermediate tendon lies on the internal
jugular vein and is attached to its adventitia so that
the muscle can dilate the vein by contraction. The
superior belly runs parallel to the sternohyoid and
inserts lateral to it in the body of the hyoid.
Because of its functional topography - it originates
Ill. 105: This simplified lateral view demonstrates the con-
in the dorsal functional region of the scapula and
nections between the posterior and anterior areas, and has
switches to the ventral functional region of the the possibility of influencing the position of the hyoid. The
hyoid muscles - the omohyoid is a significant "con- position of the mandible is indirectly co-determined by the
veyer" of frequently improper scapular posture to functions of the posterior group.
the hyoid, and thereby to the mandible (see ill. 106,
right and ill. 107, p. 130).

Musculus sternothyreoideus
Below the previously described muscles lies the
wide, thin band of the sternothyreoid muscle, which
originates from the middle of the inner side of the
episternum, somewhat more superior than the ster-
nohyoid, and from the cartilage of the 1st rib. The
right and left muscles first meet in the middle, then
extend superiorly to the oblique line of the thyreoid
cartilage, diverging and covering the thyreoid gland.
Innervation of the inferior hyoid muscles is pro-
vided by the 2nd -3rd cervical nerve, through
hypoglossal branches, formed by the descending
hypoglossal recess and the descending cervical
recess. Each of the two parts of the muscle has its
own neural branch. Ill. 106: In this isolated view, the rather lateral origin on the
scapula is shown.

Musculus thyreohyoideus
From the oblique line of the thyreoid cartilage and
separated from the sternothyreoid, as if by a tendi-
nous attachment, the thyrohyeoid extends superior-
ly to the dorsal area of the lateral third of the body
of the hyoid, and to the greater horn of the hyoid.
Innervation is provided from the 1st and 2nd cer-
vical nerves through a direct branch of the
hypoglossus nerve.

129
R. Slavicek • The Masticatory Organ

Ill. 107: The medial insertion of the omohyoid muscle on the hyoid demonstrates the fact that problems in the scapular region may
be transferred to the hyoid.

130
 Structures - the Neuromuscular System

Functions of the infrahyoid muscles

The combined effect of infrahyoid muscles is to fix
the hyoid so that it can function as a stabilizer for
the action of the superior hyoid muscles on the
mandible and the tongue. They can lower the
hyoid with the larynx so that the attachment tube
of the glottis becomes extended. As they insert in
the same skeletal region as the hyopharynx and
laryngopharynx, they also serve to initiate deglu-
tition.
The thyreohyoid raises the thyreoid cartilage and,
thereby, the entire larynx against the hyoid during
deglutition, so that the opening to the larynx can
be sealed by the epiglottis. The omohyoid is a fas-
cia tensor and can therefore dilate the deep cervi-
cal veins. It is involved in unilateral and bilateral
tension in the scapula region (Musculus levator
scapulae) and also influences the position of the Ill. 108: The origin of the powerful, two-headed sternocleido-
mastoid muscle, with is origins on the sternum and clavicle,
mandible through its insertion in the hyoid bone. and its insertion on the mastoid process and superior nuchal
Tension leads to a compensating increase in activ- line of the occipital bone, establishes it as an exceptionally
ity in the adductor region of the mandible. The important muscle for the mobility of the head.
influence of this muscle in cases of stress on the
venous outflow of the greater cranio-cervical ves-
sels in vascular headaches has not yet been fully
researched.

Musculus sternocleidomastoideus
This muscle originates with two heads from the
sternum and the clavicle (see ill. 108, right). The
head originating from the episternum (sternoclei-
domastoid muscle) inserts on the mastoid process.
The second head originates in the medial third of
the clavicle and extends to the mastoid process
and the occipital bone of the superior line of nucha
(cleidomastoid muscle and cleido-occipital mus-
cle). Its superior half covers splenius, the levator of Ill. 109: This vector illustration shows the diversity of its
the scapula and the posterior belly of the digastric functions as a rotator and incliner of the head.
muscle; its inferior half covers the greater cervical
vessels.

Function of the Musculus

sternocleidomastoideus
From its position in the cervix of the fascia, this
muscle has considerable influence on the position
of the mandible; it turns the head and tilts it to
the side (see ill. 109, right). Its contraction affects
the atlanto-occipital joint, as well as, all joints of
the cervical spine. This muscle holds the head

131
R. Slavicek • The Masticatory Organ

upright, but can also tilt it posteriorly. In its posi-

tion lying across the cervical spine, it can throw
the head posteriorly and increase cervical lordosis.
It raises the sternum when the head is fixed, and
is therefore, a supplementary muscle for deep
inhalation. It is significantly involved in forced
thoracic breathing in anxious patients. This mus-
cle serves as a turner of the head, especially when
the individual expresses intense interest. It enables
the eyes and ears to "turn towards" the dominant
sensory side for better perception. This is worthy
of note when evaluating improper posture.
Innervation is provided by the accessory nerve C.
2-4. The nerve bores through the muscle to
extend to the trapezius muscle.

Musculus trapezius
The trapezius muscle (see ill. 110, p. 133) is one of
the several wide back muscles. Its elongated base
lies on the spine and extends inferiorly from the
external occipital protuberance to the 12th tho-
racic vertebral spina. This muscle originates in the
throat, from the septum of nucha in the thoracic
region of the spinae, as a thin, tendinous plate that
extends onto three places on the aponeurosis. One
of the aponeuroses is located near the external
occipital protuberance. When this muscle is high-
ly developed it travels along the superior line of
nucha and joins the insertion of the tendon of the
sternocleidomastoid muscle. The insertion on the
occipital bone is perforated by the greater occipital
nerve and from the A. occipitalis.

Function of the musculus trapezius

Because of the convergent and partially antago-
nistic paths of muscle fibers, the effect of the indi-
vidual parts of the trapezius on the thoracic girdle
is variable. The superior regions of both muscles,
the ascending parts, raise the shoulders. They are
supported synergistically by the levator of scapula
and the rhomboid muscle. The shoulder is able to
bear a load, using these muscles. This should be
especially pointed out to patients who, in spite of
muscular tension and the problems resulting from
it, carry a bag on one side with a shoulder strap,
thereby raising the "load-carrying" shoulder.
Antagonistic muscles from the point of view of
their vectors (superior upwards, inferior down-

132
 Structures - the Neuromuscular System

Ill. 110: This image elucidates the fusion of the aponeurotic insertions of the head rotator with the trapezius.

133
R. Slavicek • The Masticatory Organ
Observing the condition of the scapulae in an
upright relaxed posture, is therefore of great
diagnostic interest.
While studying the actual functions of the
muscular apparatus of the cranio-cervical
region, it is found that there are hardly any
isolated individually classifiable areas, but
rather muscle groups assuming a variety of
responsibilities.
134
wards), frequently involve these two areas in
chronic postural problems. In contraction, as well
as in cases of chronic tension, the scapula can turn
on an axis, passing sagittally and horizontally
through the middle of the spine. Observing the
condition of the scapulae in an upright relaxed
posture, is therefore of great diagnostic interest.
Innervation of the trapezius muscle is provided by
the accessory nerve and by ventral branches of the
cervical nerves 1-4.
Musculus levator scapulae
This muscle originates on the oblique processes of
the first four cervical vertebrae and inserts on the
dorsal side of the margin of the scapula vertebra. It
is therefore in direct connection with the oblique
process of the atlas and, because of its especially
effective lever arm, is mainly involved in tension in
the atlanto-occipital region. In one variation, its
origin may extend onto the mastoid process.
Function and innervation of the Musculus
levator scapulae
This muscle raises the scapula and simultaneously
rotates it to the inside. Through tension in the
thoracic girdle, it pulls the cervical spine to the
same side. Innervation is provided by the dorsal
scapular nerve and branches of the cervical plexus.
Summary
The NMS of the human masticatory organ must
be viewed from the standpoint of its extended
functions, especially as its functions may overlap
into other areas. While studying the actual func-
tions of the muscular apparatus of the cranio-cer-
vical region, it is found that there are hardly any
isolated individually classifiable areas, but rather
muscle groups assuming a variety of responsibilities.
Mastication
The NMS functions on the basis of individual pat-
terns, which are carried out under proprioceptive
control and adapted to nutrition. The true mastica-
tory muscles involved are the tongue and the
mimic muscles, the floor of the mouth and the
supra- and infrahyoid musculature.
 Structures - the Neuromuscular System

Deglutition
Deglutition is executed by the adductors, muscles
of the CMS, the soft palate, the pharynx, the
tongue, the floor of the mouth and the supra- and
infrahyoid musculature. Deglutition is one of the
primary functions of the masticatory organ with
its extremely unique morphology, which takes
place frequently, perpetually and generally with-
out a conscious effort.

Speech
Speech is actually the primary function of the
human "masticatory" organ, as it gives rise to the
quality of being human. It involves the true mas-
ticatory muscles, mimic muscles, tongue, floor of
the mouth, supra- and infrahyoid musculature,
larynx, muscles of the superior pharyngeal region
and respiratory muscles including the diaphragm.

Posture of the head

Becoming a true biped created considerably
extended areas of responsibility for the NMS.
Here, it is above all the muscles of the CMS that
assumed entirely new and significant functions.
The true masticatory muscles, such as the supra-
infrahyoid musculature, autochtonal muscles of
the cervical spine, muscles of the atlantocranial
region, the thoracic girdle, and all deep regions of
muscles related to posture, play a major role in the
maneuverability of the human head. The posture
of the head and body are an inseparable entity and
must be regarded as such, both functionally and
diagnostically.

Clenching and Bruxism

As clenching and bruxism are expressions of psy- As clenching and bruxism are expressions of
chic stress management, we are mainly concerned psychic stress management, we are mainly
with the adductors of the mandible. Muscles of concerned with the adductors of the
the CMS are directly involved in these move-
mandible. Muscles of the CMS are directly
ments. Depending on the individual, the true
masticatory muscles, digastric muscle, floor of the involved in these movements.
mouth, tongue, and the mimic muscles are poten-
tially involved.

135
R. Slavicek • The Masticatory Organ
Occlusion
Articulation
The determinants of all function of the masti-
catory organ are the teeth, for they act as
functional interference to free movement of
the mandible.
Therefore, from a diagnostic viewpoint, abra-
sion and facets in atypical locations are pre-
dominantly caused by parafunction, which is
manifested in specific teeth, or regions of
teeth.
The coronal portion of a tooth is the only
structure in the human organism that is
structurally mature before it starts to func-
tion. After the tooth erupts, the coronal por-
tion can only be altered through irreversible
damage to the structure itself.
136
Occlusion - Articulation
The determinants of all function of the masticatory
organ are the teeth, for they act as functional inter-
ference to free movement of the mandible. Today,
the dentition is not subjected to high rates of abra-
sion, due to the changes in human nutritional diets.
Therefore, from a diagnostic viewpoint, abrasion
and facets in atypical locations are predominantly
caused by parafunction, which is manifested in spe-
cific teeth, or regions of teeth. The dynamic rela-
tionship of dental arches to each other is of
utmost importance for the diagnosis of the masti-
catory organ. The structures of the organ are func-
tionally intertwined. The teeth, because of their
rigid structure and their proprioceptive expression
of positional signals, are system-dominant in the
design of functional patterns, which are produced
by the slow, ontogenetic maturation of the masti-
catory organ in functional periods during growth.
The coronal portion of a tooth is the only structure
in the human organism that is structurally mature
before it starts to function. After the tooth erupts,
the coronal portion can only be altered through
irreversible damage to the structure itself. Because
of the invasive nature and capabilities of dental
medicine in all dental disciplines, the stomatog-
nathic system is often forced to adapt rapidly. The
system's adaptive capability is therefore at first
challenged and then strongly required. This adap-
tive process can, but need not necessarily, lead to
new eu- or orthofunction.
These introductory remarks are fundamentally
important in order to discuss the morphology of
the dentition and view the subsequent diagnostic
sequences with an open mind. It should be empha-
 Structures - Occlusion - Articulation

sized here that minimizing the significance of Minimizing the significance of occlusion in
occlusion in current scientific discussions is to be current scientific discussions is to be con-
condemned, and that current worldwide theories demned, and that current worldwide theories
concerning occlusion and articulation should be
concerning occlusion and articulation should
justifiably criticized. The responsibility lies above
all with those who would like to minimize the be justifiably criticized.
importance of occlusion for the masticatory organ
and its functions for didactic reasons, in favor of
other "more medical, i.e. less dental" fields. A solu-
tion to this current dental dilemma can only be
found in a more fundamental basic medical educa-
tion and, simultaneously, by communicating
through the teaching process, an optimal know-
ledge of occlusion. Let us not forget that dentists
are specialists in medicine and are responsible for
one of the most important organ systems of the
human organism.

Ontogenesis of the
masticatory organ
The concept of nature in the
development of dentition; the
development of the masticatory
organ from the viewpoint of
functional demands
I intentionally begin this section on occlusion with
a paragraph on the development of dentition, as
this is the best starting point for introducing the
reader to the overall unity of occlusal relationships,
and their resultant functional interdependence.
Diverging from the usual methods of observation
regarding the development of the masticatory
organ, for the purpose of distinguishing between
"normal" and "deviant", it would be meaningful to
regard the growth of the skull and the masticatory
organ from the viewpoint of so-called functional ... functional periods. In other words, the
periods. In other words, the organ should be evalu- organ should be evaluated according to the
ated according to the functions required to be per- functions required to be performed at a par-
formed at a particular point in time. It follows that
ticular point in time.
the masticatory organ is not to be evaluated accor-
ding to age or growth periods, but that the degree
of maturity and the qualitative functional state must
be integrated as dominant parameters into the

137
R. Slavicek • The Masticatory Organ
Morphology
Anatomy
In embryonic development, phylogenetic
aspects set the tone, although they are subject
to encompassing influences.
Reflexology
Genetics
Dental crowns, are the determining factors
for the functions of the masticatory organ
and only alterable through damage, and they
are also the only non-variable, genetically
fixed structures, in the human organism fully
developed before becoming functional.
Vojta, V.: Die zerebralen Bewegungsstörungen im Säuglings-
alter. Frühdiagnose und Frühtherapie. Ferdinand Enke
Verlag, Stuttgart 1988
138
diagnostic procedure. The value and quality of
function becomes the measuring rod for evaluating
the morph. Thus, the concept of "morphology" is
applied according to its actual definition and con-
notation, and not as a synonym for "anatomy".
In embryonic development, phylogenetic aspects
set the tone, although they are subject to environ-
mental influences.
First of all, phylogenetic dominance is observed to
persist and continue postnatally. The term "target-
ed" premature birth, which I use in the chapter on
evolution to denote the ordinary physiological time
of birth, appears to be true from this point of view
as well. The disproportional, rapid development of
cranial volume during hominization was accompa-
nied by simultaneous modification and difficulties
related to the birth passage and by a change in pos-
ture, which made it necessary for the human
neonate to be born early. The viewpoint of reflexol-
ogy supports the concept of regarding the first six
postnatal weeks following normal delivery as an
extrauterine maturation period in embryonic devel-
opment. The time when primitive reflexes play a
governing role approximately encompasses this
period of time (comp Vojta). In modern psychology
this period is also considered as an intrauterine phase.
Genetically, it should be noted that the structural
morphology of dental crowns are mature before they
start to function. This characteristic of the dental
crown led me to the following dogmatic conclusion:
Dental crowns are the determining factors for the
functions of the masticatory organ, only alterable
through damage, non-variable, genetically fixed
structures and fully developed before becoming
functional, in the human organism. Although the
relationship of the crowns to each other, the devel-
opment of roots, the emergence of dental arches
and skeletal development, and also the functional
matrix of the face, are genetically influenced or pre-
determined to a certain extent, they are constantly
subject to ever-changing conditions. The main fac-
tor here is functional necessity.
In the ontogenesis of the individual during the
development of the masticatory organ, a continu-
ous interplay between growth and functional adap-
tation takes place. The functionally adaptive and
developmental processes are coordinated above all
in the regions of the temporo-mandibular joints, in
reaction to the morphology of the erupting hard
structures. The emerging functional patterns are
 Structures - Occlusion - Articulation

striking examples of the adaptive mechanisms of the

stomatognathic system. Didactically, this point of
view should be given importance, because stark,
natural logic helps us to better understand the func-
tionally determined and predetermined temporal
course of "dentition", occlusion and articulation.

In the following, we analyzed the development and

maturation of the masticatory organ from the view-
point of so-called "functional periods". For didactic
reasons we will presume the existence of a future
"normal dentition", although such ideal dentition
usually is the exception rather than the rule.
Nevertheless, the dynamic processes of articulation
can be best understood in the light of so-called
ideal dentition. Based on this information, we will
achieve a better understanding of malocclusion and
dysgnathia.

Normally, the development of the dentition is clas-

sified into:
• Deciduous dentition • Deciduous dentition
• Changing or mixed dentition • Changing or mixed dentition
• Permanent dentition • Permanent dentition

Based on the functions of the masticatory organ,

the following functional periods are found to exist:
• The postnatal period • The postnatal period
• The developmental period of deciduous • The developmental period of
dentition deciduous dentition
• The functional period of the mature • The functional period of the mature
deciduous dentition deciduous dentition
• The first functional period of a changing • The first functional period of a
- mixed dentition changing - mixed dentition
• The second functional period of a changing • The second functional period of a
- mixed dentition
changing - mixed dentition
• The mature dentition • The mature dentition

The development of the masticatory organ has

been divided into functional periods, because its
functions are determined by changing require-
ments and new structures. Functional periods are
not to be regarded as periods of growth, but as
periods of adaptation to modifications in form and
function.

139
R. Slavicek • The Masticatory Organ
Trimenon
• Respiration
• Ingesting food
• The first primitive vocal commu-
nication
The milking function consists of a wide pro-
trusive extension, strong closing, quick,
smooth retraction, and swallowing.
Tomatis, A.: Der Klang des Lebens. Rowohlt Taschenbuch
Verlag, Reinbek 1974
Tomatis, A.: Klangwelt Mutterleib. Kösel Verlag,
München 1972
Tomatis, A.: Das Ohr und das Leben. Walter Verlag,
Düsseldorf 1977
140
The postnatal period
If we were to separate the first year of life after birth
into four trimenons, the first would be the postna-
tal period. The masticatory organ is marked by
three life-sustaining functions during this time:
• Respiration
• Ingesting food
• The first primitive vocal communication
Respiration begins immediately and automatically
at birth and is generally associated with a commu-
nicative "wail".
Communication, as a means of conveying informa-
tion to the environment, requires oral speech as the
"transmitter" by which the sounds "AA", "A", "EE"
can be produced. The mother quickly learns to
interpret the signaling language: "AA" stands for
hunger, "A" for pain and "EE" for emotion. At this
time (or earlier), the ear of the newborn already is a
mature receiver and can react to the mother's speech
and sounds (comp. Tomatis) (see ill. 111, p. 141).
Food is ingested under physiological conditions by
laying the "suckling" infant at the mother's breast,
or by offering nourishment in bottles equipped with
a nipple-like apparatus.
The skull of the newborn is characterized by a
marked disproportion between the neocranium and
viscerocranium. Both jaws are edentulous, but the
crowns of the deciduous teeth are already pre-
formed in the dental lamina. The nuclei of the first
permanent molars are also visible on radiographs at
this time; the same is true for the tips of the cusps
(see ill. 112-114, p. 141).
The temporo-mandibular joints are functionally
prepared for the first nutritional phase as "flat" slid-
ing joints. The articular fovea on the temporal bone
is either absent or barely visible; essentially it is a flat
surface. This is the optimal configuration for the
milking action of the infant, as this movement is a
purely protrusive-retrusive one that does not need
to avoid or be controlled by dental structures. The
mandible primarily consists of its horizontal branch;
a mere trace of the ascending branch is seen. The
extension of an occlusal plane constructed in the free
space between the maxilla and the mandible would
pass through the condylar process, as seen in reptiles.
The function of the organ in normal ingestion of
food is more of a milking act than a sucking one.
Structures - Occlusion - Articulation

Ill. 111: Vocal commu-

nication in the first few
months of life.

Ill. 112: The temporo-

mandibular joint and
the future occlusal sur-
face are located on the
same plane. The neuro-
cranium is dominant
and makes it necessary
for the infant to be
born early.

113: This sketch shows

the strong proportional
difference between the
viscerocranium and the
neurocranium.

Ill. 114: This illustra-

tion shows the available
tooth structures at the
time of birth. In many
cases, the bud of the
future permanent molar
reveals calcification.

141
R. Slavicek • The Masticatory Organ
"Suckling" is, in fact, incorrect.
Marie Francois Xavier Bichat 1771–1802
Peristalsis
Mastication
Thus, the natural method of ingesting food
by the infant should be regarded as the first
mandibular movement pattern, which also
remains intact later in the mature masticatory
organ. It is the basis of every mastication pat-
tern and is always demonstrated in the indi-
vidual action of mastication.
142
The milking function consists of a wide protrusive
extension, strong closing, quick, smooth retraction,
and swallowing. These flat, two-dimensional
movements are ideally suited to the developmental
stage of the organ. The function of milking the
mother's breast, performed by the newborn's "mas-
ticatory" organ ("suckling" is, in fact, incorrect),
wich encompasses the mammary papilla and the
areola with the protrusive action, then closes pow-
erfully and "milks" out the mother's breast in a
retrusive movement. Bichat's sucking pad creates
vacuum during the retrusive movement and there-
by contributes to the pumping effect. The retrusive
movement continues into a physiological, i.e., from
anterior to posterior, deglutition. The direction cor-
responds to peristalsis in the digestive tract. The
protractors (lateral pterygoid muscles), retractors
(temporal muscles and digastric muscles), the
tongue, buccal and labial muscles and the entire
musculature of the floor of the mouth are involved
in this flat, i.e. horizontal plane, movement.
Thus, the natural method of ingesting food by the
infant should be regarded as the first mandibular
movement pattern, which also remains intact later
in the mature masticatory organ. It is the basis of
every mastication pattern and is always demon-
strated in the individual action of mastication.
In physiological breast-feeding, the infant makes
"symmetrical" use of this system by switching from
the right to the left breast (see ill. 115 and 116, p.
143).
If food is ingested from a bottle, no change in posi-
tion is likely to occur. It is governed by the domi-
nant hand of the person feeding the infant. This
results in a characteristic asymmetrical function.
This problem should definitely be discussed with
parents when they are being instructed in this
regard (see ill. 117, p. 143).
In the terminology of the functional physiology of
deglutition, the term "infantile deglutition" is used
to describe a protrusive (pathological) lingual
movement during deglutition. This is misleading,
insofar as regular deglutition in the infant is a cor-
rect, retrusive process.
Structures - Occlusion - Articulation

Ill. 115, 116: These two pic-

tures show the necessity to
"shift" the baby.

Ill. 117: The risk of develop-

ing asymmetrical function due
to the dominant hand of the
feeder.

143
R. Slavicek • The Masticatory Organ
Perinatal
Nevertheless, because of the voluminous neu-
rocranium, the risk of brain trauma is rela-
tively high (comp. Vojta).
Routine perinatal check-ups and investigation
of the cranium and masticatory organ by a
neonatologist would be helpful.
Vojta, V.: Die zerebralen Bewegungsstörungen im Säuglingsalter.
Frühdiagnose und Frühtherapie. Ferdinand Enke Verlag,
Stuttgart 1988
144
Perinatal problems
For several reasons, the process of birth is laden
with risk for future functions. Modifications in the
female birth canal brought about by the evolution-
ary change in posture to the upright position and
the concurrent increase in the size of the neurocra-
nium led to early birth of the infant, triggered by
hormones. Nevertheless, because of the voluminous
neurocranium, the risk of brain trauma is relatively
high (comp. Vojta). In the event of brain damage,
free brain areas provide good chances of recovery.
Nevertheless, postnatal functional disorders may
occur. The latter must be diagnosed and treated as
early as possible. In the first trimenon, the infant
has so-called primitive reflexes. From a prophylac-
tic point of view, it is important that the physician
as well as the parents of the infant maintain a close
watch on the infant's reflexes. Well-instructed par-
ents examining the infant at regular intervals can
do much to serve as a preventive force for the sys-
tem (see ill. 118-121, p. 145-146).
However, during parturition, the viscerocranium
can also be subject to trauma, above all when, due
to abnormal presentation, it is not protected by
physiological ventral flexion. Therefore, a signifi-
cant part of any functionally oriented anamnesis
of infants and adolescents must also retrospective-
ly consider the history of the parturition. Routine
perinatal check-ups and investigation of the cra-
nium and masticatory organ by a neonatologist
would be helpful.
The postnatal period is marked, functionally, by
the ingestion of food (milking action) as well as by
the beginning of oral communication at the 1st
and 2nd levels of the Bühler-Popper scheme.
At the end of the third month, a changeover from
primarily phylogenetic development to ontoge-
netic development begins. Symphyseal elbow sup-
port is one feature of this period. The head and
face are directed forward. The infant starts to be
prepared for the altered function of the spine at
this time and should be encouraged (see ill. 122-
124, p. 147).
Structures - Occlusion - Articulation

Ill. 118: Initial

steps of re-for-
mation in the
first postnatal
weeks.

Ill. 119: First

independent
efforts of the
newborn in prone
position.

145
R. Slavicek • The Masticatory Organ

Ill. 120: The new

formation of the
cervical spine in
the first few
weeks.

Ill. 121: Rolling

exercise and
checking reflexes.

146
 Structures - Occlusion - Articulation

Ill. 122: Preparation for independent locomotion according to Vojta.

Ill. 123: Exercises for the changeover and preparation of the spine.

Ill. 124: Playful training under parental supervision.

147
R. Slavicek • The Masticatory Organ
At the end of the second trimenon, dentition
starts to develop and the first deciduous teeth
erupt.
Echolalia
The third and fourth trimenons are charac-
terized by the development of locomotion
and verticalization.
148
Verticalization of the body begins and a distinct
change in reflexes takes place. In vocalization, in
addition to pure vowels, various simple sounds start
to be formed.
At the end of the second trimenon, dentition starts
to develop and the first deciduous teeth erupt (see
ill. 125-130, pages 149-150).
A change in the ingestion of food and in the func-
tion of the organ takes place.
Vocalization becomes more and more of a kind of
echolalia, with the doubling of syllables as the first
signal of "understanding and communicating". The
child learns to use labium-supported consonantal
interruptions in its still mainly vowel-rich speech
(mama, papa).
The third and fourth trimenons are characterized
by the development of locomotion and verticaliza-
tion. Attempts to sit and stand become more inten-
sive. In the time-lapse of ontogenesis, human verti-
calization and the inherent struggle against gravity
takes place. The child passes through uncoordina-
ted wriggling, to crawling and sitting. Standing
and walking occur at the end of this period (see ill.
131-137, pages 151-153).
Exactly at this time, the masticatory organ under-
goes extensive functional modification.
The development of speech, the changeover to true
mastication, the role of the cervical spine as an
organ of support for the head, the coordination of
the shoulder and neck muscles and the develop-
ment and maturation of independent rotation of
the head, dominated by sense organs, by way of
functional "turning towards," - all of these changes
occur at this time (see ill. 138, p. 154).
The dramatic reorganization of the cranial base and
the temporal bone for the now commencing "free-
dom of movement" as a true biped are a fascinating
ontogenetic wonder in terms of rotation and
counter-rotation. At this time the human child
develops in a clearly different way than the primate
one, the two having been similar up to this point.
The conversion to true bipedal locomotion is
extremely significant for the development of the
masticatory organ. From this point on, the free pos-
ture of the head is controlled by several factors.
Structures - Occlusion - Articulation

Ill. 125 (left): The end of the second

trimester, beginning of dentition.
Ill. 126, 127: Generally, the eruption of the
mandibular deciduous dentition takes place
first, followed by the maxillary one.

149
R. Slavicek • The Masticatory Organ

Ill. 128: The skull at approximately eight months.

Ill. 129, 130: The eruption of the maxillary and mandibular deciduous dentition and
free function of the mandible.

150
 Structures - Occlusion - Articulation

Ill. 131, 132: The first attempts …

Ill. 133: The head and its cervical spine turning to "pay attention".

151
R. Slavicek • The Masticatory Organ

Ill. 134: Success …

Ill. 135: Rotational ability …

152
 Structures - Occlusion - Articulation

Ill. 136: Goals …

Ill. 137: The bipedal being - the free and moveable head.

153
R. Slavicek • The Masticatory Organ

Ill. 138: Rotation and counter-rotation, upright stance and the organ of equilibrium.

154
 Structures - Occlusion - Articulation

Tilscher postulates cranial articulation as a

The controlling factors are as follows: the inner ear, sense organ. From this viewpoint, the over-
the optical system and proprioceptive controls in lapping associations between the masticatory
the cranio-cervical region. Tilscher postulates cra- organ and postural problems become appar-
nial articulation as a sense organ. From this view-
ent.
point, the overlapping associations between the
masticatory organ and postural problems become
apparent.
During this time it is necessary that the child's
development be carefully observed, as this is the
best time to treat irregular development and diag-
nose functional asymmetry and grave postural
problems. Well-informed parents are a great help
in this task.
As the dentition progresses, close attention should
be given to the development of the dental arches.
The continued differentiation in the formation of
sounds begins to occur after the first year, starting
with the anterior deciduous teeth wavering attempts
to make dentition-supported and dental soft-tissue
supported sounds are made during this time. The The development of speech accentuates and
development of speech accentuates and imparts imparts powerful formative impulses to the
powerful formative impulses to the system. The system.
position of the tongue and the dynamic and static
harmony with the facial muscles now form the
masticatory organ.
An absolutely new and previously neglected aspect
of the possibly altered functional development of
the organ has arisen - and must be given due atten- ... the dramatically positive survival prognosis
tion in the future - through the dramatically posi- for premature infants.
tive survival prognosis for premature infants.
Regarding the masticatory organ, the developmen-
tal disorders that might possibly result from pre-
liminary neonatological life-sustaining measures Comparisons of premature infants (with and
and the preventive measures that need to be under- without intensive medical care) and those
taken in order to avoid subsequent dysfunction are born at term revealed astounding results: pre-
not yet fully known. Developmental disorders in mature infants who grow under normal phy-
the functional area of primary deglutition could, for siological conditions have the best functional
example, have an effect on future (faulty) develop-
ment of the masticatory organ. diagnostic results.
Comparisons of premature infants (with and with-
out intensive medical care) and those born at term
revealed astounding results: premature infants who
grow under normal physiological conditions have Tilscher, H.: Das Bewegungssegment der Wirbelsäule im
the best functional diagnostic results (comp. Blickpunkt der orthopädischen Rückenschule. Medizinisch-literari-
Stockner). In infants born at term, it is important sche Verlagsgesellschaft, Uelzen 1993
Stockner, A.: Die Überprüfung des Funktionszustandes des
to avoid functional disorders related to nutrition. stomatognathen Systems ehemaliger Frühgeburten und Geburten mit
At this point, improperly handled bottled food can intensivmedizinischer Behandlung in den
lead to the first pathologies in the function of the ersten Lebensmonaten. Eine Nachuntersuchung im Alter
masticatory organ (dysfunction of deglutition). von 7 bis 13 Jahren. Dissertation, Univ. Wien 1996

155
R. Slavicek • The Masticatory Organ
Ill. 139: Physiological protrusive direction during growth
Deforming influences at this time, such as
pacifiers or thumb-sucking, can disrupt regu-
lar morphological and functional develop-
ment.
During the development of deciduous teeth,
communicative speech, the "mother tongue",
develops to the third level of the Bühler-
Popper scheme.
Functional speech disorders determine form!
The assumption that dysgnathia is always
based on genetic factors is not true.
Garliner, D.: Myofunctional Therapy. W. B. Saunders
Company 1976
156
The development of deciduous teeth
When the first deciduous teeth (in most cases the
lower incisors) erupt, a rapid shift in function takes
place. The adductors are utilized to a greater
extent; the dental crests are functionally stressed by
solid food and objects. A shift to more solid food
takes place and, consequently, to mastication. This
occurs in most cases in a protrusive position (see ill.
139, left). The functional development of a dento-
alveolar process is accelerated; such development is
primarily subject to the functional influences of the
tongue and labial structures. Pacifiers or thumb-
sucking can disrupt regular morphological and
functional development at this time, causing defor-
mities. Naturally, this also applies to unwarranted
continuation of bottle-feeding. Commonly used as
a means of calming the infant before it goes to
sleep, bottle-feeding leads to oral respiration, which
has a negative effect on the development of the
maxilla and, in addition, may instigate an outdated
type of caries. "Bottle feeding decade" is the new
term to denote the period during which such caries
occurs.
Other dramatic developments take place during
this period: the shift to the upright position, its
strong influence on the cranial skeleton and the
cervical spine, and the beginning of oral communi-
cation through learning the native language.
During the development of deciduous teeth, com-
municative speech, the "mother tongue", develops
to the third level of the Bühler-Popper scheme. The
first signal for this is the child's repetition of sylla-
bles. At this time there is a danger of functional
speech disorders being transferred by the teacher to
the child. Learning a language at this point is based
on imitation. Of significance here is the fact that
(comp. Garliner) oral functions determine form,
i.e., functional speech disorders determine form!
Thus, a structure- or function-based speech disor-
der of the mother (or father) can cause a patholog-
ical form of the functional speech disorder in the
child. The transferred functional disorder may lead
to a structural deformation. The assumption that
dysgnathia is always based on genetic factors is not
true. Therefore, from the viewpoint of system pro-
phylaxis, it is speech that deserves careful observa-
tion. Language is imitation. Learning the "mother
tongue" bears the inherent risk of speech disorders
being passed on to the child by the teacher. It is the
 Structures - Occlusion - Articulation

dentist's responsibility to inform parents at this ... risk of speech disorders being passed on to
time, as the advice of a logopedist is sought much the child by the teacher.
later.
As the dental arches of deciduous teeth become
more fully developed, neuromuscular awareness and
programming become more distinct. The frequent-
ly incongruent size and form of the arch makes it
difficult for the arches to fit together. The system The system then decides on the best possible
then decides on the best possible dentition it can dentition it can achieve. For this purpose, it
achieve. For this purpose, it may considerably alter may considerably alter the position of the
the position of the mandible. The mandible is
mandible.
adjusted asymmetrically in order to achieve most
optimal function. As a result, the original symmet-
rical form of the mandible may continue to develop
asymmetrically because of function-based adapta-
tion. The adaptive process leads to the skeletal devel-
opment being forced to compensate. Functional Functional asymmetry results in morphologi-
asymmetry results in morphological asymmetry. cal asymmetry.
Compensation processes or completed compensa-
tion mechanisms must be detected in the process of
diagnosis, and there must follow a clear distinction
between the former on the one hand, and develop-
mental disorders due to other causes on the other.
Compensation processes are not only transversal in
nature, but are found at all levels. During the
process of development, the organ attempts to
adapt optimally to form, while ensuring that it is
able to execute the functions it is required to per-
form. The goal is always optimal function.
This illustrates the significance of the dentition and
the importance of observing it carefully. The pedia-
trician's role is a very significant one. Any regis- Any registered developmental anomalies
tered developmental anomalies should be eliminat- should be eliminated at this early point in
ed at this early point in time, before compensatory time, before compensatory processes start.
processes start to manifest themselves. The pedia-
trician consulted for this purpose must be able to
depend on the knowledge and understanding of
the referring dentist or orthodontist. From the
viewpoint of prevention, it would be a grave error From the viewpoint of prevention, it would
to allow such asymmetries to "mature". It should be a grave error to allow such asymmetries to
always be remembered that the form of the "mature".
mandible will be the problem, while additional
problems will be created by asymmetrical move-
ments and functional patterns. Orthodontic mea-
sures in a "mature", compensated "dysgnathic"
patient have the potential to de-compensate com-
pensated function and create dysfunction. Dysgnathia

157
R. Slavicek • The Masticatory Organ
The development of descriptive speech
initiates or deepens the functional asymmetry
of the brain and thereby determines
"(one-)handedness".
Lateralization
Of course, lateralization also affects the eyes.
Posture while sleeping is important not only
during growth but also later, when the causes
of dysfunction have to be located and
explained.
158
The first developments in speech
Speech development during this period is a contin-
uation of another significant area of brain develop-
ment, namely the so-called "lateralization" of brain
hemispheres. This means that the brain hemi-
spheres undergo, to a certain extent, a shift in their
center of gravity and responsibilities due to the
demand for a highly developed coordinating func-
tion.
The development of descriptive speech initiates or
deepens the functional asymmetry of the brain and
thereby determines "(one-)handedness". Phylo-
genetically, this development is specifically associat-
ed with hominization. Although predetermined,
the process is characterized by individual learning.
Of course, lateralization also affects the eyes and, in
a particular way, the remaining cranial nerves, espe-
cially the auditory nerves. As mentioned previous-
ly, the development of speech is of great signifi-
cance for the masticatory organ. Early diagnosis of
problems and the correction of functional disorders
are very significant for the development of the den-
tition.
Problems relating to the sleeping
position
In terms of system prophylaxis, the possibility of
the sleeping position being the cause of develop-
mental disorders related to growth must be dis-
cussed with the parents of the neonate. Posture
while sleeping is important not only during growth
but also later, when the causes of dysfunction have
to be located and explained. The individual's pos-
ture while sleeping plays an especially important
role with regard to cranial development in early
childhood. Closely associated with the psyche as an
expression of anxiety are the popular one-sided,
rolled up sleeping position or the face-down
abdominal position. Both are significantly involved
in the development of asymmetries. Timely recog-
nition and correction are important for prophylaxis
of the system.
 Structures - Occlusion - Articulation

Respiratory problems
Respiration is a major factor in the structural deve-
lopment of the dentition. Proportional developmen-
tal disorders between the maxilla and mandible
from frequent or dominant oral respiration lead to
incongruence in the arches. Both, the tongue's posi-
tion and its function are strongly altered in these
cases; the formative impulses to the maxillary arch
are lessened. Problems in respiration also have
repercussions on body posture. These interrelation-
ships were recognized, described and corrected
Ill. 140: Scheme of the full arch in deciduous dentition,
through system prophylaxis long ago (comp.
whose functional period continues to the sixth year.
Balters). Nevertheless, there still has been no gen-
eral breakthrough in dental concepts in this regard.

The functional periods of mature

deciduous dentition
At approximately two and a half years of age, the
fully developed deciduous teeth achieve maturity.
The bases of the jaws contain the dental arches,
which are rather wide and have no sagittal or trans-
versal compensation curves (see ill. 140 and 141,
right). The extension of the occlusal plane passes
through the condylar process near the articular
trochlea. The mandible is still strongly dispropor-
tional in favor of the horizontal branch. The articu-
lar eminence is minimally developed.
Ill. 141: The dental arches have no compensation curves and
Maximum learning of all the tasks of the future are therefore rather two-dimensional. The joints lie closely
masticatory organ takes place during this function- above an altered occlusal plane.
al period. Speech, mastication and deglutition are
in the foreground.
At the same time, the masticatory organ is also
stressed from the parafunctional viewpoint. Most Most children in this developmental period
children in this developmental period are heavy are heavy "grinders".
"grinders". In this extreme learning period, the
child is subjected to strong emotional stresses.
Increasing limitations are imposed on the child's
personality by the constraints of his/her education
towards becoming a "social being". As a result, the
masticatory organ is apparently used as a nocturnal
stress (safety) valve - a normal physical reaction for
balancing aggression. In many cases, the result is
distinct abrasion of deciduous teeth. Balters, W.: Neue Ergebnisse der Artikulationsforschung.
Deutsche Zahn-, Mund- und Kieferheilkunde, Bd. 3, H.4,
1936

159
R. Slavicek • The Masticatory Organ
Problems in the dentition of deciduous teeth
are common, as the dental arches of the max-
illa and mandible often do not intercuspate
congruently.
In order to achieve proper function, adaptive
compromises are achieved by modifying the
morphology.
The functional period is marked by strong
parafunctional patterns
Parafunction
Ringel E.: Die ersten Jahre entscheiden. Verlag Jungbrunnen,
Wien, München, 1987
160
During this period the mandible intercuspates with
its dentition mainly in a slightly protrusive posi-
tion. The maxillary and mandibular deciduous
molars generally close distally in a vertical plane
(post-lacteal plane). This is advantageous for the
desired Class I dentition of erupting, permanent
molars, according to several authors. The dental
crowns of the permanent incisors and also those of
the first molars are already fully formed and ready
to erupt. Thus, the morphology of teeth is ready
long before the teeth start to function. Because of
the relatively narrow arch of the child's jaw bases,
there is persistent crowding in the permanent
crowns, which manifests itself in a three-dimen-
sional echelon formation of the dental buds.
Problems in the dentition of deciduous teeth are
common, as the dental arches of the maxilla and
mandible often do not intercuspate congruently.
Orthopedic problems, for instance, i.e., incongru-
ence of the arch, are easily compensated for during
this period through adaptation of functional pat-
terns. The masticatory organ adapts in this reactive
time especially rapidly and strongly to functional
impulses. Future processes are marked by targeted
efforts to achieve function.
Of importance is the fact that functional adaptation
is followed by a phase of structural adaptation,
which is critical during the early developmental
period. In order to achieve proper function, adap-
tive compromises are achieved by modifying the
morphology.
Summary of the functional period of
"deciduous dentition"
This functional period is characterized by the estab-
lishment of all functions of the masticatory organ.
The deciduous dentition is rather two-dimensional;
the functional patterns are flat. The functional peri-
od is marked by strong parafunctional patterns
(comp. Ringel, Slavicek).
The mandible lies slightly protrusive, with a gener-
ally slight frontal overbite, resulting near the end of
this functional period in a so-called "post-lacteal
plane", which favors the position of the erupting
permanent molars in Class I. The first six years of
life are distinguished by a dramatic skeletal effort to
 Structures - Occlusion - Articulation

"catch up" and a shift in proportion, in favor of the

viscerocranium. Of importance at this time is also
the development of the mandible anteriorly.
It is of interest to follow the development of the
occlusal plane in relation to the changing propor-
tions of the mandible near the end of this function-
al period. The relationship between the horizontal
and ascending branches slowly changes in favor of
the latter, thereby increasing the distance of the
occlusal plane to the temporo-mandibular joints.
The dental arches are, in many cases, not ideally
congruent; intercuspation is occasionally ambiguous.

Ill. 142: Scheme of eruption of permanent teeth.

The first functional period of a

changing dentition
The first permanent molars generally erupt behind
the deciduous molars during the sixth year. At the
same time, there is a substitution of dentition in the
anterior region (see ill. 142 and 143, right). The
permanent teeth are hard structures, introducing a
functional interference into the movement pattern
which, up to this point, was rather free and flat
because of the deciduous teeth. The NMS must
immediately compensate for this through modifica-
tion of the functional pattern. The lingual concavi-
ty of the maxillary central incisors and the approx-
imately simultaneous eruption of the mandibular Ill. 143: The first molars erupt behind the deciduous dental
arch, the anterior teeth "change".
incisors limit and determine the protrusive pattern
of mandibular movement (see ill. 144, right). The
movements should not be mechanistically misinter-
preted in terms of catenation, in cooperation with
the temporo-mandibular joint (comp. Kubein-
Meesenburg). At this time the mandibular joints
are not morphologically adapted to a steeper gui-
dance. The NMS only limits the movement pattern
to the front. In these anterior movements, the front
teeth are recognized and accepted as obstacles, and
avoided (see ill. 145-149, pages 162-163). This
does not occur however, as a coordinated and
dependent movement on the guidance surface, as
in a crank mechanism. The special proprioceptive
role of the front teeth will be discussed later.
The eruption of the first permanent molars (see ill. Ill. 144: The permanent incisors limit the functional space
150 and 151, p. 164) behind the deciduous denti- anteriorly with their arrangement.
tion definitely alters the lateral and retral patterns
of the CNS at this early stage. With the eruption Catenate

161
R. Slavicek • The Masticatory Organ

Ill. 145: This functionally adapted limit is complemented by the structural adaptation of the developing articular eminence.

Ill. 146: The mandibular anterior teeth are arranged slightly vertical to the occlusal axis of the mandible, the dento-alveolar process
develops accordingly.

162
 Structures - Occlusion - Articulation

Ill. 147: Problems in the dentition during this functional period should be taken seriously.

Ill. 148

Ill. 149: Crossbite and anterior deep bite must be recognized and treated early.

163
R. Slavicek • The Masticatory Organ
Ill. 150: The lingual concavity of the mandibular front forms
the controlling anterior limit of functional space. There is no
direct morphological dependence on the temporomandibular
joint.
Ill. 151: The solidly structured occlusal surface of the first
permanent molars are indicative of an entirely new morpho-
logical concept.
164
and arrangement of the first permanent molars and
front teeth, a completely new morphological prin-
ciple enters the system. Genetically predetermined,
the new morphology controls functional processes
and the neuromuscular system must adapt to the
new arrangement.
At this time, careful observation of the erupting
molars by the dentist is very important. If the
mandibular molar erupts in proper relation to the
upper molar, with a normal occlusal interdigitation,
then the morphology of the two teeth will be fully
suited to fulfill their four main functions (see ill.
152-167, pages 165-167), namely laterotrusive
guidance, retral protective function, bolus trans-
portation with food processing, and protection of
soft tissues (cheek, tongue). If the molars erupt
divergently, the system will still attempt to achieve
optimal function. Faulty relations give rise to com-
pensatory measures, which may lead to dento-alve-
olar proportional and directional modifications and
also to asymmetries. These occurrences should not
be evaluated as pathologies, rather they should be
regarded as functional adaptation mechanisms.
Of interest now is the increasing differentiation of
the mandible. Through the development of the
ascending branch, the occlusal plane distances itself
from the joint. The increasing distance (DPO =
distance to plane of occlusion) leads to the develop-
ment of a distinct articular eminence; the function-
al condylar track on the eminence becomes more
steeply inclined. This increase in inclination is to be
regarded as an adaptation to the altered form of the
mandible as well as to the structures of the first per-
manent molars and the permanent anterior teeth.
If the shape of the arch is apparently asymmetrical,
the individual has occlusion problems on one side,
or if the right and left inclinations of the occlusal
plane differ during this phase, there is a risk of
asymmetrical structural maturation of the articular
eminence. Obviously different condylar track incli-
nations are problematic from a therapeutic point of
view, especially during late treatment of the sys-
tem, if the dentist wants to achieve satisfactory and
stable functional results. It is the dentist's responsi-
bility to diagnose and treat the developments as
early as possible.
It is especially important to observe the child's body
and head posture at this time. Incorrect posture
inevitably influences the development of the mastica-
tory organ. Incorrect posture at school, while writing
Structures - Occlusion - Articulation

Ill. 152 left: At

the beginning of a
normal dentition,
the mesio-buccal
cusp of the
mandibular molar
guides laterally on
the inclined mesio-
buccal cusp of the
maxillary first
molar.
Ill. 153 right: The
mesio-buccal cusp
guides laterally
against the mesio-
buccal cusp of the
maxillary molar.

Ill. 154 left: The

maxillary first
molar provides a
place for the disto-
buccal cusp of the
mandibular first
molar on its trans-
verse crest.
Ill. 155 right: The
distal slope of the
disto-buccal cusp
of the mandibular
first molar serves as
a retrusive gui-
dance control for
the protrusive
position of the
mandible.

Ill. 156 left: The

sturdy buccal cusps
of the first molar
distinguish the
soft-tissue relation
to the cheek.
Ill. 157 right: This
complete image of
the morphological
details of the max-
illary first molar
demonstrates its
functional impor-
tance.

165
R. Slavicek • The Masticatory Organ

Ill. 158 left:

The high lin-
gual cusps of
the mandibular
molar prevents
damage to the
tongue during
mastication.
Ill. 159 right:
The overall rep-
resentation of
the mandibular
first molar with
significant
dynamic details.

Ill. 160 left:

Defined contacts
on the mandibu-
lar molar.
Ill. 161 right:
Defined contacts
on the maxillary
molar.

162: The molar

relation in a
"transparent"
scheme.

166
 Structures - Occlusion - Articulation

Ill. 163: The movement pattern of the maxillary Ill. 164: The predominant spectrum of movement of
molar to the mandible. the mandibular molar to the maxilla.

Ill. 165: Structure dictates pattern. Ill. 166: The field of movement is changed by rota-
tion.

Ill. 167: In this functional period, the final arrange-

ment of the front and the first molar dictates the
dynamics of mandibular movement. The teeth shad-
ed in gray are not extant at this time, but are still a
part of the deciduous dentition.

167
R. Slavicek • The Masticatory Organ
Ill. 168: Incisors and anterior palatal structures are important
for the formation of speech, and are also subject to formative
influences.
Legasthenia
Dyslexia
The arrangement of the dental crowns and
that of the roots of the anterior mandibular
teeth follow the closing axis principle.
The morphology of the crowns is determined
by genetic factors. The form of roots and
even the entire dento-alveolar complex are
subject to permanent influences.
Page, H. L.: The Occlusal Curve. Dental Digest
S. 19–22, 1952
Orthlieb, J. D.: Intérêt de la Courbe de Spee dans la Recherche
d’un Plan d’Occlusion en Prothèse Fixée. Thèse de Doctorat en
Sciences Odontologiques, Aix-Marseille 1983
168
and reading, is frequently involved in the develop-
ment of dysgnathias. Writing, reading and listen-
ing are closely associated with the lateralization of
the brain. In cultures with horizontal writing styles,
congenital alexia (dyslexia) is a problem that affects
posture and the form of the viscerocranium. It is of
paramount importance to consider the dominant
ear and the dominant eye when selecting a seat for
the child in the classroom. The head turns the do-
minant "receivers" to the "transmitter", i.e. the
teacher. Static seating plans in the classroom are
entirely inappropriate from the viewpoint of system
prophylaxis.
In the first period of the changing dentition, the
function of speech matures fully; the arrangement
of the anterior arch is strongly subjected to the
functional influences of speech. Anomalies of lan-
guage lead to specific stresses and to the develop-
ment of particular muscle patterns. Phonation is
fully developed by the end of this period. This
includes the characteristic vowel and consonantal
sounds, along with the gutturals, which are labial-
supported, dento-labial-supported, dento-lingual
supported, dentition-related or dentition-support-
ed. The gutturals are frequently conveyed into the
anterior palatal-lingual region (see ill. 168, left).
The arrangement of the dental crowns and that of
the roots of the anterior mandibular teeth follow
the closing axis principle. Accordingly, the roots do
not develop in a straight line but in a slight arc, fol-
lowing the slow verticalization of the system.
While the vertical dimension increases the distance
to the articulation increases, the angle of inclination
of the crowns changes and the curves of the devel-
oping roots follow the closing axis principle (H.
Page) (see ill. 169-174, pages 169-170).
Naturally, this development can be viewed three-
dimensionally. The morphology of the crowns is
determined by genetic factors. The form of roots
and even the entire dento-alveolar complex are
subject to permanent influences. This means that a
fully mature asymmetrical dysgnathia will most
likely have an asymmetrical root morphology. This
is an additional problem in late treatment. Orthlieb
describes in the illustration an angle of difference
from the sagittal view, which is noteworthy from a
dynamic-static viewpoint (see ill. 175, right).
Functionally, an entirely different anterior principle
emerges when the permanent anterior dentition
erupts. From this point on, they control mandibu-
Structures - Occlusion - Articulation

Ill. 169: The mandibular incisor and its

slight orientation to the occlusal axis.

Ill. 170: The development of the mandibu-

lar dento-alveolar process also follows the
closing axis principle. However, it should
be noted that the central point of dento-
alveolar compensation is exactly at this site.

Ill. 171: The arrangement of the maxillary

front teeth takes place predominantly
under the functional influence of soft tis-
sues, above all, by the lower lip. Speech is
also a dominant factor here.

169
R. Slavicek • The Masticatory Organ

Ill. 172: The molars are arranged, deviat-

ing from Page's rule, not vertical to the
occlusal axis, but having a deviating angle
greater than 90 degrees.

Ill. 173: The line of stress to the optimal

absorption of pressure from the sagittal
view.

Ill. 174: The closing axis principle is illus-

trated in this overlay of Posselt's scheme.

170
 Structures - Occlusion - Articulation

lar movements proprioceptively by means of the

normally occurring positive overbite of the maxil-
lary incisors over the mandibular ones. The anterior
teeth are strictly avoided during mastication, as will
be more clearly explained in a later section. This
avoidance mechanism is initially a functional one,
under muscular control, but is rapidly replaced by
structural adaptation at the temporal bone and the
mandible. An increasingly inclined articular emi-
nence begins to develop; simultaneously, the
mandible undergoes continuous change in form and
proportion. During this period of verticalization, the
ramus develops individually, decending the body of Ill. 175: In one of his later works, Orthlieb determines a "dif-
the mandible away from the condyle, which ference" angle, which diverges from Page's rule in the lateral
becomes equally distanced from the occlusal plane. aspect. This will be discussed later.

The maxilla develops transversally, especially in the

posterior region, due to the increased width of the The maxilla develops transversally, especially
neurocranium. This continues until beyond the end in the posterior region, due to the increased
of the functional period, bringing about an alter- width of the neurocranium.
ation in the transversal inclination of the occlusal
table of the molars. The mandible adapts and is
remodeled to the maxilla. The anterior arch devel- The mandible adapts and is remodeled to the
ops especially in the lateral incisor region, function- maxilla.
ally inter-dependent on molar function, and vice
versa.
This period is characterized by strong development
and by increased inclination of the sagittal condylar
track. The transversal condylar track, or Bennett The transversal condylar track, or Bennett
movement, is characterized individually by inter- movement, is characterized individually by
relationships between molars and the anterior arch; inter-relationships between molars and the
the muscle pattern of mandibular movement
anterior arch.
adapts to dental morphology and its spatial pattern
and inter-relationships. Naturally, the adaptation
also takes place in the absence of ideal dental or jaw
relationships, but in such an event the adaptation
occurs in accordance with the existing dentition,
not in keeping with the "normal" pattern of denti-
tion.
During growth, the system attempts to compen- During growth, the system attempts to com-
sate functionally and structurally for dysgnathic pensate functionally and structurally for dys-
dental or jaw relationships. This applies to the gnathic dental or jaw relationships.
dento-alveolar region, as well as to development in
the temporo-mandibular region.

Enlow D. H.: The Human Face: An Account of the Postnatal

Growth and Development of the Craniofacial Skeleton. Hoeber
Medical Division, Harper & Row New York, 1968

171
R. Slavicek • The Masticatory Organ
Extractions in this region should be viewed
with great caution, both from the orthodontic
and functional points of view.
proprioceptive
The temporo-mandibular joint has now
achieved at least 90% of its full development,
at the level of the articular eminence.
172
The second functional period of the
changing dentition
In conjunction with the eruption and established
pattern of premolars, a more inclined, lateral gui-
dance principle is introduced into the functional
pattern of the dentition. In other words, this
period is characterized by a new morphology (see
ill. 176-180, p. 173).
The morphology of premolars, especially that of
the first, is important for the final dynamics of lat-
eral, retrusive and protrusive mandibular move-
ments. Extractions in this region should be viewed
with great caution, both from the orthodontic and
functional points of view, and should only be
undertaken after long deliberation and for a good,
well established reason. If possible, extractions
should only be performed after the end of the sec-
ond functional period. "Good reason" most certain-
ly does not include secondary crowding brought
about by the early loss of deciduous teeth.
Extractions in the anterior region are generally con-
traindicated, even in cases of primary crowding, as
the reason for the lack of space often lies in the pos-
terior portion of the arch. Precise diagnosis, careful
therapeutic planning and solid grounds are prere-
quisites for the decision to extract.
With the eruption of premolars, the masticatory
organ enters a preliminary stage of maturation.
The first maxillary premolar is characterized by a
steep, laterotrusive guidance principle; this tooth
now assumes dominance over the character of trans-
versal function. It also exercises important proprio-
ceptive retral control through its practical root mor-
phology and its strategic position in the arch.
Simultaneously, the anterior portion of the arch
matures, and the small maxillary incisor adapts
functionally to the first premolar under its antero-
lateral control. The joint morphology reaches a
stage of pre-maturity and adapts to the required
function. Asymmetrical relationships are counter-
balanced by functional asymmetries.
The temporo-mandibular joint has now achieved at
least 90% of its full development, at the level of the
articular eminence. Its very rapid adaptive capacity
during the first years of development is markedly
slowed down, but is still present. This capacity is
maintained throughout life, albeit to a much lesser
extent.
Observing the morphology of the temporomandibular
joint and the first premolars on X-ray overlays from
 Structures - Occlusion - Articulation

Ill. 176-179: These illustrations document the situa- Ill. 177

tion at this point in time.

Ill. 178

Ill. 179 Ill. 180: Molar and second premolar as a functional

unit.

173
R. Slavicek • The Masticatory Organ
Psychic stresses at this age are common.
Mentally induced bruxism is, therefore, wide-
spread and understandable.
In this functional period, the premolars
assume laterotrusive and retrusive protection
for a fairly long period of time.
The inclinations of the premolar buccal cusps
as lateral gliding and guiding elements are
morphologically steeper than those of the
first molar.
The retrusive control and guidance described
above in the classical sense acts as a compen-
sation mechanism in the presence of a ten-
dency to mandibular retrognathia.
Compensation
174
the axial view, one notices the practical dynamic
harmony in these regions (see ill. 181-187, pages
175-176).
Psychic stresses at this age are common. Mentally
induced bruxism is, therefore, widespread and
understandable. From a medical viewpoint, the
masticatory organ system is suitable for serving as
an occasional psychological stress safety valve.
Evaluating the effects of this parafunction on the
masticatory organ and its structures is of decisive
importance.
In this functional period, the premolars assume lat-
erotrusive and retrusive protection for a fairly long
period of time. Temporary indications and symp-
toms of dysfunction are likely to appear on a large
scale. This is due to changes in an extremely com-
plicated functional pattern, in addition to increa-
sing psychic stresses during the prepubescent and
pubescent periods.
The inclinations of the premolar buccal cusps as lat-
eral gliding and guiding elements are morphologi-
cally steeper than those of the first molar, and take
over lateral control from the latter. Thereby, lat-
erotrusive control shifts more anteriorly. In regular
development, the anterior arch matures from this
point to its final functional element, while the lat-
eral incisors adjust with the mandibular anterior
arch in group function to the first maxillary pre-
molar, which frequently erupts first. The maxillary
first premolar can (should) also assume a retrusive
protection function, especially in the presence of a
skeletal Class II with protrusive intercuspating
mandibular teeth.
The retrusive control and guidance described above
in the classical sense acts as a compensation mech-
anism in the presence of a tendency to mandibular
retrognathia. However, a precondition is early
eruption of the mandibular permanent canine. A
significant portion of the ability to build up retru-
sive contacts is located in the root morphology of
the maxillary premolars. A special factor in the
compensation of a skeletal Class II is the special
arched form, typical for Class II/1. The arches have
the typical shape of a lyre, thereby creating nar-
rowness in the anterior of the arch, which sets the
maxillary premolars as retrusive controls to the
mandibular canine.
Under normal conditions, the incisal edges of the
superior front arch are arranged functionally to the
lower lip. If the axis is correctly placed, the lower
lip "stops" the eruption of the maxillary front teeth
 Structures - Occlusion - Articulation

Ill. 181-184: Computerized tomographs illustrating the root strategy, the incision is selected parallel to the occlusal plane.

Ill. 183, 184: In a rather apical incision, note the interesting detail of the mesio-buccal roots of the first molars, as a separate unit
with two canals, appropriate to the premolar root morphology.

175
R. Slavicek • The Masticatory Organ

Ill. 185: The same incision, showing the intercuspation of the Ill. 186: This illustration of the mesio-buccal root of the first
central cusp of the first maxillary molar in the cavity of the maxillary molar shows the transfer of force to the mandibular
mandibular molar. The transfer of force takes place in the zygomatic crest during stress on the buccal cusp in eccentric
palatal root and thereby in the palatal structures. control.

Ill. 187: The red arrows show the vector of the dento-alveo-
lar processes and the teeth.

176
 Structures - Occlusion - Articulation

Ill. 188: The soft tissues stabilize the front. Ill. 189: The course of the lower lip determines the course of
the incisal edges of the front.

Ill. 190: The cavity of the ascending branch and the distance of the joint to the occlusion determine the character of the sagittal and
transversal sphere of occlusion (DPO, according to Orthlieb).

177
R. Slavicek • The Masticatory Organ
The functional pattern is again narrower and
steeper anteriorly.
Huber, E.: Evolution of Facial Musculature and Face Expression.
The John Hopkins Press, Baltimore 1931
178
and determines the esthetic course of the incisal line
(see ill. 188 and 189, p. 177).
The temporo-mandibular joint adapts to the
altered functions through additional inclination of
the eminence. Condylar growth and remodeling
change the proportions of the mandible and the
position of the occlusal plane to the joint. The
development of individual compensation curves is
necessary in order to allow for a uniform functional
distance of dental arches (see ill. 190, p. 177). This
means that the increasing distance of the temporo-
mandibular joint from the occlusal plane is com-
pensated for by the increasing sphericity of occlu-
sion.
The third functional period of the
changing dentition
The last building block in the changing dentition is
the substitution of deciduous teeth by the perma-
nent canines. In a regular arrangement, an individ-
ually dominant guidance principle for the articula-
tion emerges (see ill. 191-192, p. 179). Because of
its crown length and steep lingual surface, the
canine, reintegrated into the upper row through
hominization, is now suited to assume control of
guidance as the dominant element (see ill. 193-
197, pages 180-181).
The functional pattern is again narrower and stee-
per anteriorly. In the guidance pattern there is a lat-
eral disocclusion of the previous guidance elements.
In protrusive gliding guidance, the mandibular first
premolar takes over the stress on the front during
protrusion against the distal fossa of the maxillary
canine. However, this only applies to the regular
bite.
With the eruption and arrangement of the canines,
the steepest morphological principle in the "oral"
functional area begins. The final stage of the dento-
alveolar growth process applies to both, the anteri-
or arch and the gradually developing final arrange-
ment of the supporting zone in the lateral region,
along with the second permanent molars.
The individual spherical model of the dentition
matures, depending on the skeletal principle of the
mandible. The optimal Curve of Spee is achieved
for the masticatory organ. The temporo-mandibu-
lar joints adapt to this situation, by forming the
 Structures - Occlusion - Articulation

inclinations of the articular eminences in concert

with the anterior guidance components.
In this stage of maturation, a functional fine-tuning
of the system within the functional determinants of
the masticatory organ takes place. The transversal
compensation is distinguished by an antero-
posteriorly increasing sphericity. Maxillary and
mandibular dentitions may, but need not necessar-
ily, show equal transversal spherical behavior.
It is to be noted that the morphology of the second
molars develops in very different and individual
forms. The eruption of the maxillary second molar
has, as a rule, transversal emphasis; the occlusal
surface is strongly inclined to buccal. Therefore, in
a normal dentition, it is generally the mesio-palatal
(often alone) cusp of the maxillary second molar
that intercuspates in the central fossa of the Ill. 191: The canine completes the maxillary anterior arch and
mandibular second molar. Thereafter, continued emerges as the dominant and steepest element of occlusion.
maturation can, but need not necessarily, lead to an
uprighting into occlusion (ill. 198, p. 182).
In this stage, as a final stage of development, the
masticatory organ attempts to optimally adjust to
all of the functional demands. The individual, orig-
inal situation has differentiated and becomes less
important, because all of the completed and ongo-
ing developmental processes have the goal of
obtaining eufunction, which may also be associated
with the appearance of a "dysgnathia". It follows
that eufunction and dysgnathia are not necessarily
antithetic. This is a significant aspect of the
approach needed to deal with malocclusion. The
patient's oral functional state must be carefully con-
sidered if orthodontic corrective measures are to be
applied at this point in time. Any orthodontic mea-
sure applied to correct abnormal jaw relationship
conditions may induce a new and extreme adaptive
mechanism. The dysgnathic system has already
adapted to eufunction. Therapeutic measures must Ill. 192: In conjunction with the canine dentition, the second
be carried out with exact knowledge of the adaptive molar erupts in the back molar region.
mechanisms. This applies above all to mature
asymmetries which, in most cases, result in func- Eufunction
tional and structural asymmetries in the temporo- Eugnathia
mandibular joints.
The mandible develops to its final mature skeletal The spatial arrangement of the occlusion is
proportions and the dento-alveolar compensatory fixed and final when the second molars erupt.
processes adapt to the offered, thereby presenting,
functional patterns. The spatial arrangement of the
occlusion is fixed and final when the second molars Hüls A.: Kiefergelenke und Kaumuskulatur im Computer-
erupt (ill. 199-206, pages 184-186). tomogramm. Vergleichende klinisch-röntgenologische
Untersuchungen zu Funktionsstörungen im stomatognathen System.
Dissertation d. Med. Fakultät Tübingen, 1981

179
R. Slavicek • The Masticatory Organ

Ill. 193: The canine in normal dentition, the inter-coronal free space is worthy of
note.

Ill. 194: Beginning eccentric movement laterally restricts the free space …

Ill. 195: … and shifts by "rolling" slightly outwards.

180
 Structures - Occlusion - Articulation

Ill. 196: All incisors on the same side disocclude when they reach the canine tips.

Ill. 197: After their return, the contact of the mandibular to the maxillary canine lies far mesial on the marginal crest of the maxil-
lary canine or even against the marginal crest of the lateral.

181
R. Slavicek • The Masticatory Organ

Ill. 198: The maxillary second molar emerges normally in a buccal direction in the occlusion, the mesiolingual grinding cusp inter-
cuspates in the central groove of its namesake on the contralateral side. Often, no contact takes place on the buccal aspect.

182
 Structures - Occlusion - Articulation

Depending on the developments in the ascending

branch, an individual Curve of Spee compensates
for the increasing distance of the lateral region,
thereby maintaining the efficiency of mastication.
The inclination of the dento-alveolar region from
the transversal view also has a compensatory sphe-
rical character. As a rule, the flexion radius of the
Wilson curves are antero-posteriorly smaller; the
transversal inclination of the occlusal table in the
posterior area increases.

The discussion on changing dentition

The first stage of the functional periods is charac-
terized by the eruption of the first permanent
molars behind the deciduous dentition and their
"searching" inter-digitation, and by the eruption of
the mandibular and maxillary front teeth. This
results in a narrowing of the functional pattern
from the front and the side. The adaptation is mus- The adaptation is muscular at first, then
cular at first, then structural, because of the structural, because of the increased inclina-
increased inclination in the articular eminence. tion in the articular eminence.
Thus, alterations in the form of the condylar
process and the articular eminence occur as a result
of altered functional conditions. Retral control of
mandibular movements is carried out in regular
inter-digitation by the first molars on the transver-
sal ridge of the maxillary sixth tooth (1st molar),
thus maintaining a favorable protrusive position for
the mandible. Significant individual vertical deve-
lopment takes place, both in the dento-alveolar
region and in the ascending branch of the
mandible.
In the second period, primarily the first maxillary
and mandibular premolars erupt. The position of
the mandible is still distinctly protrusive, depending
on growth. The maxillary anterior arch and the pre- The eruption of the canine in the third func-
molars form a functional unit. The new functional tional period introduces the steepest lateral
patterns are manifested, both structurally and mor- guidance element into the occlusal principle.
phologically, in the temporo-mandibular joint.
During the second developmental phase of the
changing dentition, the course of the lower lip dis-
tinguishes the line of the incisal edge of the maxillary
front teeth. The decreasing sphericity of the occlusal Sphere
plane compensates for mandibular ramus growth.
The eruption of the canine in the third functional
period introduces the steepest lateral guidance ele- Graf Spee, F.: Die Verschiebungsbahn des Unterkiefers am
ment into the occlusal principle. It also brings pro- Schädel. Arch. Anat. Physiol. 16: 285-294, 1890

183
R. Slavicek • The Masticatory Organ

Ill. 199: Lateral view of a model in normal dentition, from the right.

Ill. 201: Cusp alignment from buccal, from the right.

Ill. 203: The lateral view of the right side shows the distinct concavity of the cusp, its
overall course is incorrectly designated the Curve of Spee.

184
 Structures - Occlusion - Articulation

Ill. 200: Lateral view from the left.

Ill. 202: Cusp alignment on the left side. Note the slight asymmetry in the inclination
of the premolars and molars in this appealing normal dentition.

Ill. 204: In this view of the left side, a slight asymmetry is also noticeable. In this
view, the course of the cusps up to the canine tips corresponds to Spee's original defini-
tion, according to which they are assigned to the lateral segment.

185
R. Slavicek • The Masticatory Organ

Ill. 205: The view from the front shows the convex course of the mandibular front edges, which change over to the concave course
of the Curve of Spee only after the canine or the first premolars.

Ill. 206: In the above model, the "hanging" lingual cusps are recognizable, on which the absorption of force takes place in closed
jaw position.

186
 Structures - Occlusion - Articulation

trusive relief for the anterior arch by means of its

distal fossa. The mandible attains skeletal maturity.
The second molars contribute to the spherical shape
of the occlusal plane. The temporo-mandibular
joints adapt both functionally and morphologically
to the final situation.

Mature, complete dentition

The skeletal foundations of the dentition, i.e., the The skeletal foundations of the dentition, i.e.,
relations of the jaw bases to each other, are in no way the relations of the jaw bases to each other,
uniform, but vary widely. Nevertheless, they are are in no way uniform, but vary widely.
counterbalanced in such a way during growth by
compensatory processes, especially in the dento-alve-
olar region, that a condition very near to a normal
dentition-occlusion can be effected. Compensatory
growth in the joint and the functional remodeling of
structures take place. This creates a jaw relation by
which the temporo-mandibular joints are placed
near or at their physiological retral border, in a
maximum intercuspal position.
It should be noted that this mature dentition is the
result of many detailed mechanisms. The genetical- The genetically determined basic relations of
ly determined basic relations of skeletal bases are skeletal bases are subject to a variety of exter-
subject to a variety of external influences and func- nal influences and functional coincidences.
tional coincidences. It should be remembered that
the goal of the development of an organism is to
achieve optimal function. From the viewpoint of
the masticatory organ, this is a functionally capable
occlusal relationship within the erupting dentition.
This, apparently, is the so-called regular bite.
Previously, occlusion was approached from an over-
all viewpoint while details of the dentition were not
discussed. This is an obvious diversion from the
common didactic path, which leads through a
detailed description of the morphology of the indi-
vidual tooth towards an overall assessment. This
frequently results in a well-known phenomenon
known as "viewing the tree very carefully but over-
looking the forest". If we were to describe occlusion
in maximal intercuspation, the tooth morphology The dentition fits best in Class I with a
of a dentulous person would determine the object regular bucco-labial overbite. This ideal of
of our description. The dentition fits best in Class I
complete matching or coupling, which is pur-
with a regular bucco-labial overbite. This ideal of
complete matching or coupling, which is purpor- ported to be a regular bite, is by no means
ted to be a regular bite, is by no means the "rule" the "rule" but rather an ideal, and generally
but rather an ideal, and generally the exception. the exception.

187
R. Slavicek • The Masticatory Organ

Nevertheless, it is important to regard a Class I

dentition as a reference point for studying the den-
tition of the patient on hand, in order to describe
deviations from the normal condition.
The definition of normal dentition is by no means
uniform and is frequently influenced by profession-
al speculation. The term Class I originates from
Angle, a classification with which he was attemp-
ting to help identify and describe normal versus
abnormal jaw(s) and tooth relationships (disg-
nathia). Angle's classification was quickly attacked
and denounced as unsuitable. However, the fact is
that it still is the most widely taught and used clas-
sification.
The so-called normal dentition, which approxi-
mates Class I of Angle's classification, seems to rep-
resent the best dentition principle from the sagittal
view. Teeth simply match up best in this Class I
relationship; the upper and lower arches also har-
monize well. In normal dentition, the arch rela-
tionship is characterized by a buccolabial overbite
from the upper to the lower arch.

Compensation
mechanisms
From a variety of basic skeletal principles that apply
during growth, the organism attempts to reach this
optimal dentition, or at least a close to normal den-
tition model. For this purpose, it makes use of so-
called compensatory mechanisms. The three main
mechanisms for compensating skeletal discrepan-
cies are as follows:

• Dento-alveolar compensation Dento-alveolar compensation

• Vertical compensation Vertical compensation
• Articular compensation Articular compensation

Angle, E. H.: Behandlung der Okklusionsanomalien der Zähne.

Angle’s System 630. S 80. Hermann Meusser (7. Auflage),
Berlin 1908

188
 Structures - Occlusion - Articulation

Dento-alveolar compensation
Dento-alveolar compensation is the tendency of the
dento-alveolar unit to set up an optimal, or at least
acceptable, occlusal relationship through modifica-
tions in inclination and height. The tendency of
development of the alveolar process is, of course,
three-dimensional, but it can be seen most instruc-
tively and distinctly in the relational arrangement
of the front teeth in a sagittal display (ill. 207,
right). This compensatory tendency can also be
established and seen in the region of the laterals.

Vertical compensation
Vertical compensation varies the final distance
between the maxilla and mandible. Because of the
required rotation of the mandible, the skeletal rela-
tionship of the two bones is also altered. Of course,
vertical facial developments necessitate modifica-
tions in the dento-alveolar region.

Articular compensation
Articular compensation is a continuous, lifelong, Ill. 207: In this specimen, the relationship of the dento-alveo-
adaptive process of the mandibular joint to alter- lar process of the region and also the contacts in the lateral
ations in occlusal requirements. In children, during tooth area are clearly seen.
the maturation periods of the masticatory organ,
and in young adolescents, it is a significant factor in
the occlusal position of the occluso-articular rela-
tionship.
Diagnostically, articular compensation can be clear-
ly seen in the sagittal border scheme designed by
Posselt. Posselt graphically compares the occlusal
position of maximal intercuspation (ICP) to an
occlusal retral contact position (RCP), which is the
retral physiological margin reached in the closing
rotation of the mandibular joints. The situation at
the margin is determined by the ligamentary retral
borders of the joints and also by the first occlusal
contact, which takes place in a terminal closing
rotation. In most adults, a difference between ICP
and RCP is found. However, in terms of quantity
and quality, the discrepancy in the joint region is
generally only a few tenths of a millimeter (ill. 208-
210, p. 190).
The didactic exaggeration, in much of the litera-
ture, of the customary schemes for sagittal diffe- Slavicek, R.: Die funktionellen Determinanten des Kauorgans.
rence has led to gross misunderstandings. These Habilitationsschrift, Wien 1982

189
R. Slavicek • The Masticatory Organ

Ill. 208: The human mandibular joints show transversal deviations between ICP and RCP, which amount
to only hundredths of a millimeter.

Ill. 209: The sagittal difference for the majority of the population lies in the range of 0.3 mm.

Ill. 210: The vertical difference is also less than 0.3 mm for a large percentage of adults.

190
 Structures - Occlusion - Articulation

exceptions, very important for diagnostics and

therapeutics, are those very few significant indivi-
duals who display the true "articular compensation"
of a relative skeletal distal relationship of jaw bases
(skeletal Class II). These patients can achieve qua-
litatively good or acceptable intercuspation by
means of a permanent protrusive position of the
mandible. Their Posselt scheme is distinctly diffe-
rent from the majority of individuals, who have no,
or very little, discrepancies between RCP and ICP.
The temporo-mandibular joint has the lifelong The temporo-mandibular joint has the life-
ability to adapt to changing occlusal requirements. long ability to adapt to changing occlusal
The close relationship or conformity of a physiolo- requirements.
gical, unforced retral joint position with a maximum,
but unforced, dental relation is desirable, as the
muscularly controlled dynamics of the mandible
are primarily directed anteriorly or anterolaterally. Modifications take place throughout life in all
Modifications take place throughout life in all structures. Thus, from a biological viewpoint,
structures. Thus, from a biological viewpoint, a a healthy system is stable within the joint.
healthy system is stable within the joint. Based on
Based on long-term investigations of conva-
long-term investigations of convalescent patients,
Kulmer established that the position of the tem- lescent patients, Kulmer established that the
poro-mandibular joints maintains an exceptionally position of the temporo-mandibular joints
stable relation to occlusion and articulation, maintains an exceptionally stable relation to
although the position of teeth and the dental arch- occlusion and articulation, although the posi-
es change distinctly over a prolonged period of tion of teeth and the dental arches change
time. This is only possible by means of permanent
distinctly over a prolonged period of time.
and continuous adaptive processes in the joint. It
also shows, however, that an unforced retral joint
position in equilibrium with the occlusion is a bio-
logically acceptable relationship and a reality.
This is not contradicted by the deviations published
by Celenza. His results show strikingly negligible
differences between a retral border as the initial
position on the one hand, and the "current" situa-
tion recorded in the articulator after an extended
period of time following dental reconstruction on
the other. The accuracy of accumulating these
small deviations and their biological significance for
a living system might be a subject for debate. These These mechanistic declarations of the impor-
mechanistic declarations of the importance of a tance of a postulated precision in hundredths
postulated precision in hundredths of millimeters of millimeters arouses little appreciation and
arouses little appreciation and the shaking of heads
the shaking of heads from orthopedists.
from orthopedists. The pseudo-scientific exaggera-
tion and concomitant denunciation of the retral
border position as a possible variation of maximal
intercuspation should be regarded as an overreac- Kulmer, S.: Long-Term Stability and Occlusion. In: Hösl, E.
und Baldauf, A.: Retention and Long Term Stability, 47–62.
tion to the dogma of the gnathological concept. 8th International Conference for Orthodontists, Munich
The reactive dogma of opponents of the retral posi- 1991. Hüthig Verlag, Heidelberg 1993
tion is just as unscientific and emotional as that of Celenza, F. V.: The Centric Position: Replacement and Character.
its dogmatic proponents. Thus, the discussion J. Prosthet. Dent. 30 (4): 591–598, Oct. 1973

191
R. Slavicek • The Masticatory Organ
Ill. 211: The area of the anterior dental arch is limited to the
four anterior teeth.
Occlusion concepts are artificial organizing
principles, which allow the dentist to apply
therapeutic principles meaningfully.
192
should concern, above all, the quantity of differ-
ences for the temporomandibular joints and the
dentist's opportunities in this context.
A clear distinction must be made between the
actual physiological and biological situation after
growth and a selected situation based on therapeu-
tic grounds. The value of the retral border position
should be placed in the foreground in diagnostics.
For this reason, I have for many years termed this
position the reference position (RP), in contrast to
the controversial term, "centric relation". I consider
it necessary to achieve a functioning, diagnostically
reproducible point of reference, under biological
conditions. This position also serves as the basis for
well intended, yet invasive, prosthetic intervention.
So-called concepts of occlusion
So-called concepts of occlusion must be mentioned
here and will be discussed in detail later. Occlusal
concepts are artificial organizing principles, which
allow the dentist to apply therapeutic principles
meaningfully. They function, first of all, in a diag-
nostic classification scheme, and then mainly in
occlusal therapy. Nature does not follow such con-
cepts, but forms its rules according to function and
is only interested in allowing function to proceed in
an optimal fashion.
A significant aspect of occlusal concepts is to provide
suitable prosthetics and to optimize the defenses for
the masticatory organ system in regard to para-
function. It makes sense, with regard to occlusal
concepts, to establish "functional areas" within the
dentition, which can be derived from root mor-
phology and the architecture of the dento-alveolar
complex.
The functional areas of occlusion
Let us depart for a moment from the speculative
dogma of occlusal concepts, and look at the mor-
phological concepts of nature in the design of den-
tal inter-relationships. From the viewpoint of root
morphology and the architecture of the dento-alve-
olar region, clearly demarcated functional areas
exist.
 Structures - Occlusion - Articulation

The functional area of the

frontal dental arch

The position of the mandibular anterior teeth rela-

tive to the maxillary teeth, the eruption of the
mandibular front teeth in accordance with the
occlusal axis, and the actual positive labial overbite
of the maxillary incisor in normal dentition create,
upon contact, a twist to and a shift of the upper
front teeth (ill. 211, p. 192, ill. 212 and 213, right).
The absorption of force generally occurs in a punc-
tual fashion in the lingual concavity, and directly
forces the upper tooth outward. As a rule, the shift
does not occur with the mandibular front teeth,
because pressure is diverted to the longitudinal axis
and distributed to the mandibular arch through the
contact points. The guidance always affects indi-
vidual areas of the maxillary anterior region. Thus,
the maxillary front teeth become the proprioceptive
main signal-giver of occlusal contact.
The maxillary central incisor has a shovel-shaped Ill. 212: In contact, the front teeth are shifted para-axially
crown, which recedes into a considerably slimmer and deformed ultra-structurally
root. Its lingual surface is distinguished individual-
ly by marginal crests. Here, there also seem to be
typical differences in ethnic groups of the human
race. The incisor’s shovel is spread wide and is met
para-axially in contact and guided outwards, both
tipping and rotating (comp. Reiber),(ill. 214-216,
p. 194). If we follow the cross-section of the crown
from the horizontal view towards the root, the pas-
sage to the root of the maxillary central incisor is at
first rectangular, then becomes rather triangular or
rounded (ill. 217-218, p. 194).
The root cross-section in the area near the crown
has its triangular base directed labially and allows
only minimal rotation in the periodontium. In con-
trast, the dentinal core of the tooth and root
becomes deformed. Through differences in pressure
in the odontoblasts, the deformation acts as an Ill. 213: Changing positions of the points of contact shift the
extremely active and highly sensitive signaler. Teeth center of rotation (comp. Lugner).
are modified sensory organs - an almost prophetical
observation made by Sigmund in the early nine-
teenth century, which has been confirmed by most Teeth are modified sensory organs.
recent research. J. H. Levy (ill. 218, p. 194) pro- (Sigmund 1867)
poses the following hypotheses in his work
"Ultrastructural Deformations and Proprioceptive
Function in Human Teeth": "It is proposed that teeth
be considered specialized tactile muccolo-skeletal
organs" and "Application of these hypotheses are exten- Reiber, Th.: Form und Funktion der Frontzähne – klinische und
sive, they include both -prevention and treatment ele- experimentelle Untersuchungen. Habilitation, Mainz 1990

193
R. Slavicek • The Masticatory Organ

Ill. 214: The lingual surface of the central incisors passes into Ill. 215: Contact with the incisal edge causes a highly sensi-
a flat and inclined section. tive sensory input.

Ultrastructural
Deformations and
Proprioceptive Function
in Human Teeth
Jay Harris Levy, DDS,
BSME

Ill. 216: The longitudinal axis of the central incisor frequent- Ill. 217: Jay Harris Levy, DDS, BSME.
ly forms a negative angle with the inclined portion. This is a
noteworthy clinical finding relative to the overall approach
from an orthodontic viewpoint.

Ill. 218: The unique structure of teeth make them a highly sensitive sensory receptor and transmitter.

194
 Structures - Occlusion - Articulation

ments and they support the clinical analysis and pro- "It is proposed that teeth be considered spe-
per equilibration of occlusion". cialized tactile musculo-skeletal organs" (Levy
Onthogenetically, during the second functional 1994)
period of changing dentition, the second maxillary
incisor is involved, for a long time, in laterotrusion
function; its root inclination is normally less steep The second maxillary incisor is involved, for a
than that of the central incisor, which definitely long time, in laterotrusion function.
plays the dominant role for the system in proprio-
ceptive signaling. The lateral incisor has a highly
variable position in terms of both its verticality
position in the frontal arch and from the viewpoint
of rotation. This is primarily because of the la-
terotrusive control function already mentioned,
which plays a significant role ontogenetically, but
also acts as part of anterior group function along
with the canine after maturation.
All front teeth are avoided during mastication, i.e.,
they determine the frontal area end point of the
mastication pattern. This significant behavior dur-
ing mastication will be discussed in detail in the
chapter on Functions and Dysfunctions.
The central incisors and the entire maxillary frontal The central incisors and the entire maxillary
arch and its functional harmony with the mandibu- frontal arch and its functional harmony with
lar arch are important for speech. Problems related the mandibular arch are important for
to the congruence of incisal edges must be adapted
speech.
to by compensatory mechanisms (generally the
tongue) in order to achieve comprehensible speech.
The morphology of the frontal arches is therefore
important from the functional point of view; in
addition, they play a determinant role as support
for the facial soft tissue in the labial region and
thereby for the esthetics of the human face.
The incisors arranged on the arch should be regar-
ded as a unit. The inclination of their longitudinal
axes to the lingual functional surface is extremely
variable and individual. The use of the maxillary The use of the maxillary incisal longitudinal
incisal longitudinal axis in X-rays and subsequent axis in X-rays and subsequent diagnostic and
diagnostic and the therapeutic applications in the therapeutic applications in orthodontics
orthodontics based on it, do not appear to be justi-
based on it, do not appear to be justified.
fied (comp. Slavicek). The lingual functional sur-
face (I avoid the term "guidance surface") does not
fit into a classifiable curvature like the speculative
insertion postulated in the interesting theory of
Nägerl and Kubein-Meesenburg, but rather is a
three-dimensional, irregular surface, distinguished
individually by its marginal crest structures. Most
tactile contacts in function also take place there (ill.
219, left). In other words, the functional palatal Levy, J. H.: Ultrastructural Deformations and Proprioceptive
surface of the maxillary anteriors must be dealt Function in HumanTeeth
with independent from the angle of the long axis of Sigmund: Die Empfindung der Zähne. Dtsch. Vierteljahrschr.
the tooth. f. Zahnheilkunde, H. III, 1867

195
R. Slavicek • The Masticatory Organ
Ill. 219: The shovel of the central incisor and its dual
arrangement.
The front teeth are not ostensibly involved in
the parafunctional actions of mature denti-
tion in a dentulous person.
In class I, the mandibular canines stand on
the mesial marginal crest of the maxillary
canines or slightly before it
Kubein-Meesenburg, D., Nägerl, H., Fanghänel, J., Thieme,
K., Klamt, B., Swestka-Polly, R.: Die allgemeinen Ebenen.
Mandibularbewegungen als Koppelbewegungen in neuro-muskulär
gesteuerten Getriebesystemen. Dtsch. Stomatol. Berlin 41:
332–336, 1991
Slavicek, R.: Die funktionellen Determinanten des Kauorgans.
Habilitationsschrift, Wien 1982
196
The mandibular anterior teeth, because of their
individual inclination, are a main part of the ante-
rior, dento-alveolar compensation, but still clearly
tend to follow Page's rule. The shape of the root is
longitudinally oval to kidneyshaped, and arranged
radial to the arch. Pressure absorption in closing is
transferred to the longitudinal axis and distributed
over the contact points.
The front teeth are not ostensibly involved in the
parafunctional actions of mature dentition in a den-
tulous person. In general, eccentric bruxism does
not primarily take place over the front teeth, but
rather over the canines. In contrast to the anterior
teeth, the powerful maxillary canines, reintegrated
into the human dental arch, are a part of the emo-
tional management principle of parafunction. They
belong to the frontal arch, complement and con-
clude the tasks of the anterior teeth in the areas of
laterotrusive and protrusive guidance. They stand
slightly prominent in the maxillary arch, with
somewhat vertical roots. Their lingual functional
surface is tangential to the arch and is generally
separated into an implied mesial and distal cavity.
In class I, the mandibular canines stand on the
mesial marginal crest of the maxillary canines or
slightly before it, between the distal marginal crest
of the maxillary laterals and the mesial edge of the
maxillary canines. Because of this arrangement and
character, it is appropriate to describe the anterior
region of the arches as a control and guidance area.
This is accepted in most occlusion concepts, and
dogmatically postulated in the gnathological con-
cept. It is unanimously agreed that the front teeth
are not primarily stressed in the closed jaw position.
The mandibular first premolar is a main part of the
anterior region. In a normal dentition, its buccal
cusp is in close contact with the distal fossa of the
maxillary canine, with which it makes contact in
protrusive function.
 Structures - Occlusion - Articulation

The frontal lateral dentition area

Functional areas of the premolars

The premolars form the important passage to the
actual support zone of the molars. If we attempt to
analyze the arches according to functional areas,
several possibilities must to be considered.
The simplest classification would involve assigning
the supportive quality to all teeth which can actu-
ally intercuspate with the tooth in the opposite jaw,
and assigning the responsibility of sensory control
to all the other teeth, which only make contact but
have no capability of intercuspation because of their
morphology. In this way, the maxillary arch could
be subdivided into two sections, the anterior canine
group, which would be the "controlling" area of the
arch, and the actual supporting zone, consisting of
the two lateral posterior sections which have a sup-
portive function. This is the same in the mandibu-
lar arch in the anterior area; the exception is the
mandibular first premolar, which generally has no
suitable opposing antagonist with a flat plane mor-
phology for intercuspation as a stop, and therefore
would probably be functionally classified with the
anterior control group. This very simple observa-
tion, from a functional viewpoint, can be stated
simply, and would be appropriate for any "gnatho-
logical" concept.
Thus, a somewhat different, modified classification
of the functional differentiation between the pre-
molars and molars becomes possible. The molars
assume support as their single, main function,
while the premolars assume a supportive function The premolars assume a supportive function
and also act as laterotrusive control structures (ill. and also act as laterotrusive control structures.
220-223, p. 198).
As mentioned previously, in ontogenesis, the premo-
lars execute this dual role for a relatively long period
of time. However, even later, in a rather large num-
ber of natural growth occlusions, the principle of
participation of "intercusping" teeth in laterotrusive
control is present. Naturally, mediotrusive contacts
also occur in many dentitions, which may have a
controlling function in mastication. For several con-
ceptual reasons, mediotrusive contacts in the para-
function of most occlusal concepts are undesirable.
A common aspect of the distribution of responsibil-
ities is that the area of pure support is limited to the
molar region. In ontogenesis, only the first molar
has laterotrusive and retrusive eccentric control.

197
R. Slavicek • The Masticatory Organ

Ill. 220: The tri-colored scheme highlights the dual role of Ill. 221: The first premolar in the mandible is functionally and
the premolars, assuming both a supportive function as well morphologically assigned to the anterior arch.
as the function of control for dynamic mandibular move-
ments.

Ill. 222: A comparison of the arches from the functional view. Ill. 223: The section from a sagittal view in an X-ray projection.

198
 Structures - Occlusion - Articulation

This eccentric participation in laterotrusive gui- This eccentric participation in laterotrusive

dance of the first molar can also function in mature guidance of the first molar can also function
dentition under physiological conditions. in mature dentition under physiological con-
When comparing the various functional areas of ditions.
individual groups of teeth, a mutually protective
function can be derived. "Mutually protective occlu-
sion" was and is the objective of the gnathological "Mutually protective occlusion"
concept. The mutually protective function implies
that, in tooth-guided gliding movements, the ante-
rior gliding guidance of the anterior canine group
uncouples the molars and premolars. The guidance
function lies, therefore, by definition, in the anteri-
or canine region and in the joints. For everyday
communicative speech, especially to avoid dogma-
tism, the term "canine control" is more meaningful
than "canine guidance". The term "canine gui- The term "canine guidance" creates the
dance" creates the impression that all of the func- impression that all of the functional processes
tional processes on the canine are gliding. This is on the canine are gliding.
not the case at all. Also in parafunction, in eccen-
tric bruxism, it is by no means true that the eccen-
tric movements over the canine, that take place in
the articulator, occur in vivo in the same fashion
(comp. Tamaki, Celar).
In contrast, when you have a forced bite, the joint
and the anterior teeth are perceptibly relieved, or
changed, from their articulations without force. The
premolars can participate in guidance within a less
dogmatic application of the principle, consequently
removing much of the controversy in the argument
between the dogmatists of "canine guidance" and
those of the "group function" schools of thought.

The morphology of the premolars

The morphology of the premolars of the maxilla
and mandible require a special discussion. The
mandibular first premolar generally shows a sturdy The mandibular first premolar generally
buccal cusp and a rather rudimentary lingual cusp. shows a sturdy buccal cusp and a rather rudi-
Its appearance, i.e., morphology, is therefore some- mentary lingual cusp.
what canine-like. Its buccal shoulder is powerfully
arched and prominent; it contributes in great mea-
sure to relieving the maxillary anterior arch in a
protrusive movement.
The occlusal surface has a distinct distal groove. The
mesial groove is rather flat and connected with the
marginal crest.
The mandibular second premolar has a strong buc-
cal cusp and one or two well-formed lingual cusps.
It is a true "premolar". Its distal groove is also more
distinct than the mesial one. The tooth is, as a rule, Tamaki, K., Celar, A., Beyrer, S., Aoki, H.: Reproduction of
single-rooted. The morphological emphasis of the Intraoral Excursive Tooth Contact in an Articulator with
distal fossa indicates a principle of intercuspation, Computerized Axiography Data. J. Prosthet. Dent. 78, 1997

199
R. Slavicek • The Masticatory Organ
This means that, between the palatal cusps of
the maxilla and the mandibular teeth, even in
a normal dentition, there is no alternating
1:2, but a 1:1 relationship.
The anterior lateral dentition, characterized
by the premolars, continues the anterior arch
and is certainly capable of assuming partial
control in eccentric movement even in mature
dentition.
The forces should be as close to axial as
possible, because the alveoli with their intra-
alveolar septi, guarantee optimal absorption
of force.
200
which would be in keeping with the interdigitation
of the palatal cusps of the other tooth of the same
name. This means that, between the palatal cusps
of the maxilla and the mandibular teeth, even in a
normal dentition, there is no alternating 1:2, but a
1:1 relationship.
The maxillary first premolar presents with two
nearly equal-sized cusps, one buccal and the other
palatal. The palatal cusp is somewhat more massive
and shaped like a mashing cusp. The normally
existing two roots of the tooth are radial to the den-
tal arch, the horizontal cross-section of the root is
kidney-shaped, with a mesial concavity, before it is
divided. Even in the presence of one root, the mor-
phology of the cross-section is kidney-shaped. The
maxillary second premolar is similar to the first one
and supplied with two cusps, although they are
somewhat shorter. It is often single-rooted; the root
cross-section is also frequently kidney-shaped, or at
least suggestive thereof.
The anterior lateral dentition, characterized by the
premolars, continues the anterior arch and is cer-
tainly capable of assuming part-control in eccentric
movement even in mature dentition. We must not
forget that the maxillary premolars exercise this
function for several years during growth. They
form a passage of the frontal arcades to the purely
supportive area (ill. 224-229, p. 201).
The anterior lateral dentition, characterized by the
premolars, continues the anterior arch and is cer-
tainly capable of assuming partial control in eccen-
tric movements even in a mature dentition. We
must not forget that the maxillary premolars exer-
cise this function for several years during growth.
They form a passage of the frontal arcades to the
purely supportive area (ill. 224-229, p. 201).
The first, second and possibly third molars form the
rather linearly directed so-called support zone.
They are, under normal conditions, very well suit-
ed for sustaining extreme forces for a short period
of time. The forces should be as close to axial as
possible, because the alveoli with their intra-alveo-
lar septi, guarantee optimal absorption of force.
The mandibular first molar possesses five cusps:
two buccal, two lingual and the fifth (distal) cusp is
the smallest and oriented purely to the distal. The
disto-buccal cusp is massively formed and is also
known as the central cusp of the tooth. The two
lingual cusps are long and clearly formed.
However, due to the curve of Wilson and the
 Structures - Occlusion - Articulation

Ill. 224, 225: The maxillary anterior canine arch encompasses the mandibular canine and 1st premolar arch, by means of
overbite and overjet, with a posteriorly directed concavity.

Ill. 226, 227: The transversal-radial arrangement of the premolars causes a series of anteriorly directed concave arches.

Ill. 228: Such a concavity can also be postulated for the max- Ill. 229: Interestingly, there is a similar or identical concavity
illary first molar. existing at the longitudinal axes of the condyles.

201
R. Slavicek • The Masticatory Organ
The tooth usually has three roots, the most
powerful of which lies palatinally and inclines
medially in the direction of the roof of the
palate.
The plural form of the title of this section
was chosen intentionally.
The position of a defined occlusal plane in
space is of great functional and dynamic sig-
nificance in diagnostics.
202
absence of antagonistic morphology, their tips do
not act as stops. The occlusal surface has a fragile,
mesial groove (anterior fovea) and a more distinct
distal, "central" groove. This tooth has two roots,
which are directed mesial to distal. The mesial root,
is especially wide and shovel-shaped, plus it is gen-
erally curved distally.
The mandibular second molar is similar to the first
molar, however without the fifth cusp. The root
relationships resemble those of the first molars. The
mandibular third molar has a variable morphology
in both the crown and the roots.
The maxillary first molar is a four-cusped tooth,
with two buccal and two lingual cusps. The mesio-
lingual (mesio-palatal) cusp is formed massively
and generally the largest cusp in the dentition. It is
also known as the central cusp of the maxillary first
molar. The tooth usually has three roots, the most
powerful of which lies palatinally and inclines
medially in the direction of the roof of the palate.
The two buccal roots lie mesial and distal and follow
the zygomatico-alveolar crest in their inclination.
The maxillary second molar has a highly variable
morphology and is often only tri-cusped. It then
has two buccal and only one, very wide, palatal
cusp. In many cases only one root is present, and its
form is variable. The maxillary third molar is simi-
lar to the mandibular one in that it is exceptionally
variable in terms of both, crown form and root
morphology.
The occlusal planes
Definitions
The plural form of the title of this section was cho-
sen intentionally, as there are many definitions of
the so-called occlusal plane and they need to be
explained and applied from a functional viewpoint.
The position of a defined occlusal plane in space is
of great functional and dynamic significance in
diagnostics. The individual position of the jaws
(bases) relative to each other changes permanently
in ontogenetic development and are compensated
for during growth, by the development of the
dento-alveolar process, with the goal of organism
to achieve the best possible functional relationship.
Consequently, it is meaningful in a discussion
 Structures - Occlusion - Articulation

aimed at setting of standards, to establish an exact

concept for the occlusal plane (OP).
The prosthetically defined occlusal plane is based
on the mandible and approximates a triangle from
the inferior incision (mandibular incisal edge) to the
two distal cusps of the mandibular first molars. We
refer to this definition of the prosthetic (gnatholo-
gical) occlusal plane when we use the articulator
and mount casts, in X-rays analyse, or when we
relate the condylar (hinge axis) track to an articulator
or make an analysis after doing some type of condy-
lar movement recording.
Nevertheless, it should be noted that during a dia-
logue on this subject, it may be advantageous to
refer to variously defined occlusal planes: the max-
illary occlusal plane (comp. Sato) is defined by the
superior incision (maxillary central's incisal edge)
and the distal contact point of the maxillary first
molar. A posterior and anterior occlusal plane (comp.
Sato-Slavicek) can be defined for the maxilla and
mandible, applicable to the sections in front of, or
behind, the contact points of the premolars to the
molars. Ricketts defines the occlusal plane from the
mandibular first molar to the intersection of the
two overlapping canine tips on an X-ray. He halves
the cusptip-to-cusptip distance created by this
overlap. The results of all these interpretations con-
jure up a wide array of biological standard deviations,
leading to absurd uniform therapeutic concepts.
The illustrations show the relatively wide range of
defined prosthetic OP statistically and compare
them with various other reference planes (ill. 230-
241, pages 204-205).
When regarding the occlusal plane, it should When regarding the occlusal plane, it should
always be remembered that it is a simplified repre- always be remembered that it is a simplified
sentation of a functionally determined dynamic representation of a functionally determined
principle. It must be borne in mind that the
dynamic principle.
occlusal relationship between the maxilla and
mandible is a functional one, and the occlusal plane
depicts a dynamic principle of the joint track. The
third dynamic element to be discussed is anterior
guidance from the maxillary arch.
The functional determinants of the masticatory
organ system can be didactically considered in a
simplified way from the sagittal view. The dyna-
mic conceptual scheme can be optimally displayed
Sato, S.: Alteration of Occlusal Plane Due to Posterior
on an X-ray and applied didactically or diagnosti-
Discrepancy Related to Development of Malocclusion –
cally (ill. 242-247, p. 206). Introduction to Denture Frame Analysis. Bulletin of Kanagawa
Dental College 15 (2): 115–123, 1987
Ricketts, M. R.: Cephalometric Synthesis. Americ. J. of Orthod.
46, 1960

203
R. Slavicek • The Masticatory Organ

Ill. 230, 231: The prosthetic occlusal plane through the hinge axis and orbital point. The dark blue line corresponds to
the actual location in this example.

Ill. 232, 233: The prosthetic occlusal plane to Frankfurter horizontal.

Ill. 234, 235: The prosthetic occlusal plane to the palatal plane.

204
 Structures - Occlusion - Articulation

Ill. 236, 237: The prosthetic occlusal plane to Camper's plane.

Ill. 238, 239: The prosthetic occlusal plane to the facial plane.

Ill. 240, 241: The prosthetic occlusal plane to the tooth plane.

205
R. Slavicek • The Masticatory Organ

Ill. 242, 243: The prosthetic occlusal plane to the lip cleft.

Ill. 244: The lateral face as a dynamic system on the lat- Ill. 245: The hinge axis - orbital plane and the tangent to
eral X-ray. the lingual concavity of the central incisors.

Ill. 246: The sagittal condylar track simplified as a cord Ill. 247: The occlusal plane in a simplified system show-
to the fifth millimeter of the protrusive track. ing the dynamic determining factors.

206
 Structures - Occlusion - Articulation

Spheres of occlusion
Nothing in the occlusion of human adults is two-
dimensional. This lapidary statement is made at the
very beginning of the discussion concerning the
sphericity of the human masticatory organ. Based
on individual development of the ascending branch
of the mandible, the occlusal tables of the lateral
tooth region are increasingly inclined towards the
joint. The more the ascending branch develops
superiorly, the more the joint condyle and its hinge
axis distance themselves from the hypothetical
occlusal plane, and the smaller is the radius of cur-
vature in the lateral tooth region. The arrangement
of the dentition and the formation of their roots in
ontogenetic development are influenced by the Ill. 248: Diagram of the sagittal compensation curve.
point in time of their eruption and the distance to
the mandibular joint. The more distally the tooth
lies and the greater the distance to the mandibular
joint, the stronger is the tendency of the occlusal
table to incline towards the joint. Consequently, a
sagittal view represents a superiorly directed, con-
cave alignment of the mandibular dentition. This
typical behavior was recognized and described by
Spee, and is therefore termed the Curve of Spee (ill.
248, 249, right). The mathematical determinants
of this curve were made legitimate by Orthlieb. He
postulated the so-called DPO, the "distance to
plane of occlusion". The greater the DPO, the
smaller the radius of the Curve of Spee. A review of
comparative research will demonstrate this.

Ill. 249: Compensation curve on an adopted model.

The behavior of the occlusal plane
and spheres in comparative research
For the alligator and most other reptiles, a Curve of For the alligator and most other reptiles, a
Spee does not exist; they have a DPO of zero. In Curve of Spee does not exist, they have a
other words, here we have a plane that serves as an DPO of zero.
occlusal relationship. Among mammals, compari-
son of the carnivore and herbivore principles shows
that the distance of the occlusal plane to the temporo-
mandibular joint determines the dimensions of the
spherical components (ill. 250-253, p. 208). We
will deal with the significance of spatial differences Graf Spee, F.: Die Verschiebungsbahn des Unterkiefers am
for mastication at a later point in time. Schädel. Arch. Anat. Physiol. 16, S. 285–294, 1890
Orthlieb, J. D.: The Curve of Spee: Understanding the Sagittal
Naturally, the spherical principle of human denti- Organization of Mandibular Teeth. Marseille
tion cannot be described from the sagittal view Orthlieb, J. D., Slavicek, R.: Geometrische Interpretation
alone. Transversal compensatory differences in the der Spee-Kurve. Zschr. f. Stomatol. 82, S. 1–18, 1985

207
R. Slavicek • The Masticatory Organ

Ill. 250: The principle of an actual plane, using the alligator as an example.

Ill. 251: The dentition of an alligator was conceived as a snapping trap and does not serve
to break up food other than to sometimes tear off chunks from the remaining carcass.

Ill. 252: Canine-type predator. The temporomandibular Ill. 253: Herbivores have a large distance to the occlusal
joint is near the occlusal plane. plane and an accentuated compensation curve in occlu-
sion, which, if extended, goes through the condyle.

208
 Structures - Occlusion - Articulation

inclination of the occlusal table are also found in the

lateral tooth region. If we lay frontal sections in
succession from anterior to posterior through the
dentitions of the maxilla and mandible, we recog-
nize the differences in the inclination of the occlusal
table within the individual frontal sections. These
transversal flexion radii are termed Wilson's curves.
They do not represent the round sphere shape of an
individual's calotte-skull cap, but rather a sequence
of different radii.

Summary of the occlusal planes

Defined occlusal planes serve, first of all, to simpli-
fy the representation of skeletal and occlusal rela-
tionships. The occlusal planes may be defined arbi-
trarily. However, they should be explained and
their predictive value evidenced by statistical find-
ings on occlusions that have grown and developed
Ill. 254: The white cross-bars show different radii from ante-
naturally, with normal function. rior to posterior.
The three-dimensional sphere is described by com-
pensating curves. The sagittal compensating curve
is designated the Curve of Spee, the transversal The three-dimensional sphere is described by
curves are known as Wilson's curves. The Curve of compensating curves.
Spee describes the progress of the buccal cusps of
the mandibular lateral segments from the canine to
the last molar (the front teeth are not included).
Wilson's curves are not at all uniform, but rather Wilson's Curves are not at all uniform.
only apply to the left and right same pair of teeth
in coronal section. They can, but need not, be equal
for the maxilla and the mandible. The compensa-
tion curves depend on the distance of the hinge axis
of the mandible to the mandibular occlusal plane.
The individuality of compensation is partly deter-
mined by the spatial position of the occlusal plane
per definition to the mandibular joint (DPO).
Thus, sagittal and transversal spheres follow indi- Thus, sagittal and transversal spheres follow
vidual skeletal rules. The compensation curves individual skeletal rules.
allow for a uniform, dynamic distance of the denti-
tions during function. The attempt to describe The attempt to describe them three-dimen-
them three-dimensionally by a calotte (comp. sionally by a calotte (comp. Monson) has
Monson) has been opposed. been opposed.

Monson, G. S.: Applied Mechanics to the Theory of Mandibular

Movements. Dent. Cosmos, 74: 1039–1053, 1932

209
R. Slavicek • The Masticatory Organ
• The active centric arch
• The passive centric occlusal
• The esthetic-functional
occlusal arch
• The three interrupted
occlusal arches
Ill. 255: Arch of the active centric in the mandible.
Ill. 256: Active centric, maxilla.
Ill. 257: Active centric, mandible.
210
Functional lines of occlusion
To facilitate didactic understanding of occluso-
articular function, we will consider the dental arch-
es from the viewpoint of their overall function and
postulate the so-called "functional lines" within the
arches. These are:
The active centric arch
The passive centric occlusal
The esthetic-functional occlusal arch
The three interrupted occlusal arches
The active centric arch consists of the incisal edges
of the anterior teeth, the canine tips, and the buc-
cal cusps of the premolars and molars of the
mandible (ill. 255 and 256, left).
The passive centric arch consists of the marginal
crests of the anterior teeth, the canines and premo-
lars, along with the marginal crests and grooves of
the molars of the maxilla (ill. 258 and 259, p. 211).
The esthetic-functional arch consists of the incisal
edges of the anterior teeth, the canine tips, the buc-
cal cusp tips of the premolars and molars of the
maxilla. It has no antagonistic contact with the
opposite jaw in a normal dentition (ill. 260, p. 211).
The interrupted arch of the maxillary active centric
consists of the lingual cusps of the premolars and
molars (ill. 261, p. 211).
The interrupted arch of the mandibular passive
centric consists of the grooves of the premolars and
molars (ill. 262, p. 211).
The interrupted arch of the lingual non-centric
mandibular cusp has, as does the esthetic functio-
nal maxillary outer arch, no antagonistic contact
during regular intercuspation.
In didactics, but also in the diagnostics, planning
and treatment of occlusion, a graphic representa-
tion of the various dental arches and their relation
to each other has been proven useful.
In conclusion, I will try to describe normal denti-
tion in order to have some "rules" with which to
compare typical malocclusions.
 Structures - Occlusion - Articulation

Ill. 258: Passive centric arch in the maxilla. Ill. 259: Passive centric, maxilla.

Ill. 260: The esthetic-functional arch in the maxilla. Ill. 261: Esthetic functional arch - passive centric arch
and the active centric of the lingual cusp in the maxilla.

My heartfelt thanks to Prof. Kulmer in Innsbruck for the

Ill. 262: Comparison of the maxillary and mandibular excellent didactic photographs of the illustrations 255-262
arches. (pages 210 and 211).

211
R. Slavicek • The Masticatory Organ
Dentition with "small errors" is much more
common than a purely eugnathic regular bite.
A direct correlation between dysgnathia and
dysfunction is not provable statistically.
212
Normal dentition and malocclusions
The characteristics of "ideal" dentition
(Class I)
• The active and passive centric match
• The teeth have a 1:2 relation, the mandibular
1st premolar and the maxillary last molar have
only one antagonist
• The esthetic-functional arch stands in a positive
horizontal overjet and overbite and allows satis-
factory functional and controlling free space
• The maxillary active lingual partial arch inter-
cuspates with the distal fossa of the mandibular
premolars and central fossa of the mandibular
molars in a 1:1 relationship
• The mandibular lingual partial arch protects the
tongue during functional movements
• The anterior teeth show individual inclination
and relation (compensation)
• The mandibular canine stands in a 1:2 relation-
ship to the maxillary arch
• The mandibular first molar stands in pure 1:2
intercuspation to the maxillary arch
• The skeletal construction of the mandible and
the inclination of the dentition to the skull
determine the spherical construction.
So-called dysgnathias, anomalies of the jaws
In naturally developed dentitions we are certainly
much more frequently confronted with the "small
errors" of moderate deviations from the norm than
with a purely eugnatic regular bite. In spite of these
small deviations, the masticatory organ functions
without disturbances in most cases. Nature gener-
ally achieves this by means of typical compensato-
ry mechanisms. Cases of pronounced abnormal
jaw(s) and dentition relationships are common in
everyday practice. Nevertheless, the functional state
can be good or at least acceptable for a long period
of time. Direct correlation between dysgnathia and
dysfunction is not provable statistically.
Therefore, it is important for the dentist to work
constructively on the basis of a "normal dentition"
concept, in order to learn the rules of dysgnathia
and to adapt any invasive therapy to the rules. The
 Structures - Occlusion - Articulation

following will describe the most typical forms of

abnormal tooth and jaw relationships and attempt
to classify them in morphological syndromes. Of
course, this is only an attempt; there are naturally
exceptions to the rules. Syndrome

The morphological syndrome of Class II/1

• the functional arches are only congruent in small
sections
• joint-related tendency to compensatory protru-
sive position
• frequent functional "double-bite position"
• typical lyre-shaped maxillary arch with anterior
compression
• tendency towards elongation of the mandibular
anterior arch
• dento-alveolar compensation in the mandibular
anterior region
• dento-alveolar decompensation in the maxillary
anterior arch, protrusive inclination of the max-
illary anterior teeth
• soft tissue phenotypically somewhat "soft"
• ligaments phenotypically somewhat loose
• skeletally somewhat neutral to dolychofacial
• vertical with good compensation somewhat low
to neutral
• DPO generally less than average
• the articular eminence average or flat (in deep
bite in the anterior region, exceptions are possi-
ble)
• mentally, the "open", "smiling", "cooperative",
and "emotional" type, who likes to laugh
and cry

Distocclusion of Class II/1 is frequently a joint- Distocclusion of Class II/1 is frequently a

related protrusive arrangement (anterior position- joint-related protrusive arrangement (anterior
ing). This position is supported by means of the bi- positioning).
laminar zone in the joint (ill. 263, p. 215) and
actively maintained by muscular programs. This
results in a double-bite position, the so-called
Sunday bite, which may or may not function for the
individual without problems. Vertically, the well-
compensated Class II/1 is generally average or low.

213
R. Slavicek • The Masticatory Organ
The mandibular anterior arch is vertically
more strongly erupted, a small step is seen
behind the mandibular canine.
This typical early retral contact generally lies at
the end of a protrusive gliding facet.
Because of its root architecture, the first pre-
molar is perfectly suited for assuming propri-
oceptive control for this position.
214
A functionally well-compensated Class II/1 has
typical features in terms of the position of teeth and
their arrangement.
The mandibular arch has a small and retrally lying
base, with good dento-alveolar compensation, i.e.
strong tooth inclination towards the anterior. The
occlusal plane points towards the joint with a small
DPO. The ascending branch of the mandible is
rather short in comparison to the horizontal one.
The Curve of Spee generally has a large radius.
The mandibular anterior arch is vertically more
strongly erupted, a small step is seen behind the
mandibular canine, the first premolar lies some-
what deeper, the disto-incisal edge of the canine is
somewhat exposed. The alignment of the incisal
edges shows a positive convexity superiorly.
The maxillary arch has a decompensated, i.e., pro-
trusive anterior dento-alveolar region, which leads
into transversal premolar crowding. In the molar
region, the arch increases in width, creating the
lyre-shaped line of the maxillary dentition, into
which the mandibular arch fits well, in a protruded
position.
In an articular well-compensated Class II/1, which
can often function for a lifetime without major
complaints, the teeth can take on a retral position,
resulting from light chin guidance (ill. 264, p. 215)
or active retraction by the individual. The first con-
tact in the retruded contact position (RCP) typical-
ly occurs on the maxillary first premolar.
The disto-incisal edge of the mandibular canine
touches the mesial marginal crest or the mesio-lin-
gual cusp attachment of the maxillary first premo-
lar. This typical early retral contact generally lies at
the end of a protrusive gliding facet, which reveals
activity (ill. 265, p. 215). This gliding facet is the
steepest "retrusive" guidance mechanism in the
dentition, which leads from a protrusive to a retral
joint position (ill. 266, p. 215).
Because of its root architecture, the first premolar is
perfectly suited for assuming proprioceptive control
for this position. Its transverse (generally) double
root is ideally geared for retrusive control (ill. 267,
p. 215). The protrusive, maxillary front tooth is
actively caught up and held by the lower lip (ill.
268, p. 215).
The slightly protrusive position of the mandible is
further actively exaggerated by the subject (gene-
rally women) and thereby subconsciously overcom-
pensated for esthetic reasons. Speech problems
 Structures - Occlusion - Articulation

Ill. 263: The retro-articular vascular padding of the bil-

aminar zone can bring the joint into a compensatory pro-
trusive position, compensating for a skeletal Class II
position.

Ill. 264: A slight manipulation on the chin creates dis-

tinct retraction of the mandible.

Ill. 265: The typical first early contact of an articularly

compensated Class II with simultaneous aplasia of the
maxillary small incisor on the right.

Ill. 266: The intercuspal position lies distinctly protru-

sively on the sagittal condylar track.

Ill. 267: The double root of the first premolar and its
anteriorly directed concavity are excellently suited for
producing proprioceptive signals.

Ill. 268: The two antagonistically arranged control sys-

tems, from anterior and posterior.

215
R. Slavicek • The Masticatory Organ
• Functional arches match to a great extent
• The functional free space is limited
• Near or in RP, relative to the joint
• Wide coronal and apical arch in the
maxilla
• Tendency to dento-alveolar retrognathia in
the mandible
• Typical mandibular form with high ascend-
ing branch
• Inclination of the maxillary and mandibu-
lar anterior teeth
• Dental deep bite
• Frequently, also skeletal deep bite
• Large DPO, accentuated sphere
• Phenotypically strong ligaments
• Frequently steep articular eminence (with
possible exceptions)
• Mentally the "cool", "strict", "reserved",
"serious" type
• Tendency to mentally dominated parafunc-
tion
In most cases, the jaw bases have no real dis-
tal relation, but rather a neutral relationship.
With the exception of vertical compensation,
other compensatory processes do not take
place due to the strong muscular dominance.
216
associated with the phonation of the "S" sound are
generally cleverly compensated for by the tongue.
However, this description of dysgnathia and the
possibilities of compensation also show that such
systems are susceptible to changes, and easily prone
towards decompensation.
The morphological syndrome of Class II/2
Class II/2 typically shows wide apical bases. The
two dento-alveolar processes develop typical, con-
centric internal progressing forms, so that the coro-
nal arch is generally narrower than the apical one.
The retrally inclined maxillary front teeth find no
functional abutment from the lower lip in vertical
development and develop vertically into the lower
vestibule until they are stopped by the generally
powerful and active labial muscles. The mandibu-
lar front teeth also erupt strongly and stand gene-
rally higher than the cleft. The steep, deep anterior
canine group is more of a hindrance to protrusive
function; therefore the functional pattern of Class
II/2 is transversal. The ascending branch develops
in a strong vertical fashion, the temporo-mandibu-
lar joint develops a steeper articular eminence. In
most cases, the jaw bases have no real distal rela-
tion, but rather a neutral relationship. Dento-alve-
olar retraction takes place due to the very powerful
and active circumoral mimic musculature, which
especially affects the mandibular alveolar process.
The powerful muscles prevent dento-alveolar com-
pensation. The maxilla surrounds the mandibular
arch, the buccal overbite is minimal in the lateral
tooth region and there is a great danger of
mediotrusive guidance. The vertical is not always,
but frequently, reduced. With the exception of
vertical compensation, other compensatory
processes do not take place due to the strong mus-
cular dominance. Because of the steep joint track,
intermittent or permanent joint noise occurs.

The morphological syndrome of Class III
Class III is not uniform in its skeletal presentation.
Nevertheless, the phenotype shows characteristic
traits.
Skeletal and dento-alveolar compensation takes
place in the lower face, especially in the anterior
area, and is predominantly vertical. The chin sym-
physis is extended, the mandibular dento-alveolar
complex is long and somewhat narrow, the
mandibular anterior teeth are retro-inclined. The
longitudinal axes lie in the D-point or even in front
of it. The posterior facial height, in contrast, remains
rather short; the gonial angle is very blunt, the chin
angle sharp (these details will be dealt with in a
later section). The arches of the maxilla and
mandible have a typical tendency towards incon-
gruence. The maxillary arch is too short and nar-
row, the mandibular arch too long and wide.
Consequently, the problem of so-called functional
lines matching poorly or not matching at all is a
common one. Frequently, the active centric arch
meets the functional-esthetic arch of the maxilla, or
even lies buccolabial to it. This results in special
problems, which are compensated for in a typical
way in Class III. The function is generally some-
what sagittal, control takes place on the buccal
cusps of the maxilla and on the distal appendage of
the maxillary canine. The vertical front overbite is
minimal. Nevertheless, functionally well-compen-
sated Class III cases are common and create esthe-
tic problems rather than functional ones.
Structures - Occlusion - Articulation
• The functional arches are sagittally and
transversally non-matching.
• Maxilla generally sagittally and transversal-
ly under-developed.
• Mandible both sagittally and transversally
dominant.
• The functional arches do not match.
• Therefore, in serious cases, partial or total
cross bite dentition.
• The occlusal plane has a tendency to poste-
rior-inferior.
• The mandibular anterior symphysis is high
and retro-inclined (dento-alveolar compen-
sation).
• Typical compensation mechanisms:
• Skeletal high vertical
• High anterior symphysis
• Retro-inclination of the mandibular front
• Reduced frontal and lateral overbite
• Sagittal functional pattern
• Near the joint or in RP
217
 Chapter 3

Functions

The functions of the masticatory organ

play a central role for the human orga-
© Roma, Galleria Nazionale d‘Arte Moderna. Su concessione del Ministero per i Beni e le Attività Culturali.

nism. The most important of these cer-

tainly is oral communication, which inter-
connects 6 billion people. This unique,
complex and abstract ability of expression
from the human brain, wrote the success
story of human beings. Speech, as a trans-
mitter, made it necessary to evolve a
receiving system, namely the eyes and
ears, which are intimately connected with
the functions of the masticatory organ.
The maneuverable balance of the head
introduces posture as a further inter-
related function - an overlap, that be-
comes especially important in functional
disorders, found in the routine of doing
clinical dentistry.
Self-consciousness, self-perception and
esthetics are central functions of the face,
that directly become related to some of
the psychological aspects of being human.
The psyche and the masticatory organ,
processing of suppressed and repressed
problems, are poorly understood tasks
carried out by the so-called masticatory
organ, which enhances the importance of
the dentist in medicine.
R. Slavicek • The Masticatory Organ
Evolution developed a large number of fanci-
ful variations of such "tools".
220
Mastication
The "eating tools" or "guzzling tools"
First of all, the chewing system serves in the recep-
tion, mastication and ingestion of food. Evolution
developed a large number of fanciful variations of
such "tools". These highly specialized systems func-
tion as tools during the ingestion and, in some
cases, the processing of food. Very few of these sys-
tems found in nature are actually "chewing tools".
However, some systems are highly developed and
thereby suitable for grinding food and preparing it
for further digestion. If we compare a selection of
these systems from reptiles, canine-like predaceous
animals and plant-eating ruminants, the differences
in functional principles become evident.
Reptiles
The bio-mechanical makeup of the alligator shows
absolutely no indication of a spherical arrangement
of the dentition. The jaw joint lies within the plane
of occlusion; there is no flexion at all within the
arranged dentition; it is a chewing plane in the true
sense of the term. The socket of this primitive jaw
joint is mandibular, the stylus of the joint process is
maxillary. The function of the "tool" is to grasp a
prey and to hold it securely. The organ is not sui-
table for grinding food, but rather for holding and
 Function - Mastication

swallowing. This bio-mechanical principle is pre- The organ is not suitable for grinding food,
dominantly seen in reptiles (ill. 1 and 2, p. 222). but rather for holding and swallowing.

Carnivores Carnivores

The dentition of a canine-like predaceous animal is The dentition of a canine-like predaceous ani-
considerably different (ill. 3, p. 223). mal is considerably different (ill. 3, p. 223).
One conspicuous detail is the group of three canine
teeth, which articulate in a special way. They close
and wedge, in a kind of force-bite, whereby the
mandible is pressed retrally. The condyle of the jaw The condyle of the jaw joint is pressed
joint is pressed against a strongly formed post-gle- against a strongly formed post-glenoidal
noidal process as a buttress. Powerful closing mus- process as a buttress.
cles permit secure fastening onto and killing of
prey. The canines are anchored very securely in the The canines are true killing "weapons".
jaw and are therefore true killing "weapons". The
rather flat, less powerful front teeth serve to scrape
tissue from a hard surface (bone).
The premolars do not close in occlusion; instead
there is a bi-lateral, open bite in this area. The run-
ning, hunting predaceous animal (e.g., a wolf), cre-
ates the necessary balance of warmth through a
cooling system of the tongue, which hangs out at
the side between the premolars when the animal
"pants" while it runs.
The so-called first molar is by no means a "grinding The so-called first molar is by no means a
tooth", rather it is formed like a powerful chisel that "grinding tooth".
bites past its antagonist, similar to a scissors. The
tooth cuts through flesh and tendons, and chisels
bones into pieces (ill. 4 and 5, p. 223). In contrast,
the most posterior teeth actually occlude, with
"chewing surfaces", and serve in food preparation
by flattening tough, fibrous structures such as
sinew and tendon. Flesh, however, is gulped in
large chunks (ill. 6 and 7, p. 224).
If we construct an occlusal plane through this ante-
rior group, the imaginary extension would pass
through the condyle of the temporomandibular
joint. The distance of this constructed occlusal
plane to the temporo-mandibular joint would be
zero or very small. (This distance was defined by
Orthlieb as DPO, "distance to plane of occlusion",
and a dependence on the spherical construction of
the masticatory organ system was shown.) (ill. 8, p.
224).
The posterior true molars, in contrast, incline infe-
riorly and superiorly in a sharp bend; an imaginary
plane would lie distinctly anterior to the temporo-

221
R. Slavicek • The Masticatory Organ

Ill. 1: The jaws and dentition of an alligator are formed like a snapping trap and do not grind food.

Ill. 2: The plane of the dentition follows a straight line to the jaw joint.

222
Function - Mastication

Ill. 3: The skull of a canine

carnivore in a typical section:
the group of canines, premo-
lars do not occlude, first
molars are chisels, molars with
a strongly inclined occlusal
plane. Note the strong buttress
of bone in the post-glenoidal
process.

Ill. 4: The chisel-like like form

of the first "molar", which acts
with its antagonist as a scissor.

Ill. 5: The buccal overbite of

the first molar and its rudi-
mentary lingual cusp deter-
mine the lateral border move-
ment pattern in a dog.

223
R. Slavicek • The Masticatory Organ

Ill. 6 (above, left): The recording section

of the sirognathograph.

Ill. 7 (above, right): The dog while

chewing and swallowing food.

Ill. 8 (middle, left): The jaw joint lies

within an extended occlusal plane, if we
exclude the last molars.

Ill. 9 (middle, right): Sagittal border

track scheme with a retral force-bite.

Ill. 10 (right): This sagittal view shows

the retral force-bite. The frontal view is
distinguished by the first molars (corre-
sponds to the human scheme, character-
ized by the molar). The superior view is
marked by powerful lateral ligaments.

224
 Function - Mastication

mandibular joints. This bend allows for flat, grind- An imaginary plane would lie distinctly ante-
ing movements, which would otherwise be hin- rior to the temporo-mandibular joints.
dered by the opposing teeth. The maxillary first
chisel-like "molar", with its lingual slope, shows a
similar intercoronal opening angle to its mandibu-
lar antagonist, as with ideally occluding human
canines. Therefore, a frontal scheme of the border Therefore, a frontal scheme of the border
movements of a dog is very similar to that of a non- movements of a dog is very similar to that of
abraded human dentition. In the latter, however, non-abraded human dentition.
the limitation is not effected by the molars, rather
it is limited by the canines (comp. May, Zetner) (ill.
9-10, p. 224).

Herbivores Herbivores

The skull of a ruminant serves as an example of this

species. The construction is fundamentally different
from the carnivorous type; the form of the
mandible displays a fully differentiated proportion-
al arrangement. The ascending branch (ramus) is The ascending branch (ramus) is consider-
considerably higher, the vertical distance of the ably higher, the vertical distance of the denti-
dentition (-plane of occulsion) to the temporo- tion (-plane of occulsion) to the mandibular
mandibular joint is large.
joint is large.
The strong radius of the Curve of Spee of the den-
tition going posteriorly and superiorly is especially
pronounced, giving this masticatory organ its
emphatically spherical arrangement. The maxillary
anterior teeth are missing altogether and are
replaced by a flat, horny ridge. The mandibular
anterior teeth are shaped like a shovel and open to
the front, lying antagonistic to the upper ridge.
These flat "tongs" enable the herbivore to grasp and
then tear plant food off its root system.
There is a gaping, wide, open edentulous space
between the anterior and lateral dentition. From a
superior view, the arrangement of the premolars
and molars is not arched, but in a straight line. If
an imaginary occlusal plane was extended posteri-
orly from the mandibular anterior tooth to the first
molar, this plane would lie far inferior to the
mandibular joint (ill. 11, left). From a sagittal view,
the arc of the Curve of Spee passes just before the
temporo-mandibular joint. If we draw a DPO,
there is a markedly longer distance to the joint
trochlea in comparison to the carnivore principle
(ill. 12, left).
Herbivores abrade their dentition early into a "bal- Zetner, K., Mai, M.: Electronical Assessment of Chewing
anced" articulation. This guarantees an optimal Movements in the Dog. Proceedings of the Third World
grinding surface to process finely fibred vegetable Veterinary Dental Congress, Philadelphia 1993

225
R. Slavicek • The Masticatory Organ
Ill. 11: The distance to the occlusal plane is large.
Ill. 12: The dentate mandible of a deer. The occlusal curve of
the lateral teeth would, if extended, pass close to or through
the temporo-mandibular joint.
Pongiden
The canine in male Pongids develops and
grows until late into adulthood.
... should be regarded as a sign or symbol of
strength.
226
food. Further optimization is achieved in "rumi-
nants" by a second processing pattern (the rumi-
nant's "pre-digestion") (ill. 13-15, p. 227).
The phylogenetic
changes from
Hominoids to Hominids
to Homo sapiens
The Pongids
Pongids are predominantly plant-eaters. Only the
chimpanzee has shown the desire to augment a
plant diet, with the option of eating meat.
The dentition of adult Pongids is not arch-shaped,
in contrast to its deciduous dentition. Its dentition
consists of two nearly parallel lateral rows formed
by premolars and molars. The powerful canine is
segregated from the lateral group, and separated
from the anterior group of teeth by a diastema, the
so-called "primate gap" (ill. 18 and 19, pages 228-
229).
The canine in male Pongids develops and grows
until late into adulthood. The apical foramen clo-
ses rather late in life. This suggests that, in contrast
to the predator, the canine is not a true killing
weapon, but should be regarded as a sign or sym-
bol of strength.
Pongids abrade their dentition in both right and
left lateral areas early, in order to achieve a balance
between the contralateral and ipsilateral sides for
masticatory functional contacts during articulation.
This is necessary for the survival of the species,
which are primarily herbivorous "leaf-eaters".
Function - Mastication

Ill. 13: The sheep - a typical

ruminant.

Ill. 14: Attaching the perma-

nent magnet to an anterior
portion of the mandibular jaw.

Ill. 15: The transversal masti-

cation pattern of a ruminant
shows a completely flat excur-
sion track.

227
R. Slavicek • The Masticatory Organ

Ill. 16: The orangutan is omnivorous, eating predominantly vegetation. Its dentition must be suitable for processing this vegetable
food.

Ill. 17: The comparison of a Pongid arch to the human arch shows the drastic difference in the alignments of the dentitions. The
gaping "primate gap" behind the front teeth allows for transversal vectors, for the breaking-up of vegetable food.

228
 Function - Mastication

Ill. 18, 19: The morphological makeup

of the molars in anthropoids shows
hardly any difference to human molars.
Dentition in adult anthropoids shows an
evident tendency toward Class III den-
tition.

229
R. Slavicek • The Masticatory Organ
This organ, which had primarily served in the
ingestion of food in phylogenesis, was
redesigned into a multifunctional organ.
The esthetics of the face is characterized by
the masticatory organ and its diversity,
dynamics and expression.
Modifications in the nutritional habits of our
industrial societies have effected a fundamen-
tal change in the masticatory organ.
Huber, E.: Evolution of Facial Musculature and Face Expression.
Baltimore: The John Hopkins Press, 1931
230
Homo sapiens
The viscerocranium developed the human mastica-
tory system into a closed-arch construction of the
jaw and dentition, as a result of the vehement
enlargement of the neurocranium, especially trans-
versally (ill. 20-28, pages 231-233).
This organ, which had primarily served in the
ingestion of food in phylogenesis, was redesigned
into a multifunctional organ. Although oral com-
munication was undoubtedly its main function, it
also played a role in maintaining the balance of the
freely held head and in processing psychologically
induced parafunctions. In addition, the human
masticatory organ has to fulfill the facial expression
requirements of non-verbal communication. The
esthetics of the face is characterized by the mastica-
tory organ and its diversity, dynamics and expres-
sion. Esthetics are involved to a great extent in the
"self-awareness" of the individual (comp. Huber).
The neuromuscular system (NMS) moves the
mandible in patterns, which are maintained propri-
oceptively by specific individual tooth contacts or
through independent programs.
The NMS is involved in the following functional
areas: mastication, deglutition and speech, and also
clenching and bruxism, as expressions of psychic
tension. In addition, the NMS of the masticatory
organ assumes a significant role in the posture of
the head.
The following muscles are involved in mastication
and deglutition: the true masticatory muscles,
muscles of the cranio-mandibular system, the mim-
ical muscles and the tongue, the floor of the mouth,
the musculature of the pharynx and the soft palate,
and the supra- and infrahyoid musculature, for con-
trolling the hyoid.
These functions have changed considerably in the
course of the last century, for a percentage of the
world's population. Modifications in the nutritional
habits of our industrial societies have effected a fun-
damental change in the masticatory organ. Because
of the extremely extended retention of the develop-
mental grooves in the dentition of modern humans
in the twentieth century, the functional programs
are infinitely more complicated than those of
abraded dentitions in the Middle Ages. In its con-
vergence, the latter corresponds to the mastication
pattern of herbivores, i.e., to a unilaterally or bila-
terally balanced articulation.
Function - Mastication

Ill. 20: In the newborn, the

ascending branch is merely
implied; an imaginary occlusal
plane would pass through the
joint condyle.

Ill. 21: In fully developed

deciduous dentition, there is
still hardly any perceptible dis-
tance to the occlusal plane.
The ascending branch is
scarcely developed, the articu-
lar eminence is also merely
implied.

Ill. 22: On the development of

permanent dentition, the
ascending mandibular arch is
verticalized and its height
developes to an individual
extent.

231
R. Slavicek • The Masticatory Organ

Ill. 23: Gap opening because of hypo-plas-

tic smaller incisors, as compensation for the
full lower arch. Orthodontic closing of the
gap would be inappropriate.

Ill. 25: This sketch shows the closed arch

architecture of the mandible, with the
course of the incisal edges and cusp tips.

Ill. 27: The lateral view shows the gaps on

both sides.

232
 Function - Mastication

Ill. 24: Because of discrepancies in the size

of the widths of teeth, compensating arch
variations may emerge.

Ill. 26: The maxilla with its closed archi-

tecture and the positive buccolabial over-
bite.

Ill. 28: The lateral view shows the gaps

on both sides.

233
R. Slavicek • The Masticatory Organ
In our century, humans live to be at least
twice as old. Psychological tension is on the
increase, brought about by the explosion of
population and media networking.
Mastication is the procedure of chewing food,
the preparation for deglutition and digestion.
Mastication is made possible by the coordinat-
ed activities of the tongue, the mandible, the
masticatory muscles, the structural compo-
nents of the mandibular joints etc., controlled
by the neuromuscular apparatus. The action
of mastication is concluded by deglutition.
Ringel, E., Földy, R.: Machen uns die Medien krank?
Universitas Verlag, 1992
Bouchet: Current Clinical Dental Terminology. Mosby
(2. Edition), 1974
234
This alteration, brought about by the drastic
change in the range of available food products in
industrial societies, is multiplied by further factors.
In our century, humans live to be at least twice as
old. Psychological tension is on the increase,
brought about by the explosion of population and
media networking. This necessitates a fully new
phenotype, which the dentist at the turn of the
21st century will have to deal with and care for.
Statistical prognoses documented this dramatic
development (comp. Földy, Ringel).
The medieval abraded dentition was characterized
by contacting, functional convergence. The basic
principle of non-abraded dentition consists in the
avoidance of strong contact or continuous gliding
contact. Mastication with an abraded dentition
leads to considerably better processing of vegetable
food, but also to a considerably higher load on the
dental supportive system. The periodontal wear
and tear that we see in medieval dentitions applies
to age groups that correspond to the first third of
the life span of present day populations in industri-
al nations.
The complete functional area of the so-called mas-
ticatory organ of modern humans encompasses
mastication, speech, posture, esthetics and stress
management.
Mastication- definitions,
scientific discussion
"Mastication is the procedure of chewing food, the prepa-
ration for deglutition and digestion. Mastication is made
possible by the coordinated activities of the tongue, the
mandible, the masticatory muscles, the structural compo-
nents of the mandibular joints etc., controlled by the neu-
romuscular apparatus. The action of mastication is con-
cluded by deglutition."
The mutually complementing definitions given by
Bouchet, as mentioned above, describe the task as
the complexity of the directly involved structures. I
would express it more simply:
Mastication is the life-sustaining function of pro-
cessing and ingesting food, as a prerequisite for its
digestion.
 Function - Mastication

If we regard this function from the viewpoint of the Mastication is the life-sustaining function of
"masticatory organ" as a feedback-control mecha- processing and ingesting food, as a prerequi-
nism, the complex processes that occur at this site site for its digestion.
become evident. All of the structures act in a coor-
dinated fashion. The mechanisms of detailed regu-
lation are especially interesting from a cybernetic
point of view. The complexities of the masticatory
function have been described by several authors
and recorded in even greater detail in the last few
decades, following the introduction of electronic
examination methods. Mandibular movements do
not correspond to the traditional images, as
inferred and taught by the use of so-called articula-
tors. According to the monograph, "Analysis of
Human Mandibular Movement", the authors
Goodson and Johansen, using ingenious electronic
methods, describe the mastication process as fol-
lows:
"The general appearance of a masticatory move- "The general appearance of a masticatory
ment is a highly refined, coordinated process. movement is a highly refined, coordinated
Lateral (Bennett movement) and extreme protru- process. Lateral (Bennett movement) and
sive movement of the condyles are the most con-
extreme protrusive movement of the condyles
spicuous characteristics. The movement of the den-
tition (from intercuspation) is thereby almost verti- are the most conspicuous characteristics. The
cal, without signs of rotation around an inter- movement of the dentition (from intercuspa-
condylar axis". tion) is thereby almost vertical, without signs
The separating and then protrusive movement in of rotation around an inter-condylar axis".
the occlusal area, described above, would only be
possible with a strong rotation around the inter-
condylar axis, using an ordinary articulator. It is
significant that the predominantly translatory char-
acter of mandibular movement during mastication
is emphasized. A close look at the authors' results
brings a rather notable fact to light: the rotation
around the so-called hinge-axis of the mandible is
practically negligible in comparison to the three-
dimensional translation.
If we follow the results and conclusions of the
authors Gibbs and Lundeen in their numerous pub-
lications on the subject of mastication, the behavior
of the mastication pattern relative to dental struc- Goodson, J. M., Johansen, E.: Analysis of Human
Mandibular Movement. Monogr. Oral Scien., 5: 1–80, 1975
tures is of special interest. The authors processed Lundeen, H. C., Wirth, C. G.: Condylar Movement Patterns
the recorded patterns and displayed the movement Engraved in Plastic Blocks. J. Prosth. Dent., 30: 866–875,
pattern of the mandible for the mandibular joints, 1973
as well as for the dentition, taking into considera- Lundeen, H. C., Shryrock, E. F., Gibbs, C. H.: An Evaluation
tion all six degrees of free mandibular movement. of Mandibular Border Movements. Their Character and
The so-called gnathic replicator 1 from Charles Significance. J. Prosth. Dent., 40: 442, 1978
Meyer, G.: Entwicklung und Anwendung eines elektronischen
Gibbs, who was responsible for the conceptual and Verfahrens zur dreidimensionalen scharnierachspunktbezüglichen
technical design of the studies, allows for the Registrierung von Unterkieferbewegungen für die
recording of mandibular movement by means of an Funktionsdiagnostik des stomatognathen Systems.
ingenious and practical arrangement of optical- Dissertation, Göttingen 1986

235
R. Slavicek • The Masticatory Organ
The occlusal plane was selected as the refer-
ence plane for this method and the recordings
were standardized to the individual occlusal
planes of each volunteer or patient.
Lundeen and Gibbs made their results avail-
able to schools and practitioners in a com-
pletely open and an exemplary scientific man-
ner.
In this new reality, the movement began with
a wide, symmetrical, anterior initial movement
of both condyles.
236
electronic transmitters and receivers, on a double
facebow system (ill. 29-31, p. 237). The facebows
were built ultra-light, were hardly a hindrance, and
were attached to the occlusion with rigid, function-
al occlusion wires. This made it possible for Gibbs,
Lundeen and co-workers to record the mastication
movements of volunteers and patients.
The occlusal plane was selected as the reference
plane for this method and the recordings were stan-
dardized to the individual occlusal planes of each
volunteer or patient. The apparatus allows the
investigator to execute the chewing test using var-
ious food qualities. Gibbs and Lundeen introduced
standardized research of the function of mastica-
tion. The apparatus is also distinguished by the fact
that, during the recording, the skillfully arranged
mounted models also moved in the "replicator",
with a time delay of 1:10, corresponding to the
recorded movement pattern. This movement of the
rigid model, which was mounted according to the
principle of the occlusal plane, resulted in entirely
new and surprising insights into the function of
mastication, which previously had not been exam-
ined systematically.
Diagrams of various views and overlays with denti-
tion schemes resulted in an unprecedented didactic
evaluation of the results. Lundeen and Gibbs made
their results available to schools and practitioners in
a completely open and an exemplary scientific
manner. I thank them most sincerely for their atti-
tude, which is by no means a matter of course in
current scientific research.
An especially interesting aspect of the study was
the possibility to shift the movements to individual
"occlusal tables" of the dentition (ill. 32-34, pages
238-239). A further noteworthy feature was the
display of masticatory movement in the joint,
which was achieved through the spatial possibility
of arrangement (ill. 35-36, p. 239). Joint move-
ments during mastication were, in fact, entirely dif-
ferent from those previously displayed in articula-
tors. In this new reality, the movement began with
a wide, symmetrical, anterior initial movement of
both condyles. This is reminiscent of the primitive,
first ingestion of food by the newborn, which acti-
vates the milking action in the same fashion.
The returning movement during mastication takes
place more quickly on one side and slowly on the
other, making the movement asymmetrical.
Apparently caused by the vectors of the muscula-
ture, this asymmetrical returning movement pro-
Function - Mastication

Ill. 29: The electronically con-

trolled machine replicates the
chewing activity of the subject
on the mounted models (time
delay of 1:10). The authors
selected the subject's occlusal
plane as the reference plane.

Ill. 30: The facebow on the

patient with the aid of a func-
tional occlusion attachment.

Ill. 31: Six cleverly applied

optical-electronic recorders
provide for the registration of
all the required information.

237
R. Slavicek • The Masticatory Organ

Ill. 32: The mas-

tication move-
ments were over-
laid onto
mandible plots,
to allow for bet-
ter clarity and to
reveal the possi-
ble effects on the
occlusal surface
complex. Here,
the view from
the lateral
perspective.

Ill. 33: An
occlusal view.

238
 Function - Mastication

Ill. 34: An anterior view.

Ill. 35: A time-delayed display of the joint track made it possi- Ill. 36: Time-delayed view of the progress of a cycle in the left
ble to study the elapsed time of the inherently asymmetrical joint.
mastication cycles.

239
R. Slavicek • The Masticatory Organ

Ill. 37 (above, left): The right joint from a superior view.

Ill. 38 (above, right): The elapsed time of the left joint from a
superior view.

Ill. 39 (right): The lateral return as a novel finding, relative to

the Bennett movement.

240
 Function - Mastication

duces the classic, physical shift to the more rapidly

returning side, which can now be termed the lat-
erotrusion side (ill: 37-38, p. 240). The result of
this asymmetrical course is that the lateral teeth on
both sides achieve a favorable three-dimensional
functional antagonism. This physical shift of the
mandible during asymmetrical movements is
known as the Bennett movement; it was recog-
nized and observed very early in the literature (ill.
39, p. 240).
In contrast to the knowledge deduced from articu-
lator mechanics, which had traditionally been
taught up to this point, the Bennett movement
during mastication is a phenomenon of the return-
ing phase. Thereby, the condyle on the laterotru-
sion side leaves its cranial border position, swings
Ill. 40: The conception of occlusion from the viewpoint of
inferiorly, posteriorly and externally, generally fur- protection in parafunction in the articulator.
ther back than its corresponding original position,
and then (and this was the remarkable new feature) Bennett movement
returns to its original position with a cranial, inter- Side-shift
nal, superior movement. The contralateral side Immediate Side-shift
moves more slowly in the returning movement but
remains rather cranial, relative to the border track,
and oriented towards the articular eminence. The
conformity to biomechanical laws is clearly seen in
the excellently labeled time frames on the graphic
display.
From the viewpoint of the Bennett movement,
termed "side-shift" in current dental language, it is
actually an "in-shift" of the condyles, taking place
during the returning phase, centering to the mid-
dle from a lateral position. This swinging return
movement is always associated with active control-
ling processes of the muscles in the cranio-
mandibular system. These are coupled in a "closing
active" and meaningful fashion with the controlling
temporal muscle.
If we regard the same from the viewpoint of the
articulators and transfer the movement to the den- Ill. 41: The spatial dependence of joint movement to occlu-
tition, as didactically proposed in the publication sion, which Bonwill had already termed articulation, in the
overview display from McHorris.
by W. McHorris, the movement takes place exter-
nally (ill. 40-41, right). This does not hold true for
mastication. A movement of this kind would more A movement of this kind would more likely
likely take place during the parafunction of eccen- take place during the parafunction of eccen-
tric bruxism. The section on Parafunction will deal tric bruxism.
with the extent to which a Bennett movement
actually exists.
If we look at the diagrams of typical mastication,
with regard to mandibular incisor movement, the
drop-like shape of the cycle, viewed anteriorly, is McHorris, W.: Einführung in die Okklusionslehre. 1983

241
R. Slavicek • The Masticatory Organ
A significant result ... the anterior teeth are
avoided during mastication.
These two inverse concavities are arranged
and coordinated into the same coordinate sys-
tem.
Therefore, the marking points of the elapsed
time are each taken on the joint track at the
same intervals.
Zsigmondy, O.: Über die Bewegungen des Unterkiefers beim
Kauakt. Österr. Zschr. f. Stomatol., X (6): 175–184, 1912
Slavicek, R., Lugner, P.: Der schädelbezügliche teiladjustierbare
Artikulator. Österr. Zschr. f. Stomatol., I u. II: 84–102 und
122–142, 1976
Slavicek, R., Lugner, P.: Über die Möglichkeit der Bestimmung
des Bennettwinkels bei sagittaler Aufzeichnung. Österr. Zschr. f.
Stomatol., 7/8: 270–284, 1978
242
conspicuous. A similar phenomenon was published
in 1912 by Zsigmondy, based on self-observation
(ill. 43, p. 243).
A significant result of the research on the mastica-
tion cycle performed by Gibbs and Lundeen is the
fact that the anterior teeth are avoided during mas-
tication, i.e. they do not make contact. Worthy of
note is the fact that mastication patterns are rapid
movement cycles without a high expenditure of
energy (ill. 42 and 44, p. 243).
Using a mathematical model publicized by Lugner
and myself, we will attempt to clarify the biome-
chanics with the aid of a sagittal scheme. Anterior
teeth are not used as gliding teeth on the lingual
surface but rather, in the sense of a moderate avoid-
ance mechanism, functionally programmed in a
way that they act as borders of movement without
colliding contacts, and simultaneously allow for the
closest possible convergence. On the other hand, in
the sagittal scheme, it is the synovial gliding joint
that offers the possibility of mathematically regis-
tering a corresponding protrusive sliding move-
ment (symmetrical initial movement) (ill. 45-47, p.
244). These two inverse concavities are arranged
and coordinated into the same coordinate system.
The mandibular joint movement is taken as an
even, gliding movement, without a change in
speed. Therefore, the marking points of the elapsed
time are each taken on the joint track at the same
intervals, resulting in a constant rate of speed for
the joint. In contrast, the coupled movement caus-
es an alternating speed to occur in the anterior
tooth area and the elapsed time is irregular. This
can be seen in the different marking distances.
If we analyze the different speeds of the two oppo-
sing curves, it becomes evident that the speed in
the anterior area during constant speed in the flat
area, relative to the joint's gliding speed, is slow at
first, and then increases in the steeper portion. This
is expressed in the increasing distance between the
numbered time points.
In this kind of sagittal model, it is naturally also
possible to follow a point in the area of occlusion,
e.g., the first mandibular molar, in its spatial geo-
metry and/or in elapsed time. The hinge-axis
orbital plane, and not the occlusal plane used in the
studies of the Gibbs and Lundeen team, serves as
the coordinate system. Applying this in real exam-
ples and comparing the lingual concavity of the
subject's anterior tooth section to the sagittal joint
track, it is possible to create a mathematical model
Function - Mastication

Ill. 42: Recordings in

the three observation
planes show, especially
in the anterior view,
the drop-shaped masti-
catory loops, whose
lateral aspect appears
considerably less
bunched than in the
sagittal view.

Ill. 43: Self-observation

in the mirror in 1912,
resulted in practically
similar loops as those
obtained from elec-
tronic recordings.

Ill. 44: Note that, dur-

ing mastication, no
incisor contact takes
place.

243
R. Slavicek • The Masticatory Organ

Ill. 45: The inner surface of an

anterior tooth, divided into two
sections.

Ill. 46: Calculation of the

declining track on the anterior
tooth.

Ill. 47: Condylar track of the

same subject in the same coor-
dinate system.

244
 Function - Mastication

of the geometric processes, along with all the Of special interest here is the rotational behav-
resulting consequences. Of special interest here is ior of the hinge-axis during the movement.
the rotational behavior of the hinge-axis during the
movement.
Example 1 (ill. 48-49, p. 246) shows the combina-
tion of anterior and posterior components of a
healthy subject. It is noticeable that, at the begin-
ning, the hinge-axis shows a minimal initial closing
rotation of just a few tenths of a degree.
Subsequently, an equally minimal opening rotation
occurs. Because of this process, this is an extremely Because of this process, this is an extremely
economical movement for the NMS, characterized economical movement for the NMS, charac-
by translatory components alone. terized by translatory components alone.
If the inclination of the anterior teeth is artificially
changed in the model by tipping it forward by 15
degrees (ill. 50-51, p. 247), the behavior of the
hinge-axis changes very little. If, in this example,
the movement of the contour of the anterior teeth
follows, a more distinct closing rotation takes place
and fails to reach the original value even if the
movement continues to the incisal edge. The possi-
bility of molar contact becomes a probability in this
model, if one includes an occlusal plane with aver-
age inclination into the diagram. In a further exam-
ple, if the vertical overbite of the anterior teeth is
reduced (ill. 52-53, p. 248), the controlled course in
the area of the mandibular joints is also reduced
and a moderated opening movement is initiated
immediately through the inclination of the steeper
portion of the anterior concavity, which, however, is
only briefly controlled.
In the next example (ill. 54-55, p. 249), the anteri-
or tooth is tipped back. The entire lingual concavi-
ty exercises dominant guidance control. It is evi-
dent that an initial opening movement takes place
in the sagittal scheme, characterized by strong rota-
tion.
This initial opening movement is not determined
by translation, but by rotation. This means that, if
this course of movement came about, the move-
ment would have to take place predominantly in
the inferior joint. The absence of translation near
the occlusion would strongly reduce the breaking-
up and tearing efficiency of mastication. In the
actual reality of complete overbite, this is not the
case at all; the mastication pattern "avoids" the oth-
erwise mandatory strong rotation, with a predomi-
nantly transversal movement.
It should be pointed out here that the combination
of the anterior and posterior guidance components

245
R. Slavicek • The Masticatory Organ

Ill. 48: The anterior tooth concavity and condylar track in dynamic interdependence. In between: a possible molar path.

Ill. 49: In this combination, the rotational behavior is decisive. This kind of combination refers to almost pure translation, except for
a few tenths of a degree.

246
 Function - Mastication

Ill. 50: This illustration makes the interdependence clear: the change in inclination of the anterior tooth, by tipping it forward, also
changes the molar track.

Ill. 51: The overall behavior still remains translatory.

247
R. Slavicek • The Masticatory Organ

Ill. 52: The mathematical models demonstrate how the reduction of the vertical overbite results in a reduced controlled condylar
excursion.

Ill. 53: The behavior is now rather rotational.

248
 Function - Mastication

Ill. 54: An increase in the inclination of the anterior teeth and a simultaneous flattening of the joint track would lead to entirely dif-
ferent overall behavior.

Ill. 55: If the pattern progressed sagittally, it would require strong rotation.

249
R. Slavicek • The Masticatory Organ
The consistency of the two inclinations means
that the main function of mandibular move-
ment would have to be predominantly trans-
latory in one case, but more rotational in
another, because of discrepancies.
Influencing mastication through anterior
guidance- or controlling components of the
front canine group is not limited to the den-
tulous situation.
After being applied hesitantly in the begin-
ning, this theoretical model gained increasing
general acceptance and is now established in
education as the Innsbruck Concept of
Gausch.
Tscharre-Zachhuber, Ch., Riedl, M. A.: Kaumusterunter-
suchungen von Totalprothesenträgern. Jaw Movements in Patients
with Full Dentures. Zschr. f. Stomatol., 85 (7): 423–428, 1998
250
is apparently very important for muscle and joint
physiology. The consistency of the two inclinations
means that the main function of mandibular move-
ment would have to be predominantly translatory
in one case, but more rotational in another, because
of discrepancies. In order to avoid an overly strong
opening rotation (as pointed out in the example of
complete overbite), the function would have to be
rather transversal in cases of especially steep front
components or narrowing of the mandibular arch
by the maxillary arch. This results in considerably
more complex demands on the overall muscula-
ture, instead of the simple, translatory, anterior-
posterior movement.
Influencing mastication through anterior guidance-
or controlling components of the front canine
group is not limited to the dentulous situation. In
a study of chewing patterns, the researchers from
Innsbruck, Tscharre-Zachhuber and Riedl, under
the direction of Gausch, examined wearers of full
dentures with regard to the effects of a change in
the front area. Since 1974, the Innsbruck
University Dental Clinic under Gausch has set up a
dominant canine as the control tooth in the other-
wise rather balanced concept of lateral tooth
arrangement, according to Gerber. After being
applied hesitantly in the beginning, this theoretical
model gained increasing general acceptance and is
now established in education as the Innsbruck
Concept of Gausch.
In further studies by the two authors, the examina-
tion of mastication muscles with the sirognatho-
graph showed that a definite change in the frontal
mastication pattern results when this kind of steep-
er tooth is installed in an otherwise flat occlusal
concept. The authors examined and compared per-
manent, reconstructed occlusions which were
waxed up with controlled canine guidance. The
reconstructed occlusions originated from Professor
Kulmer, who documented them minutely during a
long-term study carried out in a group of subjects
with full dentures. They were recorded before and
after a change in the canine arrangement.
Surprisingly, the results were strong changes in the
behavior of the pattern and a frontal mastication
loop pattern comparable to a dentulous situation
which, with an avoidance angle of approximately 8
to 10 degrees and a canine inclination of approxi-
mately 40 degrees, created a mastication pattern
fully appropriate to a dentulous, rehabilitated
patient (ill. 56-64, pages 252-253; many thanks to
 Function - Mastication

Innsbruck for the pictures).
Mastication should be more and more a purely
translatory movement pattern with minimal rota-
tion during the phase of bolus formation. For
dynamic mastication of optimal quality, modern
human dentition should achieve the closest possible
convergence of the dentitions, without functional
interferences among the teeth or groups of teeth.
Mastication should be more and more a pure-
ly translatory movement pattern with mini-
mal rotation during the phase of bolus forma-
tion. For dynamic mastication of optimal
quality, modern human dentition should
achieve the closest possible convergence of
the dentitions, without functional interfer-
ences among the teeth or groups of teeth.

Conclusions
Assuming that occlusion is the dominant deter-
mining factor of the system, based on the above
mentioned statements I arrived at the following
conclusions:
Anterior teeth are always strictly avoided during Anterior teeth are always strictly avoided dur-
mastication! They are to be regarded as functional ing mastication! They are to be regarded as
interferences during mastication. functional interferences during mastication.
Canines, and also other teeth in the lateral tooth
area, are sometimes touched lightly and fleetingly
during mastication. These appear to be orientation
contacts for the rapid, sequential movements of the
chewing mechanism. The informative canine con-
tacts can determine the functional pattern in a fixed
restoration, and also seem to function in the same
way in persons wearing full dentures. Informative
contacts during mastication can also take place on
other teeth, depending on the individual. They are
pattern-specific and may lead to discrete facet for-
mation.
These functional facets are to be strictly differenti-
ated from parafunctionally created abrasions, as
they are generally not so strongly distinguished and
are in no way as glossy as active parafunctional
facets. They are isolated and have no other equiva-
lent or counterpart that can be achieved in an artic-
ulator.
The mastication cycle is clearly dependent on the
inclination of the lingual contours of the maxillary
dentition. This appears to affect the incursive mas-
tication loop of the laterotrusion side. It justifies the
conclusion that the hard dental substance that is
apparently the guidance which represents the
steepest interferences to free movement, deter-
mines the mastication pattern. This, in turn, leads
to the conclusion that mastication patterns are the
consequences and results of functional interferences

251
R. Slavicek • The Masticatory Organ

56 (right): The representation of a mastication loop

according to Gibbs. The authors Tscharre-Zachhuber,
Riedl and Gausch attempt the cognitive construction of
the mastication loop using canine guidance.

57 (below): Comparison of the mastication loops of a

rehabilitated patient with a fixed restoration to an aver-
age full denture wearer.

58: Canine control in a dentulous subject. 59: Experimental canine control in full denture subject.

252
 Function - Mastication

60: Success after 2 weeks. 61: Left-sided exercise loop after a few weeks.

62: Examples.

63: Mastication loop of a rehabilitated patient with a 64: Mastication loop of a conditioned full denture
fixed restoration. patient.

253
R. Slavicek • The Masticatory Organ
This, in turn, leads to the conclusion that
mastication patterns are the consequences and
results of functional interferences of the den-
tition in a free mandibular movement.
From the viewpoint of mastication, the char-
acteristic concept of "disocclusion" has per-
verted the actual purpose of the masticatory
organ, i.e. grinding food as efficiently as pos-
sible.
Disocclusion
The quality of occlusion must be evaluated
according to whether an interference-free,
maximum convergence of the dental arches to
each other during mastication is achieved.
Metabolism
This ensures the inner metabolism of the
joint cavities.
254
in the dentition in a free mandibular movement.
This kind of behavior in the mastication cycle was
recognized early and documented from self-obser-
vation.
Prerequisites that the human stomatognathic sys-
tem must fulfill in order to be appropriate for the
function of mastication have been previously men-
tioned. The prerequisites must be the goals of ther-
apy for the dentist when he/she is called upon to
alter occlusion for therapeutic purposes. The pri-
mary goal of any reconstruction is to achieve the
most even convergence of the dentition without the
appearance of interferences.
From the viewpoint of mastication, the characteris-
tic concept of "disocclusion" has perverted the actu-
al purpose of the masticatory organ, i.e. grinding
food as efficiently as possible. The creation of mod-
ern occlusion concepts has been determined more
by thoughts of safety with regard to parafunction
than by allowing for the fact that food must be pre-
pared appropriately for digestion. This is rather
counterproductive at a time when the concept of a
vegetarian diet is gaining increasing acceptance.
The quality of occlusion must be evaluated accord-
ing to whether an interference-free, maximum con-
vergence of the dental arches to each other during
mastication is achieved. This is inordinately more
difficult when dealing with the dentition of modern
humans, which is not subject to abrasion, than with
the abraded dentition of the past. With regard to
dynamics, this requires that the cusp-carrying den-
tition be movable translationally, evenly separated
and without interference. The distance must be as
minimal as possible, in order that the individual be
able to tear up and grind food. Mastication must be
more and more translatory during the phase of
bolus formation, with minimal rotation. This is also
the optimal physiological constellation for the syn-
ovial joints of the CMS, because joint lubrication
functions optimally during the extensive move-
ment and continuous fluctuation in joint pressure.
This ensures the inner metabolism of the joint cav-
ities. It is also most economical for the musculature,
which becomes active isotonically, predominantly
through the protractors and retractors. Elevators
and distractors only execute a precisely controlled
positioning function of vertical separation.
In reiteration of the sequence of movement in the
mastication cycle, it begins with a protrusive, sym-
 Function - Mastication

metrical, initial movement. This lies within the

temporo-mandibular joints on the cranial border.
The asymmetry of the movement begins incursive-
ly. The condyle of the laterotrusion side swings
more rapidly to posterior and then, as a rule, later-
ally and caudally, the extent depending on the indi-
vidual and influence from the kind of food. The
condyle on the mediotrusion side follows with some
delay, remains closer to the border track, and
swings to medially. There follows, on the laterotru-
sion side, the renewed inward swing between the
mandibular dentition from posterior-inferior to
anterior-superior, against the maxilla. Thereby, the
two sides are brought again into symmetry and the
symmetrical initial movement begins anew. The
movements take place nearer to border track of the
temporo-mandibular joint when the quality of the
occlusion is better. Mastication is concluded by
deglutition. The functional tracks are also easy to
record and evaluate diagnostically, through the use
of electronic recordings of joint movements and
appropriate fixation of the apparatus.
The practical morphology of the articular eminence The practical morphology of the articular
(a convex trochlea with initial inclination in front of eminence (a convex trochlea with initial incli-
the cylindrical joint processes), in conjunction with nation in front of the cylindrical joint
the interposed articular disc, produces a good struc-
processes), in conjunction with the interposed
ture, suitable for meeting these requirements.
Through this synchronization, the equally practical articular disc, produces a good structure,
intercoronal free space formed by the maxillary suitable for meeting these requirements.
front teeth with their lingual concavity during the
initiating mandibular movement to allow for the
two inclined surfaces to be free from each other,
which is a prerequisite for a predominantly transla-
tory mastication function. This can be demonstra-
ted with geometrical-mathematical models, but it It must be mentioned, as a point of criticism,
must be mentioned, as a point of criticism, that the that the mechanistic model which attempts to
mechanistic model which attempts to force the free force the free system of mandibular move-
system of mandibular movement into a theoretical
ment into a theoretical corset through the
corset through the crankshaft principle (comp.
Kubein-Meesenburg, Nägerl) does not correspond crankshaft principle (comp. Kubein-
to the biomechanics of the masticatory organ. Meesenburg, Nägerl) does not correspond to
It must also be reemphasized that mastication is by the biomechanics of the masticatory organ.
no means a tooth-guided, gliding movement, but
rather an extensively free muscular pattern deter-
mining mandibular movement. The muscular pat-
tern is interrupted by fleeting non-emphatic con-
tacts of particular teeth. The contacts are proprio-
ceptive informational ones for the fine control of
the chewing movement, and are adjusted to the
current consistency of the bolus. From the frontal
view, the cusp inclinations determine the inclina-

255
R. Slavicek • The Masticatory Organ
The mastication cycle is always a pattern
determined by the occlusion.
Dysgnathic dentition requires special muscle
programs to compensate for the resultant
interferences brought about by the dysg-
nathia.
Interference-free achievement of the ICP is
desirable under physiological conditions.
Kubein-Meesenburg, D., Nägerl, H., Fanghänel, J., Thieme,
K., Klamt, B., Swestka-Polly, R.: Die allgemeinen Ebenen.
Mandibularbewegungen als Koppelbewegungen in neuro-muskulär
gesteuerten Getriebesystemen. Dtsch. Stomatol., 41: 332–336,
1991
256
tion of the closing angle, but only under normal
conditions of the canine and the anterior arch. The
canine is excellently suited for its role as a proprio-
ceptive, controlling "informant", in order to func-
tion in the control pattern, through fleeting, inter-
rupted contacts, depending on the bolus. In con-
trast, the front teeth are strictly avoided during
mastication.
The best biomechanical requirements for the func-
tion of mastication described above is offered by the
dentition type termed 1:2 intercuspation. The den-
tal arches intercusp best under these "alternating"
conditions. The largest number of dental relation-
ships occur in a Class I dentition, but this is not a
conditio sine qua non for good function. Deviations
from this intercuspation principle require alterna-
tive movement patterns for mastication, which are
frequently achieved through increased muscular
activity. The mastication cycle is always a pattern
determined by the occlusion. In cases of anterior
deep bite, the result would be a vertical pattern,
with increased rotation, which would impair masti-
catory efficiency. Generally, in this form of occlusion
there is a posterior-transversal pattern arrange-
ment, which places entirely different demands on
the cranio-mandibular system, both structurally
and functionally. In the neuromuscular system,
muscle groups with more transversal vectors are
used for this pattern. The muscle with the most
frontal vector is the medial pterygoid muscle.
Dysgnathic dentition requires special muscle pro-
grams to compensate for the resultant interferences
brought about by the dysgnathia. The conse-
quences could be less efficient mastication and
more demands on the muscles. This consequence is
practically ignored in current discussions regarding
the causality of functional disorders.
The distinctiveness and quality of the intercuspa-
tion position (IPC) are also of considerable impor-
tance for the physiological action of mastication,
because mastication is completed by the act of deg-
lutition. Interference-free achievement of the ICP is
desirable under physiological conditions, whereby
the difference in position between the ICP and the
retral joint position is of rather secondary impor-
tance for mastication and deglutition.
Obstacles in articulation are avoided during masti-
cation. The problems that arise during mastication
can result in muscular "avoidance mechanisms",
 Function - Mastication

which may then become the cause of definitive dys- The difference in position between ICP and
function. retral joint position is of rather secondary
importance for mastication and deglutition.

257
R. Slavicek • The Masticatory Organ

Speech

The development of human speech is in the center

of anthropomorphism. In the analysis of this func-
tion, we will make use of Bühler's theoretical
scheme expanded on by Popper.
The levels of human speech according to Bühler
and Popper are as follows:
• The argumentative function The argumentative function (1)
• The descriptive function The descriptive function (2)
• The signal function The signaling function (3)
• The expressive function The expressive function (4)
The above should be prioritized from the highest to
the lowest level (4-1).
Expressive speech expresses emotions; this lowest
step of communication expresses an internal condi-
tion externally (e.g., purring or growling).
Signaling speech serves to transmit messages
between the "transmitter" and the "receiver".
Both of these forms of expression are found in
humans and in the animal kingdom.
Expression and signaling can also take place
"speechlessly" and can be used by animals and
plants, but may also emanate from devices (e.g., an
alarm clock). They contribute to the communica-
tion between the "transmitter" and the "receiver".
Descriptive speech, on the other hand, is the basis
of communication among human beings. It

258
 Function - Speech

describes things or makes statements that may be

true or false, and includes the concepts of being
truthful and lying.
Argumentative speech is the language of hypo- Argumentative speech is the language of
thesis, including the dialogue and rational thinking hypothesis, including the dialogue and ratio-
associated with it. In terms of phylogenesis it nal thinking associated with it.
appears last, and its ontogenetic development also
sets in slowly, individually, and relatively late. Its
development is never completed, but continues
throughout life.
Descriptive and argumentative functions are Descriptive and argumentative functions are
unique to humans. Speech, as a complete function, unique to humans.
requires a speaker (transmitter) and a listener
(receiver). In some cases (self-conversation), the
transmitter and receiver may be the same person.
The human descriptive function requires the con-
scious formulation of thoughts. It includes, there-
fore, the possibilities of truthfulness and falsehoods
and also, independent of these, the conscious for-
mulation of a lie. In the argumentative function,
speech is used to express validity or invalidity, and
is thereby the agent for the most significant
"human" communicative function, the presentation
or refutation of a hypothesis.
The speech levels 3 and 4, which are so important
for communication, are closely connected with the
masticatory organ and are intensified by the com-
munication principle of learning and teaching; this
caused a time-lapse quantum leap in evolution. The
so-called masticatory organ, the agent of this com-
municative function, is therefore one of the deter-
mining factors of anthropomorphism.
This intensifying effect on the evolutionary deve-
lopment of the human brain, through the commu-
nication of thoughts, is being greatly accelerated in
the age of data-networking. It would be justified to
assume that the functional development of the
human brain is not yet completed, but is rather on
the verge of a new evolutionary leap.
The masticatory organ occupies a central position
in the individual ontogenetic development of every
human being. "All of the future possibilities of the "All of the future possibilities of the world are
world are entwined with the so-called masticatory entwined with the so-called masticatory organ
organ and its brain" (I. Földy, Dialogue, 1997). and its brain" R. Földy, Dialogue 1997.

259
R. Slavicek • The Masticatory Organ
Ill. 65: Section of a central incisor with a slightly "function-
ally" flattened incisal edge.
Ill. 66: Section of a different dentition with slightly more
pronounced flattening. Note the parallelism of the incisal
edge and the flat portion of the concavity.
Schareyka, R.: Sprache und inzisale Schlifflächen – eine kinema-
tographische Untersuchung. Dissertation an der Universität
Tübingen 1974
260
On the physiology and
pathophysiology of speech in a
non-abraded dentition
It should be emphasized that the most significant
function of the human masticatory organ is speech.
The modern twentieth century human is the most
communicative being that ever existed. Learning
and practicing speech serve as powerful formative
stimuli during the growth of the cranium and espe-
cially during the development of dentition. Even
after completion of growth, this function influences
the structures throughout the individual's lifetime.
In the most common "human" phenotype, food-
related abrasion of the structure of the teeth does
not take place. The lifelong retention of the deve-
lopmental grooves makes all of the functions,
including speech, much more complicated. The
formative influences of speech during the develop-
ment of dentition, and also throughout life,
affect the form of the dental arch and the maxillary
structures, especially the palatal arch. Of course,
the position and inclination of the anterior teeth are
strongly influenced by the functional interplay of
the circumoral mimic musculature with the
tongue. Powerful functional stimuli in the develop-
ment of the joint morphology during growth are
created by the speech dynamics of mandibular
movement, which are strikingly individualized and
variable.
In a dissertation, Rüdiger Schareyka (University of
Tübingen) describes the role of the anterior teeth in
speech and the occurrence of functional facets on
these teeth.
In follow-up research carried out by myself, the fol-
lowing conspicuous fact was registered: on sagittal
sections of plasticine molds on the incisors, the flat,
incisal abraded facets seemed to have an equal incli-
nation to the flat portion of the lingual concavity.
This parallelism appears to point to a dynamic asso-
ciation of the speech function with the joint move-
ment.
In further studies performed in England, Howell
examined the incisal relations of speech and arrived
at the same conclusions. Whether the abrasion
facets were the result of tooth-tooth contact alone
or whether tooth-lip contacts are liable to cause an
increasing number of facets through the rough sur-
face of the lips, needs further investigation.
 Function - Speech

Speech, a creation of sounds, is a specialized form of

breathing. The concurrent processes controlling
this highly differentiated breathing process, which
leads to the oral production of sound, apply above
all to the supra- and infrahyoid muscles, the com-
plex "larynx" system, the superior pharyngeal space
with the dynamics of the soft palate and the nasal
cavities, as well as, the true masticatory muscles.
The central muscle of speech formation is the
tongue, but the complete oral region of the mimic
musculature is also important for this function. The
vocal formation of sound, or "phonation", is a laryn-
geal function. The sounds are formed by streams of
air brought about by the varied positions of the
vocal cords.
In the formation of consonants, in contrast, the
entire masticatory organ and its structures are
involved to a large extent in the formation of
speech.
Sibilants and sharps, such as "S", ST" and "T" are,
under normal circumstances, sounds created by
contacting teeth. Alternatively, they might be sup- The functional demands of highly differenti-
ported sounds. ated speech results in the development of a
The mandible is pushed forward a certain distance functional asymmetry of the brain.
(depending on the individual) so that, with light
front tooth contact, the sounds are formed by
changing the air stream from constant to inter-
rupted. The position of the anterior teeth is of great
importance for this normal process. The tips of the
incisors are slightly worn by the pressure. The
"functional" abrasion facets flatten the incisal edges,
which are originally rounded when they erupt. The
worn surfaces have been studied and described in
scientific studies.
An additional remarkable fact for humans is evi-
denced in the development of the function of
speech. The functional demands of highly differen-
tiated speech results in the development of a func-
tional asymmetry of the brain, creating a right and
left brain. The establishment of brain asymmetry is
evidenced both functionally and morphologically.
The overall development is termed "lateralization".
Asymmetry between the left and right brains cau-
Ill. 67: Speech pattern in sagittal section in a scientific fol-
ses a demonstrable structural change in the crani- low-up study.
um. Several scientific studies have shown structural
asymmetry in a normal skull. In published studies,
based on a planimetric examination of frontal X- Howell, P. G.: The Variation in the Size and Shape of the
rays, the author has proven a distinct right-sided Human Speech Pattern with Incisor-tooth Relation. Arch. Oral
dominance in the cranium. Biol., 32 (8): 587–92, 1987

261
R. Slavicek • The Masticatory Organ
Ill. 68: The picture of a proton-emission tomogram, taken
during (the act of) speaking, shows the distinct functional
asymmetry of the activated side.
Ill. 69: The structural asymmetry of the two halves of the
brain is also significant, because of lateralization.
In addition to the tongue, the cheek is also
involved in the formation of these substitute
sounds.
Springer, S. P., Deutsch, G.: Linkes rechtes Gehirn –
Funktionelle Asymmetrien. Spektrum Akademischer Verlag,
1993
262
Ann Stabrun, who wanted to examine structural
asymmetry in patients for other reasons, has pro-
vided further evidence. She was dealing with
patients suffering from juvenile rheumatoid arthri-
tis and compared these with healthy controls. In a
further study she discovered that the healthy con-
trol group also had a cranial asymmetry in the
frontal view.
Interestingly, structural and functional asymme-
tries apparently brought about by the function of
speech also have effects on the masticatory func-
tion. In an interesting comparative study, the
human chewing cycle was compared to that of apes
(Macaca fascicularis) in a frontal view. The study
clearly showed that the chewing cycle of the
macaque is considerably symmetrical and that of
Homo sapiens sapiens is significantly asymmetrical,
displaying a distinct difference between the right
and the left side.
Further studies showed that this speech-related,
functional and structural asymmetry of the brain is
unique and is confined to a very few species.
Interestingly, some songbirds also display this
development of brain asymmetry as a result of the
process of learning more complex communication
through song verses. The asymmetry is inborn in
humans, but appears to progress during the devel-
opment of speech.
Of course, there are compensation mechanisms - in
cases of unfavorably arranged teeth as far as speech
is concerned - which are able to form sounds that
are not pure, yet comprehensible. In addition to the
tongue, the cheek is involved in the formation of
the substitute sounds. The Anglo-Saxon soft "S",
written as "th", is a typical dento-lingual sound.
The tongue is pushed forward and placed against
the front teeth, or clamped between the teeth.
Normally, the sound "L" is formed on the palate by
pressing the tongue behind the maxillary front
teeth. In cases of dysfunction, the sound can also be
formed by clasping the tongue between the front
teeth.
"F" sounds are formed by tooth-upper lip contact.
Its functional significance has been established in
the reconstructive methods and concepts of
prosthodontics.
The "R" sound is a vibration of the tongue, which is
absent in many languages. The form and extent of
the palatal vault is important for the formation of
 Function - Speech

this sound. Dysfunctional "R" formations are fre-

quently compensated for gutturally, and can lead to
problems. Therefore, the properly formed "R" is
one of the formative impulses for the development
of a normal palatal vault.

Occlusion and Speech

The importance of occlusion is recognized by

speech therapists, but only with the goal of impro-
ving the function of speech through normalization
of form. In contrast, the importance of speech as a Ill. 70: The planimetric division of the areas on a frontal X-
ray shows the structural asymmetry in scientific studies …
cause of dysfunction in the stomatognathic system,
based on occlusion, is rarely or never discussed.
In cases of poor occlusion, the resultant "avoidance
mechanisms" are highly complicated muscular
steering patterns, which can produce functional
distractions. The functional associations are very
widely ignored in discussions of the causality of
functional disorders.
Dysfunctions of the masticatory organ are seldom
considered to be causally associated with the func-
tion of speech, whereby the pathophysiology of the
speech process plays an important role. The causa-
lities can only be established through careful and
systematic analysis, by exploiting the advantages of
the dentist's instruments in conjunction with logo-
pedics. Ill. 71: … and the statistical results prove the existence of a
structural asymmetry.
An interdisciplinary dissertation with the logopedic
section of the University Clinic for HNO Vienna,
under Professor Ehrenberger, and the prosthetic
section of the University Clinic for Dental, Oral
and Orthopedic Medicine, produced astounding In cases of poor occlusion, the resultant
associations between speech disorders and the func- "avoidance mechanisms" are highly compli-
tional state of the masticatory organ. The associa- cated muscular steering patterns.
tions will be discussed in the chapter entitled
Instrumental Functional Analysis.

Dysfunctions of the masticatory organ are

seldom considered to be causally associated
with the function of speech.

263
R. Slavicek • The Masticatory Organ
Ill. 72: Asymmetry in the control group in a study per-
formed by Ann Stabrun.
Ill. 73: … and the statistical evaluation proves their
asymmetry.
Gstöttenbauer, D.: Strukturen des Kauorgans als
mögliche Ursache für Sprechstörungen. Dissertation, Wien
1994
Stabrun, A. E.: Mandibular Morphology and Position in
Juvenile Rheumatoid Arthritis. A Study on Postero-Anterior
Radiographs. Eur. J. Orthod., 7 (4) : 288–98, Nov. 1985
264
Summary
Speaking is a highly differentiated form of breath-
ing. The development of communicative speech
necessitated a functional and structural asymmetry
of the brain, which resulted in asymmetry in the
cranium. Possibly as a result, the function of masti-
cation in humans is also asymmetrical. During
growth, the speech function produces powerful for-
mative impulses in the masticatory organ.
Normally, the front teeth touch during the act of
speaking, resulting in abrasion facets on the incisal
edges, and the maxillary front teeth touch the
lower lip when making certain sounds.
Structural interferences in occlusion, which repre-
sent obstacles to speech, are compensated for by
muscular avoidance mechanisms. The avoidance
mechanisms are liable to cause dysfunction(s).
Speech is one of the possibilities of relieving
psychic tension through verbal "expression" of
stressful thoughts. Dysgnathic relations and mal-
occlusions are alleviated through compensation
mechanisms when speech is employed, whereby the
tongue is involved to a great extent.
Speech is the most important possibility of inter-
communication and "passing on information"
among humans. Writing and speech are a function-
al unit. The functional asymmetry also leads to
"one-handedness".
Pathofunctions of speech should be recognized by
the dentist and their effects on mandibular move-
ments should be registered.
 Function - Posture

Posture
On the physiology and
pathophysiology of body and head
posture in modern humans Ill. 74: The free, muscularly controlled head posture docu-
ments "maneuverability".

The evolutionary process of standing upright

caused a complete change in the human spine and,
therefore, in the posture of the human head. From
a system that "hung" on the nuchal ligament and
the powerful cervical musculature, a freely bal-
anced, maneuverable head developed, which now
mainly depends on the muscular apparatus alone
for its free posture and movement.
In this head posture system, occlusion is involved in
intermittent support.
In primarily terrestrial verticognathic primates, the
system "hangs" down. Therefore, occlusion hardly
plays a role in the supporting apparatus of the
head. In contrast, with humans, the occlusal plane
is nearly parallel to the Frankfurter horizontal plane Ill. 75: This picture documents muscular, free head balance.
and serves as intermediate support for the anterior,
muscular supporting apparatus.
The goal of evolution, the creation of a maneuver- The goal of evolution, the creation of a
able, standing, walking and running being, is being maneuverable, standing, walking and run-
regressed and perverted by the functional "degen- ning being, is being regressed and perverted
eration" to modern human beings in the western
by the functional "degeneration" to modern
world, who are predominantly static "sitters".
human beings in the western world, who are
This development contributes to the fact that epi-
demiological studies have shown damage to the predominantly static "sitters".
postural apparatuses of ten-year-old schoolchildren
in nearly 100% of the cases.
The cervical muscles, the suprahyoidal muscles, the Tilscher, H.: Das Bewegungssegment der Wirbelsäule im
true mastication muscles and also the mimic mus- Blickpunkt der orthopädischen Rückenschule. Medizinisch-litera-
cles are involved in the posture of the head, associ- rische Verlagsgesellschaft, Uelzen 1993

265
R. Slavicek • The Masticatory Organ
CMD
Craniomandibular Disorder
Defects in the position of the mandible
could, therefore, be partly responsible for
problems in the postural apparatus.
... defective mandibular positions and the
resulting problems in the CMS are not a part
of the primary therapeutic field of the phys-
iotherapist, but rather that of the examining
dentist.
266
ations with the pathophysiology of these muscle
groups are of prime importance. The decisive factor
is whether static or dynamic mandibular defects,
caused by occlusion and programmed in the NMS,
are capable of influencing these postural functions.
My previously stated opinion applies here as well: a
slowly maturing dysgnathia, during growth, finds
ample time to adapt, first functionally, then mor-
phologically. In other words, a naturally developed
moderate-grade dysgnathia is perfectly capable of
developing into normal function. Even higher-
grade dysgnathias have the chance of remaining
within the limits of normal function, through
growth-related development. The extent of the
individual's adaptability, the adaptive capacity and
the ability to compensate, can only be estimated;
they cannot be accurately predicted.
Craniomandibular Disorder (CMD) patients un-
doubtedly may have postural problems as well.
Therefore, all that remains to be determined is the
extent to which the masticatory organ may be
involved as a cause of these problems.
The greater the influence of occlusion on the posi-
tioning musculature of the mandible and the more
this "defective position" is not a naturally developed
one, the more carefully does the dentist have to
consider the area of occlusion and its involvement
in causality when dealing with the subject of differ-
ential diagnosis.
The occlusion dominates the position of the
mandible, relative to the cranium, by its develop-
mental grooves. Therefore, its influence on the com-
plete dorsal and ventral musculature is also evident.
Defects in the position of the mandible could,
therefore, be partly responsible for problems in the
postural apparatus, but primary problems in the
postural apparatus might also influence the posi-
tion of the mandible. The use of the subjunctive
here only means that the possibility exists in both
directions, within this scheme of thought.
Therefore, the following may be stated without
reservations: defective mandibular positions and
the resulting problems in the CMS are not a part of
the primary therapeutic field of the physiotherapist,
but rather that of the examining dentist. In such
cases, correction of the occlusion may, by all means,
be the focus for treatment of the functional disor-
der. Solid diagnostics and optimal teamwork with
the physiotherapist if necessary, in cases of multi-
causal origin, are prerequisites for successful thera-
 Function - Posture

py. Success would also be ensured by a long-term

common liaison with the casualty- and/or outpa-
tient ward, and with the departments for physical
medicine and the dental clinic. The positive experi-
ence of both therapy groups has been proven suc-
cessful in progressive dental practices. The interdis-
ciplinary dialogue and the resulting therapeutic The associations between breathing, body
cooperation have had extraordinarily fruitful effects posture and the masticatory organ have long
for both disciplines. been recognized and addressed in the litera-
The associations between breathing, body posture ture.
and the masticatory organ have long been recog-
nized and addressed in the literature.

Body posture of healthy humans

In studying the healthy body posture of a subject,
certain laws relating to upright posture become evi-
dent.

The lateral view

The large joints of humans, which connect the
body to the extremities, lie on a common "fall line".
This fall line, in an upright human, passes through
the atlanto-occipital joint, the thoracic girdle at the
shoulder joint and the pelvic girdle at the hip joint,
and leads approximately into the ankle joint before
the sole of the foot.
It is conspicuous that a similar vertical connection
exists between the temporo-mandibular joints, the
hyoids and the sterno-clavicular joints. These two Ill. 76: The fall line of a human standing upright connect
vertical lines are parallel to each other, and perpen- the head joints, shoulder joints, hip joints and ankle joints.
dicular to the base when the subject is standing in Also, the temporo-mandibular joints, the hyoid and the
a relaxed upright position. sterno-clavicular joint lie on one vertical line, paralleling
the other line.

Anterior view
From the anterior view we see that the inter-
pupillary plane, the plane of the thoracic girdle and
the intermediate line of the iliac crest are all paral-
lel. In this anterior view, it is also evident that the
right-dominance of the cranium apparently conti-
nues into the right dominance of that half of the
body, and the middle of the pubis appears to be
shifted to the right.
Linder-Aronson, S., Behfelt, K., Neander, P.: Posture of the
Head, the Hyoid Bone and the Tongue in Children with and
without Enlarged Tonsils. Eur. J. Orthod. Mov., 12 (4):
458–67, 1990
Hellsing, E., Forsberg, C. M., Linder-Aronson, S.,
Sheikholeslam, A.: Changes in Postural EMG Activity in the
Neck and Masticatory Muscles Following Obstruction of the
Nasal Airways. Eur. J. Orthod. Nov., 8 (4): 247–53, 1986
Forsberg, C. M., Hellsing, E., Linder-Aronson, S.,
Sheikholeslam, A.: EMG Activity in Neck and Masticatory
Muscles in Relation to Extension and Flexion of the Head.
Eur. J. Orthod. Aug., 7 (3): 177–84, 1985

267
R. Slavicek • The Masticatory Organ
Ill. 77: The inter-pupillary plane is parallel to the support-
ing surface..
Ill. 78: The vertical lines pass through the coccyx perpen-
dicular to the supporting plane.
268
Posterior view
From the posterior view, the fall line can be fol-
lowed through the atlanto-occipital region, the
thoracic girdle and the pelvic girdle, directly into
the coccyx.
When the subject assumes a muscularly active toe-
stand, we observe an immediate, considerable pos-
tural change. This causes a significantly stronger
muscular lordosis of the spine and a shift of the fall
line to the toe region, resulting in non-parallelism
of the fall lines, in the muscularly balanced situa-
tion.
If the heels are supported by a step, the result is also
a change in posture. The whole body falls some-
what backwards and relaxes the previously tensed
spine. This situation is present when a person wears
high-heeled shoes. This kind of shift is especially
conspicuous when only one side is supported by a
step, i.e., asymmetrically. After a relatively short
period of relaxation, compensation for the resulting
oblique position of the pelvis is initiated by means
of eye control (seeking the horizon), through a
reduction in the slope, increasing cranially to the
thoracic girdle, leading to a nearly complete change
in the head area, relative to the horizon. This kind
of postural change has a powerful effect on the
entire spine, because of a unilateral increase in ten-
sion in the regions of the spinal oblique processes
and the autochtonal musculature.
This experiment offers food for thought. It shows
the overall compensatory behavior of posture in
adjusting the head to correspond to the horizon. Of
course, from the opposite viewpoint, a dissymmetry
in the level of the eyes must also be viewed as a
causal factor.
Of course, tension in the lower regions supporting
the body results in a strong compensatory influence
on the whole spine, especially on the cervical spine,
and also in the anterior region of the musculature
supporting the head.
Defective posture from one's profession will be dis-
cussed in detail, from the viewpoint of pathofunc-
tion and dysfunction, in the section dealing with
the clinical functional analysis. However, from a
cybernetic point of view, this clearly shows the sig-
nificance of the environment for bodily functions.
Roccabado considers it important to describe the
"normal" position of the large joints to the skeleton,
on one hand, and the position of the hyoid to the
cranium on the other. He also assigns significance
 Function - Posture

to the quantity of lordosis in the cervical spine. He

sees a functional association between the cervical
spine and the hyoid and postulates, structurally, the
so-called alpha ligament, which increases lordosis in
the cervical spine in the instance of a defective posi-
tion of the hyoid. This especially applies to a large
loss of strong vertical through insufficiency of the
supportive zone in occlusion.
Roccabado's rules were previously reflected in
Albrecht Dürer's theory of proportion. Thus, the
fall lines of the large joints and the rules supposed-
ly discovered by us are, in reality, re-discoveries.
Especially noteworthy in Dürer's rules of posture is
his incredible observation abilities, which enabled
him to reproduce and show the differences in phe-
notypes.
Ill. 79: In a toe-stand, the slope of the line changes to
tensed balance.

Summary
The phylogenesis of the postural apparatus is cha-
racterized by the dramatic change to a true "biped".
It is reproduced during the ontogenetic process of
standing upright after the first post-natal year. This
changes the complete postural apparatus and re-
forms the spine. According to the well-founded
viewpoint of several authors, the cervical spine is
especially important in that it assumes the role of
an "additional sensory organ". Because of signifi-
cant changes in the pattern of human behavior in
industrial societies, the complete postural appara-
tus is not used according to its original concept.
Ill. 80: The total posture tips dorsally when supported.
The resulting postural problems, which arise in
adolescents, are exacerbated by increasing prob-
lems in the respiratory passages, and have an effect
on head posture.
Because of the complexity of dysfunctions caused
by posture, a distinct separation of causality may
prove difficult or even impossible. Dramatic
changes in the cranial base and especially on the
temporal bone during the ontogenetic process of
standing upright will be discussed in a separate sec-
tion.
The eyes are a significant factor regarding head pos-
ture. It is necessary to reassess the polar dominance
of the "receiving system" of the eyes and ears from
the viewpoint of system prophylaxis. From this

269
R. Slavicek • The Masticatory Organ

point of view, reassessing the seating positions in

the classroom would also help to avoid postural
problems. Defective posture caused by one's profes-
sion may also be related to the same principles of
cause.
We should also give attention to the association
between the psyche and body posture. Psyche and
body posture are inseparably connected, as evi-
denced by "body language". Psychic problems,
especially anxiety, also influence body posture while
sleeping. This is one of the frequent causes of func-
tional disorders of the masticatory organ.
Interdisciplinary cooperation, taking body posture
into account, is a conditio sine qua non in the diag-
nosis of structural relationship problems, along
with abnormal functions of the masticatory organ.
Ill. 81: The effect of high heels; the entire body posture is
shifted dorsally.

Ill. 82: The compensation for an induced change in the

length of the leg by lengthening it, in order to maintain a
horizontal inter-pupillary plane.

270
 Function - Esthetics

"Esthetics"- human
appearance as a function

When elaborating on the concept of esthetics in a Esthetics

book about dentistry, we notice that the subject is
dominated by "esthetic dentistry" because of
recent developments. The term is used ostenta-
tiously to describe a specific field of reconstructive
and prosthetic dentistry, with the goal of improv- Self-perception
ing the appearance of teeth. It culminates in the
slogan "smile", which the proponents of this
branch of dentistry vehemently preach.
The concept of "esthetics" is often applied as a sy-
nonym for cosmetics in the dentist's jargon, where-
by a perfect harmony of form and color of the den-
tition should be achieved, i.e., the artificial denti-
tion should be as natural as possible and, generally,
should also look young.
However, the esthetics of the human face or of the However, the esthetics of the human face or
individual goes far beyond that which we have pre- of the individual goes far beyond that which
viously mentioned and defined regarding the regu- we have previously mentioned and defined
lar, everyday activities of the dentist and the patient.
regarding the regular, everyday activities of
This chapter is concerned with the "function" of the dentist and the patient.
esthetics, and also with the concept of how a
human conceives one's self in the context of the
esthetic significance of the masticatory organ for The "face" is that which is seen; it is "per-
the human face. The "face" is that which is seen; it ceived" by those around us. The German
is "perceived" by those around us. The German word for "face" is "Gesicht", which also
word for "face" is "Gesicht", which also means "the
means "the seen".
seen". This perception also applies to the individ-
ual, who perceives him/herself and integrates this
perception into his/her "self-awareness".

271
R. Slavicek • The Masticatory Organ
This "self-perception" is largely subjective and,
therefore, greatly influenced by psyche.
... that a lack of esthetics, which the patient
is conscious of, or which has been sup-
pressed from consciousness, is a functional
disorder in the narrow sense of the term.
Subjective esthetics is strongly dependent on
the emotional state of the individual.
Objective esthetics can be manipulated.
272
This "self-perception" is largely subjective and,
therefore, greatly influenced by psyche. The
masticatory organ and its dentition are consider-
ably involved in self-perception, because of their
esthetic function for the face. One of the most sig-
nificant functions of the masticatory organ, from
this viewpoint, is its role in the overall esthetics of
the individual human. Therefore, it must be
emphasized here that a lack of esthetics, which the
patient is conscious of, or which has been sup-
pressed from consciousness, is a functional disor-
der in the narrow sense of the term. Here, the
teeth and their appearance may very well be sig-
nificantly involved in the functional disorder.
Objective and subjective esthetics
The original translation of "esthetics" from Greek
involves the concept of conscious perception in its
core meaning. The task now is to further break
down the meaning of esthetics and distinguish
conceptually esthetics in the context of being both
objective and subjective.
So-called objective esthetics is concerned with the
perception and esthetic experience of an object;
subjective esthetics also includes the level of
esthetic behavior and the experiential psychic
process. This refers to how we perceive ourselves,
our fellow beings, our surroundings and their inter-
relationships with the environment as a whole.
We "experience" esthetics. The experiencing of
esthetic perception is a dynamic process that
influences psychic well-being, while simul-
taneously being partly determined by it. As any
experience is an individual experience, subjective
esthetics is always an individual experience.
Subjective esthetics is strongly dependent on the
emotional state of the individual; one sometimes
sees the world through "rose-colored" glasses,
sometimes through clouds of sadness.
Objective esthetics can be manipulated, as it is
characterized by comparison.
Every epoch is characterized by new esthetic
"models". The current communicative society
proves this with its high "turnover" in characteri-
zation and definition, not only of the human face,
but also of the body as a whole, through the com-
 Function - Esthetics

municative explosion of mass media and its influ- ... the communicative explosion of mass
ence on taste. media and its influence on taste.
To repeat, objective esthetics can be manipulated.
It is characterized by ideals and is therefore not at
all objective. The borderline of cosmetics is a fluid
one, and this is widely taken advantage of com-
mercially.
A significant problem of the increasing manipula-
tion is the fusion of the concept of "beauty" with The fusion of the concept of "beauty" with
youth, leading to the unfortunate inclusion of the youth.
fear of aging and death in the self-perception of
several individuals.
In former times, the human face and its esthetics
were not determined by the teeth as they are
today. Currently, the masticatory organ with its
teeth are considerably more in the center of a per-
son’s representation, being distinguished by the
notably altered modern habit of "willingly show-
ing one's teeth". Of course, the overall bodily
image is also important, but the personality is dis-
tinguished and represented by the face and the
teeth, consciously or unconsciously. The commu-
nicative smile expresses the individual's readiness
to establish contact. A smile can also signify A smile can also signify strength, self-confi-
strength, self-confidence and aggression (bare dence and aggression (bare your teeth to the
your teeth to the world). world).

A distinct shift in the pictorial representation of

male and female faces has come about through the
increasing self-confidence of women. Men are lo- Men are losing their "bite" while women are
sing their "bite" while women are baring (their baring (their teeth) more than ever before.
teeth) more than ever before. This pun can be
observed in the behavior of models.
The psychic connotation of esthetics is especially
evidenced by emotional expression. The face
reflects human emotions in non-verbal communi-
cation. The psyche (soul) of the individual can be
inferred through the face.

273
R. Slavicek • The Masticatory Organ

A discussion of esthetics must incorporate a few

other concepts as well:
Harmony

Symmetry
Proportion
Symetry as "the very image".
This is an unacceptable fabrication. It is
both unsuitable and false in regard to the
human face and, of course, the body as a
whole.
Harmony - Symmetry - Proportion
One attempt to give meaning to the esthetics of
the face is the introduction of the concept of har-
mony. Harmony is superior to the two above men-
tioned criteria, namely symmetry and proportion.
However, the traditional interpretation of esthe-
tics is to regard and postulate symmetry as "the
very image".
Interestingly, this also applies to the diagnostic
evaluation of the masticatory organ, the assump-
tion of congruence of the right and left sides,
viewed from the so-called mid-sagittal plane.
Although anatomical planes of the human body
are useful in communicative everyday speech,
they are hardly suitable for diagnostic procedures
relating to symmetry or proportion, because of
the absence of exact classification criteria.
Nevertheless, the symmetry of the face has been
regarded as the descriptive classification in the
basic esthetic principle of evaluation. This is an
unacceptable fabrication. It is both unsuitable and
false in regard to the human face and, of course,
the body as a whole.
In diagnosis, descriptions of the function of
esthetics must always be concerned with the total
concept of harmony. Of prime importance here is
the fact that harmony cannot be inferred solely
from the soma.
The polar opposites of harmony, symmetry and
proportion are disharmony, asymmetry and dis-
proportion.
For an extremely dynamic principle such as that
represented by the masticatory organ, harmony as
a function must be taken into account, in addition
to the descriptive, structurally related principle of
esthetic classification and harmony.
Therefore, first of all, structural symmetry and
functional symmetry are to be strictly separated
from each other, as the two concepts are only indi-
rectly related. However, in the final diagnosis of
an asymmetry, it will be necessary to include both

274
 Function - Esthetics

concepts. In diagnostics, it is even essential to

correlate both factors because, frequently, an
interplay of compensation mechanisms occurs.
Recognizing the latter is the main responsibility of
the dentist when treating so-called asymmetric
dysgnathias. The goal of therapy should always be
the restoration of harmony.
A further, especially important aspect of the
observation of esthetic function concerns the con-
cept of the "functional matrix", a concept that
postulates and recognizes the complete dynamics
of the face in its functions as a factor that deter-
mines form.
Special significance is accorded to the neuromus-
cular system in the observation of disharmony in
the masticatory organ. Cause and effect can be Ill. 83: Actual picture of a face
isolated here, but may also play an important role
in unison. Comparative muscle analysis, including
the assessment of incongruent sides and function-
al asymmetry, as postulated and demonstrated in
my clinical functional analysis, is essential for an
evaluation of the functional harmony of the mas-
ticatory organ.
If we look for harmony and esthetics in the face of
a patient experiencing chronic pain, we see that
the face is generally characterized and marked by
pain; the concept of harmony is definitely inap-
plicable to such patients.

Ill. 84:Photomontage of the right half of the face

Cephalometrics and esthetics with the right half of the face.

The lateral head radiograph is one available

method that allows the dentist to approach the
concept of proportion using concrete, technical
measurements. It permits representation of the
bony bases of the skull as well as the soft tissue
contours of the face. This makes it possible to
make an esthetic classification, in addition to the
skeletal and dental evaluation.
The frontal X-ray is useful in the diagnosis of sym-
metry. In frontal X-rays, right-left asymmetries
are especially assessable, as are dissymmetries.
Esthetics and the psyche are intimately connected
with each other. Therefore, an esthetic problem
frequently is the cause of a decline in the patient's
well-being. Human beings suffer, in this case, in
Ill. 85: Photomontage of the left half of the face with
the left half of the face.

275
R. Slavicek • The Masticatory Organ

their consciousness or suppressed self-perception.

This may be an indication for therapy.
However, the examiner should never make a sen-
sitive, non-self-conscious patient aware of an esthe-
tic deficiency, which may only be significant from
the dentist's viewpoint.

General theories of proportion in

human esthetics

Ill. 86: The real face

Since the human spirit is always seeking to uncover
the principles of order of Nature and arrange
them into regular patterns, a quest was made for
esthetic regularities in the human face.
With admirable scientific meticulousness, the
great artists dedicated themselves to researching
the variety of human appearances and classifying
the same into regularities of the theory of propor-
tion. This search for rules distinguishes the artists
throughout history as true scientists, leading
them beyond the field of the fine arts.
This is evidenced in the creation of the concept of
morphology by Goethe and Burdach. According
to the commonly applied definition, morphology
is the study or science of the shapes, forms and
organizational principles of living things, as well
Ill. 87, 88: The same photomontages (right half with
as of historical, social, verbal or esthetic pheno-
right half, left half with left half).
mena and artifacts.
K. F. Burdach introduced this concept in 1800,
and it was expanded by Goethe. Morphology is
concerned with dynamic, holistic forms and also
other structures and concepts. Goethe condensed
the frustrating search, his experiences and the
results of his theory of shapes, and his search for
form in a four-liner:

All shapes are similar,

But none are exactly the same
And so the chorus points to
A secret law, an eternal puzzle

Nevertheless, or perhaps for this reason, the

search for uniform rules in the concept of esthe-

276
 Function - Esthetics

tics is an ongoing concern. I quote here many of

my own thoughts which I recorded in my scienti-
fic quest for logic and uniformity, after realizing
my own limits:

"The laying down of rules and the codification of laws

corresponds to the desire of the human spirit for invari-
ables. Once these have been drawn up and are available,
the same human spirit seeks to escape from this self-cre-
ated cage. If one invariable can be eliminated by evidence
of variables, the result is a renewed attempt to establish
uniform rules for these variables."

One of the possibilities for researching the esthe-

tics of the human face in the arts was the applica-
tion of symmetry. Ill. 89: Actual picture of a face.
Symmetry is used to denote "regular proportions",
the fusion of two concepts, resulting in a sense of
congruence.
If we attempted to evaluate the complete mor-
phology of the human face with the concept of
symmetry, it would immediately lead, according
to our scientific experience, to argumentation ad
absurdum.
We know that we are asymmetrical. With regard
to the human cranium and the face, the function
of speech and the concomitant polar development
of two halves of the brain resulted in asymmetri-
cal development of the face as well as the skeleton.
In contrast, it is conspicuous that, in the theories
of proportion of the great artists who systemati-
cally researched and measured the human face Ill. 90: Photomontage: right half with the right half.
(e.g., Leonardo da Vinci, Albrecht Dürer), the
constant striving for symmetry is seen in their sci-
entific representations. However, if we look at
Dürer's self-portrait, we see how accurately he was
aware of and painted his own asymmetry.
Perhaps this striving and desire for esthetic sym-
metry originated in the conscious or instinctive
idea that this "image" should be a representation
of divine unity.
Human beings, on account of their polarity, sim-
ply are not the "image" of God (or perhaps pre-
cisely for this reason?).

Knowledge of asymmetry and correct estimation

of its consequences are important for the dentist,
from the viewpoint of functional theory and func-
tional diagnostics. Ill. 91: Photomontage: left half with the left half.

277
R. Slavicek • The Masticatory Organ
Knowledge of asymmetry and correct esti-
mation of its consequences are important for
the dentist from the viewpoint of functional
theory and functional diagnostics.
For patients who are mentally ill, the den-
tist's refusal to deal with the main concern
("I feel different, I look different.") is, in the
words of purists, tantamount to malpractice.
Exaggerated expectations should be strictly
avoided in the treatment of esthetic prob-
lems.
Problems related to esthetics are often close-
ly associated with the undesirable problems
of aging.
278
Very often, esthetic problems are of greatest sig-
nificance in the pathogenesis of dysfunctional
patients, although they do not communicate this
immediately and are sometimes not even aware of
it, or need not be aware of it. Here also, it is a
multi-causal accumulation of latent disorders,
which are triggered at a given time by a change in
the appearance of the face and cause the patient to
seek the dentist. For the patient, his/her altered
appearance is the real problem that needs to be
handled.
The actual causality may be an extraordinarily
complex one, related to the entire body. The func-
tional disorder is possibly not necessarily, or defi-
nitely not, related to occlusion, but may neverthe-
less be related to the teeth.
For patients who are mentally ill, the dentist's
refusal to deal with the main concern ("I feel dif-
ferent, I look different.") is, in the words of
purists, tantamount to malpractice. This is also
the general opinion of those involved in the
Liaison Program at the University of Vienna.
Self-perception can also be the repressed main
cause of a psychic feeling of uneasiness, which the
dysfunctional patient need not be conscious of at
all. In the course of careful psychic handling,
disturbing esthetics (disturbing for the patient)
may eventually be discovered as the prime cause
of the condition.
However, perhaps above all for this reason, exag-
gerated expectations should be strictly avoided in
the treatment of esthetic problems, in order to
prevent the kind of "crashes" and disappointments
that drive a patient from one dentist to the next.
It is exactly the patients' expectations, oriented
towards an "ideal image", that require careful han-
dling by the dentist. It must be reemphasized here
that distorted esthetics of the dentition indicates
an actual functional disorder of the masticatory
organ, with strong psychic involvement.
Problems related to esthetics are often closely
associated with the undesirable problems of
aging. One of the important tasks of the respon-
sible dentist is to prove to the patient that esthe-
tics is not the prerogative of young (people's) faces.
Unfortunately, old age and ugliness have been por-
trayed as equals in plastic arts. This misuse has left
a strong impression on the human esthetic experi-
ence and has deepened the fear of aging and death.
 Function - Esthetics

Here we see one of the important responsibilities Unfortunately, old age and ugliness have
of the dentist, namely to deal helpfully and care- been portrayed as equals in plastic arts. This
fully with the problem of aging and the esthetics misuse has left a strong impression on the
of the human face. It is important to make the human esthetic experience and has deepened
patient realize that age and beauty are not con- the fear of aging and death.
tradictory phenomena.
Sadly, plastic arts have contributed to turning the
opposites of youth and age into antagonistic
antitheses. Klimt's painting, The Three Women,
makes this especially evident. The harmony and
esthetics of the human face must be regarded
objectively in terms of age and gender, but the
reality of the contemporary media landscape and
advertising falsifies this basic principle, leading to
the delusion that harmony is a synonym of youth-
ful appearance. Even advertisements addressing
elderly individuals present the delusion of a wrin-
kle-free face of eternal youth. This trend is liable
to cause grave problems in self-esteem, frequently
exacerbated by forced retirement from active life.
The concept of symmetry is only partly suitable
for being used as a general classification system.
In reality, there exists the individual, asymmetri-
cal beauty of the human face, independent of age.
Dental esthetics is characterized by the applica- Canon
tion of subtle irregularities. The more successful
these are, the closer the dentist approaches nature
and the more artistic is his/her work.
Polycleitus of Argos, a Greek sculptor living in the Polycleitus of Argos, a Greek sculptor living
fifth century B.C., created a fundamental work for in the fifth century B.C., created a funda-
all later theories of proportion in his "Canon". He mental work for all later theories of propor-
termed the canon of beauty the "Golden Section" tion in his "Canon".
(section aurea), an esthetic rule of proportion
based on constant division, thereby "constructing"
human beauty according to mathematical rules.
In the general language of the arts, "canon" signi- „Golden Section“(sectio aurea)
fies rules that apply to a particular field of exper-
tise. In the fine arts, for which this is primarily re-
levant, the rules of esthetics for the representation
of the human body are based on Polycleitus' theo-
ry of proportions.
The human face explodes all of the standards of
proportional theory with its diversity. Albrecht
Dürer acknowledges this in his "esthetic excursus"
at the end of the third book of his study of pro-
portion:

279
R. Slavicek • The Masticatory Organ

"Aber das Leben in der Natur gibt zu erkennen die

Wahrheit dieser Ding. Darum sieh’ sie fleißig an, richt’
dich darnach und geh’ nit von der Natur in dein
Gutgedunken, denn du wirdest verführt. Denn wahrhaftig
steckt die Kunst in der Natur; wer sie heraus kann reißen,
der hat sie. Überkummst du sie, so wirdet sie dir viel Fehls
nehmen in deinem Werk. Und durch die Geometria magst
du deines Werks viel beweisen. Was wir aber nit beweisen
künnen, das müssen wir bei guter Meinung der Menschen
Urteil bleiben lassen. Doch thut die Erfahrung viel in diesen
Dingen. Aber je genauer dein Werk dem Leben gemäß ist
in seiner Gestalt, je besser dein Werk erscheint. Und dies
ist wahr. Darum nimm dir nimmermehr für, daß du etwas
besser mügest oder woellest machen dann es Gott seiner
erschaffnen Natur zu würken Kraft geben hat. Dann dein
Vermügen ist kraftlos gegen Gottes Geschöpf."

"..but life in Nature indicates the truth of this (thing).

Therefore, look at her studiously and follow her example
and do not stray from Nature at your own discretion, for
you will be led astray. For, truly, art is contained in
Nature; he who can extract it, possesses it. If you can
overcome her, she will be established solidly in your work.
And through geometry you may prove much with your
work, but what we can't prove, we must leave to the
judgment of mankind, with good intentions. Experience
can do much in these matters. But the more your work
corresponds to Life in its design, the better your work
will appear. This is the truth. Therefore, never again
assume that you could or would want to make something
better than God gave his creation Nature the power to
effect. For your abilities are powerless against God's cre-
ations."

280

Clenching and bruxism are undesirable for
the dental practitioner and appear to endan-
ger the system.
Slavicek, R.: Gedanken zu den sogenannten Parafunktionen.
Inform. aus Orthod. und Kieferorthop. Jg. 28, Nr. 1, 1996
Function - Stress Management
The function of
stress management
The physiology and pathophysiology of stress
management by means of the masticatory organ
are defined and evaluated in extraordinarily differ-
ent ways in scientific discussions.
Stress management through the masticatory
organ evokes in the dentist a picture of abraded
teeth, split facets, periodontal wear (and tear) and
broken roots. As an introduction, I include here,
almost unchanged, my article "Thoughts about
the so-called 'Parafunction'".
Clenching and bruxism are undesirable for the
dental practitioner and appear to endanger the
system. Therefore, clenching and bruxism are a
perennial subject of interest in interdisciplinary
dialogues regarding cause and prevention and also
a subject of ongoing study.
In the search for causes, the pros and cons of the
significance of occlusion for parafunction is a long-
standing issue in so-called scientific discussion,
often turning emotional and lacking in objectivi-
ty. Of course, there cannot and should not be
(excessive) objectivity in scientific discussion,
because the only possibility for scientific progress
lies in continuous, usually controversial theoreti-
cal discussions. Ninety per cent of todays accep-
ted knowledge will have been proven outdated or
even false by the end of the next decade. In other
words, the postulation of hypotheses and
attempts to disprove their validity are the only
ways to increase our knowledge.
281
R. Slavicek • The Masticatory Organ
Even the above-stated is a hypothesis, invi-
ting argument.
I accept clenching and bruxism as normal
and significant functions of the human mas-
ticatory organ.
For the "individual" human being, the envi-
ronment must be regarded as his/her indivi-
dual reality.
Contact with the environment is established
and maintained by means of the masticatory
organ.
The psyche becomes a "garbage dump" of
unresolved problems.
For this reason, environmental factors are of
immense importance in the evaluation of the
causality of a functional disorder in the mas-
ticatory organ.
282
Even the above-stated is a hypothesis, inviting
argument. It applies to the significance of the
human masticatory organ in stress management
or, to put it more clearly, I accept clenching and
bruxism as normal and significant functions of the
human masticatory organ. This is more applicable
than ever before to the current state of man and
the extreme flood of information that will mark
the media age in the future.
It is necessary to reconsider the interrelationships
from the viewpoint of the masticatory organ as a
"feedback-control mechanism". The feedback-con-
trol mechanism of an organism, and this also
applies to human beings, makes use of its organs
indiscriminately for the purpose of living and sur-
viving.
For the "individual" human being, the environ-
ment must be regarded as his/her individual real-
ity. The "perception", "processing" and "adminis-
tration" of the individual environment involves a
process of permanent psychic confrontation with
arising problems. Contact with the environment is
established and maintained by means of the mas-
ticatory organ. For this reason, the masticatory
organ and its functions are of focal importance in
the feedback-control mechanism known as "the
human being". Human beings express themselves
through this organ, that is, it serves as an outlet
for their emotions.
The functions of the masticatory organ are both
somatically and mentally closely associated with
brain function. Owing to the position of the indi-
vidual as a single being in a social, general public,
it may be impossible, in some cases, to find imme-
diate solutions to problems. The psyche becomes
a "garbage dump" of unresolved problems. In
many cases, the result is not a late and conscious
resolution of an identified and processed problem,
but rather its deposition in the subconscious. The
now subconscious processes are of great signifi-
cance in the emergence of psychic stress in mod-
ern human beings. For this reason, environmental
factors are of immense importance in the evalua-
tion of the causality of a functional disorder in the
masticatory organ, because the organ functions as
a tool for relieving the psyche.
It must be mentioned, however, that problems in
the environment should in no way be regarded as
"present" ones, but may extend well into the past
of an individual's reality. If one considers the abi-
 Function - Stress Management

lity of building up a "memory" as formulated by

Eccles in his hypothesis of micro-localization, sub-
conscious and preconscious reactions may be
explained by such a process, based on natural sci-
ence. The German word for memory, "Erinnerung",
suggests the path of impressions inwards ("inter-
nalization"), only to be pushed out at a later point
in time, i.e., "expressed". In Eccles' hypothesis
mentioned above, this does not take place relative
to problem-specific memory alone; other similar
or unspecified triggers may also release the reac-
tion in the imprinted psychon. Therefore, psychic Therefore, psychic impressions can trigger
impressions can trigger conscious, subconscious or conscious, subconscious or "preconscious"
"preconscious" reactions, and the mouth becomes reactions.
the stage for psychic drama through the "expres-
sions" of clenching and bruxism.

The examination of patients at the University

Clinic in Vienna revealed definite associations
between the structure of an individual's persona-
lity and the tendency to chronic clenching and
bruxism. After a general health test and a tho-
rough clinical examination of all these patients, the
existence of a health disorder, in terms of a CMD,
could be seen objectively. The personality struc- Psychon
ture of patients was significantly different from
that of random test samples with regard to gene- Dendron
ral aggressive behavior. The latter was distinctly
less marked with regard to both, spontaneous and
reactive aggressive behavior, in comparison with a
comparable population structure.
In a doctoral thesis on the subject of psychology
by Ms. Karin Kail, approximately 100 patients
were randomly selected from patients in the
department known as Functional Disorders of the
Masticatory Organ and from those from my own
practice, all displaying signs of dental parafunc-
tion, including clenching and bruxism. Special
significance was accorded to the psychic profiles of
the group in comparison with a random test
sample of corresponding age and gender.
All patients underwent the same procedure of
examination. First of all, a general test of the
patients' health according to von Zsersen was car-
ried out. The results showed significant diffe- Eccles, J. C.: Die Evolution des Gehirns – die Erschaffung des
rences in comparison with the control group and Selbst. In: Eccles, J. C.: Die Mikrolokalisationshypothese.
Verlag Piper, New York, Heidelberg, Berlin 1989
their state of health, i.e., the patients' sense of Kail, K.: Behandlungserfolge bei Kiefergelenkbeschwerden in
well-being was lower than that in the general Abhängigkeit von organischen und psychischen Faktoren.
population. Afterwards, the patients underwent a Dissertation, Grund- und Integrativwissenschaftliche
screening according to the Freiburger Personality Fakultät der Universität Wien 1986

283
R. Slavicek • The Masticatory Organ
The author concluded that the paucity of
aggressive behavior may be one reason for
the parafunctional use of the masticatory
organ as a means of working off stress.
Baring the teeth as a sign of strength, threat,
or even insecurity or fear is a focal theme
pervading the entire evolution of mammals.
We find extensive eccentric nocturnal brux-
ism, as a rule, in children of pre-school age.
284
Inventory before therapeutic measures were
undertaken. A manual evaluation was carried out
according to the protocols. The results were sur-
prisingly straightforward, mainly showing a dis-
tinct difference in values for spontaneous and
reactive aggression in comparison with the control
group. Both spontaneous and reactive aggression
were distinctly lower. The author concluded that
the paucity of aggressive behavior may be one rea-
son for the parafunctional use of the masticatory
organ as a means of working off stress.
According to this theory, patients with chronic
clenching and bruxism use their masticatory
organ as a psychic stress valve. These patients
apparently had problems in using conscious
(cognitive) solutions to deal with psychic stress.
The resulting delayed emotional clog is deposited
at the somatic organic level. The atavistic stage
for psychic emotions is the masticatory organ.
Baring the teeth as a sign of strength, threat, or
even insecurity or fear is a focal theme pervading
the entire evolution of mammals, but is especially
seen in primates. These forms of expression deal
with immediate reactions to events related to the
environment. However, in humans, the "para-
functional" use of the masticatory organ for emo-
tional management takes place in a delayed fash-
ion and subconsciously.
The results of this study, in addition to the clinical
behavior of a large number of such patients, justi-
fy my conclusion that, in such cases, clenching
and bruxism can be assigned to the normal func-
tions of the masticatory organ. Proportional dif-
ferences in the effectiveness of the limbic system,
forced integration in social areas which constricts
the individual's personality, the necessity of indi-
vidual classification of good and evil and the
structures of the hierarchical system - all create
problems that need to be resolved. For this reason,
a large number of persons in the general popula-
tion are prone to occasional or permanent clench-
ing and bruxism. In these cases, the masticatory
organ is used as a tool to work off stress and not,
as commonly postulated, misused.
This behavior is especially common in children
and adolescents. We find extensive eccentric noc-
turnal bruxism, as a rule, in children of pre-school
age, during the functional period of deciduous
dentition. For a growing child, the early years are
the most intensive learning period of his/her life.
 Function - Stress Management

This not only applies to the accumulation of

knowledge and experience, in themselves massive
imprinting processes on the borderline of mind
and spirit but, above all, to the individual's com-
pelled subjugation to existing social (familial),
ethical, religious and hierarchical systems.
The period of mature deciduous dentition is the
longest and most efficient learning, educational
and training period in one's entire life. It is, there-
fore, also the period involving the most powerful
psychic inhibitions and stress. In this age group,
bruxism is a normal function for relieving the
psyche. The resulting abrasion of the normally
flat, deciduous dentition favors the required pro-
trusive arrangement and development of the
mandible.
For this reason, in my opinion, the absence of
bruxism in the growing child is more a ground for
worry than a conspicuous presence of the same.
Concerned parents should be reassured and
should only consult a child psychiatrist or psy-
chologist in the event of additional serious symp-
toms.
Adolescents and young adults have more than Adolescents and young adults have more
enough reasons for emotionality, and powerful than enough reasons for emotionality.
psychic stresses emerge as a result thereof. During
this period of "Sturm and Drang/ Storm and
Stress", the masticatory organ may be viewed as
an appropriate biological system for mental
unloading, both in the phase of changing denti-
tion and in that of mature dentition. However,
the system should be carefully examined by the
dentist with regard to its capability. It is definite-
ly a more suitable way of relieving the psyche than
the possibility offered in the limbic system, name-
ly that of resorting to drugs.
The phenotype of the occlusion of Homo sapiens
sapiens has changed distinctly in the industrial
age because of the absence of food-related abra-
sion of the dentition. The teeth maintain their
cusp morphology and thereby present consider-
ably more complex structures for the dynamics of
the masticatory organ, especially in cases of a
strong, tooth-guided parafunction.
In adults, aggression is a lifelong behavior pat- In adults, aggression is a lifelong behavior
tern, in the light of the inherent professional and pattern, in the light of the inherent profes-
social stresses of the environment. Stress is a part sional and social stresses of the environment.
of life and must be accepted as such. Direct pro-
cessing of stress is hampered by social rites and

285
R. Slavicek • The Masticatory Organ
The prime cause is, of course, the problema-
tic psychic processing by the individual
patient.
However, on principle I strictly reject the
idea of prohibiting the application of occlu-
sion for the purpose of stress management.
McNeill, C.: Craniomandibular Disorders. Guidelines for
Evolution, Diagnosis and Management. Quintessenz Chicago,
1990
Pullinger, A. G., Seligmann, D. A.: The Role of Functional
Occlusal Relationships in Temporomandibular Disorders: A
Review. Journal Craniomandibular Disorders Facial Oral
Pain 5: 265–279, 1991
De Laat, A., van Steenberghe, D.: Occlusal Relationships and
Temporomandibular Joint Dysfunction. Part I Epidemiologic
Findings. J. Prosthet. Dent. 54/6: 835:842, 1985.
De Laat, A., van Steenberghe, D., Lesaffre, E.: Occlusal
Relationships and Temporomandibular Joint Dysfunction. Part
II. Correlations between Occlusal and Articular Parameters and
Symptoms of TMJ Dysfunctions by Means of Stepwise Logistic
Regression. J. Prosthet. Dent. 55/1:116-121, 1986.
286
structural legalities, and is occasionally impossi-
ble. Situations involving conflict are unavoidable
and, to a certain extent, unresolvable.
Through the development of "self-awareness" dur-
ing hominization, a polarity and imbalance
emerge in the previously approximately balanced,
primate limbic system. This leads to the discovery
of moral concepts, such as the ability to distin-
guish between "good" and "evil", or the relin-
quishing of life-sustaining egoism in favor of
species-sustaining altruism, and to the formula-
tion of ethical rules. Although ethical rules are
recognized and accepted by most individuals, they
are frequently broken in daily life. The conflict sit-
uation may be transferred to all areas of daily life;
it arises constantly and calls for continuous han-
dling.
Occlusion is postulated in the causality of func-
tional disorders of clenching and bruxism.
Occlusion is definitely not the triggering factor -
this has been proven in a large number of studies.
The prime cause is, of course, the problematic
psychic processing by the individual patient.
We can predict, however, that detailed examina-
tions of the patterns that occur will uncover dif-
ferences, and that the "tool" of occlusion may be
more or less suitable for carrying out "the para-
function" as a life-sustaining ventilating function,
under certain conditions. The state of current lit-
erature clearly shows that the applied methods of
instrumental evaluation of the causality of
occlusal-articular factors for CMD have been
found to be unsuitable in scientific follow-up
studies. The applied methods of instrumentation
are characterized by a lack of precision and a
paucity of detailed information concerning
dynamics. Parafunctional patterns must be regis-
tered in their dynamic processes, individually for
the temporo-mandibular joints, if they are to be
evaluated for pathogenesis (not causality). It
would then be possible to carry out examinations
on an individually adjusted articulator, relative to
the border track.
However, on principle, I strictly reject the idea of
prohibiting the application of occlusion for the
purpose of stress management. This would be just
as reprehensible as forbidding an individual to
speak, when he/she wants to express a problem
verbally. As most of these patients suffer from an
 Function - Stress Management

inhibition of spontaneous, reactive aggression, it This would be just as reprehensible as for-

would be counterproductive, from our viewpoint bidding an individual to speak, when he/she
of teamwork with psychiatrists and psychologists, wants to express a problem verbally.
to calm the patients by means of medication or
behavioral therapy. Then, non-cognitively accu-
mulated stress would no longer be processed
through the masticatory organ and we would Conversion symptoms
have to worry about conversion symptoms.
Mental care, the recognition of stress-creating
factors and conscious management of stress
during targeted activity of the masticatory organ,
are definitely promising methods. In addition, one Conversion
should strive towards the optimization of occlu-
sion and articulation by means of the elimination
of dominant posterior guidance, such as through
active hyper-balancing. Making the occlusion and
articulation suitable for stress (management) is
the job of the dentist, based on his/her concept of
occlusion. The "tool", the masticatory organ, must The "tool", the masticatory organ, must be
be suitable for stress management. suitable for stress management.

Summarizing the preceding discussion, parafunc-

tions such as clenching and bruxism can be traced
to primary psychic causes. Psychic therapy must
be mainly concerned with the causes of stress and
not with its effects on the masticatory organ. The
responsibility of the dentist is to maintain the
suitability of the masticatory organ for psychic
stress management. Clenching and bruxism can,
therefore, be regarded as normal functions of the
masticatory organ for the expression of psychic
overload. It is, so to speak, practically the right of
the individual, to "clench his/her teeth" in times of
psychic stress.
Weakly aggressive or inhibited individuals have Weakly aggressive or inhibited individuals
more difficulty in dealing with problems arising have more difficulty in dealing with prob-
from stress. For such personalities, clenching and lems arising from stress.
bruxism offer a means of subconsciously working
off psychic stress organically. The masticatory
organ is utilized in this way, as a somatic stress
valve.
However, if one of the responsibilities of the organ
is stress relief, and if it is to undertake the organ-
ic function of "stress management", it must be
examined with regard to its suitability for the job.
This is primarily the responsibility of the dentist
examining the patient. The human masticatory
organ has undergone a drastic change during the
last century. In the present industrial age, entirely

287
R. Slavicek • The Masticatory Organ
Precipitated by a remarkable glut of infor-
mation, psychic stress is on the increase in
the Age of Media.
The German word for "legal incapacitation"
("Entmündigung") could also be translated as
"depriving one of his mouth".
The role of the masticatory organ as "an
emergency exit" and a stress valve must be
recognized and understood.
Ringel, E., Földy, R.: Machen uns die Medien krank?
Universitas Verlag, 1992
288
new phenotypes of the organ as well as human
beings have appeared. Because of remarkable
alterations in eating habits, abrasion related to
nutrition has become a thing of the past. The
attrition facets in modern humans are predomi-
nantly of parafunctional origin. The developmen-
tal grooves of the dentition are retained, and
determine the dynamics of mandibular move-
ment. The alterations necessitated a change in
functional processes, and these, in turn, led to
entirely new stress principles for the structures of
the masticatory organ, guided by the teeth's glid-
ing surface system. The extreme increase in
longevity, which is by no means fully developed,
means that the structures are subjected to stresses
for a considerably longer period of time, leading
to the emergence of new age groups that react dif-
ferently to their individual environments.
Precipitated by a remarkable glut of information,
psychic stress is on the increase in the Age of
Media. The media pre-process events, evaluate
them and determine their significance, thus
restricting and frequently even removing the indi-
vidual's prerogative of independently evaluating
and analyzing events with regard to their signifi-
cance. Because of the increasing manipulation, the
cognitive and therefore relieving physiological
selection mechanism in the psyche is waning. The
ability to instinctively "switch off" is less common
than it used to be. The term "legal incapacitation"
points to the significance of such deprivation of
the right to make independent decisions.
However, there are several simultaneous and
cumulative effects at work here: the masticatory
organ has become more complex, life expectancy
has increased, the environment has become more
intense and the distance between accepted ethical
principles and reality has increased to an incredi-
ble extent.
The role of the masticatory organ as "an emer-
gency exit" and a stress valve must be recognized
and understood. It is the role and responsibility of
modern dentistry to analyze this organ with
regard to whether it can assume this important
"defensive job". Disputing the significance of
occlusion, in times like these, is an act of negli-
gence and irresponsibility.
Parafunctions serve in physical and spiritual stress
management, in addition to being effective as
psychic stress valves. Georges Graber published a
 Function - Stress Management

study of CMD patients, a large number of whom

were suffering from permanent stress and had
occlusal interferences. Only a few of the CMD
patients had actual primary joint problems. A
notably high percentage (7%) was primarily
mentally ill. Georges Graber emphatically points
out the fact that such stress management in
patients with cranio-mandibular dysfunction due
to occlusion is of great significance (this is from a
personal communication and a dialogue with
Graber).
Occlusion-related stress management is by no Occlusion-related stress management is by
means limited to dentulous individuals. Wearers no means limited to dentulous individuals.
of full dentures are also frequently affected by Wearers of full dentures are also frequently
parafunctional activity as a result of stress (com- affected by parafunctional activity as a result
municated to me by Gausch).
of stress.
This inspired Gausch to introduce a canine-con-
trolled concept for these patients. Psychic stress
can, therefore, be regulated through the mastica-
tory organ and this has resulted in the emergence
of a multitude of theoretical schemes and flow-
charts (ill. 92 and 93, p. 290).
The organ must prove its ability to execute its
defensive responsibility and this is the purpose of
so-called occlusion concepts, which serve in the
diagnostic registration of unsuitable systems and,
if necessary, in modifying them. This leads to the
conclusion that, in most cases, it is psychic stress
that causes a parafunction.
At the same time, I would like to most strongly At the same time, I would like to most
emphasize the fact that a therapeutic approach strongly emphasize the fact that a therapeu-
directed by purists at the psyche, merely on tic approach directed by purists at the psy-
grounds of psychic causality, is false. It is illusory che, merely on grounds of psychic causality,
to believe that it would be possible to successfully
is false.
relieve humanity from its extreme environmental
stresses by means of purely mental approaches Even in the case of a balanced psyche, mod-
and therapy. Even in the case of a balanced psy- ern humanity needs the masticatory organ to
che, modern humanity needs the masticatory "bare its teeth".
organ to "bare its teeth" to the environment.
Naturally, it would also be completely false to
naively regard occlusion and articulation as the Graber, G.: Neurologische und psychosomatische Aspekte der
only causes of the parafunction. Myoarthropathien des Kauorgans. Zahnärztl. Welt/Reform 21,
80, 1971
The reactive mechanism in the primary emer- Graber, G.: Psychomotorik und fronto-lateraler Bruxismus –
gence of problems in occlusion is an entirely dif- Myofunktionelle Aspekte der Therapie. Dtsch. zahnärztl. Z. 35,
ferent one, and must be briefly explained. 592, 1980
Graber, G., Vogt, H. P., Müller, W., Bahous, J.:
When a change in occlusion occurs, the neuro-
Weichteilrheumatismus und Myoarthropathien des Kiefer- und
muscular system reacts directly. An initial reduc- Gesichtsbereichs. Schweiz. Mschr. Zahnheilk. 90, 609, 1980
tion in activity is followed by hyperactivity, which Graber, G.: Psychosomatische Faktoren bei Kiefergelenks-
may cause temporary problems in the muscula- erkrankungen. Schweiz. Mschr. Zahnheilk. 93, 880, 1983

289
R. Slavicek • The Masticatory Organ

Ill. 92: One of the significant innate qualities of organisms is their ability to adapt. Under nor-
mal conditions, adaptation takes place as in the flowchart shown above. In cases of very long
duration, the last step, habituation, can lead to (further) habituation under similar conditions.

Ill. 93: Adaptation can also take place in a "pathological" form, in which no adaptation occurs.
Rather, there is no response to emerging stress factors.

290
 Function - Stress Management

ture (ill. 94-95, p. 292).

Afterwards, adaptive mechanisms start to occur
and may lead to a modification of the habitual
bite into a new, secondary physiological bite (ill.
96-97, p. 296).
All structures of the masticatory organ may be
involved in this adaptive mechanism. The degree
of adaptive capacity is individually variable and
cannot be estimated. This process neither triggers
nor causes the function of stress management.
The results of such rearrangement in occlusion
may also be called functional disorders. The con- Adaption = Adaptation
cept of a functional disorder is generally viewed in
a very narrow sense. The fact that stress manage- Compensation
ment through clenching and bruxism is only one
of the organ's functions tends to be ignored in the
search for causality of dysfunctions in the mastica- Decompensation
tory organ. Disorders within the other functions
and their significance for the functional state are
discussed less frequently.

Functional patterns in clenching and

bruxism
In principle, the manner in which the course of
this parafunctional event is manifested in the mas-
ticatory organ needs to be highlighted. It is
important here that, in contrast to other func-
tions, the adductors on both sides of this system
are active to a great degree. The activities of the
masseter muscle and the medial pterygoid muscle
are in the foreground. Simultaneously, the pro-
tractors and retractors are active asymmetrically,
regardless of whether the parafunctional type is
large or small in terms of surface area. Clenching
and bruxism are only distinguished by the extent
of the dynamic stroke, because clenching is also
bruxism, although involving a smaller surface area.
The floor of the mouth and, above all, the tongue,
are highly active here. The normally asynchronous
activity of the superior and inferior heads of the
lateral pterygoid muscle becomes synchronic
through the permanent activity of the adductors.
The direction of the movement follows specific,
individual, parafunctional patterns. In eccentric
bruxism, the movement is frequently latero-pro-

291
R. Slavicek • The Masticatory Organ

Ill. 94: Under a physiological reaction, psychic stress can lead to the use of the masticatory
organ in a defense against stress, which causes a load on the muscles of mastication.

Ill. 95: In cases of insufficient stress management, the masticatory organ serves as the subcon-
scious stage for possible management of the overload, but the cognitive approach to problem-
solving is entirely absent.

292
 Function - Stress Management

trusive. However, remarkable retrusive patterns

may also occur. In cases of nocturnal parafunction,
while dreaming, the sleeping position is generally In cases of nocturnal parafunction, while
lying on one's side or stomach (the supine posi- dreaming, the sleeping position is generally
tion). This is also a sign of psychic stress and con- lying on one's side or stomach (the supine
striction (anxiety). Instead of relaxing deep sleep position).
in a supine position, a phase of tense and active
dynamics occurs. Unfavorable reinforcing effects
take place in the system, with the support of the
face and the mandible.
However, the subconscious tendency of many
patients towards parafunction during the day
should not be neglected. Dentists themselves pro-
vide good examples of job-related parafunction at
their workplace.
Clenching and bruxism take place on structures
under great loads, making the behavior of joints
especially interesting. Sagittal and transversal
condylar movements will be discussed in greater
detail in the chapter entitled Instrumental
Analysis, as these are subjects of relentless and
controversial discussions.
In connection with clenching movements, the so-
called "Bennett movement" is a highly debated In connection with clenching movements, the
subject. The movement is entirely different for the so-called "Bennett movement" is a highly
functions of mastication and speaking, therefore debated subject.
they must be evaluated differently. My own stud-
ies of axis-oriented electronic joint track record-
ings of clenching movements have conclusively
shown that, very frequently, no or minimal
Bennett movements take place. In contrast, during
mastication, observations from recordings have
shown that there is free play in the joint, with a
larger amount of Bennett movement that is gene-
rally dependent on the type and consistency of food.

It must be emphasized that problems in psychic

management are the prime causes of the types of
parafunction we have mentioned. Alterations to
the occlusion and its articulation can, at most,
induce temporary muscular hyperactivities, which
must be regarded as part of an adaptive mecha-
nism. Naturally, it is not possible to predict
whether the adaptation will lead to a satisfactory
buildup of a secondary physiological, habitual
It is extremely dangerous to demonize the
occlusion and articulation. To deduce from this a
somatic cause for the parafunction would definite- parafunction and desire to eliminate it,
ly be wrong, but it would be equally incorrect to without the actual creation of a cognitive
regard all forms of bruxism as damaging. It is approach to the central problem.

293
R. Slavicek • The Masticatory Organ
Bonwill postulated the application of the
term "articulation" instead of "occlusion".
Dentures were required to maintain their
ability to function during mastication, by
means of stabilizing contacts.
The phenotype "human being" changed
because of the modification in nutrition.
294
extremely dangerous to demonize the parafunc-
tion and desire to eliminate it, without the actual
creation of a cognitive approach to the central
problem.
The role of so-called concepts of
occlusion in parafunction
The birth of modern dentistry in the last century
made it absolutely necessary to search for classifi-
cation systems within the various disciplines.
Naturally, the principles also applied to concepts
of occlusion, which soon became a subject of
priority in many fields. Predictive thinkers such as
Bonwill warned their readers long ago against
regarding occlusion as a static phenomenon, and
they demanded that dynamic function be includ-
ed in the subject matter. Bonwill postulated the
application of the term "articulation" instead of
"occlusion".
One field, prosthodontics, especially requires the
conception of a dynamic principle of intercuspa-
tion. The discovery of vulcanization by Kautschuk
and the development of artificial teeth made of
porcelain paved the way for the general applica-
tion of dental prosthetic devices. Complete den-
tures were required to maintain their ability to
function during mastication, by means of stabiliz-
ing contacts. This led to the logical development
of a full-balance occlusal concept. This was all the
more necessary, as the population at the time had
mainly food-related abrasion in the dentition,
which afforded unilateral or bilateral gliding guid-
ance. Ingenious tooth forms were created in order
to make such theories applicable. However, deci-
sive changes emerged as the century passed.
A part of the world's population mutated into the
age of industrial development. As mentioned pre-
viously, this effected a dramatic change in the job
profile of the masticatory organ. The phenotype
"human being" changed because of the modifica-
tion in nutrition. Life expectancy rose and is still
increasing. In conjunction with the dramatic
explosion of the global population and the resul-
ting evolutionary and revolutionary changes in
structure, the pressure towards social integration
 Function - Stress Management

into new systems also has been steadily increasing.

However, this in turn, led to further mental
constraints on the individual.
The balanced concept of occlusion played a do-
minant role in almost all disciplines of dentistry,
until late into the first third of the 20th century.
Orthodontics must be cited here as an exception:
Angle, a major figure, attempted to classify the Angle, a major figure, attempted to classify
intercuspation principles of youthful, "non-abra- the intercuspation principles of youthful,
ded" dentition didactically, and left his mark on "non-abraded" dentition didactically.
the study of this subject through the formulation
of an ideal dentition.
At this time, and late into the first third of the
century, all other disciplines were, conceptually,
predominantly proponents of natural abrasion of
the dentition. This is documented by major fi-
gures and progressive thinkers of this century, for
example, in "Biomechanik der Parodontose"
(Thielemann). For Thielemann, at the time, the
natural dominance of the canine was a thorn in
the side. Later, he admitted his mistake.
The American schools also followed the principle of
balance in the reconstruction of natural dentition.
The leading figure there was McCollum, flanked by
his circle of associates. It was the unsatisfactory The leading figure there was McCollum.
prosthetic reconstructive results, despite immense
costs, which gave the impetus for new guidelines
for the balanced occlusion concept.
This was followed by the emergence of divergent
concepts of occlusion, which allowed, to an This was followed by the emergence of diver-
increasing extent, for the fact that the natural gent concepts of occlusion.
teeth of this century retained their morphology.
Concepts in dental medicine regarding the
dynamic management of the function of occlusion
or, more exactly, articulation, have been grouped
together as so-called concepts of occlusion. The
clarification of these concepts can only be attained
by establishing and defining their principles. For
this reason, defined concepts will be presented
later and examined with regard to their defensive
ability in stress management.

295
R. Slavicek • The Masticatory Organ
Ill. 96: A document from the origin of the cusp-facet theory
and of the anatoform tooth from Gysi. The engraving of
articulator-guided tracks in gypsum blocks creates a develop-
mental groove.
Ill. 97: Derived from the above, "tooth forms" based on
movement patterns of the artificial joints of a programmed
articulator.
Ill. 98: Gysi's sketches of artificial dental arches.
296
Concepts of Occlusion
The concept of balanced occlusion
The dentition intercuspates in a normal bite and
all eccentric movements should be buttressed by
the teeth on all sides, over a large surface. This
means that the dentition displays even, dynamic
close contact during the function. Mandibular
movement and the dentition harmonize optimal-
ly. Observation of previous, food-induced abrasion
of the dentition may have contributed to the
development of this concept.
While implementing this concept, it was soon
realized that the patients' movement patterns
were in no way uniform, but extraordinarily indi-
vidualized. This led to the construction of instru-
ments that could appropriately simulate the func-
tional movements. Two paths were chosen for this
purpose: the joint-related method led to the con-
struction of so-called articulators, and the masti-
cation-track method, which utilized information
from the dentition for implementing the concept.
Both methods are still in use today, one hundred
years later.
From the joint-related viewpoint, it was Gysi who
used joint movement for the creation of artificial
tooth forms. His "cusp-facet theory" led to the
production of an artificial tooth, which was suit-
able, in principle, for a balanced occlusion in a
complete denture (ill. 96-98, left; ill. 99-100, p.
297). In the non-abraded dentition of the recent
phenotype, the balanced concept is hardly realiz-
able. The defensive ability is therefore not given.
Even in an ideal situation, problem zones in gui-
dance arise in the even buttressing of gliding
movements, because of deformation of the
mandible. The large number of possible guidance
contacts is an additional reason for the NMS to be
inclined towards hyperactivity. When the out-
come is ideal, however, masticatory efficiency by
way of preparing food for further processing is
best provided for in the balanced concept.
Periodontal stress on a dentulous person, the loads
on the toothless ridge of the edentulous, are great-
est in this concept (ill. 101-103, p. 297).
 Function - Stress Management

Ill. 99: Preliminary study of an "Anatoform tooth", which cre- Ill. 100: Preliminary study of an "Anatoform tooth".
atively inspired this century.

Ill. 101: The scheme of balanced occlusion in asymmetrical Ill. 102: In the protrusive movement pattern, the entire
movement shows the simultaneous guidance on the laterotru- anterior group guides in the classical concept, with participa-
sion side and the diagonal buttressing on the mediotrusion tion of the premolars and front teeth in simultaneous but-
side. tressing in the molar area.

Ill. 103: Gerber varies the concept and removes the front
from involvement.

297
R. Slavicek • The Masticatory Organ
Ill. 104: In laterotrusion, the canines guide simultaneously
and evenly.
Ill. 105: The protrusion movement is controlled through the
front teeth and premolars.
Ill. 106: In laterotrusion, the canine guides dominantly, it
"disoccludes" all other teeth.
Ill. 107: In protrusion, the lower "8" teeth guide against the
upper "6".
298
The concept of the group function on the
laterotrusion side
The teeth intercuspate in Class I, the canine guides
in laterotrusive movement, along with the premo-
lars and the mesio-buccal cusp of the 1st molar; the
teeth of the mediotrusion side disocclude. In pro-
trusion, the maxillary anterior arch guides, includ-
ing the premolars; the lateral segments disocclude.
Notable proponents of this occlusion principle also
postulated a certain (minimal) amount of freedom
in the occluded position (freedom in centric). In the
heat of emotional discussions, the fact that the
"battlefield" of controversy is no more than approx-
imately 0.5 square millimeters in size tends to go
by unnoticed (ill. 104 and 105, left).
Smaller restorations in the group function concept
are produced with the aid of FGP (function gener-
ated path) technology. Exact application of this
technology produces a balanced principle on the
occlusal surfaces.
The concept of canine guided occlusion
The teeth intercuspate in Class I, only the canine on
the laterotrusive side guides in laterotrusive move-
ment. All other teeth disocclude. In protrusion, the
upper front teeth from canine to canine form an
arch that guides against the lower anterior eight
teeth of the front arch, which includes the lower
first premolar.
All posterior teeth disocclude.
Both the dominant canine concept and the group
functional concepts were postulated and defended
with dogmatic arguments, without taking racial or
skeletal differences into account (ill. 106 and 107,
left).
The sequential concept of occlusion
Through critical examination of the morphology of
the teeth in permanent dentitions, the observation
of ontogenetic development of dentition in humans
and the registration of the gliding dynamics of
parafunctional processes, it can be proven that
dogmatic constriction of the concepts of occlusion
given above is impractical.
 Function - Stress Management

Although occlusion concepts are artificial classifica-

tion systems with therapeutic goals, they should be
adapted as much as possible to natural occluso-
articular processes. The skeletal relations of the jaw
of the human masticatory organ cause the dentition
to behave differently in static and, more impor-
tantly, also in dynamic situations. Without the
influence of therapeutic intervention, these pheno-
types of natural dentition differ in terms of their
arrangement and are also dependent on principles
of skeletal relationships. If we follow the morpho-
logical sequence of tooth forms, it appears that all
of the possibilities of dynamic articulation are open ... all of the possibilities of dynamic articula-
for the current phenotype of modern humans. The tion are open for the current phenotype of
principles of articulation remain the same; the modern humans.
spatial relation and different sphericity determine
the dynamics. This is the reason for postulating an
occlusion concept today, which offers, in contrast to
the dogma of the past, the physiological and tole-
rant possibility of being suited to the individual
skeletal relationship and functional principles of
individual human beings.
The canine assumes a certain special status here.
The primate's symbolic weapon has become a func-
tional tooth, which, however, does not contradict
its emotionally charged nature. In humans, it is in
the focus of psychic activity and bequeaths the dis-
charging of aggression. It should, therefore, be clas-
sified conceptually as the dominant tooth in stress
management.

Summary

In a discussion concluding the meaningfulness and

indications of so-called occlusion concepts, the
most important goal should be that of being the
most optimally suited concept for all functions of
the masticatory organ. It should be reemphasized
here that these therapeutic classification systems
concern the dentist's point of view. The functions of
the masticatory organ are diverse and fundamen-
tally different in terms of their effects on the denti-
tion. The explanations of parafunctions are con-
cerned with viewing and tolerating the masticatory
organ as a psychic stress valve. It is the responsibi-
lity of dental disciplines to design the dentition in
such a way that it is suitable for the job. In the exe-
cution of a parafunctional pattern, the load on the The organ should be suitable for this vital
structures is high, sometimes extreme. The organ defensive responsibility.

299
R. Slavicek Das Kauorgan
Ill. 108: In laterotrusion, the lateral teeth lead in a reducing
fashion from posterior to anterior and end in dominant dis-
occlusion by the canine.
Older people, in advancing stages of disinte-
gration, tend to use their teeth to "work off
the frustration" of their defenselessness.
In other words, a naturally developed dysg-
nathia of moderate degree is absolutely capa-
ble of developing into eufunction.
300
should be suitable for this vital defensive responsi-
bility. This purpose is served by the discussed con-
cepts (ill. 108, left).
No phase of life is free of parafunctional activity. As
explained in detail previously, the extreme learning
period of the first post-natal years imposes
powerful psychic demands on the child. Almost
routinely, children of this age are strong "grinders".
This can be regarded as normal stress management,
so that the absence of this "parafunction" should
be considered unusual. Therefore, the tendency
towards using the masticatory organ as an
"emergency exit" is, more or less, a congenial
phenomenon.
Because of the extensive retention of developmen-
tal grooves in adults, the functional program has
become infinitely more complex than in the food-
induced abrasion of the dentition of the past which,
in its convergence, corresponds to the mastication
pattern of the herbivore, i.e., unilaterally or bilate-
rally balanced articulation.
Humans are constantly subjected to stress factors in
daily life; the impossibility of immediate processing
is a legitimate reason for utilizing the masticatory
organ to alleviate stress.
Older people, in advancing stages of disintegration,
tend to use their teeth to "work off the frustration" of
their defenselessness. Their approaching end poses
an unfathomable and therefore suppressed problem,
which inevitably ends in the "fear" of death. This is
the price for the attainment of such self-awareness.
Malocclusions
An apparently increasing problem is the presence of
so-called malocclusions and dysgnathias. My firm
belief and hypothesis regarding these may be stated
thus: a dysgnathia that slowly matures during the
growth process will find enough time to adapt, first
functionally, then morphologically. In other words, a
naturally developed dysgnathia of moderate degree
is absolutely capable of developing into eufunction.
Even high-grade dysgnathias definitely have the
chance of remaining within the limits of normal
function, through compensation during develop-
ment, depending on the conditions of growth.
The extent of the ability to adapt, the adaptive
capacity and the capability of compensation of the
individual can be estimated, but cannot be accu-
 Function - Stress Management

rately predicted. This individuality also makes it

difficult to estimate the value of epidemiological
data. Introducing the limits of adaptive abilities Introducing the limits of adaptive abilities
into collective data fails because of the current (and, into collective data fails because of the current
in my opinion, future) limited possibilities of objec- (and, in my opinion, future) limited possibili-
tifying these data. ties of objectifying these data.
Without doubt however, the defensive capabilities
of malocclusion and dysgnathia for processing psy-
chic stress through the masticatory organ are
considerably worse than those for an organ with
normal structures.

Summary and final observations

Dental medicine is currently a predominantly inva-
sive and curative field of medicine. In therapeutic
operations, the system is subjected to great pres-
sure, as an existing, functional balance is confront-
ed with structural changes. Invasive correction
through orthodontic intervention in occlusion and
articulation sets a chain reaction of adaptive
processes into motion. For this reason, such opera-
tions and modifications should always be carried
out in accordance with a concept. One of the most
important goals should be concerned with defen-
sive abilities in parafunction. I repeat myself inten-
tionally here, in order to emphasize the significance
of what I consider an essential function of the mas-
ticatory organ.
Making the occlusion and articulation suitable for
parafunction is the concern and duty of all dentists
including orthodontists.
These specialists must be keenly aware of the fact
that their work on adolescent and adult patients
signifies intervention into an extremely complica-
ted feedback-control mechanism. Any operation
and any modification of the masticatory organ
must serve to improve or at least maintain the
required functions. If stress management is placed
at the center of these functions, it should be regard-
ed as the main responsibility of the tool, namely the
masticatory organ. The "tool-smith", the dentist or
orthodontist, must design the organ in such a way
that it is suitable for its defensive role in this func-
tion. It is therefore absolutely essential to establish
clear, dynamic concepts of occlusion and articula-
tion before treatment. The concepts should be
checked upon after completion of the treatment.

301
R. Slavicek • The Masticatory Organ
The masticatory organ then becomes the
somatic "stage" for psychic illness.
... that refusing to treat the masticatory
organ in such patients amounts to mal-
practice.
This opinion is shared by other psychiatric
schools.
Stress, in the sense of eustress, is a vital
necessity, even a prerequisite for living.
Stress always creates aggression during the
phase of its management.
302
The CMD Patient with primary
psychic illness
In Georges Graber's study, those CMD patients
who have statistically documented and proven psy-
chic illness present with specific problems. Patients
of this kind are exceptionally difficult to differenti-
ate, diagnostically, from other CMD patients. They
generally have a strong tendency towards organic
manifestation of disease in the masticatory organ.
The masticatory organ then becomes the somatic
"stage" for psychic illness.
In Vienna, the patients undergo diagnostic investi-
gation and therapy under the auspices of a "liaison
department" (headed by Walter, Piehslinger). This
liaison department believes that, from a psychic
viewpoint, refusing to treat the patient's main con-
cern, namely the masticatory organ, as promulga-
ted by the purists, can be unbearable for the
patient. The prevalent opinion of the Vienna School
of Psychiatry, Psychology and Dental Medicine in
this regard is that refusing to treat the masticatory
organ in such patients amounts to malpractice.
According to the Vienna liaison department, in
cases of patients for whom an occlusal correction is
strongly contraindicated, parallel psychiatric and
dental therapy may be applied and is occasionally
even desirable and indicated. This opinion is shared
by other psychiatric schools (personal communica-
tion with Rüther, Göttingen).
The psyche, the masticatory organ and
environmental factors
Changes in our environment are causing extrane-
ous stresses to increase enormously. This applies to
both the somatic and psychic levels. Life consists of
the constant, inescapable challenge of coming to
terms with external and internal problems.
However, "coming to terms" implies the resolution
of problems. Stress, in the sense of eustress, is a vital
necessity, even a prerequisite for living. Stress
always creates aggression during the phase of its
management. After the resolution of a problem, a
gratifying increase in self-esteem sets in. The nega-
tive connotation of the word "aggression" is partly
to blame for the modification in the aggressive
behavior of some patients. They tend to feel guilty
about having to deal with their cognitively percei-
vable aggression.
 Function - Stress Management

As previously stated, primates are definitely not The behavior of primates is evaluated by the
predatory meat-eaters from the viewpoint of their author as a shift from killing to murder.
phylogenesis. However, chimpanzees, the most
intelligent of the primates, are optional hunters and
killers. They kill unprofessionally and do not
spare members of the same or similar species. In
behavioral research it is pointed out that this kind
of killing, in contrast to that of true predators,
is strongly emotional. This strictly distinguishes
such killing from that of meat-eating predaceous
animals.
This emotionally weighted area of highly developed
primates that concerns the management and
expression of aggression is of great significance for
the evaluation of human behavior, with regard to
aggression. Upbringing, social behavior, ethical
rules, religious commandments and hierarchical
demands make the management and expression of
necessary emotionality increasingly difficult. The
human limbic system has lost much of its effective-
ness because of the necessity of survival for the
species. This loss of effectiveness results in insolv-
able conflicts. This is especially elucidated by the This is especially elucidated by the moral
moral constraint, "thou shalt not kill". Here, the constraint, "thou shalt not kill".
clear ethical rule is immediately undermined by
intellectual exceptions. You may kill, if your coun-
try (pack) goes to war against another country. This
exception to the rule is then modified: if the war is
lost, then usually "uae victis" applies. Horrifying Humanity is being manipulatively misused
present-day examples veil such concepts in aloof and psychically over-stressed.
terms such as "ethnic cleansing".
Many conflict situations may be cited as extreme
examples of killing. Current mass media overloads
the psyche with acts of extreme aggression. This Recent psycho-physiological stress studies on
further significant factor of psychic stress results in rats prove the connections between working
a persistent overload of stimuli and a glut of infor- off stress and the masticatory organ.
mation. Humanity is being manipulatively misused
and psychically over-stressed. The consumer society
lives from the arousal and maintenance of perma-
nent craving and creates stress situations in the Vogel, Ch.: Vom Töten zum Mord. Carl Hanser Verlag,
individual, which can be resolved in the rarest of München, Wien 1989
Guile, M. N., Mc Cutcheon, N. B.: Prepared Responses and
cases. The significance of the limbic system with Gastic Lesions in Rats. Physiological Psychology, Vol. 8 (4),
regard to psychic stresses is seen in the individual's 480-482, 1980
escape through the "emergency exit" of drug con- Glavin, G. B., Tanaka, M., Tsuda, A., Kohno, Y., Hoaki, Y.,
sumption. Nagasaki, N.: Regional Rat Brain Noradrenaline Turnover in
One solution to these problems lies in the recogni- Response to Restraint Stress. Pharmacology, Biochemistry &
Behavior, Vol. 19, pp 287-290, 1983
tion of causes. This is made difficult or impossible Glavin, G. B., Vincent, G. P., Paré, W. P., Prenatt, J. E. D.:
by the complexity of causality. A capable mastica- Aggression, Body Temperature and Stress Ulcer. Pharmacology,
tory organ is qualified to serve as a temporary stage Biochemistry & Behavior, Vol. 32, pp 265-268, 1984
for processing. Weinberg, J., Erskine, M., Levine, S.: Shock-Induced Fighting
Attentuates the Effects of Prior Shock Experience in Rats.
Physiology & Behavior, Vol. 25, pp 9-16, 1979

303
 Chapter 4

Diagnostics

Functional diagnostics seems to be a stan-

dard requirement in modern dentistry, but
is by no means routinely applied. Although
the masticatory organ is an extremely
complex system of structural and functio-
nal connections, diagnostics is frequently
neglected when dealing with its manifold
disorders, while invasive therapy in the
organ is carried out without being based
on solid diagnostic foundations. One rea-
son for this is probably the fact that there
is no unified scientific opinion regarding
diagnostic methods. The diversity of opini-
on causes practicing dentists to feel uncer-
tain and even to be frightened away from
utilizing systematic functional diagnostics in
their daily practice.
Without a diagnosis, any invasive therapy is
hazardous. Searching for the causality of
functional disorders requires systematic
methods that can be adapted to the
demands of the individual. The decision
for therapy must be based on the founda-
tion formed by a diagnosis.
R. Slavicek • The Masticatory Organ
Functional Diagnostics
In Europe, the traditional Swiss school of
thought with its last proponent, Albert
Gerber, was especially concerned with joint
diagnostics, and a rather intuitive therapeu-
tic system based on it.
306
Clinical functional
diagnostics
The following chapter is concerned with "clinical
functional diagnostics". In a brief and therefore
non-comprehensive outline, we will describe the
developments in functional diagnostics during the
second half of this century. A list of the various con-
troversies will enhance the reader's appreciation
and understanding of the most recent develop-
ments.
The general trend in the complex known as "dys-
functions of the masticatory organ" was initially
characterized by the dentist's interest and was
therefore primarily related to occlusion. At the end
of a period of development that lasted for several
decades, the pendulum swung to other areas not
dominated by dentistry.
In recent decades, dentistry itself has been imprint-
ed by the term "functional diagnostics", which has
been interpreted in various ways, each according to
the particular school of thought.
In Europe, the traditional Swiss school of thought
with its last proponent, Albert Gerber, was espe-
cially concerned with joint diagnostics, and a rather
intuitive therapeutic system based on it. Gerber
was seasoned and experienced in complete denture
prosthetics, and his main interest was the edentu-
lous patient. This was also traditional, dating back
to Gysi. Gerber's functional diagnostics mainly
consisted of a systematic, clinical system-evaluation
 Diagnostics - clinical functional diagnostics

with subsequent instrumentation, utilizing an The second "European school" of functional

articulator of his own design. diagnostics emerged around Willi Krogh-
His diagnostic foundation was acquired with a sim- Poulsen.
ple registration, carried out with a facebow fixed to
the lower jaw (which can be traced back to Gysi)
and an intra-oral "central supporting pin" as the Arne G. Lauritzen, a Dane who emigrated to
registrant. He created his own concept of occlusion America, was a pioneer of instrumental func-
and his own tooth contours, and placed the tional diagnostics and a great teacher of pre-
mandibular joint in the center of his observations.
cision and control.
He postulated dynamic occlusal contacts as but-
tresses on the mediotrusion side, so-called
"orthobalances", for joint protection.
The second "European school" of functional diag-
nostics emerged around Willi Krogh-Poulsen. He
was a master at compiling clinical findings, a great
proponent of discussion and contact with patients,
and was also one of the most conclusive systema-
tists of muscle palpation. Only in cases of profound
doubt did he make an instrumental analysis, in
classic Scandinavian style, in the "blue Hanau", i.e.,
the Dentatus articulator. In collaboration with his
assistants he published his guidelines and notions in
two volumes.
Because of its fascinating methodology and partly
because of its enchanting dogmatism, the
American Gnathological School gained widespread
acceptance in Europe. Arne G. Lauritzen, a Dane
who emigrated to America, was a pioneer of instru-
Ill. 1: The system of interdependence of the three basic
mental functional diagnostics and a great teacher of
structures postulated by Stallard was the foundation of the
precision and control. He also was a complete den- gnathological conception of "organic occlusion". He intro-
ture prosthetist of the European school, although duced a theoretical scheme, which considered the masticato-
he was later influenced by the progressive dynam- ry organ as a functional unit.
ics of the McCollum group.
His occlusion concept in complete denture pros-
thetics was the classical one of balanced occlusion. Gerber, A.: Kiefergelenk und Zahnokklusion. Dtsch.
In natural dentition he exclusively advocated the Zahnärztliche Zschr., 26: 119–141, 1971
gnathological concept of front canine guidance, Palla, S.: Neue Erkenntnisse und Methoden in der Diagnostik
der Funktionsstörungen des Kausystems. Schweizer Mschr.
whereby the joint was in the retral border position. Zahnmedizin., 96: 1329–1351, 1986
In the American Gnathological School, the main Krogh-Poulsen, W.: Die Bewegungsanalyse. Dtsch. Zahnärztl.
emphasis of functional diagnostics shifted more and Zschr., 21: 877–880, 1966
more to instrumentation. Charles Stuart and subse- Krogh-Poulsen, W.: Die Bedeutung der Okklusion für die
Funktion und Dysfunktion des Kiefers. In: Das Kiefergelenk,
quently P .K. Thomas, resolutely placed the arti-
Diagnostik und Therapie. Edit.: Solberg, W., Clarc, G.,
culator in the center of diagnostics. Quintessenz Verlag, Berlin 1983
However, we should not forget that, at this time, Krogh-Poulsen, W.: Die klinische Untersuchung und
the "gnathological school", led by the theorist Befundaufnahme am Kiefergelenkpatienten durch den Zahnarzt.
Stallard, brought the concept of "organic thought" Okklusion und Kiefergelenk. Vlg., Zürich 1973
Stuart, C. E.: Articulation of Human Teeth. Dent. Items
to the forefront. Stallard's "organic occlusion" was Interest., 61: 1029, 1939
characterized by the relation to the mandibular Stuart, C. E.: Accuracy in Measuring Functional Dimensions
joint and the neuromuscular system. It is notable and Relations in Oral Prosthesis. J. Prosth. Dent., 9:
that Stallard was an orthodontist (ill. 1, right). 220–236, 1959

307
R. Slavicek • The Masticatory Organ
Harry Lundeen and Carl Wirth simplified the
complex instrumentation.
At an early point in time, Laskin placed
"pain" in the center of his diagnostics.
This is especially evident in the summary
published by Charles McNeill.
As examples we refer to the concepts of
William McHorris and Peter Dawson which,
although divergent, represent this body of
thought in regard to occlusion.
Lundeen, H. C., Wirth, C. G.: Condylar Movement Patterns
Engraved in Plastic Blocks. J. Prosthet Dent., 30: 866, 1973
McHorris, W.: Okklusion unter besonderer Berücksichtigung von
Funktion und Parafunktion der Frontzähne. J. Clin. Orthod.,
13: 606–620, 684–701, 1979
McHorris, W.: The Condyle-Disc Dilemma. J. Gnathol., 3:
3–16, 1984
Dawson, P.: Temporomandibular Joint Pain-Dysfunction
Problems Can be Solved. J. Prosthet. Dent., 29: 110–112,
1973
Gelb, H.: Clinical Management of Head, Neck and
Temporomandibular Dysfunction. WB Saunders Co,
Philadelphia 1985
308
Harry Lundeen and Carl Wirth simplified the com-
plex instrumentation, making occlusion diagnostics
suitable for practice, and were the first to propagate
systematic pre-therapy.
All of the above mentioned schools of thought
regarded parafunction as the "causal problem" of a
functional disorder. This led to a further funda-
mental error in dogmatic gnathology - that of
regarding occlusion as being primarily responsible
for the parafunction and for problems resulting
from it.
At an early point in time, Laskin placed "pain", par-
ticularly in the musculature, in the center of his
diagnostics. His ideas regarding the pain dysfunc-
tion syndrome were predominantly concerned with
the central role of pain in the occurrence of dys-
function in the masticatory organ.
This method of thought mainly emphasizes the
pathophysiology of pain and minimizes the influ-
ence of occlusal factors in the causality of emerging
problems.
This is especially evident in the summary published
by Charles McNeill, a comprehensive list describ-
ing cranio-mandibular disorders and their causes
from the viewpoint of the American Academy. The
Academy used the publication as an occasion to
change its name and has been called the American
Academy for Orofacial Pain ever since.
Many notable American dentists did not concur
with this development, but intensively continued
to detect and eliminate occlusal disturbances as
causal factors. They still are following this concep-
tual path of eliminating functional disorders by
means of the dentist's improvement of occlusion
and articulation. According to their concept, iatro-
genic damage can be prevented through dental
care. As examples we refer to the concepts of
William McHorris and Peter Dawson which,
although divergent, represent this body of thought
in regard to occlusion. H. Gelb also advocated an
occlusion-oriented concept and postulated inter-
mittent or permanent occlusal exclusion and dis-
tinct alteration of the mandibular position anterior-
ly with provisional orthodontic devices.
In Germany, it was Schulte who postulated the
associations through function and compiled them
under the title "Myoarthropathy".
 Diagnostics - clinical functional diagnostics

Unfortunately, the viewpoints of the "occlusionists"

and the "non-occlusionists" became more and more
polarized. Sadly, this led to uncertainty and resig-
nation on the part of many dentists, who lost their
desire to confront the most controversial subject of
functional disorders.
Of course, functional diagnostics of the masticato- Of course, functional diagnostics of the mas-
ry organ is much more than mere determination of ticatory organ is much more than mere
the fact that a patient "bruxes". Functional diag- determination of the fact that a patient
nostics must analyze all of the functions, both clin-
"bruxes".
ically and instrumentally, in order to arrive at a reli-
able diagnosis.
In the diagnostics of functional disorders in the
past, the problems of "normal" functions such as
mastication, speech and posture of the head were
neglected, and attention was mainly focused on
psychic stress management in clenching and
bruxism. From the viewpoint of multi-causality, From the viewpoint of multi-causality, this
this mono-causal train of thought must be replaced mono-causal train of thought must be
by the wider viewpoint of a feedback-control mech- replaced by the wider viewpoint of a feed-
anism.
back-control mechanism.
Therefore, it is absolutely necessary that the patient
undergo comprehensive, systematic and exhaustive
diagnostics before therapeutic methods are applied.
The clinical compilation of findings begins with a The clinical compilation of findings begins
personal conversation with the patient and a sys- with a personal conversation with the patient
tematic anamnesis. For all those who know him, and a systematic anamnesis.
Willi Krogh-Poulsen's admirable style in leading
this kind of conversation is ideal. This "art of con-
versation" during the medical "consulting hours"
(an absurd term for what actually takes place in
current medical practice) has disappeared to a great
extent. The personal conversation is either delegat-
ed to someone else or the patient receives a ques-
tionnaire that is filled out personally but, in gene-
ral, only superficially and without much thought.
What is missing here is personal contact with the What is missing here is personal contact with
doctor as a trustworthy individual to whom the the doctor as a trustworthy individual to
patient comes seeking advice. whom the patient comes seeking advice.
This first conversation with the dysfunctional
patient is exceptionally revealing. In addition, per-
sonal contact helps to build the initial personal,
human relationship between the physician and the
patient. It can be a first step towards the goal of
making a very individual diagnosis.
Making a diagnosis is a very responsible human
activity. Therefore, it must never be a simple sum-
marization of results, but rather a highly conclusive Schulte, W., Lukas, D., Sauer, G.: Myoarthropathien.
synopsis. The patient must also realize and appreci- Epidemiologische Gesichtspunkte, analytische und therapeutische
ate this fact. Ergebnisse. Dtsch. Zahnärztl. Zschr., 36: 343–353, 1981

309
R. Slavicek • The Masticatory Organ
It is problematic however, that the term
"normal" is difficult or even impossible to
define.
Zetkin/Schaldach: Medizin Zahnheilkunde Grenzgebiete, 1985
Pschyrembel klinisches Wörterbuch, 1986
Brockhaus Enzyklopädie, 1966
Boucher, C. O.: Current Clinical Dental Terminology, 1974
310
Diagnosis is the process of recognizing a type of disease
and finally classifying it in the terminology of disease
(Zetkin/Schaldach).
Diagnosis is the recognition and identification of a
disease (Pschyrembel Clinical Dictionary, 1986).
Diagnosis is the art and the act of recognizing a dis-
ease by means of its signs and symptoms by a doctor
(Brockhaus).
Diagnosis - the process by which one recognizes any
condition that may be a departure from normal (C. O.
Boucher).
Significantly, the last definition is used to determine
a deviation from the normal condition and is
termed the "oral diagnosis". This definition avoids
the word "disease", because disease must not neces-
sarily be present when a decision for therapy is
made in dentistry. A typical example is the indica-
tion for dental orthopedic therapy in a child.
Generally, this decision is made for a healthy child.
The dysgnathia to be treated is a deviation from the
"norm", but, in most cases, it would not be defined
as a disease.
It is problematic however, that the term "normal" is
difficult or even impossible to define. This is one of
the main problems in the increasing importance
being given to the computer in diagnostics. The
computer, within its linear "thought process", lists
comparisons in consecutive sequence and produces
rows of results without relationships. I would like
to attempt to make a distinction between the defi-
nitions of medical diagnosis and oral diagnosis by
introducing another term, namely "comparative
diagnostics", which evolved during a personal dis-
cussion with Dr. Ricketts in 1997.
Comparative diagnostics searches for, and
describes, the position of the individual within the
biological dispersion (to the statistical mean or an
individualized statistical mean - "zero base", accor-
ding to C. Gugino and Dr. Delamaire (personal
communication)).
 Diagnostics - clinical functional diagnostics

Diagnosis in medicine, in dentistry and, naturally, Diagnosis in medicine, in dentistry and, nat-
in orthopedics, is an ethical, responsible human urally, in orthopedics, is an ethical, responsi-
decision. It is made by the person initiating and ble human decision.
carrying out the therapy, and thus marks him/her
as the individual who bears the final responsibility.
The path to diagnosis generally passes through
diagnostics.

Diagnostics Diagnostics

Diagnostics may be defined as the collection and

evaluation of individual findings and other infor-
mation with the goal of making a diagnosis. In
most cases, diagnostic findings are compared with
diagnostic standards, which generally include
quantitative and qualitative parameters as devia-
tions from a norm.
In no instance should this "norm" (zero base) be "Norm"
regarded as "normal" in comparison to the indivi-
dual findings under consideration, as the deviations
from statistical averages would indicate that the
findings were "abnormal".
Individual findings must never be regarded singly
or separately from the overall context. Therefore, it
is entirely absurd to assign diagnostic abilities to
any apparatus.
This biomedical viewpoint with regard to the This biomedical viewpoint with regard to the
assessment of auxiliary devices encourages the de- assessment of auxiliary devices encourages
legation of the responsibility of diagnosis to the delegation of the responsibility of diag-
machines, which are incapable of thought, and
nosis to machines, which are incapable of
simultaneously leads to the incapacitation of the
physician in his/her own responsibility. An inevitable thought.
consequence thereof, is the expansion of diagnostics
and the limitation of therapy. This is made espe-
cially plain in the clear and castigating publications
of F. Capra.
Another significant disadvantage of apparatus-
oriented "laboratory medicine" is the fact that the
patient hardly ever gets acquainted with the per-
sonality of the doctor, "hidden" as it is, behind a load
of findings.
Therapy itself is being degraded to symptomatic
therapy, no longer being applied to the patient as a
whole, but presenting a complex puzzle that only
views partial aspects as objective therapeutic targets.
The term used in the definition of diagnosis, "devi-
ation from the norm", will be the starting point for Capra, F.: Die Wendezeit – Bausteine für ein neues Weltbild.
the discussion of this subject. Scherz Verlag, Bern-München 1983

311
R. Slavicek • The Masticatory Organ
The question to be asked is, who defines
these so-called "normal images".
The logical course of forming a diagnosis
must always be concerned with the indivi-
dual patient.
cognitive
The logical course of diagnostics in the mas-
ticatory organ starts with a conversation with
the patient, which is always carried out per-
sonally.
• The patient's main concern - chief
complaint
• The complete medical anamnesis
• The dental anamnesis
• The pain anamnesis in cases of chronic
pain
312
The question to be asked is, who defines these so-
called "normal images" for comparison with the
actual condition of the patient's "functions", with
the purpose of forming a diagnosis? Are these med-
ically uniform images appropriate to the nature of
human beings, or are they mere diagnostic con-
cepts, principles or fictions, corresponding to the
human spirit's persistent search for principles of
organization? Are the diagnostic standards also
possibly characterized, influenced, or even gov-
erned by other principles such as esthetic racial
images and prejudices or occasionally by economic
considerations?
The logical course of forming a diagnosis must
always be concerned with the individual patient.
Standardized diagnostic steps lead to individual
diagnostic findings, which are only useful when
taken together and viewed as a whole. This finally
culminates in the diagnosis and therapy. Thereby, it
is absolutely necessary to again "perceive" the
patient as an individual. It is the patient's well-
being that is of paramount interest. This especially
applies to the extraordinarily dominant functional
disorders of the masticatory organ, resident in the
cognitive area of well-being. The logical course of
diagnostics in the masticatory organ starts with a
conversation with the patient, which is always car-
ried out personally. Only if the dentist gets into
personal contact with the patient at this time can
significant first impressions be gained which, in
some cases, are the key to diagnostic success. The
conversation should always be marked by the doc-
tor's positive curiosity because, after all, it is the
dentist who needs to get to know the patient.
The following topics determine the course of the
conversation:
• The patient's main concern - chief complaint
• The complete medical anamnesis
• The dental anamnesis
• The pain anamnesis in cases of chronic pain
 Diagnostics - clinical functional diagnostics

The patient's main concern - chief

complaint

It is obligatory to first inquire about the actual rea-

son for the patient's visit to the dentist and to do-
cument it. However, this chief complaint should be
discussed more thoroughly after the initial diagno-
sis, in order to avoid being immediately diverted
into excessive details. Exceptions, of course, are
emergency problems, as they require immediate
treatment.

The complete medical anamnesis

As with all of the "topics of conversation", this must
be carried out and recorded personally by the den-
tist. Conversation with a dysfunctional patient is
especially important, because it builds up a rela-
tionship of mutual confidence, which will be very
useful later during therapy. The patient's behavior
during the conversation, his "body language", must
be observed and evaluated. It is advantageous if It is advantageous if this conversation does
this conversation does not take place in the treat- not take place in the treatment chair; rather,
ment chair; rather, an informal atmosphere is pre- an informal atmosphere is preferred, with
ferred, with the patient and dentist sitting opposite
the patient and dentist sitting opposite each
each other.
other.
In addition, the initial conversation allows for a
preliminary evaluation of the patient's psychic
condition. The patient's subjective views about the
complaint are considerably better communicated in
a personal conversation than by mechanically filling
out a form, which is often done too routinely or
boringly, and therefore, superficially. During the The patient fills out the form personally and
conversation, habits and peculiarities should be by hand, which gives the form the nature of a
observed and noted. Standard questionnaire forms, document.
which are available in most practices, should only
serve as guidelines during the personal conversa-
tion, and should be the starting point of a deeper
discussion. The patient fills out the form personal-
ly and by hand, which gives the form the nature of
a document. It is advisable to have the patient sign
the form upon completion.
The form should be arranged clearly, classified
according to diagnostic areas, and contain ques-
tions regarding existing or earlier diseases or infec-
tions. The patient is requested to answer the ques-
tions initially with yes or no. A brief, detailed and
interesting discussion concludes this first question-
ing period. Ill.2: Medical anamnesis

313
R. Slavicek • The Masticatory Organ
Ill. 3:
Ill. 4: This page includes the comparative muscle analysis,
provisional neurological findings, the determination of
myofunctional problems, chronic pain and occlusal findings
obtained with the occlusogram.
Based on the occlusion index, which is easily
obtained, the patient's subjective feeling of
well-being relative to his/her complaints can
be expressed.
314
The dental anamnesis
The questions are asked in the order presented on
the form. The patient is requested to answer the
questions pertaining to complaints or pain as spon-
taneously as possible and without evaluation, with
a simple "yes" or "no". Attempts on the part of the
patient to provide explanations would lead to
excessive detail and should be discouraged. The
details can be specified and discussed at a later
point in time.
After the ten questions pertaining to complaints or
functions of the masticatory organ have been
answered, the patient should locate and evaluate all
questions answered in the affirmative and subjec-
tively assign to each answer a degree of severity
("slight", "medium" "severe"). The physician will
then substitute the numbers 1, 2 and 3 for slight,
medium and severe pain, respectively. The sum of
the numbers divided by the number of affirmative
answers results in the "occlusion index".
Based on the occlusion index, which is easily
obtained, the patient's subjective feeling of well-
being relative to his/her complaints can be
expressed. For many years, this has proven to be a
reliable aid in this questioning phase.
The subsequent questions are more intensively con-
cerned with the patient's dental history. The ques-
tions asked here concern traumas to the head, neck
and throat, major dental restorations, orthodontics,
insufflation anesthesia, etc.
A comparison of subjective and objective well-
being is a key to the evaluation. The form is then
re-discussed more thoroughly with the patient and
signed by him/her. Significant results should be
noted in the correlation sheet (see below).
 Diagnostics - clinical functional diagnostics

The pain anamnesis

The pain anamnesis is of central importance in
functional diagnostics. Should the patient report
prolonged, persistent pain in the masticatory
organ, a standardized pain anamnesis should be
compiled. This concerns pain in the region of the
head, neck and shoulders. It is advantageous to
make the entries graphically with the aid of the
supplied sketches. Standardized details can be
included at a later time. The patient is offered a
selection of various expressions to describe chronic
pain. In cases of chronic pain in the craniofacial
region, an additional pain analysis is routinely car-
ried out, relative to the entire body, and is also do-
cumented graphically and orally. All significant
findings up to this point are transferred to the cor- Ill. 5: Chronic pain is advantageously portrayed by the
relation sheet mentioned above. It is the dentist's patient graphically; additional questions asked during the
responsibility to clearly arrange the obtained results conversation will provide more information on the subject.
on this correlation sheet and to classify them For the dentist, the region of the head, neck and throat is of
according to their significance. All important maximum priority at first …
reports are recorded on the sheet according to pri-
ority; other aspects are laid aside for the time being,
but may be reviewed at a later point in time.

The actual clinical functional analysis

(Physio-diagnostics)
Clinical functional analysis results in an objective,
organ-related criterion of the patient's functional
state. It encompasses the following sections and
must be carried out methodically and in all cases:
• The comparative muscle analysis
• Movement analysis Ill. 6: … however, in cases of chronic pain, the overall
• Clinical findings regarding the CMS symptomatology in the body must be discussed and evalu-
ated.
• Provisional neurological findings
• Clinical diagnostics of occlusion and articu-
lation (tooth status) • The comparative muscle analysis
• The occlusogram • Movement analysis
• Periodontal findings • Clinical findings regarding the CMS
• Provisional neurological findings
• Clinical diagnostics of occlusion and
articulation (tooth status)
• The occlusogram
• Periodontal findings

315
R. Slavicek • The Masticatory Organ
The goal of a comparative muscle analysis is
to evaluate differences by comparing the
same muscles of both sides.
Symmetry
Asymmetry
The side-to-side comparison permits registra-
tion of an asymmetrical weighting. This will
offer insights into disharmonic functional
processes.
The comparative muscle analysis:
• The shoulder-neck region
• Musculus temporalis
• The cranio-mandibular system
(temporo-mandibular joints)
• Retro-maxillary region
• Musculus pterygoideus medialis
• Musculus masseter
• Musculus digastricus
• The floor of the mouth
• The tongue
• The suprahyoid region
• The infrahyoid musculature
• The larynx
• Musculus sternocleidomastoideus
• Musculus omohyoideus
316
The comparative muscle analysis
The goal of a comparative muscle analysis is to eval-
uate differences by comparing the same muscles of
both sides. Pain in pressure points is of secondary
interest. This distinguishes the methods discussed and
demonstrated here from the compilation of findings
in other specialized schools of physiotherapy.
The functions of specific muscle groups, subjective
and objective, with side-to-side comparisons of the
muscles, when palpated and when functioning, are
the subject of primary interest. The goal, therefore,
is not a premature, conclusive, "tissue-specific" diag-
nosis, but an overall registration of the functional
state of the musculature of the stomatognathic sys-
tem. The side-to-side comparison permits registra-
tion of an asymmetrical weighting. This will offer
insights into disharmonious functional processes.
Palpation of the muscles is carried out on the
patient, while sitting freely and symmetrically, with
weight distributed evenly. The patient indicates dif-
ferences between the muscles of the right and left
sides and, if applicable, the degree of pain in the
areas being palpated. Objective findings obtained
by the dentist during the examination are also
noted and compared with the patient's subjective
evaluation. In addition, Janda's skin-roll test can be
helpful in certain areas.
The sequence of the procedure is standardized and
the entries are made on the findings form. The
scheme can be varied and updated at any time.
The comparative muscle analysis:
• The shoulder-neck region
• Musculus temporalis
• The cranio-mandibular system
(temporo-mandibular joints)
• Retro-maxillary region
• Musculus pterygoideus medialis
• Musculus masseter
• Musculus digastricus
• The floor of the mouth
• The tongue
• The suprahyoid region
• The infrahyoid musculature
• The larynx
• Musculus sternocleidomastoideus
• Musculus omohyoideus
 Diagnostics - clinical functional diagnostics

Clinical procedures

Palpation is carried out on a patient sitting freely

and upright in a normal chair. The examiner stands
in front of the patient in a somewhat straddled
position. This allows for standardized bilateral and
uniform palpation of the muscles.
Palpation is carried out simultaneously, uniformly Palpation is carried out simultaneously, uni-
and symmetrically. The patient is instructed to formly and symmetrically.
indicate any differences between the right and the
left sides. In addition, the patient may inform the
examiner of instances of pain during palpation. The
entries are made into the appropriate scheme, set
up in a mirror-image fashion. Entries are made
using the numbers 0, 1, 2, 3 for the corresponding
groups being examined; 0-1 indicates varying sub-
jective perceptions of the patient, but no pain in the
palpated area; 2 indicates pain under pressure in Palpation
the palpated area; 3 indicates severe pain. The
objective differences that the examiner registers
should be mentioned in the comments.
Palpation includes the functional groups of the true
masticatory muscles, the tongue and the floor of
the mouth, the cervical and shoulder musculature,
cranial and facial muscles, and manual examination
of the cranio-mandibular system.
The patient is instructed and sits in a free and The patient is instructed and sits in a free
relaxed position in an ordinary chair or in an appro- and relaxed position in an ordinary chair or
priate comfortable chair (ill. 7-12, p. 318). in an appropriate comfortable chair.
The examiner stands relaxed, in front of the
patient, with the patient's head at approximately
elbow level. Palpation is carried out predominantly
bilaterally and symmetrically; the patient is
requested to express differences between the right
and left sides. The presence of pain is only sec-
ondary at this time and will be acknowledged and
noted in a second set of questions. A preliminary
observation of posture of the head and overall pos-
ture at this time is of immense diagnostic value.
Illustration 7 shows the patient in a profile position,
sitting in a comfortable chair in upright position,
with the arms hanging at the sides.
In this position, differences in the cervical muscles
and in the posture of the head are especially notice-
able and, during palpation, the entire postural
musculature of the neck and head is most relaxed.
7-12, p. 318: Muscle palpation in a relaxation chair. "Knee-sit-
Only in this position, or in the freely sitting one, is ting" helps the patient to relax, both arms hang loosely at the sides
it possible to give a truly realistic evaluation of the or rest on the thighs. The examination can also be carried out
shoulders, head and cervical musculature. without difficulty on a stool or chair.

317
R. Slavicek • The Masticatory Organ

Ill. 7: Ill. 8:

Ill. 9: Ill. 10:

Ill. 11: Ill. 12:

318
 Diagnostics - clinical functional diagnostics

Here, observation is just as important as palpation.

If necessary, differences in muscular tension of the
skin can be diagnostically verified by the skin-
rolling test (Janda: ill. 13, right).
For the evaluation of a relaxed posture from the
front, it is especially important to note asymmetries
in the posture of the shoulders and the angles of the
neck to the shoulder. The neck-shoulder angle may
vary distinctly from 20 to 30 degrees. In this case,
there is actually a relatively symmetrical angle.
From an anterior view, attention must also be given
to facial asymmetries. At this time, observing the
posture of the head and the functional length of the
neck is of considerable importance in the diagnos-
tics of functional disorders in this area.
The relaxed posture is clearly seen in illustration 7.
In a posterior view, the angle between the head and Ill. 13: Grasping the folds of the skin according to Janda's
neck should be evaluated. In this subject, the method shows a visible difference in tensed muscle areas.
angles of the throat, neck and shoulders may be The fold is thicker and more resilient.
regarded as symmetrical. In the remaining illustra-
tions, the angle is somewhat different, but still in
the normal range.

319
R. Slavicek • The Masticatory Organ
Ill. 14: The examiner stands relaxed in front of the patient,
elbows at about face level.
Ill. 15: … the head is grasped and …
Ill. 16: … rolled slightly to the neck …
320
Palpation
The shoulder-neck region
Many functional disorders in the masticatory organ
occur in connection with problems of the postural
musculature. These must be recognized and exa-
mined with regard to their causal association with
problems of the masticatory organ. The question of
primary causality is secondary for the time being
and should be clarified at a later point in time. It is
advantageous to start with a symmetrical palpation
of the shoulder region (ill. 14-28, pages 320-322).
The levator muscle of the scapula is frequently
involved in problems in this area and is often affect-
ed by persistent, generally job-related, poor pos-
ture. The deep cervical musculature is also of great
interest in the region of the middle and upper cer-
vical spine and the entire area of the atlanto-occi-
pital connection.
A forwardly inclined posture of the head during
this examination would tense the neck muscles and
make palpation more difficult. Slight backward
rotation of the head helps to relax the shoulder and
neck muscles. Therefore, the patient should be
instructed to relax, lay the head back towards the
neck and look up at the examiner. Of course, all of
these examinations should be carried out on the
skin, without gloves because the tactile perception
of objective differences is much more intense when
bare hands are used.
The patient's head is grasped at the temples and
the neck, and moved slightly to the back. The
patient looks up at the examiner. In this position of
the head, the musculature of the neck is examined;
when this is done the postural muscles in the dor-
sal area should be relaxed. By laying the hands flat
on the shoulder blade, the physician can feel the
entire upper surface above the scapular region as
well as its texture. There follows a detailed search
for differences between the right and left sides in
the individual areas, through partial palpation,
with somewhat stronger pressure.
 Diagnostics - clinical functional diagnostics

Ill. 17: … whereby the neck muscles relax. Ill. 18: The palms of the hands are placed on the shoulders,
symmetrically and without pressure …

Ill. 19: ... and then examined for differences in feeling Ill. 20: Initially, it is a question of differences between the
through uniform pressure with the fingers. Objective differ- right and the left side, not one of experiencing pain.
ences felt by the investigator should also be noted.

Ill. 21: Individual conspicuous areas are now localized and Ill. 22: Palpation of the middle neck.
palpated under increased pressure.
321
R. Slavicek • The Masticatory Organ

Ill. 23 Ill. 24

Ill. 25: The atlas region must be carefully evaluated, which Ill. 26: With practice, the oblique processes of the atlas can
may be difficult in muscular patients. be perceived.

Ill. 27: Problems relating to symmetry can be felt. Ill. 28: Pain due to pressure can be triggered by symmetri-
cally increasing the pressure.

322
 Diagnostics - clinical functional diagnostics

The atlanto-occipital connector

The region of the oblique processes of the atlas is an
important point of palpation. Palpation of the atlas
may be difficult and depends on the strength of the
neck musculature. It is best to start at the mastoid
process, with the muscles as relaxed as possible, and
to probe posteriorly, carefully increasing the depth
of palpation. With practice, the oblique processes,
conspicuous asymmetries and areas of pain can be
assessed.

Musculus temporalis
The temporal muscle is palpated extra-orally in the
temple region and intra-orally on the ascending
branch, i.e., ramus of the mandible. In the extra-
oral examination, the examiner's hands are placed
on both of the patient's temples; the thumb, index
finger and middle finger lie approximately on the
assumed border of the muscle plate. The patient
bites down strongly, making the crossover to the
periosteum clearly felt. The fingers are then placed
behind the border and the process is repeated as a
control, then palpated evenly and with uniform
pressure, with the patient in a relaxed state. If the
patient indicates differences, he/she should be asked
to indicate the region in which the difference is felt
and/or where the pain reaction is triggered.
The insertion of the tendon of the temporal muscle
is palpated intra-orally with the index finger. The
ascending branch of the mandible is probed behind
the molars and then palpated superiorly under
slight pressure up to the muscular process, and
then to the temporal tendon insertion on the gle-
noid process. Palpation can be carried out unilater-
ally and then bimanually and bilaterally as well. In
general, however, it is better to use the unilateral
approach, moving the mandible to the appropriate
side, thus creating more space in the retromolar
region (ill. 29, right; ill. 30-35, p. 324). Ill. 29: Comparative palpation of the temporal muscle, along
the course of its fibers.

323
R. Slavicek • The Masticatory Organ

Ill. 30, 31: The thumb, index and middle finger palpate the insertion of muscle fibers on the fascia.

Ill. 32: The muscular process is examined intra-orally on the Ill. 33: Approximately 30% of the time, the temporal mus-
ascending branch. cle also inserts on the condylar process with an anterior part,
and is integrated into the CMS musculature.

Ill. 34: The temporal muscle, shown in yellow, inserts poste- Ill. 35: This illustration of vectors shows the anteriorly
riorly on the capsule and on the disc. directed traction of the temporal muscle against the emi-
nence.

324
 Diagnostics - clinical functional diagnostics

The cranio-mandibular system

(temporo-mandibular joints)
Here, we palpate the lateral pole of the joints and
the ascending branch dorsal to the insertion of the
capsule and the insertion of the temporo-mandibu-
lar ligament (ill. 36-42, pages 326-327).
The behavior of the lateral and collateral ligaments
is examined while opening and closing movements
are being performed. By shifting the mandible to
the side, the retro-articular space of the bilaminary
zone becomes accessible and is examined for any
specific anomalies (in this case, pain), or swelling
from a capsulitis.
We palpate with the middle finger, using increas- We palpate with the middle finger, using
ing, uniform pressure on the lateral pole. Under increasing, uniform pressure on the lateral
increasing pressure, the patient is asked to indicate pole.
any differences between the right and the left side,
or the prevalence of pain. The middle finger is
located on the lateral pole, which is then palpated
by internal and external rotation. The palpation
itself is done in a loosely closed mouth position.

In the next step, palpation is applied to the lateral

collateral ligament, which can now be felt clearly,
emerging at its origin, as an absence of roundness
or as a roughness on the lateral pole. This could be
the cause of ligament noise, which the patient may The noises appear predominantly during
also mention during the anamnesis. The noises rotation.
appear predominantly during rotation. The inser-
tion of the temporo-mandibular ligament can be
strongly sensitive from pain on pressure, because of
retrusive bruxism with a decrease in vertical dimen-
sion. In addition, naturally, any capsular problems
may be post-traumatic, or may result in a corres- Mediotrusion
ponding soreness in the region of the insertion of
the capsule. This examination is carried out bilate- Medioretrusion
rally and symmetrically.
Protrusion
The next examination is performed unilaterally on
the mediotrusion side, with a laterally rotating Retrusion
mandible. Here, of course, the bilaminar zone is
more easily accessible and is palpated from inferior
to posterior with the index finger, while the patient Opening
opens the mouth slightly. Passive mobility of the
temporo-mandibular joints is carried out with this Closing
manipulative technique (ill. 43-49, pages 327-328).

325
R. Slavicek • The Masticatory Organ

Ill. 36: Palpation of the joints is also carried out initially Ill. 37: The lateral pole is probed.
symmetrically on both sides.

Ill. 38 Ill. 39: The movement is followed on the lateral pole.

Ill. 40: Marked sensitivity to pain on the lateral pole is an Ill. 41: The course of movement on the lateral pole is easily
important finding. evaluated.

326
 Diagnostics - clinical functional diagnostics
Ill. 42: In an asymmetrical jaw position, the insertion of the
capsule on the ascending branch and, thereby, the temporo-
mandibular ligament provide important information during
palpation.
Ill. 44: For guided mandibular movements, the thumb is
placed on the mandibular arch and the horizontal branch is
fixed from underneath.
Ill. 46: In the subsequent passive movement, the second
hand is placed "probingly" on the joint to check the move-
ment.
Ill. 43: Palpation of the ascending branch and the capsular
insertion of the joint are clinically significant, as the reinforc-
ing fibers of the so-called temporo-mandibular ligament
insert here. In retral hyperactivity and also in cases of strong
vertical loss, the patient experiences pain on palpation here.
Ill. 45: This grip technique allows for confident, controlled
guidance of mandibular movements.
Ill. 47
327
R. Slavicek • The Masticatory Organ

Ill. 48: Palpation of the opposite side. Ill. 49: Using manipulative pressure.

Ill. 50: The little fingers are inserted bilaterally into the Ill. 51
tuberosity region.

Ill. 52: This region is often painful; it is important to question Ill. 53: The "shifted" opening of the pharynx in a tensed
the patient in regard of differences in the left and right sides. patient.

328
 Diagnostics - clinical functional diagnostics

The movements to be examined here are mediotru-

sion, medioretrusion, protrusion, retrusion, open-
ing and closing. The movements are initially per-
formed actively by the patient, and then carried out
by the examiner on the passive patient.
Manipulatively, the joint can be forcefully loaded or Manipulatively, the joint can be forcefully
distracted downwards. loaded or distracted downwards.
The retro-tuberosity region (the space behind the
maxillary tuberosity): the lateral pterygoid muscle
meshes behind the maxillary tuber with the fibers
of the medial pterygoid muscle. Both of these po-
werful muscles originate on the sphenoid, on the
sphenoid process and on the maxilla, and insert on
the mandible. The powerful masses of muscle fill
the space of the pterygo-palatine fossa. The inter-
meshing musculature is followed by indirect palpa-
tion in the retro-tuberosity area (ill. 50-52, p. 328).
Palpation is performed with the little fingers, which
are placed on both sides on the superior alveolar
process. The patient opens the mouth slightly,
relaxes, and is then palpated bilaterally for differ-
ences between the right and the left side.
Palpation of the retro-tuberosity region is carried Palpation of the retro-tuberosity region is
out best on one side, as the access is opened wider carried out best on one side, as the access is
by the mandible being pivoted to the side. The opened wider by the mandible being pivoted
patient may again indicate differences, if any,
to the side.
between the right and the left sides.
It is obligatory that the opening of the pharynx also
be observed when these muscle groups are studied.
Here, the musculature of the soft palate and that of
the opening of the pharynx are of interest. Clinical
experience has shown that, in cases of strong
involvement of the pterygoid muscle, there may be
a transfer of indirect tension to the opening of the
pharynx, resulting in its asymmetrical constriction
and in the uvula being pulled to the affected side
(ill. 53, p. 328).
If the hamulus of the pterygoid process is touched
intra-orally with the index finger and placed under
slow and constantly increasing pressure, a typical
pain reaction can be triggered in the patient. The
patient will report a rather stabbing pain behind
the eye. This would be a clear indication for a sutu-
ral tension in the skull region.

329
R. Slavicek • The Masticatory Organ
Ill. 54: The insertion of the medial pterygoid muscle is pal-
pated on the inner lower edge of the mandible.
Ill. 55: The superior head is examined especially with
regard to differences in muscle mass.
Ill. 56
330
Musculus pterygoideus medialis
The medial pterygoid is best examined inside the
mouth (ill. 54, left). It is important to place the fin-
ger on the inner mandibular alveolar process,
approximately in the region of the first molar, and
to slide the finger slowly, posteriorly and inferiorly.
The goal is to go to the angle of mandible, where
the muscle inserts. This technique is also best
employed unilaterally. When it is done carefully,
the vomiting reflex can be avoided.
Musculus masseter
Upon pure observation alone, it will be found that
the masseter muscle is an indicator of occlusal
hyperactivity. This examination applies to both,
the superficial parts of the actual masseter muscle
and the deep parts on the back ridge. Palpation of
both parts, which have entirely different function-
al responsibilities (see the chapter entitled
Structures, NMS), is carried out symmetrically.
The deep head is localized by having the patient
strongly close the mouth. Probe the back edge,
which is clearly distinguishable as a tensed ridge,
and instruct the patient to relax. Then increase
the pressure in the dorsal area near the joint and
ask the patient to indicate differences and areas
where he/she experiences pain. The deep part of
the masseter muscle is much more frequently
painful on palpation than the superficial head.
The anterior portion is grasped bilaterally with
the thumbs and index fingers and palpated along
its course, superior to inferior. The points of inser-
tion to the periosteum on the zygomatic arch and
on the mandible are also examined for pain on
palpation.
The floor of the mouth
The floor of the mouth with the mylohyoid and
the anterior belly of the digastric muscles are
examined unilaterally and bimanually. The exami-
nation is carried out extra-orally and intra-orally
(ill. 55 and 56, left). In the intra-oral examination,
the floor of the mouth is palpated with the index
finger inside, under pressure from the outside. This
makes it possible to clearly distinguish the spool-
shaped digastric muscle from all of the other struc-
tures. The patient again indicates any subjective
differences between the right and the left sides.
 Diagnostics - clinical functional diagnostics

Ill. 57: Palpation during flexion permits the investigator to Ill. 58: The deep head of the masseter on the posterior mar-
evaluate its activity as well as asymmetries between the right gin of the superior head.
and the left side.

Ill. 59: From retro-mandibular, an attempt is made to pal- Ill. 60: The floor of the mouth and the overlying digastric
pate the posterior head of the digastric muscle and the stylo- muscle (venter anterior) are examined unilaterally and
hyoid muscle. bimanually.

331
R. Slavicek • The Masticatory Organ

Differences in dimension between the two sides,

which are quite common, should be noted in the
findings.
The intra-oral examination is concluded with an
examination of the tongue.

Ill. 61: Examination of the tongue is obligatory for the den-
tist.
Ill. 62: The lateral edges of the tongue and also the base of
the tongue must be examined.
The tongue
It is obligatory to examine the tongue (ill. 61-67,
pages 332-333). Initially, the findings are aspec-
tive. The tongue is involved in every function of
the masticatory organ, especially in so-called
parafunctions. Therefore, the tongue deserves
special attention and should be examined care-
fully and systematically. The dorsum, the tip, the
side edges and the base are examined for pecu-
liarities and changes.
In addition, the mobility and motility of the
tongue should be observed. It is moved to the
left and the right; the patient is instructed to
perform these movements as extensively as pos-
sible. Asymmetries in the range of movement
should be noted. Next, the tongue is extended
far to the front and examined with regard to its
behavior and for any noticeable hyperactivity.
The tongue is also palpated and tested for any
peculiarities in the muscular structure and/or
sensitivity to pressure.
The suprahyoid musculature (ill. 68 and 69, left)
is systematically examined superiorly from the
hyoid, because this musculature, above all, could
be affected by functional problems and avoid-
ance mechanisms. The palpation ends in the
retro-mandibular triangle around the posterior
belly of the digastric muscle. It should be noted
that several muscles (e.g. the stylohyoid and
digastric muscles) are located in this area.
Therefore, it is very difficult to make a differen-
tial diagnosis.
The anterior belly of the superior rectus capitis
may also influence this region in the presence of
postural problems.
The position and behavior of the hyoid during
swallowing should be observed. The hyoid
should be able to move lightly and easily to the
right and left, with the patient in a relaxed posi-
tion.

332
 Diagnostics - clinical functional diagnostics

Ill. 63 Ill. 64

Ill. 65 Ill. 66

Ill. 64: The dorsum and the edge of the tongue are fre-
quently altered by functional disorders.
Ill. 65, 66: Mobility and motility of the tongue in free
movement.
Ill. 67: In this case, the form during flexion is symmetrical.
Ill. 67

333
R. Slavicek • The Masticatory Organ

Ill. 68: Examining the suprahyoid group. Ill. 69: Palpation during swallowing.

Ill. 70: Comparative palpation of the infrahyoid group. Ill. 71: Palpation of the sternocleidomastoid muscle.

Ill. 72 Ill. 73

334
 Diagnostics - clinical functional diagnostics

Ill. 74: Palpation of the course from superior to inferior Ill. 75

determines symmetry and pain on palpation.

Ill. 76 Ill. 77: Insertion on the sternum.

Ill. 78

335
R. Slavicek • The Masticatory Organ

The infrahyoid musculature

This musculature is palpated by starting from its
insertion on the clavicle superiorly to the larynx and
up to the hyoid (ill. 70-78, pages 334-335). By
strongly rotating the head laterally, the ventral por-
tion of the omohyoid muscle can also be palpated
in the infrahyoid, lateral region of the throat (ill.
79, 80, left). Associations with dorsal postural
problems can be determined here.
The sternocleidomastoid is probed bilaterally from
inferior to superior and examined for peculiarities.
The infrahyoid musculature is classified functional-
ly as postural musculature. In addition, in conjunc-
tion with the suprahyoid group, it is closely
involved in positional mechanisms of the hyoid
bone and larynx.
Ill. 79: Tightening the cervical fascia during the examina-
tion of the omohyoid muscle.

Ill. 80: The omohyoid muscle.

336
 Diagnostics - clinical functional diagnostics

Examination of the
movements of
antagonistic muscle
groups

The behavior of antagonistic muscle groups in the

dynamics of movement is also routinely checked
according to a prescribed scheme. Mobility and
motility during these antagonistic functions are
tested in a predetermined sequence, with slight Ill. 81: Examination of mobility and motility of the cervical
manual resistance being applied to the move- spine in assuming the upright position and ventral flexion.
ments.

• Assuming the upright position and ventral flex-

ion against slight resistance on the patient's
forehead (ill. 81-86, pages 337-338).
• The opposite movement to upright position
and dorsal flexion against slight resistance of
the hand on the back of the patient's head (ill.
87-91, pages 338-339).
• Rotation to the right from the end position of
left rotation with resistance from the examiner's
hand lying on the patient's right temple area
(ill. 92-97, pages 339-340).
• Reversal of the hand position and immediate
counter-rotation in analogous fashion (ill. 98-
102, pages 340-341). Ill. 82
• The laterally inclined head assumes the upright
position against resistance from the examiner's
hand (ill. 103-111, pages 341-342); this is also
carried out to the left and the right.

Mobility

Motility

Ill. 83

337
R. Slavicek • The Masticatory Organ

Ill. 84 Ill. 85

Ill. 86 Ill. 87: Checking dorsal flexion.

Ill. 88 Ill. 89

338
 Diagnostics - clinical functional diagnostics

Ill. 90 Ill. 91

Ill. 92: Checking rotation to the right … Ill. 93

Ill. 94 Ill. 95

339
R. Slavicek • The Masticatory Organ

Ill. 96 Ill. 97

Ill. 98: … and to the left. Ill. 99

Ill. 100 Ill. 101

340
 Diagnostics - clinical functional diagnostics

Ill. 102 Ill. 103: Upright position from lateral inclination …

Ill. 104: … against slight resistance. Ill. 105

Ill. 106 Ill. 107

341
R. Slavicek • The Masticatory Organ

Ill. 108 Ill. 109

Ill. 110 Ill. 111

342
 Diagnostics - clinical functional diagnostics

Free mobility of the atlanto-occipital

joints and the cervical spine
The free mobility of the cranial joints and the cer-
vical spine is now observed and any limitations
and/or peculiarities are registered. (ill. 112-121,
pages 343-344).

The analysis of mandibular movement

• active movement (quantitative and qualitative)

• passive (mobility)
Ill. 112: Observation of free upright posture and the differ-
• end feeling ence in the shoulder-neck angles.
• resilience

In examining the ability of active mandibular

movement, mobility and motility are evaluated by
performing movement exercises. The quantitative
entry is made on the findings form and may only
be evaluated as an individualized observation.
Epidemiological comparisons and standards may
not be made, as the differences in size and distance
to the temporo-mandibular joint do not permit
these.

Ill. 113: Observation of the fall-line of the skull joints

(atlanto-occipital to the shoulder joints, the mandibular
joints to the sternoclavicular region).

Ill 114: Observation of free dorsal flexion. Ill. 115: The forced area.

343
R. Slavicek • The Masticatory Organ

Ill. 116: Ventral inclination in the border area. Ill. 117: Free movement to the left border …

Ill. 118: … and to the right side. Ill. 119: Rotation to the left from superior view.

Ill. 120: The middle position (eyes shut). Ill. 121: Rotation to the right.

344
 Diagnostics - clinical functional diagnostics

Clinical examination of mandibular

movement - manipulative techniques
The examination of the CMS is undertaken
through palpation, auscultation, and observation
of active and passive movement. The evaluation of
joint mobility and the state of the ligament situa-
tion requires extensive practice, but finally results
in an assessable picture of the actual condition for
the examiner. A comparable standardization, how-
ever, is not possible.
This also applies to other clinical findings compiled
by responsible therapists. The examination itself is
the instrument, whose results can neither be dupli-
cated nor used for standardization. Excessively
Ill. 122: Examining mandibular mobility against slight
detailed diagnostics at this point must be assigned resistance.
to the realm of speculation. This also applies to the
evaluation of so-called end feelings, which were
commonly used to formulate rather grave diag-
noses (ill. 122-123, right; ill. 124-128, p. 346).

Preliminary neurological findings

The standardized preliminary examination of the
cranial nerves is mandatory for reasons of differen-
tial diagnostics. The dentist must detect signs of
neurological problems in this area as early as possi-
ble and refer the patient to a neurologist for clari-
fication. The findings for the sensory area are also
compiled as comparisons of sides. Findings con-
cerning the motor activity of individual muscles
are obtained using various techniques as well as Ill. 123
through the anamnesis. Should positive findings be
elicited, the patient must be referred to a neurolo-
gist (ill. 129, p. 346; ill. 130-141, pages 347-348).

Procedures:
N. olfactorius Anamnesis
N. opticus Anamnesis, Clinical
N. oculomotorius Clinical
N. trochlearis Clinical
N. abducens Clinical
N. trigeminus Clinical
N. facialis Clinical
N. stato-acusticus Anamnesis, Clinical
N. glosso-pharyngeus Anamnesis, Clinical
N. vagus Anamnesis, Clinical
N. accessorius Anamnesis, Clinical
N. hypoglossus Anamnesis, Clinical

345
R. Slavicek • The Masticatory Organ

Ill. 124 Ill. 125: Retraction of protrusive movement against slight resistance.

Ill. 126: Manipulative technique with control on the pogonion. Ill. 127: Manipulative technique through "Dawson's grip".

Ill. 128: Manipulative technique. Ill. 129: Checking the sensitivity of the forehead through
light stroking.

346
 Diagnostics - clinical functional diagnostics

Ill. 130: Checking the cheeks. Ill. 131

Ill. 132: Palpation of the supra-orbital nerve. Ill. 133

Ill. 134: Palpation of the infra-orbital nerve. Ill. 135

347
R. Slavicek • The Masticatory Organ

Ill. 136: Palpation of the mentalis nerve. Ill. 137

Ill. 138: Observation of facial motor activity through grimaces. Ill. 139

Ill. 140 Ill. 141: Blowing out the cheeks and examination of lip closure.

348
 Diagnostics - clinical functional diagnostics

Clinical diagnostics of occlusion and

articulation (dental status)

The tooth status (dentin)

• Tooth status • Tooth status
• Vitality status • Vitality status
• Fillings and restorations • Fillings and restorations
• Dentures/Artificial dentition • Dentures/Artificial dentition
• Abrasion facets • Abrasion facets
• Particularities • Particularities

Findings concerning occlusion and articulation are

obtained by inspection and listing of the overall
condition, the compilation of individual findings
and entry into a tooth scheme for the current
tooth status. It is also necessary to record the
tooth vitality status.
An evaluation of any artificial dentition should be
included in these findings. In cases of dentures that
are partially or fully attached to the mucous mem-
brane, an evaluation of the condition of the pros-
thesis and a sketch of its resilience are required.
The results of this wax occlusogram are entered
into the standardized findings form (ill. 142-147,
pages 350-351).
The observation of abrasion facets and their corre-
lation to the occlusogram entries can be very infor-
mative. Information published in the literature
underlines the excellent clinical validity of this
method. Findings concerning occlusion and articu-
lation are obtained by inspection and with the
occlusogram.

The occlusogram

• retral pre-contact • retral pre-contact

• retrusive guidance • retrusive guidance
• protrusive guidance • protrusive guidance
• laterotrusive guidance • laterotrusive guidance
• entry into the files • entry into the files

Tamaki, K., Celar, A., Beyrer, S., Aoki, H.:

Reproduction of Intraoral Excursive Tooth Contact in an
Articulator with Computerized Axiography Data.
J. Prosthet. Dent., 78, 1997

349
R. Slavicek • The Masticatory Organ
Ill. 142: Right lateral bruxism movements show perforations
in the area of the canine on the first premolar of the right
side, and perforation on the second molar of the mediotru-
sion side.
Ill. 143: Laterotrusion left: the canine and first premolar
guide dominantly, but a slight perforation is also seen on
the second molar of the left side. A distinct perforation is
observed on the second molar of the mediotrusion side.
Ill. 144: The protrusion movement only moves along the
left upper central incisor.
350
The periodontal examination
This is an important requirement for the overall
diagnosis and for provisional and definitive thera-
peutic planning. It encompasses the current plaque
findings, the measurement of mobility, findings
obtained from probing, and the results of a tho-
rough intra-oral X-ray status. In conjunction with
the existing signs of periodontitis, the actual peri-
odontal situation frequently overlaps with func-
tional problems in a typical way. Thorough exami-
nation and correlation to the occlusogram is
absolutely necessary.
The overall occlusal and periodontal results must
be correlated with the acquired knowledge of the
principles of occluso-articular relations and their
conformity. The arch form and arch relationship as
well as intercuspation must be evaluated. This pre-
liminary evaluation will be expanded upon later by
cast model analysis in the chapter dealing with
instrumentation.
Ill. 145: The primary support in ICP takes place on the
right side in the molar areas 6 and 7 and on the left side in
the area of the second molar.
 Diagnostics - clinical functional diagnostics

Ill. 146

Ill. 147

351
R. Slavicek • The Masticatory Organ

Clinical
functional
analysis with
the aid of
instrumental
devices
Condylography
The principle of joint track recording relative to
the hinge axis has been known in dentistry since
the turn of the century, when Campion defined it
as a recording near the joint, using the mandibu-
lar hinge axis.
When Heinz Mack and I again approached the
concept of recording mandibular border move-
ments near the joint in 1973, our goal was to
achieve a rational simplification of pantographing,
which was conventional at the time.

To briefly describe the situation at the time and its

development: The clinical application and wide-
Ill. 148: Campion applies a recording near the joint and
mentions the necessity of the hinge axis.
spread use of so-called fully adjustable articulators
were mainly hindered by the considerable amount
Condylography of time required and the complicated application
of the recording devices, as well as by difficulties
in appropriately adjusting the conventional arti-
culators. For instance, utilizing the Stuart system,
the compilation of a patient's pantographic data
after time-consuming preparation in the laborato-
ry generally required more than an hour for the
experienced user. Programming the articulator for
an average case required about two and a half
hours, and up to four hours for a patient with dif-
Ill. 149 ficult recordings. In addition, the attachment sys-

352
 Diagnostics - Clinical functional analysis - Instrumental devices

tem was "a mouthful" in the truest sense of the

word, and altered the vertical dimension consider-
ably during the recording. The recordings of
mandibular movements were graphical and mul-
tilocular in several planes, and were therefore not
appropriate to the hinge axis, but rather subject to
considerable geometric distortions. Incorporating
the Bennett movement was almost a "work of
art", as the Bennett inserts had to be polished and
set individually. The use of this expensive and
highly instructive system was restricted to very
few elite dental practices. Occasionally, arrogance
and attitudes of superiority may have been the
reasons why it was used.

In contrast, simpler systems such as the Whip-

mix articulator and its facebow system, the
Quick-mount, as well as the Dentatus articulator
gained increasing popularity. These simple articu-
lators were either set to average values or pro-
grammed with the aid of symmetrical and asym-
metrical eccentric registers.
In addition to his ideas regarding the "panto-
graph", Gysi had already introduced a simple sys-
tem that allowed for an easy registration of
mandibular movements near the joint.
Concurrently, Campion described the significance
of the mandibular hinge axis for setting articula-
tors and also recorded joint tracks near the joint.
From his recordings, it follows that the system
was attached in a way that the patient was able to
close without hindrance.
Gysi expanded on recording near the joint by
recording the transversal mandibular movement
both near the joint and in front of the mouth,
with the recording of the classic gothic bow.
The American School under McCollum refined
the recording system to make it true pantogra-
phy; the instrumental climax and final point was
achieved by Stuart and his system (ill.151-154,
pages 354-355).
Robert Lee returned anew to hinge axis-related
theories and developed the system of axio-pantog-
raphy, which engraved the movement tracks of
the mandible in plastic blocks using three air tur-
bines equipped with tempered steel cutters. It was
his brilliant idea to make the recordings as the
movement of the previously localized mandibular
Ill. 150: The simple sagittal recording system from Gysi, on
the face. A transversal recording with a hand-held bow.
Pantography
Axiopantography
The American School under McCollum
refined the recording system to make it true
pantography.
Campion, G. C.: Method of Recording Graphically the
Movements of Mandibular Condyles in Living Subjects.
Br. Dent. J., 23: S. 713–716, 1902
Campion, G. C.: Some Graphic Records of Movements of the
Mandible in the Living Subjects. Dental Cosmos, 47:
S. 39–42, 1905
Lee, R. L.: Jaw Movements Engraved in Solid Plastic for
Articulator Controls. Part 1, Recording Apparatus. J. Prosthet.
Dent., 22: S. 209–224, 1969
Lee, R. L.: Jaw Movements Engraved in Solid Plastic for
Articulator Controls. Part 2, Transfer Apparatus. J. Prosthet.
Dent., 22: S. 513–527, 1969
Lundeen, H. C.: Centric Relation Records: The Effects of Muscle
Action. J. Prosthet. Dent., 31: S. 244–251, 1974
Lundeen, H. C., Wirth, C. G.: Condylar Movement Patterns
Engraved in Plastic Blocks. J. Prosth. Dent., 30:
S. 866–875, 1973

353
R. Slavicek • The Masticatory Organ

Ill. 151: The clutches fill the mouth and interfere in the lin- Ill. 152: The Stuart pantograph during a recording on a
gual space. patient.

Ill. 153: The complicated articulator with separate strategies for the condylar elements (four heads).

354
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 154: Evaluation of the Bennett results.

In the SAM® System, continuously registered values for non-guided and guided Bennett movement are converted into tables, in
Bennett angle values, for programming the articulator, and are represented graphically in a magnification of 1:10. The registered
points are connected with a French curve. Using the transparent overlay foil, a selection of the Bennett inserts for the articulator
can be achieved through approximation.

SAM® is a registerated Trademark of SAM Präzisionstechnik GmbH

355
R. Slavicek • The Masticatory Organ
However, the system proved the important
fact that an adjustable intercondylar distance
in the articulator is not necessary.
The phenomenon is termed the immediate
side-shift.
356
hinge axis. This resulted in a revival of the theory
that, by primary localization of the hinge axis, it is
possible to record translatory tracks that remain
unaffected by rotation during the movements.
Although we must be grateful to this procedure
for much of our fundamental knowledge, it was
complicated, expensive and, because of the high
recording friction, open to argument. However,
the system proved the important fact that an
adjustable intercondylar distance in the articulator
is not necessary, because altered parameters permit
complete programming of the mandibular border
movements even in a case of static maintenance of
the intercondylar distance. Therefore, we are
grateful to Mr. Lee for this clearly formulated the-
ory of recording in accordance with the hinge axis.
With the Quick analyzer Lee also returned to
Gysi's old system, which, for incomprehensible
reasons, was abandoned by the Swiss school. In a
practically unaltered principle, Lee added a very
simple system for the registration of the Bennett
movement, which allowed for a linear, total side
shift of the mandible by means of the shift of two
registration beads placed next to each other. The
side shift was recorded during a strong manually
guided movement, thereby making it possible to
achieve an extensive side shift, especially in
patients with weak ligaments. This frequently
results in the artifact of a flat movement to the
laterotrusion side, one-dimensional in the initial
phase, which only appears under pathological
conditions, or in the event of a non-centralized
and/or caudally displaced system. The phenome-
non is termed the immediate side-shift.
At this time our work team focused its attention
on the detailed acquisition of an individual
Bennett movement. Based on Gysi's ideas, the
system of mechanical joint track recording was
more stable and included a registration set-up for
the side shift. The set-up was attached to the cor-
responding mediotrusion side to allow for conti-
nuous reading of the side shift. The mathematical
formulas for conversion into angle values of the
articulator were developed by Lugner. This made
it easy to program articulators (ill. 155-156,
right).
 Diagnostics - Clinical functional analysis - Instrumental devices

I introduced the principle of hinge-axis-related

joint track recording in a lecture in 1976, on the
occasion of the tenth anniversary of the New
Group. It involved a new method of compiling
three-dimensional data of mandibular move-
ments. In addition, elapsed time was represented
as the fourth dimension of movement. A suitable
mathematical method allowed for conversion into
the arbitrary working distances of the systems, so
that the goal of programming every type of artic-
ulator to duplicate mandibular movements could
be realized. The method was also publicized.
However, the primary elimination of rotational
distortion in combined rotation and translation by Ill. 155: The protrusion track of a subject with no disorder.
localizing the geometrical hinge axis, as described
by Lee, also made it possible to record and com-
pare distortion-free tracks.
The possibility of producing distortion-free
graphs finally led to the diagnostic observation of
track curves and the application of the axis-relat-
ed joint track recordings in clinical functional
analysis, namely as instrumental aids in the clini-
cal diagnostics.
By comparing the track curves of healthy subjects
to those of patients with functional disorders, we
succeeded in creating a system of classification
that provided the possibility of differential diag-
nosis in the detection of functional disorders of the Ill. 156: The graph of a dysfunctional joint with reciprocal
stomatognathic system. The system is also integ- cracking.
rated into an overall diagnostic complex of clinical SAM® is a registerated Trademark of SAM Präzisionstechnik GmbH
functional analysis and is only applicable in this
context. With experience, early symptoms of dis-
orders that would be missed by other more expen- With experience, early symptoms of disorders
sive and invasive methods can be discovered. This that would be missed by other more expen-
results in a greater likelihood of therapy achieving sive and invasive methods can be discovered.
a "restitutio ad integrum".

Slavicek, R., Lugner, P.: Über die Möglichkeit der Bestimmung

It is important to set up a coordinate system by
introducing a defined plane, namely the hinge-
axis-orbital plane. The system should be such that
it can be transferred to other diagnostic methods.
The common reference plane applies to the joint
track recording of the sagittal and transversal
condylar track. Programming appropriate articu-
lators, however, makes it possible to transfer the
dynamics of the system to the lateral X-ray and to
other imaging procedures.
The diagnostic possibility of representation and
evaluation of the dynamic interrelationships in the
des Bennettwinkels bei sagittaler Aufzeichnung. Österr. Zschr. f.
Stomatol., Heft 7/8: S. 270–284, 1978
Slavicek, R., Lugner, P.: Der schädelbezügliche teiladjustierbare
Artikulator. Österr. Zschr. f. Stomatol., Teil I und Teil II: S.
84–102, S. 122–143, 1976
Slavicek, R.: Die funktionellen Determinanten des Kauorgans.
Habilitationsschrift, Wien 1982
Grunert, I.: Die Kiefergelenke der Zahnlosen. Eine anatomische
und klinische Untersuchung. Habilitationsschrift, Quintessenz
Verlag, Berlin
Helkimo, M.: Studies on Function and Dysfunction of the
Masticatory System. II. Index for Anamnestic and Clinical
Dysfunction and Occlusal State. Swed. Dent. J., 67:
S. 101–121, 1974

357
R. Slavicek • The Masticatory Organ
Examination procedure and
initial therapeutic methods
1. Health form, occlusal index
2. Questions concerning the patient's main
problem (CC), anamnesis
3. Explaining the growth, composition and
metabolic process of microbial plaque
(complex carbohydrates, caries, gingivi-
tis, periodontitis) to the patient
4. Demonstration of the relations in the
patient's mouth, photographic documen-
tation
5. Staining the microbial plaque, plaque
index, bleeding index, demonstration of
the relationship between plaque and
pathological manifestations in the
patient's mouth
6. Demonstration and instruction
concerning effective oral hygiene
7. Removal of plaque and tartar/concretion
8. X-ray status
9. Measurement of the depth of probing
10. Sensitivity test
11. Caries diagnostics
12. Muscle findings, clinical examination of
the mandibular joints, neurological
orientation
13. Examination of myofunctional disorders
14. Clinical functional analysis
15. Tooth mobility
16. Normal (habitual) X-ray of the temporo-
mandibular joint
17. Functional analysis using instruments
UJ (upper jaw): proper mounting on the
head
LJ (lower jaw): joint-related registration
18. Provisional therapy plan if indicated
19 X-rays
20. Axiography - Condylography
358
masticatory organ allows for a comparison of a
conventional skeletal-dental analysis with a
dynamic, functional examination using a comput-
er-assisted X-ray analysis. More on this subject
later.
Clinical functional analysis with the aid of instru-
ments should not be carried out in isolation - as is
frequently reported in mechanical and electronic
processes. Like all other detailed diagnostic meth-
ods, instrumentation alone is not reliable enough
for making a reliable diagnosis when no correla-
tion with systematic clinical findings is undertak-
en. The examiner is responsible for making such a
diagnosis after carefully weighing all the diagnos-
tic records. The dentist bears the immediate
responsibility.
Instruments used in medical diagnostics (this
applies to all medical technical devices, including
imaging procedures) are currently incapable of
and inappropriate for making a diagnosis inde-
pendently.
The procedure used at the University Clinic for
Dentistry, Oral Medicine and Orthodontics in
Vienna, as well as the 20-point program of the
ÖGZMK (Österreichische Gesellschaft für Zahn-,
Mund- und Kieferheilkunde/Austrian Society for
Dentistry, Oral-Medicine and Orthodontics),
regard instrumentation as a logical element of sys-
tematic clinical findings/examination, and in no
way, as an isolated method for making a diagnosis
(see left).
 Diagnostics - Clinical functional analysis - Instrumental devices

The principles of joint track

recording relative to the hinge-axis

The following will describe the basic principles of

such recording. For this purpose, appropriate
graphic instruments that have proven their value
in clinical use and in practice should be used.
In addition, we will consider some alternatives
that were proven to be additional positive deve-
lopments in recent years. A further purpose of this
chapter is to describe significant improvements in
these methods and their advantages through the Ill. 157: In the simplest form, an anatomic facebow fixed to
use of electronic devices. the skull and a simple writing block/pad on the mandible
offer the most expeditious possibility of graphically record-
ing the sagittal condylar track. The decision to dispense
with localization of the hinge axis was made on rational
grounds, and therefore included the acceptance of distor-
Mechanical graphic recording of joint tions from rotation.
movement

A practicable and very simple mechanical method

made it possible to introduce the diagnostic pro-
cedure of recording the sagittal condylar track.
The sagittal condylar track is reproduced easily
and generally very well with all of the methods,
which is not the case for the transversal condylar
track. The obvious explanation is that the sagittal
track is determined by the structure, while the
transversal track is determined by function and
ligaments. Therefore, we consciously omit record-
ing the Bennett movement in the method
described here, which goes hand in hand with the Ill. 158: Only the purely protrusive recording produces
speed of the facebow system in the transfer to the assessable results. In combined movement, distortions
upper jaw cast (ill. 157-159, right). appear; the sagittal condylar tracks …

The expense is extraordinarily low, as are the diag-

nostic possibilities, while the great advantage is
the possibility of designing the basic setting of the
sagittal condylar track individually in the articula-
tor.
The graphic recording of the Bennett movement
or the reading of the transversal shift in asymmet-
ric movements may be regarded as the next
improvement (ill. 160-162, p. 360).

I still don't understand why it happened to be

American colleagues who expressed a reserved,
and occasionally even negative evaluation of "jaw Ill. 159: … and comparison of the left and right protrusive
tracking" in the diagnostics of functional disor- graphs.

359
R. Slavicek • The Masticatory Organ
Ill. 160: The possibility of attaching the flags horizontally
and the primary localization of the hinge axis are absolutely
necessary …
Ill. 161: … and correcting the inclination.
Ill. 162: In utilizing the condylographs of the reference sys-
tem, the transversal condylar track is graphically recorded
and evaluated. The use of electronic recordings makes these
procedures unnecessary, as the evaluation is carried out in
predetermined articulator intercondylar distances and can
be printed.
360
ders. Of all diagnostic methods, and especially in
imaging procedures, a diagnosis without a physi-
cian's interpretation is impossible. From the view-
point of correlating findings, the joint track
recording is a non-invasive, safe method of com-
piling dynamic clinical findings on the patient.
Such a recording would otherwise be practically
impossible. In combination with imaging proce-
dures, it is possible to pursue goal-oriented differ-
ential diagnostics.
The introduction of electronic aids made it easy to
record, store and evaluate rapid and complex
dynamic sequences. Naturally, this is carried out
in conjunction with all records of clinical func-
tional analysis and, depending on the case, with
the required imaging procedures.
It must be repeated that both graphic as well as
electronic devices can be used. The procedure is
the same in the clinical field. With the use of
graphic methods, however, the diagnostic possi-
bilities for evaluation are limited.
Electronic Condylography: procedures for
using the devices
• Instructing the patient
The patient must be informed about the steps
and should be as relaxed as possible. Each
recording can be repeated, so one need not worry
about doing anything wrong. The procedure is,
of course, painless. All this information must be
given to the patient. The instructions for the
movements and sequences must be practiced
before fixing the instruments.
• Preparation of the selected instruments
The instrument should be placed in a standard-
ized location and should be readily accessible.
This requires good cooperation with auxiliary
personnel. Anything that is not necessary for the
registration or that could cause additional strain
because of weight should be omitted. A magni-
fying glass should be available at the workplace
for hinge axis location (in the graphic methods).
 Diagnostics - Clinical functional analysis - Instrumental devices

• Attaching the functional clutch

In diagnostics as well as in the goal-oriented
instrumentation for programming the articula-
tor, only individualized possibilities for attach-
ment are used, so that functional movements can
be performed in a most unhindered fashion. It is
important to achieve full intercuspation and
interference-free dynamics in the mandibular
movements, with no disturbance. When this is
done, the vertical dimension will also remain
unaltered. The individual attaching clutches can
be either prepared indirectly on the articulator
from the diagnostic cast or prepared directly on
the patient (ill. 163-173, pages 362-363).

• Attaching the flags

The flags should be attached step by step accord-
ing to the instructions (ill. 174-181, pages 363-
365).

• Setting the orbital pointer as the third

reference point
As a standard method, it is recommended to
use a fixed distance of 21 mm on the bridge of
the nose, because determining the actual orbital
is irrelevant and is poorly reproduced.

• Measuring and entering the facebow geo-

metry of the upper bow
The data is read from the bow's measuring rods
and entered onto the findings form or the com-
puter. This is the basis for doing calculations
from arbitrary distances, and standardizing them
to the articulator with its predetermined inter-
condylar distance of 110 mm. In other words,
the distance between the recording flags varies
patient to patient, along with effecting the
geometry of the non-protrusive tracks, which
needs to be recalculated to the articulator.

• Attaching the registration sheet

The registration sheet is attached so that the
crossbar is parallel to the bipupillary plane, and
the sagittal arms lie parallel to the flags (ill. 182-
190, p. 365-366).

361
R. Slavicek • The Masticatory Organ

Ill. 163: Placing a wax bite between the teeth. Ill. 164

Ill. 165 Ill. 166: The clutch is coated with acrylic.

Ill. 167: The wax bite prevents the acrylic from running Ill. 168: The finished clutch is removed in order to be com-
onto the occlusal surface. pleted.

362
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 169: Attachment is achieved with zinc-oxide eugenol. Ill. 170

Ill. 171 Ill. 172

Ill. 173: Centric and eccentric pulling free of the individual Ill. 174: Trial application of the facebow.
clutch.

363
R. Slavicek • The Masticatory Organ

Ill. 175: Support from the patient. Ill. 176: Applying the neck band.

Ill. 177: The fully adjusted upper bow. Ill. 178

Ill. 179 Ill. 180

364
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 181: The attached flags in the joint area. Ill. 182: The freely hanging recording unit.

Ill. 183: Attaching the lower bow. Ill. 184: Screwing it on the bar.

Ill. 185: Attaching the electronic recording block. Ill. 186: The side plates on the upper bow.

365
R. Slavicek • The Masticatory Organ

Ill. 187: The system's parallelism. Ill. 188: The styli in place.

Ill. 189 Ill. 190

Ill. 191: Localization by a closing movement in the terminal Ill. 192: Determining the reference position on the patient
hinge axis relation (THR). sitting relaxed and upright.

366
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 193: Marking the orbital point. Ill. 194: Marking the skin points.

Ill. 195 Ill. 196: Removing the bow.

Ill. 197 (left): Lead marks of the skin points for the coordi-
nate classification on the lateral X-ray (lateral cephalogram).

367
R. Slavicek • The Masticatory Organ
Reference position RP
The goal of the chin point control described
here is to attain a reference position, by
which no load is applied to the joint struc-
tures.
368
• Localizing the hinge-axis
The hinge axis is localized in the usual way: the
mandible is fixed in the retral position and gui-
ded in open movement to the position where
rotation converts to translation. Now, beginning
from this position, the stylus is observed in a
closing rotation and then the side arm is adjus-
ted. This is repeated until the stylus tip shows no
apparent movement, only rotation. When using
the electronic double stylus method, the axis sty-
lus is moved to the center of the calculated rota-
tion center, guided by the program. Here also,
one additional repetition is recommended (ill.
191, p. 366).
• Marking the reference position
The patient sits freely and upright during the sub-
sequent steps. The back of the head is lightly sup-
ported by an assistant with three fingers, as the
examiner guides the patient to retral border posi-
tion without pressure. This position is marked as
a red point on the flag by placing a red foil under-
neath and sliding the needle to the flag. Similar
manipulation is used in the electronic method;
marking is done by the computer. The goal of the
chin point control described here is to attain a ref-
erence position, by which no load is applied to the
joint structures (ill. 192, p. 366).
• Attaching the styli
• Carrying out the six basic recordings (each
done twice)
The following six basic recordings are always
done without guidance and without tooth con-
tact. If additional recordings are made for diag-
nostic reasons, they must be done on the replace-
ment flags, with new graphs. The same proce-
dure applies to electronic recordings.
• Carrying out the six manipulated basic
recordings (each done twice)
The six guided basic recordings are used for
diagnostic comparison between manipulated and
non-manipulated recordings.
• Mandibular positional analysis
For the diagnostics of the ICP, recording of a sin-
gle protrusion track for the reference recording is
 Diagnostics - Clinical functional analysis - Instrumental devices

recommended. Because there is always positive The position of the pin to the protrusion
outward pressure from the vector system in the track offers a good means of measuring the
protrusion track, it may be taken as the cranial mandibular position.
border track and as reference. This also applies to
the diagnostic method described here for deter-
mining the position of the ICP to the border
track. After recording a protrusion track, the
patient is instructed to assume his/her normal
occlusal position. The position of the pin to the
protrusion track offers a good means of measur-
ing the mandibular position. The use of an elec-
tronic method affords a much wider range of
diagnostic possibilities. These will be discussed
in detail later.

• Resilience test Resilience

Joint resilience is an expression of the compres-
sibility of the soft tissues of the joint under pres-
sure against the eminence from the condyle.
Because of its non-reproducibility, the resilience Because of its non-reproducibility, the
test is disputable, according to Kundert and resilience test is disputable.
Gerber, and should be clinically applied only as
an adjunct to other relevant findings. Testing
resilience during a recording may be instructive,
because of the patient's behavior while the com-
pression techniques are being applied, for
instance, in Dawson's manipulation.

• Forced bite
For the forced bite, the patient is instructed to
close under maximum pressure. The behavior of
the pin is observed in comparison to normal
occlusion. The normal pattern is determined by
the different periodontal behavior of the tooth
groups (front canine group, premolars and
molars). Thielmann, referring to Hanau (rocking- Thielmann, referring to Hanau (rocking-
chair-occlusion), termed this behavior the "rock- chair-occlusion), termed this behavior the
ing-chair phenomenon". In this instance, the "rocking-chair phenomenon".
joint and the front teeth are perceptibly relieved
when maximal forced bite is applied. If the nee-
dle moves further cranially than the border track
during a forced bite, the occlusion in the molar
region is no longer primarily bearing the load.

• Speech
The protrusion track is again recorded as refer-
ence. A standardized speaking sequence is then
carried out. The patient counts aloud clearly Thielemann, K.: Biomechanik der Parodontose. J. A. Barth,
from ninety backwards, whereby the extent, München 1956

369
R. Slavicek • The Masticatory Organ
The extent, position and symmetry of the
functional tracks are evaluated.
Stronger deviations are noteworthy findings
and might indicate a functional hindrance
and/or an avoidance mechanism resulting
from it.
Special attention should be given to abrasion
facets in the course of the parafunctional
activity, and the patient should be directed to
use these areas.
This provides a new perspective to the pre-
vailing tendency of designing occlusion con-
cepts according to guided movements.
370
position and symmetry of the functional tracks
are evaluated. Special attention should be given
to the appearance of the side shift or deviations
from the sagittal border track. The speech pat-
tern should show no or at most minimal devia-
tions to the side or from the border track down-
wards. Stronger deviations are noteworthy find-
ings and might indicate a functional hindrance
and/or an avoidance mechanism resulting from
it.
• Bruxism (parafunctions)
The protrusion track is again recorded as refer-
ence. Then a parafunctional pattern is graphed
from the patient. The location of the bruxing or
clenching movement relative to the free record-
ing, the extent and the symmetry are evaluated
and registered. Special attention should be given
to abrasion facets in the course of the parafunc-
tional activity, and the patient should be direct-
ed to use these areas. Of special importance here
is the observation of transversal behavior. It is
surprising that, in contrast to traditional opi-
nion, many cases show no Bennett movement.
This provides a new perspective to the prevailing
tendency of designing occlusion concepts accord-
ing to guided movements.
• Mastication
A graph of a protrusion track is again used as ref-
erence. The patient chews standardized food.
The extent, location and symmetry to the free
recording should be evaluated. With practice, a
good estimation of the extent of the side shift can
be attained by using a measuring instrument, or
a horizontal graph.
• Deglutition
The patient sits with the mouth slightly open
and receives approximately 2 ccm of water placed
onto the tongue from a prepared syringe. The
patient is then directed to swallow and the
movement is recorded. This process is repeated
several times. Both the congruence of the posi-
tions of the recordings and an overlay obtained
by means of a protrusion graph are then evaluated.
 Diagnostics - Clinical functional analysis - Instrumental devices

• Determining the incisal position

• Determining the canine position

• Possible application of supporting manipu-

lative techniques

• Determining a possible therapeutic

position

• Removing the flags

• Marking the hinge axis points on the skin

• Taking lateral X-rays, frontal X-rays and

submento-vertex X-rays

• Upper jaw position transfer to the

articulator and centric mounting in RP

• Initial evaluation, provisional diagnosis

The initial account is purely descriptive; it does
not include an interpretation. It describes the It describes the quantity, characteristics and
quantity, characteristics and quality of the quality of the tracks.
tracks. In addition, a preliminary symmetry
evaluation is carried out. Parameters of classifica-
tion can be selected, based on statistical evalua-
tions and results (ill. 193-195, p. 367).

• Evaluation of retral stability

The patient is instructed to make a free incursive
movement. The behavior of the CMS in a free, Characteristics of curves
non-occlusion-supported position at the end of
the movement can be evaluated only by the use Quality of registration
of electronic aids. The electronic measuring sys-
tem shows no or minimal movement under
physiological conditions in retral position with
the mouth slightly open. In the case of a dys-
function of the CMS, the retral position is desta-
bilized and changes.

• Evaluating the Bennett movement

The individual side shift of the mandible in The individual side shift of the mandible in
asymmetric movements is known as the Bennett asymmetric movements is known as the
movement. The behavior of the side shift should Bennett movement.
be observed, especially in the first third of trans-
lation, and can be registered either graphically or
by means of a mechanical device. Naturally, non-
guided movements should be compared to guid-
ed movements.

371
R. Slavicek • The Masticatory Organ
... be repeated at least once in order to check
the reproducibility of the findings and phe-
nomena.
The systematic evaluation of results is one of
the most significant responsibilities of the
dentist who makes the recordings.
A standardized and methodical procedure is
absolutely necessary.
372
Graphically, the side shift can be displayed and
analyzed well in horizontal or coronal recordings.
As mentioned, the Bennett movement can be
registered both guided and non-guided. In guid-
ed movements, great care must be taken to
ensure proper guidance. The mandible must be
strictly centered to the cranium on the mediotru-
sion side towards the laterotrusion side; other-
wise serious errors may occur due to distraction
and decentering. The direction of the induced
force should approximately correspond to the
vector of the medial pterygoid muscle, and
should be applied at the angle of mandible.
Later, we will discuss the usefulness and/or use-
lessness of manual guidance.
Diagnostics using clinical recordings of
mandibular movement
The application on the patient must be designed
in such a way that the obtained results can be
compared. Therefore, each of the recordings
should be repeated at least once in order to check
the reproducibility of the findings and phenome-
na. Mechanical methods have the disadvantage
that the transversal behavior of mandibular move-
ments is extremely difficult to ascertain only
through observation and by reading values. This
is usually difficult or impossible to achieve in the
diagnostic procedure, as phenomena and overall
behavior are generally marked by rapid sequences.
Before the introduction of electronic methods, a
video recording of the processes proved to be
helpful.
The systematic evaluation of results is one of the
most significant responsibilities of the dentist who
makes the recordings. This applies to both
mechanical and electronic methods. A standard-
ized and methodical procedure is absolutely nec-
essary; the advantage of electronic methods lies in
the fact that stored data can be repeatedly evalu-
ated. Slow-motion and magnification of details
are also very helpful.
 Diagnostics - Clinical functional analysis - Instrumental devices

Creating standards of evaluation

The following will present the systematic nature

of evaluation and the terminology of diagnostic
descriptions.
First, all symmetrical and asymmetrical move- First, all symmetrical and asymmetrical
ments are described and evaluated according to movements are described and evaluated
their quantity, characteristics and quality. In addi- according to their quantity, characteristics
tion, the recordings are also examined for symme-
and quality.
try or asymmetry.
The bases for these evaluations were obtained by
the compilation of statistical data and their evalu-
ation. From these, both quantitative and qualita-
tive comparisons can be made. The results are
shown in the following table.
The first findings are purely descriptive. This is The first findings are purely descriptive.
the basis for all interpretation. The systematic
descriptive method is used to collect diagnostic
data. Interpretations based on this must also take
the previously obtained results from the clinical
and instrumental functional analysis into account.
It must be re-emphasized that the free, non-
tooth-guided movements performed by the It must be re-emphasized that the free, non-
patient should be evaluated first. tooth-guided movements performed by the
patient should be evaluated first.

Systematic evaluation of the eight basic

recordings
Standardized, descriptive, orthopedic and diag-
nostic evaluation of the mobility and motility of
the mandibular joint.

• Quantification • Quantification
• Qualification • Qualification
• Characteristics • Characteristics
• Side comparison (symmetry) • Side comparison (symmetry)
• Elapsed time (right-left-comparison)
• Elapsed time (right-left-comparison)
• Speed phenomena
• Speed phenomena
• Particularities
• Particularities
The scheme of descriptive analysis shown here,
analogous to other descriptive orthopedic proce-
dures, uses the neutral-zero method and is initial-
ly concerned with a quantitative evaluation.

373
R. Slavicek • The Masticatory Organ
Ill. 198: Attempt to show the neutral-zero method in the
evaluation of joint vitality.
In the classical neutral-zero method, the
neutral position of the joint is regarded as a
functional zero value.
• Reduced or hypomobile
• Average
• Increased or hypermobile
374
In the sense of a reference position, the retral bor-
der position is selected as the zero value for evalu-
ating the mobility of the mandibular joints. In the
classical neutral-zero method, the neutral position
of the joint is regarded as a functional zero value,
from which the joint to be described can carry out
movements in different directions.
In the temporo-mandibular joint, movements
from the reference position retrally are only possi-
ble under tension or stress on the joint structures.
The quantity is determined by the linear distance
from the reference position to the endpoint of the
completed excursive movement. This course is
designated with a small "s". Distances for protru-
sive translation should not fall below 10 mm; if
they do, they are rated hypomobile. Distances
that exceed 14 mm are termed hypermobile.
Introduction to practical descriptive
diagnostics
To make use of condylographic diagnostics, it is
necessary to observe the average tracks of distur-
bance-free subjects. At first, attention should be
given to the translatory behavior. These kinds of
bilateral symmetrical processes are shown in
overview in the graphic illustration (ill. 199-202,
pages 375-376).
In the evaluation of condylographic displays, it
must be noted that this concerns the recording of
the overall behavior of joint structures, including
the bony surfaces and all mutable structures.
Nevertheless, the reproducibility of behavior in
such processes is astounding.
Terminology of quantification
• Reduced or hypomobile
• Average
• Increased or hypermobile
It is important to determine the quantity of rota-
tion. This can only be done by electronic means,
with the aid of double stylus technology. As the
distance of the incisal edges to the mandibular
joint depends on the individual, conclusions
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 199: This graph shows the characteristics of a disturbance-free protrusion movement. The sagittal view shows average quantity,
the quality is excellent, the characteristics anteriorly are concave, the tracks are symmetrical. In the superior view, no deviation to
the side is seen.
This descriptive illustration can be used for every patient and should be included in diagnostics. Similar to radiological diagnostics,
at first it only describes the overall behavior of the protrusive translation, without forming a diagnosis.
The protrusive overall dynamics of the system can be registered by this procedure - not only the joint movement, but also the
behavior of the protractors (inferior head of the lateral pterygoid), the behavior of the elevators and distractors - in order to achieve
a rotation-free protrusion. The quality of the synovial gliding joint can also be determined.

Ill. 200: If the patient continues with a returning movement, the electronic recording shows a slight separation of the tracks, which
may be approximately 0.3 mm. In regular symmetric translation, the superior track is protrusive and the inferior track is retrusive.
The retrusive movement is controlled by the retractors, digastric muscle and temporalis muscle from the posterior bundles of fibers.
Between the protrusive and retrusive movement, a slight difference in pressure in the joint occurs, which is very important for joint
metabolism (see chap. CMS).
In the superior view, the tracks are congruent. The overall behavior also allows for the evaluation of the ligament apparatus, which
in this case is entirely inconspicuous.

375
R. Slavicek • The Masticatory Organ

Ill. 201: In this protrusion graph, the characteristics, deviating from the first illustration, are no longer concave anteriorly, but
straight. This is a noteworthy difference, but quantity and quality are inconspicuous.
The tracks are symmetric, also in the superior view, there are no deviations to be seen. This kind of graph would be classified as a
variation of an average track.

Ill. 202: In this recording, the characteristics are changeable, an initial convexity changes to a concavity. In cases with excellent
muscular control, the superior view proves symmetrical behavior; in this case, a somewhat less tight ligament apparatus probably
allows for translatory movement in the inferior compartment.
The findings are noteworthy and should be correlated with the patient's overall ligamentous apparatus.

376
 Diagnostics - Clinical functional analysis - Instrumental devices

regarding rotational joint capacity cannot be

made. As previously mentioned, the utilization of
SKD/ID (incisal distance) for creating epidemio-
logical standards without taking the individual
into account is scientifically disputable and false.
Even when a mechanical recording is used, this
can only be done by converting the ID into the
relation of the distance of the RP to the inferior
incision on a lateral X-ray. If a joint falls below the If a joint falls below the given standard refer-
given standard reference values in translation or ence values in translation or rotation, the
rotation, the phenomenon is termed "limitation" phenomenon is termed "limitation" in diag-
in diagnostics. nostics.

Quantity Limitation

Limitation
Joint movements may be limited on the whole or
for single partial movements. In the mandibular
joint, the limitation in movement may affect the
upper, lower or both joint compartments. The dif-
ferentiation of localization of a limitation of move-
ment caused by the joint is of greatest importance
in differential diagnosis.
Limitation of movement in the mandibular joint
itself may arise due to:
• Acute inflammation in the CMS
• Acute inflammation outside the CMS
• Pain and muscular inhibitions
• Acute trauma in the CMS
• Acute trauma outside the CMS
• Effects of trauma (ankylosis)
• Adhesions
• Pseudo-adhesions (synovial problems)
• Joint capsule (scars, systemic disease)
• Functional problems of the articular disk
• Problems of the ligamentary apparatus of the
CMS
• Mechanical hindrances
• Degenerative joint changes (arthrosis)
• Problems of the facial soft tissues
• Limitation of movement in the temporo-
mandibular joint
Ankylosis
Adhesion
Pseudoadhesion
Arthrosis
• Acute inflammation in the CMS
• Acute inflammation outside the CMS
• Pain and muscular inhibitions
• Acute trauma in the CMS
• Acute trauma outside the CMS
• Effects of trauma (ankylosis)
• Adhesions
• Pseudo-adhesions (synovial problems)
• Joint capsule (scars, systemic disease)
• Functional problems of the articular disk
• Problems of the ligamentary apparatus of
the CMS
• Mechanical hindrances
• Degenerative joint changes (arthrosis)
• Problems of the facial soft tissues
• Limitation of movement in the temporo-
mandibular joint

377
R. Slavicek • The Masticatory Organ
Differential diagnosis of an acute joint is car-
ried out clinically, as a rule, or through labo-
ratory diagnostics.
Muscle-splinting
... trauma in children and adolescents.
Rasse, M.: Diakapituläre Frakturen der Mandibula. Eine neue
Operationsmethode und erste Ergebnisse. Zschr. f. Stomatol., 90
(8): S. 413–428, 1993
Rasse, M.: Diakapituläre Frakturen der Mandibula. Die
operative Versorgung – Tierexperiment und Klinik.
Habilitationsschrift, 1992
Rasse, M., Beck, H., Futter, M.: Ergebnisse nach konservativer
und operativer Versorgung von Gelenkfortsatzfrakturen des
Unterkiefers. Zschr. f. Stomatol., 87 (5): S. 215–225, 1990
Rasse, M., Fialka, V., Paternostro, T.: Modifikation des
Zuganges zum Kiefergelenk und Ramus mandibulae. Acta Chir.
Austr., 1: S. 49–54, 1993
Rasse, M., Koch, A., Traxler, H., Mallek, R.: Der
Frakturverlauf von diakapitulären Frakturen der Mandibula –
eine klinische Studie mit anatomischer Korrelation. Zschr. f.
Stomatol., 90: 119–125, 1993
Rasse, M., Schober, C., Piehslinger, E., Scholz, R.,
Hollmann, K.: Intra- und extrakapsuläre Kondylusfrakturen
im Wachstumsalter. Dtsch. Zahnärztl. Zschr., 46: S. 49–51,
1991
378
Acute inflammation in the CMS
In cases of acute arthritis, either one side or both
sides of the temporo-mandibular joints reveal the
classic symptoms of inflammation. Naturally, this
also includes the Functio laesa, the limitation of
movement. Differential diagnosis of an acute joint
is carried out clinically, as a rule, or through labo-
ratory diagnostics, but very rarely with the help of
instruments. Arthritis is usually easy to diagnose,
because of swelling, inflammation and reddening
(of the skin). In these cases, pain is the predomi-
nant factor.
The sub-classification and causality, however, may
pose problems. If the symptoms of inflammation
are less acute, nuclear medicinal diagnostics may
be helpful in revealing the inflammatory process-
es. A synovial fluid analysis may also provide valu-
able information.
Acute inflammation outside the CMS
Painful muscular obstructions (muscle splinting)
resulting from other causes (e.g., post-extraction
pain) may lead to strong limitations in movement.
Acute trauma
During or after acute trauma, a temporary or con-
tinuous limitation in movement of the mandible
may occur. The cause frequently lies in the region
of the joint capsule; this does not always indicate
bone trauma. It applies above all to trauma in
children and adolescents. An astounding number
of childhood traumas are incorrectly diagnosed
and even fractures remain unnoticed.
Here, in addition to radiology, joint track record-
ing would be helpful for the differential diagnosis.
This especially applies to injuries suffered in the
distant past. Extracapsular or intracapsular
condylar fractures are associated with strong or
very strong deformations of the joint tracks.
The recordings can also serve as an aid in mak-
ing a decision regarding therapy. Of course, in
cases of suspected trauma in the joint region, a
thorough and appropriate representation with a
reproduction procedure is required. Especially
early traumas are frequently a primary cause of
later dysfunction.
Therefore, the anamnesis of trauma should be
carried out very thoroughly, especially if scar tis-
 Diagnostics - Clinical functional analysis - Instrumental devices

sue in the jaw or face is seen. This must be done

in conjunction with the collection of findings, so
that the two can be correlated.

Effects of trauma (ankylosis)

Limitations in movement commonly appear after
major traumas that are not subjected to proper
functional treatment in primary and secondary
post-traumatic therapy, and more importantly,
did not receive follow-up physiotherapy.
A major error is post-traumatic immobilization by
means of intermaxillary lacing, because the risk of
a future limitation in movement is especially high
in this setting. Thick, scarred adhesion closures
tend to emerge in both cranial and caudal joints.
Subsequently, compensatory hypermobility causes
the entire apparatus to make an acceptable func-
tional compromise. In the recording, this is best
assessed by performing free movements. Joints
that are damaged to a great degree are hardly
capable of performing regular individual move-
ments. Ankylosis may also occur as a result of
birth trauma (cephalotraction). Purulent arthritis
may lead to arthrotic and/or ankylotic changes
after healing.
Operations on the joint, such as arthroscopic Operations on the joint, such as arthroscopic
surgery or open joint surgery almost always result surgery or open joint surgery almost always
in limitation of movement. result in limitation of movement.

Adhesions
Adhesions can lead to major changes in joint
mobility. Micro-traumas or local, inflammatory
changes on the surface of cartilage may lead to the
formation of bridges of connective tissue between
corresponding joint surfaces. These, in turn, may
cause moderate to severe limitations in joint
mobility. The limitations frequently concern the
cranial joint and therefore affect translation more
than rotation. The differential diagnosis of a
chronically locked joint (joint lock) in a case of a
dislocated temporo-mandibular joint without
reduction to the clinical appearance of an adhe-
sion, is often difficult and can only be evidenced
through the invasive method of arthroscopy.
Nevertheless, the joint recording can be helpful
here in differential diagnostics, by providing infor-
mation about the behavior and characteristics of
the movement.

379
R. Slavicek • The Masticatory Organ
In case of suspected pseudo-adhesions, a
joint lavage is indicated.
Joint lavage
This creates ligament-related noise.
380
Pseudo-adhesions (synovial problems)
Thickening of the synovial fluid may occur due to
changes in joint metabolism. The normal absence
of friction in gliding movements is slowed and
imposes a load on the ligamentary connecting
structures. Drying can be triggered by a general
dehydration of the organism (in the senium), or by
limitations in movement or lack of movement.
Here, the recordings show shorter tracks, but they
also generally show a compensatory hypermobili-
ty in the inferior joint. The changes may have
their primary causes in the CMS or may be traced
to external causes.
Graphic or electronic findings show a quantitative
limitation, translations are generally more strong-
ly limited than rotation. In case of suspected pseu-
do-adhesions, a joint lavage is indicated and may
be of exceptionally informative value, as it
improves joint mobility in a dramatic way.
Joint capsule (scars, system diseases)
Limitations in movement can also be traced to
thickening and shrinking of the capsule. All inva-
sive surgery causes lesions in the capsule and may
trigger these effects. However, it must be remem-
bered that a systemic change in the collagen appa-
ratus may also be the cause of limitation of joint
movement.
After surgery in the joint, as well as after traumas,
scar tissue develops in the capsule, where a gene-
rally permanent reduction of the quality of move-
ment is found. The worse the post-operative train-
ing program proceeds, the more severe is the per-
manent limitation. In these cases, translatory
movements may be taken over to a great degree
by the caudal joint section, as a result of compen-
sation.
Problems of the ligamentary apparatus of the CMS
Ligamentary noise and obstacles may occur in com-
bined movements. Usually they are caused by la-
teral-collateral ligaments, which conflict with the
irregularities of the lateral pole of the condyle. This
creates ligament-related noise as well as temporary
and sometimes total inhibition during individual
movements (partial block). The blockages may, but
do not always, appear. They mainly affect protru-
 Diagnostics - Clinical functional analysis - Instrumental devices

sion and opening movements, and disappear dur-

ing mediotrusion. In general, the inhibitions can be
influenced by manipulation. This is easy to distin-
guish by means of condylography.
Ligamentary problems typically influence the
elapsed time of the movement. The elapsed time is Ligamentary problems typically influence the
slower, and may be suddenly accelerated at the dis- elapsed time of the movement.
tinct point of release when unblocking occurs.
Ligamentary inhibitions in movement may appear
during rotation as well as translation.

Functional problems of the articular disc

A total dislocation of the condyle could result in
permanent limitation of all movements anteriorly,
anterior-median and anterior-lateral. The record-
ing of the joint track is altered on the side of the
dislocated joint. According to the condition of the
capsule and the ligaments, the quantity of the
joint track is absolutely or relatively limited.
Terming this an "acute" or "chronic" lock does not
fit the circumstances, because we are then assu-
ming a time factor for the emergence of the
pathology. To be precise, the condition of the con-
nective tissue is most significant for the quantitative
extent of the lock. In this case, the recording is not
characterized and sometimes, especially when
forced movement is elicited, it is inversely charac-
terized (convex). It is not altered even during
warm-up exercises. Clinically, the inhibition is
painless and the end feeling is elastic. During a
combined movement, in the case of a unilateral
inhibition, the deviation of the point of the chin to
the damaged side is clearly evidenced. In a joint
locked in this way, the articular disc is located
anterior from the capitulum and can be displaced
anteriorly, anterior-median and anterior-lateral. Semantic note: The terms used for the rela-
The condyle is dislocated behind the disc. tive status of the condyle's position in med-
Semantic note: The terms used for the relative sta- ical orthopedic terminology are "dislocation
tus of the condyle's position in medical orthopedic or luxation" and "setting or reduction". For
terminology are "dislocation or luxation" and "set- the discus, the functional socket of the joint,
ting or reduction". For the discus, the functional the term "displacement" is used.
socket of the joint, the term "displacement" is used.
A trauma-related acute luxation of the capitulum
anteriorly is rather rare. The articular disk is then
located dorsal to the capitulum (a European term Ewers, R.: Zur Terminologie der intrakapsulären
for head of the condyle). Clinically, the patient Funktionsstörungen des Kiefergelenkes. Dtsch. zahnärztl.
does not achieve maximum intercuspation, but Zschr., 42: S. 772–777, 1987

381
R. Slavicek • The Masticatory Organ

rather protrudes (usually on both sides), for rea-

sons of compensation, and is hindered incursively
by an elastic and generally painful resistance. The
middle line of the dentition deviates to the non-
luxated side, and no retral stability is seen on the
condylograph. Although the retral position can be
changed by manipulation, it is elastic and gener-
ally very painful (the diagnosis is usually made
clinically, so that condylography is unnecessary in
most cases.)

Luxation to anterior
In cases of limitation or slowed movement in the
articular disk (synovial problems or adhesions), a
locked joint may be seen both clinically and with
condylography. It could result in an anterior luxation
during opening or closing movements or a forced
protrusion. A differential diagnosis of the resul-
ting appearance of the clicking phenomenon can
be made by manipulation during the course of the
movement. If anterior luxation is suspected,
strong cranial pressure is exerted on the angle of
mandible from a protruded position in the retru-
sive movement. If an incursive blockade appears
or the clicking phenomenon becomes distinctly
stronger, the suspicion is confirmed. On MRI, the
condylar process is located in closed position cor-
rectly in the articular disk. When the mouth is
opened wide (after the clicking noise), the articu-
lar disk lies dorsal to the condyle. The position of
the articular disk is only slightly changed.
Arthroscopy establishes the presence of pseudo-
adhesions or adhesions. This raises the question as
to whether the hypermobility of the lower jaw
space is not the "compensatory" result of the
adherent articular disk. The recorded joint track
may show average or above average quantity. The
movements avoid the adherent structure of the
disk and use the structure as a functional ramp.

Mechanical hindrances
Within the joint, free floating cartilage or
stronger irregularities of the joint surface may be
the cause of limitations in movement. Depending
on the case, floating cartilage creates obstacles
that sometimes cause blockage, but are visible
neither clinically nor in the recordings in repro-
ducible positions.

382
 Diagnostics - Clinical functional analysis - Instrumental devices

Changes in the form of the joint surface can gen- Changes in the form of the joint surface can
erally be very distinctly verified in the condylo- generally be very distinctly verified in the
graphic recording, where the superior and inferior condylographic recording.
joints can be recorded differentially. If we change
the "timing" between rotation and translation, a
clear change is seen in the track.

Degenerative changes in the joint

(arthrosis)
Such degenerative changes in the joint surface are
clearly displayed in the joint track recording by
way of form and characteristics; the quantity of
the movement is usually reduced.

Problems of the facial soft-tissue

The results of traumas such as extensive burns,
systemic changes (sclerodermia), or changes after
immunosuppressive therapy may lead to strong or
extremely severe hindrances to mandibular move-
ment. The hindrances bring about a secondary
reaction in the temporo-mandibular joints, which
develop signs of arthrosis because of inadequate
metabolism.

Limitation of movement in the

temporo-mandibular joint
Completed, inflammatory processes in the bilam-
inary zone, e.g., a recurrent inflammation of the
middle ear during childhood, may cause problems
in the hydrodynamic system of the retro-articular
padding (comp. Zenker). Limitations in protru-
sion may occur because the physiological equal-
ization of pressure through the retro-articular
padding is hindered. In rapid protrusive move-
ment, a lengthy, continuous, distinct retraction
occurs behind the protruded condyle. Other limi-
tations of movement are:
• pain and muscular inhibition
• ligamentary problems in the CMS

Pain and muscular inhibition

In general, pain and muscular inhibition are
always present together when limitations of
movement occur.
Pain is one of the most frequent causes of limited
mandibular movement. Every instance of pain in
Zenker, W.: Das retroartikuläre plastische Polster des
Kiefergelenkes und seine mechanische Bedeutung.
Z. Anatomie und Entwicklungsgeschichte, 119:
S. 375–388, 1956

383
R. Slavicek • The Masticatory Organ
Ill. 203: A joint that has been repeatedly subjected to open
joint surgery and shortening of the left capitulum shows a
bilateral connective tissue ankylosis. Opening and closing
movements are asymmetrical and show the compensatory
avoidance movement of the left side superiorly.
Ill. 204: The time curve of the left side shows the possibility
of rotation (Gamma nearly 16°), which allows for an open-
ing movement of approximately 30 mm with a strong devi-
ation to the left side.
In the anamnesis, the hindrance does not
appear suddenly, but steadily and progres-
sively.
384
the area of the temporo-mandibular joints, as well
as, in the remaining movement apparatus leads to
a limitation in the range of movement.
The goal of the organism is to immobilize the
painful joint through such muscular inhibition;
the condition is known as muscle splinting.
A typical example is the difficult eruption of a
mandibular wisdom tooth. In this kind of dentitio
difficilis, the increasingly painful movement
caused by the inflammation is blocked by intensi-
fied muscle splinting. Because of the reduced
metabolism, however, the advancing muscle con-
traction also becomes painful, leading to further
overlapping and a further increase in pain; open-
ing of the mouth is progressively limited.
Clinically, in this case, the deep heads of the mas-
seter muscles (Musculi zygomatico-mandibulares)
are most painful on palpation. From the viewpoint
of the Gamma motor system, this is an exagger-
ated effect akin to a vicious circle.
After physiological contraction is achieved, no
deprogramming of Gamma motor fibers or relax-
ation of regular muscle fibers occurs.
The condylography track shows an extremely lim-
ited opening movement. Although the translato-
ry movements are also limited, they are propor-
tionally not as limited as rotation. Clinically,
mouth opening is limited, but lateral movements
and protrusive movements are generally possible.
The general cardinal symptom is pain.
In the anamnesis, the hindrance does not appear
suddenly, but steadily and progressively. The con-
dition can be easily assessed clinically, and does
not require further diagnostic procedures by way
of recording or imaging.
Ligamentary problems in the CMS
Limitations in movement may also originate in the
connective tissue attachments of the mandible.
One example is that of ligamentary changes in the
stylohyoid in the case of Eagle’s syndrome.
Because of the resultant alterations in functional
processes during mandibular movement, the
changes also apparently result in considerable lim-
itation of movement in the temporo-mandibular
joints. The joints near the skull also seem to be
affected by the changes, especially the atlanto-
 Diagnostics - Clinical functional analysis - Instrumental devices

occipital joint. Strongly altered processes can be

disclosed and documented with recordings rela-
tive to the hinge axis (ill. 203, left; ill. 205-208,
below and right; ill. 209-214, p. 386).

Ill. 207: The graph of a protrusion movement in the case of

unilateral limitation on the left side. Clinically, the deviation
of the chin tip to the limited side is conspicuous; the differ-
ential diagnosis must correlate all of the parameters of the
previous diagnostic procedures and introduce further diag-
nostic measures if necessary. Manipulative techniques can be
helpful; this is the advantage of using instrumental assis-
tance in the clinical examination.

Ill. 205: The X-ray of a patient showing ankylosis of both

joints caused by an accident, and an extreme open bite.

Ill. 208: The opening and closing movements show, on the

left side, a distinct limitation. The right side compensates
towards the limited side.

Ill. 206: The recording of a continuous free movement

shows the remaining range of movement of the joints after
the trauma.

385
R. Slavicek • The Masticatory Organ

Ill. 209: The time curves of the right and left sides show the Ill. 210: The hinge axis display from a superior view shows
distinct difference and asymmetry, and also the adequate the clear shortening which, in this projection, is not caused
rotation (Gamma). by the shortening alone, but also by the inclination.

Ill. 211: In a different patient: radiological verification of Ill. 212: The free movement also shows the strong differ-
post-traumatic arthrosis. The right joint shows a distinct ence between the two sides.
reduction in quantity, less quality than the left side and a
considerably flatter inclination.

Ill. 213: The anamnesis form for the diagnostic procedures of Ill. 214: The hands (operated on several times) of a young
a patient indicates general medical problems in conjunction patient suffering from a type of rheumatism.
with the current chief complaint.

386
 Diagnostics - Clinical functional analysis - Instrumental devices

Ill. 215: During an orthopedic intrusive treatment of deep Ill. 216: Findings on the lateral X-ray.
anterior overbite, the patient suffered strong discomfort
which, at first, received no attention. After a relatively short
period of time, the bite changed dramatically and an open
anterior bite developed.

Ill. 217 and 218: Radiological findings in the temporo-mandibular joints show marked changes on the condylar process and the
articular eminence.

219: The graphic recording of mandibular movement indi-

cates a limitation and a distinct change in characteristics.

SAM® is a registerated Trademark of SAM Präzisionstechnik GmbH

387
R. Slavicek • The Masticatory Organ
Ill. 220: Recording of an initial translation and end rotation
(thick line). A fine line shows the strong difference in an ini-
tial rotation.
Ill. 221: The graphic attempts to illustrate the distinct dif-
ference between a translational recording and a rotatory-
translational one.
SAM® is a registerated Trademark of SAM Präzisionstechnik GmbH
388
Avoidance mechanisms
Muscular changes in movement may also appear
in the course of avoidance mechanisms. This
process is marked by the emergence of muscle
patterns that do not contain movements in parti-
cular directions, or avoid these with a change of
direction. The two main functions, speech and
mastication, are affected by this condition.
Improperly placed teeth are sometimes functional
interferences. In other words, during mastication
or speech, disturbing tooth contacts would occur.
This could result in avoidance mechanisms, which
control the movements into or out of occlusion in
such a way that the hindrance to articulation is
avoided. In most of these cases, the symmetry of
the protrusive movement in the joint is disturbed.
Straight, symmetrical protrusion is, under normal
functional conditions, the initial preparatory
movement in mastication and shows no signifi-
cant excursive tendency to asymmetry. In a case of
an avoidance mechanism caused by occlusion, a
distinct side shift in the joint takes place. The shift
is known as the Bennett movement, which would
otherwise only appear in asymmetrical move-
ments of the mandible. In the clinical analysis of
this instance, the majority of painful pressure
points are evidenced in the area of the mandibular
insertion of the medial pterygoid muscle.
Frequently, significant differences are seen in pain
on palpation of the anterior bellies of the digastric
muscles. In cases of a persistent avoidance mecha-
nism, the densities of the anterior bellies of the
digastric muscles are significantly different. The
closer to the occlusion the recordings are made,
the earlier the mechanisms can be detected. This
makes the functional occlusion clutch attachment
modus operandi so important. In recording,
avoidance mechanisms are mainly detected during
mastication and phonation. Asymmetries of func-
tion and avoidance through distraction can be dis-
played well. In the latter, a correlation to the sub-
jective and objective symptomatology of the
suprahyoid muscles can also be achieved.
Lesser muscular inhibitions are evidenced in
chronic or acute muscular tension, whereby move-
ment exercises may achieve a distinct change and
 Diagnostics - Clinical functional analysis - Instrumental devices

extension of the range of movement. The quanti-

ty of the range of movement is increased through
the exercises. After the first recording, translation
movements are carried out. The excursion mea-
surements are then compared with the reduced
range of the first recording. An increase of more
than one millimeter in the excursion measure-
ment will confirm that the inhibition is due to
muscular causes.
Muscular limitation can also appear in cases of
strong involvement of the protractors. In this
case, the protractor movement is limited and is
generally painful in the end phase (Musculus Ill. 222: This approximately 50-year-old patient shows a clear
limitation of the left side; it is conspicuous that straight protru-
pterygoideus lateralis caput inferius). The record-
sion is not possible and a side shift to the right side occurs. The
ing shows both shortened protrusion and track is markedly shortened on the left side. The characteristics
mediotrusion, but the characteristics of the on the left are rather convex anteriorly. The side shift appears
recording are retained. Prominent features at this illogical because of the shorter track on the left.
point are pain during movement and the usual
uncoordinated image of the six basic recordings
reflect reduced quality.
Clinically, pain on palpation on the control points
of the lateral and medial pterygoid muscles can be
established. The symptom is usually unilateral
and is generally associated with eccentric bruxism;
highly active facets are seen at the clinical exami-
nation.
The "end feel" postulated by many clinicians for
differential diagnosis between muscular or ligamen-
tary inhibition (arthrogenic or myogenic) does not
seem capable of being standardized and is therefore
Ill. 223: The hinge axis illustration from an anterior view
misleading in many cases.
clearly reveals shortening and a side shift.
An asymmetrical function caused by habit is gen-
erally coupled with problems of the digastric mus-
cle. Here, pain on palpation in the posterior
and/or the anterior head and distinct differences in
density in the anterior head are evident. Retral to
the maxillary tuberosity, unilateral pain on palpa-
tion is seen (origin of the medial and lateral ptery-
goid muscles).
Acute and chronic muscle tension is marked by
shortening of the tracks in the condylographic
findings of the patients, but also shows that they
are not coordinated. Muscular problems are not
accurately reproducible. The quality of the record- Ill. 224: Axis illustration from a superior view.
ing is poor.

389
R. Slavicek • The Masticatory Organ

Ill. 225: Mastication is fully asymmetrical and, in the left Ill. 226: Speech is also asymmetrical, transversal; there is a
joint, strongly limited. side shift to the right.

Ill. 227: The capitulum on the CT (computer tomogram) in

the coronal plane.
Ill. 228: The CT shows the involvement of the atlanto-
occipital joint through arthrotic changes, typical for this syn-
drome.

Ill. 229: The computer tomogram shows the extensive calci-

fication of the stylohyoid ligament in a case of the Eagle’s
syndrome.

390
 Diagnostics - Clinical functional analysis - Instrumental devices

Discussion of limitations
The differential diagnosis of limitations in
mandibular movement is of great significance,
because causal therapy is diverse and manifold.
Using the non-invasive clinical-instrumental
method of condylography, an exact differential
diagnosis based on clinical findings can be estab-
lished in many cases. In the past, the clinical diag- In the past, the clinical diagnosis of a joint
nosis of a joint locked dorsally through luxation locked dorsally through luxation (acute or
(acute or chronic "lock") was certainly made far too chronic "lock") was certainly made far too
often.
often.
In conjunction with the clinical axis-related joint
track recording, these methods of exact quantifica-
tion, qualification, changes through movement
exercises and the influence of manipulation, offer,
in unison, a further possibility of non-invasive dif-
ferential diagnosis of a limitation.

Hypermobility
If a joint exceeds average values during translato-
ry movement, the term hypermobility is used to
describe the condition. It is caused by primary or
secondary "loose" connective tissue and is associat-
ed with a larger range of joint movement. This
condition is found in children and adolescents
during growth. If the condition of the connective
tissue corresponds to the overall constitution of
the individual, it should be considered physiolog-
ical. This form of hypermobility affects the supe-
rior joint.
Hypermobility of the mandibular joints may also
be secondary and a sign of a functional disorder.
The opinion that this concerns a "hyperex-
The opinion that this concerns a "hyperextension"
tension" of the ligaments does not corre-
of the ligaments does not correspond to the phys-
spond to the physiology of the ligamentary
iology of the ligamentary apparatus. Ligaments
apparatus.
are tight stabilizers of the joints and display mi-
nimal elasticity. If ligaments are "stretched", this
involves mini-ruptures which, if continued, would
gradually lead from chronic micro-traumas to a
secondary loosening of the stability provided by
the connective tissue.
A further path frequently adopted in pathological A further path frequently adopted in patho-
hypermobility is demodelation of the capitulum. logical hypermobility is demodelation of the
In this case, the bony covering of the condylar capitulum.
process and the insertion of the ligament are
altered through reconstruction; the articular cap-
sule and the collateral ligaments become tighter.
Here also, the result is secondary hypermobility.

391
R. Slavicek • The Masticatory Organ
This corresponds then to an individual, but
physiologically increased, range of movement
in the superior joint.
Laterotrusion, latero-surtrusion, latero-
retrusion, latero-detrusion and also latero-
protrusion.
In certain cases, hypermobility of the inferi-
or joint cavity may also be regarded as a
compensation mechanism of hypermobility
in the superior joint.
Hansson, T., Öberg, T.: Arthrosis and Deviation in Form in
the Temporomandibular Joint, a Macroscopic Study on Human
Autopsy Material. Acta Odontol. Scand., 35: S. 177, 1977
Hansson, T.: Temporomandibular Joint Changes, Occurence and
Development. Dissertation Universität Lund, Malmö,
Schweden 1977
Hansson, T.: Der Einfluß der Okklusion auf das Kiefergelenk.
In: Das Kiefergelenk. Diagnostik und Therapie. Quintessenz
Verlag, Berlin 1983
392
The latter mainly affects the inferior joint. The
articular disk is increasingly inclined to shift,
because of muscular contraction. The lateral col-
lateral ligament is incorporated into the function-
al space of the joint, the median portions of the
disk increase in thickness and the median collater-
al ligament shows an enlarging recess.
A negative side shift as well as an initial difference
between the protrusion- and mediotrusion-tracks
are seen on condylography. Manipulative tech-
niques can be used to confirm the suspected diag-
nosis (ill. 230-243, pages 393-395).
It is important here to differentiate hypermobility
of the superior joint from that of the inferior joint
cavity. A spacious capsular structure and the
favorable vector of the inferior head of the lateral
pterygoid muscle may allow for large translation
movements in the superior joint. The quantity of
the movement may amount to 20 mm or more.
This corresponds then to an individual, but phys-
iologically increased, range of movement in the
superior joint.
The increasing translatory components in the
inferior joint have to be evaluated in an entirely
different way. The inferior joint, predominantly
classified as the rotational component, is then also
affected by translatory dislocation.
Translations in the inferior joint markedly influ-
ence the joint track recording of the laterotrusion
side during asymmetrical movements. The phe-
nomena which then appear are known from pan-
tographs: laterotrusion, latero-surtrusion, latero-
retrusion, latero-detrusion and also latero-protru-
sion. A later chapter will be concerned with their
consequences and effects on the form of the occlu-
sion in reconstructive dentistry. In certain cases,
hypermobility of the inferior joint cavity may also
be regarded as a compensatory mechanism of
hypermobility in the superior joint.
 Diagnostics - Clinical Functional Analysis - Instrumental devices
Ill. 230: Protrusion-retrusion shows a distinct concavity
anteriorly, with average quantity and quality. Note the dis-
tinct deviation to the right from the superior view.
Ill. 232: The opening and closing movements display the
extreme mobility of the system, with an excursion measure-
ment of 18 mm. Here also, a deviation to the right is seen
from a cranial view.
Ill. 231: Mediotrusion on the right shows markedly different
excursive and incursive recordings of movement on the
mediotrusion side. From a superior view, the anterior move-
ment is straight, without a sign of a Bennett movement.
Returning, the track deviates significantly to the right and
lies from the sagittal view more superior than in the move-
ment anteriorly. This is a typical indication of hypermobility
in the inferior compartment, the opposite side also shows
strong hypermobility.
Ill. 233: Bruxism is rather somewhat emphasized to the
right and hardly shows a side shift; the left side reveals a
superior and posterior tendency.
393
R. Slavicek • The Masticatory Organ

Ill. 234: The function of speech shows good muscular coor- Ill. 235: Mastication shows a well-coordinated pattern,
dination despite the loose ligaments, and is very well cen- somewhat rather emphasized to the right, and displays a
tered, from a cranial view. high degree of side shift.

Ill. 236: The time curve of mastication of the right side Ill. 237: The left side shows a somewhat less intensive coor-
shows the regular chewing cycles, with moderate rotation dinate development.
and strong side shift. This is typical for mastication.

Ill. 238: The axis movement shows the slight asymmetry of

the function with the tendency to function to the left and
back.

394
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Ill. 239: The opening and closing movements on the left
show a clear limitation. The right side compensates towards
the limited side. This example was cited previously. The fol-
lowing three illustrations show the patient after successful
treatment.
Ill. 240: In the axis illustration, the opening and closing
movement on the left shows a clear limitation, the right side
compensates towards the limited side.

Ill. 241: The combined movement is extensive and hypermo- Ill. 242: The time curve of the reciprocal click shows the
bile after the reduction. The ligamentary situation is "loose" resulting change in speed during "reduction" and then some-
and displays a reciprocal click. what less in the ensuing new luxation during the return
movement.

Ill. 243: In this case, mastication is transversally somewhat

shifted to the left, and marked on the left side by several
clicking phenomena.

395
R. Slavicek • The Masticatory Organ
Joint tracks of a healthy joint are repro-
ducible and display the quality of a synovial
joint, functioning without friction.
The functional state of the masticatory mus-
culature and the system-immanent muscula-
ture of the mandibular joints also influence
the quality of the tracks.
Loose ligament structures can be compensat-
ed through good muscle condition.
The quality is rated excellent, average or poor.
The excursive track usually lies more to
cranial than the incursive one.
396
The quality of the recording
Joint tracks of a healthy joint are reproducible and
display the quality of a synovial joint, functioning
without friction. This is marked on condylogra-
phic recordings by clear, non-wavy and reproducible
lines. The physiological quality of translatory
recording can be changed through morphological
(structural) and functional joint problems. The
functional state of the masticatory musculature
and the system-immanent musculature of the
mandibular joints also influence the quality of the
tracks.
The quality of the track and its characteristics can
be additionally altered by loose ligaments and
internal hypermobility of the joint. The changes
are aggravated in a combined movement of trans-
lation and rotation.
Loose ligament structures can be compensated
through good muscle condition, so that clear or
relatively reproducible records emerge. This
applies, above all, to recordings carried out under
the control of the pterygoid-masseter loop, with-
out significant rotation. These are predominantly
movements characterized by translation. Early
symptoms of a disorder or good muscularly com-
pensated situations are most easily detected in
combined movements during diagnostic proce-
dures.
The quality is rated excellent, average or poor.
Characteristics of the recording
Translation and combined movements generally
show a distinctly formed concavity of the protru-
sive and mediotrusive border tracks under physio-
logical conditions. The excursive track usually lies
more to cranial than the incursive one. Protrusion
and mediotrusion are congruent or at least nearly
congruent. When compared with purely transla-
tional movement, the combined movements
(translation and rotation) frequently show a smal-
ler radius at the end of the track curve.
During the basic recordings, uniform characteris-
tics should be achieved as a result of friction-free
movement within the temporo-mandibular sy-
novial joint.
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Changes in these characteristics are recorded and The joint tracks are described as concave,
correlated with other findings. The joint tracks straight, convex or of changeable characteris-
are described as concave, straight, convex or of tics.
changeable characteristics.
In cases of loose ligaments, the initial recording
near the reference position is frequently convex
going anteriorly, especially if it is started from a
relaxed and deliberate position.
Distinct differences in the form and inclination of
the six basic recordings should be considered
important. If they cannot be modified by mani-
pulation against structural boundaries, they have
a morphological cause. Structural peculiarities or
changes here must be evaluated separately for the
superior and the inferior joint cavities.
It must be pointed out that a most exact hinge ... that a most exact hinge axis localization is
axis localization is a prerequisite for this evalua- a prerequisite for this evaluation.
tion. The characteristics within the basic record-
ings must be reproducible if they are structurally
determined.

Side comparisons (symmetry) of the

recordings
Quantitative and qualitative asymmetries are cor-
related in descriptive form. Especially in cases of
asymmetry, it is very difficult to obtain evidence of
pathology. This is because it could well be an
instance of functional compensatory mechanisms
of structural-morphological asymmetries.
Of course, in cases of asymmetries as well, all spa-
tial aspects should be evaluated from a three-
dimensional viewpoint.

Temporal course of the recordings

Comparative observation of speed in both joints
offers a possibility to detect dynamic asymmetries.
Diagnostically, time phenomena can only be Diagnostically, time phenomena can only be
assessed in electronic recordings. assessed in electronic recordings.
This also applies to the next section, which con-
cerns the rapid change in speed during a move-
ment.

397
R. Slavicek • The Masticatory Organ
Muscle-triggered phenomena can be distin-
guished from ligamentary phenomena.
It is absolutely necessary to distinguish
between noises that occur during translation
and those that occur during rotation.
398
Speed phenomena of the recordings
The behavior of speed during joint movements is
very important. Changes in speed, sudden acceler-
ations and delays appear, above all, in the pres-
ence of functional problems of the disk. Here, the
electronic method is vastly superior to the
mechanical one, which is dependent on observa-
tions alone. Muscle-triggered phenomena can be
distinguished from ligamentary phenomena.
Extensive experience in mechanical recording is
required. Above all, the measuring device must be
carefully observed. It clearly shows transversal
changes in direction and their speed behavior.
So-called joint noises
The phenomenology of joint noises does not indi-
cate any uniform cause. The literature of the last
decade describes reciprocal clicking in connection
with non-permanent luxation of the joint. In no
way can all joint noises be traced to this cause. On
the contrary: because of the excessive attention
given to this one cause, joint noise has been false-
ly interpreted and, what is more serious, incor-
rectly treated. A differential diagnosis is therefore
of fundamental importance before causal therapy
can be initiated. It is absolutely necessary to dis-
tinguish between noises that occur during transla-
tion and those that occur during rotation, because
the phenomena must be assigned to the superior
or inferior joint. Here, the speed behavior is also
an important component of the diagnostics. In
addition, reproducibility in localization and
behavior during manipulative influence are signi-
ficant for forming a diagnosis.
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Causes of joint noises • reduction clicking and luxation

• reduction clicking and luxation clicking
(according to Farrar)
• reduction clicking and luxation clicking
after over-rotation
• patho-morphological clicking
• ligamentary clicking
• distraction clicking
• crepitating and rubbing noises
clicking (according to Farrar)
• reduction clicking and luxation
clicking after over-rotation
• patho-morphological clicking
• ligamentary clicking
• distraction clicking
• crepitating and rubbing noises

Reduction and luxation clicking

(according to Farrar)
These occur in the typical reciprocal clicking
described by Farrar. The condyle is located in a
retral position, partially or totally luxated, behind
the articular disk. This means that the luxation is
primary, reduction follows in consequence and in
the end, the luxated situation returns. The shift of
the disk is usually not purely sagittal, but multi-
dimensional. A considerable disadvantage of all A considerable disadvantage of all customary
customary schematic illustrations is their excessive schematic illustrations is their excessive
emphasis on sagittal phenomenology. Transversal emphasis on sagittal phenomenology.
components are poorly depicted or insufficiently
discussed. The reorientation of the condyle on the
disk is a four-dimensional phenomenon (that is,
taking the time component into account), which
is best displayed electronically with a clinical-
instrumental recording method. Although the
transversal components of clicking can be
observed well on the measurement recording
device, localization in a time-space relationship is
not possible.
In addition to spatial changes, elapsed time, the
fourth dimension, is important. Therefore, stan-
dardized observation of the six basic recordings
relative to sagittal, transversal, and vertical views,
as well as to elapsed time, is a prerequisite for a
proper diagnosis. Evaluating the sagittal phenom-
enon alone is insufficient and clinically mislead-
ing.
Using a mechanical version, the elapsed time in
the clinical observation can be estimated and eval- Mauderli, A. R., Lundeen, H. C.: Simplified Condylar
uated by the very experienced. Electronic record- Movement Recorders for Analyzing TMJ Derangements.
ing offers better possibilities here, because data J. Craniomandib. Prac., 4: S. 207–212, 1986
Mauderli, A. R., Gibbs, Ch., Mahan, P., Wilkinson, T.:
can be saved and stored. EMG Activity of the Superior Belly of the Lateral Pterygoid
After producing the basic recordings, which are Muscle in Relation to Other Jaw Muscles. J. Prosthet. Dent.,
performed on a freely sitting patient without any 51: S. 691–702, 1984

399
R. Slavicek • The Masticatory Organ
After producing the basic recordings, which
are performed on a freely sitting patient
without any guidance, the recordings are
repeated under manipulation.
Therefore, it would be more appropriate to
refer to excursive and incursive noises during
translation or rotator movement.
400
guidance, the recordings are repeated under
manipulation. Here also, the value of manipula-
tive alteration must be emphasized. Limitations,
as described in the literature, restrict the diagnos-
tic value. A further considerable disadvantage is
the prevailing chaos in terminology, which, for
example, assigns reciprocal clicking to combined
movements, i.e., opening and/or closing. Exact
determination of whether and when the phenom-
enon appears in translation and/or rotation is of
the utmost importance. Therefore, it would be
more appropriate to refer to excursive and incur-
sive noises during translation or rotational move-
ment.
So-called "reciprocal clicking" in the
six basic movements.
This sequence provides the graphic presentation
of reciprocal clicking according to the old graphic
model with speed intervals.
Protrusion
After determining the retral luxated (unforced) bor-
der position (deranged reference position = DRP),
a straight protrusion is recorded without tooth
contact, and if possible, without considerable rota-
tional movement. First, this sagittal movement
produces a graphic registration of a luxated joint
while gliding forward into the x/z planes in a pro-
trusive direction, and records the reduction at a
particular position. Usually, a distinct avoidance
pattern appears, first in a posterior direction, then
deviating superiorly. Before the posterior devia-
tion, the movement slows down and generally a
brief abortive blockage occurs. In a transversal
direction, an increasing side shift before the block-
ade is observed. The side shift is usually directed
laterally (from the viewpoint of the affected joint).
A change in the direction of movement superiorly
is generally accompanied by a swift increase in
speed, which affects all three spatial coordinate
directions. At the zenith of the superior move-
ment, the usually clear clicking from the reduction
occurs. The excursive course going further is, as a
rule, devoid of significant features or peculiarities.
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Retrusion
Even unguided retrusion shows a typical, incur-
sive track, with generally good characteristics, but
of equally poor quality. In the last part of the
course, before reaching the retral position, there
usually is a slight slowing of the movement. The
development of the track in a superior direction
(z-coordinate) flattens out or is diverted towards
the z-coordinate slightly positive posteriorly. After
a renewed rise superiorly, the recording generally
achieves the original Deranged Reference Position
(DRP) without blockage. A transversal shifting
movement is sometimes also seen in the incursive
movement pattern. Joint noise is weaker and
duller during incursive luxation clicking than in
excursive reduction clicking. The recorded graphic
corresponds to a lying figure-of-eight, as quoted
in the literature.

Mediotrusion
The behavior of mediotrusion movement is simi-
lar to that of protrusion in most cases.
Occasionally, no clicking occurs at all, or is much
weaker. In such instances, the track curve is with-
out any conspicuous features and we interpret this
difference as subtotal luxation with strong median
rotation of the disk. Clinically, a typical "jump" in
the lateral collateral ligament can be felt.

Medioretrusion
In regular reciprocal clicking during an incursive
mediotrusive movement, an equally rather weak,
but still clear noise is evident.
In the so-called "quiet" mediotrusion movement,
no conspicuous features appear in the sagittal
track; the progress of the Bennett movement dif-
fers from the excursive one. In the most retral
area, a lateral side shift generally occurs. It most
cases it is accompanied by a weak noise. This shift
can be felt clinically and displayed graphically.

Opening
During an opening movement, the sequence
(rotation and translation) in the combined move-
ment should be observed and registered. The phe-
nomenon usually first appears in the combination
of rotation and translation. If possible, have the

401
R. Slavicek • The Masticatory Organ
Ill. 244: The patient reports a somewhat painful clicking in
the temporo-mandibular joint, which she cannot exactly
assign to a specific side. During opening-closing, the condy-
lography shows a typical reciprocal clicking on both sides,
which occurs simultaneously.
Ill. 246: In the mediotrusion track of the right side, clicking
is evident.
402
Ill. 245: The course of the axis shows a very thick initial area
in excursion, with a "gap" and a strong increase in speed
afterwards, and thereafter a rather steady speed.
Ill. 247: The unilateral mediotrusion of the left side also
shows clicking. The diagnosis is therefore a bilateral inde-
pendent reduction-luxation clicking, which, by coincidence,
appears simultaneously during symmetrical movement.
Diagnostics - Clinical Functional Analysis - Instrumental devices

Ill. 248: The time curve of the right joint shows a distinct
peak of speed at the time point of excursive clicking.

Ill. 249: The left side shows very similar behavior.

Ill. 250: The time curves of the right and left sides are prac-
tically identical in terms of their speed behavior.

403
R. Slavicek • The Masticatory Organ

patient practice a sequence of movements to be

repeated in such a way that first, as pure a rota-
tion as possible is performed, and then translation
is carried out. This is important for the purpose of
arriving at differential diagnosis in phenomenology.
In the instance of a distinctly noticeable blockade,
a strong transversal phenomenon (y-axis) is
observed in most cases.

Closing
In the closing movement as well, it is important
to observe the combination of movement and
then evaluate the images. Not every instance of
clicking that occurs during closing is luxation
clicking. Evidence for such a diagnosis must be
obtained carefully, as the therapeutic conse-
quences of a luxation are, as a rule, entirely differ-
ent from those in a case of a non-luxated joint.
Manipulatively influencing the six basic move-
ments during reciprocal joint clicking.
The free movements in the first diagnostic proce-
dure are repeated in the second phase under
manipulation by the examiner.

Guided movements

Pressure directed superiorly

The movements correspond to those described in
the first section. Changes must be observed and
registered. In protrusion in general, two distinct
changes occur. The excursive phenomenon is
somewhat more eccentric and generally more
accentuated. Sometimes the blockade cannot be
overcome by the protractors and the recording
behaves as it does in the instance of a locked joint.
If there is no noticeable forward shift, the cause
may be adherent disk behavior.
If the joint is protrusively reduced, cranial pres-
sure is also exerted in retrusion. The incursive
recording lies further to cranial and rather has the
image of a normal track curve with good charac-
teristics. The luxation phenomenon generally lies
somewhat more incursive, closer to the Reference
Position. Altogether, there is typically a slight

404
 Diagnostics - Clinical Functional Analysis - Instrumental devices

"splaying" of the two phenomena. If the splayed

position does not exist, the anteriorly shifted disk
is probably adherent. This has a decisive influence
on the therapy. Differential diagnosis based on
MRI is indicated. If the disk is, in fact, immobile,
repositioning therapy is contraindicated. Surgical
plication is probably also contraindicated. If ne-
cessary, a graphic marking on the flag can be done
on the incursive recording, just before the new
retrusive luxation; this is termed the therapeutic
position (THP). In electronic recording, this can
be repeated several times in the mandibular posi-
tion analysis, then superimposed with the retru-
sion track in order to determine a therapeutic
position. In this way, the therapeutic position is
quantifiable with both methods, and can be used
as the protrusive setting of a track in general the-
rapy for repositioning. Typically, in this case, the
excursive phenomenon is more accentuated than Deranged Reference Position DRP
the incursive one, both in the guided and unguid-
ed mode. The mediotrusion movement is mani-
pulated superiorly as well as medially. By median
manipulation the phenomenon can be suppressed
and may remain as it is; this condition is known as
silent mediotrusive reduction. This may be
regarded as a diagnostic indication for a stronger
median component in the shifting of the disk. It
indicates the direction to be adopted with regard
to therapeutic measures. Opening and closing are
also manipulated. Here, a blockade of the opening
movement is commonly achieved and translation
cannot take place. A further diagnostically valu-
able manipulation is that of forcing a pure rota-
tional movement through slight pressure on the
tip of the chin. Quantifying the movement up to
the blockade affords valuable information regard-
ing the overall ligamentary condition. After suc-
cessful reduction, the lower section of the joint can
be checked with regard to its functioning in pure
rotation, by applying cranial pressure.
Morphological changes in the inferior joint can be
detected and evaluated with differential diagnostics.

Luxation-reduction anterior clicking

Reciprocal clicking may also occur in reverse
order. The condyle is located in a retral position
within the articular disk. In an instance of anteri-
or luxation, it exits the discus structure anteriorly

405
R. Slavicek • The Masticatory Organ
In functional joint pathology, a structurally
altered or damaged disk is a frequent cause
of the clicking phenomena.
Unfortunately, in these cases, the soft tissue
on MRI are equally difficult to interpret.
406
into the capsular region due to disk immobility or
to delayed disk movement, and clicking occurs.
There is hardly any noticeable change in speed
during cranial manipulation, no blocking takes
place and the incursive track shows distinct char-
acteristics. Before reduction, a very clear vertical
development begins. During a superior manipula-
tion, the phenomenon becomes strongly accen-
tuated. Incursive clicking can be heard more
clearly than excursive clicking.
The reversal of vertical development (negative-z
moves temporarily into positive-z) and speed
behavior is especially characteristic.
In combined movement and further opening of
the mouth, the phenomenon occurs more often,
and is then termed "over-rotational clicking". In
this instance, an anatomically short and steep
articular eminence is commonly observed.
In functional joint pathology, a structurally
altered or damaged disk is a frequent cause of the
clicking phenomena. Interpretation of the track
curves is then difficult or impossible. Unfortunately,
in these cases, the soft tissue on MRI are equally
difficult to interpret.
Patho-morphological clicking
Changes in the posterior joint may give rise to
joint noises, as congruent corresponding irregular-
ities between the condyle and disk become incon-
gruent during rotation. The resolution of such a
congruent irregularity may cause noise. This is
clearly observed in clinical-instrumental diagnos-
tics. Here also, a clear distinction must be made
between translation and rotation. Phenomena of
the posterior joint chamber can be demonstrated
most clearly during rotation. They occur in the
same rotational position and are reproducible
through cranial manipulation. The phenomenon
is generally more distinct when a superiorly
directed force is applied. The "timing" of the
movement shows different behavior; there is no
gradual slowdown with resultant blockade of ten-
sion, and the transversal rapid movement is
absent. In pure translation, the phenomenon is
totally absent or appears weakly in the recording.
Even when guided, no significant "splaying"
occurs during counter-rotational movement. As
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Ill. 251: A somewhat shortened track of a non-painful joint Ill. 252: In translation (protrusive-retrusive) the phenome-
with slight clicking during opening and closing, noticed by non disappears and is also not noticed by the patient.
the patient. In the condylographic recording of opening and
closing movement, the phenomenon is slightly visible. It lies
in the counter-rotational movement, almost at the same
position.

Ill. 253: In speech, it appears now and then. Ill. 254: During mastication, it is occasionally present.

407
R. Slavicek • The Masticatory Organ
Ill. 255: MRI shows a circumscribed, globular, high reso-
nance in the articular disk.
Ill. 256: The computed tomogram shows a corresponding
defect in the bone. This irregularity creates a slight "recipro-
cal" clicking during rotation, which, however, should never
be mistaken for Farrar's phenomenon.
408
the changes are morphological in nature, they
cannot be quantitatively altered by manipulation.
The excursive and incursive graphics are approxi-
mately congruent.
Ligamentary clicking
Loose cartilage and ligamentary reinforcements may
cause noise during movements, especially during
rotation. As previously mentioned, it is primarily
the lateral collateral ligament (palpable in the cli-
nical analysis as well) that is the cause of noise.
Clinically, the possibility of passive joint movement
is increased by way of hypermobility. This can be
quantified instrumentally and standardized.
The causes might be found in an individual,
habitual, ligamentary weakness. However, gene-
rally the cause is secondary loosening of the liga-
ments. In these cases, as a result of demodellation,
there is a structural alteration of the joint mor-
phology on the lateral pole of the joint. If flatten-
ing occurs here, the lateral buttress for the colla-
teral ligament is altered. Pain on palpation at the
lateral pole is the clinical indication of possible
progression. An irregularity of the bone surface
can now produce distinct noise during movement.
In the recording, this kind of phenomenon can be
verified three-dimensionally and it frequently
induces changes in the elapsed time. In general,
the phenomena are not as reproducible as those of
reciprocal clicking, for instance. During manipula-
tion, a different kind of behavior is observed.
Under a superior force, ligamentary clicking shows
a weakening of the phenomenon on the angle of
mandible. Frequently, medial manipulation also
causes the noises to disappear. It is very important
for the differential diagnosis that the patients have
a non-luxated retral position. The treatment for
luxation-reduction clicking is entirely different.
Synovial noise
In the anamnesis, the patient will occasionally
report noises that mainly occur during a function,
e.g., while chewing tough food. The noise is
described as a smacking or clicking or even
squeaking. It may be difficult to duplicate by cli-
 Diagnostics - Clinical Functional Analysis - Instrumental devices

nical and instrumental analysis. The clinical finding

is probably best achieved by examination of the
mastication record in the joint track recording.
Occasionally, a strong distraction may appear du-
ring mastication and the noise may occur. Noise
that is mainly registered during mastication of
tough food might be a case of synovial opening
noise, similar to the way the knuckles click when
the fingers are pulled.

Observing function
The following functions of the masticatory organ
can be documented and evaluated with the aid of
the joint track recording: mastication, speech,
stress management (clenching and bruxism) and
deglutition.

Mastication
It is absolutely necessary to make sure that the
functional occlusion clutch allows a disturbance-
free articulation pattern during mastication.
Therefore, correctional adjustments to the clutch
must be carried out very carefully before initiating
instrumentation. The food used for the test should
be as standardized as possible. Hard cookies that
make for distinct crushing, pieces of apple (with
peel) and chewing gum are suitable foods.
When using mechanical recording devices, a free
retrusion movement should be plotted with a red
colour lead in front of the functional display. The
patient's mastication is then registered with the
customary black lead. This is carried out on both
sides. Here, the behavior of the transversal shift is
evaluated and the quantity of the side shift during
mastication is measured and assessed. Again,
video taping is most useful here.
The behavior of the mastication tracks of the joint
relative to the red basic recording is observed and
evaluated. Special attention must be given to the
side-to-side comparison. Generally, the recorded
tracks differ according to the test food that is
used. As the tracks are recorded external to the
joint distance, the use of mechanical devices cau-
ses geometrical distortions. This is not the case
when electronic recording is used, as the values
can be calculated back to a standardized joint dis-
tance (110 mm) or to any individual distance of

409
R. Slavicek • The Masticatory Organ
Ill. 257: Sketches from the scientific studies of
Gstöttenbauer: protrusive contacts in the articulator on the
central incisors.
Ill. 258: Lateral contacts of the same subject, as pure canine
control.
Gstöttenbauer, D.: Strukturen des Kauorganes als mögliche
Ursachen für Sprechstörungen. Dissertation, Universität Wien
1994
410
the condyles. In functional diagnostics, electronic
recording has the unprecedented advantage that
practically all movements in the space can be eva-
luated in measured time. This is important during
mastication, especially for the evaluation of the
Bennett movement, the symmetry of patterns and
the quantity of rotation, particularly in the final
phase of bolus formation. A further advantage is the
possibility of achieving an overlay of the functional
movement to the freely recorded protrusion track.
Speech
Speech, the most important function of the sto-
matognathic system, has been discussed in several
sections. It is significant that this highly compli-
cated pattern is rendered possible by the interplay
of several structures and functional cycles.
However, the fact that the structures of the CMS
are considerably involved in the speech process
receives little attention. The control of mandibu-
lar movement during speech is determined by
occlusion. The accomplishment of regular speech
with dental involvement is also an occluso-articu-
lar problem. If possible, occluso-articular disor-
ders are balanced by compensatory compromises
with regard to the speaking technique. However,
the mechanisms may lead to dysfunction of the
entire system. This is given little attention when
the causality of functional disorders of the masti-
catory organ is discussed.
By correlating the clinical-instrumental function-
al diagnostics of the function of speech with the
instrumental analysis in an articulator that is
adjusted to the individual being examined, factors
disturbing the occlusion during speech can be
identified. Further associations are then revealed
and lead to meaningful results and conclusions
regarding therapy. The procedure is similar to
recording mastication. A free, protrusive joint
track is plotted in red on both sides and superim-
posed with a recording of the speech process in
black. In doing so, the sagittal recording is
assessed in its position, relative to RP and to the
joint track, and the symmetry of both sides is
evaluated. The transversal behavior during the
recording is also of great importance. Of course, in
this case, mechanical recording is clearly inferior
to electronic recording.
 Diagnostics - Clinical Functional Analysis - Instrumental devices

Ill. 260: The protrusion track of the subject with a superim-

posed speech pattern is totally relative to the border track.

Ill. 259: The contralateral side also reveals pure canine con-
trol.

Ill. 262: The superimposed speech pattern deviates strongly

from the border track.

Ill. 261: Protrusion and laterotrusion contacts in the articu-

lator for this subject are entirely different, with eccentric
interferences.

Ill. 264: The speech pattern is also not related to the border
track, but clearly rises from it.

Ill. 263: In this case, there is a strong mediotrusive interfer-

ence.

411
R. Slavicek • The Masticatory Organ

Ill. 265: The protrusive recording of a patient with symp- Ill. 266: Mastication recordings shows a clear deviation of
toms in the suprahyoid region; the track is asymmetrical in the masticatory loop on the left side, with a strong retral
quantity, the characteristics are concave, and the quality is, component.
at best, average.

Ill. 267: The recording of the speech function in superimpo- Ill. 268: The mandible of the patient. An early extraction of
sition shows the extreme asymmetry and transversal devia- the first molar on the left side caused a tipping of the second
tion from the protrusion. and third molars.

Ill. 269: Tipping and "closure" to the maxilla are evident. Ill. 270: The lateral X-ray shows the sharp bend in the
occlusal plane in the molar region.

412
 Diagnostics - Clinical Functional Analysis - Instrumental devices

In the standardized speech sequence, the patient

is asked to count backwards from 90, so that
speech is less automatic and more accentuated.
Without doubt, the quantity of rotation is also
important, but cannot be recorded with the
mechanical method.
If a detailed analysis of the very important func-
tional diagnostics of "speech" is to be achieved, an
electronic device must be employed. In many
cases, it is particularities in the speech pattern that
cause problems leading to muscular avoidance
mechanisms with far-reaching consequences. The Ill. 271: Excessively steep (negative) protrusion movements
use of electronic joint track recording in conjunc- may be indications of this kind of avoidance, but may also
tion with phoniatrics has proven very valuable. indicate mechanical functional problems in the joint.

Stress management
The protrusion track (red) must also be recorded
before the investigator starts to register parafunc-
tional processes with the mechanical device. The
patient is instructed to perform clenching and
bruxing movements either on the existing facets
or in maximal intercuspation. This should be done
as realistically as possible and forcefully. The
recorded tracks are then superimposed on the free
protrusion track and analyzed. Special attention
should be given to compressive and distractive
tracks. The procedure discloses the significance of
existing abrasion facets in relation to the behavior
of mandibular joints from the viewpoint of the
course of movements. The tracks can easily be
read electronically, as the electronic mode permits
storage of data. Thus, the individual sequences
can be repeated and examined in detail.
In the parafunctional pattern, we distinguish
between neutral, deflecting and compromised
behavior. The definition and evaluation of possible
contacts in articulation are rendered possible by
means of differential diagnosis between
orthobalance and hyperbalance. Dynamic com-
pression behavior can be registered with this clin-
ical instrumental method, whereby retrusive
bruxing patterns, which frequently show deflect-
ing behavior, are of special importance.

Deglutition
Deglutition is a very significant functional area of
the masticatory organ and usually proceeds auto-
matically. During all other functional processes,
this function occurs in between or is initiated at

413
R. Slavicek • The Masticatory Organ

Ill. 272: The speech pattern is asymmetrical and directed to Ill. 273: An overlay of a speech pattern on the protrusion
retral. track.

Ill. 274: Asymmetrical speech pattern: the scheme shows a Ill. 275: Deglutition pattern and clenching pattern near the
joint track displayed in red. The overlay (blue) shows the Reference Position, somewhat compressed, on the left.
patient's speech pattern. In this case, the avoidance mecha-
nism affects the function and not the border movement.

Ill. 276: A mastication scheme, the right side is laterotru- Ill. 277: Eccentric bruxism, a bruxism pattern rising retrally
sively emphasized. to the right side.

414
 Diagnostics - Clinical Functional Analysis - Instrumental devices

the end, as in mastication. Swallowing, empty

swallowing or swallowing air are subject to strong
psychic influences. The processes during deglutition
should be thoroughly discussed from the view-
point of logopedics, orthodontics and functional
disorders. In addition, the entire myofunction of
the mouth should be recorded diagnostically and
evaluated.
By means of joint track recordings with reference
to the axis, the position at which deglutition takes
place can be registered. Here, the position relative
to the border track, to the Reference Position and
to ICP should be evaluated. With regard to repro-
ducibility, it is important to compare the position
by repeating the procedure. As mentioned previ-
ously, a protrusion track recorded in red is used for
reference in the mechanical method. In order to
avoid non-physiological empty swallowing,
approximately 2 ccm of water is sprayed into the
patient's mouth from a prepared syringe. With
the aid of the electronic method, deglutition can
be documented much better. Functional patholo-
gies in deglutition have multiple effects on the
entire system. Regular deglutition is a very pre-
cise, reproducible pattern, generally coupled with
an ICP of good quality.

Conclusions
Recordings of joint movements relative to the hinge
axis are historically a part of the study of articulation.
Recordings near the joint and electronic methods
that allow for retrospective calculation of the joint
distance can also be used for diagnostic purposes. It
is necessary to correlate such recordings with other
findings from the clinical functional analysis.
Quantifying and qualifying the records makes it pos-
sible to classify them along with other findings. The
greatest advantage, however, seems to be the possi-
bility to make recordings of functional processes in
addition to border movements. Based on the results
obtained thus far, it appears justified to regard para-
functional processes in the functions of the mastica-
tory organ as causal phenomena in CMD patients.
The use of condylographic methods may help in the
process of decision-making as far as differential diag-
nosis is concerned. Ligamentary behavior is better
documented with this method than with physio-
therapeutic manipulation.

415
R. Slavicek • The Masticatory Organ

Instrumental functional analysis

with the CADIAX® Compact:
For the practicing dentist, it is especially impor-
tant to achieve this goal as quickly and economi-
cally as possible. With the aid of the aforemen-
tioned and discussed steps, it is possible, in a sui-
table articulator, to evaluate an exact cast statical-
ly from the viewpoint of occlusal determination
and relative to the joint. It is also possible, with
the aid of additional instruments, to diagnostical-
ly qualify and quantify the differences in the joint
positions in ICP and RCP.
One major shortcoming, however, is that the
dynamics of mandibular movement do not fit
into this simple diagnostic procedure. Not only
the elementary articulators, but also those of
highest quality are hardly ever programmed and
applied dynamically in daily routine, as several
dentists are deterred from using "laborious" diag-
nostic procedures and complex systems.
Naturally, this happens at the expense of detailed
diagnostic findings and, more importantly, to the
detriment of subsequent reconstructive and
therefore invasive measures.
Unfortunately, this drawback is also a problem in
international follow-up studies, some of which are
critical of occlusion. The overwhelming majority
of the studies have been carried out on devices of
average quality, but the results were evaluated
with high-quality statistical methods. The con-
clusions were drawn from results based on impre-
cise original information; therefore, their value is
questionable.
The simple Compact system was developed with
the goal of serving as a connection between the
articulator and joint dynamics.
Using this simple system, the dental practitioner
is able to make a quick recording of mandibular
movement before the mandatory facebow regis-
tration. It then becomes easy to apply the results
of the recordings to programming the articulator.
Here, it is not necessary to localize the hinge axis,
because translatory and not rotational movements
are mainly used when the articulator is pro-
grammed. A major advantage is that the system
is not restricted to any particular articulator, but
can be employed with any of a number of types
that allow for the skull-related and/or joint-rela-
ted principle and are dynamically adjustable.

416
 Diagnostics - Instrumental Functional Analysis

A further significant advantage of the method is

the possibility to record and document special
features of the movements. This might disclose
information that helps to differentiate "uncompli-
cated" patients from "more complex" ones, so that
the latter may be subjected to thorough diagnos-
tic procedures with appropriate methods.
The simple Cadiax Compact system is not sui-
table for such detailed diagnostics; a systematic
analysis, as described in detail in this book, would
then be the method of choice.

Ill. 278: Insertion of the clutch, which covers the occlusion.

Ill. 279: Pushing down the mass to cause as little vertical

lock as possible.

Ill. 280: The clutch should be aligned as straight as possible.

417
R. Slavicek • The Masticatory Organ

Ill. 281: … horizontal. Ill. 282: Putting on the aural facebow.

Ill. 283 Ill. 284

Ill. 285: The finished set-up of the bow rests reliably and stable. Ill. 286: Attaching the lower registration bow.

418
 Diagnostics - Instrumental Functional Analysis

Ill. 287: Alignment and … Ill. 288: … screwing it down.

Ill. 289: This detail shows the measurement of facial width; Ill. 290: The adjustment bolts clicked on the side-arm in
the system converts automatically to the articular distance. arbitrary axis position.

Ill. 291: Removing the adjustable bow. Ill. 292: Detailed photograph.

419
R. Slavicek • The Masticatory Organ

Ill. 293: The position of the lower bow centered to the upper. Ill. 294: Before attaching the transmitter and recorder.

Ill. 295: The electronic flags. Ill. 296: Attaching the flags.

Ill. 297: Attaching the styli. Ill. 298: Connection to the basic device.

420
 Diagnostics - Instrumental Functional Analysis
Ill. 299: The position of the styli on the registration block.
Ill. 301: The basic unit is a mini-computer especially
designed for this purpose. The following advantageous fea-
tures have been successfully incorporated in the device: easi-
est possible handling, fast, dependable data acquisition and
display with mathematical conversion for individually set-
ting the condylar elements of the articulator. The results can
be stored, documented and printed on a data sheet. Thus, a
relationship with the dental technical laboratory is estab-
lished. At the same time, it is a graphic documentation of
the current condylographic functional status of the
mandibular joints.
Ill. 300: Connecting up.
Ill. 302: After checking the properly attached bow system,
the reference position is entered under controlled guidance.
The instructed patient carries out the customary basic
recordings without making contact with the clutch; protru-
sion/retrusion, mediotrusion/medio-retrusion left and right,
opening/closing. The reference position and the quality are
checked at this point. The system makes it possible to start
simple diagnostics and to program the articulator. The selec-
tion of condylar elements, determining the SCI and TCI are
calculated and produced by the device. If a functional clutch
is attached (this means that ICP can be achieved), a
mandibular position analysis can also be carried out in the
CPM mode.
421
R. Slavicek • The Masticatory Organ

Ill. 303: Upper jaw facebow after the recording. Ill. 304: Holding the bite fork tightly.

Ill. 305: Docking the bite fork. Ill. 306: Removing the bow after the recording process.

422
 Diagnostics - Instrumental Functional Analysis

Instrumental functional
analysis

Most dental activities are associated with and

characterized by work on plaster casts. The
patient is represented by the model in this appli-
cation for demonstration. The model is then com-
monly (but not always, unfortunately) mounted
on devices that define its spatial correlation. The
spectrum of devices ranges from the simple
occludator to complex articulators and simulators,
which then not only verify static relations, but can
also duplicate dynamic processes.
In the course of complex diagnostics, such devices
permit the registration and analysis of static and
dynamic processes in the masticatory organ to a
certain degree.
The following will describe one of the "instrumen-
tal" analyses, which, however, is merely one of se-
veral variations. The examiner should acquaint
himself/herself thoroughly with one method and
learn to perform it perfectly. It is important to
constantly check each of the procedural steps.
I begin here with the transcript of a lecture I
delivered in Washington in 1988, on the occasion
of the annual congress of the former A.A.C.D.,
where I had to answer precise questions regarding
the method, with precise answers.

423
R. Slavicek • The Masticatory Organ
Methods that involve instruments and are
used on the patient and in diagnostics must
fulfil the following requirements:
• Safety
• Validity and dependability
• Diagnostic sensitivity
• Diagnostic specificity
• Prognostic value of the finding
• Prognostic value of a negative find-
ing
• Evidential value within a scientific
examination procedure for creating
standardized data acquisition
• Repeatability and reproducibility
• Findings of additional interest
• What will the diagnostic method be
used for?
• When is the application of this
method justified?
• The dentist's responsibility with
regard to whether he/she does or
does not use the application
424
"Instrumental Functional Analysis" -
a definition
Instrumental functional analysis is concerned with
the exact casting of the impression of the denti-
tion, the production of casts and the mounting of
casts on an "articulator". The cast is mounted in
anatomical relationship to the skull and the joints.
The goal is to examine and analyze static and
dynamic relations of the dentition from the view-
point of occlusion and the joints. The precision
and reproducibility as well as the diagnostic possi-
bilities and projections of such an assemblage of
dental casts in an articulator should then be sub-
jected to a critical evaluation. The value of "instru-
mental functional analysis" is not based on clinical
registration of patient data. Rather, it is an analy-
sis based on casts of the dentition. It should,
therefore, be regarded as a necessary complement
to clinical functional analysis, but by no means as
a substitute for it. It does, however, allow for a
more exact and detailed evaluation of the teeth
and of dental relationships, and, under appropri-
ate conditions, also of occlusal and articular rela-
tionships. The procedures integrated into the con-
cept "instrumental functional analysis", represent
a standardized sequence of clinical and laboratory
technical steps with the goal of recording and
diagnostically evaluating the static and dynamic
relations of the teeth and temporomandibular
joints. The steps and procedures required for the
standardization of instrumental methods are car-
ried out according to the customary criteria of sci-
entific methodology.
Procedures (list of work procedures)
• Creating exact casts of the dentition and
related structures
• Verification of the retral physiological position
(or pathophysiological position) of the
mandibular joints (RP or DRP)
• Creating a possibility to transfer this lower
jaw relation as a diagnostic reference position
(centric registration)
• Obtaining a plane relative to the reference
position, construction of a coordinate system
 Diagnostics - Instrumental Functional Analysis

with reference to the joints

• Placing the dental cast in the articulator
according to criteria appropriate to the skull
and joints
• Mandibular position analysis
• Tooth position analysis
• Analysis of the dynamics of mandibular move-
ment after programming the articulator
appropriately to the joints
Each of these steps must be checked for accuracy Each of these steps must be checked for
and reproducibility. There might be overlaps accuracy and reproducibility.
between clinical applications and intermediate
technical steps, depending on the materials.

Creating exact dental casts

Nearly all disciplines of dental, oral and orthope-

dic medicine utilize plasticine casts for the repre-
sentation and documentation of relationships in
the mouth. The method of choice is correct cast-
ing with irreversible Hydrocolloid (Alginate),
whereby careful casting of the functional surfaces
is especially important.
A cast is created with super-hard plaster in the
prescribed proportions for the mixture. Care must
be taken to ensure optimal compatibility between
the casting material and the impression material.
In order to allow all further steps to be checked, a
"split cast" must be made. The surfaces of the cast
should be examined with a magnifying glass for
minute errors, or even better, under a microscope
(10-20 X magnification), and corrections must be
made where necessary. If further steps are antici-
pated in the occlusal diagnostics, it is recom-
mended that a pinned cast be made for the lower
jaw, affording the ability to isolate individual teeth.
When the accurate casts have been completed, a Lauritzen, A. G.: Atlas of Occlusal Analysis. HAH Public.,
standardized cast analysis is performed. Casts of Colorado Springs 1974
the upper and lower dentition are first evaluated Motsch, A.: Funktionsorientierte Einschleiftechnik für das natür-
separately and then brought into intercuspation. liche Gebiß. Carl Hanser Verlag München, Wien 1977
Meyer, G.: Entwicklung und Anwendung eines elektronischen
The quality of ICP relative to the casts is evalua- Verfahrens zur dreidimensionalen scharnierachspunktbezüglichen
ted and the point of first contact from intercuspa- Registrierung von Unterkieferbewegungen für die
tion is registered. Other findings from the inter- Funktionsdiagnostik des stomatognathen Systems. Dissertation,
cuspation of the casts are documented in writing. Göttingen 1986

425
R. Slavicek • The Masticatory Organ

Ill. 307: The lower jaw primary after exact casting in the Ill. 308: The view of the left side shows a very slightly
occlusal view. formed Curve of Spee in the region of the premolars and
molars. Only the canine is distinctly higher than the lateral
tooth area, a typical characteristic of Class II/1.

Ill. 309: The frontal view shows distinct crowding and supe- Ill. 310: In the right lateral view, the lateral segment inclu-
riorly directed convexity of the front teeth. ding the canine shows a moderated, compensation Curve of
Spee.

426
 Diagnostics - Instrumental Functional Analysis

Ill. 311: The upper jaw cast in the lateral view from the left, Ill. 312: The right side also reveals this gap, the third molar
with a distinct gap between the canine and small incisor. is tipped posteriorly.

Ill. 314: In ICP on the cast, a large, sagittal step is seen. The
Ill. 313: In the anterior view, the incisors lie approximately right side intercuspates in full Class II.
at the same level.

427
R. Slavicek • The Masticatory Organ

Ill. 315: The view from the left is conspicuous in that the Ill. 316: In the anterior view, the wide apical base of the
intercuspation roughly corresponds to a Class I. maxilla and the internal inclination of the lateral teeth are
seen.

Ill. 317: In the view from the back, the lower front rises into Ill. 318: The lateral view reveals the conspicuous feature of
the palatal tissue. new contact of the distal inclination of the canine to the
mesio-lingual cusp of the upper premolars.

Ill. 319: On the right side the first molar intercusps in Class I.

428
 Diagnostics - Instrumental Functional Analysis

Verification of the retral physiological posi-

tion (or pathophysiological position) of the
temporo-mandibular joints.

In the course of instrumental diagnostics which

we applied and have described here, this position
will be termed the reference position (RP), and
may be defined as follows:

Both temporomandibular joints are located in Both temporo-mandibular joints are

translatory fashion in their retral border position, located in translatory fashion in their
the structures of the joints are not under tension; retral border position, the structures of
the condyles are located in the structures of the
the joints are not under tension.
corresponding articular disks, in contact with the
articular eminence. The position is a joint-relative
one and is not determined by the occlusion. It is
dependent on and influenced by the ligamentary
situation and determined by the muscles of the
CMS. A further retral movement can only be exe-
cuted under tension of the ligaments or by lifting
structures further up or posterior to the eminence.
In cases of a "loose" ligamentary situation, a retral
shift or side shift of the condyle into the disco-
condylar compartment is also possible. If the sys-
tem closes in RP, an antagonistic contact is
achieved in a dentulous person. Every contact of
antagonistic teeth or rows of teeth is termed
occlusion. This initial contact in RP is known as
the retral contact position or RCP. The retral con-
tact position differs, in most cases, from maximal
intercuspation (ICP) of the casts.

Rotation and translation can be evaluated and

quantified separately from this reference position,
so that clinical linear measurements of the incisal
area (SCD) can be converted to the angular rota-
tion in the articulator.

Diagnostic evidence resulting from this examina-

tion: internationally, it is customary to determine
the range of movement (mobility) of the joints in
orthopedic findings according to the "neutral-zero
method". Here, potential joint movements within
their physiological borders are determined in
degrees of angles and compared with standard
values. The respective unforced mid-positions of
the joints to be recorded serve as reference posi-
tions.

429
R. Slavicek • The Masticatory Organ
The temporo-mandibular joints are not
included in this international convention.
The "retral border position" of the mandibu-
lar joints is used as the reference position in
diagnostic evaluation of the stomatognathic
system in instrumental analysis.
430
The temporo-mandibular joints are not included
in this international convention. In instrumental
analysis of the masticatory organ, we use the retral
border position of the mandibular joints in the
articulator as the basis for mounting the joint-rel-
ative to the casts. In contrast to all other joints in
the human organism, there is no "unforced" mid-
position which the temporo-mandibular joint
assumes. The retral translation border position is
used as the zero position, as it is diagnostically
reproducible. I call this position RP or the refer-
ence position.
In clinical functional analysis, we utilize various
methods to record the mobility of the temporo-
mandibular joints, both quantitatively and quali-
tatively. The methods are seemingly standardized
and several epidemiological studies have been
based upon them. However, quantification by
means of a linear opening measurement is an
incorrect method, because the difference in size
does not allow for comparative geometry, as all six
degrees of freedom require assessment, as well as
rotation and translation.
A further error in simplified methodologies con-
sists of not evaluating translation and rotation
together. The "retral border position" of the tem-
poro-mandibular joints is used as the reference
position in diagnostic evaluation of the stomatog-
nathic system in instrumental analysis. The com-
parison of this retral border position to the normal
occlusal position, maximum intercuspal position
(MIP) is recorded diagnostically, both qualitative-
ly and quantitatively.
The definition of the retral position, its terminol-
ogy and the significance of the difference between
a retral relation and intercuspation, are long-
standing subjects of scientific discussion.
 Diagnostics - Instrumental Functional Analysis

Ill. 320: Preparing the lower arch for a "pinned cast". Ill. 321: The arch in a split-cast form.

Ill. 322: The form, filled with stone for a base. Ill. 323: Completed cast of the lower dentition and related
structures.

324: After successful assemblage, the cast is sawn through;

all of the teeth in the lateral tooth area are sectioned and the
anterior block of teeth is removable.

431
R. Slavicek • The Masticatory Organ

Ill. 325: The controversial "retral border position" of the

mandible serves as reference of the range of movement. The grip
of the thumb and forefinger embracing the chin is a "controlling"
one, whereby the joint structures are not stressed.

Ill. 326: This diagram of a copy of Posselt's scheme from a text-

book dealing with function exaggerates the sagittal component
and dramatizes the difference between RCP and ICP.

Ill. 327: This photograph of a sketch, from a course in 1972,

shows the average reality of the so-called "slide in centric". The
sagittal component is only a third of a millimeter. Clinically, in
contrast, the vertical component is distinctly visible.

432
 Diagnostics - Instrumental Functional Analysis

Ill. 328. The vertical difference for the majority is also less than 0.3 mm.

Ill. 329: The sagittal difference for the great majority lies below 0.3 mm.

Ill. 330: Based on available statistics from more than 4500 patients, the transversal diver-
gence between ICP and RCP in the joint is no more than a few hundredths of a millime-
ter.

433
R. Slavicek • The Masticatory Organ

Open questions and discussions

Is this retral position as the reference position

significant in the diagnostics of the
functional state of the masticatory organ?
The customary determination or proof of differ-
ences between RCP and ICP in clinical functional
analysis does not allow for conclusions regarding
the quantity or quality of deviation in the joint
region. If diagnostic evidence is inferred from a
discrepancy, then the instrumental diagnostics
become exclusively authoritative. All clinical con-
clusions regarding the extent or direction of the
"slide in centric" in a patient are speculative in
nature. Imaging methods of joint representation,
including computer-assisted methods, are entirely
unsuitable for detailed diagnostics.
Therefore, in order to determine the possible
effects of differences between RCP and ICP on the
CMS, it will be necessary to perform an instru-
mental evaluation, in which both the quantity
and quality of the shift can be confirmed three-
dimensionally.

To what extent is this position reproducible,

i.e. to what extent can it be repeated on the
patient?
Using suitable methods, it has been shown, scien-
tifically, that even beginners can obtain repro-
ducible results in determining the reference posi-
tion of the temporo-mandibular joints. In addi-
tion, reproducibility has been confirmed inter-
operatively by several examiners. Prerequisites for
achieving this goal are mastery of the method and
strict adherence to all instructions during the pro-
cedures, which should be continuously controlled.

Is this reference position modifiable by means

of therapeutic measures?
The experience of all authors has shown that the
retral border position (RP) can be altered by the-
rapeutic measures on the dysfunctional patient.

Is it physiologically acceptable that the refe-

rence position and ICP match, and to what
extent is this match stable and reproducible,
in a biological sense, after therapeutic measu-

434
 Diagnostics - Instrumental Functional Analysis

res have been concluded?

If, in the course of reconstructive measures, ICP
and RCP match, then the position is physiologi-
cally acceptable and, in the biological sense, sta-
ble. Evidence of discrepancies in the realm of a few
tenths of a millimeter is no evidence of the con-
trary, but is based on misguided thinking by way
of regarding the biological system and life itself as
a static and not a dynamic phenomenon.
For this reason, it is time to terminate the dissat- For this reason, it is time to terminate the
isfying discussion about this fiction in dentistry, dissatisfying discussion about this fiction in
the so-called "centric relation". All attempts at a dentistry, the so-called "centric relation".
definition have failed, as the efforts have been
focused on trying to determine the position of the
mandible according to anatomical facial points.
The border positions of all joints in the human The border positions of all joints in the
body are known and accepted as physiological human body are known and accepted as
borders. Because of the special characteristics of physiological borders.
the human temporo-mandibular joints, a specific
kind of system emerged during evolution. The
system equipped the retral space of the joints for
positional change. The disturbance-free function-
ing system has a definite retral border position
during controlled, but not forced, guidance,
which can be registered and displayed and is
reproducible. This retral, unforced position of the
mandible is the reference position (RP) for the
diagnosis and therapy of the occlusal relation. A A requirement for this definition is integrat-
requirement for this definition is integrated ed behavior between the condyle and the
behavior between the condyle and the disk. If this disk.
is not the case and the joint is partially or com-
pletely dislocated in the retral position, it is
referred to as a deranged reference position
(DRP). Nevertheless, the position is capable of
serving as a reference position, which can be used
as such in therapy.
Clinically, the reference position can be obtained,
irregardless of RP or DRP, through unforced con-
trol of the retral border position on the tip of the
patient's chin with the patient sitting upright,
without occlusal contact, the mouth relaxed and
slightly open.
It should be repeated here that this technique is
concerned with determining the current condition
of the joint for diagnostic purposes. This is not a This is not a contradiction of other tech-
contradiction of other techniques whose purpose niques.
is to obtain speculative positions for definitive
therapy by means of manipulation or the use of
auxiliary measures such as the "leaf-gage" tech-
nique.

435
R. Slavicek • The Masticatory Organ
Ill. 331: A wax plate (beauty pink x-hard) serves as the base.
Ill. 332: The lower jaw is guided to retral position in three
aluwax stops.
Ill. 333: The preferred method is separate wax registration
(Lauritzen), because it does not interfere with the lingual
functional space..
436
The reference position described above concerns
the actual situation, the present status of the
CMS (ill. 331-333, p. 436).
I use the following methods for instrumental
registration:
• Plate registration
• Separate wax registration
All registrations are done in the unforced, retral
physiological border position. Registration with
the central supporting pin is proposed by many
and recommended in functional diagnostics. I no
longer use this method, because I consider it too
laborious and susceptible to error. Recording is
carried out through the patient's musculature,
describing a so-called arrowhead angle, by means
of free, non-guided exercise movements. The re-
gistering plates are fixed in this retral border posi-
tion (arrowhead angle) with plaster, followed by
the diagnostic montage.
Recent attempts to enhance the value of the cen-
tral supporting-pin method by means of electro-
nic aids and to obtain reproducible odontoscopic
results have been refuted.
Generating a coordinate system
appropriate to the reference position
(appropriate to the joint)
Establishing the mandibular hinge axis makes it
possible to use it, in its retral, physiological and
unforced position, as the reference position appro-
priate to the joint. Conventionally, the left orbital
point or orbitale, an anthropological landmark, is
used as the anterior reference. This establishes a
reference plane, which is recorded by a facebow,
and used for transferring the model into an arti-
culator. Here, it does not matter whether you pre-
fer the old primary mandible-dominant montage
of the European school or decide in favor of the
more complex method of the European-American
school (Hanau-Thielemann), namely that of pri-
mary maxillary montage. Based on published
studies, the localization and representation of the
hinge axis can be assumed with a radius of
 Diagnostics - Instrumental Functional Analysis

0.8 mm for reproducibility in the kinematic dis-

play technique. Using electronic aids, it seems
that even this minimal error can be reduced.
The effects of these errors have been studied and
depicted relative to occlusion. This coordinate sys-
tem should be retained, if possible, for all further
diagnostic methods.

Attaching the jaw models in the articulator

As mentioned, this is carried out in accordance

with criteria related to the skull and joints. The Ill. 334: Most modern articulators have an intercondylar
fixed distance of 110 mm. The fixed geometry can be
technical steps in the laboratory for mounting on
equalized by means of dynamic adjustment parameters.
an articulator are critical and susceptible to error.
However, by careful workmanship and strict
adherence to the guidelines, the procedure can be
performed accurately and without error. The pro-
cedures can be checked in a manner that resem-
bles practical application, by using the split-cast
control method from Lauritzen.

Analysis of mandibular position

The casts mounted on the articulator are oriented

to the retral reference position and the joint. This
position can be repeated with the articulator with- Ill. 335: The coordinate systems on the skull, the lower jaw
out any problems. The reference position is gener- and in both parts of the articulator should match.
ally established in the retral contact position to
the occlusion (RCP). Because of the construction
of conventional articulators, the setting cannot be
adjusted to maximum intercuspation. In order to
compare the position relative to the joint with the
occlusion-dominant position, one uses additional
devices. This mandibular position analysis allows
the investigator to record the occlusion-dominant
of ICP quantitatively, in accordance with the coor-
dinates. Such diagnostic methods have long been
standard, but the first true three-dimensional evi-
dence was achieved with the condymetry provid-
ed by Gausch and Kulmer. Practical methods
were developed for mandibular position analysis
and/or condylar position analysis and gained
widespread acceptance. In addition, it is possible
to compare the positions electronically by means
of three-dimensional data acquisition (ill. 334-
335, right; ill. 336-356, pages 438-441).

437
R. Slavicek • The Masticatory Organ

X
Y

Ill. 336: The articulator is a coordinate system that allows Ill. 337: With a simple, anatomical transfer bow, transfer of
for skull-relative or joint-relative transfer of dental casts. the upper jaw’s relationship, adjusted to the skull, is started
in the articulator.

Ill. 338: The bite-fork, coated with reference material, is Ill. 339: … and clamped onto the facebow.
held firmly …

Ill. 340: Removing the facebow for instrumental functional

analysis.

438
 Diagnostics - Instrumental Functional Analysis

Ill. 341: The anatomical parallel facebow locked onto the Ill. 342: The upper cast is mounted in this position with
articulator with its bite-fork and a cast of the upper denti- quick-setting plaster.
tion supported in relationship to the articulator.

Ill. 343: An example of assemblage of the upper cast, rela- Ill. 344: Preparation for lower cast mounting with applied
tive to the hinge axis, with a so-called "exact" bow. registering strips.

Ill. 345: Preparation for lower cast mounting with applied Ill. 346: The lower cast is placed in the registration device.
registering plates.

439
R. Slavicek • The Masticatory Organ

Ill. 347 Ill. 348

Ill. 349 Ill. 350

Ill. 347- 350: After mounting, this procedural step must be verified by means of a split-cast control. In addition, the reproducibili-
ty of the reference position should be checked by means of a second centric registration. Now the articulator allows the RCP (retral
contact position) to be represented; the mouth can be examined. The ICP (intercuspal position) cannot be determined with certain-
ty, because the structures of the articulator have an inhibiting effect. Therefore, it is recommended that a mandibular position
analysis be performed at this time, in order to diagnostically record the influence of occlusion on the mandibular joint.

440
 Diagnostics - Instrumental Functional Analysis

Ill. 351: Instead of the condylar housing, CPM cubes Ill. 352: The reference position is marked on the left and
equipped with registering labels are inserted. right after removing the cubes with red foil in between.

Ill. 353: On the back side of the upper part, the transversal Ill. 354
position is marked on foil with a needle.

Ill. 355: The position is marked on labels by removing the Ill. 356: The transversal deviation is also fixed by etching.
cubes again. This permits a three-dimensional analysis of mandibular
position.

441
R. Slavicek • The Masticatory Organ

Analysis of tooth position

The significance of instrumental analysis becomes

very evident in the spatial location of the teeth.
The system is fixed as a measurement system
through the reference position and reference plane
(articulator). For the coordinate system, a
Cartesian system rotated to the right is estab-
lished. When this is correctly applied, the spatial
position of the individual teeth and of the com-
plete dentition in the entire system can be
Ill. 357: Back view of the registering label with the adjust-
ment base.
defined. This is a prerequisite for diagnostics as
well as for planning therapy (wax-up and set-up).

Analysis of the dynamics of mandibular

movement

This can only be carried out with an individually

programmed articulator. Analysis from articula-
tors set for average values are misleading and sci-
entifically questionable. The same is true for pub-
lications that make statements regarding the
Ill. 358: Side view of the label after registration of the ICP.
dynamic relations of the teeth without using indi-
vidually adjusted articulators.
It is possible to set suitable articulators according
to instrumental joint track recordings. When this
is done, the recordings of temporo-mandibular
joint border movements are used for individual
programming of the articulator. This makes it
possible to reproduce a very good approximation
of the movements in the mechanical system of an
articulator, which is invaluable in diagnostics as
well as in reconstruction. Comparisons with clini-
cal methods show good matching, but also reveal
the distinct limitations of instrumental methods
that are applied to rigid cast models. The natural
resilience of the structures is missing.

442
 Diagnostics - Instrumental Functional Analysis

Ill. 359: Diagnostic equilibration in the articulator is done Ill. 360: The articulator is fixed in the reference position.
under strict control of the vertical on the incisal pin.

Ill. 361: The sequence of early contact is entered in the occlusal Ill. 362: The form at the end of the procedure serves as a
scheme and sequentially numbered; the incisal pin height is reference if equilibration is also done on the patient.
entered at the beginning and at the end of the process.

Ill. 363: The cast of the upper jaw is not pinned and already Ill. 364: The lower cast is double-pinned and sawn through.
carries the markings of the procedure.

443
R. Slavicek • The Masticatory Organ

Ill. 365: In this case vertical is raised by 5 mm. Ill. 366: The sequence of early contacts during the proce-
dure is noted and marked in the base.

Ill. 367: The sketch of the goal of a wax-up is determined by Ill. 368: In a diagnostic wax-up, the planned vertical is set on
the dentist. the incisal pin; the articulator is programmed eccentrically.

Ill. 369: This sketch applies, in this case, to the determina-

tion of the future occlusal plane and the canine tips for the
active centric of the lower jaw.

444
 Diagnostics - Instrumental Functional Analysis

Ill. 371: On this duplicate cast, the dental technician contin-

ues the diagnostic set-up and wax-up in detail, according to
the sketch.

Ill. 370: The strongly protruding front teeth are shaped and
then arranged in a planned position and inclination.

Ill. 372: The right side in full Class II. Ill. 373: The left side is made in Class I.

445
R. Slavicek • The Masticatory Organ

Ill. 374: The first search for contact, occlusally. Ill. 375: Contacts in the lower arch.

Ill. 376: The clean, lingual Class I dentition on the left side. Ill. 377: Class II dentition of the right side, from a lingual
view. Note the typical intercuspation of the lingual cusp of
the first upper premolar to the distal slope of the lower
canine.

Diagnostic equilibration, diagnostic wax-up and, if necessary,

diagnostic set-up, are frequently used together in complex
cases. In unison, they are used to develop treatment plans
that concern all disciplines of dental, oral, and orthopedic
medicine. The dentist is responsible for the initial sketch of
the initial occlusal plane and for determining the concept of
occlusion.

Ill. 378: Intercuspation of the canine group.

446
 Diagnostics - Additional Diagnostics

Additional Diagnostics

During extensive functional analysis, it will occa-

sionally be necessary to request additional informa-
tion and to process it using diagnostic methods.
Here we list the main options that can be used to
supplement the diagnostic procedure.

• Lateral X-ray Scintillation graphs

• Radiological imaging techniques
• Magnetic resonance imaging of the
mandibular joints (MRI) MRI
• Scintillation graphs
• Biofeedback, electromyographics
• Psychic diagnosis Biofeedback
• Physiologic diagnosis
• Logopedic diagnosis
Cephalometrics

Lateral X-ray
Understanding the different individual phenotypes
of human "races" requires the application of certain
principles of classification. This can be achieved
within the framework of "cephalometric analyses"
using lateral and frontal X-rays.

447
R. Slavicek • The Masticatory Organ
Ill. 379: The face, from a lateral view.
Ill. 380: In cephalometric analysis, the construction and
architecture of cranial structures are of great importance.
Ill. 381: Lead-markings of points on the skin.
448
Lateral X-rays and their evaluation are the foremost
and most commonly used procedure. The basic
principles must be understood and mastered not
only by orthodontists, but also by all dentists work-
ing with the masticatory organ.
Within the field of extensive functional diagnostics,
once a hinge-axis related registration of the joint
track is performed and a diagnostic analysis of the
same made, it is common to make an image of the
patient's skull in a lateral view - a so-called ceph or
lateral X-ray. This diagnostic method is not only
employed in orthodontics, but also routinely in a
functional diagnosis. The patient's soft tissue profile
is always viewed laterally. The advantage is that
one is able to assess the contours of soft tissue pro-
file as it relates to the skull (ill. 379-381, left;
ill. 382, p. 449).
Procedure for obtaining
a lateral X-ray
• Attach lead markers to fix the axis-orbital plane
• Instruct the patient
• Fixing and adjustment of the patient in the
cephalostat; removal of ear plugs; taking the
image
• Develop the film and control the result
• Trace the hard and soft tissues
• Evaluate the lateral head X-ray
• Diagnostic evaluation
• Interactive planning
Attaching the lead markers to fix the
axis-orbital plane
The skin markers attached after registration of the
hinge-axis related joint track are used to set up a
common diagnostic coordinate system that had
been previously determined by the instrumental
functional analysis. The markers indicate the right
and left hinge-axis skin marks and the left orbital
point (orbitale cutaneum), projected onto the
immobile skin of the nose. The latter is used in a
hinge axis - orbitale facebow transfer, so that the
 Diagnostics - Additional Diagnostics

maxillary cast for functional analysis can be mount-

ed correctly and appropriately to the skull. These
points must also be entered for the lateral X-ray, in
order to be able to create a common coordinate sys-
tem for the diagnostic procedure in conjunction
with the instrumental analysis. By this method, it
becomes possible to incorporate the hinge-axis-rel-
ative joint track recordings into the lateral X-rays.
This is done by attaching lead markers (1 mm
diameter) to the skin markers. They leave conspic-
uous marks on the film and thereby determine the
hinge axis and the hinge-axis-orbital plane on the
lateral and/or frontal films.

Ill. 382: An example of a cephalometric overlay. The lateral

Patient instructions head X-ray "projects" the spatial image of the skull on the
median-sagittal plane. The overlay evaluation is subject to
Accurate arrangement of the patient in the laws of descriptive geometry. All landmarks and "planes"
cephalostat is important for the quality and usabil- are subjected to this principle.
ity of the lateral X-ray. A prerequisite is profession-
al setting of the X-ray device and the cephalostat.
This calls for painstaking and careful adjustment
of the patient, as well as, attachment of auxiliary
devices needed for alignment. The precise align-
ment of the glabella support is of paramount
importance for the technique. After inserting the
ear plugs, the patient is informed that the side sta-
bilizers will be removed shortly before the image is
taken, in order to prevent lateral displacement of
the lead skin markers. The patient must maintain
this position of the head, without support. For this
purpose it is important that he/she bend forward
and support himself/herself on the glabella support.
The patient needs to be instructed to keep the den-
tal arches in occlusion when the image is taken.

Fixing and adjusting the patient in the

cephalostat; removal of ear plugs; taking
the image
After the patient is instructed he/she is aligned, the
ear plugs are provisionally removed and then rein-
serted, checked for fit, then removed, and the X-ray
is taken. It is essential that the dental arches be in
occlusion before the image is taken.

449
R. Slavicek • The Masticatory Organ
Ill. 383: The hinge-axis skin points visible as lead markings,
and the orbitale point marked on the bridge of the nose,
bring the reference plane of the articulator into a direct rela-
tionship with the lateral head X-ray. Diagnostic procedures
are related to the same reference plane-coordinate system
principles.
Ill. 384: The mandibular central incisors and the two distal
cusps of the mandibular first molars determine the prostho-
dontic plane of occlusion.
450
Developing the film and control (not
necessary for digital imaging)
After the film is developed, while the patient is still
present, the film is checked and if necessary, an
additional X-ray image is taken. While sitting, the
same reference system is used for an instrumental
functional analysis, which is performed using an
appropriate facebow for the articulator.
Tracing
Tracing is done by employing the customary ortho-
dontic method. The magnification factor, which is
a function of the distance between the object (head)
and the film, must be registered for the evaluation
of linear measurements.
Evaluation of the lateral X-ray
The diagnostic analysis of lateral and, occasionally,
frontal x-rays of the skull and soft tissues is now
standardized in orthodontics. Tracings from images
obtained at a specific distance are "measured"
according to cephalometric principles. The mea-
surements permit an individual evaluation of the
patient's skull and soft tissue, relative to the collec-
tive sample. By this procedure, dentists-orthodon-
tists are able to compile a classifiable diagnosis, an
individual therapeutic plan, therapeutic goals and
make predictions regarding growth.
Once the evaluation has been made and the results
obtained, it is not permissible to make dogmatic
decisions based on statistical norms (which, unfortu-
nately, is rather commonly done). By obtaining fur-
ther consecutive recordings during and after treat-
ment, therapeutic steps, their results and their sta-
bility are more easily controlled and surveyed. The
surgeons in the team need to be well versed in
cephalometrics in order to collaboratively plan
orthopedic surgery, which may be necessary. Various
methods and modes of analyses are in use.
Unfortunately, they are frequently applied in a nar-
row-minded dogmatic fashion and therefore impose
limitations on communicative dialogue.
For a prosthetic diagnosis or the diagnosis of func-
tionally impaired patients, the lateral X-ray is a
valuable complement to the results of clinical and
instrumental diagnosis. It is a procedure that is
 Diagnostics - Additional Diagnostics

gaining increasing acceptance. Cephalometry

enhances the willingness of dentists, orthodontists
and oral surgeons to pursue inter-disciplinary dia-
logue and communicative planning.
When obtaining and evaluating lateral X-rays,
standardized procedures are recommended. The
basics for evaluation should be selected in a manner
so that conventional analyses can be applied as uni-
versally as possible.
The film is traced according to standardized proce-
dures and includes the soft tissue contours of the
profile, as well as all relevant bony contours, which
can serve as "landmarks" (ill. 385-386, right; ill.
387-395, pages 452-453).

The tracing is evaluated according to the following Ill. 385: During growth, the proportions of the mandible
aspects: are steadily changing; the length of the ascending branch
(ramus) increases.

• Evaluation of the skeleton

• Assessment of vertical dimension
• Assessment of the planes of occlusion
• Dental analysis
• Esthetic evaluation
• Dynamic analysis
• Compensatory mechanisms

Evaluation of the skeleton

Ill. 386: The increasing distance from the hinge axis to the
Based on collected data, a brief analysis classifies the plane of occlusion leads to the compensatory sphericity of
skull architecture according to statistical reference the dentition.
norms in comparison to the average values of a pop-
ulation sample corresponding to the patient's race,
sex and age.
The mandible and the maxilla are evaluated as sep-
arate skeletal units. After this basic classification,
the principle of the architecture is assigned to an
appropriate sub-group facial pattern, based on the
values on hand. An important aspect of this skeletal
diagnosis concerns the position of the mandible re-
lative to the reference structures of the skull, as well
as the relative relationship of the lower jaw to the
upper jaw. In other words, the position of the
mandible and maxilla relative to the skull on one
hand, and their position relative to each other on the
other, must be ascertained. Obviously, any change
in the position of the mandible relative to the skull,
will change all the analyses using mandibular land-

451
R. Slavicek • The Masticatory Organ

Ill. 387: Conformities on the lateral head X-ray such as the

occlusal plane, incisal inclination and DPO, are obvious in
this illustration.

Ill. 389: This composite of the joint track, front tooth con-
trol and information from the lateral head X-ray, presented
in this manner for didactic reasons, demonstrates the advan-
tages of a common coordinate system, based on a reference
plane.

Ill. 388: The reference plane is the hinge-axis-orbital plane. SAM® is a registerated trademark of SAM Präzisionstechnik GmbH

Ill. 390: The occlusal plane as an important dynamic deter- Ill. 391: The lingual functional surface, taken from the artic-
minant of diagnostics. ulator, is the anterior determinant of the dynamics of
mandibular movement on the lateral head X-ray.

452
 Diagnostics - Additional Diagnostics

Ill. 392: The track of the sagittal condylar inclination (SCI) Ill. 393: The enclosed angle of extended front tooth guid-
and front tooth guidance (FG) in symbolic interplay on the ance with the occlusal plane is known as relative front tooth
lateral head X-ray. guidance.

Ill. 394: The angle enclosed by the extended sagittal condy- Ill. 395: Because of the spatial situation, the Curve of Spee
lar inclination track with the occlusal plane is known as the can be seen on the X-ray.
relative condylar inclination track (RCI).

453
R. Slavicek • The Masticatory Organ
Imaging diagnostics using the lateral
head X-ray
• Skeletal recording of the skull
• Skeletal recording of the mandible
• Vertical dimension of the face
• Dental recording
Skeletal trend of the skull
• Facial axis angle, FA
• Facial plane angle, FP
• Chin angle, CA
• Mandibular plane angle, MPA
• Bjoerk sum
• Facial length relation
• Y-axis angle
Skeletal trend of the mandible
• Collum angle, CA
• Gonion angle (ant/post), GA
• Ramus height, (Ar-Go)
• Corpus length, (Go-Me)
• Mandible: anterior base
• Corpus length (Ricketts), Pm : Xi
Skeletal class
• Maxillary position
• S-N-A angle
• Facial plane angle FaA
• S-N-B angle
• S-N-D angle
• Difference - maxilla : mandible
• Position of the maxilla
• Position of the mandible
• A-N-B angle
• Wits
• Facial convexity angle, N-A-Pg
• A-B to the facial plane, (Downs)
Functional principle
• Functional plane of division
• Anterior arch height
• Molar relation
454
marks related to the skull, in both the linear and
angular measurements.
Individual preparation is important because all fur-
ther results of analysis will have to be compared
with the individual values that correspond to the
patient's skeletal pattern.
Assessment of the vertical
An important prerequisite for objective evaluation
of the relationship of jaws is the maintenance of dis-
tance, i.e., the vertical relationship between the
maxilla and the mandible.
Based on the first skeletal analysis, the facial verti-
cal, which is important for function, is assessed indi-
vidually.
It is inexcusable to evaluate individual face mor-
phologies according to static, uniform guidelines.
There is currently a tendency in orthodontics to use
uniform averages as a foundation of treatment. This
can lead to serious errors in planning, because there
is no standard norm for maintaining jaw distance for
individual phenotypes. Different human faces devel-
op an individual, and therefore characteristic, verti-
cal. Only after a careful initial analysis will it be pos-
sible to assess deviations from a subgroup corre-
sponding to the individual. Even after an individu-
alized classification has been made, dogmatism
must be avoided. The calculated values may only be
regarded as guidelines.
Furthermore, the development of an individual ver-
tical is to be viewed as a compensatory mechanism.
During growth, the vertical development of the face
plays a major role in the sagittal and transversal
relationship of dento-alveolar processes.
If there is a tendency of a relatively distal relation-
ship to the skull, created by the position of the
mandible, if there is an emerging Class II skeletal
relationship then a reduction of the vertical devel-
opment may be regarded as a compensatory mech-
anism.
If there is a tendency towards a Class III skeletal
relationship, created by a more anterior relationship
of the mandible relative to the skull, then an added
vertical development through downward rotation of
the mandible will be both beneficial and compen-
satory.
Of particular interest to the dentist, naturally, is the
spatial orientation of the teeth to one another.
 Diagnostics - Additional Diagnostics

Dental analysis and the assessment of the Lower face height

occlusal plane
• Lower face height to PM
The assessment of the dentition requires a careful
tracing. It starts with the assessment of the anteri- • Lower face height to D
or teeth, the inclination of the long axes of the teeth • Mandibular plane angle MpA
to the respective skeletal bases, and the mutual • Palatine plane, (Sns-Pns)
relationship between the anterior teeth. The latter • Maxilla height, (CF- Pt- A)
are evaluated linearly and angularly with regard to
their inter-relationship.
A major aspect of the diagnosis is the morphology
Upper incisor (Pos.)
of the palatal surfaces of the anterior teeth. The • Upper incisal protrusion
palatal surface of the upper anterior teeth which is • UJ 1 to N-A
of decisive importance for their function, is trans- • UJ 1 to N-Pg
ferred onto the lateral X-ray. This is done through • UJ 1 to A-pg
the articulator; the procedure will be described in
the chapter on dynamic analysis.
First, the occlusal plane is defined and evaluated Upper incisor (Incl.)
relative to the mandible, whereby the lower incisor
• Upper incisor inclination (to A-Pg)
is connected with the distal cusp of the first molar,
by a line. Thereafter, the occlusal tables of the first, • UJ 1 to S-N
second and third molars are established and drawn. • UJ 1 to N-A
The sagittal compensation curve can also be record-
ed and evaluated with regard to its functional
importance.
Using his method, Orthlieb presented geometric Lower incisor (Pos.)
relationships with statistical corroboration and • Lower incisor protrusion (to A-Pg)
established them with the definition of a DPO (dis- • LJ 1 to facial plane
tance to plane of occlusion). • LJ 1 to N-B (distance)
A significant component of cephalometric analysis
is that the position of a single tooth must be given
in a well-defined coordinate system.
The tooth itself is best defined via three reference Lower incisor (Incl.)
points on its structure. Every tooth partitions the • Lower incisor inclination (to A-Pg)
occlusal plane by defining its own occlusal plane, • LJ 1 to H-Inc.inf.
which may be termed the occlusal table.
• LJ 1 to Go-Gn
Every tooth can be regarded as an element of the
overall coordinate system, but can also be repre- • LJ 1 to N-B
sented as its own coordinate system. • LJ 1 to OE
Further complex morphological compensatory
mechanisms optimize the functions of the mastica-
tory organ for the organism. Inter-incisal angle
• Inter-incisal angle
• Lower incisor inclination
Esthetic evaluation and assessment • Upper incisor inclination
Soft tissue is well depicted in the lateral cephalo-
gram by the use of reduction filters. The method
allows both an evaluation of the esthetics of the
face, as well as a qualitative assessment of struc-
tures around the molars. The positions of the teeth

455
R. Slavicek • The Masticatory Organ
Functional Analysis
• Sagittal condylar inclination track,
SCI=HCI
• Front tooth guidance, FG
• Occlusal plane inclination, OPI
• Relative condylar inclination track, RCI
• Relative front tooth guidance, RFG
• Distance to plane of occlusion, DPO
456
relative to each other and relative to the labial
structures, are also important for diagnosis and
planning. The position of the lower and upper lip
in the facial soft tissue profile can be evaluated re-
lative to esthetic reference planes.
Static diagnostic analysis
Here we do not make a diagnosis, but only an ini-
tial assessment by means of a descriptive verbal
summary. Premature conclusions or specific exag-
gerated evaluations should be avoided. Only in
conjunction with a final overview of all findings can
the implications of the lateral X-ray be used to
make a final diagnosis.
The lateral X-ray provides an optical display of the
cranium and reveals its dynamic interrelations. It
also offers the possibility to detect compensatory
processes and may therefore be of decisive impor-
tance for patients with functional disorders.
Dynamic (functional) Analysis
A significant component of lateral X-ray analysis is
the dynamic evaluation of mandibular motion. This
concerns the aforementioned palatal surfaces of the
upper anterior teeth and their relationship with the
opposing mandibular anterior teeth, as well as, the
forward movement of the jaw joints derived from
the results of joint track registration. Based on this
supplementary information, it will be possible to
detect functional determinants along with their
associations and to evaluate them diagnostically.
The hinge-axis orbital plane, defined by lead mark-
ers, is used as a reference plane for the additional
information that is to be included in the analysis.
The two protrusive condylar tracks derived from
the joint track recording are transferred to the lat-
eral X-ray tracing. The dynamic registrations are
placed under the tracings of the lateral X-ray. The
red reference point is superimposed on the estab-
lished hinge-axis point from the lateral head X-ray.
Then, by rotating the tracing, the hinge-axis-
orbital plane is brought into superimposition and
finally both tracks are transferred onto the tracing.
In the event of considerable asymmetry of the tracks,
of bone contours or of the occlusal plane, tracings of
the left and the right sides should be made and the
joint tracks should be assigned to the respective sides.
 Diagnostics - Additional Diagnostics

The dynamics of the system are described by the

relationship between the sagittal condylar track
fixed to the skull on the one hand, and the occlusal
plane relative to the mandible on the other. It is
known as the relative condylar track (RCI).
The RCI can be recorded for every point on the
protruding mandibular track. Simultaneous rota-
tion around the hinge axis is not taken into
account.

The introduction of front tooth control into

the lateral X-ray
After mounting on the articulator, a mold of the
maxillary anterior teeth is made in accordance with
the coordinate system, from a special jig made for
this purpose, and a cast poured. Once the stone has
hardened, a cut is made through the cast of the cen- Cadias®
tral incisor, after assessing the morphology of the
• Numerical analysis
palatal surface. If the morphology presents a deep
depression in the middle of the tooth, then select a • Analysis of the tracing
more lateral slice, as you want the functional sur- • Verbal analysis
face. Prior assessment using articulating paper as a • Visualization of the goals of therapy
functional marker for the linear protrusive contact • Statistical analysis
is advised. This slice has the hinge-axis-orbital
plane as a reference, thereby creating an angle • Vertical manipulation
between the central's palatal functional surface to • Sagittal manipulation
the reference plane, from the molding jig. The slice • Conversion into articulator geometry
of the molding putty is either copied on a sheet of • Cadiax data transfer
paper from a copy machine, or hand traced and
then laid under the previous tracing in the same
fashion, whereupon the lingual surface of the cen-
tral incisor is also traced, after aligning the slice to
the reference plane.
Using this method, two dynamic units of informa-
tion important for the lateral X-ray can be
obtained. Evaluating functional determinants such
as the sagittal condylar track, anterior tooth control
and the occlusal plane permits the investigator to
make a dynamic analysis. Currently, the availabili-
ty of computer programs has considerably simpli-
fied and accelerated the process of evaluation. The
program I use also permits interactive planning.
There is hardly any diagnostic tool as suitable as the
lateral X-ray for the visual development of treat-
ment plans. They serve in documentation and dis-
cussion, when intra- and/or interdisciplinary coop-
eration is required. The use of data processing has
made the task easier and less time-consuming. By
means of the common coordinate system, the

457
R. Slavicek • The Masticatory Organ
Hansson, T.: Der Einfluß der Okklusion auf das Kiefergelenk.
In: Das Kiefergelenk. Diagnostik und Therapie.
Quintessenz Verlag, 1983
458
acquired solutions can be simply transferred back
into the articulator. The procedure is extremely
helpful, whenever it is necessary to generate a diag-
nostic set-up from an orthodontic or surgical view-
point, or prosthodontic wax-up.
Radiological and imaging procedures
• Panoramic overview recording and other slice
techniques
• Lateral-transcranial joint X-ray
• Temporomandibular joint tomography
• Computed tomography of temporomandibular
joints
• Arthrography
Panoramic overview recordings and other
slice techniques
The panoramic overview is indispensable in system-
atic functional diagnostics. It not only allows for an
initial assessment of the dentulous situation, but also
provides a clear overview of an edentulous situation.
In addition, it permits an initial evaluation of joint
morphology. The relation to the length of the mus-
cular process allows the diagnostician to infer mor-
phological changes in the condylar process.
A further possibility is the assessment of the peri-
hyoidal and retro-mandibular space as well as the
area of the styloid process. However, the panoram-
ic skeletal x-ray overview is not a substitute for
intra-oral periapical radiographs and related diag-
nostic analyses.
With other devices (e.g., Scanora), it is also possible to
obtain a goal-oriented lamination/layering of the tem-
poromandibular joints, and good assessments from
laminated sections of the dento-alveolar region.
Latero-transcranial joint X-rays
The technique has been discussed, criticized and
controversially appraised in the literature. Cur-
rently, although technical improvements have opti-
mized its readability, the method has been replaced
by more efficient technology. Its projection value is
disputed and limited, while positional/conditional
 Diagnostics - Additional Diagnostics

evaluations are not possible. Morphological

changes in the lateral pole of the joints can, possi-
bly, be adequately assessed. Because of the unsuit-
able design characteristics of typical dental x-ray
units, radiation exposure in the pituitary region is
unacceptably high for the patient, despite the
intensifying screen.
For this reason and from the viewpoint of radiation
protection, this imaging technique is outdated.

Mandibular joint tomography

By means of relatively simple devices that are suitable
for dental practice, it is possible to obtain good-qual-
ity representations of the temporo-mandibular joints.
As the devices are also suitable for other purposes,
they provide supplementary information for the pur-
pose of joint diagnosis. Under no circumstances may
conclusive statements regarding the position of the
condyle relative to structures of the skull structures be
made. A descriptive diagnosis of morphology, on the
other hand, is certainly permissible.

Computer tomography of
mandibular joints
Today, the CT examination is indispensable for con-
firming a tentative diagnosis of morphological alte-
rations in the joint as well as for all other hard tissues
in the system. Because this method of examination is
relatively time-consuming, costly, and exposes the
subject to radiation, the indication should be estab-
lished with great care. According to current scientific
standards, the procedure is indispensable for clarify-
ing questions related to the morphology of hard tis-
sue. By making use of the appropriate software, it is
possible to produce reconstructive displays and even
three-dimensional images, which may be of high
diagnostic value in individual cases. However, a final
evaluation of the position of temporomandibular
joints cannot be made with this method.
It would be inconceivable from the viewpoint of cur-
rent diagnostics to evaluate edentulous areas in the
jaw, or to consider planning any implantation proce-
dure without obtaining a CT of the jaw. Specific pro-
grams permit the investigators to arrange interdisci-
plinary planning among the radiologist, dentist and
surgeon. In this setting, the role of the dentist is con-
siderably enhanced.

459
R. Slavicek • The Masticatory Organ

Arthrography Arthrography
From the current viewpoint, the evaluation of soft
tissue with the invasive arthrographic method is
rarely indicated because the physiology and patho-
logical physiology of joint spaces are greatly altered
by this invasive procedure. Its evidential value is
therefore strongly diminished. Likewise, the loca-
tion and evaluation of so-called disk perforations
does not necessarily have therapeutic implications
because the finding does not allow for an inference
of joint disease. From a clinical point of view, the
method is obsolete.

Magnetic resonance imaging of the

mandibular joints
One of the most significant enhancements in the
functional evaluation of the soft tissue in the SGS is
afforded by MRI, because it provides insights into
the functional problems of joint mechanics.
However, in no case may MRI be regarded as the
gold standard of joint diagnostics. It should be
remembered that it is a technique and, like all tech-
niques, it is subject to the interpretation of an eva-
luator/critic.
Furthermore, it is not yet customary to apply a
comparable coordinate system to MRI. This is very
significant with regard to reproducibility.
The fact that the current state of technology does
not yield truly dynamic information should also be
kept in mind. In addition, there is a risk of over-
interpretation, which is exactly what occurs in the
diagnosis of avascular necrosis. Finally, the cost of
the method is a significant factor. The absence of an
exact, spatial classification makes it impossible to
assess the position of structures. In borderline cases
for example, this is apt to lead to an ad absurdum
evaluation of the position of the disk.
MRI is a great step forward in terms of serving as a
complement to complex functional diagnostics in
the stomatognathic system. We merely want to
draw attention to a kind of diagnostic over-expen-
diture that is practiced here, in contrast to treat-
ment. Over-treatment, however, is even more dan-
gerous.

460
 Diagnostics - Additional Diagnostics

Additional diagnostic measures in the

articulator

Diagnostic equilibration
Diagnostic equilibration of mounted cast is an
excellent means of prospectively documenting, on
the cast, the effect of correctional, subtractive mea-
sures. When this diagnostic procedure is used on a
cast created with the double-pin technique, it is
timesaving, informative and expeditious.

Procedures

• The basic requirement for this supplementary

instrumental analysis is a double-pinned sec-
tioned cast of the mandibular teeth.
• RCP is set up, and the height of the incisal pin
in RCP is read and noted on the findings form.
• Likewise, IP is set up, and the height of the
incisal pin is noted.
• With color foil, all early contacts are marked
and entered precisely in the tooth scheme on
the findings form.
• Mandibular tooth contacts are removed and
marked with the number one (1).
• The procedure is continued, with ascending
numbering, until contact with the anterior
tooth segment is achieved. The functionality of
the situation is evaluated.
• The height of the incisal pin is read again, and
vertical change is documented.
• The findings are correlated with the lateral
X-ray from a vertical view and evaluated.

Diagnostic wax-up
In supplementary diagnostics, waxing-up on the
articulator is an excellent way of planning measures
to improve occlusion by means of additional tech-
niques. Furthermore, it is an especially efficient way
of planning reconstructive measures and devising
effective measures to provisionalize. Of course,
diagnostic waxing-up and equilibration can be
done in combination.

461
R. Slavicek • The Masticatory Organ

Orthodontic and surgical set-up

Orthodontic and surgical set-ups are important
aids in, and foundations of, complex inter-discipli-
nary diagnostics, i.e., cooperation among the den-
tist, orthodontist and surgeon. The dentist is the
focal point of the team, as he/she has to execute the
final treatment and also provide the maintenance
program.

462
 Diagnostics - Additional Diagnostics

Summing up ideas about

diagnostics and diagnosis

The masticatory organ as a

feedback-control mechanism
- the human being as a
feedback-control mechanism
As mentioned in the chapter entitled The New
Organ, nothing in a living organism can be regard-
ed in isolation. A living organism is a dynamic, hier- A living organism is a dynamic, hierarchically
archically arranged unit made up of organs and sys- arranged unit made up of organs and sys-
tems that maintain the required function of life tems that maintain the required function of
through constant, mutual cooperation. Dynamic life
life through constant, mutual cooperation.
is ensured by the adaptive capability of the respective
organism, i.e., its structures, systems and functions.
The capacity for adaptation is individual. It is The capacity for adaptation is individual.
assigned to an individual, who cannot be compared
with another. Organs and systems are a means to the Organs and systems are a means to the end
end of maintaining the adapted organism. This pur- of maintaining the adapted organism. This
pose is survival; this applies in the same extent to the purpose is survival.
survival of the single individual, as it does to natural
selection in the evolution of organisms.
A human being is one of several organisms.
However, what distinguishes him from other organ-
isms is the development of the human brain in con-
junction with the emergence of species-specific self-
consciousness, which has assigned the human being
a conscious, central role within his/her individually
perceived environment.
From a biological viewpoint, this permits a schematic
construction and comparison of the human being,
who is conscious of his/her individual environment,
with other organisms.
Therefore, when discussing human behavior, func-
tions, dysfunction and illness, it is important to
adopt an approach that views the individual in
his entirety. The human being is a psycho-socio- The human being is a psycho-socio-somatic
somatic unit who, as an organism, lives in and is unit who, as an organism, lives in and is also
also able to mould his/her environment. able to mould his environment.
From the viewpoint of modern medicine, therefore,
a mono-causal method of regarding individual sys-
tems or organic functions, extracted from the gen-
eral context, is obsolete. Sadly, focusing on mono-
causality is currently the rule in diagnostics of the
masticatory organ. Organisms and organs must be
defined in terms of structure, but they must be

463
R. Slavicek • The Masticatory Organ
The mouth is the most sensitive and intimate
region of a human being but, through its
function of ingesting food, is also making
life-sustaining contact with the environment.
In addition, it transmits thoughts and feel-
ings, both verbal and non-verbal, to the
environment.
The structures themselves must be examined
with regard to their suitability and capability.
The theoretical diagnostic scheme must
especially take the close relationship between
the masticatory organ and the psyche.
464
described according to their functional tasks. The
functions must then be viewed in relation to the
overall function of the organism on the one hand,
and to the environment on the other.
The mouth is the most sensitive and intimate
region of a human being but, through its function
of ingesting food, is also making life-sustaining
contact with the environment. In addition, it trans-
mits thoughts and feelings, both verbal and non-
verbal, to the environment.
The role of the masticatory organ within the organ-
ism cannot be discussed with regard to its struc-
tures alone. The functions it is required to perform
and their significance must be viewed within the
context of a feedback control mechanism. What
follows is a renewed attempt to present this scheme
as a basic concept for understanding and appreciat-
ing this notion. In addition, it creates a theoretical
scheme of coordination and correlation in diagnos-
tics towards the creation of a diagnosis, and is also
logically applicable to the therapeutic concept.
The functions that need to be taken into account in
diagnosis are speech, posture, esthetics, stress man-
agement, mastication and deglutition. Only when
all these functions are given due consideration will
it be possible to evaluate negative effects on the
structures (i.e. occlusion, the neuromuscular system
and the temporo-mandibular joints).
The structures themselves must be examined with
regard to their suitability and capability for under-
taking the functions required of them - either com-
pletely, partially, or possibly, not at all.
The theoretical diagnostic scheme must especially
take the close relationship between the masticatory
organ and the psyche into account. It should also
be applicable for evaluating the significance of the
masticatory organ in somatic projection in cases of
actual primary psychic disease.
After collecting diagnostic information and find-
ings, it would be practical, from this point of view,
to perform a comprehensive evaluation. Causes and
associations should be correlated in order to initiate
the most suitable causal therapy. All significant fea-
tures of the patient's history, the clinical functional
analysis and the instrumental analysis carried out
by the dentist himself/herself, must be correlated
with the results obtained from supplementary inter-
and intra-disciplinary diagnostics. Both purely den-
tal therapy and complex teamwork must be coordi-
nated and controlled by the diagnostic approach.
 Diagnostics - Additional Diagnostics

Principles of correlation diagnostics

• Streamlining the results of diagnostic
procedures
• Entry into a correlation scheme
• Evaluation of the validity of the individual
findings
• Arranging individual findings according to
their significance
• Cybernetic synopsis and diagnosis
• Therapeutic planning
• Execuring the therapy; follow-up
• Setting up a maintenance program
• Streamlining the results of diagnostic
procedures
• Entry into a correlation scheme
• Evaluation of the validity of the individual
findings
• Arranging individual findings according to
their significance
• Cybernetic synopsis and diagnosis
• Therapeutic planning
• Execuring the therapy; follow-up
• Setting up a maintenance program

Streamlining the results of diagnostic

procedures
It is necessary to enter all of the significant data
from the individual sections of the examination into
the correlation scheme. This requires a thorough
processing of all diagnostic findings, under specific
conditions, through an inter-disciplinary dialogue.
In principle, this streamlining process is a subjec-
tive and responsible way of arriving at a tentative
diagnosis. Omitting seemingly insignificant data
narrows the range of definitive causality of the dis-
eases. This process suppresses findings, but does
not by any means discard them permanently.

The form of a correlation scheme

• Medical history
• Dental history and occlusion index
• Comparative muscle analyses
• Analysis of mandibular movement
• Neurological pre-evaluation
• Estimation of the psychological situation
• Occlusion
• Occlusogram
• Clinical evaluation
• Instrumental evaluation of the occlusion
• CPM
• Joint track recording

465
R. Slavicek • The Masticatory Organ

• Lateral head X-ray

• CT
• MRI
• Logopedic-myofunctional diagnostics
• Physiological diagnostics
• Psychological diagnostics
• Other significant results of the examination
• Further inter-disciplinary diagnostic results

Entering data into a correlation scheme

The results obtained from the systematical steps
used in this form are entered into the scheme and
carefully reviewed.

Evaluation of the validity of the

individual findings
Under the aspects of the cybernetic scheme, the
findings are now compiled and the associations
examined. An overall report expressing the diagno-
sis is formulated.

Arranging individual findings according to

their significance
When dealing with several findings, it may be
helpful to explain their significance and to arrange
them in a specific sequence.

Synopsis and diagnosis (verbal summary)

The diagnosis should be concise and should be
briefly explained on the basis of its determining
factors. It should be informative for the specialist,
but also comprehensive for the patient by way of
making an explicit understandable statement.
Complicated terminology is an admission of one's
own uncertainty and doubt. In such cases, it is
important to realize it, admit it, and redefine.

466
 Diagnostics - Additional Diagnostics

Determining the therapeutic value
The immediate consequence of a diagnosis is the
question of therapy. The decision with regard to
therapy must be carefully weighed, as functional
disorders may be compensated for or tolerated by
the patient. Therapy is an intrusion into a feedback-
control mechanism, which sets the entire system in
motion, and must therefore be carefully considered.
The decision with regard to therapy must be
carefully weighed, as functional disorders
may be compensated for or tolerated by the
patient. Therapy is an intrusion into a feed-
back-control mechanism, which sets the
entire system in motion.

Planning therapy
Once a diagnosis is made, a final and causal solu- Once a diagnosis is made, a final and causal
tion to the problem must be found. solution to the problem must be found.
Injudicious therapy, which creates new problems, is Injudicious therapy, which creates new prob-
dangerous. In cases of complex clinical conditions, lems, is dangerous.
which are usually related to multiple causal factors,
the individual in charge of administering goal-ori-
ented treatment bears a heavy responsibility.
Providing the therapy is based on a carefully estab-
lished diagnosis, the responsibility is incumbent on
those who have made the effort to treat the patient.
The therapy should improve or cure the physical
and psychic state of the patient. This is not always This is not always achieved with a restitutio
achieved with a restitutio ad integrum. Patients, ad integrum.
especially chronically ill ones, tend to set their
expectations too high because of thoughtless state-
ments made by their dentists. It is important to
eliminate the symptom of chronic pain, or at least
to relieve it for a length of time, and thereby
improve the patient's overall wellbeing. Patients
should be reintegrated into their customary sur-
roundings, as chronically dysfunctional individuals
tend to be segregated from their pre-established
environment.

Implementing the therapy and control

Implementing the therapy for the dysfunctional
masticatory organ requires specific controls. As
nearly all difficult cases have an understandable
psychological component, especially chronic, pro-
tracted cases, strict control of planned steps is
absolutely essential in the interest of the patient. In
several cases, the patient needs careful guidance by
the dentist. Complicated therapeutic measures
require not only medical, but also human commit-
ment.
Human attention and medicine should be an insep-

467
R. Slavicek • The Masticatory Organ
Human attention and medicine should be an
inseparable unit in therapy.
However, the expectations of the dentist and
his/her patients should be realistic.
Healing means bringing the patient's feelings
of wellbeing into harmony, in relation to
him/her self and his/her environment.
However, it should by no means lead to the
creation of a "dependent" patient.
From the perspective of holistic medicine I
think it is impossible to exclude or discrimi-
nate against specific diagnostic methods on
the basis of reductionistic approaches of
thought.
468
arable unit in therapy. This especially applies to
functional disorders of the masticatory organ.
However, the dentist's human involvement must
be governed by explicit goals. The patient may
need to accept rather strict guidance, if he/she
experiences a motivational crisis during extensive
and possibly invasive therapy.
However, the expectations of the dentist and
his/her patients should be realistic. The aforemen-
tioned traditional, mechanistic opinion of a restitu-
tio ad integrum in dentistry is the greatest stum-
bling block to holistic thinking. A return to the
original condition is an absurdity in a living organ-
ism; the goal should be to stabilize the organism
and to serve in the preservation of its harmony.
Healing means bringing the patient's feelings of
wellbeing into harmony, in relation to him/her self
and his/her environment.
Setting up a maintenance program
The maintenance program serves to control the
patient's condition after therapy. However, it
should by no means lead to the creation of a
"dependent" patient. The responsible dentist
should never allow himself/herself to be trans-
formed into a lifelong crutch. The previously dys-
functional patient must realize the necessity of
assuming responsibility himself/herself. Control in
this setting is no different from control exercised
during maintenance programs in periodontology.
The prerequisites are systematic establishment of
the structures and functions of the masticatory
organ with the purpose of detecting relapses as
early as possible.
Thoughts on the current situation
regarding the application of
diagnostic measures
Because of currently prevalent attitudes in biomed-
icine, a plethora of diagnostic methods are in use.
Traditional medicine and official organizations tend
to assess alternative diagnostic methods in an
inhibitory and, occasionally, restrictive manner.
From the perspective of holistic medicine I think it
is impossible to exclude or discriminate against spe-
 Diagnostics - Additional Diagnostics

cific diagnostic methods on the basis of reduction-

istic approaches of thought. Every diagnostician
who assumes responsibility for a patient must have
the freedom to pursue his/her diagnostic path, as
long as he/she strictly avoids handing over the
responsibility of diagnosis to instrumental systems.
It is absurd for scientists or institutions to presume
they know the truth and make final judgments. We
should not forget that 90% of our currently accept-
ed and scientifically proven knowledge will be
refuted in a decade!
We also must not forget that the currently preva-
lent "natural science-based bio-medical" mode of
argumentation regarding epidemiology is long out-
dated from the viewpoint of modern science.
Let us also bear in mind the fact that the current ... that the current tendency to "over-diag-
tendency to "over-diagnose" has led us away from nose" has led us away from patients.
patients. Our goals should be commitment to the
patient and simplification of our diagnostic
resources.
Alternative, or rather complementary, methods
need not be excluded. However, utmost impor-
tance must be given to ensuring that an objective
examination is carried out in accordance with cor-
rect scientific method.
One of the significant reasons for the success of
"non-traditional" medical methods probably lies in
the fact that patients themselves, disappointed with
traditional medicine, are searching for other
methods.

469
 Chapter 5

Therapy

The treatment of the masticatory organ

from the viewpoint of functional disorders
is extraordinarily complex. Mono-causality
does not exist. This is the main reason why
therapy is a matter of interdisciplinary
involvement. It is counterproductive to
strive for mono-causality or to minimize
the importance of the masticatory organ
and its structures. This chapter presents an
overall view, which respects multi-causality,
but also establishes and simplifies some of
the focal points and directions for decision-
making. It is strongly recommended that all
dentists, physicians and specialists engaged
in any activity involving the masticatory
organ possess excellent basic knowledge as
to how all the organs and tissues function.
The dentist does have basic knowledge but
frequently lacks the approach of medicine
as a whole. Others usually have excellent
knowledge of their specialty (although
their knowledge is occasionally too sector-
oriented), but little or inadequate know-
ledge of the system itself.
The organization of teams that "speak the
same language", based on common know-
ledge, is a conditio sine qua non for the
future.
R. Slavicek • The Masticatory Organ
Symptomatic pain-therapy
This means that acute pain is treated as a
symptom before a systematic search for the
cause is undertaken.
472
A few thoughts
regarding the treatment
of functional disorders of
the masticatory organ
This book is dedicated to diagnosis, not to thera-
py, but I think it is necessary to express a few con-
cepts regarding any treatment that might be
administered.
After the diagnosis has been formulated and the
decision to initiate therapy been made, a route
should be adopted that is as cause-effect oriented
as possible. Symptomatic pain-therapy is only
indicated for patients whose paramount symptom
is acute pain.
In all other cases, even those involving prolonged,
severe, chronic pain, causal therapy must be intro-
duced. Let me emphasize: acute pain is rare in a
dysfunctional patient.
However, if you believe that acute pain truly
exists, then appropriate measures should be taken
to eliminate it, or at least to relieve it as quickly as
possible, in order to make a thorough diagnostic
examination.
This means that acute pain is treated as a symp-
tom before a systematic search for the cause is
undertaken.
The only goal here is to eliminate the phase of
pain. Acute pain is measured by the fact that its
quality renders the patient unable to perform nor-
mal activity.
The following overview lists a selection of possi-
bilities that have proven useful in my many years
of work with dysfunctional patients.
 Therapy

Symptomatic therapy for acute pain

• Drug-based treatment for pain
• Physical therapy
I set a maximum time limit of one week for achiev-
ing success with symptomatic therapy. The mea- • Physical and physiological therapy
sures must be initiated in a responsible and goal- in combination
oriented manner. Combinations of the methods • Methods for harmonizing the flow
may well be used. of energy
If it is not possible to eliminate or strongly reduce • Emergency provisional occlusal appli-
acute pain within a short period of time, the ances
patient should be referred to a specialist, or at
least an out-patient pain department should be
consulted.
In all other cases, the systematic approach of this In all other cases, the systematic approach of
book applies. The search for causes or main caus- this book applies.
es seldom leads to a single cause, especially if the
functional disorder is already persistent and
accompanied by chronic pain. Nevertheless, an
attempt should be made to disclose the main
aspects of causality.
Within the "initial therapy" required for these
patients, it is by all means permissible to make a
correction or two in the diagnosis, based on
progress controls. It would be incorrect to cling, It would be incorrect to cling, dogmatically,
dogmatically, to any therapeutic decision when no to any therapeutic decision when no explicit
explicit evidence of success is obtained. The initial evidence of success is obtained.
therapy should be carried out quickly and con-
cluded within a foreseeable period of time.
Here also, I would like to present a few possibili-
ties that would simplify the selection of a method
which can be utilized in the initiation of treat-
ment. Although we are generally dealing with Dealing with multi-causality direct the thera-
multi-causality, I consider it very important to peutic approach through one main causal
direct the therapeutic approach through one main focal point.
causal focal point. This is because treatment
becomes more specific when it is determined by a
diagnosis focused on a central theme.

Cause-related initial therapy of the

dysfunctional masticatory organ

Therapy for causes from predominantly

muscular origins

The neuro-muscular system is a backdrop for most

dynamic causes of dysfunction. Therefore, it is

473
R. Slavicek • The Masticatory Organ
• Therapy for causes of predominantly
muscular origin
• Therapy for causes predominantly
located in the joint area
• Therapy for causes predominantly
related to occlusion
• Therapy for causes predominantly of
psychological origin
• Therapy for causes predominantly of
neural origin
• Therapy for somatic causes external
to the masticatory organ
• Therapy in cases involving environ-
mental factors
• Immobilization with a relief splint
• Relaxation from biofeedback
• Physical therapy and localized
myofacial therapy
• Drug therapy
• Rules for behavior
• Relief with a temporomandibular
joint decompression splint
• Anti-phlogistic medication
• Anti-rheumatic medication
• Irradiation
• Mobilization therapy
• Lavage (joint irrigation)
• Rules for behavior
474
generally the muscles that furnish the patients'
symptoms. The cause is frequently found in para-
functional hyperactivity, but also in a whole series
of functional disturbances of the main functions of
speech and mastication. A large number of mus-
cular causes are found in the postural apparatus of
the head and in overall body posture. The options
for initial therapy are listed relative to their fre-
quency of application.
If the diagnosis has correctly indicated a myopa-
thy, systematic therapy must achieve noticeable
improvement or elimination of the complaint,
within the first three weeks.
Therapy for causes located predominantly
in the joint area
First of all, the therapeutic approach applies to the
affected joint. Pain in the joint may originate from
the system-immanent musculature, the capsular
region, the bilaminar zone, or the joint's bony
structures.
Painless symptoms such as reciprocal clicking
require special treatment, if at all.
The order of the initial therapeutic measures list-
ed here mainly applies to those joint problems
that have pain as one of their symptoms. After a
reasonable period of time, e.g. a few weeks, pain
should have been eliminated, so that further diag-
nostic measures can lead to a definitive therapy.
Therapy of predominantly occlusal causes
The dentist's main area of activity is occlusion.
Most patients in a routine dental practice do not
consult the specialist because of functional distur-
bances, but rather for banal reasons. Latent disor-
ders often manifest themselves during the initial
examination. The reasons for intervention
through reconstruction of the existing occlusion
should be carefully evaluated and assessed utiliz-
ing non-invasive techniques, prior to implementa-
tion.
However, in the course of comprehensive diagnos-
 Therapy

tic procedures, it may be found that a disharmony The dentist's main area of activity is occlu-
in the maxillo-mandibular relationship created by sion.
the occlusion is the main cause of a functional dis-
order.
As mentioned previously, it is unscientific, unwise It is unscientific, unwise and, therefore not
and, therefore not permissible, to exclude occlu- permissible, to exclude occlusion as a cause.
sion as a cause.

It is by no means only the psychically-based para-

function, but rather a variety of dysfunctional
mechanisms that may be causally responsible for
the emergence of dysfunction, manifested by
occlusal-articular discrepancies. In these cases, the
proper method for treatment is to correct the fac-
tors causing the occlusal disorders.
The therapies listed initially, performed with the
aid of a provisional occlusal repositioning appli-
ance, will correct the inappropriate position of the
mandible, resulting from occlusion. At the end of • Goal-oriented therapy with the aid
this approximately two-week phase, the primary of a provisional occlusal reposition-
casts should be remounted and a final plan for
ing appliance
therapy should be generated to correct the occlu-
sion. • Selective equilibration without
changing the bite
• Equilibration in conjunction with
changing the bite
Therapy for causes of predominantly • Orthodontic measures
psychic origin • Restorative-prosthodontic measures
• Orthopedic-surgical measures
The problem of mental involvement in the occur- • Biofeedback
rence of disease, of psychic or secondary psychic • Combinations of the above measures
overlapping in patients suffering chronic pain, or • Rules for behavior
the existence of a primary psychic illness, is
predominantly a problem of differential diagnos-
tics. It may be difficult to distinguish between dis-
eases on the basis of their appearance alone; such
differentiation may require interdisciplinary coop-
eration. The presence of the somatic expression of
a primarily psychic illness may be difficult to
detect, because somatic indications may, in fact,
be present in the diagnosis, and the patient's med-
ical history may reveal plausible associations
between his/her problems and surgical interven-
tions by a dentist. Therapy in these cases is truly
interdisciplinary, whereby, from the dentist's view-
point, direct treatment of the masticatory organ
may well be carried out simultaneously, although
priority should be given to treating the psychic
cause. Such cooperation has proven its value in the

475
R. Slavicek • The Masticatory Organ
• Psychological therapy
• Psychiatric therapy
• Medication (only temporary, as far as
possible)
• Rules for behavior
• Behavioral therapy
• If necessary; simultaneous planned
dental therapy
• Medical therapy
• Physical therapy - physiotherapy
• Exercise therapy
• Rules for behavior
• Causal therapy of specific neural
diseases
476
liaison departments at the Vienna Dental Clinic.
It has a high rate of success and has proven
extremely helpful for patients.
Therapy for causes of predominantly
neural origin
Neurological disorders may be a significant cause
of pain. Diseases in the region of the trigeminal
nerve may be difficult to detect and may require
examination and treatment by a neurologist.
The preliminary examination of cranial nerves is
also especially important, because serious diseases,
such as tumors, may be a part of the symptoma-
tology of a functional disorder. This, thankfully, is
rare, but not unknown. At the least hint of a
doubt, it is mandatory to obtain the advice of a
neurologist.
Motor loss in the area of the facial nerves, which is
common in the very aged, may have consequences
for the dentist. Therapeutic measures in neurolog-
ically afflicted patients should only be attempted
in conjunction with a neurologist, and in some
cases with a trained physiotherapist.
The treatment of somatic causes or
systemic diseases involving the masticatory
organ
In cases of rheumatic diseases, the masticatory
organ and its joints, as well as its musculature may
be affected.
A special disease from a systemic viewpoint is
Eagle's syndrome, a moderately frequent disease,
which, in addition to other symptoms, is associat-
ed with increasing ossification of the ligamentary
apparatus connected to the hyoid.
 Therapy

Therapy in cases of predominantly • Interdisciplinary causal therapy

environmental factors • Supporting local therapy
• Rules of behavior
The knowledgeable dentist is, to an increasing
extent, the person the patient consults when
his/her wellbeing relative to the masticatory organ
is disturbed by external factors. We need only
consider the several job-related problems of incor-
rect posture. A dentist demonstrating his compe-
tence in this situation would do much to enhance
his general role and importance. • Rules of behavior
These lists are intended to show the variety of • Behavioral therapy
means by which causal initial therapy can be car- • Psycho-social medicinal therapy
ried out. The methods I have presented here and
practiced are by no means comprehensive. The
main goal of these therapeutic measures is to
bring about stability and harmony for the patient
- in some cases with no further measures taken
and in others, with subsequent definitive therapy.
Ongoing, long-drawn out "pseudo-therapy" in
non-stabilized patients, in persistently unstable
and insecure situations, is counterproductive. The
goal of all our therapeutic measures is to heal.

477
R. Slavicek • The Masticatory Organ

Ill. 1: In symptomatic treatment of acute pain, a predominantly

somatic approach to the central nervous system is indicated.

2: The problem may lie in a primary muscular disease; this indi-

cates the (very rare) therapeutic approach.

Ill. 3: When confronted with problems of the musculature, the

dentist's first thought is parafunctional causes. Therapeutically,
the connection between the psyche and occlusion and the NMS
is in the foreground.

Ill. 4: Muscular pain may originate in the postural apparatus.

Problems of head and body posture must be taken into account
in therapy.

478
 Therapy

Ill. 5: Speech and mastication can trigger severe muscular problems,

especially in the suprahyoid region, by means of avoidance mecha-
nisms. Here, of course, occlusion is a primary cause.

Ill. 6: In cases of deficient support in the area of lateral teeth and

a tendency towards parafunction, structural and functional joint
problems may occur.

Ill. 7: Primary joint diseases of the temporomandibular joints

must be recognized as such and specific therapy must be initiated.

Ill. 8: Secondary joint injuries (mostly post-traumatic) should be regis-

tered during history-taking and separately evaluated with regard to
therapy, because adaptive and compensatory mechanisms already have
taken place.

479
R. Slavicek • The Masticatory Organ

Ill. 9: Occlusion-articulation (occlusal-articular) problems in the

patient's history should be evaluated, as they may affect all func-
tions. Of course, they may also influence other structures.

Ill. 10: Esthetic concerns are frequently associated with causes in the
occlusal-articular area. The "face" is the therapeutic goal for the
patient, as well as, the dentist.

Ill. 11: Psychological causes not resulting from the masticatory

organ may be expressed somatically through this system.

Ill. 12: Frequently, psychological causes may be found in the

environment and require an appropriate therapeutic approach.

480
 Therapy

Ill. 13: Neural causes must be treated through a causal somatic

approach: this is reserved for medical specialists. Timely referral
to a specialist is mandatory.

Ill. 14: The masticatory organ may be involved in a disease of

the organism. The dentist's responsibility is to relieve pain and to
provide for the most optimal state of oral health.

Ill. 15: Environmental factors may be causally involved in dys-

function, both mentally and somatically. In causal therapy, this
should be kept in mind.

481
 Chapter 6

The structural
anatomy of the
cranium as
a dynamic
principle
Anthropogenesis is dominated by the
development of the brain. Thus, the neu-
rocranium makes "premature birth" a
necessity and is marked by continued, dra-
matic, post-natal growth. It practically
overlaps the viscerocranium and forces it,
especially the mandible, to undergo three-
dimensional development in an, above all,
transversal direction. This resulted in an
enormous remodeling process of the
mandible. Dr. Sato's method of observation
is concerned with the architecture of
sutures and the syndesmosis of the cranial
base. This viewpoint reveals new and
astounding aspects regarding the growth
and direction of growth of the viscerocra-
nium. In addition, Dr. Sato's observations
highlight entirely novel aspects of dysfunc-
tion, based on potential structural bracing
in the sutural area as a result of a forced
bite malocclusion.
The influence of impaired function, para-
function and the problems of malocclusion
gain entirely new diagnostic significance
from the viewpoint of the dynamics of cra-
nial structures.
R. Slavicek • The Masticatory Organ
Introduction
Evolutional Aspects of Craniofacial Bones
Craniofacial Bone Connection
Sphenoid Bone
Occipital Bone
Vomer Bone
Temporal Bone
Craniofacial Bone Dynamics
Occiput-Spheno-Maxillary Complex
including the Vomer in relation to
the growth of the maxillary complex
Temporomandibular System
The Importance of Occlusal Function
on the Mandibular Growth
Craniofacial Growth and Development with
Special Attention to the Occlusal Plane
Implication of Dental Practice
484
Sadao Sato:
The dynamic functional
anatomy of the cranio-
facial complex and its
relation to the
articulations of dentition
Introduction
Every bone that constitutes the modern human
skull formed an essential framework for adapting
the brain and sensory organs. Craniofacial
mandibular structures, being a functioning system,
are regarded as the most complicated system in the
human body (Fig. 1). They consist of 28 bones: six
ossicular bones (malleus, incus and stapes), eight
vault bones (occipital, parietal, temporal, frontal
and sphenoids) and fourteen facial bones (maxilla,
nasal, lacrimal, ethmoid, concha, vomer, mandible,
malar and zygoma).
The craniofacial bones are joined together at their
junctions by so-called sutures or synchondroses. It is
important to understand that, owing to these
attachments, the bones are situated within a flexi-
ble or moving structure when pressure or tension is
exerted on craniofacial mandibular structures. The
sutures resist gross separation of the component
bones, but also permit slight relative movement.
However, in the past anatomists regarded cranial
sutures as immovable joints, believing that each
bone is rigidly positioned and that the bones are rel-
atively fixed to each other, although the movement
of skull bones is mainly due to brain growth, mus-
cle contraction and functions of the masticatory
 Sadao Sato

organ. Retzlaff (1, 2) and Frymann (3, 4) reported that

cranial bones exhibited a state of motion.
Frymannís' study using fixed transducers with the
head stabilized in a fixed position revealed that cra-
nial motion is an independent one, affected by the
individual's breathing cycles.
To understand the dynamics of the craniofacial To understand the dynamics of the craniofa-
complex, it is of utmost importance that we first cial complex, it is of utmost importance that
discuss its functional anatomy (5 - 10). The cranium is we first discuss its functional anatomy
composed of the upper and mid facial skeleton. The
calvarium surrounds the superior and lateral por-
tions of the brain and the bones of the cranial base
lie beneath the brain. Sometimes all bones sur-
rounding the brain are collectively referred to as the
neurocranium, as they originated from the meninx
primitiva that surrounds the rostal portion of the
neural tube. The midfacial skeletal frame is a fur-
ther part, known as the visceral cranium. However,
the cranium and the facial bones are not separate
functional units.
The size of the cranium at birth is approximately 60
to 65% its final size and it grows rapidly. By the age
of five years the cranium has developed to approxi-
mately 90% its final size; this growth is achieved by
sequential remodeling of the morphology of each
region. External forces applied to these forming
structures have the potential to distort shape and
growth, with grave consequence for the final form
and functions.
The floor of the brain case or cranial base was
described as a foundation or scaffolding for the face.
The facial complex may also be regarded as a super-
structure.
The maxilla is a unique structure in its own way.
Aside from one extension or process that directly
braces the maxilla against the cranial bone, like the
maxillo-frontal process, no other contact exists
between the maxilla and the skull base. It is there-
fore braced against other bones as floating buttres-
ses (11).
The facial bones also support various organs
enclosed in its cavities such as the oral, nasal,
orbital, nasopharyngeal sinuses, which include the
organs of sight, breathing, smelling, eating, spea-
king and hearing.
Functions of the facial skeleton that involve denti-
tion are mastication, deglutition, speech, respira- The functions of facial skeleton, which
tion, facial expression, and posture as well as stress
management. Functional movements of the involves the dentition, are mastication, deglu-
mandible, chewing, swallowing, speaking and tition, speech, respiration, facial expression,
bruxing behavior, are now regarded as the most and posture as well as stress management.

485
R. Slavicek • The Masticatory Organ
The base of the skull that part which con-
nects the skull vault and the facial skull
changed dramatically during the processes of
human evolution.
Therefore, in ontogenesis of modern human,
the viscerocranium especially the maxillary
complex mainly grows in downward direction.
486
effective and important functions of the craniofacial
structure. As homeostasis and the stability of occlu-
sion involve other systems as well, the dentist is
confronted with problems of equilibration of the
teeth, whereby the problems might originate from
factors quite remote from articulation.
Evolutionary Aspects of
Craniofacial Bones
The base of the skull, the part that connects the
skull vault and the facial skull, changed dramatical-
ly during human evolution. Comparison of a mod-
ern human skull with that of a modern ape reveals
some striking differences (12) (Fig. 2). The human
neurocranium with its vertical forehead, bulbous
occiput, rounded cranial vault, and centrally locat-
ed foramen magnum appears to constitute the
upright posture of the skull, although the viscero-
cranium in humans seems to be significantly small-
er and wider than that in apes. The inferior projec-
tion of the mastoid process in human beings is rela-
ted in part to the flexure of the cranial base. The
geometry and mechanics of the cranial base flexure
are determined by the spheno-occipital region of
the cranial base.
The anteroposterior dimension of the human visce-
rocranium is strikingly small, especially if the rela-
tive size of the neurocranium is taken into account.
When viewed in profile, one observes retrog-
nathism of the mid and lower face to flat appear-
ance with more vertically inclined long face than
that in apes. When a monkey skull is viewed from
below, the projection of the maxillary region is far
forward, with a longer anteroposterior dimension of
the spheno-occipital connection of the cranial base.
A feature that determines the skull base in humans
is the flexure of the cranial base, which is measured
by ascertaining the flexion angle (cranial angle)
(Fig. 3). In comparison to the skull of the
quadruped, the skull base angle in humans is rela-
tively small (Fig. 4). This is believed to be mainly
due to upright posture, the increase in brain vo-
lume, and frontal positioning of the eyes - a conse-
quence of stereoscopic vision. Postnatal changes in
the proportion of the human cranium also result in
a smaller basal flexion angle. Therefore, in the onto-
genesis of the modern human being, the viscerocra-
nium and especially the maxillary complex mainly
grow in downward direction (Fig. 5).
 Sadao Sato

Based on these considerations, the vertical growth

of the viscerocranium in modern humans creates
some difficulty in terms of proper fitting of the
upper and lower dentition, because the descending
spatial position of the maxillary occlusal plane easi-
ly creates anterior opening of the upper and lower
jaws without continuous mandibular adaptation by
rotation (Fig. 6). Therefore, functional adaptation
of the mandible to maxillary occlusal surfaces that
continuously descend in vertical position is funda-
mental in order to achieve proper functional occlu-
sion. The anterior mimic muscles help to close the Anterior mimic muscles help to close the
anterior opening of the jaws, which prevents the anterior opening of the jaws which prevents
development of anterior open bite malocclusion the development of anterior open bite maloc-
(Table 1) (13).
clusion.

Craniofacial Bone Connection

The bones constituting the craniofacial complex are
in a dynamic state of functional motion during
life (14). Cranial bones mainly consist of two parts
(Fig. 7 and 8):
1. Central connection of bones: ethmoid, sphenoid,
occiput, vomer, maxillary bones
2. Bilateral connection of bones: temporal bones,
mandible
Lets us first consider the different parts or structures
that interconnect with each other to form craniofa-
cial structures.

Sphenoid Bone
The sphenoid bone comes from the word ìsphenî
meaning wedge, as it forms a wedge between the As they are wedge between the face
face and the brain. The sphenoid bone plays a vital and the brain.
role in craniofacial morphology. It is joined by the
occipital, ethmoid and frontal bone, and is consi-
dered to be an essential element of the mid-sagittal
cranial base. The sphenoid bone is a principal cen-
tral bone of the skull that is formed by cartilage. It
provides early protection of capsular attachments
for vital organs and also plays a role in the early
development of the skull, both phylogenetically
and ontogenetically.
It is also a major superstructure for the attachments
of masticatory muscles, principally the temporalis
on the greater wings, the superior belly of the exter-
nal pterygoid in the horizontal portion of the
greater wing (wherein both pterygoids arise from

487
R. Slavicek • The Masticatory Organ
It is separated from the sphenoid body by a
synchondroses known as the spheno-occipital
synchondroses.
The synchondrosis between the basilar por-
tion of the occipital bone and the sphenoid
bone is considered to be the greatest joint in
the skull.
In great apes, the cranial base is less flexed in
the sagittal plane.
488
the lateral pterygoid plates) as well as the tensor
palatal muscles originating in the scaphoid fossa
and extending downward, crossing the hook of the
hamulus. In addition, the sphenoid bone serves as a
buttressed area for the temporal bone, as it is nec-
essary to resist the pull of the external pterygoid
muscles during function of the temporomandibular
joint (11) (Fig. 9).
Occipital Bone
The occipital bone is slightly funnel-shaped, with a
large opening known as the foramen magnum. The
basilar process is triangular in shape and is distin-
guished by an outer cortex and by inner cancellous
bone. It is hollowed out in adults by the sphenoidal
sinus. In youngsters, up to puberty, it is separated
from the sphenoid body by a synchondrosis known
as the spheno-occipital synchondrosis.
The synchondrosis between the basilar portion of
the occipital bone and the sphenoid bone is consi-
dered to be the largest joint in the skull. It is made
up of thick fibrous cartilage, which serves as a shock
absorber, permitting growth, and simultaneously
providing motional adjustment against external
stress.
Vomer Bone
The vomer bone consists of two small flanges of
bone that conform with the underside of the body
of the sphenoid. It is important because of the nasal
septum and its attachments to the palatine and
maxillary bones. Aside from serving as a buttress for
the upper jaw to receive shear forces, it is an impor-
tant site of downward growth of the human face
(Fig. 10).
In great apes, the cranial base is less flexed in the
sagittal plane, and the base of the vomer is posi-
tioned further anteriorly. The vomer plays an
important role as a transmitter of dynamic forces
from the cranial base to the maxillary complex.
Temporal Bone
In the dynamic mechanism of the craniofacial skele-
ton, the temporal bone is the most important one
because of its anatomical position. The temporal
bones are located in the lateral-most aspect of the
skull and fit in the space between the occipital, pari-
etal and sphenoid bones (Fig. 11). The temporal
bone's squamosal suture is fan-shaped and flaps
 Sadao Sato

over the parietal bone at its junction with the squa- The temporal boneís squamosal suture is fan
ma (Fig. 12). shaped and flaps over the parietal bone at its
The temporal bone is the keystone of the cranium junction with the squama.
because several muscles affect its movements. One
of the key factors in dysfunction of the cran-
iomandibular system is distortion and displacement
of the temporal bone. The temporal bone consists of
three main parts: the internal petrous portion, the
external squama and the mastoid sections. Squama
gives a zygomatic process, which extends forward
and articulates with the malar bone and acts as the
shock absorber for the TMJ. In the cranial scheme,
the temporal bone articulates with the occiput,
parietals, sphenoid, malar and mandibular
condyles. Its primary motion is derived from the
occiput, which gently moves the temporal bones
into internal and external rotation during the respi-
ratory phases of expiration and inspiration, respec-
tively.
Two of the primary muscles of mastication, tempo- Two of the primary muscles of mastication,
ralis and masseter muscles, have a direct influence temporalis and masseter muscles, have a
on the movement of the temporal bone. The large direct influence on the temporal bone move-
fan-shaped temporalis partly originates in the tem-
ment.
poral squama and inserts in the mandible at the
coronoid process and its anterior border.
Contraction of this muscle exerts powerful down-
ward and anterior force on the squama when the
posterior teeth occlude. This force has the effect of This force will have an effect of causing an
causing external rotation, i.e. the superior border of external rotation.
the squama moves anteriorly and laterally while the
mastoid tips move superiorly, posteriorly and medi-
ally. The mandibular condyles compensate by mov- The mandibular condyles compensate by
ing posteriorly and medially within the glenoid moving posteriorly and medially within the
fossa. glenoid fossa.
Internal rotation of the temporal follows a move-
ment that is the direct opposite of external rotation.
The mastoid tips move inferiorly, anteriorly and la-
terally while the superior border of the squama
moves posteriorly and medially. The condyle com-
pensates in anterior and lateral position within the
fossa.
Contraction of the sternocleidomastoid, splenius Contraction of the sternocleidomastoid,
capitis, longis capitis and digastric muscles will splenius capitis, longis capitis and digastric
induce internal temporal rotation. The stylohyoid muscles will induce an internal temporal
and styloglossus muscles provide balancing move-
rotation.
ment of the temporal bone. The muscular attach-
ments have their origin in the styloid processes.
During contraction they inhibit and balance the
movement of the temporal bone. The articulation
between the temporal squama and the parietal
bone is referred to as a shindylesis joint (joint with a
long bevel). This architectural design provides a

489
R. Slavicek • The Masticatory Organ
Dental malocclusion with mandibular dis-
placement will disrupt the temporomandibu-
lar joint function, which in turn causes tem-
poral bone distortion.
The midline bones of the cranium provide
flexion and extension movements.
The clinical significance of flexion-extension,
a side bending and torsion lesion is that they
are usually self-correcting once the primary
lesion is resolved.
490
gliding potential for jamming, especially when the
temporalis muscle goes into a spasm. Dental mal-
occlusion with mandibular displacement will dis-
rupt the function of the temporomandibular joint,
which in turn causes distortion of the temporal
bone (14).
The temporal bone affects the rotating movement
of the sphenotemporal articulation, which is formed
between the temporal and sphenoid bones; and
temporal occipital articulation, which is formed
between the temporal and occipital bones. The
temporal bone itself rotates in the petrotemporal
axis of the pyramidal portion. In recent orthodon-
tics, during occlusion or in conjunction with a pros-
thetic construction bite, it was found that the facial
bone is secondarily affected, once mandibular
movement is transmitted to the temporal bone.
Craniofacial Bone Dynamics
The sutural connections between bones permit
articular mobility of the cranium. The midline
bones of the cranium allow flexion and extension
(Fig. 13) (15). Continuous flexion of the midline
bones results in a movement that reduces the
anteroposterior dimensions of the cranial base and
increases the lateral transverse dimension (Fig. 14),
while the opposite is true in extension (Fig. 14). The
sphenobasilar articulation is the most important
joint for identifying the resultant motional dynam-
ics of craniofacial function. However, The spheno-
occipital synchondrosis acts as a joint that permits
various kinds of motion in different planes such as
flexion-extension, side bending, torsion and strain.
The motion of flexion-extension occurs in the verti-
cal plane, similar to normal spheno-basilar joint
motion. As a general rule, cranial distortions of flex-
ion-extension are transient. Distortions are a com-
pensatory reaction to primary lesions of forces sec-
ondary to occlusal function. The clinical significance
of flexion-extension, a side bending and torsion
lesion, is that they are usually self-correcting once
the primary lesion has resolved. However, correc-
tion of these cranial faults does not have a stable
effect; relapses are a common occurrence.
The normal flexion-extension motion responds
around the transverse axis. Bilateral temporal bones
respond to occlusal function through the temporo-
mandibular joint in a manner referred to as external
and internal rotation. As the bilateral bones go into
 Sadao Sato

external rotation, the midline bones go into flexion. Tooth extraction, deflective contact of poste-
Tooth extraction, deflective contact of posterior rior teeth, deviation of occlusal plane, hyper-
teeth, deviation of the occlusal plane, hypertonicity tonicity of cranio-mandibular-hyoid-cervical
of the craniomandibular-hyoid-cervical connection
connection of the muscles, clenching and
of muscles, clenching and bruxism, and many other
factors may cause minor to major bone malalign- bruxism, and many other factors may cause a
ment. slight to major bone malalignment.
As midline bones go into flexion, the anterior por-
tion of the sphenoid rotates downward. This causes
the posterior portion of the ethmoid to rotate
downward, with its anterior part rotating upward.
When rotating upward, it moves postero-superior-
ly under the glabella. This, in conjunction with
vomer flattening and vertical elongation of the
maxilla with external rotation, causes lengthening
and widening of the face.
As the sphenoid goes into flexion, it descends
downward, carrying the vomer against the hard
palate, causing the palate to flatten, and vertical
elongation of the maxilla. This is responsible for
poor anteroposterior dimensions of the maxillary
bone and also hinders adequate growth of the pos-
terior alveolar process for molar eruption, resulting
in posterior discrepancy or posterior crowding. In
this sense, posterior discrepancy, which creates sev- In this sense, posterior discrepancy which
eral types of malocclusions, is not a genetic prob- acts in creating many malocclusions is not a
lem, but is closely related to the dynamic state of genetic problem, but rather closely related
craniofacial structures.
with the dynamic state of craniofacial
structure.

Occiput-Spheno-Maxillary Complex
with the Vomer bone
The occiput-spheno-maxillary system consists of
the occiput, sphenoid bone, maxillary bone and
vomer bone (Fig. 7, 10 and 14). The body of the
sphenoid forms an important joint or synchondrosis
with the basilar process of the occipital bone. This
joint fuses in late puberty, indicating that the
dynamic motion of the joint continues until the ter-
minal stage of functional growth, as a result of
articulation of upper and lower dentitions.
Hanging down from the undersurface of the body
of the sphenoid bone are two pairs of bony plates,
the medial and the lateral pterygoid plate. The lat-
eral pterygoid plate provides the origin of the ptery-
goid muscles, which are responsible for mandibular
movement.
The maxillary bone articulates directly with 45% of The maxillary bone articulates directly with
cranial bones. Sutural attachments are shared with 45% of the cranial bones.

491
R. Slavicek • The Masticatory Organ
One of the primary etiologic factors in cran-
iomandibular dysfunction is the loss of verti-
cal dimension.
492
the malar, frontal, ethmoid, vomer, lacrimal, inferi-
or nasal concha, palatine and sphenoid bones. The
forces generated during swallowing, speech, chew-
ing and parafunctional activities such as clenching
and bruxing are directed via the vomer to the sphe-
no-basilar area, in order to enhance the flexion
movement. The posterior bicuspid and molar axial
root planes are directed within the range of the
spheno-basilar symphysis. Anatomically, the sphe-
noid bone is supported by the vomer bone, which
rests on the palatine bone and extends vertically to
contact and support the sphenoid near the spheno-
basilar junction. Forces from dental contact and the
tongue help to raise the maxilla, palate and vomer,
thereby directing vertical force against the sphe-
noid, ensuring adequate amplitude of the spheno-
basilar symphysis into flexion and influencing cra-
nial motion.
One of the primary etiologic factors in cran-
iomandibular dysfunction is loss of the vertical
dimension. Lack of the vertical dimension as a result
of inadequate normal eruption of natural dentition
or loss of molar and bicuspid teeth or severe attri-
tion of the occlusal biting surface and inadequate
tooth contact reduces the amplitude of spheno-basi-
lar flexion and affects cranial motion (extension
lesion).
Maxillary Bone Growth According to
the Dynamics of the Cranial Base
The process of bone displacement, translatory
movement of the entire bone caused by the sur-
rounding physical forces, is a primary and charac-
teristic mechanism of skull growth. The entire bone
is carried away from its articular interfaces, sutures,
synchondroses, and the condyle with adjacent
bones (16). Displacement of the maxillary complex is
caused by the sum of pushing forces from sphe-
noidal motion via the vomer bone. It occurs paral-
lel to bone growth, thus creating space around the
contact surfaces into which the bone can enlarge.
The rotating movement of the cranial base occurs at
the spheno-occipital articulation. The rotating axes
of the sphenoid and occipital bones are the anterior
portion of the sella turcica and the posterior portion
of the major occipital foramen, respectively. The
rotating movement of the sphenoid bone is trans-
mitted to the mandible through the vomer, which
 Sadao Sato

results in anteroinferior pushing of the maxilla. The The rotating movement of the sphenoid bone
vomer has a direct effect on the rotation of the sphe- is transmitted to the mandible through the
noid, as the sphenoid and vomer are communicat- vomer, which results to the anteroinferior
ing with the rostrum of the inferior surface of the
pushing of the maxilla.
sphenoid and the wing of the vomer. In addition,
the rotating movement of the sphenoid bone is
indirectly transmitted to the maxilla because the
inferior border of the vomer is connected to the
maxillopalatine process and the nasal crest of the
palatine horizontal plate. This is how the move-
ment of cranial bones affects the maxilla, especially
when the pushing direction of the maxilla changes
in relation to the rotating direction of the cranial
base; this would indicate growth of the maxilla. For
example, rotation of the sphenoid bone is flexion.
This would influence the rotating force of the wing
of the vomer, which is posteroinferior, preventing
anterior pushing of the maxilla. Instead, it would
move inferiorly. On the other hand, when the rota-
tion of the sphenoid bone is extension, rotation of
the vomer will be anterior, and the maxilla will be
strongly pushed anteriorly. The pushing movement
of the maxilla affords adequate space in the posteri-
or portion of the upper teeth, allowing growth of
the posterior border of the maxillary tuberosity.
The direction of displacement of the maxilla is
influenced by the dynamic states of the occiput-
spheno-ethmoidal connection of the cranial base.
There are three types of maxillary growth secondary
to displacement of the maxillary complex: transla-
tion with the frontal bone, vertical elongation, and
anterior rotation (Precious et al (17), 1987) (Fig. 15).
Flexion motion of the cranial base causes vertical
elongation of the maxillary complex. This is com-
monly seen in the development of a Class III skele-
tal frame. Extension of the cranial base causes ante-
rior rotation of the maxillary complex. This is relat-
ed to the development of a Class II skeletal frame.
Translation of the maxilla (anteroposterior) with the
frontal bone to which it is attached below the
frontal sinus shifts the maxilla in forward direction.
The maxilla is passively displaced due to expansion
of the middle cranial fossa, the anterior cranial base,
and the forehead, without the growth process of
maxilla itself being directly involved. Vertical elon-
gation of maxillary complex and the formation of
the alveolar process increase the height of the max-
illa.
Bone deposition on the wall of the maxillary
tuberosity is mainly important for creating space to
allow the eruption of posterior teeth, resulting in

493
R. Slavicek • The Masticatory Organ
The temporo-mandibular complex is one of
the most important functioning systems of
the cranium.
Each temporal bone consists of the squamous,
petrous and mastoid portions.
494
posterior lengthening of the bony maxillary arch.
This posterior elongation of the upper jaw is cou-
pled with translation and anterior rotation of the
maxillary complex, although the vertical elongation
of maxillary bone does not provide posterior length-
ening (Fig. 16).
The tooth buds of the upper molars have to be
formed in the relatively small area of the maxillary
tuberosity, indicating posterior discrepancy (18,19). As
the maxilla displaces by forward translation and
anterior rotation, the formation of the alveolar
process accompanies the downward movement of
tooth buds. Thus, posterior crowding of the molars
is eliminated.
Temporo-Mandibular Complex
The temporo-mandibular complex is one of the
most important functioning systems of the crani-
um. In the functional cranial scheme, a U-shaped
mandible, representing the most active functional
movement in craniofacial structures, connects the
two temporal bones at the lateral surface of the cra-
nium. The temporo-mandibular system is com-
posed of the articulation of the mandible with the
cranium; this joint is referred to as the temporo-
mandibular joint. The mandible and temporal
bones affect their position and movement recipro-
cally (Fig. 17).
Each temporal bone consists of the squamous,
petrous and mastoid portions. They also have other
distinct parts such as the tympanic plate and the
styloid process. The parietal notch of the temporal
bone articulates with the mastoid angle of the pari-
etal bone located above the mastoid process. A fur-
ther unique characteristic of the temporal bone is
that the squamous temporal considerably overlaps
the parietal bone, rather than interdigitating, as
many cranial bones do. The type of articulation that
occurs between the temporal, occipital and parietal
bones in the cranium may well reflect the large
masticatory forces generated around the cranium.
In addition to the overlapping articulation that
occurs in all hominoid crania, the parietal bone
overlaps with the mastoid portion of the temporal
bone as well as with the occipital bone. Rak
(1978) (20) and Kimbel and Rak (1985) (21) reported
that this might be due to the resistance to extreme
masticatory stresses in the vault bones of this
region. The condition of overlapping vault bones
 Sadao Sato

appears to be a unique adaptation among homi-

noids.

The Importance of the Function of

Occlusion for Mandibular Growth
It has long been believed that the growing enlarge-
ment of condylar cartilage was the primary reason
for mandibular displacement. According to this
concept, the pressures exerted on the glenoid cavity
by the growing condyle caused the mandible to be
displaced out of articulator contact (16).
Two simple questions may be raised in an attempt
to explain clinical experience and the articulation of
teeth. First, how do the upper and lower teeth fit
together if the mandible is displaced by predeter-
mined condylar growth? Second, is the maxillary
bone, including upper dentition, adaptable to the
continuously changing mandibular dentition?
Recent studies showed that mandibular displace- However, recent studies showed that
ment is the primary process and that condylar mandibular displacement is the primary
growth is secondary and adaptive. This reestablish- process and condylar growth is secondary and
es the relationship of the displaced mandible in the
adaptive.
temporomandibular joint (22-25).
The mandible is greatly influenced by functional
demands, especially the articulation. These are con-
trolled by the central nerve-muscle system.
According to Moss, a specific cranial component
controls each function while the size, shape and spa-
tial position of the individual components are rela-
tively independent of each other.
The functional matrix includes the functioning
space and the soft tissue components required for a
specific function such as breathing or mastication.
The function of the mandible is always executed in
relation to the spatially positioned upper dentition
(Fig. 18). Mandibular translation is caused by the
functional shift of the mandible, which is induced
by the functional articulation of teeth. The entire
mandible is displaced downward and forward, away
from its articular joints.
This translatory movement stimulates the enlarge-
ment and remodeling of the condyles and the rami,
which take place parallel to displacement. Bone
growth processes are directed upward and back-
ward to an extent that equals the displacement of
the mandible. From this standpoint of the mastica-
tory system, the cranial determinant of mandibular
growth is the spatial position of maxillary teeth.

495
R. Slavicek • The Masticatory Organ
The most significant point in the cybernetic
model is that occlusal function is an impor-
tant factor in the mandibular growth.
The most important point in this concept is
that mandibular growth is not only controlled
by the endocrine system and intrinsic capacity
of the mandibular growth, but also the posi-
tion of the occlusal surface (functional
occlusal plane) of the maxillary teeth to which
it is functioning with.
496
Craniofacial Growth and
Development with Special Attention
on the Occlusal Plane
Petrovic (1975) (26, 27) comprehensively studied fac-
tors affecting the growth of the maxillofacial skull.
As a result, he described the cybernetic model of
mandibular growth using Moss' concept as his fun-
dament (28-30). The most significant point in the
cybernetic model is that occlusal function is an
important factor in mandibular growth (31). In
anteroinferior displacement of the maxilla, the
mandible is able to functionally adapt. This dis-
placement directs adaptation of mandibular
growth. In the cybernetic model, the functional fac-
tor that regulates mandibular growth is occlusal
function.
The cybernetic model of Petrovic can be simplified
in the manner shown in Fig. 19. The most impor-
tant local factor in the control of mandibular
growth is the spatial position of the maxillary
occlusal surfaces and the maxillary dental arch.
Functional movement of the mandible is dependent
on the action of the central nervous system and
masticatory muscles. Anteroinferior growth of the
maxilla functionally shifts the mandible, making
the TMJ adjust to the new mandibular position,
which leads to mandibular remodeling or growth.
The most important point in this concept is that
mandibular growth is not only controlled by the
endocrine system and the intrinsic capacity of
mandibular growth, but also by the position of the
occlusal surface (functional occlusal plane) of the
maxillary teeth, with which it is functioning. For
instance, in a patient in whom the maxilla descends
vertically, the functional occlusal surface will change
to inferior position. In response to this, the
mandible will move inferiorly and elongate vertical-
ly (Fig. 20).
Moreover, adaptation to the new mandibular posi-
tion is not always simply due to mandibular growth
and internal remodeling of temporomandibular
joint. The functional force from the mandible to the
temporal bone through the joint, the masseter mus-
cle, changes in traction force from the masticatory
muscles to the temporal bone, and movement or
rotation of the temporal bone, are liable to alter
positional adaptation of the mandible.
In addition, the tension of the medial and lateral
pterygoid process, which is related to the positional
 Sadao Sato

change of the mandible, affects rotation of the sphe-

noid bone. Movement of the sphenoid bone
changes maxillary movement and the vertical posi-
tion through the vomer. The altered mandibular
position due to occlusion controls the harmony of
the entire maxillofacial skeleton.
Occlusal function and the maxillofacial skeleton are The occlusal function and the maxillofacial
closely related, creating a unified dynamic mecha- skeleton are closely related, creating a whole
nism. The balance of this dynamic mechanism has dynamic mechanism.
a great influence on the growth of the maxillofacial
skeleton in active infants. Therefore, orthodontic
occlusal treatment is not simply an alteration of
occlusion but the consideration of a maxillofacial
dynamic mechanism. This type of mandibular
adaptation to occlusion causes a load on the
mandibular condyle, where its growth will be regu-
lated. However, when this load exceeds the adap-
tive capacity of the TMJ, it affects function in the
temporal bone, articular disc, and masticatory mus-
cles, causing TMJ arthrosis.
On the other hand, an increase in the vertical
dimension that exceeds the growth of the mandibu-
lar condyle results in rotation of the mandible, pre-
senting an open bite condition of the front teeth
and creating a fulcrum in the molars, which in this
case causes an abnormal load for the TMJ.
As mentioned earlier, the increase in the vertical
dimension and mandibular growth are closely relat-
ed. It is important to develop and maintain the har-
mony of both. Once the vertical dimension increas-
es or decreases, the mandible adapts through func-
tional displacement.
The occlusal plane is the most important compo-
nent influencing the vertical dimensions of the
lower face. For instance, the vertical position of pos-
terior teeth in a Class III high angle and in open
bite malocclusion is not stable during growth (Fig.
21). Continuous molar eruption occurs not only
during growth, but also during post-puberty. In
this sense, genetics may not be the sole reason for
this type of malocclusion. Rather, the continued
eruption of second and third molars in a limited
space must be the major contributing factor. The
development of such malocclusions must be regard-
ed as an effect of posterior discrepancy or posterior
crowding (32, 33).

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R. Slavicek • The Masticatory Organ

Cephalometric Evaluation of the

Denture Frame (Denture Frame
Analysis)
The skeleton, whose shape is directly related to
occlusion and is the basic unit that supports the
maxilla and mandible, is known as the denture
frame. Since the denture frame is a basic skeleton
that supports the upper and lower dentition, it
must be in harmony, especially with the occlusal
plane. The denture frame changes in response to
occlusal changes because mandibular displacement
affects it. The changes associated with its morphol-
ogy and growth are closely related to occlusal func-
tion.
Occlusal construction is the most important mea-
sure for establishing the spatial position of the
occlusal plane in the denture frame. In other words,
orthodontic occlusal treatment restores the harmo-
ny of the denture frame and occlusion through
attaining a correct occlusal plane. From this stand-
point, denture frame analysis is done to determine
the basic morphology of the denture frame (34).
The palatal plane (PP), occlusal plane (OP),
mandibular plane (MP) and AB plane (AB) of the
morphology of the denture frame are closely relat-
ed to occlusal function. Listed below are the refer-
ence points and planes used in denture frame analy-
sis (Fig. 22).

1. FH plane (FH)
2. Palatal plane (PP)
3. Mandibular plane (MP)
4. AB plane (AB)
5. Occlusal plane (OP)
6. A’, 6’, A’-P’ 6’-P
7. Maxillary median incisal axis
8. Mandibular median incisal axis
9. 1st molar axis of the upper and lower mandible

Denture frame analysis is measured with the above

mentioned items, which are also studied with
regard to their respective functional background.

498
 Sadao Sato

FH-MP
This determines the position of the denture frame in
the craniofacial skeleton and is an important index
to determine the functional adaptation capacity of
the mandible to occlusion. When the FH-MP is
high, the functional adaptation capacity due to
anterior rotation of the mandible to the occlusion is
low.
Usually, when the mandible shows excellent adap-
tation capacity due to its growth, it displays pro-
trusive rotation. However, when the adaptation
capacity is poor, it usually displays a retruded rota-
tion. In case of protrusive rotation with bone
remodeling of the inferior border of the mandible,
there is a minimal change in the FH-MP angle
while the AB plane and the MP angle decrease due
to the protrusive position of the mandible (Fig. 21).
In case of retruded rotation, the FH-MP angle
increases, with minimal changes in the AB-MP
angle. This presents the so-called high angle condi-
tion.

PP-MP
It is the angle formed between the palatal plane
(PP) and the mandibular plane (MP). This shows
the basic morphology of the denture frame. When
this is increased, like the FH-MP, it does not induce
protrusive rotation of the mandible as a functional
response; rather it adapts to the occlusion through
backward rotation. Although the PP-MP and the
FH-MP are nearly the same, the significant differ-
ence lies in the descent of the palatal plane due to
the protrusive rotation of the maxilla. This is usual-
ly observed in patients with mandibular distocclu-
sion associated with deep overbite.

OP-MP
This is the angle of the occlusal plane (OP) and the
mandibular plane (MP). Normally, the occlusal
plane and the mandible have a functional relation-
ship in order to maintain the OP-MP angle with
neuromuscular function. In other words, when the
occlusal plane changes to parallel or slightly hori-
zontal during the growth process, the mandibular
plane also moves in parallel to it. Even if the
occlusal plane is changed to horizontal, the
mandible reacts to maintain the OP-MP angle by
rotating protrusively in response to the occlusal
plane.

499
R. Slavicek • The Masticatory Organ

This phenomenon is also seen in individuals with

normal occlusion, and slight changes of the occlusal
plane are recovered through this type of mandibu-
lar adaptation. This does not result in a serious
occlusal abnormality because it maintains the func-
tional occlusion. However, when the occlusal plane
is excessively displaced, it results in a backward
rotation of the mandible, leading to an increase in
the OP-MP angle.
Since the vertical support of the occlusion is insuffi-
cient, mandibular condyle growth is inhibited. The
OP-MP angle does not adapt forward and remains
decreased even during the growth process.
The angle of the OP-MP is not merely the angle
formed between the occlusal plane and mandibular
plane. It is the measurement of the relationship of
the occlusal plane and the mandibular plane as a
functional unit of the denture frame, which has a
dynamic relationship with the functional adapta-
tion capacity of the mandible.

OP-MP/PP-MP
This is the ratio of the OP-MP angle to the PP-MP
angle. In effect, it shows the positional relationship
of the denture frame and the occlusal plane. The
value of a normal occlusal plane is 0.54; which is
the basic morphology of the denture frame. If it
exceeds 0.60 it is presumed that there is a deviation
of the occlusal plane and that the mandible is not
adapting to it. In an occlusal plane of less than 0.5,
the posterior vertical dimension is insufficient,
which leads to a retruded mandible brought about
by the inhibition of the mandibular condylar
growth due to a chronic compression load.

AB-MP
This is the angle formed between the AB plane, the
point of A and B, and the mandibular plane (MP).
It reveals the anterior border of the denture frame
and the anteroposterior relationship of the lower
and upper jaws. This usually shows the anterior dis-
placement of the mandible due to its forward rota-
tion. When there is over-eruption in the molar part,
the mandible avoids the posterior interference
through protrusive displacement. Persistent push-
ing of the molar in posterior discrepancy allows pro-
trusive displacement to occur continuously, which
somehow affects the mandibular condyle growth
and alters the denture frame morphology.
There is a mutual relationship between the change
of the occlusal plane and the change of the AB

500
 Sadao Sato

plane, which results in an alteration of the occlusal

plane to flat, associated with a reduction of the AB-
MP angle. However, when the adaptation capacity
of the mandible is low, there is no change in the
AB-MP angle, and there is a tendency for the PP-
MP to increase.

A'-P'
It is the distance between the A' and P'. This repre-
sents the anteroposterior diameter of the maxillary
basal bone. The A'-P in a 6-year-old child with a
normal occlusion is 44.1 mm. and this gradually
increases during growth. At the age of 13 years it
becomes 50.0 mm. and is nearly consistent there-
after.
The increase of A'-P' is brought about by the
growth of the bone in the posterior border of the
maxillary tuberosity. However when the growth in
this part is decreased, the A'-P' angle is sustained,
leading to an insufficient space in the posterior den-
tition, resulting in posterior discrepancy.

A’-6’
It is the distance between the A' and 6'. This shows
the protrusive length of the 1st molar in the maxil-
lary basal bone. In an individual with a normal
occlusion and without posterior discrepancy, the
distance nearly does not change at all and the 1st
molar position is extremely stable during the
growth period.
However, in a patient with posterior discrepancy,
A'-6 ' decreases because of the eruption of the 2nd
and 3rd molar associated with the mesial move-
ment and the vertical pushing on the 1st molar. In
effect, both the mesial movement and supraerup-
tion are forms of posterior discrepancy. The degree
of posterior discrepancy can be estimated with the
A'-6' parameter.

A’6’/A’-P’’
This is the ratio of the values measured above. It
shows the anteroposterior position of the 1st molar
tooth in the maxillary basal bone.

0 Denture frame of the upper and lower frontal

teeth and the measurement of the relationship of
tipping and position of the molar.

501
R. Slavicek • The Masticatory Organ

1 – AB (°): the angle formed between the

tooth axis of the maxillary central
incisor and the AB plane.
1 – AB (mm): the distance from the incisal mar-
gin of the maxillary central incisor
to the AB plane.
1 – AB (°): the angle formed between the
tooth axis of the mandibular cen-
tral incisor and the AB plane.
1 – AB (mm): the distance from the incisal mar-
gin of the mandibular central
incisor to the AB plane.
Intermolar (°):the angle formed between the
tooth axis of the upper and the
lower 1st molar.

The angle and position of the frontal teeth are all

evaluated through the relationship of the AB plane.
Changes in the AB plane are due to maxillary rota-
tion and adaptational change of mandibular posi-
tion to the occlusal plane. Moreover, the AB plane
and the occlusal plane are nearly at right angles to
each other, and this reflects the adaptive capacity of
the mandible to changes in the occlusal plane.
For example, the vertical dimension does not
increase when there is a steep occlusal plane; the
AB-MP angle increases because the mandible
adapts to it. As a result, there is the relationship of
the occlusal plane to the right angle. On the other
hand, when the occlusal plane changes to flat, the
mandible takes the protruded position and the AB-
MP angle decreases, thus maintaining the relation-
ship of the occlusal plane to the right angle.
The first molar axis has the most stable centric stops
when the occlusal force is in vertical direction.
However, in a patient with posterior discrepancy,
mesial tipping is usually extensive and this has to be
uprighted through an orthodontic occlusal recon-
struction. Uprighting of the molars provides space
for the dental arch, which offers the possibility to
improve crowding and protrusion.

Implication for Dental Practice –

Developmental Mechanism of
Growth Abnormality
Research studies of maxillofacial skull growth occu-
py an important position in dental and orthodontics

502
 Sadao Sato

research studies. When continuing the occlusal

management of an orthodontic patient, it is impor-
tant to note that the important elements of the
maxillofacial growth concept are certainly within
the maxilla and the mandible. The growth of the
mandible through time disregards the orthodontic
approach and the efforts of both the surgeon and
the patient are instantly wasted.
Various orthodontists are puzzled by the thought
that the growth phenomenon is nothing but abnor-
mality. What, then, is the mechanism of this type of
growth abnormality? To ascertain this, it is by all
means important to conduct a very accurate
occlusal reconstruction.
As mentioned, environmental factors have a strong
influence on the maxillofacial skull growth after
birth and, more importantly, in the dynamic func-
tion of the stomatognathic system. Without doubt,
the abnormalities of occlusal function could easily
displace the mandible. In fact, various malocclu-
sions show a displacement of the mandible from the
center position. Moreover, this displacement in mal-
occlusions increases with age (Fig. 22).
As understood in the cybernetic model of Petrovic,
mandibular displacement, mediated by the neuro-
muscular system, induces secondary growth of the
condyle. A persistent mandibular displacement
consequently results in displacement of the skeletal
morphology. According to Moss, the latent growth
capacity of the cartilage is extremely low.
Mandibular elongation is explained as a secondary
or compensatory growth, which is achieved through
the functional displacement of the mandible, relat-
ed to the protrusive movement of the maxilla.
If this is true, it may be concluded that the abnor-
mality in mandibular growth is actually an abnor-
mal adaptation to occlusal function in the normal
skeletal pattern. Moreover, the sudden increase in
the abnormality of the TMJ, post puberty, creates
an abnormal occlusal function which makes the
mandibular condyle adapt by means of immense
growth. This growth, however, diminishes the
growth capacity of the mandibular condyle. Either
way, the abnormal growth is assumed to be proba-
bly caused by the functional factor of the stomatog-
nathic system in occlusal function.
In the field of orthodontics, it was long believed
that growth-related development was the basic cul-
prit. Orthodontists blame the growth factor to be
the unknown cause of skeletal malocclusion. In case
of no response to malocclusion treatment, or when

503
R. Slavicek • The Masticatory Organ

the anticipated growth does not match with skele-

tal changes, or if there is recurrence of malocclusion
after surgical treatment, abnormal growth may be
considered to be the underlying cause. All inconve-
nient circumstances for the orthodontist are due to
growth. If growth-related development alone is,
indeed, the cause of the development of malocclu-
sion, it would be impossible to disregard such devel-
opment and simply improve malocclusion. In the
long run, we cannot help but disregard orthodontic
treatment.
To assert that growth is the culprit of all, as men-
tioned a while ago, is incorrect. Rather, the abnor-
mal growth pattern is the result of mandibular
adaptation related to occlusal function abnormality.
Therefore, early orthodontic management has a
very important implication in the harmony of max-
illofacial skeleton growth. This viewpoint is impor-
tant in reconsidering the developmental process of
skeletal malocclusion.
Management does not end with tooth replacement,
especially in occlusal training and occlusal guid-
ance. The harmony of the maxillofacial skeleton
and the management of the entire growth are
important. In order to achieve these, it is important
to understand the relationship between occlusal
development, the maxillofacial skeleton, and the
development of specific skeletal growth abnormali-
ty. This theory is merely based on the dynamic
mechanism of the maxillofacial skeleton and the
developmental mechanism of skeletal malocclusion.

504
 Sadao Sato

Figure 1a and 1b: Composition of the craniofacial complex. The skull consists of several different sophisticated bones that collectively
form a hollow bony shell that houses the brain and sense organs, and provides a base for the teeth and the chewing muscles. In the
stage of growth, the bones are in a flexible state and are dynamically interrelated. The components also have the ability to adapt to
functions of the skull. The skull functions as a base and a structural framework for the first stage of the digestive system and mastica-
tory organ. It also serves as an encasement for the brain and for the sense organs of sight, smell, and hearing. The functional balance of
craniofacial bones is influenced by occlusal functions such as mastication, respiration, speech, clenching and bruxism.

Figure 2a and 2b: Composition of the skull of humans and primates. The connection of the Occipital-Sphenoid-Vomer-Maxillary bones
in the primate skull (a) shows an expanded and longer anteroposterior dimension than that in humans; (b) the human skull indicates
expansion of the neurocranium and reduction of facial prognathism. A shift in the position of the foramen magnum can be seen due to
the uprighting effect of the skull and the increase in brain size. As a consequence of the great reduction in the anteroposterior dimen-
sions of the viscerocranium, the human skull exhibited wider and more vertical growth than the primate one.

505
R. Slavicek • The Masticatory Organ

Figure 3a and 3b: Comparison of cephalogram tracings of human and primate skulls. In contrast to humans, primates have a large
cranial base angle (N-S-Ba) with a posteriorly located foramen magnum and forward translation of the vomer and the maxillary bone.
The modern human face tends to rotate backward and downward underneath the brain case, with the brain developing on the top of
the facial skeleton. The human cranial base located between the face and the brain assumes a larger bend, thereby reducing the degree
of flexure (N-S-Ba) compared to that in primates.

Figure 4: Superimposition of cephalogram tracings from mod-
ern humans and primates. This superimposition indicates how
the flexure of the cranial base angle is related to changes in
the craniofacial skeleton. Reduction of the cranial base angle
greatly influences the facial profile and the direction of growth
of the maxillary complex.
Figure 5: Verticalization of the viscerocranium during ontoge-
netic growth and development. As the viscerocranium increas-
es in its vertical rather than anteroposterior dimensions, the
facial complex of the modern human creates the necessity of
functional mandibular adaptation in order to fit upper and
lower dentitions.

506
 Sadao Sato

Figure 6a and 6b: Adaptation of occlusion against verticalized growth of the facial skeleton. Vertical growth of the viscerocranium in
the human skull creates an anterior open bite (a); the maxillary complex translates downward, resulting in posterior contact of the
upper and lower teeth (wedge effect). Functions of the anterior mimic muscles such as the orbicularis oris, mentalis, depressor and leva-
tor anguli oris, and buccinator muscles, include closing the mandible and helping to adapt the mandible by rotational movement, so
that it fits with the upper and lower occlusal surfaces (b). Patients with weak mimic muscle activity develop an anterior open bite mal-
occlusion, as the mandible cannot adapt through rotation.

Figure 7: Craniofacial connection of the Occiput-Sphenoid- Figure 8: Temporo-mandibular complex. The mandible is con-
Vomer-Maxillary bones. The sphenoid bone is located in the nected with the temporal bone through the temporomandibu-
center of the skull and joins with other mid-line bones such as lar joint. The complex is the most dynamic functional unit in
the occiput, ethmoid, and vomer. It is directly connected to the craniofacial skeleton. Dynamic movement of this complex
the maxillary bone via the vomer and palatine bones. The influences the state of the Occiput-Spheno-Maxillary complex.
sphenoid bone is also connected to the occipital bone by a syn-
chondrosis known as the spheno-occipital synchondrosis,
which is in dynamic motion during the development of occlu-
sion. The dynamic motion of the cranial base is transferred to
the maxillary bone through the vomer bone.

507
R. Slavicek • The Masticatory Organ
Figure 9: Connection of the sphenoid and temporal bones.
The vertical and horizontal portion of the greater wing of the
sphenoid and temporal bone are interconnected by a heavy
butt joint (arrow). The dynamics of the temporal bone influ-
ence the spheno-occipital balance of the cranial base through
this heavy joint. If the glenoid fossa were to receive compres-
sion force from occlusion, especially when the upper and lower
teeth grind strongly during bruxism, the forces would be
transferred to the cranial base via the rotational movement of
the temporal bone.
Figure 11: Connection of mid-line bones and bilateral tempo-
ral bones. The mid-line bones of the cranium undergo a
motion defined as flexion and extension. Two of the mid-line
bones, the greater wings of sphenoid and occiput, articulate
with the petrous portion of the temporal bone. This petrous
extension acts as a rotational axis (petro-temporal axis) during
motional activities.
508
Figure 10: The dynamic connection of the Sphenoid-Vomer-
Maxillary bones. The vomer bone plays an important role in
transferring cranial motion to the maxillary bone. Therefore,
the motion of the cranial base influences displacement of the
maxillary bone.
Figure 12: Dynamics of the Temporo-Parietal suture. The long
beveled suture of temporo-parietal bones possesses the ability
of gliding movement. Reciprocating movements of the suture
from external forces adjust themselves to balance cranial
bones. The presence of malocclusion will disrupt the temporo-
mandibular joint, resulting in mandibular displacement, which
in turn causes distortion of the temporal bone.

Figure 13: Sagittal connection of the Occiput-Sphenoid-
Vomer-Maxillary bones. The flexion-extension motion of the
cranial base influences the direction of maxillary bone dis-
placement, followed by sutural growth.
Figure 14b
Sadao Sato
Figure 14a, 14b and 14c: Sagittal expression of the relation-
ship between motion of the cranial base and displacement of
the maxillary complex. Flexion of the cranial base causes verti-
cal elongation of the maxilla while extension causes anterior
rotation of the maxillary complex.
Figure 14c
509
R. Slavicek • The Masticatory Organ

Figure 15a-15d: Different types of maxillary bone displacement. There are 3 types of maxillary displacement: translation (b), vertical
elongation (c), and anterior rotation (d), according to the growth study done by Precious et al. (1987). It was suggested that the dif-
ferent types of maxillary displacement were closely related with cranial growth and cranial motion. Increase of the anterior cranial base
causes translational displacement of the maxillary complex. The flexion motion of the cranial base induces vertical elongation of the
maxilla while extension provides anterior rotation of the maxilla, as shown by an anterior-upward inclination of the palatal plane on
the cephalogram.

Figure 15c and 15d

510
 Sadao Sato

Figure 16: Growth of the upper jaw and eruption of posterior teeth. Most of the growth in the anteroposterior
dimensions of the maxilla originates through bone apposition from the posterior aspect to the maxillary tuberosity.
The initial appositional growth at the tuberosity arises with forward translation of the maxillary complex. Lack of
maxillary translation makes it difficult to provide eruption space for the posterior molars; this creates posterior dis-
crepancy.

Figure 17a and 17b: Frontal view of the craniofacial complex. Connection and posture of sphenoid, temporal bone, vomer, maxilla, and
mandible are closely interrelated with the dynamic function of occlusion (a). Unilateral over-eruption of posterior teeth creates posterior
interference and induces a mandibular lateral shift. Consequently the individual develops an asymmetrical balance of the craniofacial
complex (b).

511
R. Slavicek • The Masticatory Organ

Figure 18a and 18b: Function of occlusion and mandibular growth. In the growing facial skeleton, adaptability is primarily located in
the function of dentition and secondarily in the sutures and at the condyles. The growth of the lower face is guided by the function of
occlusion, followed by secondary condylar growth. Thus, the three-dimensional change of the occlusal plane is an extremely important
determinant of facial growth (a). Horizontalization of the maxillary occlusal plane provides rotational mandibular adaptation, with a
simultaneous reduction in the mandibular plane angle (b).

Figure 19: Denture frame analysis of the lower face. Palatal
plane (PP), mandibular plane (MP), maxillary occlusal plane
(OP), and AB plane (AB) are used to assess the construction of
the lower face. The Frankfort horizontal plane (FH) is used as
a cranial reference line.
Figure 20: Longitudinal changes in the denture frame in a
normally growing subject. The pattern of mandibular growth
is closely related to changes in the spatial position and inclina-
tion of the upper occlusal plane.

512
 Sadao Sato

Figure 21a and 21b: Longitudinal growth patterns of denture frame in cases developed skeletal Class III (a) and Class II open bite (b)
malocclusions. Alteration of occlusal plane related not only with mandibular posture, but also with dynamic state of the cranial base.

Figure 22a and 22b: Shows two adults with skeletal Class III (a) and skeletal Class II (b) malocclusions. Differences in the length and
angle of cranial base, position and inclination of the occlusal plane, position and posture of the maxilla and mandible, and dento-alveo-
lar vertical height are seen.

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3. Frymann, V.M.: A study of the rhythmic motions of the
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Biomech. 4:1–12, 1971
10. Gillespie, B.R.: Dental considerations of craniosacral
mechanism. J. Craniomand. Pract. 3:380–384, 1985
11. Ricketts, R.M.: Provocations and perceptions in cranio-facial
orthopedics. Dental science and facial art. RMO Inc. USA
1989
12. Cousin, R.P., Fenart, R.: Etude Ontogenetique des
Elements Sagittaux du Fosse Cerebrale Anterieure chez
líHomme Orientation Vestibulaire. Archives Anat. Path.
9:383–395, 1971
13. Bhatia, S.N., Leighton, B.C.: A manual of facial growth.
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14. Upledger, John E., Retzlaff, Ernest W., Vredevoogd, M.F.:
Diagnosis and treatment of Temporo-parietal suture head
pain. Osteopathic Medicine. 19–26, 1978
15. Hooper, H.: Cranio-gnathic implication. In Orthopedic
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16. Rakosi, T., Jonas, I., Graber, T.M.: Color atlas of dental
medicine. Orthodontic diagnosis. Thieme Med. Publisher
Inc., New York 1993
17. Precious, D., Delaire, J.: Balanced facial growth : a schema-
tic interpretation. OSOMOP 63:637–644, 1987
18. Sato, S.: Case report: Developmental characterization of
skeletal Class III malocclusion. Angle Orthod.
64:88–95,1994
19. Sato, S., Suzuki, Y.: Relationship between the development
of skeletal mesio-occlusion and posterior tooth-to-denture
base discrepancy. Its significance in the orthodontic recon-
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47:768–810, 1988
20. Rak, Y.: The functional significance of the squamosal suture
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23. McNamara, J. A. Jr., Carlson, D. S: Quantitative analysis of
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24. McNamara, J. A. Jr., Bryan, F. A.: Long-term mandibular
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15:115–123, 1987

515
R. Slavicek • The Masticatory Organ
A monograph (the word is of Greek origin)
is a scientific presentation of a particular
problem or a specific personality.
This kind of work makes it possible to select
a freer and more subjective approach. The
danger here, of course, is a certain loss of
objectivity.
516
Final observations
When working at a monograph, self-critical
doubts will inevitably arise and create a sense of
insecurity.
A book like this present one is not intended to be
a scientific publication. In scientific publications, a
specific field is worked at in detail and, if possible,
original and new topics for discussion are present-
ed. Another form of scientific publication involves
critical literary consolidation of previously pub-
lished material. A monograph, on the other hand,
deals with a defined, overall theme.
Here again, two basic approaches may be adop-
ted. The first is to separate the theme into specific
fields and then objectify the topic as thoroughly as
possible through a presentation of controversial
scientific results. Such papers are generally pre-
pared in conjunction with several authors, all hav-
ing established themselves as outstanding specia-
lists in their relatively small fields of study which,
however, are relevant to the overall subject of
study.
These textbooks have the indisputable advantage
of being able to impart to the reader the current
state of the science at the time of publication and,
by their very nature, also encourage the reader to
update his knowledge in view of the expanding
state of science.
The second route is to process a predetermined
overall theme on the basis of established associa-
tions with the purpose of presenting problems in
a network and showing their interconnections and
interdependencies. This kind of work makes it
 Final Observations

possible to select a freer and more subjective

approach. The danger here, of course, is a certain
loss of objectivity. For the reader, this may be
advantageous in terms of making it easier to keep
track of the line of thought and, perhaps, also
making the lecture more interesting because of its
tangible emotional subjectivity.
As this is a homogeneous approach, it would be
sensible to restrict the number of authors, or to
leave it to a single author. This requires that the
author(s) have a longstanding association with the
topic, including a sufficient quantity of processed
information and practical experience in dentistry
with regard to the general subject under study. Of
course, it also requires the willingness to expose
such a presentation to objective criticism. This has
the advantage of leading to open dialogue. A pre- A presentation of this nature is in keeping
sentation of this nature is in keeping with the pro- with the procedure of developing and pre-
cedure of developing and presenting a hypothesis, senting a hypothesis, proposing it for discus-
proposing it for discussion and thereby exposing it
sion and thereby exposing it to validation or
to validation or invalidation.
invalidation.
The initial dialogue in a monograph is a self-dia-
logue on the part of the author, who in this stage
pores over and processes his/her thoughts and
ideas. This is inevitably followed by a phase of
doubt and uncertainty. At this point it is necessary
to summarize one's thoughts and ideas, if only to
prove to oneself how sound a literary product of
this nature really is.
The introductory chapters are concerned with the
specific features and uniqueness of the masticato-
ry organ. By the process of evolution, a multi-
functional system emerged from a feeding tool, its
capacity for communication being intimately con-
nected with the development of the brain.
This qualitativel, as well as, quantitative develop-
ment of the brain necessitates an enormous
change in the form of the cranium in Homo sapi-
ens sapiens. The most extreme functional change, The most extreme functional change, how-
however, occurs in the brain itself, which polarizes ever, occurs in the brain itself.
into two functional halves. The results of this
polarization of the brain are decisive, both func-
tionally and morphologically.
The social development of the hominid to Homo
during evolution also dramatically changes the
psychological balance of the brain and, thereby, its
social perspective. For each individual, the emer-
gence of self-consciousness creates a unique,
"individual" environment, as a product of his/her
psyche.

517
R. Slavicek • The Masticatory Organ
The masticatory organ then becomes a sub-
conscious stage for psychic processing.
These decisive evolutionary changes, which
take place within a relatively short period of
time, repeat themselves dramatically in the
ontogenesis of human beings.
518
The masticatory organ itself is directly associated
with psychology, specifically with transmission,
perception and processing. Emotionality is
expressed outwardly through the masticatory
organ, but is also processed internally. The
advancing social integration of the individual
results in the inhibition of immediate unloading of
aggression, thereby frequently delaying the solu-
tion of problems. The masticatory organ then
becomes a subconscious stage for psychic proces-
sing. The weaker the aggressive behavior, i.e.
the more it is inhibited or even prevented, the
more the masticatory organ is stressed as an out-
let valve.
Therefore, one of the messages of this book is to
regard this feature as a legitimate task of the sys-
tem. It is well justified to emphasize the psycho-
somatic significance of the stomatognathic sys-
tem.
A further equally dramatic evolutionary change
occurs in the postural and supportive apparatus
during the process of attaining an upright pos-
ture. Free balancing of the head requires the inte-
gration of the masticatory musculature into a
complex postural apparatus for the skull. This
new function necessitates alterations in the mus-
cular apparatus and also extensively affects the
ligamentary attachments to the mandible, which
is now subject to the forces of gravity.
The vestibular system is confronted with specific
problems resulting from the considerably more
intricate responsibilities involved in spatial orien-
tation in upright position. During the process of
achieving upright posture, the already complex
primate respiratory passages, with the typical
intersection of two vital functional passages,
become narrower and are repositioned on the
spine. The function of the lid of the epiglottis
becomes more critical, probably due to the
increasing ability to speak.
These decisive evolutionary changes, which take
place within a relatively short period of time,
repeat themselves dramatically in the ontogenesis
of human beings. Postnatal brain and speech
development, and standing upright, mark the
first two years of an individual's life. Psychic
restrictions brought about by the individual's
upbringing and integration into existing social
structures are significant factors in the develop-
 Final Observations

ment of human individuality. A child's emotional-

ity must inevitably find a means of unloading.
One way of achieving this is through the mastica-
tory organ, "armed to the teeth". An important
aspect of this book concerns ontogenetic function-
al development: it places functional thinking in
the center of discussion.
The discussion of structures involved in the mas-
ticatory organ had to be extended considerably for
several reasons. The structures are not limited to
the true masticatory muscles alone. Understanding
dysfunction requires familiarity with the entire
human postural apparatus, especially the shoul-
ders, neck and throat.
Body posture, head posture and the masticatory
organ are an inseparable whole. The dentist must
be earnestly concerned with these problems, if
he/she is to treat a patient's functional disorders.
Working together with physical medicine, overall Working together with physical medicine,
medical orthopedics and cooperating with an overall medical orthopedics and cooperating
understanding physiotherapist are absolutely with an understanding physiotherapist are
essential. Building up an appropriate and commu- absolutely essential. Building up an appropri-
nicative language is necessary in order to achieve
mutual understanding. ate and communicative language is necessary
in order to achieve mutual understanding.
The human temoro-mandibular joints underwent
extraordinary development. As a result of dramat-
ic enlargement of the cranium, processes of the
joint, relative to the cranial base, slid under the
middle cranial cavity. The upright position caused
posterior shifting of this area and loss of a strong
post-glenoidal process at the margin. The retroar-
ticular structures developed a distinct, bilaminar,
vascularized zone, which serves as a protective, as
well as, a positioning force.
The system-immanent musculature centers the The system-immanent musculature centers
joints against the articular eminence, working the joints, working against gravitational
against gravitational forces. Based on this differ- forces.
entiation, it would be inappropriate to refer to this
unit as a single joint. The term cranio-mandibular
system (CMS) is more suitable. Sicher's brief and
concise definition of "a synovial gliding joint with
a moveable socket" is as valid now as it was then,
but the concept of a CMS is a much more expan-
sive theoretical concept than that of a joint.
The functions of the CMS are susceptible, as the
joints are dominated by other structures of the
masticatory organ. Here, not only parafunctional The functions of the CMS are susceptible, as
stress but also mastication and speech may exert a the joints are dominated by other structures
negative influence. of the masticatory organ.

519
R. Slavicek • The Masticatory Organ
In this setting, the dentist has a theoretical
head-start in the diagnosis and therapy of
this orthopedic "no-man's land".
Therefore, the dentist's knowledge of the pos-
tural apparatus must be well above average.
My goal was a functional synopsis of the con-
cepts of occlusion and articulation.
Evidence is offered by way of so-called "well-
controlled" studies, which rather deserve the
epithet "well-selected" (i.e., unscientific).
520
The dentist must use this process of functional
thinking in order to understand dysfunction. In
this setting, the dentist has a theoretical head-
start in the diagnosis and therapy of this orthope-
dic "no-man's land", which was excluded from
medical and orthopedic realms of thought for a
long time.
This book is concerned with the movement appa-
ratus of the system. I have attempted to present
the broad interrelationships of the muscular mas-
ticatory apparatus with other important areas of
function. It is by no means a simple chewing
apparatus operated by muscles. The head, on a
flexible neck, is justifiably regarded in modern
orthopedics as an additional sensory organ.
Therefore, the dentist's knowledge of the postural
apparatus must be well above average when
he/she is dealing with functional disorders.
Human posture ends at the top - a region occu-
pied by sense organs, consisting of the eyes, ears
and the sense of smell. An organ providing further
information that plays a dominant role here is the
vestibular system. However, the neuromuscular
system of the masticatory organ must first execute
its main function, namely speech to elicit commu-
nication. Speech is considerably significant for
human beings, and its function must be compre-
hensively understood by the dentist, in order to be
able to work in cooperation with otolaryngology
and logopedics in the areas of both diagnosis and
therapy.
The structure of the teeth, that is, the occlusion
and the articulations that go with the dentition,
which, from my point of view are rather neglect-
ed worldwide, receives ample attention in this
book. My goal is a functional synopsis of the con-
cepts of occlusion and articulation. I resent the
fact that, based on didactic exaggeration, many
reputed scientists, including friends of mine, mi-
nimize the significance of occlusion. I resent the
fact that they attempt to provide scientific evi-
dence of no or minimal associations between
occlusion and functional disorders. Such exagger-
ation can be dangerous if it ignores the exceed-
ingly invasive possibilities of dental medicine in
the areas of restorative, prosthetic and orthodon-
tic dentistry, and (generally based on opportunis-
tic considerations) attempts to prove that these
measures cannot or can hardly cause functional
disorders. Evidence is offered by way of so-called
 Final Observations

"well-controlled" studies, which rather deserve the Depicting the masticatory organ, together
epithet "well-selected" (i.e., unscientific). The with the brain, as the most human of all
result is that current instruction in dentistry is human traits and functions, was the main
marked by tangible deficiencies in the fields of objective of this book.
theory, as well as, practice.
A noticeably positive reorientation of opinion is
currently under way - occlusion is again being rec-
ognized as an important and valued structure of
the masticatory organ.
My attempt to illustrate these complex subjects
through ontogenesis and its so-called functional
periods is guided by the intention to underline the
importance of the teeth for the entire system.
My professional life has been determined not only
by the dazzling variety of functional interdepen-
dencies, but also by the puzzling dysfunctional
occurrences, that set every patient apart as a true
"individual". Occasionally, individuality emerges
from patients during the deeper questioning
phase, haltingly at first, and then more explicitly.
The direct coupling of the psyche and soma as a
unit, actually representing the human being, is
nowhere more apparent than in the masticatory
organ.
Depicting the masticatory organ, together with
the brain, as the most human of all human traits
and functions, was the main objective of this
book.

Vienna, August 2000

521
R. Slavicek • The Masticatory Organ
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533
R. Slavicek • The Masticatory Organ

534
 Glossary
Glossary
Axio-pantography: Registration of the movements
of the mandibular hinge axis

Adaption = Adaptation: Adjustive change in res-

ponse to altered conditions

Adhesion: Bridges of connective tissue between the

functional joint surfaces

Aggression: Emotional attitude of belligerence

Allopatry: Condition in a territory where there is no

overlapping of species

Altruism: "Selflessness"

Anatomy: Describes the structural makeup, esp. of an

organ or its parts

Ankylosis: Stiffening of the joint

Arthrography: Radiography of a joint after injection

of an opaque contrast material

Arthrosis: Degenerative alteration of a joint; disease

of a joint

Articulation: The dynamic relationship of the occlu-

sal surfaces during function

Asymmetry: Dissimilarity in corresponding parts or

organs on opposite sides

Bennett movement: Physical shift of the mandible to

the laterotrusion side during asymmetrical movement

Biofeedback: For therapeutic reasons, feedback into

the biological control system, through training

Canon: A main theme within the study of proportion

Carnivore: Meat-eater

Catenate (Catenoid): Surface described by the rota-

tion of the curve as it rotates around a straight line,
which is parallel to the tangent in the vertex of the curve

Cephalometry: Standardized process of measuring

and evaluating X-rays according to anthropological

535
R. Slavicek • The Masticatory Organ

and dental viewpoints

Cladogenesis: Evolutionary deviation from anagene-

sis, branching out and leading to new varieties in form

Curve characteristics: Geometric classification of the

movement curves

CMD: Abbreviation for Craniomandibular Disorder:

Cognitive: Conscious awareness

Compensation: Making up for insufficient function

or lack of function through the increased activity of
other areas

Compression: The amount of pressure on the struc-

tures

Congenital alexia: Inborn deficiency in learning to

read and write

Condylography: Graphic or electronic registration of

mandibular movements on the hinge axis of the man-
dible

Conversion: A psychological situation or inner emo-

tion converted into physical symptoms

Craniomandibular Disorder: Dysfunction in the

masticatory organ

Cybernetics: The study of the feedback-control

mechanism

Decompensation: Discontinuation of balancing

compensating factors and the resulting functional
breakdown

Dendron: A bundle of the apical dendrites of pyra-

midal cells in the neocortex, in which the "Psychon"
can stimulate a neural event

Deranged Reference Position (DRP): Retral border

position of a luxated mandibular joint

Diagnostics: Collecting examination data for the

purpose of making a diagnosis

536
 Glossary

Disocclusion: Separation of opposing teeth during

eccentric mandibular movements

DRP: see Deranged Reference Position

Dysgnathia: Defective position of the jaw

Dyslexia: Synonym for congenital alexia

Echolalia: Automatic repetition of syllables or words

during speech development in early childhood

Egoism: "Love of self", based biologically on the drive

for self-preservation

Emergence: The appearance of completely new (not

foreseeable) qualities

Emotion: Stirring the mind, nature, disposition or fee-

lings (positively or negatively)

Esthetics: Deals with the conception and perception

of beauty

Eufunction: Healthy function, normal function

Eugnathia: Normal maxillo-mandibular relationship

Evolution: (biology) The course of the historical deve-

lopment of life forms

Extension: Stretching

Flexion: Bending

Functional Diagnostics: Diagnostics for the registra-

tion of all functions of an organ

Joint Lavage: Rinsing the joint's functional surface for

therapeutic reasons

Genetics: The study of the heredity and variation of

organisms

Harmony: The concept of balanced order

Herbivore: Plant-eater

Hominid: Human-like, incl. recent humans and

537
R. Slavicek • The Masticatory Organ

extinct or related ancestral forms

Hominization: The evolutionary development of

human characteristics

Hominoid: Super-family of primates, having similari-

ties to human beings

Homo erectus: Human standing erect (true bi-pedal

human)

Homo habilis: The "skillful" one (handy), the first

representative of the species Homo

Hypothesis: The "assumption" of a scientifically gro-

unded theory

Immediate side-shift: Immediate side movement of

both condyles without vertical development (plane
movement)

Kyphosis: Dorsal convex curvature of the spine (e.g.,

the cervical spine)

Lateralization: Lateral displacement of the brain fun-

ctions due to the development of speech

Limitation: Restriction in movement

Lordosis: Ventral convex curvature of the spine (e.g.,

the thoracic spine)

Luxation: Dislocation

Mastication: Chewing

Medioretrusion: The return movement of the man-

dible, after excursion

Mediotrusion: The asymmetric movement of the

mandible to one side. The terminology of the move-
ment is from the perspective of the jaw joint.

Metabolism: The sum of the chemical and physical

processes in an organism

Mobility: The range of motion of a joint

Morphology: The study of forms and structures and

538
 Glossary

how they interact in their functions

Motility: The course of the movements of the joint

MRI: Magnetic Resonance Imaging (synonym NMR

= Nuclear Magnetic Resonance, nuclear tomography)

Muscle-Splinting: Limiting muscular movement in

order to avoid pain

Myon: A bundle of parallel muscle fibers; the smallest

functional unit of the muscle

Norm: Generally accepted rule; average

Opening: A combination of rotation and translation

of both jaw joints

Occlusion: Any contact between antagonistic mandi-

bular and maxillary teeth

Ontogenesis: The individual development of an orga-

nism

Palpation: Examination through touch and/or digital

manipulation

Pantography: Registration of mandibular movements

on various recording surfaces

Parafunction: Nocturnal deviation in function, consis-

ting of centric and eccentric bruxism

Perinatal: The period of time from the newborn's

birth to its seventh day of life

Peristalsis: Concentric, continuous contraction waves

in the digestive tract for transporting its contents

Phenotype: The visible properties of an organism

Phyletic Gradualism: Gradual change in the species

Phylogenesis: The development of the species

Pongids: Anthropoids

Prognathic: Protruded position of one or both jaws

539
R. Slavicek • The Masticatory Organ

Proportion: The relation of the parts of a whole to

each other

Proprioceptive: The body's own sensory reception,

with regard to compensation

Protrusion: The symmetrical pushing forward of both

jaws

Pseudo-adhesion: Thickened synovial fluid, which

slows and hinders joint movement

Psychon: A postulated mental unit, which can trigger

a neural event

Psychosomatic: The study of the connection between

body and soul

Punctualism: Rapid (not gradual) emergence of a

species, based on the theory of "Punctuated
Equilibrium"

Quality of the registration: Description of the syno-

vial gliding process

Reduction: Correction of a fracture or dislocation

Reference Position (RP): The retral border position

of the mandible, in which the joint structures are not
stressed

Reflexology: The science of unconditioned and condi-

tioned reflexes

Resilience: Elasticity of the joint structures, their abi-

lity to return to original form

Retrognathic: Retruded position of one or both jaws

Retrusion: Movement of the condyles to posterior

Closing: Return from an open to a closed position

Self-perception: In connection with self-awareness

(self-consciousness), the individual's own knowledge
and awareness of himself/herself as a whole

Side-shift: Like the Bennett movement

540
 Glossary

Speciation: The emergence of a new species

Species: Class, race, kind

Spherics: Curvilinear perspective in which a figure is

formed on a spherical surface

Symmetry: Mirror-image proportionality

Sympatry: Coexistence of varieties of a species in a

mutual territory

Syndrome: Clinical picture, manifested by a number

of similar symptoms

Synovia: Joint fluid

Scintigraphy: Nuclear medical diagnostics for deter-

mining tissue activity

Trimenon: Division of the first years of human life

into three-month periods

Verticognathia: The jaw hangs downwards

Viscerocranium: The visceral skull (as opposed to the

neurocranium)

541
R. Slavicek • The Masticatory Organ

Acknowledgements
I would like to thank all those who motivated me
over the years to put my thoughts on paper. This
includes all of my friends as well as students, who
never lost patience with me. First of all, to my son
Christian, who played a significant role by way of
providing ideas and administrative support, I wish
to extend a special "thanks". From my circle of col-
leagues I would like to especially mention my
friends in Lübeck, Bernd Klemt and Wolfgang
Drücke, whose sharp and well-meaning criticism,
during my several years of course-related activities
with them, greatly helped me to organize my
thoughts.
Regarding the retrospective assessment of the
"instrumental field", my thanks go to Heinz Mack,
who has been a long-time companion and friend. R.
Cramer was and is an ingenious partner by way of
converting ideas into precision mechanics.
I also thank Dieter Reusch for his candid and friend-
ly comments regarding me and my thoughts.
Thanks to Hansi Seeholzer and the Royal Dental
College Aarhus for their generous provision of se-
veral anatomic preparations, and to Fleming Melsen
for his organizational help in regard of histological
interpretation of joint musculature.
Special thanks to my friend Peter Lugner for his
mathematical know-how, which applies both to
instrumentation and functions.
Heartfelt thanks to my colleagues in Innsbruck,
above all Siegfried Kulmer, who contributed to this
book in great measure, not only through their criti-
cal and constructive ideas, but also through their
elucidative photographic interpretation of my ideas.
Kurt Gausch receives my thanks for his friendship
over the years and his inimitable style of "getting to
the bottom" of an idea.
Ingrid Slavicek showed untiring patience while ser-
ving as a model for many photographic illustrations.
Dear Ingrid, "thank you".
Patrizia Grecht for her wonderful make-up skills.
My special thanks to my long-time clinical photog-
rapher Mr. Christian Hofer for his precision and eye
for detail in the production of outstanding illustra-
tions, some of which are computer-assisted.
My long-time secretary, Ms. Heidi Taibl contributed
in a significant manner to this book. She accom-
plished a great deal through her sacrifice and energy,

542
 Acknowledgements

failing which, the work would probably have never

gotten done. Your repeated proof-reading and correc-
tion were a great service. "Thank you", dear Heidi.
Many of the anatomical images came from the
"Med-Art" group, especially from my young col-
league Dr. Czernicky: thank you for your superb
artistic interpretation of my ideas.
Special thanks also to the publishers Spektrum der
Wissenschaft (Heidelberg) for their permission to
use several instructive illustrations of the hominid
evolution from the publication "Evolution".
Ms. Mag.Scolik and her team for their frequently
disputed, but always constructive editing; and their
critical help in designing the "layout", which took
shape under the painstaking efforts of Mr.
Wurzinger and Mr. Pfundner. My heartfelt thanks
to all of you.
My young colleague, Franz Schuster, who took over
the job of editing the medical terminology, also
deserves my gratitude.
My special thanks to my long-standing loyal
"Course-Interpreter" Silvano Naretto for his under-
standing, competent and professional translation of
the chapter on Occlusion. I also thank Sujata
Wagner for her painstaking, persistent and
smoothening hand in formulating the text in British
and American English. Especially heartfelt thanks
to my longstanding friend Mike Maloy for his skil-
ful and enduring work in producing the basic trans-
lation - a task that he executed in a most admirable
fashion. My gratitude also to Mr. Müller for his
stressfull job in "lay-outing".
And, of course, to my long time friend Bill Missert,
a fellow soldier in the war of "occlusion", who has
the insatiable desire to be curious at my expense, I
render my thanks for listening to me and becoming
a dentist, plus for his assistance in editing this
English version.
I want to give my gratidute also to all my friends in
the vienna study group for my very special time in
teaching and learning.
Finally, thanks again to my teachers, of whom I will
name a few here: Leopold Petrik who pointed out
the path towards understanding occlusion as well as
cephalometry; Willi Krogh Poulsen for the applica-
tion of correlating clinical functional analysis; Arne
G. Lauritzen for controlled precision of instrumental
functional analysis, and Harry Lundeen along with
Carl Wirth for their thoughts on occlusion and for
pointing out the necessity of pre-treatment tech-
niques for dysfunctional patients.

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