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N e w definition for relating occlusion to varying conditions of the temporomandibular joint

P e t e r E. D a w s o n , D D S a

Center For Advanced Dental Study, St. Petersburg, Fla.


Centric relation is the accepted term for defining the condylar axis position of intact, completely seated, properly aligned condyle-disk assemblies. However, some structurally deformed t e m p o r o m a n d i b u l a r joints m a y function comfortably, even though they do not fulfill the requirements for centric relation. A w i d e range of temporomandibular disorders from partial to complete disk derangements w i t h or without reduction m a y adapt to a conformation that permits the joints to comfortably accept m a x i m a l compressive loading by the elevator muscles. There has been no accepted terminology to define the condition or position of such joints. The purpose of this article is to define a n e w term, adapted centric posture, and to explain its rationale and h o w it is determined. Verification of successful adaptation is an important step in diagnosis, because it rules out structural intracapsular disorders as a source of orofacial pain and establishes responsible guidelines for initiation of occlusal treatment or prosthetic dentistry. It also establishes a m u c h n e e d e d terminology for more specific description o f t e m p o r o m a n d i b u l a r joint position and condition for clinical research on the relationship b e t w e e n occlusion and the temporomandibular joints. (J PROSTHETDENT

1995;74:619-27.)

C o n f u s i o n about the relationship between dental occlusion and the temporomandibular joints (TMJs) has been evident in the literature for many years. Many authors advocate that condyle position is critical to the equilibrium of the masticatory system at maximal intercuspationY TM Others have argued that little or no relationship exists between faulty occlusion and temporomandibular disorders. 2~ In contrast to published information that occlusion is not a factor in temporomandibular disorders (TMDs), a review of the literature suggests that such a conclusion is not totally supported, because the information is routinely devoid of specific details about the position or the condition of the temporomandibular joints in relation to occlusal contacts.20-2t Further confusion results from the use of the single term "TMD" to denote a whole constellation of signs or symptoms with no specificity of the type of intracapsular deformation or whether any structural deformation has even occurred. It is important to determine the type of intracapsular deformation or change in TMJ structures before attempting to determine the optimal relationship between the temporomandibularjoints and maximal intercuspation of the teeth. Because the position of the condylar axis can be aDirector. Copyright 9 1995 by The Editorial Council of THE JOU~AL OV
PROSTHETIC DENTISTRY.

altered by these changes, this article attempts to clarify the rationale for positioning healthy condyle-disk assemblies in centric relation and suggests more definitive terminology and rationale for positioning temporomandibularjoints that have undergone intracapsular deformation and structural change. This article suggests three categories for condyle-fossa relationships: centric relation, adapted centric posture, and treatment position. These categories will be defined, explained, and related to maximal intercuspation of the teeth. CENTRIC RELATION Centric relation is defined in this article as the precise location of the horizontal condylar axis when properly aligned condyle-disk assemblies are completely seated in their respective bony sockets. Because the position of the horizontal condylar axis determines the maxillo-mandibular relationship during jaw closure, any variation in condylar position will change the closing arc of the mandible and thus affect the initial contact of the mandibular teeth against the maxillary teeth. If maximal intercuspal tooth contact is not coincident with the completely seated position of both condyles, the condyles must be displaced to achieve complete jaw closure into maximal intercuspation. Numerous electromyographic studies reported that occlusal interferences to centric relation disrupt the coordination of masticatory muscle function. 25-3~ The most important criterion for centric relation is the

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Fig. 1. In coordinated muscle function, triad of strong elevator muscles pulls condyles up slippery posterior slopes of eminentiae. Inferior lateral pterygoid muscles release and stay released through complete closure if no occlusal interferences to centric relation occur.

complete release of the lateral pterygoid muscles during jaw closure. 2 During jaw closure in intact TMJs the condyle-disk assemblies are pulled up the eminentiae by a triad of strong elevator muscles (Fig. 1). To ensure a coordinated neuromusculature function, the release of inferior lateral pterygoid muscle contraction must allow the condyles to slide up to the apex of force positions,n~ at which point the medial pole of each condyle-disk assemble would be stopped by bone. This buttressed bone stop occurs at the height of concavity in the medial third of each fossa (Fig. 2). This relationship would then be considered the ideally aligned or completely seated condyle-disk assembly. The condyles must be free to move down and up the posterior slope of the eminence during function. The function of the masseter and internal pterygoid muscles should keep the condyles loaded 2 against the eminentiae in all excursive movements (Fig. 3) and in centric relation. Following this philosophy, it may be more descriptive to say that centric relation is the most superior position that the properly aligned condyle-disk assemblies can achieve against the eminentiae. This position would appear to be physiologic, because it results mechanically from coordinated release function, which completely seats the condyledisk assemblies if no occlusal inclines interfere. The significance of this uppermost position is that only at this bone-braced relationship is the coordinated activity of the inferior lateral pterygoid muscles achieved through complete closure. Ligament bracing is not a factor, because the condyles can be displaced down and back from centric relation before the ligaments reach their functional limita-

tions. This "uppermost" position is a departure from the concept of"most retruded." To equate centric relation with the "retruded position" is still common in the literature, which, although it may be confusing, is acceptable if achieved by coordinated masticatory muscles. It should not be considered centric relation if the condyles are forced away from the eminentiae to a more retruded position than the one achieved by the coordinated muscle function. Unfortunately, in patients undergoing dental procedures the technique of pushing the jaw back to record centric relation is still too prevalent. The reason we advocate preciseness in l(~cating centric relation is because of the common clinical observation that even the most minute deflection from the bone-braced condyle position may activate uncoordinated contraction of the lateral pterygoid muscles in opposition to elevator muscle contraction. Our observations of this uncoordinated muscle activity suggests that it can result in myofascial pain if disruptive occlusal contact is prolonged. It is reasonably assumed that prolonged isometric contraction of antagonistic muscles can result in myogenous pain, particularly in the smaller lateral pterygoid muscles, which are at a disadvantage. The trigger that activates lateral pterygoid contraction can be inconspicuous. The exquisite sensitivity of periodontal and interdental proprioceptive sensors can trigger painful reflex muscle patterns from deflective occlusal interferences that are easily missed by clinicians who do not recognize their importance or the importance of verifying the accuracy ofcentric relation before starting any occlusal correction procedures (Fig. 4). In most, if not all, of the published studies that downplay the role of occlusion, no attempt has been reported to precisely locate and verify an accurate centric relation. If this verification is not done, any conclusions drawn regarding the relationship between correct occlusion and properly positioned temporomandibular joints are highly suspect. The mandible is in centric relation if four criteria are fulfilled: 1. The disk is properly aligned on both condyles. 2. The condyle-disk assemblies are at the highest point possible against the posterior slopes of the eminentiae. 3. The medial pole of each condyle-disk assembly is braced by bone. 4. The inferior lateral pterygoid muscles have released their contraction and are passive. If all four of these criteria are fulfilled, healthy temporomandibular joints in centric relation can accept all of the loading that the elevator muscles can apply, because all of the force is directed through avascular, noninnervated structures that were designed to be load-bearing. 3236If the upward slide of the condyle-disk assemblies is stopped by bone, no resistance should be required from the inferior lateral pterygoid muscles once the condyles are completely seated; therefore upward loading should not alter their

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F i g . 2. The condyle-disk assemblies slide up convex posterior slopes of eminentiae until medial poles (solid arrow) are stopped by buttressed bone at medial third of fossae. Circle indicates uppermost position at which medial pole braces against bone (with disk interposed). Lateral two thirds of roof of fossa is thin and not bearing area.

Fig. 3. No muscles are in a position to distract condyles. Whether occlusal contact is on anterior teeth only or posterior teeth only, all elevator muscles combine to direct the condyles antero-superiorly in centric relation (A) and also keep them loaded against eminentiae as they travel up and down the slopes in function (B).

passive state during closure or activate their contraction even during strong clenching. So unless the muscles are triggered by a disruptive occlusal contact that occurs before maximal closure is complete, the coordinated release of the inferior lateral pterygoid muscle should remain consistent with elevator muscle contraction during the repetitive clenching posture associated with swallowing. When both condyle-disk assemblies are completely seated in centric relation, their medial poles should be at

the highest point of concavity of that part of each fossa. From where the medial poles are stopped by bone the fossae walls curve downward on three sides so that from a correct centric relation, the condyles cannot travel forward, backward, or medially without moving downward (Fig. 5). The understanding of this apex of force position is extremely important to our concept of centric relation. It means that failure to completely seat condyles when harmonizing an occlusion invariably results in a muscle-

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ADAPTED CENTRIC POSTURE Many TMJs function with complete comfort and apparent normalcy, even though they have undergone deformation caused by disease, trauma, or remodeling and therefore automatically cannot fulfill all of our criteria for centric relation. Some TMJs click or exhibit other signs of intracapsular disorder, but they do not prevent patients from functioning in an acceptable and comfortable manner. Determining whether a deformed TMJ can function acceptably with comfort and with a reasonable degree of stability is one of the most important decisions in the diagnostic process. The author defines adapted centric posture as the relationship of the mandible to the maxilla that is achieved when deformed temporomandibular joints have adapted to the degree that they can comfortably accept firm loading when completely seated at the most superior position against the eminentiae. Like centric relation, adapted centric posture is a horizontal axial position of the condyles. It occurs irrespective of vertical dimension or tooth contact. It is also a midmost position, because even if the disk is totally displaced, the medial pole of the condyle adapts to the concavity of the fossa and maintains contact against its medial incline. The mandible is in adapted centric posture if four criteria are fulfilled: 1. The condyles are comfortably seated at the highest point against the eminentiae. 2. The medial pole of each condyle is braced by bone. (The disk may be partially interposed.) 3. The inferior lateral pterygoid muscles have released contraction and are passive. 4. The condyle-to-fossa relationships occur at a manageable level of stability. The consequences of adaptive changes in the temporomandibular articulation may be positive or negative with regard to symptoms. The same adaptive changes that result in reduction of symptoms may simultaneously produce serious and progressive deformation ofintracapsular structures and damage to collateral structures eleswhere. Teeth and supporting structures can be especially affected by structural changes of the TMJs. We note that excessive occlusal wear or hypermobility of teeth is routinely observed as disharmony between the TMJs and the occlusion progresses. 3s Our clinical observation is consistent: unstable TMJs result in unstable occlusions. Adapted centric posture may be achieved in a variety of intracapsular deformations. The progression from a healthy, intact TMJ to one that is deformed and has adapted may include stages that produce pain and dysfunction as the adaptation process takes place. The progression of deformation may occur with little or no intracapsular pain. Diagnosis made on the basis of symptoms only is insufficient and may lead to false assumptions about the source of pain in patients with TMD.

Fig. 4. Load testing conducted at suspected centric relation hinge position with torquing action starting with gentle loading first, then increasing pressure from light to very firm. Any sign of tension or tenderness in either joint indicates that centric relation has not been achieved. Fingers must be placed on posterior half of mandible during manipulation.

braced condyle instead of a bone-braced condyle. It also means that whenever the condyles go to their more upward centric relation position during function, the closing forces are directed more on the most posterior teeth, which become pivotal to the upward moving condyles (Fig. 6). Contrary to some opinions that centric relation is not a functional position, that observation has not been supported by extensive research at the University of Florida is or in studies that show that the retruded position is used frequently in swallowing. 37 If the idea that the condyles do go repeatedly to centric relation is doubted, it would only be necessary to observe the facets of wear on the teeth of a number of patients. Casts mounted correctly in centric relation routinely show that if wear facets are present, the facets always extend to centric relation on tooth inclines that interfere with centric relation. A study of condyle/fossa anatomic condition makes it evident that the medial wall of the fossa braces against the medial pole of the condyle disk assembly when the condyles are in centric relation. This fact is why centric relation is the midmost position of the mandible (Fig. 7). Thus from centric relation it is not possible for either condyle-disk assembly to move horizontally toward the midline. If such a movement occurs, it is an indication that the condyles were not completely seated in centric relation at the start of movement. From centric relation the orbiting condyle must move downward as it moves medially.

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Fig. 5. Medial pole of each condyle-disk assembly is braced against uppermost roof of concavity at medial third of each fossa. From that seated position condyles cannot move forward, backward, or medialward without traveling downward (circle represents medial pole position). Because anterior face of each condyle disk assembly (line with three arrows) is against eminence in centric relation, no forward translation is possible without downward movement.

Proper diagnosis requires an orderly evaluation ofintracapsular structures, not just to see whether deformation is present but to determine the specific stage of deformation responsible for the discomfort. The clinical experience of the author has shown that in most patients with so-called TMD, the discomfort is far more likely to be myogenous rather than intracapsular, even when some deformation has occurred within the intracapsular structures. This diagnosis cannot be determined on the basis ofepidemiologic percentages. It must be determined by specific testing of each individual patient to determine whether any intracapsular structures are disordered, and, if they are deformed, to determine whether they have adapted to a manageable level of comfort and stability. A combination of history, load testing, auscultation, and palpation can usually lead to a diagnosis, but some type of imaging may be needed for specificity. Some of the most common intracapsular conditions that may permit an adapted centric posture are (1) lateral pole disk derangements, (2) complete disk derangements with formation of a pseudo-disk, (3) complete disk displacement with perforation, and (4) other partial disk derangements and asymptomatic clicking TMJs.

displaced off the medial pole, it is possible to achieve complete seating ofthe condyle with no discomfort. This is true even when a lateral pole click has progressed to closed lock of the lateral half of the disk. If the intracapsular deformation is intercepted at these stages, it has been our clinical experience that stability of the articulation can b e achieved if harmony is established between the occlusion and the completely seated condyle-disk assemblies. The experience of the author also suggests that lateral pole disk derangements can be treated as normal joints if the medial pole disk alignment is acceptable and if adapted centric posture can be verified by load testing. 39 In my experience the key to success is in maintaining coordinated musculature function through elimination of all occlusal interferences to a verified adapted centric posture.

Complete disk d e r a n g e m e n t s w i t h formation o f a p s e u d o disk


In the early stages of a complete disk displacement it is the experience of the author that a period exists during which pain is a symptom. Considerable pain may result from compression of the vascular and richly innervated retrodiskal tissue by the condyle (Fig. 8). If this compression occurs, adapted centric posture cannot be achieved because the TMJ will not accept loading without some degree of discomfort. Although not predictable, the retrodiskal tissue is sometimes converted to a fibrous connective tissue pseudo-disk. We have observed such pseudo-disk formation in cadaver specimens, in open-joint microsur-

Lateral pole disk d e r a n g e m e n t s


Piper's classification of intracapsular disorders distingnishes between lateral pole disk derangements and derangements in which the disk is displaced off both the lateral and medial poles of the condyle. If the disk is not

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Fig. 7. Medial pole bracing in line with medial pterygoid muscle contraction establishes position at centric relation. This midmost position is consistently s imultaneous with uppermost position.

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Fig. 6. Because condyles must displace downward to accommodate intercuspal position that is forward of centric relation (A), most posterior tooth that interferes becomes pivotal point when condyles are pulled up into centric relation. B, Inferior lateral pterygoid must remain actively contracted whenever teeth are intercuspated,

Fig. 8. In early stages of complete disk derangement, condyle loads onto vascular, retrodiskal tissue, which is richly innervated. When this structural misalignment occurs, TMJ cannot accept loading without pain.

gery, and on magnetic resonance images. If this formation occurs, it is possible that blood vessels and their accompanying sensory nerves will evacuate the bearing area, and the fibrous extension of the original disk will eventually be able to accept loading with no discomfort. It may then be possible to achieve an adapted centric posture that appears to be as stable as an intact condyle-disk alignment.

Complete disk displacement with perforation


The most likely progression from a closed-lock, anterior displacement of the disk is to proceed through a painful stage of compression of the retrodiskal tissues, which become less painful as the condyle perforates the sensitive

vascular tissues and begins to load against bone. As the soft-tissue perforation expands, a complete bone-to-bone contact may result that permits loading with no impingement against innervated structures. At this stage it is possible to verify an adapted centric posture by the absence of discomfort when the condyles are loaded. The typical sequence of events that we have experienced after the retrodiskal tissue is perforated is a progressive flattening of both the condyle and eminence. The osteoarthritic deformation starts at the articular cartilage, causing a loss of height of the condyle. Because the perforation

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and disk derangement disrupts the flow of synovial fluid, nourishment to the articular surfaces is compromised. Thus the osteoarthritic joint is not completely stable. Although the condyle will continue to lose height as its bearing surface breaks down, the deformation can usually be slowed to a manageable condition by reestablishing coordinated muscle function and reducing muscle hyperactivity. Any discomfort in this type of problem is invariably myogenous. It can be readily resolved by restoring harmony between the occlusion and the completely seated TMJs, even though they have undergone deformation. It is the author's contention that patients with slowly progressing osteoarthritis can be made as comfortable as patients with intact TMJs if occlusal harmony is established with adapted centric posture. If both condyles can accept loading with no discomfort, relief of myofascial pain is highly predictable if all occlusal interferences to the bone-braced condyle position are completely eliminated. Typically, it is necessary to adjust the occlusion periodically as condylar height is lost, but it does not create a management problem if patients are informed of this need in advance. In my clinical experience minimal corrections to the occlusion are all that is needed at 9- to 12-month intervals to maintain comfort in the masticatory musculature.

with disk displacement. When the retrodiskal tissues are swollen and painful, the condyles cannot completely seat to either centric relation or adapted centric posture without compressing these structures. A treatment position that reduces the compressive force and allows the inflammation to subside should be determined. Antiinflammatory medication and soft diet are recommended in combination with the use of a treatment position that is protruded enough to prevent compression of retrodiskal tissue. The condyles should be permitted to return to centric relation or adapted centric posture as soon as the edema is reduced, which is usually a matter of a few days. 3. Pathologic conditions and structural or functional disorders that affect the ability of the intracapsular structures to accept loading can result from a variety of causes. The basic rule is, "If the TMJs cannot accept loading with complete comfort...find out why." Differential diagnosis must first confirm that the source of pain is within the intracapsular structures and not isolated in muscle. Load testing is the most effective way to make that determination. Masticatory muscle pain is common when intracapsular pathosis is present, because the muscles tend to protect the painful joint from overload. Attempting to treat masticatory muscle problems without knowledge of the specific type of intracapsular problem is inappropriate. Appropriate treatment combines an attempt to resolve the intracapsular problem while simultaneously establishing equilibrium within the total masticatory system. If this procedure requires harmonization of the occlusion with a temporary treatment position for the joints, that decision should be based on determining the optimal treatment position first. Not all pathologic deformation results in pain on loading. It is sometimes possible to load condyles with advanced bone disease, but the condition may be too unstable to warrant treatment procedures that are irreversible. A complete diagnosis including history, palpation, load testing, Doppler auscultation, range and path of motion testing, and appropriate imaging should be used to determine a specific diagnosis. 2, 39Blood studies, surgical exploration, or both may be needed in some cases. It is not the purpose of this article to outline all the protocols for diagnosing the wide range of diseases that may be encountered. Advancements in diagnostic tests and imaging capabilities make it difficult for structural disorders to hide from an astute diagnostician.

Other partial disk derangements and a s y m p t o m a t i c c l i c k i n g TMJs


Reciprocal clicking is a sign that some degree of deformation has occurred in the diskal ligaments. The variations in deformation of the ligaments and the disk appear unlimited. However, many clicking and deformed joints have adapted sufficiently so that they can comfortably accept loading. If a structural analysis shows that the condition is reasonably stable, adapted centric posture may be achieved, even though the disk is deranged and a click is present. The key to successful treatment of adapted TMJs is the complete seating of both condyles so that the inferior lateral pterygoid muscles can release their contraction during closure all the way to maximal intercuspation. TREATMENT POSITION Three general types ofintracapsular disorders result in pain or discomfort when the temporomandibular joints are loaded. 1. In complete displacement of the disk, disk displacement is almost always anterior to the condyle, which results in compression of the vascular, innervated, retrodiskal structures. If the disk is not reducible and compression ofretrodiskal tissue causes discomfort, it is necessary to determine a treatment position for the condyle for the purpose of developing an adapted centric posture that can eventually accept loading. 2. Retrodiskal inflammation and edema usually occurs as a result of trauma and may or may not be associated

Determination of treatment position


The need for a treatment position can be determined after it has been verified that neither centric relation or adapted centric posture can be achieved. Two objectives exist in determining the most favorable treatment position for the condyles: (1) relief of pain, and (2) eventual stabilization of the condyles in either centric relation or adapted centric posture.

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I t m a y b e d i f f i c u l t to d e t e r m i n e w h e t h e r a t r e a t m e n t pos i t i o n is n e c e s s a r y i f l a t e r a l p t e r y g o i d m u s c l e c o n t r a c t i o n is n o t r e l e a s e d . T h e p a i n o f m u s c l e s p a s m or p r o l o n g e d h y p e r c o n t r a c t i o n m a y m a k e i t too difficult to a c h i e v e comf o r t a b l e s e a t i n g of t h e condyles, e v e n w h e n n o i n t r a c a p s u l a r d i s o r d e r is p r e s e n t . U n l e s s a n a c t i v e i n t r a c a p s u l a r diso r d e r is obvious, a n a t t e m p t s h o u l d b e m a d e to d e p r o g r a m lateral pterygoid contraction before assuming that the T M J s a r e t h e p r i n c i p a l s o u r c e of t h e p a i n . I t is s u g g e s t e d t h a t t h i s d e p r o g r a m m i n g is b e s t d o n e b y c o m p l e t e l y sepa r a t i n g all p o s t e r i o r t o o t h c o n t a c t b y u s i n g a s m o o t h , flat, anterior bite plane. Such a permissive splint allows the muscles to move the mandible in coordinated function that is u n d i s t u r b e d b y d e f l e c t i v e t o o t h c o n t a c t s . I f t h e p e r m i s sive s p l i n t p e r m i t s r e l e a s e of l a t e r a l p t e r y g o i d m u s c l e cont r a c t i o n a n d a l l o w s t h e c o m p l e t e s e a t i n g of t h e c o n d y l e s to c e n t r i c r e l a t i o n or a d a p t e d c e n t r i c p o s t u r e , u s e of a t r e a t m e n t p o s i t i o n will n o t b e n e c e s s a r y . T h e r e l i e f of occlusom u s c l e p a i n o c c u r s quickly, m o s t o f t e n w i t h i n h o u r s w h e n all o c c l u s a l i n t e r f e r e n c e s a r e e l i m i n a t e d . I f t h e p e r m i s s i v e s p l i n t does n o t r e s u l t i n r e l i e f of all d i s c o m f o r t w h e n t h e c o n d y l e s a r e l o a d - t e s t e d , a n i n t r a c a p s u l a r d i s o r d e r is s u s p e c t e d , a n d f u r t h e r t e s t i n g is i n o r d e r to d e t e r m i n e w i t h specificity t h e t y p e o f s t r u c t u r a l d i s o r d e r t h a t is p r e s e n t . T h e t r e a t m e n t p o s i t i o n t h a t is s e l e c t e d s h o u l d b e specific for t h e t y p e of d i s o r d e r t h a t is d i a g n o s e d .

REFERENCES

SUMMARY L a c k of d e f i n i t i v e t e r m i n o l o g y to c l a r i f y d i f f e r e n t posit i o n s a n d c o n d i t i o n s of t h e t e m p o r o m a n d i b u l a r j o i n t s h a s caused confusion in the literature and has complicated scientific d i s c u s s i o n r e g a r d i n g t h e r e l a t i o n s h i p of t h e T M J s to occlusion. U s e of t h e n o n s p e c i f i c t e r m T M D is i n a d e q u a t e for d e s c r i b i n g specific d i s o r d e r s of t h e m a s t i c a t o r y s y s t e m . T h e t e r m T M D does n o t specify w h e t h e r a d i s o r d e r i n v o l v e s d e f o r m a t i o n o f i n t r a c a p s u l a r s t r u c t u r e s , does n o t specify w h e t h e r a d i s o r d e r is p r i m a r i l y a m a s t i c a t o r y m u s c l e p r o b l e m w i t h or w i t h o u t i n t r a c a p s u l a r d e f o r m a tion, does n o t specify w h e t h e r a d e f o r m e d T M J h a s a d a p t e d s u f f i c i e n t l y to a c c e p t l o a d i n g w i t h o u t d i s c o m f o r t , does n o t specify w h e t h e r a n a d a p t e d T M J is s t a b l e or u n s t a b l e , a n d does n o t specify t h e t y p e of d e f o r m a t i o n or p a t h o s i s w i t h e n o u g h c l a r i t y to b e m e a n i n g f u l i n d e t e r m i n i n g a n o p t i m a l t r e a t m e n t p o s i t i o n for T M J s t h a t c a n n o t a c c e p t l o a d i n g . I t is t h e a u t h o r ' s b e l i e f t h a t u n c o o r d i n a t e d , h y p e r a c t i v e , m a s t i c a t o r y m u s c l e s a r e t h e p r i m a r y s o u r c e of r e p e t i t i v e , t e n s i v e , a n d c o m p r e s s i v e forces a g a i n s t t h e T M J s a n d t h e t e e t h a n d o t h e r m a s t i c a t o r y s y s t e m s t r u c t u r e s . I t is t h e a u t h o r ' s b e l i e f t h a t a n a l y s i s of t h e c a u s e s for m a s t i c a t o r y m u s c l e p a i n or d y s f u n c t i o n m u s t i n c l u d e a c c u r a t e d e s c r i p t i o n of t h e r e l a t i o n s h i p o f t h e o c c l u s i o n to t h e p o s i t i o n a n d c o n d i t i o n of t h e T M J s .

1. Rami~ord SP, Ash MM. Occlusion. 4th ed. Philadelphia: WB Saunders Co, 1983:76. 2. Dawson PE. Evahiation, diagnosis and treatment of occ]usal problems. 2nd ed. St Louis: CV Mosby Co, 1989:28-39. 3. Celenza FV, Nasedkin JN. Occlusion, the state of the art. Chicago: Quintessence Publishing Co Inc, 1978:31-46. 4. Gilboe D. Centric relation as the treatment position. J PROSTI-IETDENT 1983;50:685-9. 5. Williamson EH. Larainographic study of mandibular condyle position when recording centric relation. J PROSTHETDENT 1978;39:561-4. 6. Gibbs CH, Lundeen HC, Mahan PE, et al. Movements of the molar teeth and mandibular condyles during chewing [Abstract]. J Dent Res 1980;59:915. 7. Lucia VO. A technique for recording centric relation. J PaOSTKETDENT 1964;14:492-505. 8. Granger ER. Centric relation. J PROSTHETDENT 1952;2:160-71. 9. Okeson JP. Management of temporomandibular disorders and occlusion. 3rd ed. St Louis: Mosby-Year Book, 1992:110-1. 10. Guichet NF. Biologiclaws governing functions ofmuscles that move the mandible. Part 1: Occlusal programming. J Prosthet Dent 1977;37:64856. 11. Long JH Jr. Locating centric relation with a leaf gauge. J PROSTHET DENT 1973;29:608-10. 12. Woelfel JB. A new device for accurately recording centric relation. J PROSTHETDENT 1986;56:716-27. 13. McHorris WH. Occlusal adjustment via selective cutting of natural teeth. Part I. Int J Periodont Rest Dent 1985;5:8-25. 14. Lauritzen AG. Functional analysis technique in the natural dentition: atlas of occlusal analysis. Colorado Springs: HAH Publications, 1974. 15. Schuyler CH. Fundamental principles in the correction of occlusal disharmony, natural and artificial. J Am Dent Assoc 1935;22:1193-202. 16. Lytle JD. The clinicians index of occlusal disease: definition, recognition and management. Int J Periodont Rest Dent 1990;10:102-23. 17. Beyron H. Optimal occlusion. Dent Clin North Am 1969;13:537-54. 18. Lundeen HS, Gibbs CH. Advances in occlusion. Boston: John Wright, 1982. 19. Mann AW, Pankey LD. Oral rehabilitation. Part I: Use of the P-M instrument in treatment planning and in restoring the lower posterior teeth. J PROSTHETDENT 1960;10:135-50. 20. Greene CS. Orthodontics andtemporomandibulardisorders. Dent Clin North Am 1988;32:529-38. 21. Lipp MJ. Temporomandibular symptoms and occlusion: a review of the literature and the concept. N Y State Dent J 1990:56:58-66. 22. Dworkin SF, Hanson Huggins K, Le Resche LH, et al. Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc 1990;120:273-81. 23. Goodman P, Greene CS, Laskin DM. Response of patiente with myofasclal pain-dysfunction syndrome to mock equilibration. J Am Dent Assoc 1976;92:755-8. 24. Adler RC. What do a leech and a handpiece have in common? J Cranio Practice 1993;11:1. 25. Ramijord SP. Dysfunctional temporomandibularjoint and muscle pain. J PROSTHETDENT 1961;11:353-74. 26. Bakke M, Moller E. Distortion ofmaximum elevator activity by unilateral tooth contact. Scand J Dent Res 1980;80:67. 27. Riise C, Sheikholeslam A. The influence of experimental interfering occlusal contacts on postural activity of the anterior temporal and masseter muscles in young adults. J Oral Rehabil 1982;9:419-25. 28. Williamson EH, Lundqnist DO. Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles. J PRosTHETDENT 1983;49:816-23. 29. Hannam AG, DeCow RE, Scott JD, Wood WW. The relationship between dental occlusion, muscle activity and associated jaw movement in man. Arch Oral Biol 1977;22:25-32. 30. Mahan PE, Wilkinson TM, Gibbs CH, Mauderli A, Brannon LS. Superior and inferior bellies of the lateral pterygoid EMG activity at basic jaw positions. J Prosthet Dent 1983;50:710-8. 31. Schaefer P. Stallard RE, Zander HA. Occlusal interferences and mastication: an electromyographic study. J PROSTHETDENT 1967;17:43849.

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32. Zola A. Morphologic limiting factors in the temporomandibular joint. J PROSTHETDENT 1963;13:732-40. 33. Sicher H. The temporomandibular joint. In: Sarnot BG, editor. 2nd ed. Springfield, Ill: Charles Thomas Publisher, 1964. 34. Mansour RM, Reynik RJ. In vivo occlusal forces and moments: forces measured in terminal hinge position and associated moments. J Dent Res 1975;54:114-20. 35. Smith DM, McLochlan KR, McCall WD. A numerical model of temporomandibular joint loading. J Dent Res 1986;65:1046-52. 36. Hylander WL. The human mandible: leverorlink. Am J Phip Anthropol 1975;43:227-42. 37. Graf H, Zander HA. Tooth contact patterns in mastication. J PEOSTHET DENT 1963;13:1055-66.

38. Schellhas KP, Piper MA, Omlie MR. Facial skeleton remodeling due to temporomandibular joint degeneration: an imaging study of 100 patients. Am J Neuroradiol 1990;11:541-51. 39. Dawson PE, Piper MA. Temporomandibular disorders and orofacial pain. Seminar Manual. St Petersburg: Center for Advanced Dental Study, 1993:130-45. Reprint requests to: DR. PETER E. DAWSON 111 SECONDAVE., NE SurrE 1109 ST. PETERSBURG,FL 33701

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