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Functional Occlusion: From TMJ to Smile Design ISBN-13: 978-0-323-03371-8

ISBN-10: 0-323-03371-7
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate.
Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their
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ISBN-13: 978-0-323-03371-8
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 As the years pass, the values that really matter come into sharper focus.
It is to these great incentives in my life that I dedicate this book.

To My God
The designer of the masticatory system who programmed a complete set of in-
structions into every living cell using the alphabet of DNA. It is only because
an element of love was integrated into that design that the masticatory system
is also the organ of speech, expression, and beauty that is reflected in our
smiles.

To My Family
To Jodie, my helper, supporter, best friend, and mom to our four wonderful
children, Mark, Anne, Kelly, and Cary. I can’t imagine how I could have the
contentment I enjoy without such a loving family. This dedication also extends
to the future of eight very special grandchildren.

To My Profession
Especially to those in it whose primary motivation is to care enough about
every patient that they continue to study and improve their knowledge and
skills. It is for those true professionals that this book was written.
This page intentionally left blank
 Foreword

The form, function, and pathofunction of the dynamic mas- sociated with these conditions frequently provide a complex
ticatory system comprises one of the most fascinating, basic, diagnostic dilemma for the dentist and physician. Even
and important areas of study in dentistry. The explosion of when the causative factors are apparent, implementation of
technological and procedural advances coupled with im- appropriate therapeutic measures may be difficult. Important
proved materials and the general public’s awareness of the additions to this text are:
importance of quality oral health and its role in quality over-
1. A scheme for the classification of occlusion
all health herald a new age in dentistry. Additionally, the
2. A classification system for TMJ pathology
amalgamation of evolving science with the art of dentistry
3. Detailed discussion of myogenous forms of TMD
has fostered a true clinician-scientist model of dental prac-
4. Diagnosis-specific treatment based on detailed assess-
tice in the quest to provide “complete dentistry” for patients.
ment of all aspects of the stomatognathic system
The goals of complete dentistry include optimal oral health,
5. Recognition of other potential causes, co-morbid condi-
anatomic harmony, functional harmony, orthopedic stability,
tions, maintaining factors as related or unrelated to TMD
and natural esthetics. It is clear that to achieve these goals,
6. A review of imaging of the TMJs in health and patho-
today’s dentist must become a physician of the masticatory
logic states
system and beyond. Over the years, Dr. Dawson has advo-
cated such a concept. Importantly, the keys to predictable By providing these means of individualizing diagnosis,
treatment outcomes that have been espoused in his prior the reader is provided with important anatomic, physiologic,
works stress that enhanced form (esthetics) does not have to and neurologic perspectives that will certainly enhance
come at the sacrifice of optimal function. In this book, he problem-solving skills.
brings to the forefront basic principles of complete dentistry A highlight of the book is a detailed discussion of cases
that can be applied to every dental discipline regardless of representative of commonly presenting restorative chal-
the practitioner’s level of education and expertise. lenges. Each of these is presented with a detailed description
Diagnosis is the key to successful treatment outcomes. of the problem list, appropriate diagnostics, and treatment
Unless one understands the system in health, it will be diffi- considerations. Importantly, the potential pitfalls that might
cult at best to accurately recognize pathology and to develop arise in the treatment of these cases are discussed.
a case-specific, principle-centered plan of care. Dr. Dawson Postoperative care is delineated on a case-specific basis. Dr.
has done a masterful job of organizing the book in an easy- Dawson has also provided objective measures that delineate
to-follow, logical flow, beginning with the complete exami- specific criteria for success.
nation. Each chapter is organized in a manner that will en- Dr. Dawson once said “If you are going to quote me, date
hance one’s understanding of how the interrelated me.” It is clear that this text is the crowning jewel of a true
components of the entire masticatory system function in pioneer in dentistry and clearly illustrates his commitment
health. With the aid of excellent drawings and photographs, to being a perpetual student. Rare is the individual who ex-
the reader can attain a clear understanding of important cels at teaching a subject and writing about the subject, and
anatomic relationships and gain a greater appreciation for who can perform to the level of excellence promoted by his
basic orthopedic principles. The text clearly explains how teachings/writings. In this book he shares the wisdom,
pathology/dysfunction of one component may impact on the knowledge, and skill he has acquired during his illustrious
entire system. career. He is to be commended for the logical sequencing of
The sequelae related to maladaptive occlusion are multi- chapters, the detailed discussion of each concept in confor-
faceted. Compromise may occur at one or more of the oc- mity with our present-day knowledge, and the reader-
clusal interfaces to include: the tooth to tooth interface, the friendly style. This text will surely serve as an important ref-
tooth to supporting structure interface, the neuromuscular erence to those who desire to better recognize orthopedic
interface, and/or the temporomandibular joint (TMJ) inter- instability, develop and implement a treatment plan that will
face. It is well understood that the primary manner in which re-establish orthopedic stability, and help their patients at-
orthopedic systems are compromised is due to mechanical tain and maintain their stomatognathic system in maximum
stress or overload. Once disequilibrium develops in the mas- comfort, function, health, and esthetics.
ticatory system the patient may develop one or more of a
number of pathologic conditions representative of temporo- Henry A. Gremillion, DDS
mandibular disorders (TMDs). To develop an individualized Professor, Department of Orthodontics
treatment plan the practitioner must be specific regarding Director, Parker E. Mahan Facial Pain Center
the diagnosis, recognizing that TMD represents a number of University of Florida College of Dentistry
arthrogenous and myogenous conditions. The symptoms as- Gainesville, Florida
vii
This page intentionally left blank
 Preface

There is a primary tenet that embraces the entire subject of dentists that there need not be a big mystery about the cause or
occlusion from the TMJs to smile design. It is that the teeth treatment of TMDs. This mindset is absolutely required if one
are but one part of the masticatory system, and if the teeth is to be successful in treating problems of occlusion because
are not in equilibrium with all the other parts of the total sys- all occlusal analysis starts at the TMJs. Not a single type of
tem, something is likely to break down. This means that to TMD cannot be understood and specifically classified today; it
be a truly competent “teeth doctor” one must be a “mastica- can be done by general practitioners and it must be done by
tory system doctor.” No specialty in dentistry can be effec- any dentist who aspires to the level of master dentist. In this
tively practiced at the highest level of competence without age of the “esthetic revolution” and the “extreme makeover,”
an understanding of how the teeth relate to the rest of the failure to relate “smile design” to the rest of the factors that
masticatory system, including the TMJs. control occlusal stability is an invitation to ultimate dishar-
A reader of this text should have the following expectations: mony that can in time result in dysfunction and breakdown at
the weakest part of the system. Most often that weakest part is
• A clear picture of how the masticatory system func-
the teeth or the TMJs, or both.
tions in maintainable harmony.
Dentists who ignore the TMJs can never be competent in
• A detailed understanding of how to tell what is wrong
smile design or in diagnosing or treating occlusions.
when any part of the system is not functioning in com-
Dentists who ignore occlusion can never be competent in di-
plete comfort and long-term stability.
agnosing or treating problems of the TMJs. Dentists who ig-
• A specific process for developing a complete treat-
nore the relationship of the occlusion to the position and
ment plan for every type of occlusal disorder from the
condition of the TMJs can only guess at diagnosing a myr-
simplest to the most complex.
iad of problems that are seen in every general practice . . .
• An understandable proficiency in diagnosis and treat-
problems such as excessive tooth wear, sore teeth, fractured
ment of orofacial pain, including management of
restorations, loose teeth, masticatory muscle pain, and a va-
TMDs. Every dentist should know this.
riety of other orofacial pain problems. But understanding
• Elimination of all guesswork in design of the most
what it takes to keep the total masticatory system in har-
functional and esthetically pleasing smiles regardless
mony has positive consequences beyond achieving the goal
of the initial starting condition.
of a peaceful neuromusculature. It is the absolute key to de-
• Reliable background information regarding how to
termining many of the most important decisions regarding
analyze touted clinical concepts and procedures that
esthetics and tooth alignment, including the precise posi-
violate principles of functional harmony and that can
tioning and contour of anterior teeth.
lead to problems of instability, discomfort, dysfunc-
My goal is to take the guesswork out of everything the
tion, or patient dissatisfaction.
dental team must do to be successful in clinical practice. If
Dr. L.D. Pankey wrote that only 2% of dentists ever reach you will study the pages that follow, and commit to the time-
the status of “master.” A master dentist can interview, diag- tested principles, you will eliminate the number one source
nose, plan treatment, and motivate patients to proceed with of frustration and burnout in dental practice: a lack of pre-
a comprehensive treatment plan . . . but most important of all dictability. Achieving that high level of predicable success
he or she can execute the services needed with a very high that Dr. Pankey wrote about is not pie in the sky. It is the ul-
level of predictive success. timate goal of the master dentist, and it is my fervent passion
The primary motivation for writing this text was to provide to help you achieve it.
a framework by which any dentist could develop into a master It is easy to misinterpret clinical results because just re-
dentist. In my role as a restorative dentist, I have had the op- lieving symptoms may not mean a problem has been cor-
portunity to treat thousands of complex occlusal problems and rected. We have learned through long-term observation that
TMJ disorders. As a passionate student of the literature I have symptoms may sometimes be relieved at the expense of per-
had the opportunity to evaluate research efforts for more than mitting worse problems to progress.
50 years to see if the literature was true to clinical reality. In I have tried to expose my own clinical observations to the
many cases it has opened new doors to our understanding, test of time as well as the invited scrutiny of a wide variety of
whereas in too much of the literature, conclusions have been special expertise. At the Dawson Center for Advanced Dental
based on false presumptions. The most prevalent misconcep- Study we have developed a multidisciplinary “think tank” to
tions in the literature have been in the discipline of occlusion evaluate not only our own concepts but also the concepts of
and the relationship of occlusion to the TMJs and orofacial anyone with an opposing viewpoint. For more than 25 years
pain. It is my goal to clarify those misconceptions and show we have been inviting an international array of clinicians, re-

ix
x Preface

searchers, and specialists of many different persuasions to through dentist-laboratory controls to post-op maintenance.
meet with us for the purpose of evaluating all the pros and These advancements in principles and clinical protocols are
cons of their ideas plus our own. In addition, all our treatment presented in this text.
results are open for inspection to our entire practicing faculty, One of the most notable results from this “think tank” en-
and criticism of results is invited. Many notable advance- vironment is the formulation of specific, measurable criteria
ments have resulted from this effort and it has had a profound for success (see Chapter 47). I recommend an early reading
effect on the development of quality controls that start at the of this chapter. It will enable you to start your study of this
examination and carry through all phases of treatment text with the end in mind.
 Acknowledgments

I am grateful that there have been so many great minds in pertise is tremendously enhanced by his thorough under-
our profession who were willing to share so generously. I standing and adherence to the principles of occlusion ex-
was particularly blessed to have come into the profession at plained in this text. I have enjoyed his friendship and a close
a time when great changes were taking place. The journey working relationship that has been the stimulus for many
has been one of constant excitement. “think tank” discussions. I have looked through his micro-
My eyes were opened to the importance of occlusion by scope during his impeccable surgeries and I can testify to the
Dr. Sigurd Ramfjord early in my practice years and we con- integrity of his reporting of exceptional results.
tinued a close relationship until his death. Through Sig, I Dr. Parker Mahan deserves special acknowledgment for all
met and developed a wonderful friendship with Dr. Henry he has contributed to the profession and to my understanding
Beyron, from Sweden, considered by many to be the “father of anatomy, physiology, neurology, and pharmacology in a
of occlusion.” He was always a strong supporter of my rec- clinical context. He has been one of my closest friends and a
ommended changes in centric relation and anterior guidance treasured ally. His contributions in diagnosis and treatment of
and he was a great encourager as well as a thoughtful critic. orofacial pain are recognized internationally.
One of the greatest influences in my life was Dr. L.D. A special measure of appreciation goes to Vernon
Pankey. I was so fortunate in meeting him during my first year (Buddy) Shafer, CDT for his constant support and for his
in practice and he soon became my role model and one of my contributions to the doctor-technician interface. He has been
closest friends. Through L.D. I was introduced to Drs. Clyde a dynamo, incorporating solid principles of complete den-
Schuyler, John Anderson, Henry Tanner, Harold Wirth, and tistry into the laboratory, and his influence has affected
many other super stars of that era who invited me to be a part countless dentists as well as technicians.
of their excitement in elevating the status of dentistry. Dr. Lee Culp, CDT has also been a resource of tremendous
Pankey was a leaders’ leader. His contributions to restorative value to me and to the profession. A master teacher and in-
dentistry, occlusion, and practice management were mixed novator, Lee is one of the most respected leaders in all of
with a philosophy of life that still affects the way I live. I am dentistry. I am grateful for all the updated information he
truly grateful. The L.D. Pankey Institute stands as tangible provides to me, and I thank him for the special contribution
proof that many others feel the same gratitude that I do. he makes to this text.
Dr. Clyde Schuyler gave dentistry the first sound principles I have called on a number of special clinicians to provide
of occlusion, and many of the thoughts and concepts in this the most current clinical updates for this text. Dr. Glenn
book started with seeds that were sown by Dr. Clyde. I was DuPont, senior partner in my former practice, has been a
privileged to have him as a friend, and his visits to my office tremendous resource and contributor. As Director of Faculty
that extended into long evenings are treasured memories. at the Dawson Center, he has developed an exceptional
Early in my career, I spent uncountable hours in learning “hands-on” curriculum for teaching some of the most im-
about gnathology, particularly from Dr. Charles Stuart but portant concepts and techniques. He is a meticulous restora-
also with Drs. Peter K. Thomas, Harvey Paine, Earnest tive dentist who excels in functional esthetics, so his contri-
Granger, and others. Dr. Niles Guichet and I developed a butions are much appreciated. Dr. DeWitt Wilkerson has
close personal relationship along with Dr. Frank Celenza also been a great source of current information and is a con-
that endures to this day. I am grateful to them for all the tributor to the text. Witt has taught thousands of dentists the
times we spent gelling our own conclusions about so many fundamentals of occlusion and how to achieve a perfect cen-
facets of occlusion. tric relation. He directs classes at the Dawson Center that al-
On many occasions, arriving at the best treatment plan in- ways achieve rave critiques. I treasure his friendship and his
volves varying degrees of orthodontics. My mentor in my many contributions to the profession. I am also particularly
early years was Dr. Clair McCreay and I still use the many proud of Dr. John Cranham, who has developed an interna-
concepts I learned from him plus all the additional help re- tional reputation as a clinician. I appreciate his continued
ceived from Dr. Gerry Francatti. support of our teaching efforts as well as his loyal friend-
Regarding analysis and treatment of TMJ disorders, all of ship. Special thanks also for notable contributions to fur-
dentistry should be grateful for the contributions of Dr. thering the goals expressed in the text go to Dr. Jeff Scott,
Mark Piper. Mark is a brilliant surgeon and the best diag- Dr. Michael Sesemann, Dr. Ken Grundset, and Dr. Kim
nostician I have known. His innovative approaches to repair Daxon. Many thanks also to technicians Rick Sonntag,
complex TMJ deformations is only one facet of his genius. CDT, Nancy Franceschi, CDT, Karl Wundermann, CDT,
His classification system is the gold standard for TMJ disor- and Harold Yates for their continuing source of current tech-
ders and it is a privilege to present it in this text. Mark’s ex- nologic expertise. Robert Jackson, MDT has also been a

xi
xii Acknowledgments

steady source of support in many different ways. I would be and to my special assistant, Esther McCrackin. I also have
remiss if I did not acknowledge Dr. Pete Roach for all the the joy of working with my daughter Anne Dawson, who for
past great years of sharing ideas as my partner in practice. 20 years has been a major source of help as my Seminar
They were joyful years. Coordinator. Dee Mortellaro was also an indispensable help
This text is in large part a compilation of the principles in preparing the manuscript.
and procedures I have taught to more than 30,000 dentists And finally, a very appreciative “thank you” to the ex-
and technicians at seminars and in classroom sessions at the cellent editorial staff at Elsevier/Mosby publishers. Julie
Dawson Center for Advanced Dental Study. I owe a huge Nebel has been great to work with and I have been grateful
debt of gratitude to the very special staff that makes the cur- for the help from Publisher Penny Rudolph and Senior
riculum run so efficiently and in such a happy, warm man- Editor John Dolan, as well as artist Don O’Connor. Thanks
ner. A special thanks to Joan Forest, the Executive Director, to all of you.
for her outstanding leadership. Deep appreciation also to
Sallie Bussey, Mary Lynn Coppins, Jody Booth, Greg Sitek, Peter E. Dawson, DDS
 Chapter 1

The Concept of Complete Dentistry

PRINCIPLE
The ultimate goal for every patient should be maintainable health for the total mastica-
tory system.
4 Part I Functional Harmony

Immediate implications. These consist of problems that are

COMPLETE DENTISTRY in an active stage of progressive disease or deformation, or
disorders that are a causative factor for pain or discomfort.
The defining philosophy that underlies an honest concern If disorders in this category are not treated as priority, the
for patients can be summarized in one word: complete. implication is that delaying treatment will result in a greater,
Embracing the concept of complete dentistry always puts more complex problem, or an increase of pain, or will re-
the patient first. It says that every patient is entitled to a com- quire more extensive, more complicated, or more expensive
plete examination and a clear understanding of every prob- solutions with a possibility that delayed treatment results
lem that should be treated. It recognizes that almost every will not be as good as what could be achieved with immedi-
dental disorder is, in all probability, a progressive disorder ate attention. Such decisions cannot rely only on what a pa-
that will cause increased problems if not detected and tient perceives as “wants.” It requires searching for signs, of
treated in a reasonable time frame. which patients are often not aware, because signs of damage
It is axiomatic that patients cannot perceive a need for typically occur before symptoms are noticed.
treatment if they do not clearly understand what problems
are present. That is the primary purpose of the complete Deferrable implications. These consist of problems that
examination. But think about this: patients cannot make a will need to be treated but could be deferred without caus-
truly informed decision about treatment unless they also ing more complex problems, and delaying treatment for a
understand the implications of not treating each problem reasonable time period would not result in a less successful
within a reasonable time frame. Practitioners cannot reli- treatment outcome. Some problems with immediate impli-
ably predict implications if they don’t have a working cations can be made deferrable by conservative intervention
knowledge of the total masticatory system, which includes that stops or slows the progression of the disorder so it can
the interrelationships of the teeth, the temporomandibular be effectively treated at a later time.
joints (TMJs), the muscles, and the supporting tissues, in
addition to a clear picture of the causes and effects of oc- Implications for optional treatment. These are indications
clusal disease. for treatment that would be nice to have but are not problems
that will lead to progressive damage if left untreated.
Cosmetic restorations that are done solely for the purpose of
Examining With an “Implication Mindset”
improving esthetics fall into this category. Careful observa-
A key question in every complete dental examination is fun- tion for signs of stability versus instability is a critical part
damental to the integrity of the doctor-patient relationship: of the decision process before informing a patient that
“Are all the components of the masticatory system main- treatment is not necessary for long-term health. This does
tainably healthy?” This requires analysis to determine the not imply that treatment done solely for esthetics is inap-
implications of not treating any parts that are disordered or propriate, and experience has shown that being honest with
diseased. Answering these questions is the foundational ba- patients about what is optional versus what is necessary
sis for the complete examination. It is also the guiding prin- will rarely deter a patient from accepting esthetic treatment
ciple for formulating what treatment should be started, what for improving appearance.
could be deferred, and what may not be required to save
teeth but might be desired for improved esthetics.
Understanding the short- and long-term implications of GOALS FOR COMPLETE DENTISTRY
each type of dental disorder is the basis for establishing pri-
orities of treatment and is the essential information that is A dental examination is complete if it identifies all factors
used to establish “phased” treatment for patients who cannot that are capable of causing or contributing to deterioration of
proceed right away with an extensive treatment plan in its oral health or function. It is incomplete if it does not expose
entirety. every sign of active deterioration within the masticatory sys-
tem. A complete examination does not rely solely on symp-
toms because signs almost always precede symptoms. It is
Types of Implications
the responsibility of the examiner to observe signs of deteri-
Every dentist needs to develop a clear picture of what a sta- oration before they cause symptoms. In doing so, it is possi-
ble, maintainably healthy masticatory system looks like . . . ble to develop treatment plans that are aimed at optimum
not just teeth, but all parts of the system. In a complete ex- maintainability of the teeth and their supporting structures.
amination, each part of the system should be analyzed to see Seven specific goals should be the objective for patient care:
if there are any signs or symptoms that indicate disease, dis-
order, or dysfunction. If any departure from health is noted 1. Freedom from disease in all masticatory system struc-
in any structure, the key to both diagnosis and treatment rec- tures
ommendations will be directly related to the implications of 2. Maintainably healthy periodontium
not treating that disorder in a timely manner. Those implica- 3. Stable TMJs
tions can be classified into three types: 4. Stable occlusion
 Chapter 1 The Concept of Complete Dentistry 5

5. Maintainably healthy teeth long to expect a complete return to ideal health. But the de-
6. Comfortable function gree to which we can eliminate the causes of deterioration
7. Optimum esthetics will directly relate to our degree of success in changing un-
healthy mouths to healthy ones.
The establishment of these goals is the foundation for
complete dentistry. If a goal is clear enough, it can be visual-
Causes of Deterioration
ized and in fact must be visualized. A good rule is to avoid
starting any treatment until the desired result can be clearly Dental disease rarely results from a single entity. It is almost
visualized. Until the practitioner has a clear picture of how always the result of a combination of factors. The same
each type of tissue looks and acts when it is optimally healthy, causative insult can produce a variety of responses because
there will be no frame of reference for knowing whether treat- of differences in host resistance. The response can also be
ment is needed or if it is successful when rendered. Clearly altered by variations in intensity or duration of the insult,
defined goals give purpose to treatment planning and make it sometimes to such an extent that a completely different set
possible to be highly objective. When the goals listed above of symptoms may result from increased intensity of the
are fulfilled, the consequence will be fulfillment of a further same causative factor.
goal that is essential for long-term stability and comfort. That Because similar symptoms may result from different
is the goal of a peaceful neuromusculature. causes, and a variety of symptoms may result from the same
When the entire masticatory system is healthy and there is causative factor, treating symptoms alone is generally short-
harmony of form and function, and the relationships are sta- sighted therapy. It is always advantageous to determine the
ble, the treatment can be said to be complete. Furthermore, es- cause of both signs and symptoms. If the causative insult can
thetic requirements, including the highest level of functional be completely eliminated (such as occlusal overload on a
smile design, can also be fulfilled because all of the guidelines painful, loose tooth with a “high” restoration), the normal
for a naturally beautiful smile are dependent on the same har- adaptive response of the body should activate a return to
mony of form that is necessary for harmony of function. comfort and reduced hypermobility when the overload on
In the analysis of any oral diagnosis, each of the above the tooth is eliminated. Of course it may still be necessary to
goals should be evaluated for fulfillment. This evaluation will repair damaged tissues, but this can then be done with a
fall short unless the reasons for form and function relation- greater chance of a long-term successful treatment outcome.
ships are understood along with the cause-and-effect nature Much of the confusion about cause-and-effect relation-
of health versus disease. This type of analysis eliminates de- ships results from failure to differentiate between causative
pendency on empiric treatment or making patients fit aver- factors and contributing factors. A contributing factor does
ages. There are many stable healthy dentitions that do not fit not by itself cause disease. Rather it lowers the resistance of
the averages, that are not Class I occlusions, and that violate the host to the causative factor, or increases the intensity of
customary guidelines for normalcy. Attempts to “correct” function or tension. Contributing factors may lower host re-
these dentitions often end in failure, and existing harmony of sistance biochemically or increase intensity biomechani-
form and function may be disturbed by the treatment. Such cally. The resistance may be lowered in a specific tissue or
mistakes can be prevented, and a high degree of predictabil- in an entire system. Generally the weakest link breaks down.
ity can be developed if the goals of treatment are based on a The greatest susceptibility to disease occurs when a
foundation of “why” rather than “how.” causative factor is present in a host with increased stress and
There is an understandable reason for every position, lowered resistance. Both causative and contributing factors
contour, and alignment of every part of the gnathostomatic must be considered when deciding on a path of treatment,
system. There is always a reason for every incisal edge po- but the most effective approach is to give the highest prior-
sition, every labial contour, every lingual contour, and every ity to direct causative factors. Attempts at increasing host re-
cusp tip position. There is always a reason why some teeth sistance and decreasing stress levels should be kept in
get loose, and others wear away. There is a reason why proper perspective as adjunctive therapy.
TMJs hurt, why masticatory muscles become tender, and Let’s use a simple illustration to show how a single direct
why teeth get sensitive. There is a reason why certain occlu- causative factor can produce a variety of signs and symptoms,
sions remain stable and others do not. Treating the effect depending on variations in how different patients respond:
without treating the cause is rarely a satisfactory outcome, In a healthy patient with a perfect dentition, note the va-
and is almost never necessary. riety of responses that can occur if a single high restoration
Every diagnostic or treatment decision should be made with deflective incline interference is placed on a second
on the basis of understanding the reasons for the problem, molar. There are many different ways that patients might re-
and the reasons for the treatment. All treatment should be spond to the same, specific causative factor (Figure 1-1):
consistent with the goal of providing and maintaining the
highest degree of oral health possible for each patient. Total 1. The tooth may become sensitive to hot or cold, or it
elimination of all causative factors to the point of complete may ache
reversal of deterioration is not always possible. The prob- 2. The tooth may become tender to biting on it
lems of some patients are too severe, or have gone on too 3. The tooth may become loose
6 Part I Functional Harmony

ference on the second molar. None of the contributing fac-

tors that altered the response actually caused the problem. If
the causative insult (the deflective occlusal contact) had
been corrected before irreversible damage occurred, all
symptoms would have disappeared without any changes be-
ing made in host resistance or emotional stress levels.
Host resistance is not the only variable. Variations in in-
tensity of function can dramatically alter the response. The
same type of occlusal interference may go completely un-
noticed by a very relaxed patient who has no tendency to
clench or brux. The mouth breather or the person who sleeps
with the mouth open will have fewer, if any, of the above
symptoms because no stress or tooth damage results in the
absence of tooth contact. The same person under duress may
begin to clench or brux, activating the muscles into occlusal
overload and an avoidance pattern that produces symptoms
in the teeth, muscles, and possibly the joints.
Despite the complexity of the multicausality concept, it
is still possible to simplify our approach to diagnosis and
treatment planning if we understand how the masticatory
system was designed to function. In the chapters that fol-
low, you will learn how all parts of the system are interre-
lated in a functional design that is so logical, it will be ap-
parent when there is destructive disequilibrium. By
knowing how the system works, it will be obvious what is
FIGURE 1-1 A deflective incline interference on a second molar can be wrong when it isn’t working properly, causing stressful
the primary causative factor that results in many different signs and symp-
forces to build up within the system. It is not possible to
toms in the masticatory system.
completely eliminate stress, but treatment planning should
always be directed at reducing stress to a level that is not
4. The tooth may wear excessively destructive. Ensuring that the total system is in equilibrium
5. The mandible may be deflected around the interfer- is a goal of complete dentistry.
ence into other teeth that become loosened It is a very popular concept to blame emotional stress for
6. Other teeth can be abraded as the mandible is de- many of the disorders that are, in fact, caused by structural
flected forward disequilibrium. None of the patient responses listed above
7. Other teeth can become sore as they are traumatized would have occurred if the deflective incline on the “high”
at the end of the slide tooth were not present, regardless of the patient’s emotional
8. Forced deviation of the mandible can cause mastica- state. This is not to say that emotional stress cannot result in
tory muscles to become painfully hyperactive, or pain or discomfort. What is important is that it is possible
even become spastic and practical to isolate structural causes for pain or dys-
9. Trismus may result from the spastic musculature function and correct those causative factors. If treatment is
10. Muscle tension headaches may develop limited to covering up symptoms with medications, the struc-
11. The combination of sore teeth, sore muscles, and tural disharmony is allowed to continue its progressive de-
headaches may cause stress and tension formation of teeth, joints, or supporting tissues. Experience
12. Constant tension and stress may lead to depression has also shown that when pain or dysfunction is eliminated,
13. The combination of the uncoordinated musculature emotional stress is relieved in many patients. It appears that
and the deflected mandible may contribute to a psychosocial stress is often a result of, rather than a cause of,
condyle/disk derangement orofacial pain.
14. Eventual displacement of the disk by uncoordinated Patients lose their teeth in two ways: either the teeth
masticatory muscle hyperactivity may initiate break down, or the supporting structures break down. As
painful compression of retrodiskal tissues simplistic as it may sound, if we exclude neoplastic disor-
15. Degenerative arthritic changes in the TMJ may fol- ders and specific pathological conditions, almost every dete-
low disk displacement and subsequent perforation of riorating effect on the teeth or supporting structures is a di-
the retrodiskal tissues rect result of one or both of two causative factors:
16. All of the above
17. None of the above 1. Stress from microtrauma or physical injury (macro-
trauma)
All of the signs and symptoms listed above can be a di- 2. Microorganisms including gingival diseases of spe-
rect result of the same causative factor, the occlusal inter- cific bacterial, viral, or fungal origin
 Chapter 1 The Concept of Complete Dentistry 7

Stress from microtrauma results from repeated occlusal Short-term improvements can be misleading. The dra-
overload. Diagnosis and treatment of occlusal disharmony matic results that can be achieved by either occlusal therapy
will be discussed in detail throughout the remaining chap- or plaque elimination can be impressive, but years of careful
ters. As factors of occlusal overload are better understood observation almost always present a different picture of pro-
and the destructive evidence of occlusal disease is better rec- gressive breakdown if either treatment approach is ignored
ognized, there is sometimes a tendency to downplay other when a combination of periodontal and occlusal factors is
equally important causes of deterioration. The role of mi- present.
croorganisms must always be given a high priority in every A concentrated mouth hygiene program may transform
dental examination and treatment protocol. bleeding, edematous gingiva into healthy-appearing tissue. In
addition, occlusal correction may greatly improve the comfort
of the teeth, and even eliminate hypermobility. But such no-
The Role of Microorganisms
ticeable improvement can be misleading if, underneath the
There is no doubt that the elimination of bacterial plaque and healthy-looking tissue, an untreated intrabony lesion remains.
the thorough cleaning of gingival sulci are essential for main- No matter how healthy the gingiva appears, deterioration of
tenance of oral health. Acidic microbial waste products not the alveolar bone and periodontal structures will continue if
only cause caries through decalcification of the tooth surface, the entire sulcus is not cleanable. The healthy appearance on
but they are inflammatory to soft tissues and destructive to the the outside merely produces a false sense of security while de-
bony support. Dentistry cannot be called “complete” if it fails terioration continues at the depth of the lesion.
to address the elimination of this important causative factor. No matter how thorough the plaque control, even if com-
bined with perfected occlusal therapy, it is incomplete den-
Any condition that prevents thorough cleaning of any tistry if there remain deep lesions that are capable of contin-
tooth surface or any portion of the sulcus should be con- ued deterioration.
sidered a causative factor that can lead to loss of teeth.
Occlusal Trauma and Pocket Formation
There is no such thing as a “healthy” mouth that has
long-standing deposits of bacterial plaque. As long as orga- Despite the extreme mobility patterns that can be caused by
nized masses of microorganisms are present, progressive occlusal disharmony, it is doubtful that occlusal trauma can
breakdown of the supporting tissues is almost inevitable. cause an increase in pocket depth unless inflammation is
The only variable is the rate of deterioration, which may present within the sulcus. If the gingival attachment is intact,
vary from patient to patient or even from tooth to tooth in the and there is a sufficient level of supporting bone remaining,
same mouth. The tissue response to the noxious products of even severely mobile teeth can usually be returned to normal
the microbial colonies depends both on the general resis- firmness and health by correcting the occlusion. With metic-
tance of the host and the resistance of the specific areas that ulous hygiene to keep the sulcus free of plaque, inflamma-
are being subjected to the microbial toxins. tion can be prevented. Lindhe and Nyman1 have shown
Even in a dentition that is uniformly coated with plaque, rather conclusively that occlusal trauma of the jiggling type,
the destructive effects may not be uniform. Periodontal de- even with greatly reduced periodontal support, will not
struction around some teeth may be severe, whereas other cause further destruction of the attachment apparatus once
teeth may retain all or most of their bony support. Since the the plaque-induced periodontitis has been eliminated.
intensity of the microbial attack is about the same around However, the combination of plaque-induced periodontitis
all teeth, there must be a tooth by tooth difference in resis- and occlusal trauma causes a more progressive loss of con-
tance to the microbial toxins. The difference in resistance nective tissue attachment than in nontraumatized teeth.2
from one tooth to the next is often directly related to differ- Recent clinical observations and scientific data have
ences in intensity of occlusal stress. It is a common clinical given added credibility to the relationship of occlusal over-
finding that the degree of bone breakdown is in direct pro- loads to periodontal damage.3 Comparative studies to deter-
portion to the intensity and direction of occlusal overload mine if there is an association between occlusal trauma and
on each tooth. periodontitis4 show that there appears to be a definite link.
Although there does appear to be a clinical relationship Teeth with a combination of functional mobility and
between occlusal stress and the amount of microbial dam- widened periodontal ligament space were found to have
age, occlusal stress is not a necessary factor in periodontal deeper probing depth, more clinical attachment loss, and
damage. Severe periodontal disease can occur in an envi- less radiographic bone support than nonmobile teeth. While
ronment of occlusal perfection. It is important to understand this relationship between occlusally induced tooth hypermo-
that even the best occlusal treatment cannot prevent deterio- bility and increased levels of periodontitis has been a com-
ration of supporting structures if inflammation is present. mon clinical finding for years, the actual mechanism for the
Occlusal therapy without control of plaque is incomplete bone loss was not fully understood. Recent investigations
dentistry. On the other hand, soft-tissue management, even have provided an explanation.
with exceptional control of plaque, falls short of the long- Interleukin-1 beta is a potent stimulator of bone resorp-
term maintainability that can be achieved when excessive tion and a known key mediator involved in periodontal dis-
occlusal forces are reduced. ease. It has now been determined that interleukin-1 beta is
8 Part I Functional Harmony

produced by human periodontal ligament cells in response treatment, it is more difficult to keep the supporting tissues
to mechanical stress.5 It has also been shown that older healthy around a loose tooth than it is around a firm one.
periodontal ligament cells produce an increased amount of Occlusal stress must be considered as a primary cause of
interleukin-1 beta in response to mechanical force, and may supporting structure breakdown around the teeth. Correction
well be positively related to the acceleration of alveolar of misdirected or excessive forces against the teeth is one of
bone resorption.6 the essential considerations in maintaining optimum health
Some authorities have argued that occlusal factors play of a dentition, and it also has the added benefit of making the
no role in periodontal breakdown because inflammation is patient more comfortable.
the essential causative factor for increased pocket depth.
This opinion presents a limited viewpoint of what causes
Anatomic Harmony
periodontal disease. A total picture of periodontal health,
and the goal of complete dentistry, involves all of the struc- The most common shortcoming in analyzing or treating oc-
tures that support the teeth, not just the gingival attachment. clusal relationships is failure to consider all parts of the
The way in which bone is destroyed can be learned from masticatory system. We are prone to many mistakes if our
careful clinical observation. The reason why teeth in hyper- understanding of occlusion is limited solely to occlusal
function loosen is because the bone around the roots breaks contacts. The teeth are just part of the total system, and
down. The bone breakdown follows a specific pattern in frankly there is no way to evaluate occlusal relationships
which bone resorption directly relates to the direction of until we have ascertained that the temporomandibular artic-
compressive forces by the root against the bone. The pres- ulation is in harmony. There is no such thing as a perfect oc-
sure stimulation results in thrombosis, hemorrhage, and de- clusion with a displaced TMJ. That means both the position
struction of collagen in concert with the activation of inter- and the condition of the TMJs must be considered in rela-
leukins that have been shown to convert fibroblasts into tion to the maximum intercuspation of the teeth. The peace-
osteoclasts. The osteoclastic activity, in turn, destroys bone ful function of the masticatory musculature depends on a
in direct proportion to the intensity and direction of the pres- harmonious relationship between the occlusion and the
sures exerted. This means then, that intra-alveolar bone TMJs, so this relationship is always of critical concern in
breakdown follows a pattern that is definitely related to oc- diagnosis and treatment planning. There will always be
clusal stress patterns.7 Careful clinical observation repeat- some price to pay when any part of the masticatory system
edly confirms this relationship, which can occur even when is at war with muscle. That includes the lips, tongue, and
the gingival attachment apparatus is intact. cheek musculature.
If the occlusion is corrected to negate directional over- Harmony of form is a prerequisite for harmony of func-
loads on the teeth before inflammation or injury deepens the tion, and it is necessary to have a working knowledge of how
sulcus to create a communication through the gingival at- the two interrelate. Every aspect of each tooth’s position and
tachment into the area of bone resorption, osteoblastic ac- contour can be determined on the basis of its harmony with
tivity will repair the osteoclastic destruction and bone will functional requirements. As examples, the upper anterior
fill back in to its original level. The loose tooth will tighten teeth must relate to the closing path of the lower lip as it
and can return to normal health and function. moves up to seal contact with the upper lip during every swal-
If the occlusal correction is delayed, our clinical experi- low. The upper incisal edges must relate to a consistent align-
ence has shown that in time, the sulcus depth very often ment with the lower lip contour for proper phonetics. The up-
deepens to eventually communicate with the bone loss area per lingual contours must relate to the functional pathways of
to form a deeper intrabony lesion. Understand that the in- the lower anterior teeth as they move along a repetitious pat-
crease in pocket depth requires inflammation or injury to tern referred to as the envelope of function. Both upper and
penetrate the gingival attachment, so it theoretically can be lower anterior teeth are subject to positioning within a zone of
prevented on selective patients who are willing to follow neutrality between the outward forces of the tongue versus the
meticulous hygiene procedures under increased professional inward forces of the lips. There are other functional relation-
supervision. Although possible, successful maintenance on ships that must be understood to achieve consistently pre-
an overloaded, hypermobile tooth is unpredictable at best. dictable results in occlusal treatment, but the important point
Bone resorption often is worst in furcation areas that are to grasp at this time is that every part of the masticatory sys-
hardest to clean and where communication with the sulcus tem has an understandable reason for its position, contour,
or pocket is most likely to occur. Once there is any break- and alignment. Learning these reasons will take the guess-
through between the sulcus and the area of bone breakdown, work out of everything from smile design to treatment of oro-
the pocket is immediately deepened to the extent of the total facial pain. Not knowing these interrelationships reduces too
intra-alveolar defect. More intensive periodontal treatment many diagnosis and treatment decisions to guesswork.
is then required, but even with that, the bone level will not If any anatomic component is not in harmony with the
be returned to its original contour. That opportunity is lost rest of the masticatory system, some part or all of the system
whenever occlusal correction is delayed too long. must adapt to regain equilibrium. Adaptive changes should
The repair of intraosseous defects is more predictable be evaluated as responses to imbalance. Such adaptation is
when the teeth are firm. From almost every viewpoint of not always a problem. Whether the system’s attempts at cor-
 Chapter 1 The Concept of Complete Dentistry 9

recting imbalance are beneficial or destructive is dependent anatomic limit without mechanical interference, but must
on the response of the altered tissue or part. Astute diagnos- not be restricted to function solely at that limit. It must func-
ticians must know the norm and must be able to determine tion to the limit when required. It must be at peace when
when an imbalance exists and whether the tissue or parts functional demands are reduced. Achieving such functional
have successfully adapted to the altered balance. harmony in an environment of optimally healthy teeth,
There are many so-called “physiologic malocclusions” joints, periodontium, and musculature, and in combination
that are stable and function well. They do so because the cu- with the best possible esthetic result, is the essence of com-
mulative effects of different dynamic factors produce a sta- plete dentistry.
ble result, even though it does not fit the Class I stereotype
of a classically correct occlusion. When we get into the sec- References
tion on treatment planning of different types of occlusal
problems, it will be apparent how important it is to under- 1. Lindhe J, Nyman S: The role of periodontal disease and the bio-
logic rationale for splinting in treatment of periodontitis. Oral Sci
stand the dynamics of functional and anatomic harmony. It Rev 10:11-13, 1972.
is not possible to adequately evaluate cause and effect influ- 2. McGuire MR, Nunn ME: Prognosis versus actual outcome III. The
ences in the dentition or the TMJs without knowledge of effectiveness of clinical parameters in accurately predicting tooth
functional interdependencies, because if we don’t know survival. J Periodontal 67:666-674, 1996.
what causes a malrelationship we will probably fail in our 3. Nunn ME, Harrel SK: The effect of occlusal discrepancies on peri-
odontitis. I. Relationship of initial occlusal discrepancies to initial
treatment. We may subject our patients to unnecessary clinical parameters. J Periodontal 72:485-494, 2001.
overtreatment or inadequate undertreatment if we attempt to 4. Harrell SK, Nunn ME: The effect of occlusal discrepancies on
treat signs or symptoms without knowing what caused them. periodontitis II. Relationship of occlusal treatment to the progres-
Teeth do not simply move out of alignment, become sion of periodontal disease. J Periodontal 72:495-505, 2001.
loose, or wear away without a specific underlying cause (or 5. Hallmon WW: Occlusal trauma: effect and impact on periodon-
tium. Ann Periodontal 4(1):102-108, 1999.
causes). The primary cause may be at the beginning of a 6. Shemizu N, Gaseki T, Yamaguchi M, et al: In vitro cellular aging
chain reaction that is started by a structural disharmony. stimulates interleukin. 1 beta production in stretched human peri-
Regardless of how and when the process was initiated, odontal ligament derived cells. J Dent Res 76(7):1367-1375, 1997.
treatment will not be successful unless all currently active 7. Pikhstrom BL, Anderson KA, Aeppli D, et al: Association between
causes for disharmony or deformation are corrected. signs of trauma from occlusion and periodontitis. J Periodontal 57
(1):1-6, 1986.
The goal of functional harmony is a peaceful neuromus- 8. Waerhaug J. The infrabony pocket and its relationship to trauma
cular system. The masticatory system is capable of high- from occlusion and subgingival plaque. J Periodontal 50:355-365,
capacity demands. The system must be free to function to its 1979.
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 Chapter 2

Perspectives on Occlusion
and “Everyday Dentistry”

PRINCIPLE
Whether general practitioner or specialist, practicing without a comprehensive under-
standing of occlusal principles exacts a costly penalty in missed diagnoses, unpredictable
treatment results, and lost production time.
12 Part I Functional Harmony

More Accurate Treatment Planning

OCCLUSAL PRINCIPLES
AT EVERY LEVEL OF PRACTICE Most of the problems that lead to compromised treatment re-
sults could be avoided if requirements for occlusal stability
At every level of general practice, a dentist routinely faces were adhered to in the treatment planning stage. Programmed
problems of sore teeth, excessive wear, loose teeth, temporo- treatment planning (see Chapter 29) is based on selection of
mandibular joint (TMJ) disorders, and orofacial pain. the best treatment options for fulfilling each requirement.
Patients want correct answers. They want to know if they Successful treatment planning pays huge dividends regardless
need orthodontic treatment, or an occlusal splint, or why a of the type or level of practice.
joint clicks, or why anterior veneers chip or crack. A dentist
who does not have a working knowledge of occlusal princi-
Improved Esthetics
ples must resort to guesswork and time-wasting trial-and-
error attempts to solve problems that could be confidently The very best, most naturally beautiful esthetics does not re-
solved by understanding cause-and-effect responses to oc- quire guesswork if the relationship between anatomic har-
clusal disharmony. Even achieving predictable function and mony and functional harmony is understood. The best smile
beauty of smile design is dependent on incorporation of design is automatically achieved when the anterior teeth are
sound occlusal principles. Those principles are not just for in harmony with all of the guidelines for occlusal function
complete mouth prosthetics. When principles of occlusal and stability. Furthermore, these guidelines provide a pre-
harmony are understood, the entire approach to examination, cise framework for a step-by-step process.
treatment, and problem solving takes on a new perspective. It
is a perspective that pays huge dividends of predictability and
Increased Productivity
increased productivity, regardless of the type of practice.
There are good reasons why general practitioners should Just imagine how much more productive a practitioner can be
learn principles of occlusal harmony, and develop skills re- if all restorations could be placed without need for “grinding
quired to recognize and treat typical problems associated in” high or uncomfortable occlusions, or remaking restora-
with occlusal disharmony. Descriptions of some of the bene- tions that are not correctable. How much time could be put to
fits follow. better use than trying to reshape anterior restorations that are
too thick on the lingual. How much wasted time could be
saved if incisal edges weren’t too far out, too long, too short?
Patient Comfort
These are the typical everyday problems that must be faced
Many problems of discomfort are related to occlusal dishar- if principles of occlusal harmony are not understood and
mony.1-3 Teeth that are sensitive to hot or cold after a restora- used to plan and execute treatment.
tion is placed are frequently symptomatic because of a de- It is unrealistic to expect that every restoration could be
flective incline interference or a vertical overload from a placed without any need for some occlusal correction. But it
new restoration. Indiscriminate grinding to relieve the inter- should be unnecessary to do more than minimal corrections
fering tooth can trigger new and bigger problems in other if the rules for occlusal harmony are faithfully practiced.
teeth and/or the masticatory musculature, and even the
TMJs. Not understanding occlusal principles is a barrier to
Decreased Stress
solving such everyday problems, and it puts a practitioner in
jeopardy of actually causing problems that are sometimes From interviews with more than 200 dentists, it appears that
worse than the original complaint. a major cause of burnout is a lack of predictability when at-
tempting to satisfy the needs and desires of patients. This
lack of predictability is especially noted in restorative and
Restoration Longevity
prosthodontic treatment and in attempts to solve issues of
Cracks, fractures, and excessive wear on restorations are all discomfort. When time is being wasted attempting to solve
signs of occlusal disharmony. Such problems are rare in per- a bite problem by trial and error, the next patient is kept
fected occlusions. waiting, and an already full schedule gets further jammed
up because of “working in” patients to redo or rework den-
tistry that isn’t quite comfortable. The result is increased
Occlusal Stability
stress on the entire office team. Some of these problems are
Post-treatment shifting of teeth, opening up of contacts, or caused by inadequate quality- control procedures, including
creating unesthetic misalignment are common problems of dentist-technician communication shortcomings. But the
occlusal mistakes. The use of long-term retainers to main- major cause of unacceptable treatment results is failure to
tain post-orthodontic tooth alignment could be dramatically visualize a clear correct goal for the treatment. This is usu-
reduced if occlusal principles were better understood. ally accompanied by inadequate treatment planning. The
Fremitus is almost always an early sign of a correctable oc- problem is that unless the requirements for occlusal har-
clusal disharmony. mony are understood, there can’t be a clear vision for a de-
 Chapter 2 Perspectives on Occlusion and “Everyday Dentistry” 13

sired end result . . . and without a clearly defined goal, try- resentation of what knowledgeable clinicians consider ap-
ing to arrive at a logical treatment sequence is folly. It is a propriate treatment for specifically diagnosed disorders.
problem that can only be solved by a clear understanding of Trying to arrive at sensible answers about the importance
requirements for a stable, comfortable, maintainably of occlusion in daily practice requires some insight into
healthy masticatory system. evaluation of the literature. With the growing dependence on
“evidence-based” reporting, the rules for judging research
studies and even clinically based opinions have made it eas-
RELEVANCE OF OCCLUSION ier to evaluate differing dogmas.12 Evidence-based research
TO “EVERYDAY DENTISTRY” on occlusion may not provide final answers to every ques-
tion, but it points out when there are serious enough flaws in
Even though an understanding of occlusal principles has any research study to invalidate its conclusions. Since so
value to every level of dental practice, there is a pervasive much of the negative literature proposes a nonrelationship of
misconception that concepts of dental occlusion are not rele- occlusion to “TMD,” an analysis of that literature is in order.
vant to “everyday dentistry.” It is important to understand When the NIH position states that “research refutes the
how such a viewpoint was ever germinated, and why it has view that a bad bite (malocclusion) can trigger TMD,” the
influenced so many dentists and educators to regard princi- statement fails the test for a scientifically accurate conclu-
ples of occlusal harmony with skepticism. sion. A truly scientific study must ask, “What kind of
To a large extent, a negative viewpoint regarding the im- TMD?” TMD is not a single disorder. It is not even a single
portance of occlusion has been by misguided assumptions multifactorial disorder.
that disorders of the TMJs and muscles represent the only TMD is an all-inclusive term that includes many different
focus for occlusion in dentistry.4 A negative view of the types of disorders, any of which may be multifactorial. A
occlusion-TMJ relationship has permeated the teaching of cardinal rule for evidence-based research requires homo-
occlusion and has resulted in a profuse amount of literature geneity of the disorder being studied. This means that for a
that downplays the role of occlusal therapy5-8 in general proper study of the relationship between occlusion and
practice. A conceptual belief that occlusion is unimportant TMD, the specific type of TMD must be isolated and de-
or is too difficult to teach at the dental school level has in- fined. An evaluation of the literature illustrates that this is
fluenced a whole cadre of dentists who are ill equipped to rarely done.13-15 This error creates a glaring source of misin-
properly diagnose or treat a broad spectrum of occlusal formation because there are many different disorders of the
problems that are routinely faced in every dental practice.9 masticatory system that are typically included in the TMD
The failure to embrace sound occlusal principles has also category. These different disorders have many different eti-
led to a plethora of fringe-type treatment modalities, unnec- ologies, require different treatment strategies, and can result
essary overtreatment, and denials of responsibility for prob- in different treatment outcomes. A proper choice of treat-
lems that are a direct result of occlusal mismanagement. ment demands specific classification of the type and stage of
The disparagement of occlusion as an important part of the disorder to be treated before treatment is selected. Any
daily practice has become so pervasive that the National reported clinical studies that use the term TMD without
Institutes of Health (NIH) and the National Institute of specifically classifying the exact type of TMD being studied
Dental and Craniofacial Research (NIDCR) published a are too seriously flawed to be considered valid. This error is
pamphlet10 to advise the public that occlusal adjustment or found almost universally throughout the literature on both
any other irreversible occlusal treatment for temporo- sides of the occlusion-TMD debate.
mandibular disorders (TMDs) is “of little value and may Scientific analysis also demands a much-improved expla-
make the problem worse.” Further admonitions that “recent nation that more clearly defines “a bad bite” and requires
research disputes the view that a bad bite (malocclusion) can characterization of “malocclusion” in more descriptive
trigger TMD” provokes distrust of all forms of occlusal ther- terms.16,17 The use of Angle’s Classification of Malocclusion18
apy. A profuse amount of seriously flawed literature sup- to describe arch-to-arch relationships or to define “maloc-
ports this viewpoint and denounces all alterations of occlu- clusion” is perhaps the most consistent and serious flaw in
sions as an unacceptable choice of treatment. the literature that disparages the idea of a relationship be-
Limiting judgment of occlusal principles on such a nar- tween occlusion and TMD. The cause of confusion is self-
row focus as its effect on “TMD” distorts the true value of evident because Angle’s classification does not relate
occlusal harmony as a realistic treatment goal for many dif- maximum occlusal contact to either the position or condi-
ferent problems, in addition to its indisputable value in treat- tion of the TMJs. Use of a classification system that ig-
ing certain types of TMDs,11 including masticatory muscle nores any relationship between occlusion and the TMJs
pain, by far the most common type of TMD. can hardly be considered an analytical model for studying
The NIH admonishment that occlusal treatment “is of lit- the relationship between occlusion and the TMJs. A search
tle value and may make a TMD problem worse” may be true of the literature confirms that this serious flaw has been
if it refers to inappropriate occlusal changes that are repre- consistent in a profuse amount of reported studies that are
sentative of the lowest common denominator of treatment. cited to discredit the value of occlusal harmony as a treat-
But such a negative view of occlusal treatment is a misrep- ment objective.
14 Part I Functional Harmony

Ruling out all rationales for occlusal changes in patients tion of signs or symptoms that are not within dentistry’s
with TMD is an indefensible position in light of extensive field of expertise.
clinical experience with conservative occlusal treatment that It is a serious mistake for any dentist to minimize the im-
is close to 100 percent predictable when performed by prop- portance of understanding the interrelationships of the teeth
erly skilled clinicians on properly selected patients. There is with the rest of the masticatory system structures. It is impos-
extensive clinical evidence to support the relationship be- sible to understand occlusion without understanding the rela-
tween deflective occlusal interferences and masticatory tionship of the teeth to the TMJs, the musculature, and the
muscle symptoms. There is also a proven scientific rationale functional patterns of jaw movement. It is equally impossible
for establishing occlusal harmony with the TMJs. The ratio- to have a realistic understanding of orofacial pain or TMD
nales for treatment are practical, learnable, and appropriate without a total masticatory system perspective. Failure to un-
for general practitioners as well as specialists. Attempting to derstand these perspectives is the primary reason why treat-
restore an occlusion, correct a bite problem, or even to re- ment of so many TMD pain patients is limited to medications
shape a high restoration without knowing the precisely cor- for controlling symptoms while ignoring signs of progressive
rect maxillo-mandibular relationship, can be a time-wasting, structural damage. Dentistry can do better than that.
frustrating, and unnecessary experience. Accepting the role of the dentist as a “masticatory system
physician” puts the practitioner on a higher level of obser-
vation. Looking for signs of structural deformation while the
Diagnosis of Orofacial Pain
cause of the problem is still correctable will enlighten any
in General Practice
dentist to needs that too often go undiagnosed. The destruc-
The dentist of today must become a physician of the total tive factor, that in the opinion of many clinicians, causes
masticatory system. A frequent focus of head, neck, and oro- more damage, more lost teeth, more discomfort, and more
facial pain is within structures that comprise the masticatory need for extensive dentistry than any other causative factor
system. Analysis of such pain requires a working knowledge is occlusal disease.19 Every practitioner should be able to
of masticatory system structure and function, including the recognize it, treat it, and when detected early enough, pre-
intraoral and collateral effects of dysfunction. The variety vent it from destroying a dentition. Any dentist who does not
and vagaries of pain from dental origins are complex feel competent to render adequate treatment should, at the
enough, but interrelationships between the TMJs, the teeth, very least, be able to recognize occlusal disease in its vari-
and the masticatory musculature require special expertise to ous forms. Patients should be informed of the problem and
evaluate the diversity of signs and symptoms that can result should be referred when a need for treatment is evident.
from structural disorder within the system. Occlusal disease can be detected in many forms. The next
Dentists are the only health professionals who are trained chapter describes its signs and symptoms.
(or should be) to diagnose problems of the teeth or to un-
derstand masticatory system function as a baseline for relat-
ing orofacial symptoms to variations of dysfunction. This References
means that the general dentist practitioner is regularly put 1. Barber DK: Occlusal interferences and temporomandibular dys-
into the position of “gatekeeper,” responsible for determin- function. General Dentistry Jan Feb; 56, 2004.
ing if a dental or masticatory system disorder is or is not a 2. Ramfjord SP: Dysfunctional temporomandibular joint and muscle
factor in head, neck, or orofacial pain. Physicians and other pain. J Prosthet Dent 11:353-374, 2004.
health professionals who do not have the training to deter- 3. Kirveskari P, LeBell Y, Salonen M, et al: Effect of elimination of
occlusal interferences on signs and symptoms of craniomandibu-
mine if a dental or masticatory system disorder is or is not a lar disorder in young adults. J Oral Rehabil 16:21-26, 1989.
factor in head, neck, or orofacial pain must be able to rely on 4. Ash MM, Ramfjord SP: Occlusion, ed 4, Philadelphia, 1995, WB
this expertise. Dentists must accept this responsibility and Saunders.
must develop the competence to fulfill it. 5. Trolka P, Morris RW, Preiskel HW: Occlusal adjustment therapy
Pain from dental origins can combine with sources of for craniomandibular disorders; a clinical assessment by a double
blind method. J Prosthet Dent 68:957-964, 1992.
pain from outside the masticatory system to produce con- 6. McNamara JA, Seligman DA, Okeson JP: Occlusion, orthodontic
fusing patterns of symptoms, so unraveling specific sources treatment, and temporomandibular disorders; A review. J
of overlapping or referred pain sometimes requires expertise Orofacial Pain 9:73-90, 1995.
from different specialists. For such a multidisciplinary effort 7. National Institutes of Health Technology Assessment Conference
to succeed, each specialist must separate out potentials for Statement: Management of temporomandibular disorders. J Am
Dent Assoc 127:1595-1603, 1996.
pain in the specific structures that fall within his or her spe- 8. Mohl ND, Ohrbach R: The dilemma of scientific knowledge ver-
cialty. This puts a serious responsibility on the dentist to be sus clinical management of temporomandibular disorders. J
a reliable resource, capable of determining whether all of the Prosthet Dent 67:113-120, 1992.
pain, some of the pain, or none of the pain has its source 9. Ash MM, Ramfjord SP: Occlusion, ed 4, Philadelphia, 1995, WB
within masticatory system structures. This is why it is so im- Saunders.
10. NIH #94-3497: TMD Temporomandibular Disorders, 1996.
portant for dentists to be able to rule out masticatory system 11. Dawson PE: Position paper regarding diagnosis, management and
structures as sources of pain, and to develop sufficient ex- treatment of temporomandibular disorders. J Prosthet Dent
pertise to select appropriate medical specialists for evalua- 81:174-178, 1999.
 Chapter 2 Perspectives on Occlusion and “Everyday Dentistry” 15

12. Sackett DL, Straus SE, Richarson WS, et al: Evidence-based med- 16. Dawson PE: New definition for relating occlusion to varying con-
icine: How to practice and teach EGM, ed 2, New York, 2000, ditions of the temporomandibular joint. J Prosthet Dent 74:619-
Churchill Livingstone. 627, 1995.
13. Greene CS: Orthodontics and temporomandibular disorders. Dent 17. Dawson PE: A classification system for occlusions that relates
Clin North Am 32:529-538, 1988. maximal intercuspation to the position and condition of the tem-
14. Dworkin SF, Huggins KH, LaResche L, et al: Epidemiology of poromandibular joints. J Prosthet Dent 75:60-66, 1996.
signs and symptoms in temporomandibular disorders: clinical 18. Angle EH: Classification of malocclusion of the teeth, ed 7,
signs in cases and controls. J Am Dent Assoc 120:273-281, 1999. Philadelphia, 1907, SS White Dental Mfg Co, pp 35-59.
15. Goodman P, Greene CD, Laskin DM: Response of patients with 19. Lytle JD: The clinician’s index of occlusal disease; definition,
pain-dysfunction syndrome to mock equilibration. J Am Dent recognition, and management. Int J Periodont Rest Dent 10:102-
Assoc 92:755-758, 1976. 123, 1990.
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 Chapter 3

Occlusal Disease

PRINCIPLE
Signs of occlusal disease almost always precede symptoms. The severity of structural dam-
age is routinely progressive if not treated.
18 Part I Functional Harmony

dis•ease n, the failure of the adaptive mechanisms of an tooth structure, and he showed specific pathognomonic char-
organism to counteract adequately the stimuli or stresses acteristics for each different etiology. He did not diminish the
to which it is subjected, resulting in a disturbance in role of bruxism or parafunction. He did show how combined
function or structure of any part, organ or system of the mechanisms of chemical effects could interact with occlusal
body overloads to intensify destruction of tooth surfaces.
—Gould Medical Dictionary

BASIC MECHANISMS FOR

TOOTH SURFACE DEFORMATION
SIGNS AND SYMPTOMS
According to Grippo et al, it is now apparent that deforma-
It is a puzzling observation that the most prevalent evidence tion of tooth structure results from three basic physical and
of damage to teeth is so routinely ignored, both in clinical chemical mechanisms that can act alone or in combination3:
practice and in the dental curricula. It is still more bewilder-
1. Stress results in compression, flexure, and tension. It
ing if one recognizes that signs of occlusal disease are so
can produce microfracture and abfraction as a dental
easily observed even at the earliest stages when progression
manifestation.
of the damage can usually be intercepted. Symptoms of oc-
2. Friction includes abrasion from exogenous material
clusal disease may not be as obvious, but to an astute diag-
and attrition, which is endogenous and results from
nostician, both signs and symptoms are readily recognized
empty mouth bruxing and parafunction. The end point
and typically respond to treatment at a high level of pre-
of both is wear of tooth surfaces.
dictability. If therapy is not delayed until the damage is se-
3. Corrosion is the result of chemical or electrochemical
vere, the complexity and cost of treatment can be dramati-
degradation.
cally reduced.
Attention to occlusion would be elevated to a much These three basic mechanisms often overlap and interact
higher priority if the following observations were more uni- to accelerate structural damage to the teeth. Thus much of
versally noticed and analyzed. the structural deformation of teeth must be considered as
Occlusal disease is: multifactorial. It does appear, however, that occlusal over-
load is almost always the dominant factor that must be ad-
• The #1 most common destructive dental disorder.
dressed in treatment planning for severely damaged tooth
• The #1 contributing factor to eventual loss of teeth.
structure.
• The #1 reason for needing extensive restorative
dentistry.
• The #1 factor associated with discomfort within masti- Clarification of Terminology
catory system structures. This includes pain/discomfort
Grippo, Simring, and Schreiners’ classic work3 should be
in the musculature, the teeth, and the region of the tem-
studied in detail. It is a scholarly analysis of the many dif-
poromandibular joints (TMJs).
ferent causes of tooth surface lesions, and it includes their
• The #1 factor in instability of orthodontic treatment.
clarification of terminology. At this time however, there are
• The #1 reason for tooth soreness and hypersensitivity.
conflicting concepts that should also be analyzed in every
• The #1 most commonly missed diagnosis leading to
detail. The extensive effort by Abrahamsen2 to clear up con-
unnecessary endodontics.
fusion regarding tooth surface lesions is based on an un-
• The #1 most undiagnosed dental disorder until severe
matched number of clinical case studies and results in some
damage becomes too obvious to ignore.
differences in terminology as well as causes and effects. In
The above observations have not, at this date, been con- presenting my current viewpoint, I make no pretext of cer-
firmed by formal evidence-based protocols, but they are tainty. This debate will go on for a long time and will require
consistent with many years of careful observation of thou- critical analysis, research, and an open mind. Nevertheless,
sands of patients. Attention to periodontal disease and con- none of the disagreements regarding terminology or etiol-
trol of caries have become more consistent in most dental ogy diminishes the importance of recognizing and treating
practices, but a complete evaluation of occlusal disease is in- tooth surface damage.
complete in too many examinations.
Lytle1 was the first to introduce the term occlusal disease.
Attrition
At that time, he defined it as “the process resulting in the no-
ticeable loss or destruction of the occluding surfaces of the Attrition is wear due to tooth-to-tooth friction. This is the
teeth.” He postulated that the disease is primarily but not kind of wear that results from bruxism and empty mouth
necessarily precipitated by bruxism or parafunction. parafunction. The implication is that enamel is the hardest
Abrahamsen2 added greatly to our understanding of oc- structure in the body. When wear penetrates enamel into
clusal disease by defining different causes for destruction of softer dentin, wear increases seven times faster.
 Chapter 3 Occlusal Disease 19

scribed by Lee and Eakle7 as the possible consequence of

Abrasion
tensile stresses through bending of teeth under occlusal
Abrasion is wear due to friction between a tooth and an ex- overload. McCoy8 added to the controversy by defining
ogenous agent. This is the kind of wear that comes from McCoy’s notches as the result of what he labeled “dental
chewing on a food bolus or from tobacco chewing. It can compression syndrome.” When Grippo put the abfraction la-
also come from overzealous toothbrushing or improper use bel on his concept of stress-induced non-carious cervical le-
of dental floss, toothpicks, pencils, or any foreign object. sions, it was almost universally accepted as a common form
of occlusal disease. Numerous investigators have claimed
that occlusal loading forces do in fact cause flexure of teeth
Erosion
that produce microfractures and structural loss in the cervi-
Erosion is tooth surface loss due to chemical or electrochem- cal area. Further studies9-12 indicated that acid penetrates the
ical action. It can be endogenous or exogenous. By defini- microcracks and undermines tooth surfaces that are then
tion, it does not include association with bacterial activity. more susceptible to mechanical deformation.
Grippo and Simring have decried the use of this term. I must admit that I was one clinician who accepted the
They suggest that erosion refers to loss of material from the validity of abfractions as a result of occlusal overload. I
action of fluids against a structure, as in beach erosion from have had to rethink that position in light of some convinc-
water, and that no such mechanism exists in the mouth.4 So, ing data to the contrary. Abrahamsen13 has demonstrated
it is inappropriate terminology, and the term erosion should several inconsistencies to the occlusal overload theory.
be discarded from the dental literature. Abrahamsen2 and Since I consider Abrahamsen to be the foremost authority
others disagree, and properly point out that Webster defines on occlusal wear, and recognize that he is a prosthodontist
erosion as a “wearing away as acid erodes metal.” Gould with an in-depth understanding of occlusion, I feel his
Medical Dictionary defines it as “superficial destruction of a analysis is worthy of my consideration. It is also consistent
surface area by inflammation or trauma.” Gould also de- with the current research done by Dzakovich,14 which
scribes dental erosion as “loss of tooth surface due to a leaves little doubt that the so-called abfraction lesions are
chemical process.” Dental erosion is distinguished as a sep- not the result of occlusal overload, but rather are caused by
arate cause that excludes bacterial action. toothbrushing with toothpaste.
The heretofore accepted characteristic of abfractions as
Endogenous erosion. This can result from bulimia and is wedge-shaped lesions with sharp line angles is actually char-
recognizable by a unique pattern of enamel loss on the acteristic of toothpaste abrasion, according to Dzakovich.
palatal surfaces of the upper anterior teeth from forceful pro- His research using standardized brushing machine action on
jection of vomitus. extracted teeth also showed that brushing without toothpaste
does not cause any wear problem. The addition of toothpaste
Gastroesophageal reflux disease (GERD). This condition results in deep lesions with sharp line angles. The type of
produces hydrochloric acid and the proteolytic enzyme toothpaste has little effect on the resulting wear patterns. At
pepsin from gastric juices. Erosion may occur wherever the this writing, it appears that almost all toothpastes are abra-
acid reflux juice is permitted to pool. Erosion on the lingual sive, and that the pattern and intensity of the brushing strokes
of molars is diagnostic. Referral to a gastroenterologist is in account for the varied contours of the lesions.14
order when signs of GERD are observed. It is interesting that Miller described the same abrasive
effects of toothpastes and powders in an extensive three-part
Gingival crevicular fluid. This has an acidic pH and can be series in 1907.15 Miller’s insights into the wasting of tooth
erosive in combination with non-carious cervical lesions.5 tissue from various causes is as up-to-date today as it was in
1907. In repeating Miller’s toothbrushing research,
Exogenous erosion. Any food or liquid with a pH of less Dzakovich has verified that the original conclusions were
than 5.5 can demineralize teeth. The tremendous increase in correct. What we have been calling abfraction lesions are re-
sale and consumption of soft drinks is taking its toll on pa- ally the result of toothpaste abuse.
tients who bathe their teeth in citric acid solutions on a daily If there is an occlusal overload component to the cause of
basis. The “Coke swishers” and “fruit mullers” described by abfractions, it needs to be confirmed with convincing scien-
Abrahamsen2 are classic examples of exogenous exposure to tific data. It does appear that occlusal forces can definitely
acidic products. Other examples are chewable vitamin C bend and torque teeth. If that is a co-factor in creating non-
tablets, aspirin, and other acidic drugs. carious gingival lesions, more evidence is needed at this writ-
ing. Until this is confirmed, it is a certainty that deep, angu-
lar cervical lesions can be caused by toothpaste abrasion.
Abfractions
Admittedly, it is hard to give up a concept that appears
The role of occlusal overload on non-carious cervical le- so logical and is so solidly accepted into so much of the
sions has not been as incontrovertible as many have as- dental literature, including the Glossary of Prosthodontic
sumed. What Grippo6 labeled as abfractions were first de- Terms. There are many reasons to suspect that abfractions
20 Part I Functional Harmony

are the result of occlusal overload. While the current re- The stimuli and stresses from occlusal overload and mis-
search seems to argue against that concept, the best advice directed forces are not limited to teeth. As noted in the defi-
is to keep an open mind while examining all the data. At nition of disease, a disturbance in function and structure ex-
this writing, one clinical observation that seems evident is tends into other structures in the masticatory system.
that teeth with deep non-carious cervical lesions are more To appreciate the full scope of occlusal disease, it is nec-
likely to produce signs and symptoms when subjected to essary to understand how interdependent all parts of the
occlusal overload.14 masticatory system are. Any disharmony between the teeth,
Confining occlusal disease to destruction of occluding the muscles, and the TMJs is sufficient to cause stress, de-
tooth surfaces falls short of the true extent of occlusal over- formation, or dysfunction on any or all of the other parts in
load. My partner in practice, Dr. R. R. (Pete) Roach, demon- the system. With that understanding in mind, a redefinition
strated on numerous occasions a view through a clinical mi- of occlusal disease is in order:
croscope that showed carious lesions forming precisely in
vertical cracks in the center of proximal surfaces. Such cracks Occlusal disease is deformation or disturbance of func-
were invariably on posterior teeth with wear facets on inner tion of any structures within the masticatory system that
inclines of cusps in occlusal interference to lateral jaw move- are in disequilibrium with a harmonious interrelationship
ments, or were deflective inclines in interference to centric re- between the TMJs, the masticatory musculature, and the
lation. The consistency of these findings and the rarity of occluding surfaces of the teeth.
proximal caries on non-stressed teeth in the same mouth sug-
gest the possibility that occlusal overload can be a co-factor in
the etiology of proximal caries on posterior teeth.
 Chapter 3 Occlusal Disease 21

EXAMPLES OF OCCLUSAL DISEASE

Attritional wear
This type of wear on the lower anterior teeth is one of the
most common untreated problems. It is also a typical sign of
two prevalent causes for such wear. The first place to look is
at the posterior teeth where deflective incline interferences
to centric relation are so often the cause of a forward slide
of the mandible during closure to maximum intercuspation.
This forces the lower anterior teeth forward into a collision
with the upper anterior teeth. The muscles respond by at-
tempting to erase the colliding tooth surfaces through brux-
ing or parafunctional rubbing (A). Destruction of lower in-
cisal edges should never be allowed to progress to such a
severe degree because the implications point to more com-
plex treatment requirements if not corrected early.
A
The second most common cause for this type of wear is di-
rect interference of the anterior teeth to complete closure in
centric relation (B). This will virtually always be the result
of improper restorations on the anterior teeth or improper
positioning of the anterior teeth. Interference to the
mandibular envelope of function is also a potent trigger for
attritional wear. Correct diagnosis and treatment selection
for this or any other example of attritional wear requires a
complete understanding of occlusal principles.

B
Erosion of enamel
A combination of acid from fruit, abrasion from mulling
fruit between end-to-end anterior contacts, and attrition
from bruxing produces invagination of incisal enamel.
Evidence of erosion is obvious because cupped-out dentin
areas cannot be contacted by opposing teeth.

Splayed teeth
The same type of mandibular deflection that causes wear
problems can, in a different patient, force the upper anterior
teeth forward. Splaying of teeth is a common sign of oc-
clusal disease that should be diagnosed and treated early by
eliminating the deflective interferences that force the
mandible forward.

Other signs of the same problem are fremitus and soreness

of the anterior teeth in the early stages. Improperly con-
toured restorations that are too thick on the lingual of the up-
per anterior teeth or overcontoured lower restorations are
common causes of splaying.
22 Part I Functional Harmony

Destroyed Dentition
This is the result of not intercepting occlusal disease early.
Signs of severe wear, fractured maxillary (A) and mandibu-
lar (B) teeth, and elongated alveolar processes are typical
when treatment of delta-stage bruxism is delayed. This is
one of the most demanding occlusal problems to treat even
if diagnosed early. When such patients are “watched” until
the problem becomes this severe, all aspects of treatment are
made more complex and results are compromised.

Advanced occlusal disease

This disease results from a combination of attritional wear
and moved teeth. This is occlusal disease left undiagnosed
and untreated until the late stage of progressive damage has
occurred. In my practice, I treated hundreds of patients with
severely advanced occlusal disease, and it was the rare pa-
tient who had ever been warned about the implications of al-
lowing the damage to progress without treatment.
 Chapter 3 Occlusal Disease 23

Anterior guidance attrition

This occurs when anterior teeth that either interfere with
centric relation closure or interfere with functional jaw
movement patterns (envelope of function) develop early
signs of attritional wear of the lingual enamel on upper an-
terior teeth (A). This type of occlusal disease too often goes
undiagnosed until the incisal edges become so thin they start
to chip and fracture (B). Patients are rarely aware of the
problem until major damage has been done.

Sensitive teeth
One of the most missed diagnoses is failure to recognize that
a common cause of hypersensitivity is occlusal overload. A
tooth subjected to occlusal pounding or wiggling can be-
come extremely sensitive even though the pulp is vital. The
sensitivity can result from pulpal hyperemia or from the ef-
fects of non-carious cervical cracks. Coleman et al.16
showed that sensitivity to a measured puff of air at cervical
lesions was completely eliminated when occlusal equilibra-
tion corrected the occlusal overload. This is consistent with
our experience.
24 Part I Functional Harmony

Sore teeth
Compression of periodontal ligaments can be combined
with pulpal hyperemia to cause considerable soreness or
pain on biting. If empty mouth clenching causes any dis-
comfort in a tooth, it is an indication that the sore tooth is in
occlusal interference. It does not rule out other possible
causes for pain, but it is a definite indication that occlusal in-
terference is a factor.

Note: The simple clench test to determine if occlusion is a

cause of hypersensitivity or soreness in a tooth will elimi-
nate a misdiagnosed need for endodontic treatment in a sur-
prisingly large number of teeth that do not have radiographic
evidence of pathology.

Hypermobility
An early sign of occlusal disease is tooth hypermobility. It
can result in widened periodontal space and greater suscep-
tibility to periodontal disease. Patients are rarely aware of
mobility in teeth until later stages of bone loss, so every ex-
amination should include checking every tooth for signs of
mobility. All loose teeth should be evaluated to see if a de-
flective contact or occlusal overload is a factor.
 Chapter 3 Occlusal Disease 25

Split teeth and fractured cusps

A, Note the fracture lines that routinely develop when a cusp
incline interferes with strong occlusal forces (arrows). This
is a typical sign of occlusal disease that precedes cusp frac-
ture or split tooth (B).

Painful musculature
A common symptom of occlusal disease results from dishar-
mony between the occlusion and the TMJs. Deflective oc-
clusal interferences that require the jaw joints to displace to
achieve maximum intercuspation are a potent cause for
painful masticatory musculature. The term for this is occluso-
muscle disorder. Posterior teeth that are in interference also
are subject to occlusal overload that can cause excessive
wear, hypermobility, fractured cusps, and hypersensitivity.
Observing and resolving this condition early can often pre-
vent major problems of occlusal disease from developing.
26 Part I Functional Harmony

Other types of occlusal disease will be defined and dis- 5. Bodecker CF: Local acidity: a cause of dental erosion-abrasion.
cussed in the chapters that follow. It is important to under- Ann Dent 4(1):50-55, 1945.
6. Grippo JO: Abfractions: a new classification of hard tissue lesions
stand that diagnosis and treatment of all forms of occlusal of teeth. J Esthet Dent 3(1):14-19, 1991.
disharmony are dependent on the clinician’s knowledge of 7. Lee WC, Eakle WS: Possible role of tensile stress in the etiology
total masticatory system design and function. of cervical erosive lesions of teeth. J Prosthet Dent 52(3):374-380,
An all-too-common mistake is to overplay the role of 1984.
psychosocial stress as the primary factor in bruxism and 8. McCoy G: On the longevity of teeth. J Oral Implantology
11(2):248-267, 1983.
parafunction. Even if emotional factors are a dominant in- 9. Grippo JO, Masi JV: The role of biodental engineering factors
fluence, teeth must be in interference to jaw movements to (BEF) in the etiology of root caries. J Esthet Dent 39(2):71-76,
create attritional wear or tooth bending. Regardless of the 1991.
emotional state of the patient or the intensity of bruxism, oc- 10. Khan F, Young WG, Shahabi S, et al: Dental cervical lesions as-
clusal harmony must be established as a treatment goal. The sociated with occlusal erosion and attrition. Aust Dent J 44(3):
176-186, 1999.
chapters that follow are dedicated to explaining how this is 11. Whitehead SA, Wilson NF, Watts DC: Development of noncarious
accomplished. cervical notch lesions in vitro. J Esthet Dent 11(6):332-337, 1999.
12. Palamara D, Palamara J, Tyas MJ, et al: Effect of stress on acid
dissolution of enamel. Dent Mater 17(2):109-115, 2001.
References 13. Abrahamsen TC: The worn dentition—pathognomonic patterns of
abrasion and erosion. Int Dent J (4):268-276, 2005.
1. Lytle JD: Clinician’s index of occlusal disease: definition, recog- 14. Dzakovich JJ: In vitro reproduction of the non-carious cervical le-
nition, and management. Int J Periodontics Restorative Dent sion. Am Acad Rest Dent February 2006 (in press).
10(2):102-123, 1990. 15. Miller WD: Experiments and observations on the wasting of tooth
2. Abrahamsen TC: Occlusal attrition—pathognomonic patterns of tissue variously designated as erosion, abrasion, chemical abra-
abrasion and erosion. Presented at the American Academy of sion, denudation, etc. Dental Cosmos Jan, Feb, March (3 parts),
Restorative Dentistry, Chicago, February 1992. XLIX:1-23, 1907.
3. Grippo JO, Simring M, Schreiner S: Attrition, abrasion, corrosion 16. Coleman TA, Grippo JO, Kinderknecht KE: Cervical dentin hy-
and abfraction revisited: a new perspective on tooth surface le- persensitivity. Part III: resolution following occlusal equilibration.
sions. J Am Dent Assoc 135(8):1109-1118, 2004. Quintessence Int 34(6):427-434, 2003.
4. Grippo JO, Simring M: Dental “erosion” revisited. J Am Dent
Assoc 126(5):619-630, 1995.
 Chapter 4

The Determinants of Occlusion

PRINCIPLE
Neuromuscular harmony depends on structural harmony between the occlusion and the
temporomandibular joints.
Other documents randomly have
different content
sat thinking about him; but as she looked up and began to speak,
she saw that the tired old man could not answer; he was sound
asleep in his chair. The good ale had warmed and soothed him so
that she had not the heart to wake him. She resigned herself to
silence, but listened for footsteps, and to the ceaseless clink of
glasses and loud clatter of voices in the room beyond. The outer
door had a loud and painful creak, and for a long time she heard
nobody open it, until some one came to give a loud shout for
passengers who were intending to take the packet. Then there was
a new racket of departure, and the sound of the landlady angrily
pursuing some delinquent guest into the yard to claim her pay; but
still Mr. Davis slept soundly. The poor woman would be getting her
kitchen to rights now; presently it would be no harm to wake her
companion, and see if their business might not be furthered. It was
not late; they really had not been there much above an hour yet,
only the time was very slow in passing; and as Mary watched Mr.
John Davis asleep in his chair, his kind old face had a tired look that
went to her affectionate heart. At last she heard a new footstep
coming down the narrow stairway into the passage. She could not
tell why, but there was a sudden thrill at her heart. There was a
tumult in her breast, a sense of some great happiness that was very
near to her; it was like some magnet that worked upon her very
heart itself, and set her whole frame to quivering.

XLIV
THE ROAD'S END
"In sum, such a man as any enemy could not wish him worse than to be himself."

"I found him in a lonely place:

Long nights he ruled my soul in sleep:
Long days I thought upon his face."

After the packet went there were three men left in the kitchen, who
sat by themselves at a small table. The low-storied, shadowy room
was ill lighted by a sullen, slow-burning fire, much obscured by pots
and kettles, and some tallow candles scattered on out-of-the-way
shelves. The mistress of the place scolded over her heap of
clattering crockery and heavy pewter in a far corner. The men at the
table had finished their supper, and having called for more drink,
were now arguing over it. Two of them wore coats that were well
spattered with mud; the third was a man better dressed, who
seemed above his company, but wore a plausible, persistent look on
his sallow countenance. This was Dickson, who had been set ashore
in a fishing boat, and was now industriously plying his new
acquaintances with brandy, beside drinking with eagerness himself
at every round of the bottle. He forced his hospitality upon the
better looking of his two companions, who could not be made to
charge his glass to any depth, or to empty it so quickly as his mate.
Now and then they put their heads together to hear a tale which
Dickson was telling, and once burst into a roar of incredulous
laughter which made the landlady command them to keep silence.
She was busy now with trying to bring out of the confusion an
orderly supper for her patient guests of the parlor, and sent
disapproving glances toward the three men near the fire, as if she
were ready to speed their going. They had drunk hard, but the
sallow-faced man called for another bottle, and joked with the poor
slatternly girl who went and came serving their table. They were so
busy with their own affairs that they did not notice a man who
slipped into the kitchen behind them, as the Welshmen went out. As
the three drank a toast together he crossed to the fireside, and
seated himself in the corner of the great settle, where the high back
easily concealed his slight figure from their sight. Both the women
saw him there, but he made them a warning gesture. He was not a
yard away from Dickson.
The talk was freer than ever; the giver of the feast, in an
unwonted outburst of generosity, flung a shilling on the flagged floor,
and bade the poor maid scramble for it and keep it for herself. Then
Dickson let his tongue run away with all his discretion. He began to
brag to these business acquaintances of the clever ways in which he
had gained his own ends on board the Ranger, and outwitted those
who had too much confidence in themselves. He even bragged that
Captain John Paul Jones was in his power, after a bold fashion that
made his admiring audience open their heavy eyes.
"We 're safe enough here from that mistaken ferret," he
insisted, after briefly describing the ease with which he had carried
out their evening plans. "You might have been cooling your heels
here waiting for me the whole week long, and I waiting for my
money, too, but for such a turn of luck! If I did n't want to get to
France, and get my discharge, and go back to America as quick as
possible without suspicion, I'd tell you just where he landed, and put
him into your hands like a cat in a bag, to be easy drowned!"
 "He 's in Bristol to-night, if you must know," Dickson went on,
after again refreshing himself with the brandy; "we set him ashore
to ride there over Clifton Downs. Yes, I might have missed ye. He 's
a bold devil, but to-night the three of us here could bag him easy. I
've put many a spoke in his wheel. There was a young fellow aboard
us, too, that had done me a wrong at home that I never forgave;
and that night at Whitehaven I 've already told ye of, when I fixed
the candles, after I got these papers that you 've come for, I
dropped some pieces of 'em, and things that was with 'em, in my
pretty gentleman's locker. So good friends were parted after that,
and the whole Whitehaven matter laid to his door. I could tell ye the
whole story. His name's Wallingford, curse him, and they say he 's
got a taste o' your Mill Prison by this time that's paid off all our old
scores. I hope he 's dead and damned!"
"Who 's your man Wallingford? I 've heard the name myself.
There 's a reward out for him; or did I hear he was pardoned?"
asked one of the men.
"'T was a scurvy sort o' way to make him pay his debts. I'd
rather ended it man fashion, if I had such a grudge," said the other
listener, the man who had been drinking least.
Dickson's wits were now overcome by the brandy, hard-headed
as he might boast himself. "If you knew all I had suffered at his
hands!" he protested. "He robbed me of a good living at home, and
made me fail in my plans. I was like to be a laughingstock!"
The two men shrugged their shoulders when he next pushed
the bottle toward them, and said that they had had enough. "Come,
now," said one of them, "let's finish our business! You have this
document o' one Yankee privateersman called Paul Jones that our
principal 's bound for to get. You 've set your own thieves' price on
it, and we 're sent here to pay it. I 'm to see it first, to be sure
there's no cheat, and then make a finish."
"The paper 's worth more than't was a month ago," said
Dickson shrewdly. His face was paler than ever, and in strange
contrast to the red faces of his companions. "The time is come
pretty near for carrying out the North Sea scheme. He may have
varied from this paper when he found the writing gone, but I know
for a fact he has the cruise still in mind, and 't would be a hard blow
to England."
"'T is all rot you should ask for more money," answered the first
speaker doggedly. "We have no more money with us; 't is enough,
too; the weight of it has gallded me with every jolt of the horse. Say,
will you take it or leave it? Let me but have a look at the paper! I 've
a sample of their cipher here to gauge it by. Come, work smart, I tell
ye! You 'll be too drunk to deal with soon, and we must quick
begone."
Dickson, swearing roundly at them, got some papers out of his
pocket, and held one of them in his hand.
"Give me the money first!" he growled.
"Give us the paper," said the other; "'t is our honest right."
There was a heavy tramping in the room above, as if some one
had risen from sleep, and there was a grumble of voices; a door was
opened and shut, and steady footsteps came down the creaking
stair and through the dark entry; a moment more, and the tall figure
of a young man stood within the room.
"Well, then, and is my supper ready?" asked Wallingford,
looking about him cheerfully, but a little dazed by the light.
 There was a smothered outcry; the table was overset, and one
of the three men sprang to his feet as if to make his escape.
"Stand where you are till I have done with you!" cried the
lieutenant instantly, facing him. "You have a reckoning to pay! By
Heaven, I shall kill you if you move!" and he set his back against the
door by which he had just entered. "Tell me first, for Heaven's sake,
you murderer, is the Ranger within our reach?"
"She is lying in the port of Brest," answered the trapped
adventurer, with much effort. He was looking about him to see if
there were any way to get out of the kitchen, and his face was like a
handful of dirty wool. Outside the nearest window there were two
honest faces from the Roscoff boat's crew pressed close against the
glass, and looking in delightedly at the play. Dickson saw them, and
his heart sank; he had been sure they were waiting for Paul Jones,
half a dozen miles down shore.
"Who are these men with you, and what is your errand here?"
demanded Wallingford, who saw no one but the two strangers and
his enemy.
"None of your damned business!" yelled Dickson, like a man
suddenly crazed; his eyes were starting from his head. The landlady
came scolding across the kitchen to bid him pay and begone, with
his company, and Dickson turned again to Wallingford with a sneer.
"You 'll excuse us, then, at this lady's request," he said,
grinning. The brandy had come to his aid again, now the first shock
of their meeting was past, and made him overbold. "I 'll bid you
good-night, my hero, 'less you 'll come with us. There's five pounds
bounty on his head, sirs!" he told the messengers, who stood by the
table.
 They looked at each other and at Dickson; it was a pretty
encounter, but they were not themselves; they were both small-sized
men, moreover, and Wallingford was a strapping great fellow to
tackle in a fight. There he stood, with his hack against the door, an
easy mark for a bullet, and Dickson's hand went in desperation a
second time to his empty pocket. The woman, seeing this, cried that
there should be no shooting, and stepping forward stood close
before Wallingford; she had parted men in a quarrel many a time
before, and the newcomer was a fine upstanding young gentleman,
of a different sort from the rest.
"You have no proof against me, anyway!" railed Dickson. He
could not bear Wallingford's eyes upon him. His Dutch courage
began to ebb, and the other men took no part with him; it was
nothing they saw fit to meddle with, so far as the game had gone.
He still held the paper in his hand.
"You have n't a chance against us!" he now bellowed, in despair.
"We are three to your one here. Take him, my boys, and tie him
down! He's worth five pounds to you, and you may have it all
between ye!"
At this moment there was a little stir behind the settle, and
some one else stepped out before them, as if he were amused by
such bungling play.
"I have got proof enough myself now," said Captain Paul Jones
quietly, standing there like the master of them all, "and if hanging 's
enough proof for you, Dickson, I must say you 've a fair chance of it.
When you 've got such business on hand as this, let brandy alone till
you 've got it done. The lieutenant was pardoned weeks ago; the
papers wait for him in Bristol. He is safer than we are in England."
 Wallingford leaped toward his friend with a cry of joy; they were
in each other's arms like a pair of Frenchmen. As for Dickson, he
sank to the floor like a melted candle; his legs would not hold him
up; he gathered strength enough to crawl toward Wallingford and
clutch him by the knees.
"Oh, have pity on my sick wife and little family!" he wailed aloud
there, and blubbered for mercy, till the lieutenant shook him off, and
he lay, still groaning, on the flagstones.
The captain had beckoned to his men, and they were within the
room.
"Give me my papers, Dickson, and begone," he said; "and you
two fellows may get you gone, too, with your money. Stay, let me
see it first!" he said.
They glanced at each other in dismay. They had no choice; they
had left their pistols in their holsters; the business had seemed easy,
and the house so decent. They could not tell what made them so
afraid of this stern commander. The whole thing was swift and
irresistible; they meekly did his bidding and gave the money up. It
was in a leather bag, and the captain held it with both hands and
looked gravely down at Dickson. The other men stared at him, and
wondered what he was going to do; but he only set the bag on the
table, and poured some of the yellow gold into his hand.
"Look there, my lads!" he said. "There must be some infernal
magic in the stuff that makes a man sell his soul for it. Look at it,
Dickson, if you can! Mr. Wallingford, you have suffered too much, I
fear, through this man's infamy. I have doubted you myself by
reason of his deviltries, and I am heartily ashamed of it. Forgive me
if you can, but I shall never forgive myself.
 "Put this man out!" said the captain loudly, turning to his sailors,
and they stepped forward with amusing willingness. "Take him down
to the boat and put off. I shall join you directly. If he jumps
overboard, don't try to save him; 't were the best thing he could do."
Dickson, wretched and defeated, was at last made to stand, and
then took his poor revenge; he sent the crumpled paper that was in
his hand flying into the fire, and Paul Jones only laughed as he saw
it blaze. The game was up. Dickson had lost it, and missed all the
fancied peace and prosperity of the future by less than a brief half
hour. The sailors kicked him before them out of the door; it was not
a noble exit for a man of some natural gifts, who had undervalued
the worth of character.
The captain took up the bag of gold and gave it back to the
men. "This is in my power, but it is spies' money, and I don't want
such!" he said scornfully. "You may take it to your masters, and say
that Captain John Paul Jones, of the United States frigate Ranger,
sent it back."
They gave each other an astonished look as they departed from
the room. "There 's a man for my money," said one of the men to
the other, when they were outside. "I'd ship with him to-night, and I
'd sail with him round the world and back again! So that's Paul
Jones, the pirate. Well, I say here 's his health and good luck to him,
Englishman though I be!" They stood amazed in the dark outside
with their bag of money, before they stole away. There was nothing
they could do, even if they had wished him harm, and to-morrow
they could brag that they had seen a hero.
The mistress of the inn had betaken herself to the parlor to lay the
table for supper. Mr. Alderman Davis had just waked, hearing a fresh
noise in the house, and the lady was bidding him to go and look if
the captain were not already come. But he first stopped to give
some orders to the landlady.
The two officers of the Ranger were now alone in the kitchen;
they stood looking at each other. Poor Wallingford's face was aged
and worn by his distresses, and the captain read it like an open
book.
"I thank God I have it in my power to make you some amends!"
he exclaimed. "I believe that I can make you as happy as you have
been miserable. God bless you, Wallingford! Wait here for me one
moment, my dear fellow," he said, with affection, and disappeared.
Wallingford, still possessed by his astonishment, sat down on
the great settle by the fire. This whole scene had been like a play;
all the dreary weeks and days that had seemed so endless and
hopeless had come to this sudden end with as easy a conclusion as
when the sun comes out and shines quietly after a long storm that
has wrecked the growing fields. He thought of the past weeks when
he had been but a hunted creature on the moors with his hurt
comrade, and the tread of their pursuers had more than once jarred
the earth where their heads were lying. He remembered the dull
happiness of succeeding peace and safety, when he had come to be
wagoner in the harvest time for a good old farmer by Taunton, and
earned the little money and the unquestioned liberty that had
brought him on his way to Chippenham market and this happy
freedom. He was free again, and with his captain; he was a free
unchallenged man. Please God, he should some day see home again
and those he loved.
There was a light footstep without, and the cheerful voice of an
elderly man across the passage. The kitchen door opened, and shut
again, and there was a flutter of a woman's dress in the room. The
lieutenant was gazing at the fire; he was thinking of his mother and
of Mary. What was the captain about so long in the other room?
There was a cry that made his heart stand still, that made him
catch his breath as he sprang to his feet; a man tall and masterful,
but worn with hardships and robbed of all his youth. There was
some one in the room with him, some one looking at him in
tenderness and pity, with the light of heaven on her lovely face;
grown older, too, and struck motionless with the sudden fright of his
presence. There stood the woman he loved. There stood Mary
Hamilton herself, come to his arms—Heaven alone knew how—from
the other side of the world.

XLV
WITH THE FLOOD TIDE

"Swift are the currents setting all one way."

No modern inventions of signals of any kind, or fleet couriers, could

rival in swiftness the old natural methods of spreading a piece of
welcome news through a New England countryside. Men called to
each other from field to field, and shouted to strangers outward
bound on the road; women ran smiling from house to house among
the Berwick farms. It was known by mid-morning of a day late in
October that Madam Wallingford's brig, the Golden Dolphin, had got
into Portsmouth lower harbor the night before. Madam Wallingford
herself was on board and well, with her son and Miss Mary Hamilton.
They were all coming up the river early that very evening, with the
flood tide.
The story flew through the old Piscataqua plantations, on both
sides of the river, that Major Langdon himself had taken boat at once
and gone down to Newcastle to meet the brig, accompanied by
many friends who were eager to welcome the home-comers. There
were tales told of a great wedding at Hamilton's within a month's
time, though word went with these tales, of the lieutenant's forced
leave of absence, some said his discharge, by reason of his wounds
and broken health.
Roger Wallingford was bringing dispatches to Congress from the
Commissioners in France. It was all a mistake that he had tried to
betray his ship, and now there could be no one found who had ever
really believed such a story, or even thought well of others who were
so foolish as to repeat it. They all knew that it was Dickson who was
openly disgraced, instead, and had now escaped from justice, and
those who had once inclined to excuse him and to admire his
shrewdness willingly consented to applaud such a long-expected
downfall.
The evening shadows had begun to gather at the day's end,
when they saw the boat come past the high pines into the river bay
below Hamilton's. The great house was ready and waiting; the light
of the western sky shone upon its walls, and a cheerful warmth and
brightness shone everywhere within. There was a feast made ready
that might befit the wedding itself, and eager hands were waiting to
serve it. On the terrace by the southern door stood Colonel
Hamilton, who was now at home from the army, and had ridden in
haste from Portsmouth that day, at noon, to see that everything was
ready for his sister's coming. There were others with him, watching
for the boat: the minister all in silver and black, Major Haggens, with
his red cloak and joyful countenance, the good old judge, and
Master Sullivan, with his stately white head.
Within the house were many ladies, old and young. Miss Nancy
Haggens had braved the evening air for friendship's sake, and sat at
a riverward window with other turbaned heads of the Berwick
houses, to wait for Madam Wallingford. There was a pretty flock of
Mary Hamilton's friends: Miss Betsey Wyat and the Lords of the
Upper Landing, Lymans and Saywards of old York, and even the
pretty Blunts from Newcastle, who were guests at the parsonage
near by. It was many a month since there had been anything so gay
and happy as this night of Mary's coming home.
Major Langdon's great pleasure boat, with its six oarsmen, was
moving steadily on the flood, and yet both current and tide seemed
hindering to such impatient hearts. All the way from Portsmouth
there had been people standing on the shores to wave at them and
welcome them as they passed; the light was fast fading in the sky;
the evening chill and thin autumn fog began to fall on the river. At
last Roger and Mary could see the great house standing high and
safe in its place, and point it out to Madam Wallingford, whose face
wore a touching look of gratitude and peace; at last they could see a
crowd of people on the lower shore.
 The rowers did their best; the boat sped through the water. It
was only half dark, but some impatient hand had lit the bonfires; the
company of gentlemen were coming down already through the
terraced garden to the water-side.
"Oh, Mary, Mary," Roger Wallingford was whispering, "I have
done nothing that I hoped to do!" But she hushed him, and her
hand stole into his. "We did not think, that night when we parted,
we should be coming home together; we did not know what lay
before us," he said with sorrow. "No, dear, I have done nothing; but,
thank God, I am alive to love you, and to serve my country to my
life's end."
Mary could not speak; she was too happy and too thankful. All
her own great love and perfect happiness were shining in her face.
"I am thinking of the captain," she said gently, after a little
silence. "You know how he left us when we were so happy, and
slipped away alone into the dark without a word....
"Oh, look, Madam!" she cried then. "Our friends are all there;
they are all waiting for us! I can see dear Peggy with her white
apron, and your good Rodney! Oh, Roger, the dear old master is
there, God bless him! They are all well and alive. Thank God, we are
at home!"
They rose and stood together in the boat, hand in hand. In
another moment the boat was at the landing place, and they had
stepped ashore.

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