JA D A

R e v ie w A r t ic l e

There are m any approaches to occlusal

adjustment, but some may be more
effective than others.

A critical evaluation of occlusal therapy:

occlusal adjustment procedures

Glenn T. Clark, DDS, MS

Robert C. Adler, DMD

O cclusal therapy involves any dental

procedure that changes occlusion. These
procedures commonly include orthodon­
tic treatment, orthognathic surgery, fixed Fig 1 ■ Sagittal plane diagram of various envelope of motion patterns resulting
and removable prosthetic therapy, as well from different occlusal contact schemes. Left, normal pattern showing small slide
as occlusal adjustment therapy. Occlusal from retrusive contact position (RCP) to intercuspal position (ICP); middle, point
adjustment therapy or “coronoplasty” is a contact centric relation without any difference between RCP and ICP; and right,
procedure of selective coronal tooth mod­ long-centric or area-of-centric with freedom of movement between RCP and ICP
ification.1-3 This reshaping of the teeth is but without a change in vertical dimension of occlusion. (From Carranza, F., ed.
Clinical periodontology, ed 6. Philadelphia, W. B. Saunders Co, p 79, Fig 5-13.
performed on one or more teeth. The
Reprinted by permission of the W. B. Saunders Co.)
coronoplasty procedure is usually done
by selective removal of enamel and usu­
ally does not produce dentinal sensitiv­
ity. The goal of occlusal adjustment pro­
cedures is to achieve a stable, nontrauma- justment therapy has even been done to in maximum intercuspation, the excur­
tic occlusal contact relationship between protect the TMJ from excessive wear and sive guidance scheme, and the occlusal
the maxillary and mandibular teeth in tear.11,18'20 In fact, dentists have claimed contact scheme. Two distinct theories are
maximum intercuspation and in all func­ that disk condyle displacements and re­ used to explain the rationale behind oc­
tio n al e x cu rs iv e c o n ta c t p o sitio n s. modeling changes produced by adverse clusal adjustment therapy: the traumatic
Another requirement of the adjustment TMJ loading can be prevented and even tooth contact theory and the avoidance of
procedure is that the temporomandibular reversed by stabilizing and improving an tooth contact theory. In addition to these
joint (TMJ) be stable in the position of unstable or incorrect mandibular posi­ theories, the “behavioral or placebo ef­
maximum intercuspation.4,5 tion.21'28 In addition, several claims have fect” of occlusal adjustment therapy must
For many years, the dental profession been made that an occlusal adjustment also be considered. This paper discusses
has believed that there is a strong rela­ can reduce noxious or harmful dental in­ these various techniques and theories and
tionship between occlusal stability, man­ put, thereby improving neuromuscular reviews experimental evidence regarding
dibular function, and TMJ health.6 14 Den­ function (reduce muscle hyperactivity occlusal interferences, but does not dis­
tists have claimed that occlusal adjust­ and bruxism).11'13,14,29'34 cuss the rationale or experimental evi­
ment procedures can improve mastica­ Several techniques of occlusal adjust­ dence underlying other types of occlusal
tory function and reduce individual tooth ment are advocated that differ in three therapy (that is, orthognathic surgery, or
trauma.15 17 In some cases, occlusal ad­ major ways: the position of the mandible orthodontic or prosthetic treatment).

JADA, Vol. 110, May 1985 ■ 743

REVI EW ART I CLE

tored EMG activity levels and tooth con­

tact via intraoral radio transmitters, and
compared canine rise versus group func­
tion guidance. They reported no signifi­
cant difference in muscle activity for
either excursive guidance scheme. In a
study of 50 adult patients, Ingervall46 ex­
amined the functional (working side) and
nonfunctional (balancing side) contacts
in a 3-mm lateral excursion position.
Overall, there was no significant differ­
ence between the two groups. Ingervall,
surprisingly, found that 85% of the sub­
jects had balancing side molar contacts,
and only 18% had pure, unilateral canine
rise, with only 2% having this pattern
bilaterally. Overall for the adults, the
Fig 2 ■ Figure represents three typical excursive guidance contact schemes: left, most common working side teeth in con­
canine guidance; middle, canine segment guidance; and right, group guidance tact were the canines (40%), followed by
on working side. the first premolars (20%) and first molars
(10%). The most common pattern, there­
fore, might be characterized as canine
segment guidance (the canine plus one or
two adjacent teeth).
Methods of occlusal adjustment
the terminal hinge arc of closure as the
M andibular position optimal maxillomandibular reference po­ Occlusal contact schem e
sition, is not considered. One approach
The “centric relation” approach to occlu­ uses certain skeletal, alveolar, and dental Stuart and Stallard8 advocated a posterior
sal adjustment gained prominence when landm arks to re p o sitio n the ja w .40 tooth-to-tooth contact pattern that was
McCollum and Stuart35,36 advocated posi­ Another technique uses radiography of characterized by tripodal cusp contacts.
tioning the mandible in the terminal the joint to position the condyle in an as­ In theory, a tripodal contact arrangement
hinge arc of closure. Schuyler,1,2 and later sumed optimal location.19,41 A third ap­ is stable but difficult to achieve clinically.
Mann and Pankey,9 advocated a slightly proach advocates applying external elec­ Another difficulty with the tripod ar­
different approach to mandibular posi­ trical pulses to the preauricular region to rangement is that, to fulfill the stability
tion. They used the terminal hinge posi­ find a new jaw position.42 This latter factor, the practitioner has to assume that
tion as a reference point but allowed for a method is highly disputed in that it as­ the patient can function comfortably from
small amount of forward or protrusive sumes that the jaw closure produced by a single “point centric” starting position.
movement in the horizontal plane with­ electrical stimulation of the trigeminal One research paper38 on occlusal contact
out a change in the vertical dimension37 motor nerve is a p h ysiologic neuro­ patterns suggested that most people func­
(Fig 1). This commonly used approach muscular position.43,44 A fourth and more tion within an “area” of centric relation
became known as the “freedom in cen­ common method uses various types of rather than a single point. This implies
tric” or long centric concept. The neces­ intraoral appliances to experimentally that in a precisely tripoded case, most pa­
sary am ount of n atu rally o ccu rrin g locate a more functional jaw position be­ tients will eventually create a slight area
buccolingual and mesiodistal “freedom fore stabilizing the occlusion in the “ap­ of movement by enlarging the occlusal
in centric” has been measured.38 There is, pliance determined” position.45 contact scheme with wear facets. Several
h ow ev er, a co n tin u in g co n tro v ersy authors1,2,8,11 have advocated the “free­
among experts as to which mandibular Excursive gu id a n ce schem e dom in centric” concept as an approach
position is more biologically accept­ that allows more practical cusp tip-to-
able.39 McCollum35 was also one of the first to open-fossa or marginal ridge occlusal
Spot grinding is not usually described advocate adjusting and restoring the oc­ contact patterns, rather than the poten­
as a separate technique. This widespread clusion to achieve a fully balanced guid­ tially more “ lock ed -in ” tripodal ar­
method of occlusal adjustment therapy is ance scheme in all excursive movements. rangement.
done in an existing maximum inter­ This concept was later criticized because, In summary, it should be obvious that
cuspation position. As this approach does as e x cu rsiv e co n ta c t p attern s were as so many different approaches exist,
not advocate any particular change in analyzed by dental investigators, obser­ there is no universally accepted “ideal”
mandibular position, it means adjusting vations of unrestored natural dentitions jaw position requisite to normal jaw func­
only those teeth that appear to be in did not support the widespread applica­ tion. Furthermore, abetter understanding
heaviest contact to distribute the occlusal tion of the balanced guidance concept.46 of what is physiologically normal and
load over more teeth. The technique is A more clin ically realistic guidance what is an acceptable range of normal po­
usually done without external manipula­ scheme is the canine rise (guidance) or sition regarding these factors is neces­
tion of the jaw, and it assumes that the pa­ even the unilateral working side group sary before definitive approaches to oc­
tient has an acceptable and reproducible guidance (group function) scheme (Fig clusal therapy can be applied. Compara­
maxillomandibular relationship. 2).8 Historically, there has been a debate tive studies are necessary to determine
Several other less common methods for as to which lateral guidance scheme is the efficacy of one occlusal approach over
determining the “ correct” mandibular more “natural” and, therefore, more ac­ another before a definitive statement can
position before an occlusal adjustment ce p ta b le .47 D ’A m ico 48,49 a d v o cated be made with regard to technique. Fi­
have been advocated. These less common canine rise and substantiated his argu­ nally, as a result of this review, it was
methods differ from earlier methods in ment with an extensive study. Adams and found that patients must be carefully ex­
that maximum intercuspation, or even Zander50 and Butler and Zander51 moni­ amined to see if their existing mandibular

744 ■ JADA, Vol. 110, May 1985

 REVI EW ARTI CLE

position, excursive guidance scheme, in d ication s for o cclu sal adjustm ent
and contact scheme are acceptable. If not, therapy.
occlusal changes should be kept to a
minimum and the existing dentition and Avoidance of tooth contact theory
jaw position used as a guide for the neces­
This theory is based on the concept that
sary dental restorative procedures.
occlusal contact relationships can be per­
ceived as noxious by the trigem inal
Traumatic occlusal contact theory neurosensory system .64 Further, this
theory proposes that the neuromuscular
This theory has two goals: adjustment of system that controls jaw movements will
the occlusion to remove forceful contacts adapt and develop patterns of mandibular
from individual teeth, and adjustment to movement to avoid these points of noxi­
distribute the tooth contact forces in a ous tooth contact.21 This differs some­
Fig 3 ■ Testing tooth for fremitus is done by placing s ta b le , i n t e r f e r e n c e -f r e e o c c lu s a l what from the previous theory in that the
finger against tooth. Patient is asked to firmly tap
scheme.4,5 This procedure is designed to primary effect of the “adverse or noxious”
♦eeth together and grind side-to-side and forward.
Increased movement or vibration on one tooth is evi­
reduce or eliminate harmful local effects tooth contact is at a peripheral level in­
dence of fremitus. of traumatic occlusion. The criterion that volving reflex and accommodative mus­
determines if a tooth is in a traumatic con­ cular behaviors.65,66 Mandibular muscle
tact relationship is based on clinical evi­ activity has been studied after artificial
dence of dental or periodontal (or both) occlusal interferences have been placed
inju ry. T h ese inju ries can p rodu ce in both centric and lateral excursive posi­
cracked or fractured teeth, pulpitis, pul- tions.64,6776 These studies have looked at
pal degenerative changes, tooth mobility, postural activity levels, chewing pat­
and traumatic alveolar-periodontal pain terns, motor coordination with chewing
(Fig 3-6). and other movements, and nocturnal ac­
Much research has shown the damag­ tivity indicative of bruxism.51,64,67,69,77'89
ing effects of a traumatic occlusal contact
on the periodontium.15'17,52’57 Anderson Postural m uscular activity and centric
and Picton58 measured the load on a tooth contact in terferen ces
covered by a removable crown in which
the occlusal surface was 0.5 mm higher Changes in postural muscle activity have
than the adjacent tooth surfaces. A strain been shown, using electromyographic
Fig 4 ■ Illustration of one method of testing teeth for gauge measured the load and showed that (EMG) analysis before and after experi­
mobility. Mobility greater than 1 mm is possible sign it was twice the normal level. In another mental premature occlusal centric con­
of occlusal trauma. study, Picton59 experimentally placed a tacts were placed on a tooth.76 In eight
premature contact on a tooth to produce a subjects, Randow and others72 experi­
vertical and horizontal load on the tooth. mentally placed a “high” gold onlay on
He found an aseptic necrosis and remod­ occlusal surfaces of mandibular molars,
eling of the periodontium in an attempt to approximately 0.25 mm above the con­
accommodate the new load demands. tacting plane. They found increased
These studies and others60,61 have asymmetric postural muscle activity, and
shown that excessive occlusal forces can these higher activity levels remained ele­
cause enough pressure on the periodon­ vated until the interference was removed.
tium to decrease the blood flow to this This study also discussed, but did not
structure, thereby causing periodontal measure, a disturbed mandibular coordi­
d am ag e. O rb an 62 and W e in m a n n 63 nation. The eight subjects in this study
microscopically examined several hard had TMJ tenderness, clicking, and muscle
and soft tissue specimens that had evi­ tenderness as a result of the occlusal in­
Fig 5 ■ Presence or absence of occlusal contact can
be tested by using thin Mylar strips (.0005/inch). dence of traum atic occlusion (tipped terference.
Strip is held by hemostat and placed between teeth teeth and extrusion of teeth into opposing Funakoshi and others73 studied the
being tested. Patient is asked to “close and hold.” If edentulous spaces). They showed such electromyographic activity of three sub­
strip cannot be removed, there is positive occlusal responses as inflammation of the peri­ jects in whom a 0.3-mm experimental
contact between those teeth. odontal space, an interrupted lamina high restoration was placed on second
dura, cem entum hyperplasia, hem or­ molars. They concluded that an unbal­
rhage, necrosis of the periodontal mem­ anced postural muscle activity resulted
brane, and some bone resorption. Orban62 from the occlusal interferences. Further,
believed that the cause of these problems when this interference was reduced, the
was directly linked to traumatic tooth activity levels returned to a normal, bal­
contacts. anced level. Ramfjord67 was one of the
In summary, occlusal interferences first investigators to demonstrate a reduc­
(centric and excursive) that are constantly tion in postural EMG levels after occlusal
contacting in an adverse or forceful man­ adjustment. Ramfjord examined 34 pa­
ner have shown a traumatic effect on the tients who had bruxism and made EMG
investing periodontal tissues of the tooth. recordings of the masseter and temporal
In this regard, any iatrogenically induced muscles while the mandible was in the
“interferences” should be considered rest position, while the teeth were lightly
harmful. The local dental and perio­ tapped together, in various lateral excur­
Fig 6 ■ Advanced attrition indicative of bruxism is dontal-osseous effects of traumatic tooth sions, and in a chewing exercise. The oc­
evident on incisal edges of guiding teeth. contacts are generally well accepted as clusion was adjusted to eliminate inter-

Clark-Adler : EVALUATION OF OCCLUSAL THERAPY ■ 745

REVI EW ARTI CLE

tivity levels until the amalgam was re­ jaw pain or dysfunction. Williamson and
moved (Fig 7). Lundquist,87 in a paper on anterior guid­
> A - Before versus 48 hours after ance, showed that by using a bite appli­
Excursive in terferen ces and ance, less muscle activity was generated
B - Before versus 1 week after
3.0 postural m uscle activity without posterior tooth contact. Whether
jaw closing muscle activation is signifi­
2.5- Several investigators have looked at the cantly reduced with canine guidance ver­
effect of an excursive interference that sus group function has yet to be shown
2.0 - disrupted normal guidance but was not with natural dentitions.
“high” in the maximum intercuspation Overall, research shows increased
1.5 position.70,74 Ingervall and Carlsson71 levels of postural EMG activity levels are
studied temporal and masseter postural quite evident when a high crown or fill­
1.0 muscle activity in 25 patients with and ing disrupts the occlusal contact scheme.
without naturally occurring excursive There seems to be enough evidence to
0.5 interferences. Of the 25 patients exam­ state that occlusal contacts that disturb
ined, 13 had unilateral balancing inter­ maximum intercuspation cause an altera­
0 ferences. The 12 who had no interfer­ tion in postural activity and mandibular
A B A B ences served as the control group. EMG m ovem ent response in the stom ato-
Temporalis Masseter recordings were made of the temporal gnathic system. This response, however,
and masseter muscles. Occlusal adjust­ is not always absolute or permanent.
Fig 7 ■ Mean differences in postural EMG ac­ ment was performed on the 13 patients Some successful adaptation to the altered
tivity levels of both right and left anterior tem­ with the interferences so that the jaw was state, in some instances, may not require
poralis and masseter muscles after experi­ in the retruded contact position and there any type of corrective procedure.64 Con­
mental occlusal interference was placed. Mas­ were no lateral interferences. They con­ versely, research on lateral interferences
seter muscles do not show statistical difference cluded that the subjects with naturally that do not disrupt m axim um inter­
in activity levels, but temporalis muscles were
occurring excursive interferences did not cuspation, but are only “high” in an ex­
significantly affected by interference.76
have elevated postural activity levels or cursive movement, shows little definitive
bite force levels, but did have altered evidence of significant changes in jaw
chewing cycles (Fig 8, 9). They also function.
suggested that balancing side interfer­
ences make more of a difference in muscle Chew ing pattern studies
ferences, defined in this case as any slide activity levels than working side interfer­
between terminal hinge closure occlusal ences. In addition to those already mentioned,
c o n ta c t p oin t and m axim um in ter- Schaerer and Stallard69 placed balanc­ several studies have directly examined
cuspation. Ramfjord then repeated the ing interferences in four subjects and the effect of occlusal interferences on the
EMG recordings after the occlusal ad­ noted that the only change was that these chewing cycle.69,89,90 Because abnormal
justment, and the results showed that all teeth touched more often. There was no chewing patterns and chewing cycle du­
34 patients had lower postural EMG activ­ change in the number of chewing strokes ration have been related to occlusal inter­
ity. Finally, Riise and Sheikholeslam76 or the overall pattern of the chewing cy­ ferences, several investigators have mea­
experimentally placed an amalgam on the cle. Graf and Zander68 also studied the ef­ sured EMG levels during chewing activ­
occlusal surface of a maxillary right first fects of experimentally placed balancing ity and concluded that the greater the du­
molar that was 0.5 mm above the occlusal interferences in five subjects, and again ration of the chewing strokes, the more
surface. They found increased postural showed an increased tendency for these unstable the occlusion. Butler and Zan­
muscle activity, pain as early as 1 hour teeth to contact during chewing but with­ der51 placed small radio transmitters in
after insertion, and generally higher ac­ out significant clinical effect regarding fixed partial dentures, and designed an

Fig 8 ■ Median of maximal mean voltage of anterior temporalis muscle be­ Fig 9 ■ Median for number of chewing cycles and duration of chewing
fore (B), after (C), and at follow-up (D) of subjects with occlusal interference cycle while chewing bread. Control group (A), and experimental group be­
who underwent occlusal adjustment. In all instances, experimental group’s fore (B), after occlusal adjustment (C), and at follow-up (D). No statistical
EMG activity is lower than that of control group (A).71 differences were evident.71

746 ■ JADA, Vol. 110, May 1985

 REVI EW ARTI CLE

occlusal scheme with lateral canine dis- coordination, and, at other times, “un­
clusion. Surface electrodes were placed conscious” behavior will cause a grind­
over the masseter and temporalis mus­ ing away of this contact.97 According to
cles, and the subjects were instructed to this theory, tooth grinding behavior
chew a piece of white bread while the re­ U b (bruxism) occurs during periods of stress
cordings were being made. The EMG rec­ 2 o or great concentration and sleep.98'101
U JS
ords disclosed no silent periods and no Bailey and Rugh102 conducted unilat­
excessive levels of muscle activity, which eral EMG recordings of the masseter mus­
£> 15-
demonstrated that the chewing cycle is a •5 cle of nine patients with bruxism. The re­
passive action provided that the occlusal cordings were taken before, during, and
scheme is a physiologic one. Schaerer after occlusal adjustment and disclosed
and others89 made partial dentures with no significant reduction in bruxism in
balancing interferences for three subjects. eight of nine patients. Kardachi and
The EMG levels consistently showed si­ others103 measured nocturnal masseter
lent periods when the balancing side was EMG levels on four patients with bruxism
in contact but no silent period when only before, during, and 3 months after an oc­
g
working contacts were made. Z clusal adjustment.103 In another two sub­
The issue of reflex actio n (silen t jects with bruxism, the authors performed
periods) taking place with occlusal inter­ the same recordings but used a mock
Before During After
ferences is still unresolved.91,92 Storey64 equilibration for treatment. No signifi­
points out that the mandible is capable of Fig 10 ■ Mean values of nocturnal EMG activ­ cant differences in the EMG levels of any
compensating for some interferences by ity of masseter muscle before, during, and after of the groups were found.
moving away from the contact and can do placement of crown with deflective occlusal Rugh and others104 placed deflective
so without producing a noxious reflex re­ contact. Unexpected finding was that nine of molar occlusal interferences in ten pa­
ten subjects showed significant decrease in
sponse. Therefore, what constitutes a tients (Fig 10). They monitored the level
masseter activity after placement of experi­
malocclusion requiring some type of ad­ of nocturnal masseter muscle activity for
mental prematurity (n = 10).104
justment procedure may depend on the at least ten nights before, during, and after
severity of the interference rather than the the placement of the interference. This
mere existence of it. The jaw can ade­ study showed no relationship between
quately adapt to abnormal occlusal con­ occlu sal interferences and increased
tacts and, as Storey points out, only those was related to an avoidance of a noxious , levels of bruxism. Several of these sub­
contacts that produce a “noxious reflex or painful tooth contact. The conclusion jects did, however, have some mild uni­
response” should be treated. Unfortu­ was that the jaw can “fine tune” the lateral muscle tenderness, TMJ tender­
nately, a “noxious reflex response” is not movement patterns to avoid premature ness, and mobility on the tooth with the
clearly defined at present. contacts. It must be remembered that interference.
m andibular incoord ination can and Overall, these studies appear to provide
Motor coordination studies probably does occur for many other rea­ significant support to the fact that noc­
sons besides tooth contact avoidance. turnal bruxism is probably not related to
Another clinical criterion used to deter­ This study, however, did not pass judg­ occlusal interferences. It is important to
mine if a tooth contact relationship is ment as to whether these prematurities realize that when an experimentally in­
producing avoidance behavior in the needed to be corrected. In another study, duced disruption in the occlusal scheme
mandibular motor system is based on the Crispin and others94 studied 26 subjects occurs, symptoms appear at the tooth
presence or absence of mandibular coor­ who underwent pantographic recordings level (mobility or tooth pain), at the joint
dination. Mandibular incoordination is to establish their reproducibility score. level (joint soreness or clicking), and at
the inability to make specific, directed This score was verified by using panto- the muscle level (muscle tenderness,
mandibular movements in a smooth fash­ graphic recordings that were numerically changes in the chewing cycle, and pos­
ion. Exam ples of mandibular incoor­ segmented to develop a pantographic tural activity). These effects may be tran­
dination include the inability or diffi­ reproducibility index (PRI).95,96 The sient in many situations, or they may
culty in making a lateral jaw movement higher the score, the less reproducible the theoretically contribute to a chronic mus­
from intercuspal position with the teeth tracing. Five subjects whose tracings cu lo s k e le ta l c o n d itio n . R ugh and
in light contact, and the inability or diffi­ were reproducible and ten whose tracings others104 postulated on mechanisms by
culty in closing firmly, rapidly, and accu­ were nonreproducible were placed in two w hich these effects are m ediated by
rately into a repeatable intercuspal posi­ control groups. The remaining 11 sub­ suggesting that a disruption of chewing
tion. jects with nonreproducible tracings be­ patterns, an altered distribution of occlu­
Gibbs and others91,93 attached a record­ came the experimental group, receiving sal forces, and a change in mandibular
ing device to the maxilla and mandible of occlusal splint therapy and occlusal ad­ postural positions may all result when an
seven subjects. The apparatus allowed justments. The two control groups re­ interference is placed into the occlusal
simultaneous recording of jaw movement ceived no treatment. All of the experi­ scheme. The clinical significance of these
in all three planes. The jaw movements mental subjects ended up with a consis­ changes, however, requires further study.
were traced to see how the jaw functioned tent, reproducible score confirming the In summary, occlusal interferences,
in typical chewing patterns. Two of the value of follow-up occlusal adjustment as usually iatrogenic, that disrupt the exist­
subjects had m alocclusion and their part of the treatment approach. ing contact pattern of maximum inter-
chewing patterns were classified as atyp­ cuspation have had an immediate effect
ical. These subjects did not function in Bruxism studies on postural muscle activity, thereby pro­
the retruded position, but rather anterior ducing an abnormal asymmetric activity
to it. Further, the opening, closing, and Another, more controversial, variation of pattern. This response may account for
protrusive jaw movement patterns were the avoidance theory is that a noxious some of the painful clinical myalgia
also inconsistent. The authors postulated tooth contact will be avoided some of the (muscle pain) symptoms that patients
that this mandibular movement disability time, thereby producing mandibular in­ have after a new restoration is placed.

Clark-Adler : EVALUATION OF OCCLUSAL THERAPY ■ 747

REVI EW ART I CLE

lem.106,107 Kopp108 examined two groups function with meprobamate and aspirin
of patients with occlusal interferences (Fig 14). The subjects were also asked to
7 5 -, and mandibular dysfunction along with rate their symptoms on a scale before and
clinical signs of TMJ problems (crepitus, after treatment. The patients were treated
tenderness, or both) (Fig 12 ,1 3 ). The sub­ with a nonocclusal therapeutic approach
jects were examined three different times. and both the symptoms and occlusogram
The first visit consisted of counseling evaluation greatly improved. This study
50-
each person about the probable cause and sh o w e d th e p o w e rfu l e ffe c t of
g prognosis of the problem. They were told nonocclusal treatment on symptoms of
E/3
d to chew carefully and avoid painful pain and dysfunction in the jaw and
movements. The second visit appor­ suggested that abnormal occlusal contact
tioned the patients into two groups so that sounds are an effect, not a cause, of these
one group received occlusal adjustment symptoms.
to a retruded jaw position or within 1 mm, In addition to nonspecific treatment
and the other group received no treat­ factors (placebo effects), the positive re­
ment. The third visit consisted of a sponses seen after occlusal adjustment
0j—müüiü----- follow-up examination. Kopp’s conclu­ could also be the result of the adjustment
Total/near total No remission sion was that the combination of counsel­ changing the dental contact relationship.
remission ing and occlusal therapy was better than As most adjustments improve the me­
counseling alone, but that psychologic chanical force distribution of tooth con­
Fig 11 ■ Treatment results of patients with factors are important in treating this prob­ tact, occlusal adjustment therapy will
MPD after undergoing mock (placebo) equili­ lem as the nonadjusted group also re­ serve, at least transiently, to make the pa­
bration as treatment; 64% reported total or sponded well. tient aware that his or her bite is more
near total relief of symptoms as result of treat­
Edmiston and Laskin106 compared the comfortable. If the patient becomes more
ment (n = 25).105
sound produced by forceful closure occlusally aware because of changes in
(occlusograms) before and after treatment oral-occlusal tactile stim ulation, this
of patients with myofascial pain and dys­ awareness may serve to alter abnormal
These interferences also have been shown
to produce dysfunctional joint symptoms
(that is, clicking) in some subjects.
Less significant are those interferences
that disturb the excu rsive guidance
scheme as they do not apparently disturb
postural muscle activity or significantly
alter chewing cycle patterns. This is not
to say that a relationship has not been
shown between occlusal contact schemes
and ch ew ing cy cle. These findings
showed only that balancing interferences
do not have a powerful influence on this
complex behavior. Regarding avoidance
of occlusal interferences, it can be shown
that mandibular movement patterns are
influenced by occlusal changes but how
significantly these movement distur­
bances relate to clinical problems is not Improved No change Worse
known. They simply may be accommoda­ Fig 12 ■ Treatment result scores derived from Helkimo Index. Scores show
tive behaviors without significant clini­ change in level of mandibular dysfunction after counseling (n = 30).108
cal relevance. Further, no significant evi­
dence has correlated nocturnal muscle
activity levels (thought to be indicative of
bruxism) and occlusal interferences.

The placebo effect

A lthough the previous two theories
(traumatic tooth contacts and avoidance
of tooth contacts) are the more commonly
used, many researchers have failed to
consider the behavioral effect of occlusal
adjustment when reporting their results.
Goodman and others105 have shown a
64% reduction in subjective symptoms
after two mock equilibration (grinding on Improved No change Worse
nonocclusing surfaces) sessions (Fig 11).
Fig 13 ■ Treatment result scores derived from Helkimo Index for mandibular
Several other investigators have found
dysfunction patients. Treatment group was treated first with counseling, then
this nonmechanical component to be a with occlusal adjustment. Control group was treated only with counseling (n =
significant factor in the accurate assess­ 15).108
ment and treatment of the patient’s prob­

748 ■ JADA, Vol. 110, May 1985

 REV I EW ART I CLE

turer, section of gnathology and occlusion, School of

Dentistry, University of California, Los Angeles,
90024. Address requests for reprints to Dr. Clark.
Poor1"I
1. Schuyler, C.H. Fundamental principles in the
Severe5 -
correction of occlusal disharmony, natural and artifi­
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750 ■ JADA, Vol. 110, May 1985