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Occlusion for fixed prosthodontics:

A historical perspective of the

gnathological influence
Paul H. Pokorny, DDS, MSD,a Jonathan P. Wiens, DDS, MSD,b
and Harold Litvak, DMD, MSDc
University of Detroit Mercy School of Dentistry, Detroit, Mich;
New York University College of Dentistry, New York, NY
This article addresses the historical perspective of the gnathological influence upon the concepts of occlusion for
fixed prosthodontics. A critical assessment and subsequent scientific validation of occlusal theories require an un-
derstanding of their evolution in the formative years and the subsequent development of effective models for clinical
practice. While gnathological concepts offer a structured methodology for prosthodontic procedures, further research
is needed to corroborate current occlusal treatment approaches. This review focuses on the “classic” fixed prosth-
odontic literature and the currently available scientific literature involving fixed prosthodontic dentate occlusion and
gnathology. A MEDLINE search was performed to identify English-language peer-reviewed publications spanning the
last 56 years, along with an extensive hand search for years prior. Electronic searches of the literature were performed
in MEDLINE using the key words: case series, clinical trials, cohort studies, fixed partial denture occlusion, dental oc-
clusion, dental occlusion research, centric relation, incisal guidance, maximal intercuspation, occlusal vertical dimen-
sion, and occlusion, in various combinations to obtain potential references for review. A total of 10,382 English-lan-
guage nonduplicate titles were obtained for 1950-2006 for the key words “dental occlusion.” Other key word searches
produced smaller numbers of articles, many of which were duplicates due to multiple searches and were subsequently
eliminated. Manual hand searching of the MEDLINE reference list and other journals of interest was performed to
identify any articles missed in the original search. Articles were included for review if they contained emerging occlusal
theories, new technologies, or occlusal studies that included multiple subjects in contrast to case reports. (J Prosthet
Dent 2008;99:299-313)

The recognition of gnathological its subsequent scientific validation, obtain potential references for review.
concepts, which began in the 20 th which is the aim of this paper. Select A total of 10,382 English-language
century, may have reached its greatest literature, both supporting and con- nonduplicate titles were obtained for
penetration in predoctoral education trasting, is highlighted. 1950-2006 for the key words “dental
in the 1970s. Since then, there has A MEDLINE search was per- occlusion.” Other key word searches
been an apparent attenuation as a formed to identify English-language produced smaller numbers of articles,
result of the reduction of predoctoral peer-reviewed publications spanning many of which were duplicates due
prosthodontic education and by its the last 56 years, along with an exten- to multiple searches and were sub-
integration into other disciplines. sive hand search for years prior. Elec- sequently eliminated. Manual hand
An understanding of occlusion tronic searches of the literature were searching of the MEDLINE reference
must be based on knowledge of the performed in MEDLINE using the list and other journals of interest was
physiology of the masticatory system key words: case series, clinical trials, performed to identify any articles
and insight into its functional geom- cohort studies, fixed partial denture missed in the original search. Articles
etry and dysfunctional adaptations.1-5 occlusion, dental occlusion, dental were included for review if they con-
A critical assessment requires a review occlusion research, centric relation, tained emerging occlusal theories,
of the historical evolution surround- incisal guidance, maximal intercuspa- new technologies, or occlusal stud-
ing the concepts and theories of oc- tion, occlusal vertical dimension, and ies that included multiple subjects in
clusion in the formative years and occlusion, in various combinations to contrast to case reports.

Presented at the Academy of Prosthodontics annual meeting, Niagara Falls, Ontario, May, 2004.

Clinical Professor, University of Detroit Mercy School of Dentistry.
Clinical Professor, University of Detroit Mercy School of Dentistry.
Clinical Professor, New York University College of Dentistry.
Pokorny et al
300 Volume 99 Issue 4
History of gnathology or interferences with a loss of cen- the condyle by using an anatomically
tric-related closure. Patients noted aligned lateral transcranial temporo-
Stallard first coined the term gna- that their masticatory freedom was mandibular joint (TMJ) radiographic
thology in 1924, defining it as the sci- lost and it caused them to bite their technique so that interpretations
ence that relates to the anatomy, his- cheeks and tongue. could be made. When radiographs
tology, physiology, and pathology of of the TMJs were made with the pa-
the stomatognathic system and that Fundamentals of gnathology tients’ mandible in the maximal in-
includes treatment of this system on tercuspal position, the investigators
the basis of examination, diagnosis, The fundamentals of gnathol- believed that deflective occlusal con-
and treatment planning. McCollum6 ogy include the concepts of centric tacts would displace the position of
formed the Gnathological Society relation, anterior guidance, occlusal the condyle within the glenoid fossae
in 1926 and, along with Harlan, is vertical dimension, the intercuspal asymmetrically, either anteriorly, pos-
credited with the discovery of the design, and the relationship of the de- teriorly, or superiorly.13-16
first positive method of locating the terminants of mandibular movements This observation may be measured
transverse horizontal axis and trans- recorded using complex instrumenta- quantitatively and used as a diagnos-
ferring the recording to an articulator tion to the occlusion in fixed prosth- tic aid along with the clinical evalua-
using components from a Snow Face- odontics. These fundamentals were tion and occlusal analysis of mounted
bow. The Gnathological Society grew reported in Principles of Occlusion by diagnostic casts. A pre- and posttreat-
from a few to 15 and finally 24 den- Pokorny DK, Blake FP, Anaheim, De- ment axially corrected tomogram will
tists, converging as a “clinic club” at- nar Corp, 1980, and in The History produce a more accurate segmented
tempting to explore and record their of Gnathology by Stuart CE, Golden image of condylar position, as com-
observations of occlusion and eccen- IB, Ventura, CE Stuart Instruments, pared to a transcranial radiograph.
tric movements in a scientific manner 1984. Diagnostic information related to the
over a 13-year period between 1924 condyle disc articulation also can be
and 1937. Centric relation acquired with a nuclear magnetic reso-
Stuart6 became associated with the nance (MRI) image.17,18 A central gna-
Gnathological Society early and pub- The early gnathologists studied thological theme was to have maximal
lished the classic “Research Report” the recorded tracings made during tooth intercuspation coinciding with
with McCollum in 1955. Their obser- manipulated mandibular movements. centric relation.19 Often this situation
vations led to the development of the When the mandible travels forward or goal was historically referred to as
principles of mandibular movements, along the sagittal plane it is consid- centric relation occlusion (CRO). The
transverse horizontal axis, maxillo- ered a protrusive excursion or pro- Glossary of Prosthodontic Terms,
mandibular relationships, and an ar- trusion. Therefore, retrusion is the eighth edition (GPT-8), describes
con articulator that was designed to movement toward the posterior, and CRO as centric occlusion, which may
accept the transfer of these records. it is the most retruded physiologic re- or may not coincide with maximal in-
The goal was to truly capture maxil- lation of the mandible to the maxilla tercuspation.20 After prosthetic inter-
lomandibular relationships that accu- to and from which the individual can vention and/or occlusal equilibration
rately reproduced border jaw move- make lateral movements that defines to CRO, new radiographs of the TMJs
ments and which would prescribe the centric relation (CR) to the gnatholo- can illustrate changes mimicking sym-
best occlusal interface. The registra- gist. Further investigations led the metry and concentricity of the con-
tion of the horizontal and sagittal dis- gnathologists to believe that mandib- dyles in the glenoid fossae.
placements of patients was believed to ular (condylar) movements are gov- It is important to note that there
allow the maximum cusp height-fos- erned by the 3 axes of rotation. The are no high-level research studies that
sae depth with proper placement of concept of centric relation evolved relate mandibular concentricity to
ridges and grooves as described in the as a 3-dimensional characterization, temporomandibular disorders (TMD)
anatomical illustrations of McHorris7 resulting in its description of centric and orofacial pain.21 This finding does
and Schillingburg.8 relation as the rearmost, uppermost, not eliminate the obligation of docu-
It is interesting to note that Mc- and midmost (RUM) position of the menting the pre- and posttreatment
Collum believed in the concept of condyle in the glenoid fossa. condylar position for clinical proce-
bilateral balanced occlusion in the The gnathologists believed in dures that alter the occlusal vertical
restoration of the natural dentition. the concentricity of centric relation. dimension and mandibular position
However, Stuart5 did not, as he ob- The radiographic interpretation in with occlusal devices, occlusal equili-
served failures due to the unequal Weinberg’s9-11 research supported this bration, and complex restorations in-
wear of the buccal and lingual cusps concept. Weinberg12 showed the 2- volving maximum intercuspation.22
causing deflective occlusal contacts dimensional space of the long axis of In the GPT-8, centric relation is
The Journal of Prosthetic Dentistry Pokorny et al
April 2008 301
defined as the maxillomandibular re- mension, and changes in mandibular lingual cingulum area of the maxillary
lationship in which the condyles ar- position that cannot be equilibrated incisors, and facial-tooth esthetic pro-
ticulate with the thinnest avascular easily to a new maximum intercuspal filing.29,30 The mandibular-maxillary
portion of their respective disks with relationship. It is the authors’ opinion incisal relationship assists in estab-
the complex in the anterior-superior that, out of convenience, clinicians lishing the anterior reference of occlu-
position against the shapes of the ar- attempt to accomplish these revisions sal vertical dimension (OVD). After
ticular eminencies. The inclusion of with laboratory-processed acrylic res- studying children through adoles-
a nonclinically verifiable anatomical in provisional restorations. cence and edentulous adults, Thomp-
relationship added to the definition son and Brodie31,32 reported that oc-
compelled Ash23 to question whether Anterior guidance clusal vertical dimension is constant
centric relation was destined for obso- and does not vary though life. Other
lescence. A study of 7 dental schools, Disocclusion refers to separation investigators found that the vertical
including both faculty and students, of opposing teeth during eccentric dimension of rest varies with speech,
resulted in the conclusion that there movements of the mandible, as re- emotion, jaw relationship, resorption,
is no consensus on the definition of ported by Christensen.26 D’Amico,27 body position, and after natural tooth
centric relation, which contributes to after making anthropologic obser- contacts are lost.33-43 As such, these
the confusion students have regard- vations of skulls of Native American variations may impact determinations
ing the definition and the record- Indians and reviewing studies of Aus- of the OVD.
ing of centric relation.24 The clinical tralian Aborigines that had edge-to- Desjardins44 noted that the rest
practice of prosthodontics would be edge anterior occlusions, and noting and occlusal vertical dimensions are
difficult without the application of a the severe wear of the entire denti- considered some of the most difficult
repeatable reference point that CR tion, suggested the concept of ca- mandibular positions to evaluate and
encompasses in the development of nine guidance. Stuart and Stallard4 are evaluated in the most unscientific
fixed and removable prostheses. Daw- also observed this phenomenon and manner. He concluded that because
son25 believed that there is hardly an therefore developed anterior guid- all methods of determining rest posi-
aspect of clinical dentistry that is not ance as part of their gnathological tion are somewhat unscientific, evalu-
adversely affected by a disharmony concept in mutually protected articu- ation of OVD should not be confined
between the articulation of the teeth lation. According to the philosophy of to a single technique or consider-
and the centric relation position of the gnathology, the anterior teeth protect ation.
temporomandibular joints. In many the posterior teeth in eccentric move- If the anterior teeth are to be re-
gnathological circles the treatment ments and conversely have the poste- stored, then from the articulated di-
of patients with severely disorganized rior teeth protect the anterior teeth agnostic casts, a diagnostic arrange-
occlusions would begin reconstruc- in maximal intercuspation (mutually ment can be designed to optimize the
tion with transitional restorations, in- protected articulation) without any mutually protected articulation, and
cluding cast-metal occlusal surfaces. deflective occlusal contacts or inter- this relationship can then be trans-
The occlusion would be subsequently ferences in speech. ferred to the provisional restorations.
adjusted to a centric relation-centric Additionally, this design may be used
occlusion position with a mutually Occlusal vertical dimension to fabricate a custom incisal guide
protected articulation until the physi- table in autopolymerizing acrylic res-
ological adaptation of the patient was Anterior guidance may be devel- in onto the articulator’s incisal guide
achieved. The gnathological treat- oped through multiple disciplines in table.45 In gnathology, this technique
ment concept typically required that oral and maxillofacial surgery, ortho- should be performed first so that the
both the maxillary and mandibular dontics, prosthodontics, occlusion, OVD and anterior guidance are estab-
teeth be prepared so as to eliminate or a combination of these. The devel- lished and then harmonized with the
any deflective tooth contacts, depro- opment of occlusal vertical dimension posterior determinants. The posterior
gram the musculature, and stabilize (OVD) is a function of maxillary and tooth morphology is then designed so
the temporomandibular joints to a mandibular growth along with the as to incorporate the maximum devel-
reproducible position. Following this eruption of the dentition and accom- opment of a mutually protected artic-
adjustment or tooth preparation, a panying alveolar bone formation.28 ulation, without infringement upon
pantographic recording would be Growth variations and acquired pro- phonetics and/or esthetics.
made prior to definitive rehabilitation cesses can alter the OVD. This spatial
to achieve an “organic occlusion.” relationship is often measured by the Intercuspal position
Cast-metal transitional crowns have evaluation of phonetics, the interoc-
limitations related to cost, inability clusal distance from rest position to Once a functional and reproduc-
to increase the occlusal vertical di- mandibular incisal contact into the ible centric relation is established that
Pokorny et al
302 Volume 99 Issue 4
is without TMJ pathology, and a func- along the occlusal plane as dictated tric” as it relates to centric relation,
tional mutually protected anterior by the Curve of Monson. The maxil- centric occlusion (intercuspal posi-
guidance is developed, then the pos- lary posterior teeth are developed tion), reproducibility, and the effect
terior occlusal morphology may be after the completion of the mandibu- of head posture on the recording. In
designed. The goal of gnathology is to lar restorations as dictated by a wax a study of 10 individuals, the authors
establish an occlusion that is interfer- functionally generated path record, concluded that the “Myomonitor cen-
ence free and entails the concept of as suggested by Meyer,53 and placed tric” is not reproducible because the
an organic occlusion. Organic (orga- on a vertical displacement articulator. reference point, rest position, varies
nized) occlusion encompasses disoc- The definitive restorations are equili- on anterior-posterior head position,
clusion, cusp to fossae relationship, brated into a centric relation position and its pulsed intercuspation position
centric (relation) occlusion, uniform with mandibular buccal cusps onto is anterior to centric relation and cen-
centric contact, forces directed in line fossae-marginal ridge contact with tric occlusion. Also, the axis of rota-
with the long axes of the teeth, tripo- “freedom in centric” anterior guid- tion is located anteriorly and inferiorly
dism, twin centric contact for cross ance and group function in laterotru- from the transverse horizontal (termi-
tooth stability, narrow occlusal table, sive (working) excursion. It must be nal hinge) axis. Clinically, it would ap-
maximum cusp height, and fossae noted that the PMS philosophy was pear to be difficult to integrate a veri-
depth with supplemental anatomy.4 developed and its use advocated on a fiable and repeatable occlusal design
nonarcon articulator, which may not (cusp-fossae, ridge and groove direc-
Competing occlusal concepts accept interocclusal records made at tion) with this concept. Kantor59 and
increased OVD.54 Strohaver,60 in independent studies,
As gnathology was evolving, sev- Moller55 reported on the electro- concluded that Myomonitor registra-
eral competing occlusal concepts myographic study of the actions of tions, in reality, recorded a protrusive
and permutations were theorized, the muscles of mastication in 1966. relationship.
ranging from modification of the In the process, other occlusal con- The selection of maximal intercus-
gnathological schema to other treat- cepts evolved, including the myocen- pation (MI), irrespective of centric
ment approaches based upon differ- tric (neuromuscular) occlusion phi- relation, as a treatment position is of-
ent reference perspectives. Beyron,46 losophy that selects the rest position ten used for the placement of a single
following his observations on Aus- as the reference position. In 1969, crown in the presence of an accept-
tralian Aborigines, suggested that Jankelson56,57 introduced the use of able anterior guidance, OVD, TMJ,
uniform tooth contact and resultant transcutaneous electric neural stimu- and neuromuscular-proprioceptive
attrition on several teeth in lateral oc- lation (TENS), in the form of a Myo- health.61-62 The use of MI as a treat-
clusion was a positive and inevitable monitor unit (Myotronics-Noromed, ment position relies upon the presence
outcome. As a modification of canine Kent, Wash). After a time period of of a predominating anterior guidance,
guidance, the Pankey-Mann-Schuyler stimulation with the unit and when it noted by Schuyler,52 and neuromus-
(PMS)47 philosophy in complete oral is determined that the muscles are re- cular-proprioceptive feedback. How-
rehabilitation was to have simultane- laxed, an interocclusal record is made ever, the selection of a patient’s exist-
ous contacts of the canine and pos- to establish “myocentric occlusion.” ing MI as a treatment position is not
terior teeth in the laterotrusive (work- Jankelson57 defines myocentric occlu- always possible, as centric occlusion
ing) excursion, and only anterior teeth sion as that terminal point of occlu- may not exist or may be eliminated by
contact in the protrusive excursive sion achieved by isotonic muscle con- missing teeth or as tooth quadrants
movement.48-49 traction from the rest position along are prepared for fixed restorations.
Schuyler50-52 further suggested that the myocentric (muscle-balanced) Quadrant casts, which lack cross-arch
incisal guidance without freedom of trajectory. He further observed that articulation, and a nonadjustable or
movement from a centric relation oc- the position created may or may not average value articulator are typically
clusion to a more anterior tooth inter- coincide with the intercuspal position, used with this method. Additionally,
cuspation will “lock-in” the posterior but in no instance did it coincide with this approach lacks appropriate bi-
occlusion. The incisal guidance along centric relation. In a study of 10 sub- lateral condylar determinants and/or
with “long centric” is determined by jects, he concluded that, by means of exact 3-dimensional spatial dynamics
the distance from transverse horizon- inspection, palpation, and intensity- of jaw movements. As a result, any
tal axis-centric relation and the normal duration curves, the unit stimulated treatment or intervention that alters
freedom of movement in the envelope the fifth and seventh cranial nerves the occlusal interface without respect
of function. This method requires that neurally.56 A particular occlusal mor- to a reference position and/or poste-
the incisal guidance be established phology was not described. rior guidance factors may potentially
and the mandibular posterior buccal Remein and Ash58 investigated the become contributory to occlusal dis-
cusps be placed to a height measured characteristics of “Myomonitor cen- cord, which may be visualized as oc-
The Journal of Prosthetic Dentistry Pokorny et al
April 2008 303
clusal interface errors, in particular, the intercuspal position, is illustrated process, some of the approaches to
in posterior molar regions, requiring as in an occlusal adjustment and as removable prosthodontic treatment,
significant chairside adjustments to incorporated into a restoration. Daw- such as geometric formulations for
achieve proprioceptive acceptance by son73 illustrates the “freedom in cen- bilateral balanced occlusion to stabi-
the patient. tric” concept within the lingual con- lize denture bases,79,80 were eliminated
In a literature review of the his- cavity of the maxillary anterior teeth. or modified for fixed prosthodontics,
torical concepts of anterior guidance, He redefines long centric as “freedom while others were retained as clinical
Thornton63 divided articles into those to close the mandible either into cen- observations and supporting scien-
that advocated group function and tric relation or slightly anterior to it tific research advances were made.
those that supported canine pro- without varying the vertical dimension The exact number of patients ex-
tected articulation. Thornton con- at the anterior teeth.” Additionally, amined and the manner in which pa-
cluded that evidence-based science long centric accommodated changes tients were included or excluded is not
does not preclude superiority of one in head position and postural closure. readily apparent in the research report
philosophy over another, but current The measurable amount of long cen- by Stuart.6 The control of examiner bi-
observations appear to number more tric needed is the difference between ases and variables or the comparisons
proponents of canine protected ar- centric-related closure and postural to control groups were nonexistent.
ticulation. closure, which is rarely more than 0.5 During these seminal years, when
In relation to incisal guidance, it mm. evidence-based dentistry was not yet
is important to note the research of The gnathologists believe that conceived, prosthetic dentistry had to
McNamara64 on a rhesus monkey, once the condyles are positioned in rely upon the lowest level of scientific
followed by Gibbs and Mahan et al65 centric relation, any movement out of proof to make decisions about meth-
on 11 human subjects with complete this position would disarticulate the ods to replace missing teeth as well as
dentitions, that showed the indepen- TMJs and disocclude the posterior the shapes of the occlusal surfaces. As
dent EMG recordings of the superior segment, thus, nullifying any hori- a result, from many critical thinking
(SLP) and inferior (ILP) bellies of the zontal cusp-fossae area contact. This dentists of that time, a variety of oc-
lateral pterygoid muscle. Stabiliza- belief, combined with the immediate clusal theories with permutations and
tion of the disk occurs when the SLP anterior disocclusion, would question accompanying terminology devel-
muscle and the ILP muscle work in- the validity of an adjusted and/or re- oped. Therefore, reaching even a con-
teractively. The SLP contracts maxi- stored horizontal contact area in the sensus or finding treatment parame-
mally upon clenching, such as during posterior segment. The task of adjust- ters in the presence of many different
maximal intercuspation, and the ILP ing maximum intercuspation contacts occlusal philosophies and mechanis-
contracts during protrusive move- in 2 different positions on an articula- tic treatment proved difficult, if not
ments with incisal guidance. This ob- tor may result in a lack of precision in contentious. Additionally, consider-
servation of reciprocal muscle activity both positions. ations for those patients with severe
suggests the elimination of posterior discordant skeletal malocclusions or
and/or laterotrusive contacts in pro- The evidence for gnathological con- craniofacial anomalies did not always
trusive excursive movement because cepts fit the gnathological model.81-85
of the potential effect on the TMJ-disk
relationship and a possible contribut- Reviewing the literature and Centric relation and maximal inter-
ing factor in temporomandibular dis- searching for a scientific basis for oc- cuspation
orders. clusion leads to the realization that the
Though 90% of natural dentitions earliest reports were predicated upon Celenza86 studied 32 subjects who
have a deflective occlusal contact or years of successful clinical observa- had fixed complete-mouth restora-
an occlusal “prematurity” between tions or subjective experiences and tions articulated and restored in the
centric relation and the intercuspal closely held anecdotal opinions that centric relation position (centric occlu-
position, it is usually in the form of a were sometimes associated with pro- sion) over a 2- to 12-year period. The
slide that has both a vertical and hori- prietary mechanical instrumentation. subjects were reexamined by manual
zontal component occurring in all 3 Occlusal concepts were initially for- guidance into centric relation, reveal-
planes.66-70 Pullinger et al71 suggests mulated and developed for the eden- ing that no occlusal deflections were
that an intercuspal position anterior tulous patient requiring prosthetic observed either by the operator or the
to the retruded contact position in rehabilitation. Following the exercise patient. However, with use of a de-
association with bilateral occlusal of these concepts in clinical practice, conditioning device (occlusal plane)
stability may be protective. According they were refined and applied to the for 5 minutes, there was a perceivable
to Ash and Ramfjord,72 the horizontal fixed prosthodontic reconstruction deflective occlusal contact for 30 of
“long centric,” from centric relation to of the natural dentition.74-78 In the the 32 patients. Celenza interpreted
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304 Volume 99 Issue 4
this observation as a strong adapta- cepted occlusion based upon a reduc- eliminated. These studies suggested
tion on the part of the neuromuscula- tion of the muscle’s silent period simi- to the investigators that there will be
ture, where the centric relation loca- lar to a control group. Experimentally less wear on posterior teeth and less
tion then becomes a neuromuscular induced interferences in the retruded stress on the temporomandibular
position, not a ligamentous position, range of healthy individuals have been joint with anterior guidance. Jemt et
and because of the neuromusculature reported to elicit masticatory muscle al,100 in a case series crossover study of
conditioning “the precision of the oc- tenderness. Experimentally induced 5 individuals treated with a maxillary
clusion may be more important than occlusal interferences may cause tooth implant-supported FPD and oppos-
the position.” Celenza concluded that pain, loosening of the tooth, a change ing mandibular dentition, observed
these observations do not dictate a in muscle tension levels, masticatory that the masticatory pattern may be
change in methodology, but might patterns, and sometimes a clicking influenced by canine protected artic-
help in explaining occlusal discrepan- joint. However, this effect appears to ulation versus group function type of
cies between centric relation and the be transient as the traumatized teeth occlusion. Carlsson et al101 reported
intercuspal position in the natural tend to move away from the adverse that occlusion type and tooth wear in
dentition. occlusal forces.95 Occlusal adjustment childhood predicted increased anteri-
While it has been demonstrated therapy has been advocated as a treat- or tooth wear 20 years later, whereas
that bimanual manipulation with an ment modality for temporomandibu- nonworking-side interference reduced
anterior Lucia-type deprogrammer lar disorders. Dawson96 questioned the risk for such wear in 35-year-old
for recording centric relation offers the 1996 National Institute of Health subjects.
the greatest repeatability in record- technology assessment conference97 The evolution from analog sty-
ing condylar position, the importance on TMD that indicated that there are lus and graphic table pantographic
in the number of centric stops for no clinical trials that demonstrate recordings to the development, im-
proper masticatory function remains that occlusal adjustment is superior proved convenience, and verification
unreported.87,88 Reproducibility of the to noninvasive therapies. of digital electronic jaw tracking de-
transverse horizontal axis (THA) was It is the authors’ opinion that cen- vices (Denar Cadiax Compact; Whip
investigated by Preston,89 who sug- tric relation should not be dismissed Mix Corp, Louisville, Ky) has been
gested that in determining the THA, as a treatment position of “prosth- studied.102-104 Reproducibility of bor-
an apparent arc may result from the odontic convenience,” as it allows for der movements was investigated by
resolution of compound condylar a reproducible reference point during Clayton,105-108 who made mandibu-
movements. He suggested that the the extended treatment phase and an lar recordings on a patient with a
single transverse horizontal axis exists occlusal scheme to be designed and dysfunctional temporomandibular
as a fact in articulating instruments developed. joint(s) that illustrated irregular trac-
and as a theory in the human cranio- ings using an electronic pantograph
mandibular complex. It is important Anterior guidance to determine a pantographic repro-
to note that locating the THA arbi- ducibility index (PRI). After occlusal
trarily and accompanied by interoc- Many treatment philosophies have splint therapy and reduction of TMD
clusal records made at an increased indicated that the element of disoc- symptoms, rerecordings on the panto-
OVD has been shown to create dif- clusion should be brought forward graph would show reproducible trac-
ferent paths of closure and resultant to the anterior teeth and, thus, estab- ings. At this time, definitive treatment
deflective occlusal contacts of resto- lish anterior guidance. Shupe et al,98 would include occlusal equilibration
rations.90 through an electromyographic (EMG) or prosthodontic treatment to the re-
The masticatory system has the study of the masseter and temporalis producible centric relation position.
capacity to adapt to various influ- muscles of 9 subjects with a maxillary While the PRI may serve as an indi-
ences.91 The centric position may occlusal splint, suggested that there cator of a repeatable centric relation
change over time because of joint is less muscle activity generated in a position, uniform border movement
remodeling, functional alterations canine protected articulation versus path, or a neuromuscular release, its
in the condyle-disc articulation, and a group function guidance. William- use as a diagnostic modality for pa-
neuromuscular release.92 Posterior son and Lundquist,99 through use of tients with TMD and orofacial pain
displacement at both the occlusal a maxillary occlusal splint for 4 TMD has not been scientifically validated
surfaces and the condyles was small symptomatic and one asymptomatic as a gold standard.109
when deflective occlusal contacts on subject, showed decreased EMG ac-
the retruded path of closure were re- tivity of the masseter and temporalis Occlusal vertical dimension
moved.93 McNamara94 reported on muscles when anterior guidance was
the occlusal adjustment of natural developed on the splint, which then Severely worn dentitions and/or
teeth to achieve a physiologically ac- increased when anterior guidance was patients with missing teeth may re-
The Journal of Prosthetic Dentistry Pokorny et al
April 2008 305
quire restoration of a collapsed OVD Clinical observations by others ing factor to an acute periodontal dis-
to an appropriate level. Bernhardt et have shown that the use of an acryl- turbance. However, Yi et al121 reported
al110 reported on the risk factors for ic resin occlusal splint for posterior that subjective function was not sig-
high occlusal wear: bruxism, male teeth with an increased OVD, without nificantly influenced by FPD design,
gender, loss of molar contact, and regard to anterior guidance or rest occlusal factors including various oc-
edge-to-edge incisor relations. DiPi- position, can result in the intrusion of clusal schemes, or the number of FPD
etro111 noted that individuals with a the posterior teeth and extrusion of units. DeBacker et al122 found that
low Frankfort Mandibular Plane An- the anterior teeth.114 In a closed OVD caries and the loss of retention were
gle (FMA) do not tolerate procedures with a collapsed posterior or severely the primary reasons for FPD failures
that increase the occlusal vertical worn occlusion, it has been suggested over a 20-year period. The impact of
dimension. Turner and Missirlan112 to increase the support of the poste- occlusion upon loss of retention or
suggested evaluation of loss of pos- rior teeth to allow the anterior teeth crown retainer stability was not re-
terior support, phonetics, interocclu- to couple to provide anterior tooth ported.
sal distance at rest, and face height, guidance.115 The incisal edges of the The authors note other factors that
along with facial soft tissue contours, mandibular incisors are directed into could possibly be directed to occlusal
before altering the OVD. The authors the cingulum fossae of the maxillary complications, but there were insuffi-
observed heavy molar contact for lingual area of the anterior teeth. The cient data and studies to substantiate
patients with high FMAs along with design should result in disocclusion this possibility, which would include
a lack of incisal guidance. Patients of the posterior segment in excursive TMD, pain and sensitivity, and mobil-
with low FMAs may develop exces- movements, and when maximum clo- ity of the abutments. Anterior FPDs
sive vertical overlap/incisal guidance sure occurs, the anterior teeth should need to restore gliding tooth contacts
initially, but as a result of tooth attri- touch only by the slightest amount to eliminate deflective posterior tooth
tion over time, they subsequently de- (0.0005 in).116,117 All of these observa- contacts in eccentric jaw movements,
velop an edge-to-edge occlusion and tions suggest that while OVD may be while posterior FPDs need to main-
its destructive results. Therefore, the represented by a variable range, there tain the OVD, and together they may
patient with a low FMA may require are inviolate end points and other in- provide mutual protection for each
greater intervention as a result of the fluencing factors. other. It is believed by the authors that
discordant occlusion and tooth attri- single FPDs required to restore both
tion. Either extreme will challenge the Fixed prosthodontics functions may load abutment teeth in
development of an occlusal scheme directions or vectors other than the
that will protect the TMJ, anterior Beyron118 surmised that the occlu- long axis or create simultaneous com-
guidance, and dentition at an accept- sal restorative requirements should pression and tension moments on the
able OVD. attain the jaw and tooth relations es- terminal abutments and may, as a re-
Rivera-Morales and Mohl113 re- sential for harmonious and self-per- sult, lead to failure of the restoration,
viewed the research on occlusal verti- petuating occlusal harmony. These cement bond, or abutment tooth.
cal dimension as it relates to the health requirements included bilateral con- Placing these selected articles into
of the masticatory system on severely tact with axial loading between most a hierarchy of evidence, as recom-
worn dentitions. The hypothesis that teeth in the intercuspal position and mended by Eckert et al123 and by Ja-
moderate changes in the OVD cause in the retruded contact position with cob and Carr,124 would rank them in
hyperactivity of the muscles of mas- a distance of less than 1 mm between the lowest level of confidence relative
tication, or involve TMD symptoms, them, group function-gliding con- to any particular occlusal therapy.
was not supported by scientific re- tacts, and an acceptable interocclusal Table I lists examples of publications
search. distance. Goodacre et al119 reviewed that were expert opinion (level V) or
Additionally, there are many extrin- the research on the clinical complica- reports in which a case series of pa-
sic and intrinsic factors that affect the tions in fixed prosthodontics and did tients (level IV) were described and as
rest position and its reproducibility not link occlusion directly as a caus- such are rated at a greater confidence
as a fixed entity, and, therefore, OVD ative factor. Indirectly, those compli- level than expert opinion. However,
should be considered a range. Rivera- cations involving porcelain/prosthesis the lack of a proper study design/
Morales and Mohl113 conclude that fracture, loss of retention, and tooth question/methodology, inclusion or
the absence of compelling scientific fracture may have been associated exclusion criteria, control groups, and
evidence to prove or disprove the rou- with occlusal or parafunctional fac- elimination of potential examiner bias
tinely used clinical techniques should tors. Pokorny,120 in an article on FPD weaken their scientific strength. There
not be regarded as a justification for failures, indicates that deflective oc- are currently no research publications
careless or haphazard approaches in clusal contacts can loosen an FPD, identified on dentate occlusion that
the establishment of OVD. cause sensitivity, and be a contribut- qualify at level I, II, or III, and this indi-
Pokorny et al
306 Volume 99 Issue 4
Table I. Level IV-V research strength. Chronological series of publications focusing on occlusal research studies and
related key concepts as they first appeared in literature. Duplicate or replication studies are not listed unless study
design was improved or if results were different. Key: N = number of subjects in study, OVD = occlusal vertical dimen-
sion, TMD = temporomandibular dysfunction, CR = centric relation, CO = centric occlusion, CRO = centric relation
occlusion, FMA = Frankfort-mandibular angle, FPD = fixed partial denture, ICP = intercuspal position, RCP = retruded
contact position, M = men, W = women, IFP = inferior belly of lateral pterygoid muscle, SFP = superior belly of lateral
pterygoid muscle, RP = retruded position, IP = intercuspal position
Method/ Study Results/
Author Year Study Parameters Conclusion Hierarchy
McCollum, 1955 Clinical observations of centric Unknown Condylar movement and anterior Expert opinion
Stuart6 relation replicability, centric occlusion guidance/canine disclusion with
coincident and pantographic maximal intercuspation coinciding
recordings transferred to mechanical with centric relation prescribe the
articulator replicating recordings occlusal interface.

Schuyler51 1959 Clinical experience/observations of Unknown Maximal intercuspation should be Expert opinion
incisal guidance based upon esthetics, based upon functional closure that is
phonetics, lip support, and incisal anterior to centric relation (<1 mm),
contact incisal guidance predominates
occlusal interface.

Pankey, 1960 Clinical approach to treatment Unknown Group function, long centric occlusion Expert opinion
Mann47 developed using the Monson spherical prescribe the occlusal interface.
theory, Meyer functional generated
path, and Schuyler incisal guidance

D’Amico27 1961 Anthropological observations of Unknown Canine guidance important to prevent Expert opinion
American Indian skulls with advanced destructive tooth attrition.
attrition and severe tooth destruction.
Australian Aborigine comparisons by
Hector Jones

Beyron47 1964 Observational study of living n=46 Helocoidal wear form resulting in Case series
Aborigines by clinical exam, casts (35M/11W) group function; recommend-
tooth attrition and resultant 15-45 age range ed bilateral contact between most
occlusion, cinematography of teeth in intercuspal position and
masticatory patterns between posterior teeth in retruded
contact position with distance less
than 1 mm between them, with axial
loading, group function-gliding
contacts, and acceptable inter-
occlusal distance.

Jankelson56 1969 Myomonitor stimulation of V and VII n=10 (4M/6W) Neuromuscular occlusion approach to Case series
cranial nerves to develop occlusion 20-60 years restoration. Occlusal interface was not
9 dentate/1 described.

Weinberg10 1970 Radiographic imaging study of TMJ for n=14, Radiographic technique is repeatable, Case series
duplicability and concentricity radiographs consistent, and TMJ is concentric.
made 1 week

The Journal of Prosthetic Dentistry Pokorny et al

April 2008 307
Table I. continued (2 of 5) Level IV-V research strength. Chronological series of publications focusing on occlusal
research studies and related key concepts as they first appeared in literature. Duplicate or replication studies are not
listed unless study design was improved or if results were different. Key: N = number of subjects in study, OVD = oc-
clusal vertical dimension, TMD = temporomandibular dysfunction, CR = centric relation, CO = centric occlusion, CRO
= centric relation occlusion, FMA = Frankfort-mandibular angle, FPD = fixed partial denture, ICP = intercuspal posi-
tion, RCP = retruded contact position, M = men, W = women, IFP = inferior belly of lateral pterygoid muscle, SFP =
superior belly of lateral pterygoid muscle, RP = retruded position, IP = intercuspal position
Method/ Study Results/
Author Year Study Parameters Conclusion Hierarchy
Clayton, 1971 Study of whether graphic tracings are n=3 Mandibular movements can be Case series
Kotowicz, affected by different OVD, bearing affected by changes in all 3 variables
Myers105 surface forms, and tooth contact tested.

Strohaver60 1972 Comparison study of 5 centric relation n=1M with full Myo-centric recordings were most Case report
recording methods and myo-centric dentition variable compared to others.
Part I: Retrospective study of fixed n=32
restorations where centric occlusion
coincided with centric relation

Celenza86 1973 Part II: Prospective study of individu- I. n=32 with 2- After using occlusal splint, 30 of 32 Case series
als with restored occlusions not to 12-year patients displayed deflective contacts
necessarily restored to CRO position treatment wearing occlusal splint. Concluded
to assess recording methods follow-up that precision of occlusion may be
II. n=15 more important than position.
31-55 years

Calagna93 1973 Centric relation registrations of n=15 (9M/6W) Variety of deconditioning methods Case series
completely dentate patients, with 22-49 years were used with extended occlusal
measurable CR and CO difference, device producing best results
normal health, and no TMD compared to other chair-side

Kantor, 1973 Centric relation registrations by chin n=15 Centric relation can be located using Case series
Silverman, point guidance with/without or 21-45 years many techniques, with bilateral
Garfinkel59 anterior deprogramming device manipulation producing the greatest
consistency and Myomonitor
techniques the least.

Hoiffman, 1973 Condylar position measured 3- n=52M Centric relation found to be 0.28 mm Case series
Silverman, dimensionally in articulator mountings 22-46 years posterior and inferior to centric
Garfinkel22 recorded by chin point occlusion with some medio-lateral
guidance in comparison to hand- differences.
articulated casts in ICP

McNamara 64 1973 Rhesus monkey study on EMG lateral n=1 Recorded independent activity of IFP Case report,
pterygoid muscle activity and SLP, suggesting anterior guidance animal study
development for occlusal treatment.

Pokorny et al
308 Volume 99 Issue 4
Table I. continued (3 of 5) Level IV-V research strength. Chronological series of publications focusing on occlusal
research studies and related key concepts as they first appeared in literature. Duplicate or replication studies are not
listed unless study design was improved or if results were different. Key: N = number of subjects in study, OVD = oc-
clusal vertical dimension, TMD = temporomandibular dysfunction, CR = centric relation, CO = centric occlusion, CRO
= centric relation occlusion, FMA = Frankfort-mandibular angle, FPD = fixed partial denture, ICP = intercuspal posi-
tion, RCP = retruded contact position, M = men, W = women, IFP = inferior belly of lateral pterygoid muscle, SFP =
superior belly of lateral pterygoid muscle, RP = retruded position, IP = intercuspal position
Method/ Study Results/
Author Year Study Parameters Conclusion Hierarchy
Remein, Ash58 1974 EMG study of Myomonitor centric n=10 (3M/7W) Myomonitor centric position is Case series
position using a fully adjustable 21-50 years anterior and inferior to transverse
articulator hinge axis, is variable with head
position, and is not reproducible.

DiPietro, 1976 Significance of Frankfort-mandibular Not stated Reported that low FMA patients have Expert opinion,
Moergheli111 angle and OVD literature report greater occlusal forces and do not review of
supported by cephalometric data and tolerate increase in OVD. orthodontic
studies collected by others literature

McNamara 1977 Electromyographic (EMG) study of n=27 (18 with Duration of EMG silent periods and Case series with
DC94 patients before and after elimination functional latency of jaw-opening reflex was attempt to
of deflective occlusal contacts in disturbances and reduced following treatment (occlusal compare with
centric and eccentric positions 9 without to adjustment) of functional disturbance “normal”
compared to nondysfunctional group serve as control group within range similar to EMG control group.
group) silent periods of control groups.

Jankelson57 1979 Myomonitor-neuromuscular occlusion n=400 Rest position is reference position for Case series
derived from stimulating temporalis Over 6-year maximum intercuspation.
and masseter muscles period

Weinberg9 1980 Radiographic imaging of TMJ n=138 Posterior condylar displacement Case series
concentricity, dysfunction, and (10M/80W) associated with dysfunctional centric
occlusal factors 16-71years relation.

Jemt, 1982 Light-emitting diodes to track jaw n=5 Individuals preferred group function Case series with
Lundquist, movement for patients with maxillary occlusion prosthesis and had more crossover
Hedegard100 fixed implant prosthesis opposing horizontal mastication patterns;
mandibular dentition, canine canine guidance group had more
protected articulation, or group vertical mastication patterns.
function occlusion

Williamson, 1983 EMG study of effects of anterior n=5W of which 4 Elimination of posterior contacts by Case series
Lundquist99 guidance provided by occlusal splint had history of anterior discussion occlusal splint
TMD decreases activity of elevator muscles.

Gibbs, 1984 EMG study on inferior (ILP) and n=11 (8M/3W) SLP and ILP demonstrated nearly Case series
Mahan, superior lateral pterygoid (SLP) dental students, reciprocal EMG activity. SLP activated
Wilkinson, muscle activity 2 had TMD during clenching in retruded contact.
Mauderl65 symptoms

The Journal of Prosthetic Dentistry Pokorny et al

April 2008 309
Table I. continued (4 of 5) Level IV-V research strength. Chronological series of publications focusing on occlusal
research studies and related key concepts as they first appeared in literature. Duplicate or replication studies are not
listed unless study design was improved or if results were different. Key: N = number of subjects in study, OVD = oc-
clusal vertical dimension, TMD = temporomandibular dysfunction, CR = centric relation, CO = centric occlusion, CRO
= centric relation occlusion, FMA = Frankfort-mandibular angle, FPD = fixed partial denture, ICP = intercuspal posi-
tion, RCP = retruded contact position, M = men, W = women, IFP = inferior belly of lateral pterygoid muscle, SFP =
superior belly of lateral pterygoid muscle, RP = retruded position, IP = intercuspal position

Method/ Study Results/
Author Year Study Parameters Conclusion Hierarchy

Turner, 1984 Clinical observations of severely worn n=unknown Multiple methods of assessing OVD Expert opinion
Missirlan112 dentition and methods used to used in individuals with severely worn
determine decreased OVD dentition.

Shupe, 1984 EMG study comparing group function n=9 (5M/4W) Canine guidance should be required to Case series
Mohamed, to anterior guidance on maxillary 23-41 years reduce forces to posterior teeth and
Christensen, occlusal splints muscle activity.

Clayton, 1986 Electronic pantographic reproducibil- n=25 Electronic method of assisting in Case series
Beard108 ity study and indexing for diagnosing graphic detection of TMD and
TMD reproducibility of tracing border

Brose, 1987 Literature review of anterior coupling N/A Anterior teeth can be modified to Expert opinion
Tanquist115 influence on mandibular movement achieve coupling to posterior controls
by occlusal adjustment and anterior

Pullinger71 1988 Study of occlusal variables associated n=224 ICP anterior to RCP in association Case series
with joint tenderness and dysfunction (120M/102) with bilateral occlusal stability may be
23.9 mean age protective.

Agerberg, 1988 Study of occlusal interference n=140 Observed that majority of individuals Case series
frequency between centric relation 15-22 age-range had deflective contacts that did not
and centric occlusion or nonworking appear to interfere with mastication.
contacts that prevented group

Wilson, 1989 Clinical assessment of centric relation n=15 dental Determined 0.2-0.4 mm difference Case series
Nairn68 and centric occlusion students/ between RP to IP.

Rivera- 1991 Extensive review of animal and human N/A Literature reviewed does not substan- Systematic
Morales, studies regarding restoration of OVD tiate that a moderate increase in the review of
Mohl113 OVD will result in hyperactivity of the literature
masticatory muscles and symptoms of

Pokorny et al
310 Volume 99 Issue 4
Table I. continued (5 of 5) Level IV-V research strength. Chronological series of publications focusing on occlusal
research studies and related key concepts as they first appeared in literature. Duplicate or replication studies are not
listed unless study design was improved or if results were different. Key: N = number of subjects in study, OVD = oc-
clusal vertical dimension, TMD = temporomandibular dysfunction, CR = centric relation, CO = centric occlusion, CRO
= centric relation occlusion, FMA = Frankfort-mandibular angle, FPD = fixed partial denture, ICP = intercuspal posi-
tion, RCP = retruded contact position, M = men, W = women, IFP = inferior belly of lateral pterygoid muscle, SFP =
superior belly of lateral pterygoid muscle, RP = retruded position, IP = intercuspal position
Method/ Study Results/
Author Year Study Parameters Conclusion Hierarchy
Yi, Carlsson, 1996 Study of 34 patients with 43 FPDs Of 200 patients, All 3 types of occlusal contact Case series
Ericsson, worn for 10 years with variety of 34 (19W/15M) patterns seemed to be compatible
Wennstrom121 occlusal schemes were willing to with long-term function of extensive
participate in FPDs.
retrospective study

Goodacre119 2003 MEDLINE search, 50-year literature N/A Fixed partial dentures failures: caries Meta analysis
review of survival and failure modali- (18% of abutments and 8% of design with
ties of FPD prostheses), endodontic treatment systematic
(11% of abutments and 8% of review of
prostheses), loss of retention (7% of literature.
prostheses), esthetics (6% of
prostheses), periodontal disease (4%
of prostheses), tooth fracture (3% of
prostheses), and prosthesis/porcelain
fracture (2% of prostheses).

Carlsson, 2003 Randomly selected 7-, 11-, and n=100 (original Oral parafunctions in childhood may Longitudinal
Egermark, 15-year-old subjects were examined 402) random be persistent trait in many subjects. case series
Magnusson101 clinically and using questionnaire for selection, Class II occlusion and tooth wear in
parafunction and tooth wear focusing examined after 20 childhood predicted increased
on occlusal factors and function and years anterior tooth wear 20 years later,
dysfunction of masticatory system whereas nonworking-side interference
reduced risk for such wear in
35-year-old subjects.

Nilner92 2003 Literature review of musculoskeletal N/A Extensive literature review supporting Systematic
disorders and occlusal interface Beyron’s original observations. review of

Forsell, 2004 Application of evidence-based N/A Review methodology on occlusal Systematic

Kalso125 medicine to occlusal treatment of splints and TMD. review of
TMD literature

Bernhardt, 2004 Occlusal wear studied and related to n=2529 Factors for high occlusal wear: Epidemiologic
Gesch, risk factors such as bruxism, gender, bruxism, male gender, loss of molar case series
Splieth110 and social situations contact, edge-to-edge incisor
relations, unemployment.

De Backer, 2006 Study to investigate longevity of 332 n=193 66% FPD survival rate, caries and loss Retrospective
Van Maele, FPDs over 20 years performed by of retention were primary causes for case series
De Moor, students and faculty failure. Impact of occlusion not
Van den Berghe, reported.
De Boever122
The Journal of Prosthetic Dentistry Pokorny et al
April 2008 311
cates a void in the current literature. SUMMARY 9. Weinberg LA, Lager LA. Clinical report
on the etiology and diagnosis of TMJ
A recent systematic review of oc- dysfunction-pain syndrome. J Prosthet Dent
clusal treatments revealed 16 random- As prosthodontists, the authors 1980;44:642-53.
ized controlled clinical trials (RCT) of recognize the need for reliable evi- 10.Weinberg LA. An evaluation of duplicability
of temporomandibular joint radiographs. J
occlusal splints, and 4 on occlusal dence-based research to support Prosthet Dent 1970;24:512-41.
adjustments revealed equivocal re- specific treatment for a variety of oc- 11.Weinberg LA. An evaluation of asymme-
sults.125 The etiologic significance of clusal situations. This research must try in TMJ radiographs. J Prosthet Dent
occlusal factors has been questioned encompass measurability, reproduc- 12.Updegrave WJ. Radiography of the tem-
based upon the weak or nonexistent ibility, transferability, and ease in poromandibular joints individualized and
epidemiological data and systematic simplified. Compend Contin Educ Dent
performance of treatment. Gnatho-
studies.126 To date, there have not logical concepts offer a structured 13.Weinberg LA. Anterior condylar displace-
been randomized controlled trials or methodology for prosthodontic ment: its diagnosis and treatment. J Pros-
comparative clinical evaluations of thet Dent 1975;34:195-207.
treatment in the presence of a disor- 14.Weinberg LA. Posterior bilateral condylar
the different therapeutic principles ganized or dysfunctional occlusion displacement: its diagnosis and treatment. J
in oral reconstructions with indica- requiring fixed prosthodontics. Gna- Prosthet Dent 1976;36:426-40.
15.Weinberg LA. Posterior unilateral condylar
tors to determine mandibular posi- thology will historically be judged as displacement: its diagnosis and treatment. J
tion, contact pattern of mandibular a significant stimulus to relate the Prosthet Dent 1977;37:559-69.
excursive movements, and occlusal physiology of occlusion to biomedical 16.Weinberg LA. Superior condylar displace-
ment. Its diagnosis and treatment. J Pros-
designs.127,128 concepts in complex restorative treat- thet Dent 1975;34:59-76.
Ash129 concluded that until evi- ment. Further scientific research is 17.Katzberg RW, Schenck J, Roberts D, Tal-
dence-based science finds one or needed to validate occlusal treatment lents RH, Manzione JV, Hart HR, et al.
Magnetic resonance imaging of the tem-
more acceptable causal factors, the theories and prescribed treatment of poromandibular joint meniscus. Oral Surg
clinician is faced with the need to the occlusal interface. The lack of an Oral Med Oral Pathol 1985;59:332-5.
provide therapy that has some rea- evidence-based model does not di- 18.Carr AB, Gibilisco JA, Berquist TH. Magnet-
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sonable degree of objective and/or minish the goal of precision and ex- dibular joint: preliminary work. J Cranio-
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a disorder. Klineberg and Stohler130 19.Pokorny DK. Current procedures in fixed
fixed prosthodontics. Ultimately, the
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