OCCLUSION 0011-8532/95 $0.00 + .

20

PHILOSOPHY OF OCCLUSION:
PAST AND PRESENT
Major M. Ash, Jr, DDS, MS, Dr he

When first asked to write this article the title did not seem appropriate for
scientific subject matter and "reflections" appeared to be a better word than
"philosophy"; however, with further thought the title seemed to be in line with
this definition: "philosophy is the art of forming, inventing, and fabricating
concepts."" From such a definition it is possible to deal with articles with a
touch of philosophy in the title, such as quo uadis"; to look philosophically for a
moment at the search for an immutable condylar position; to question the use of
such terms as pure rotation, true centric, and point centric; and to wonder about
voting on an optimal position for the condyle in the mandibular (glenoid) fossa.
Thus, the reviewer and the reader must be prepared to deal sometimes with
ideology rather than science, that is, to recognize there exists for some a deep-
seated ideological need to reach for immutable constants rather than accept the
variability of a biological system.
Anyone who proposes to cover past and present concepts of occlusion in a
few pages must limit the number of topics to be discussed in some meaningful
way while at the same time attempting to avoid personal and ideological biases
in selecting what is to be included. Recognizing the problem of subjective
partiality in the selection of topics to be considered, this article cannot be
considered to be even a brief history of occlusion. Even so, it is hoped that the
selection of material does not appear to be altogether arbitrary, and that which
is presented will provide useful approaches for present as well as future ways
of viewing occlusion.

CENTRICS

The word centric is an adjective, but it is used frequently as a noun in place

of centricity. The problem that arises when the term is used as a noun is that the

From the Department of Periodontics, University of Michigan School of Dentistry, Ann

Arbor, Michigan

DENTAL CLINICS OF NORTH AMERICA

VOLUME 39 • NUMBER 2 • APRIL 1995 233

234 ASH

reader may be in a quandary as to which centric is actually meant. Declaring

the word obsolete or worse, however, will not erase it from the literature for
centric has a long history of use to describe various forms of occlusion and
mandibular position, for example, centric occlusion, acquired centric, habitual
centric, power centric, perverted centric, point centric, centric position." mandib-
ular centricity.!" freedom in centric.'?' freedom from centric." slide in centric,
and centric relation. 53.55 Of these uses of the term centric, only a few are
considered within this article.

Mandibular Centricity

The word centric, whether used as an adjective or as a noun in dentistry,

has been the stuff of which ideologues dream about when attempting to make
the biological and physical aspects of jaw positions and occlusion into a unified
theory of mandibular centricity, a term that Stuart!" used in describing the
condylar determinants of occlusion. In this concept, the condyles are in the
rearmost position in the mandibular fossae. Conceptually, all components of the
masticatory system that were not but could be aligned, had to be aligned with
those that were already aligned. In this scenario, the condyles were the aligned
and the occlusion was the misaligned, for example, the occlusion had to be
aligned with the transverse intercondylar axis with the condyles in the rearmost
position of the mandibular fossa.!" Conceptually, "all lower teeth had to close
evenly against the upper teeth at the same time about the transverse intercondy-
lar axis when it was in the rearmost position."!" It is unlikely that the concept
of radiographic condylar concentricity!" or distal displacement of the condyle
as a cause of temporomandibular disorder, were considered by the gnathology
group to be of significance relative to using a strained, most retruded position
of the condyles for restorative treatment.

Historical Aspects

The history of centric relation is closely related to earlier concepts of denture

occlusion, balanced occlusion, and balanced articulation. 10. 51. 55.76. 77 The concept
of balanced occlusion, which included the idea that the most posterior position
of the condyles was the optimal functional position for restoring denture occlu-
sion, was applied to restoration of the natural dentition by McCollum,85
Schuyler,'?" and others. The idea of a balanced restored occlusion for the natural
dentition was found to be incorrect, however, and the concept of centric relation
being a functional position (no matter how defined) has been a controversial is-
sue.
The need for the occlusion to be related to a frame of reference which
could be transferred to an articulator was important to the concept of balanced
occlusion. Fischer." McCollum,85 and Beyron? considered that they were able to
demonstrate a transverse horizontal axis that could be used as the basis for
mandibular movements and maxillomandibular relations. The concept of a man-
dibular axis led to development of comprehensive articulators, almost to the
point where some clinicians thought that the mouth could no longer be accepted
as the best articulator for the reconstruction of a dentition."
It is possible to trace the beginning of some of the concepts of centric
relation by reviewing the ideas of balanced occlusion and bite analysis that
eminated from American concepts from the period of 1916 to 1926 and became
 PHILOSOPHY OF OCCLUSION: PAST AND PRESENT 235

the basis for the clinical treatment and the development of departments of "bite
analysis" in Scandinavian countries." Unlike the history in the United States
where autonomous departments of occlusion were first formed only in 1969 and
which are now extinct, departments of occlusion (i.e., stomatognathic physiol-
ogy) departments of "bite analysis'?" or their derivatives (such as stoma tog-
nathic physiology) still exist in some form in the dental schools in Sweden.
Gone from the active scene in research in occlusion are such names Arstad,
Beyron, Brill, Krogh-Poulsen, Posselt, and others who contributed so much to
the development of occlusion in the Scandinavian countries. Even so, there
remains strong support for the study of occlusion in Europe, especially in
Sweden, Denmark, Finland, Switzerland, and the Netherlands. Research in oc-
clusion in these countries still remains a strong area of interest.

Balanced Occlusion: Application to Natural Dentition

The application of the concept of mandibular centricity and balanced den-

ture occlusion was applied to complete mouth restoration of the natural denti-
tion from the 1930s until the 1960s79 when some of the gnathology group came
to the conclusion "that balanced occlusion is not suitable for the natural teeth,
and probably, not fit even for denture teeth."!" It was still believed, however,
that for an optimal functional state, maximum intercuspation had to occur when
the condyles were in a rearmost position in the mandibular fossae.
The impact of the concept of mandibular centricity and its variations on
occlusal therapy in general has not necessarily been negative, but the unique
biophysical interface with which dentists must deal daily requires that concepts
be based on more than a concept that could be applied only to complete
dentures, full mouth restorative dentistry, and theoretically to orthodontics.
One of the basic premises about the rearmost position of the condyle and
how to obtain it changed during the late 1970s, and the position proposed by
Dawson" for the condyles in the fossae was accepted by at least some of the
gnathology group. At the same time that the term centric relation was being
defined and redefined (Glossary of Prosthetic Terms130), it was supposed to be on
its way to forced obsolescence; a controversial issue itself. This aspect of centric
relation will be considered later in this article.

Transverse Horizontal Axis

The frame of reference for "mandibular centricity" was the position of the
condyles in the fossae; all other components of the masticatory system, especially
the occlusion, had to reflect this ideology. Until the time of the 1980s, the
putative ideal position of the condyles in the mandibular fossae for the gnathol-
ogy group generally was a rearmost position; the applied realization of the
position was believed to be the transverse horizontal [hinge] axis from which
"pure rotation" could be transferred to an appropriate articulator.
The position of the transverse horizontal axis has been identified at one
time and another with centric position" or centric relation." Earlier in this
century, Gysi52,53 utilized in theory and practice the gothic arch (arrow point or
needle point) tracing in edentulous cases as the starting point for lateral gliding
movements of the mandible, For the McCollum group, the arrow point was true
centric relation, The arrow point relation has been used in connection with
centric occlusion." centric position.':" centric relation." true centric relation.!'"
and terminal (Schlussbiss) occlusion," to name a few,
236 ASH

Aids for Locating and Recording Centric Relation

Putative aids to locating and recording centric relation include the use of
an anterior acrylic jig and a leaf gauge.": 136These so-called anterior deprogram-
mers and programmers'< are believed to allow the condyles to be positioned
correctly by deprogramming/reprogramming of the jaw muscles; however, a
recent study" casts doubt on the value of the clinical practice. According to
Hobo and associates= regardless of which guidance technique is being used.": 103
there is in the mandibular fossae a 0.1 to 0.3 mm "buffer" space between the
condyle and fossa. Clinically comparing initial centric relation contacts using
correct bimanual and correct chin point guidance shows that there is no differ-
ence in techniques." 25.103
Considerable reliance has been placed on the concept of a stationary hinge
axis and the use of pantographics, hinge axis locators, kinematic facebows, and
gothic arch tracings; however, the correct location of the transverse horizontal
axis of mandibular rotation is one of the most disputed areas and still unresolved
problems of functional instrumental diagnostics.s- 102It would be hoped in the
day of "high tech" that precise, error-free methods of obtaining and registering
centric relation would be developed; however, centric relation has no reference
to muscle behavior, growth, or joint function." and a precise location requires
some point of reference besides itself. The error in a kinematically determined
hinge axis is a dispersion of 1.7 X 1.7 mm." which reflects one of the mechanical
aspects of the problem of a point centric reconstruction. Obviously, the location
cannot be determined by radiographic methods. Recently, electronic-mathemati-
cal approaches to determining the center of mandibular rotation have been
described so; however, the maximum deviation from the kinematically located
axis point is 0.5 mm and the complexity of the possible sources of error requires
closer quantitative and comparative analyses. The terminal hinge axis cannot be
considered to be unchanging or an error-free, pinpoint axis.

Centric Relation Occlusion

Perhaps the most difficult problem encountered by the gnathology group

in the 1980s to 1990s was how to erase the terms retruded and rearmost from the
concept that for more than 50 years applied the basic tenet that the optimal
position of the condyles in the mandibular fossae was the retruded or rearmost
position. Once it became evident that that condylar position was incorrect,
such terms as rearmost, retruded, and retruded contact position (retrusions kontakt
stellung-RK) or centric relation occlusion became an anathema and another term
was needed to describe the intercuspal occlusal position of completely restored
occlusions. Perhaps under the ruberic of a transition to obsolescence, "centric
occlusion" appeared as a redefined term in the Glossary of Prosthetic Terms
(1987)130to meet this need. Centric occlusion will be considered later in this arti-
cle.

Freedom in Centric

The concept freedom in centric?' 106provides for freedom for the mandible to
close into maximum intercuspation in centric relation (centric relation occlu-
siori") anteriorly to centric occlusion'?' (intercuspal position, habitual, or ac-
quired centric), and in between, as well as slightly lateral and anterior to this
 I

PHILOSOPHY OF OCCLUSIO : PAST AND PRESENT 237

area (broad centric) of occlusal contacts. In this concept, "there is a flat area in
the central fossae upon which opposing cusps contact which permits a degree
of freedom in eccentric movements uninfluenced by tooth inclines.:"?'
Freedom in centric, which is obtained by an occlusal adjustment'Pv 133 or by
restorative dentistry, allows the mandible to close into an intercuspal position
without the need for gross neuromuscular responses to premature occlusal
contacts. After an occlusal adjustment, the posterior-anterior range of maximum
intercuspation is from centric relation occlusion to the original centric occlusion.
The lateral range (broad centric) of maximum intercuspation is determined by
the amount of lateral deflection (slide in centric) from premature contact in
centric relation to centric occlusion on mandibular closure. For freedom of
centric in complete occlusal restorative treatment, the term long centric has been
used": however, the anterior range of freedom need not be long enough to
include the original centric occlusion but may be established at less than 1
millimeter (e.g., 0.5 mm) anterior to centric relation.'?' The concept is also
applied to the occlusal bite plane splint?

Point Centric

At various times, depending on the definition of an optimal condylar

position, it has been proposed that with proper operator guidance, or tooth
guidance, the condyles should seat in a rearmost position in the mandibular
fossae exactly at the time when maximum intercuspation of the teeth occurs in
the retruded contact position": 122 This concept has been termed point centric. In
long centric, supporting cusps make contact with flat areas prepared in the
restored teeth, not only when condyles are in centric relation but when slightly
anterior to centric relation; however, in the concept of point centric, supporting
cusps must make occlusal contact at a point when the condyles are only,
and precisely, in centric relation. Unlike long centric, which has some anterior
dimension, point centric has zero anterior dimension. If the analogy of a point
is carried out, the following are needed to realize the concept of mandibular
"centricity": maximum intercuspation must occur in the centric relation occlusal
contact position; simultaneous contact of all the teeth must occur in centric
relation on mandibular closure; and all mandibular closing and opening move-
ments must occur into or out of the intercuspal occlusal position with the
mandible in the centric relation position.
After the time that the gnathology group had left the application of the
concept of balanced occlusion to the natural dentition, there was an emphasis
on immediate "disclusion" of all the posterior teeth by the canines> or canine-
protected occlusion, and cusp-to-fossa "tripodization."!" These additions further
complicated the need to obtain precise gnathologic restorations because of the
number (187) of occlusal contacts that had to occur simultaneously on reaching
centric relation at the time of complete mandibular closure into maximum
intercuspation.!"
For strict adherents of the point centric concept, all diagnostic criteria and
treatment goals are built around the border position, centric relation. However,
perhaps ooisinage centric might be a better term inasmuch as the French word
"voisinage" has for one of its definitions, "neighborhood of a point." The sense
of this term fits in exactly with the mathematical and statistical idea of a
dispersion of points around the theoretical point of the axis of rotation of
the condyles in centric relation. II. 71 From the aspect of biophysical interfaces,
238 ASH

indeterminacy, predictability, and causality must exist peacefully side by side: an

impossibility for any dream of a final unified theory of a concept of point centric.

Assumptions

It is sometimes assumed incorrectly that positions defined as centric relation

can be equated accurately with an anatomic position that is determined by a
particular technique or system for clinically positioning the condyle-disk com-
plex in the mandibular fossa; however, the assumption has never been substanti-
ated. From a clinical standpoint, what really matters is the way patients (teeth,
muscles, and joints) respond to treatment based on using centric relation as a
functional position rather than a reference position for diagnosis. There is
agreement that centric relation is a border position and a useful reference
position; however, it cannot be assumed that a border position is a functional po-
sition.
If it is assumed that the position of the condyle in centric relation is settled
for the moment, is it an optimal position for complete restorative treatment?
Assuming that the mandible was manipulated correctly to reach the anterior-
superior position now being advocated, how do we know if the position of the
condyle satisfies the definition proposed for centric relation (Glossary, 1994)130
and meets the functional requirements of the temporomandibular joints? No,
anecdotal clinical experiences alone will not answer those questions.

Where is Centric Relation?

Centric relation is sometimes identified with the position of the condyles

relative to the transverse horizontal axis or a gothic arch tracing. The primary
thrust of the definitions of centric relation that has recently been proposed in
the fifth edition of the Glossary of Prosthetic Terms'?' is anatomical. The definition
cannot be equated with the actual position of the transverse horizontal axis or
even that it should reflect a point of "pure" rotary (stationary, terminal hinge
axis, etc) mandibular movement. It is possible to locate a small dispersion of the
points of the transverse horizontal axis on the skin or a flag, but this does not
indicate where the condyle-disk assembly is located.
Despite all the rhetoric about "true centric," none of the definitions about
centric relation or centric position can state where the true anatomic position of
the condyle-disk complex is in the mandibular fossae irrespective of how or
what method is used to guide the mandible into centric relation. It hardly needs
to be said that radiographic concentricity of the condyles (or a lack of it) in the
mandibular fossae provides the answer. The anatomist Sicher!'" described the
position of the mandible with the teeth in contact as the occlusal position. In the
occlusal position the condyles were opposite the posterior slope of the articular
eminentia and not in the deepest part of the fossa. This definition is virtually
the same as that now being used for centric relation, that is, an anterior-superior
position; however, a significant point of difference is that the teeth were closed
into occlusal contact which is, 9 out of 10 times, maximum intercuspation and
anterior to centric relation.'?'

Is Centric Relation a Functional Border Position?

The general answer is that border positions of joints are not considered to
be functional positions. If so, then centric relation is not an optimal functional
 PHILOSOPHY OF OCCLUSION: PAST AND PRESE T 239

end point for mandibular closure into maximal intercuspation; therefore, a

goal of coincidence may reflect ideas largely transferred to the natural denti-
tion from earlier concepts of denture occlusion, balanced occlusion, and "true
centric.i''" 76,85,107
The observation made by Posselt'?' that centric relation is a border position
that does not often coincide with centric occlusion in the normal occlusion has
been supported by other scientifically controlled tests, Both the stressed and
unstressed positions for centric relation are border positions; the difference
between the two may be a fraction of a millimeter,
Although Posselts's findings did not support the concept of physiologic
coincidence of centric relation and maximum intercuspation for occlusal recon-
struction, it was not until the 1970s that the conceptual basis for restoring to
centric relation occlusion using a border position was seriously questioned,I9,21
It has been shown by biotelemetry that centric relation is not an important
functional position for swallowing and for chewing, 1,45,97,98According to Cel-
enza." "The gnathological concept that centric relation is a loaded position and
that centric occlusion should therefore occur there is not supported by recent
findings,"

Guidance into Centric Relation

Although it seems clear that generally until the 1980s the gnathologic group
adhered to the concept that for an optimal complete mouth restoration the
condyles had to be in a rearmost position in the mandibular fossae.!" there are
only a few detailed statements and research reports on how the mandible is
manipulated into centric relation irrespective of the technique used." 15,59,64,66,92,
103,lIS The techniques are described with variations as the: (1) chin-point tech-
nique which uses the thumb and one finger on the chin to guide the mandible
backward and upward" 47,84,112, 116;(2) chin-point using the thumb to guide the
mandible posteriorly and the first two outstretched fingers to guide the mandible
upward+ 103;and (3) the bimanual technique using four fingers of each hand to
guide the mandible upward and both thumbs on the chin to guide the mandible
posteriorly." 78 Several studies on these methods and variations have been
published showing that the skill of the operator is the most important factor in
placing the condyles in a three-dimensional domain in the mandibular fossae
irrespective of technique, 15,59,62,64,66,92,
101,
115,
117

Strained and Unstrained Positions

On the basis of electromyographic (EMG) evidence, Posselt'?" concluded

that from a neuromuscular standpoint centric relation is not a neutral position,
and only a slight amount of shift anteriorly was necessary to obtain minimal
EMG activity. The degree of shift was considerably less than the 1 mm average
distance from the retruded contact position to the intercuspal position. The
distance between a strained and unstrained position of the condyles in centric
relation is as small as a fraction of a millimeter.'?' Posselt considered his findings
to be evidence against a border-type centric for restorative treatment.
Three-dimensional projections about the positions of the condyles include
assumptions about the precise location of the condyles that have never been
resolved; however, from a relative standpoint there seems to be no reason not
to suggest that some vertical and lateral differences between unstrained and
strained positions of the condyles do exist."
240 ASH

Some Clinical Concerns

The concern for relapse of point centric reconstructions that was considered
by Celenza" appeared to be related to a proscribed and strained, retruded
position of the condyle." a strained retruded-superior position." or a strained
retruded, uppermost, midmost (RUM) position!" of the condyles in centric
relation. Reasons for the return of centric slides were carefully considered by
Celenza and several possible explanations for his own cases were suggested":
however, he concluded that the observations he made did not suggest a change
in the method of treatment.
According to Hobo and associates.v the RUM position of the condyles
advocated by Stuart and Colden'> has been used for almost half a century as
the foundation for gnathology. Although Kornfeld" was cited by Hobo and
associates= as being one of the gnathologists using the RUM concept, Kornfeld?'
indicated in his textbook (p 54) that he enthusiastically accepted Dawson's
method " of determining centric relation. In Kornfeld's textbook (p 78), a refer-
ence to a personal communication from C.E. Stuart is cited that states, "Centric
relation of the mandible is its rearmost, midmost, untranslated hinged position.
It is a strained relation as are all other border positions. It is the only maxillo-
mandibular relation that can be statistically repeated." On the basis of this
communication from Stuart, it is evident that, when the concept of RUM is
applied, the clinician is expected to push the mandible backward into a strained
position. By inference it is suggested that what the gnathologists had in mind
was a strained retruded position for centric relation, not an unstrained retruded
position. The RUM position, like all other such definitions about the position of
the condyles, is only speculation about a specific anatomic position of the
condyle-disk assembly in centric relation.

Occlusion Focus Meeting

Because of the concerns about the clinical problems being seen with gnatho-
logic reconstructions to point centric by Celenza" and others, who thought the
problems were related to concepts of centric relation, an attempt was made to
come to an agreement on the optimal position of the condyles in centric relation
at a meeting in Las Vegas in 1976. The report of the Occlusion Focus meeting"
included a questionnaire with the answers to questions about centric relation
that were asked of the nine presenters of position papers at the meeting. No
one selected the most retruded position of the condyles for centric relation, and
some of the presenters defined the condylar position as being slightly anterior
to the uppermost position. "Voting" on this question, "When the jaws are in
centric relation should the teeth be in maximum intercuspation," six of the
presenters voted yes; three voted no. Of the nine presenters of position papers,
only one of the presenters answering the questionnaire voted without other
qualifications that the condyles should be in the anterior superior position in
centric relation; however, four other presenters voted for that position but
indicated an additional one or more qualifications.
It was recognized at the Occlusion Focus meeting that there was no scientific
evidence available to definitively answer these questions; a fact reflected in the
conflicting answers within and between respondent answers in the question-
naire. At that time the presenters appeared to be far from consensus in defining
centric relation.
Of interest was the absence in the report of the Focus meeting of a vote on
 •

PHILOSOPHY OF OCCLUSION: PAST AND PRESENT 241

how centric relation was determined clinically by the presenters of papers. One
of the presenters gave his method of obtaining centric relation," but no one
described the technique that had been used or was being used to guide the
condyles into a strained, "retruded," or RUM position.

What Causes Relapse of Point Centric?

On the basis of animal and human studies, it would appear that the teeth
are the structures that change in relapse of point centric reconstructions. It may
be that coincidence of centric relation and maximum intercuspation is inherently
biologically incorrect for some reason. It should not be concluded that a differ-
ence between the position of the mandible in centric relation and centric occlu-
sion is a precursor to occlusal dysfunction and needs to be eliminated prophylac-
tically. The magnitude of the difference may be intrinsic to the individual, for
example, a normal by-product of mandibular function and the attachment of
the teeth." In most instances of comprehensive reconstructive dentistry" or
orthodontics, where a moderate difference between maximum intercuspation
and centric relation has existed, it may be expected that a regression will occur
after treatment to a point where some discrepancy exists again."
Perhaps it is time to consider that a difference between a border position of
the joints (centric relation) and the teeth (centric occlusion, intercuspal position)
reflects an inherent minimum need for adaptation and begin to research the
difficult, but interesting biological problem of adaptation as did Harvold.>

Centric Relation Occlusion

Perhaps a difficult problem encountered in the 1980s to 1990s for those who
had advocated the rearmost position was how to erase the terms retruded and
rearmosi from a concept that for over 50 years had applied the basic tenet that
the optimal position of the condyles in the mandibular fossae was the retruded
or rearmost position. Once it became evident that this condylar position was
incorrect because of a relapse of centric slides, such terms as retruded, rearmost-
retruded and retruded contact position (retrusions kontakt stellung-RK) or centric
relation occlusion became an anathema and other terms would be needed to
replace them as well as centric relation if possible. Under the ruberic of a
transition to obsolescence, "centric occlusion" was redefined in the Glossary of
Prosthetic Terms (1987)130apparently to meet the need of a point centric occlusion.
However, no lateral moves for centric relation were made although it also had
been slated for obsolescence. Perhaps for definitions, the focus should be on the
unreconstructed, natural dentition rather than dentures and the complete mouth
reconstruction. The management of the changes in the definitions of centric
relation and centric occlusion will be considered in the following sections.

Centric Relation: Destined for Obsolescence?

There have been ongoing changes in the definition of centric relation and
how it is obtained since it was recognized to have reference value for maxillo-
mandibular relations in the edentulous patient. The impact that such changes
have had on the practice of restorative dentistry has not been determined;
however, compared with the extensive literature on the concepts of centric
242 ASH

relation, there are much fewer detailed descriptions of the science and theories
related to the methods for obtaining and recording it. There is an incorrect
assumption that duplication of a record (i.e., interocclusal, needle point, elec-
tronic) of centric relation is more than two points of a statistical dispersion.
Perhaps as suggested in the fifth edition of the Glossary of Prosthetic Terms
(1987),130the "term [centric relation] is in translation to obsolescence." A consid-
eration probably reflected in the suggestion by Moss." "Despite its theoretical
clinical utility, the search for an immutable condylar position, defined as centric
relation, within the temporomandibular joint unfortunately is an ephemeral
undertaking."
It should not be concluded that definitions of centric relation began with
the first edition of the Prosthetic Glossary (1956)130;discussions about the centric
intermaxillary relationship began much earlier and were often related to the
arrow point tracing. Posselt'!" summarized opinions on the arrow point tracing.
The gnathology group85,88,124,128, 49 believed that the arrow point contact position
should coincide with the intercuspal position to be physiologic, whereas a lack
of coincidence should be nonphysiological. Another group headed by GysiI2.40,
50,61believed that the mandible could be moved actively or passively posterior
of the arrow point, into a strained or forced relation, The Hall group": 33, 54,72
thought that the arrow point was a retruded or strained intermaxillary relation-
ship and preferred the mandible to be about one rnrn anterior to the arrow
point. The interpretation of an arrow point tracing also involved a number of
other terms including centric position.':" mandibular posteriority."? and centric
relation.v- 53,93 At one time or another, positions of the mandible corresponding
to the arrow point, or anterior to it and even the rest position have been called
centric relation.'?' However, the identity of the location of centric relation has
not been in serious question for more than 50 years; only the name, centric
relation, appears to cause some ideological distress.
Obviously the possibility that a strained or forced relationship could be
involved in determining centric relation was a concern in the period of the 1920s
to 1950s as there was for the period of time when editions 1 through 4 of the
Glossary of Prosthetic Terms were being prepared,
From the first edition (1956) to the fifth edition (1987) of the Glossary,130 all
the definitions of centric relation have included the terms most retruded, lateral
movements, and most posterior unstrained position of the condyles in the glenOid
fossae definition, As seen by these terms, there was concern about a strained
relationship that can occur in guiding the mandible into centric relation, includ-
ing a caution against a strained relationship that was sufficient to cause discom-
fort in lateral movements. The inclusion of the phrase "from which lateral
movements can be made" does not indicate to me that there are posterior
positions where no lateral movements can be made as suggested by Celenza":
it does tell me that it is possible to force the mandible so far distally as to make
lateral movements uncomfortable, strained, and unphysiologic, Because of the
presence of detailed descriptions of obtaining and recording centric relation by
Ramfjord and Ash,'03 Dawson," and others, it does not seem likely that dentists
in general have forced (over-retruded) the mandible into strained position be-
cause of the terminology used in the Glossaries of Prosthetic Terms (first through
fourth editions), Perhaps the definition of centric relation in these editions were
reflections of gnathological concepts of centric relation,
The fifth edition of the Glossary of Prosthetic Terms (1987) defines centric
relation as, "A maxillomandibular relationship in which the condyles articulate
with the thinnest avascular portion of their respective disks with the complex
in the anterior-superior position against the slopes of the articular em i-
 PHILOSOPHY OF OCCLUSION: PAST AND PRESENT 243

nence .... This is clinically discernible when the mandible is directed superi-
orly and anteriorly and restricted to a purely rotary movement about a trans-
verse horizontal axis." This definition of centric relation is very close to that
described by Sicher!':' for an occlusal position and by Dawson" for centric relation
and his method of obtaining centric relation. However, the assumption that the
exact position of the condyle-disk assembly is clinically discernible does not
seem defensible. The issue about whether centric relation is a functional position
is not addressed. If the term centric relation is on its way to obsolescence as
suggested in the definition, what will replace it? Hopefully, not an ideological
term, marinated in semantics and arrived at ex parte. There seems to be more
than enough definitions in the 6th edition (1994)130but no evidence of the term
becoming obsolete yet.

Significance of Conceptual Changes

Although in the definition of centric relation the position of the condyles

(condyle-disk complex) in the mandibular fossae has changed, the practical
significance of those changes have yet to be clarified. Because the position of the
hard and soft tissues making up the condyle-disk cannot be determined exactly
when the mandible is clinically guided into centric relation regardless of the
definition of centric relation, discussions of where the complex is actually located
relative to a reconstruction can only be speculative.
Reconstruction to point centric now involves a change from a strained,
over-retruded position of the condyles to a anterior-superior position which has
been defined by appropriate mandibular manipulation for decades as centric
relation and defined as a reference border position irrespective of the way the
position has been defined by the Glossary of Prosthetic Terms over the years until
recently (1987). The statement by Celenza." "centric relation should be consid-
ered as a means to an end rather than a position with therapeutic capability,"
means to me that reconstruction to a border position (or centric relation, how-
ever defined) is not recommended.

CENTRIC OCCLUSION

Centric occlusion is the intercuspal position of the teeth; for example, the
position of the teeth in maximum intercuspation. It is a definition that has been
in the literature for years. For about 90% of normal young adults, the average
distance between occlusal contact when the mandible is in centric relation, and
the intercuspal position when the teeth are in maximum intercuspation is about
1 mm.101 The intercuspal position and centric occlusion have been equivalent
for decades.
In the 4th edition of the Glossary of Prosthetic Terms,'?' the term centric
occlusion is defined as "The centered contact position of the occlusal surfaces of
the mandibular teeth against the occlusal surfaces of the maxillary teeth." How-
ever, in the 5th edition (1987), the definition has been changed to "The occlusion
of opposing teeth when the mandible is in centric relation .... This mayor
may not coincide with the maximum intercuspation position." It would be better
if the latter statement read "This position coincides with maximum intercus-
pation in the natural dentition in no more than 10% of normal young adults."
In the 5th edition centric occlusion was slated for obsolescence. In view of the
absence of a reference to obsolescence in the 6th edition (1994), a number of
244 ASH

questions about the lateral shift in the definition could be, and should be raised
about centric occlusion, quo vadis?
The definition of centric occlusion remains the same in the 6th edition of
the Glossary. In addition, the reader is asked to see "maximum intercuspation,"
which is defined as "complete intercuspation of the opposing teeth independent
of condylar position." Contrast the way that the definition of centric relation is
done compared with the way that centric occlusion is managed in the 6th edition
of the Glossary.13l
The term centric relation occlusion was used by Celenza IS to indicate a
position of maximum intercuspation coincident with the joints in a centric
relation position. Centric occlusion (acquired occlusion) was defined as intercus-
pation without reference to the joint position. IS Because the term centric relation
has not become obsolete after all, the term centric relation occlusion would be a
much better term to avoid confounding the literature by changing the definition
of centric occlusion to satisfy a few.

OCCLUSAL INTERFERENCES
An occlusal interference is an occlusal contact relationship that interferes in
a meaningful way with function or parafunction." 103 Thus, an operational defini-
tion for treatment of an occlusal interference requires that some evidence of
an interference to function or parafunction be present. The effect of occlusal
interferences on the masticatory system has been studied with the placement of
experimental interferences.v- 104
A premature contact is a general term referring to any occlusal contact
relationship that prematurely stops closure into acceptable occlusal contact rela-
tions in centric relation, centric occlusion, and into a functional (working) or
nonfunctional (balancing) side position, regardless of whether the contact ac-
tively interferes with function or parafunction. Thus premature contacts do not
necessarily interfere with function or parafunction or cause dysfunction (e.g.,
trauma from occlusion) if efficient functional or structural adaptation occurs.
Balancing side contacts that do not interfere with function, cause or aggravate
bruxism, or do not cause traumatic occlusion, are not considered occlusal inter-
ferences. Slow avoidance of an interference by structural adaptation occurs
(e.g., tooth movement) with transient, sometimes overt, symptoms. Functional
adaptation to premature contacts (e.g., rapidly learned or already learned, pre-
programmed jaw movements) may only be reflected in the muscle response to
prevent closure onto a premature contact in centric relation. Most clinicians
have felt the effect on the mandible of reflex muscle action that occurs when the
jaw muscles are generally relaxed except when the mandible is guided in centric
relation closure onto a premature contact that has a significantly greater vertical
than horizontal component to a slide in centric.
As much as 90% of healthy young individuals have an average difference
of 1 mm between centric relation and maximum intercuspatiori'?': therefore it
can be expected that most young adults will have premature contacts in centric
relation but that not all of the premature contacts will interfere with function
sufficiently to cause dysfunction. The identification of those premature contacts
that do cause dysfunction requires appropriate evaluation; however, diagnostic
certainty is not always possible. Iatrogenic premature contacts are usually the
easiest to associate with dysfunction.
The concept of occlusal relations causing microtrauma to the joints and
periodontium is considered possible but a prophylactic occlusal adjustment
 PHILOSOPHY OF OCCLUSIOI : PAST AND PRESENT 245

cannot be considered to be appropriate at this time without further prospective

therapeutic studies like those of Kirveskari and associates=?" and Burgett and
coworkers." Until reviews and personal ideologies are replaced by sufficient
scientific facts, the association of occlusion to temporomandibular muscle disor-
ders (TMD) and periodontal disorders will remain a controversial issue.
Iatrogenic premature contacts in centric occlusion can usually be identified
as active occlusal interferences and involved in trauma from occlusion. Patients
generally object very rapidly to premature contacts in centric occlusion from
new restorations with such complaints as the tooth "feels high," "it's sore to
bite down on," "my jaw (joint) aches," and other forms of discomfort such as
atypical facial pain. Vague symptoms associated with phantom tooth pain and
phantom bite may make diagnosis more difficult.
Premature contacts in centric relation, and premature contacts on the work-
ing and balancing side may arise from natural causes (growth and development
of jaws and eruption of the teeth); dysfunctional causes, such as temporomandib-
ular joint and muscle disorders; or acquired causes, including restorations,
extractions, orthodontics, and interocclusal devices.
Symptoms of dysfunction from iatrogenic occlusal interferences can some-
times be related to the time of placement of restorations. If so, occlusal
adjustment or removal of the restoration(s) will usually result in quick relief of
symptoms; however, muscle symptoms are relieved much more quickly (i.e., 5
to 7 days) than those arising from the temporomandibular joints (e.g., weeks to
months), especially where the joint was already compromised before the place-
ment of the restoration .•' 103
The beneficial effects of an appropriate occlusal adjustment on trauma from
occlusion, whether it relates to the teeth, muscle, or joints, are not always
clear. It is relatively easy to understand, however, how removal of an occlusal
interference ("high filling") that prevents closure into maximum intercuspation
can give quick relief of symptoms. The relief from temporomandibular joint
symptoms that often occur with an appropriate and indicated occlusal
adjustment may consist of providing a slightly greater range of movement, that
is, allow the condyle-disk assembly to seat into a slightly different position in
the mandibular fossa that is non traumatic. The change to a more favorable
position may be only a fraction of a millimeter.
When the mandible is guided correctly into centric relation, and an occlusal
contact prevents maximum intercuspation, the premature contact in centric
cannot be considered operationally as an occlusal interference unless it can be
determined at the time that it interferes with function or parafunction. In
epidemiological studies where associations between occlusal interferences and
dysfunction are being considered, it is not unusual to find that all premature
contacts in centric (or other positions) are "counted" as being occlusal interfer-
ences in the absence of evidence of being an interference to function or parafunc-
tion. Counting all kinds of premature contacts as occlusal interferences leads to
"swamping" of real data with false-negative data and contributes to the contro-
versy about the role of occlusal interferences in dysfunction.
The significance of occlusal factors in the etiology of dysfunction has been
questioned in several studies and reviews I., 32,74. Ill; however, a relationship has
been supported but again only a few will be cited.": 63, 68, 69, 9. The reasons for
these different points of view are complex but certainly one factor is the way
that occlusal interferences are defined, and with the exception of the ongoing
study by Kirveskari and coworkers.":" there is a virtual absence of prospective
longitudinal studies of the effects of the removal of all active and passive
occlusal interferences by occlusal adjustment. Objections to the statistical
246 ASH

evidence presented in the ongoing study by Kerveskari and associatesw " have
never been substantiated,

BRUXING AND CLENCHING

It has been shown experimentally that bruxism can be initiated by the

placement of occlusal interferences'< 10";however, not every patient with prema-
ture contacts bruxes. Clenching and grinding of the teeth are complex psycho-
physical events.'!' and a number of factors can be involved. For example,
clenching and bruxing can be aggravated by medications (e.g. lithium), by
occupational stress, or by intraoral local physical or stressful factors (e.g.. occlu-
sal interferences to parafunction-bruxing). There is a significant correlation be-
tween bruxism, palpation muscle tenderness, and tension-type headaches. The
use of stabilization type, occlusal bite plane splints not only prevents the effects
of bruxism on the teeth, but reduces the severity of bruxism.':" Even so, the role
of occlusion in bruxism remains a controversial issue.38,39

TEMPOROMANDIBULAR DISORDERS

Temporomandibular joint and muscle disorders (TMD) or craniomandibular

disorders (CMD) represent collectively mandibular musculoskeletal disorders
that may be part of a larger system (body) disorder with associated complex
behavior." Thus, for example, a muscle or joint disorder of TMD may be only
one area involved in a generalized fibromyalgia or generalized arthritis; and the
behavior of chronic TMD pain may be a reflection of a generalized anxiety
disorder. The relationship of tension-type headache associated with masticatory
muscles painful to palpation has been considered in The Headache Classification
Committee of the International Headache Society (IHS).58 The IHS classification
includes term oromandibular dysfunction (OMD)89 OMD is a collective term for a
number of clinical problems that involve the masticatory musculature, temporo-
mandibular joint, and related structures."

Etiology

The etiology of temporomandibular and muscle disorders collectively has

been considered to be multifactorial, but generally caused by an untoward
interplay between neuromuscular, TMJ, occlusal, and psychological factors.
There is a trend to view the problem, however, as involving social as well
as physical and psychological factors, and such terms as psychophysical and
psychosociophysical have been used to replace the term multifactorial in describ-
ing etiologic factors in TMD. Even so, the degree of uncertainty that relates
to social and psychological factors, singularly or in combination should be
recognized.
Except for acute trauma to the mandible, joints, and muscles, the effect of
proposed chronic, micro traumatic incidents, has not yet been clearly established,
for example, trauma from occlusion from clenching and bruxing, painful, acci-
dental biting on hard objects, and prolonged mouth opening during dental
treatment. The adverse response of the muscles to unavoidable occlusal interfer-
ences have been clearly established. The long-term prospective studies of Kirv-
eskari6ll-70indicate that removal of premature occlusal contacts does reduce the
 PHILOSOPHY OF OCCLUSION: PAST AND PRESENT 247

symptoms of TMD. The role of clenching and grinding of the teeth in the
etiology of TMD is not understood but may relate to persistent microtrauma of
the temporomandibular joints.
The role of psychological stress as a factor in bruxism seems apparent, but
a role for stress-induced dysfunction has not been demonstrated. The psychosoc-
iophysical factors that have been suggested include stress, anxiety, depression,
and somatization. These factors appear to be significant only for those relatively
few patients seen in general practice that have chronic pain (determined by
appropriate assessment) associated with a TMD and the psychosociophysical
dysfunction is expressed as depression, anxiety, multiple physical symptoms,
excessive utilization of health care services, overuse of medications, and avoid-
ance of personal, social, and work responsibilities.

Some Historical Perspective

The problems of temporomandibular and muscle disorders seem to have

been recorded in the literature no better or no worse than other medical prob-
lems so the history of treatment will be sketchy as well. It is not always possible
to ascertain exactly what disorder is being described in early publications.
However, articles on TMJ problems and treatment are to be found from the
1880s onward, especially those that relate to surgical treatment of ankylosis,
luxation of the mandible, trauma, infection, and disk disorders+ 134 Surgical
treatment for disk displacement has continued 30, 36, 67; however, considerable
changes in approaches to disk replacement have occurred because of inadequacy
of the materials being used.

Loss of Vertical Dimension

In the early part of this century, Monson." Wright.':" and Goodfriend" were
concerned about a loss of vertical dimension, especially as it related to deafness.
This changed the emphasis away from the temporomandibular joint structures
to loss of teeth and changes in the occlusion which were thought to be related
to hearing problems.'?' Onlay splints on posterior teeth were used to increase
vertical dimension; however, the undesirable side effects were intrusion of
posterior teeth and extrusion of anterior teeth. Other kinds of splints for increas-
ing vertical dimension resulted in intrusion of the anterior teeth and extrusion
of the posterior teeth.57, 129

Costen's Syndrome

Costen" described a syndrome of ear symptoms and later additional symp-

toms that he attributed to disturbed function of the joints due to loss of teeth
and mandibular overclosure. Although the rationale for the symptoms was
incorrect, recent reappraisals of subjective hearing loss and tinnitus have sug-
gested that occlusal therapy for some TMJ and muscle disorders may be
beneficial." 105

Distal Displacement of Condyles

Another idea for the cause of dysfunction was distal displacement of the
condyles with damage to the joint structures. Radiographic techniques were
248 ASH

used for the diagnosis and various forms of occlusal therapy were used to correct
the displacement, including biteplanes, splints, and restorative dentistryH.75. 135
This concept, however, does not appear to be valid." A variation of this concept
is related to anterior disk displacement; however, the emphasis was on treatment
related to repositioning the disk rather than on obtaining condylar concentricity
(radiographically). In the first case, the position of the disk was not known or
perhaps not of interest at the time; in the second case, the position of the disk,
except for arthrography or later magnetic resonance imaging, was assumed to
be displaced on the basis of clinical assessments that were based on incorrect
diagnostic procedures.

Occlusal Bite Plane Splint

In the 1950s to 1960s, bite planes and occlusal splint appliance were advo-
cated by Posselt'?' to eliminate temporary occlusal interferences and to allow
ideal seating of the condyles in mandibular fossae. The Sved appliance."? which
was used on the maxillary arch, and an occlusal splint, which was used on the
mandibular arch, were used for the treatment of TMJ and muscle disorders
related to occlusal dysfunction. During the same period of time, the occlusal
bite plane stabilization splint was developed for treatment of TMJ and muscle
disorders.'?' This device is a hard heat processed acrylic device with a flat plane,
cuspid rise, no incisal guidance, full coverage, and freedom in centric? It is not
a flat occlusal splint."

TMJ Internal Derangement

Internal derangement is a biomechanical interference with smooth gliding

movements of the temporomandibular joint resulting from a disturbance of the
disk, capsule, or articulating surfaces of the condyle or eminentia, including
elongation, tearing, adhesions, perforations, synovitis, and capsulitis. Some ante-
rior displacement of the disk may be present without symptoms, and pain
may be absent even with advanced derangement and associated degenerative
osteoarthritis that can be seen radiographically.
In one classification of internal derangement.':" three types are described:
Type 1, disk displacement with reduction (TMJ clicking); Type II, disk displace-
ment with reduction and episodic catching; Type III, displacement without
reduction. It is no longer felt that Type I will progress to Type III as a conse-
quence of a natural history of temporomandibular disorders. Treatment for disk
displacement includes reversible forms of treatment.tv ?' anterior repositioning
devices." and surgery."

Anterior Repositioning Devices

A nonsurgical approach to disk displacement, such as, repositioning the

disk anteriorly by positioning the mandible anteriorly using a protrusive splint,
was advocated by Parrar-" and by the 1980s anterior repositioning devices were
in general use." 23•• 2. 95 This form of treatment for temporomandibular disorders,
however, raised a number of questions about its benefit-cost effectiveness.
One of the proposed benefits of the device was to "recapture the disk,"
which in many instances was not displaced or could not be "captured" in any
 PHILOSOPHY OF OCCLUSION: PAST AND PRESENT 249

case. Unfortunately some of the devices were little more than destabilization
splints that covered only the posterior teeth. Some were being used even when
the state of the disk was unknown. There was a high risk of producing malocclu-
sion when the mandible could not be "stepped back" even after a few weeks
use of the device. For the risks involved it was not predictably effective for relief
of pain or "locking." There were dramatic effects in some instances, but it was
often used without an acceptable diagnosis for a treatment that could and did
lead to irreversible changes that required difficult and time-consuming treat-
ment.v 83,118Generally accepted, specific indications for the use of anterior reposi-
tioning devices have not been established.

Diagnosis

The diagnosis of one of the temporomandibular disorders cannot be based

simply upon a categorical grouping of classical symptoms, for example, pain/
tenderness of joints and muscles, joint noises, and deviation or limitation of
mandibular movements, Diagnostic criteria need to have significance, For exam-
ple, painless TMJ clicking was considered in the past to have significance for
preventing the progression of TMJ dysfunction, This dogma of a downhill
progression in the natural history of TMD is no longer considered to be valid,
and preventive therapy for painless TMJ clicking is considered to be over
treatment, that is, outside the appropriate standard of patient care.
A part of the diagnostic process is to determine what occlusal therapy is
likely to be effective, Removal of a premature contact that does not interfere
with function or parafunction (e.g., aggravate bruxism) is not likely to benefit
the patient's symptoms; however, it is likely to benefit the patient if the develop-
ment of TMD symptoms parallels the placement of a crown with a premature
contact in centric relation.
Of help in the diagnosis of temporomandibular and muscle disorders is the
development of clinical diagnostic criteria and classifications of TMJ and muscle
disorders'" 125,132;integration of temporomandibular disorders into the Interna-
tional Headache Society (IHS) headache classificatiorr", and the use of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R),29 Unfortunately,
it is easy to get carried away with somatization of occlusal dysfunction and
forget that psychosociophysical problems usually only make up a small part of
the problems of patients with temporomandibular joint and muscle disorders,

Imaging

Some reasonable clinical evidence should substantiate the need for imaging:
usually pain that does not appear to be responding to conservative treatment in
5 to 7 days, irreversible treatment being planned, history of rheumatoid or
degenerative arthritis, after trauma, and when there is chronic internal derange-
ment with disk displacement without reduction, Special imaging methods, such
as arthrography, arthroscopy, magnetic resonance methods, or even simple types
of dental office radiographs, are not routine procedures and require specific
indications.' In a contentious litigious locality, the absence of any TMJ imaging
(e.g., transcranial, panoramic) may be more damaging than an accusation of
overdiagnosis or not being cost-effective, TMJ or panoral radiographs taken for
TMD diagnostic purposes must have a written report, however brief. Do not
assume that radiographs in the record speak for themselves,
250 ASH

At this time chronic TMD pain is considered in the same light as other
musculoskeletal disorders, including low back pain, and recognized to have an
impact on the life of the patient and may lead to the development of illness
behavior. For the relatively small number of patients with chronic TMD pain,
including those presenting with neurosensory complaints, for those whose
symptoms indicate psychological distress, for example, sleep dysfunction and
eating disorders, and for those that have other relevant stressors, psychosocial,
or psychiatric evaluation may be indicated.

Patient Management

The management of patients with temporomandibular disorders has

changed recently in the last 5 to 10 years from an emphasis on structures to a
concern for symptoms, that is, from the diagnosis of internal derangement and
treatment of disk displacement to the assessment and control of pain and
behavior disorders. There is much more emphasis on conservative, reversible
forms of therapy.
The emphasis in therapy should be the alleviation of pain without alteration
of the structural and functional integrity of the masticatory system; however, it
is recognized that in a small percentage of patients there may be a need for
irreversible therapy. The need should be clearly established by careful evaluation
of the patient's history, clinical examination findings, and an assessment of the
response of the patient to appropriate reversible forms of therapy over a reason-
able period of time.
The initial treatment for the majority of patients with TMD is (1) physiother-
apy, dietary, and occupational restrictions when indicated, appropriate analge-
sics and counseling with assurance about the nature of the problem; and (2)
occlusal bite plane therapy if the measures outlined in (1) are not in themselves
effective after about 2 weeks.v " 103
Occlusal therapy for active TMD is indicated when occlusal contact relations
(1) interfere with function or aggravate clenching or bruxism; (2) cause trauma
from occlusion; or (3) contribute to occlusal instability.
The identification of psychological problems in TMD patients may be
needed in some instances, especially for those patients with chronic pain and
associated behavioral disorders. Brief self-rating instruments to assess psycho-
logical factors may provide the best cost-benefit-risk approach in the private
practice setting for solving the problem of knowing when to refer a patient to a
clinical psychologist or pain clinic."

SUMMARY

Controversy in a field usually stimulates research to find answers and to

promote clinical excellence. Thus, differing ideas about occlusion relative to
centrics, gnathology, TMD, occlusal adjustment, and periodontal therapy have
led to a controversial body of literature; however, I think also it has led to better
treatment for patients, regardless of whether, for example, the concept of point
centric or freedom-in-centric is advocated. No one can practice dentistry without
some concept of occlusion whether it is applied to one or two teeth or to
complete mouth restoration. Although the work of committees to clarify termi-
nology is quite appropriate, common usage, semantics, avoidance of confusion
in the literature, and the ideological nature of the bias in science must be
254 ASH

88. McLean OW: Diagnosis and correction of occlusal deformities prior to restorative
procedures. J Am Dent Assoc 26:928, 1939
89. McNeil C (ed.): Craniomandibular Disorders. Guidelines for Evaluation, Diagnosis,
and Management, ed 2. Chicago, AAOP, 1993
90. Monson GS: Impaired function as a result of closed bite. atl Dent Assoc J 8:833, 1921
91. Moss ML: A functional cranial analysis of centric relation. 19:431, 1975
92. Muraoka H, Iwata T: A comparative study on manipulation for centric relation. J
Gnathology 1:47, 1982
93. ational Society of Denture Prosthetists [Report]: J Am Dent Assoc 17:1122, 1930
94. ilner M: Relationships between parafunctions and functional disturbances in the
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95. Okeson JP: Management of Temporomandibular Disorders, ed 2. St Louis, CV
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96. Palla S: Eine studie uber die Kondylenposition in Roentgenbild. SSO Schweiz Mo-
natsschr Zahnheilkunde 87:304, 1977
97. Pameijer J, Brion M, Glickman I, et al: Intraoral telemetry: IV. Tooth contact during
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98. Pameijer J, Brion M, Glickman 1, et al: Intraoral telemetry: V. Effect of occlusal
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99. Phillips GP: Fundamentals in the reproduction of mandibular movements. J Am Dent
Assoc 14:409, 1927
100. Posselt U: Physiology of Occlusion and Rehabilitation. Philadelphia, FA Davis, 1962
101. Posselt U: Studies in the mobility of the human mandible. Acta Odontol Scand,
lO(suppl 10):1-160, 1952
102. Preston J.D: A reassessment of the mandibular transverse horizontal axis theory. J
Prosthet Dent 41:605, 1979
103. Ramfjord SP, Ash MM: Occlusion. Philadelphia, WB Saunders, 1966
104. Randow K et al: The effect of an occlusal interference on the masticatory system: An
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105. Rubinstein B, Carlsson GE: Effects of stomatognathic treatment on tinnitus: A retro-
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106. Schuyler CH: Freedom in centric. Dent Clin orth Am 13:681, 1969
107. Schuyler CH: Correction of Occlusal disharmony of the natural dentition. NY J Dent
13:445, 1947
108. Schuyler CH: Principles employed in full denture prosthesis which may be applied
to other fields of dentistry. J Am Dent Assoc 16:2045, 1929
109. Schwartz L: Disorders of the Temporomandibular Joint. Philadelphia, WB Saunders,
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110. Sears VH: Problems of occlusion in partial denture construction. J Am Dent Assoc
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111. Seligman DA, Pullinger AG, Solberg WK: Temporomandibular disorders: Part III:
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114. Sicher H: Oral Anatomy. St. Louis, CV Mosby, 1949
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carefully considered. At times we learn from history that all ideologies need
constant revisions; too often the need leads to changes by fiat rather than by
virtue of research on problems that may actually exist in communication.

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Major M. Ash, Jr, DDS, MS, Dr hc
University of Michigan
School of Dentistry
Ann Arbor, MI 48109