Dental equilibration and osteopathy

HAROLD I. MAGOUN, SR., D.O.. FAA() Belen, New Mexico

Osteopathic medicine

The problems of pain and dysfunction in the temporomandibular joint and the efforts of the dental profession to ameliorate them by equilibration or pivoting of teeth is reviewed. The difficulties encountered and the divergent opinions of experts in the dental field are discussed. The thought is then advanced that at least part of the problem could be solved by dentists' recognition of Sutherland's discovery that the cranial articulations possess slight mobility throughout life that the temporal bones and so the temporomandibular articulations are not linked in rigid juxtaposition to serve as reference points in obtaining balance in the occlusion. The need for cooperation by informed members of both professions is discussed.

One of the high priorities ... in our program for the future of osteopathic medicine must be to increase our contribution to the world's medical literature about the effectiveness of those distinctly osteopathic modes which have played such a role in our successful search for recognition.

The American Equilibration Society, an international group of dentists and physicians, was organized in 1955 for the study, prevention, and treatment of temporomandibular dysfunction. The late Victor H. Sears, DDS, was its first president. Thanks to the results obtained by the late Alvera Miller, D.O., in treating patients, Dr. Sears was convinced of the logic and efficacy of osteopathy in the cranial field in his specialty. This review of the interrelated philosophies of dentistry and osteopathic medicine may well be dedicated to these two stalwarts, along with the others who participated in the practice. Their work illustrates Northup's i statement:

In simplest terms, three symptoms of temporomandibular dysfunction predominate: limited mandibular movement, pain, and joint noise. The first efforts of the American Equilibration Society were directed toward a correct functional relation between upper and lower dentures. To achieve this, an anatomic landmark which could be used as a reference point in determining existing jaw relations was sought. At first the condylar fossae were thought to be the controlling factors in determining the position and excursion path of the mandible and were deemed to be the desired landmarks. It was found, however, that internal balance alone was not enough, especially in the presence of partial dentures, because of the retrusion or protrusion of the mandible as well as the rotary movement often present in chewing. Further study suggested that hypertonic or hypotonic muscles of mastication cause imbalance in the tooth-to-tooth relations, and it was deduced that the function of the temporomandibular joint (TM J) and related structures depends on correct occlusion of the biting surfaces of the teeth. It was recognized also that a correct functional relation between the upper and lower jaws was absent in many adults with all their own teeth and that even children sometimes need equilibration. For this reason methods of remedying the abnormality by grinding off prominences, training muscles, or building up the low areas with so-called pivots or occlusal splints were developed. Sears2 has been called "the father of occlusal pivoting." He experimented for years on the theory that stress in the chewing mechanism might be lessened or relieved if the "feedback" of muscle spasm from malocclusion was neutralized by having the splints, the build-up on the deficient teeth, adjusted for equilibrium at the optimal working length of the

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Dental equilibration and osteopathy

muscles. This was a trial-and-error procedure, but it worked sufficiently well to induce many dentists to use it. Gradually the field of interest widened. While the postural relations of the upper and lower jaws were of primary concern, because improper positioning could exert harmful influences on the teeth as well as the muscles of mastication and related structures, research was directed to painful syndromes in the head and neck, abnormal muscle habits, headache, earache, tinnitus, intermittent deafness, jaw locking, trismus, bruxism, accelerated wear, hypermobility, hypersensitivity, and other symptoms. May3 even went so far as to suggest that every time the teeth are put together the entire nervous system is programmed. So the science of "oral orthopedics," including both intraoral and extraoral areas, came into being. Much has been written about the possible implications of abnormalities in this area. Attention has been directed to the muscles of the tongue and cheek, the hyoid mechanism, and other related structures of the neck and shoulder girdle. Stoll* extended the concept to its limits when he contended:
When a part of the body, e.g., the mandible, assumes an abnormal position in relation to the rest of the body, it upsets the correct postural maintenance of the body against gravity.

The diagnosis and treatment of such abnormal relations, as well as the disturbances arising therefrom, have brought out a considerable variety of opinions and conflicting views concerning the problem. Much careful study and skillful craftsmanship have gone into the work, but apparently the complete answer has yet to appear. Sears 2 expressed the opinion that osteopathy in the cranial field provided at least a partial solution to the enigmas. It is my purpose here to bring that possibility to the attention of both dental and osteopathic professions. Sears' untimely death prevented him from doing so. Considering some of the more common etiologic factors, Dawson5 found a cause-and-effect relation between deviating interferences and muscle spasm,

especially of the pterygoid muscles. When there was disharmony between opposing muscles of mastication, he logically looked for spasms from prolonged contraction or stretching, with resultant fatigue and pain of local circulatory stasis and toxemia. He expressed the belief that the chronic contraction was due to the effort of the muscles to hold the mandible in its proper position of physiologic balance in the presence of malocclusion or an ill-fitting denture. According to his philosophy of treatment, elimination of such irregularities would remove the stimulation to the muscles and thus the pathosis. He noted that involvement of the temporalis muscle could contribute to headache and that with involvement of all the muscles of mastication the chain of contraction and stretch reaction could include neck and shoulder muscles. Dawson was impressed with how little abnormality was required to disturb muscle balance. "The most minute discrepancy," he stated, "can trigger severe muscle imbalance and pain." However, he contended that build-up of the occlusal bite is an unscientific remedy. Stone, Dunn, and Rabinov6 attributed the TMJ pain-dysfunction syndrome to muscle hypertonicity, psychic tension, and occlusal disharmony, the last being the most common cause. A local disturbance, they suggested, could compromise the normal pattern of jaw movement, and the patient would unconsciously adopt the distorted pattern to avoid injury to the interfering tooth or teeth. The results would be a disturbance of the normal reflex pattern of mastication and loss of harmony or balance, possibly aggravated by psychic tension. The greater the compromise of muscle activity, the more intense the pain and the greater the stimulus in response to pain would be. They noted that discomfort might radiate upward into the temporal fossa, downward along the ramus of the mandible, superiorly to the vertex, anteriorly along the zygoma, posteriorly to the occiput, and even down along the trapezius muscle. Their treatment took the form of occlusal modification by grinding, muscle training movements, or

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the use of occlusal splints, usually the last, with emphasis on the best possible arrangement to meet the needs of the individual. The use of surgery or prosthetic devices was rare. Solberg, Flint and Brantner, 7 however, found little relation between the anxiety level and dental occlusion mandibular symptoms and reported that mandibular pain and dysfunction seemed to arise from muscular hyperactivity and some form of abnormal tooth contact, not psychic tension. Perry, 8 leaning toward the theory of neuromuscular control of mandibular movements, described two concepts for evaluating the relation between the integral parts of the masticatory system. The most retruded position of the lower jaw would allow sufficient mobility so that a small opening and closing movement, when the mandible is in the centric position, would conceivably be the hinge axis. Or he considered the rest position, in which the mandible is involuntarily suspended by the reciprocal coordination of the muscles of mastication and the depressor muscles of the jaw. He followed with a lucid explanation of the interrelation of the anterior and posterior neck muscles with the muscles of mastication and the importance of balance between the two groups. Emotional tension, he stated, can cause bruxism and pain. "Pain radiating in all directions from the damaged and painful capsule of the joint may simply be a case of referred pain, but more often it is muscular pain," he explained. In the temporal region it would be from a spastic temporalis muscle; in the cheek and jaws, from the masseter; in the tongue, from the digastric and geniohyoid muscles. "Mandibular joint pain," he concluded, "affects the muscles involved in mastication by spasm, trismus, and myositis, due to the long-standing isometric contraction of the muscles." In spite of the varied concepts advanced, the dental profession as a whole is still preoccupied with the condylar fossae. The basic concept seems to be that structural normality involves essentially tooth-totooth relations, plus the relations of the jaws to each

other and to the head. Structural aspects of the muscles occupy a less important role. Silverman') added a new and promising observation pointing toward what may be a better solution of the TMJ pain-dysfunction syndromes. In his own occlusion he noted the difference caused by sleeping on his face, using hand pressure against the facial bones, biting on a pipestem, vigorously blowing his nose, or opening his mouth wide as in a yawn. He even added a session in the V-shaped headrest of the average dental chair. He found that such pressures on the bones of the skull caused a temporary distortion and so a change in the normal occlusion which he suggested could be productive of pathologic change. He further noted that swallowing, eating, vigorous respiration, and some other influences would return the occlusion to normal. He stated:
A chronic, slight pathosis-producing occlusion can defeat the complete elimination of problems such as muscle spasms, sensitive necks of teeth, periodontal conditions, headaches, bruxism, and the like. . .. The skull is an elastic complex which can be temporarily distorted by various pressures on any one or more of its bones.

Silverman was not the first to recognize the possible etiologic contribution of such factors. Sears' saw the validity of such a concept years earlier. Bakee had an experience with a mild occlusal problem which led to a significant scientific research project, with the collaboration of Henningsen, who had written extensively about the matter previously." Other members of the dental profession also have seen the light. Had Silverman gone only one step further, he might have uncovered the key to many malocclusions and associated problems, especially the puzzling enigmas which have plagued devoted dentists who strive hard to solve them. He noted the resiliency in his own cranium and its temporary distortions. It would have been one short step further, but a long one for human suffering, had he recognized the presence of distortions that are not just temporary from the common trauma of this hectic life.

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Dental equilibration and osteopathy

To understand this, certain anatomic facts must be taken into account. The popular notion that the sutures of the skull fuse in midlife is absolutely erroneous. Sutures in the human cranium never fuse, unless there is local bone disease. This false concept has persisted because textbooks were written on the basis of study of dry, defatted laboratory specimens, the essence of rigor mortis. One fact should disprove the concept: No matter how old a person may have been at death, his skull, filled with dry beans and immersed in water so that the beans will swell, will come apart at the suture lines. The sutural conformations are consistently similar as to bevel, pattern, and type in every person who ever lived, even as every face has certain general characteristics which are always present. These sutures are true joints, not diarthroses but synarthroses, with a membrane always present within the joint and the usual nerve supply. The nerve in the suture is of considerable significance when pain is a factor. Because lifelong existence of sutures is a definite anatomic fact, it becomes necessary to go one step further and accept the concept of physiologic motion, however minimal, in these articulations. Indeed, only motion is physiologically capable of maintaining such joint surfaces throughout life and preventing ankylosis. Pritchard, Scott, and Girgis" made a histologic study of cranial sutures in man and a number of laboratory animals and concluded that they form "a firm bond of union between the neighbouring bones, which nevertheless allows a little movement" (Fig. 1). It would be logical to ask why there should be articular surfaces at all if not for movement. Moreover, the direction or type of movement suggested by any of the more than 100 marginal surfaces is never rendered impossible by formations adjacent or distant. The human skull is a marvelous example of unitary mechanism designed for physiologic function. To bridge the gap from the smooth-edged plates of membrane or cartilage in the newborn to the well-integrated sutures of the 6-year-old is to accept some plausible explanation

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i
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' ;,

niting iddle Capsular ambial

Fig. 1. Schematic drawing showing the results of histologic study. The periosteum splits into two layers at the suture line. The outer layers continue across on either perimeter to form the two uniting layers. The inner layer turns into the suture from either perimeter to form the fibrous capsules covering the edges of the bones. Between these two capsules there is a central zone, which, "with weak fiber bundles running in all directions and sinusoidal blood vessels, might allow some slight movement of one bone against the other and so could be considered analogous to a synovial joint cavity" (Adapted from Pritchard, Scott, and Girgis").

for such conformity. Sutures are serrated, beveled, grooved, harmonic, or interdigitated, or a combination of these, but they are consistently patterned in every human being who ever lived, just as are the facial characteristics. What more logical answer can be given than that every articulation evolves in relation to and in proportion to the slight amount of purposeful motion present physiologic motion that persists throughout life? It has been said often that life is motion. Why should the cranium be an exception to this? Its articular mobility can be recorded electronically, but the palpable clinical evidence is the most conclusive of all. After provisionally accepting the fact of cranial motion, however minimal, the next step is to look at some of the bones concerned with the oral cavity for evidence of the correctness of the premise. First the maxillae: why is it that some persons have a broad, flat palatine arch while others have a high and nar-

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row hard palate? The probability is that, over and beyond racial characteristics, heads were molded differently in the perinatal period. If both maxillae are rotated externally, the hard palate is low and the upper teeth tend to flare a bit. If both maxillae are in internal rotation, the roof of the mouth narrows and rises. The change may be so extreme that there is not room for the tongue, so that mouth breathing results (Fig. 2). The upper teeth are crowded. The premaxillae, carrying the four incisors, are pushed anteriorly to assume the position known as buck teeth. I have fully described the mechanics of such deformities elsewhere." The text also describes the application of molding in infant skulls warped by birth trauma and the modification of adult distortions from trauma. In some cases one maxilla may be in internal rotation and the other in external rotation. This explains why upper dentures often are asymmetric when viewed from the rear, with one flaring laterally more than the other. Vertical flutings in the intermaxillary suture allow some vertical shift also. Such positional disturbances contribute greatly to malocclusion. However, the mobility in cranial bones that is of greatest significance in dentistry is that of the temporal bones and consequently the temporomandibular fossae. Apparently most members of the

dental profession, misled by the anatomists, believe these two articulations to be fixed in position and coupled together as a rigid unit. This is not true. They are independently movable. Therefore, much of the painstaking work of the dental profession in diagnosis and treatment of TMJ pain-dysfunction syndromes has been confusingly disappointing. With such basic uncertainty the criteria of diagnosis and treatment have been difficult to establish. Henningsen" stated :
The true point of centric or balanced relationship of the jaws will not be found if the temporal bones controlling the position of the mandibular fossae are out of balance.

The axis of internal or external rotation (referring to the petrous ridge) of a temporal bone runs from the petrous apex to the jugular surface. In external rotation the temporomandibular fossa, being below the axis, moves slightly posteromedially. With internal rotation it moves anterolaterally. Commonly one temporal bone is lesioned externally and the other internally. While the arc of movement is slight, it is palpable and indeed often suggested by the position of the ears in relation to the sides of the head. Perinatal molding explains why some persons have both ears close to the head while others have ears that protrude noticeably, and still others have a combination, with one ear on an

Fig. 2. Left, external rotation of the maxillae, the ideal position, with a low, broad hard palate, ample room for the teeth and tongue, and no sagittal ridge (torus palatinus). Right, internal rotation of the maxillae with a narrowed, high palatine arch, crowding of the teeth and tongue, and a tendency for the premaxillae to protrude anteriorly. (From's).

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Disturbed joint mechanics, perverted function, abnormal motion, pain, and all the other symptoms are inevitable. The syndrome instead of having no apparent cause has a very evident one. Bessette, Bishop, and Mohl" said that the cause of the TMJ syndrome is controversial. They asserted that degenerative disease of the TMJ, congenital anomalies, arthritis, trauma, and inflammation may cause the condition but the vast majority of patients with symptoms have no radiographic or physical diagnostic signs. Neither sinusitis nor otitis media explains the syndrome. Obviously their investigation did not include the position of the temporal bone. Silverman 9 reported a deviation of the mandible of 0.978 mm. into an "abnormal, eccentric, maximum occlusal contact" caused by leaning the face on the hand, with the elbow on the table. He added: "The change in occlusion caused by skull distortion can be noted visually and by the proprioceptive 'feel' of the slide from this deflective occlusal contact." Checking the upper and lower midincisal line with the teeth gently closed is a quick way of noting such deviation. It would seem that if the dental profession would grasp the significance of these few facts, that the skull never ossifies without bone disease, that there is slight mobility in the cranial sutures, that the TMJ is particularly vulnerable to temporal malalignment, and that lesions of the cranial bones as to position or motion are almost universal because of birth trauma, toddlers' tumbles, adolescent roughhousing, school athletics, adult head bumps, whiplash injuries, and even rotation of the temporal bones internally by the V-shaped dental head rest, much that is shrouded in mystery could be clarified, and many patients would be relieved. It is of great credit to the dental profession that its members have striven hard to explain the various enigmas encountered in their work. It is not easy to part with ideas which have been handed down through generations of research. However, acceptance of Sutherland's" discovery with regard to cra-

nial physiology would simplify many of their problems. Checking the midincisal line or the mental tubercle indicates the side of the posteromedial fossa by the direction of the shift. Usually as the jaw opens the mandible will deviate in that direction and then back to the anterolateral side, the "rotary motion" many dentists have noticed. It should not be too difficult, then, to change the mental picture of the temporomandibular fossae from structures that are fixed in position and coupled together as a rigid unit to structures that move independently. The overlooked anatomic distortion of the temporal bones and their fossae would seem to explain a great many dental findings already noted," such as the early conclusion of the American Equilibration Society that internal balance alone is not enough because of the retrusion or protrusion of the mandible as well as the rotary movement often present in chewing. Comments on the "efforts of the muscles to hold the mandible in its proper position of physiological balance" when "the most minute discrepancy can trigger severe muscle imbalance and pain"5 also might be explained, as could the observation that a local disturbance could cause a compromise of the normal pattern of jaw movement, with unconscious adaptation by the patient to the distorted pattern. Also explainable are the conclusion that "the long-standing isometric contraction of the muscles" could be responsible for spasms, trismus, myositis, and pain in the muscles of mastication and the idea that "a chronic, slight pathosis-producing occlusion can defeat the complete elimination of problems such as muscle spasms, sensitive necks of teeth, periodontal conditions, headaches, bruxism, and the like." Trismus and bruxism deserve some consideration in this context. Trauma has been mentioned by several authors. In one case," there was a history of walking into a telephone pole, hitting the left side of the mandible, and later falling and striking the jaw on the corner of a desk. There was no fracture, but headache, trismus, and pain and stiffness in the

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shoulder and neck followed. All these were finally relieved when a general anesthetic was given. This seemingly relaxed the tissues so that normal motion returned. The condition was called "hysterical trismus," but traumatic would have been a more appropriate adjective. Bruxism is an abnormal habit of muscle hyperactivity, which Solberg and Rugh 19 said "causes excessive tooth wear, trauma from occlusion, and TMJ pain and dysfunction." The movement may be performed unconsciously while the patient is asleep or awake and may be brought on by nervous tension." Elaborate portable devices for registering muscle hyperactivity have been used to warn the patient to relax. A more logical approach might start with the idea that grinding the teeth is merely a conscious or unconscious effort on the part of the patient to relieve the discomfort of bony malalignment or, more fundamentally, to correct it. Babies act similarly when they have lesions of the condylar parts of the occiput from birth trauma. All the hair may be worn off the back of the head by constant rubbing. Head bumping may be continuous, yet when the structural correction has been made, all such action ceases. The same can be true of bruxism. Dawson 5 was puzzled by a burning pain in the muscles of mastication. Such phenomena are not uncommon in other parts of the body. Relief comes when the nerve is supplied with sufficient blood by correction of structure. A dentist, Dr. N. A. Shore, was reported2 to have told the American Association for the Study of Headache that TMJ dysfunction resulting in dental malocclusion "can set off a 'perpetual feedback cycle' of muscle spasms and pain," especially in the external pterygoid muscle. Reflex stimuli from this and other muscles in the area, he stated, "can produce pain in many parts of the head, neck and shoulders." It cannot be denied that phenomena of transference from the site of excitation to the site of reference is commonest over the peripheral branches of

the trifacial nerve, whose ganglion lies in close contiguity with upper cervical nerve roots, as well as the three occipital nerves on either side. However, a physician trained in the cranial concept is inclined to wonder if the so-called reference of pain to various parts of the head is not rather an indication of the site of the primary structural disturbance which is causing temporal malalignment and joint trouble. Again, let it be emphasized that there is a nerve in every one of these cranial sutures and that the lack of normal physiologic motion or a disturbance in position can arouse a painful response, locally or referred elsewhere. The cranium, like the rest of the body, is a unitary mechanism, and there cannot be malfunction in one part alone. Many dentists find it difficult to explain pathologic processes elsewhere on the basis of reflex disturbances in the bite. Cathie21 well elucidates the anatomic reasons:
Dental lesions and changes in the temporomandibular articulation are . . . capable of causing varied local and/or distant disturbances. The mechanism responsible . . . is neither a simple nor usually a single one. The answer may be through any structure along which force may be transmitted, in any structure upon or through which abnormal tension or traction may be applied, or in those liable to torsional deviation. The related vascular and nerve tissues are to be included. . . . Fascia and fascial specialization are of immediate interest . . . with . . . relation to the osseous structures lodging the dental arches.

In describing the various parts of the connective tissue, Cathie2 ' notes a variety of attachments that can be of significance between these osseous structures and the skull base: 1. A thickened portion of the superficial layer of the deep fascia passing from the styloid process of the temporal bone to the lower border of the mandible, the stylomandibular ligament. Further attachment of deep fascia along the mastoid processes, superior nuchal lines, and external occipital protuberance. 2. The pharyngobasilar fascia attached to the occiput, thence laterally to the angular spine of the sphenoid, the under surface of the petrous portion of the temporal bone, the medial pterygoid plate,

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up partly of branches from the cervical sympathetic ganglia. The cervical sympathetic chain lies on the longus coli muscle and the prevertebral fascia posterior to the carotid sheath, within which is the vagus nerve, which is also concerned with heart innervation. "Such a complexity of structure and function," Cathie" concludes, "is responsible for the production of some of the most bewildering problems of body and mind." This patient received intensive osteopathic manipulative treatment during the whole episode. It was noted that when the cervical and cranial areas were relaxed the symptoms abated, but changing the bite caused marked tensions in these areas, along with rather constant headache of a congestive type. While this was an unusually severe and involved case, it suggests that equilibration can be responsible for far-reaching effects, usually for good but sometimes for bad. Sears' was among the first members of the dental profession to accept osteopathy in the cranial field as of great significance in TMJ problems and malocclusion. Either from personal experience or from results on patients he had found it to be a more adequate answer to many dental enigmas. He remarked: "Dentists are finding that delicate adjustment of the occlusion, plus correction of the bony lesions, is much more satisfactory." Cooperation between the dental and osteopathic professions in selected cases would be the ideal solution. However, there is a fine line between correcting bony relationships and pivoting teeth which calls for the most skilled cooperation between the two professions, with mutual understanding of what is being done. The most careful work of the equilibrationist to meet a certain problem obviously can be undone if the cranially trained osteopath alters bony positions, even though it be for the betterment of the patient. At the same time, the most expert correction of structure will not persist if the tooth build-up is not physiologic. As Dawson' said, "The most minute discrepancy can trigger severe muscle imbalance

and pain." Logically, the anatomy should be normalized as far as possible first, and then attention should be paid to the deficiencies in tooth height and the like. But let no one insist that the reaction to such changes may be ignored. Henningsen" summed up the situation when he wrote:
The maintenance of a mobile, symptom-free cranial complex requires the team effort of both disciplines: the dentist to restore good occlusion and eliminate points of premature tooth contact . . . and the cranially oriented osteopathic physician who can maintain the cranium, including the temporal bones, in physiologic balance and function.

Summary
Dental equilibration by osteopathic manipulation is a relatively new approach to some of the problems encountered in that profession. The growth and development of the concept is briefed herewith with a discussion of some of the enigmas incidental to the temporomandibular joint pain-dysfunction syndrome, TMJ as it is commonly referred to in the literature. The use of build-up pivots or splints in the treatment of malocclusion and related problems is included. Attention is called to the fact that dentists, as a group, are unaware of the physiologic motion present in the cranial sutures and the possible influence of osteopathic cranial lesions, especially of the temporal bones in TMJ problems. Dental problems are compounded because of the fact that the maxillae are not in a fixed relation to each other nor are the temporomandibular fossae fixed in position and coupled together as a rigid unit, for articulation with the mandible. Cooperation between the two professions is urged.

I. Northup, G.W.: Where is the record? Osteopath Horizons 12:5, May 74 2. Sears, V.H.: Lecture to the Sutherland Cranial Teaching Foundation, Kirksville, Mo., 1956 3. May, W.B.: Personal communication 4. Stoll, V.: The importance of correct jaw relations in cervico-oro-facial orthopedia. Dent Concepts 2:5-9, 18, Apr 50

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5. Dawson, P.E.: Temporomandibular joint pain-dysfunction problems can be solved. J Prosthet Dent 29:100-12, Jan 73 6. Stone, S., Dunn, M.J., and Rabinov, K.R.: The general practitioner and the temporomandibular pain-dysfunction syndrome. J Mass Dent Soc 20:262-8, Fall 71 7. Solberg, W.K., Flint, R.T., and Brantner, Temporomandibular joint pain and dysfunction. A clinical study of emotional and occlusal components. J Prosthet Dent 28:412-22, Oct 72 8. Perry, C.: Neuromuscular control of mandibular movements. J Prosthet Dent 30:714-20, Oct 73 9. Silverman, M.M.: Effect of skull distortion on occlusal equilibration. J Prosthet Dent 29:425-33, Apr 73 10. Baker, E.G.: Alteration in width of maxillary arch and its relation to sutural movement of cranial bones. JAOA 70:559-64, Feb 71 11. Henningsen, M.G.: Living osteology of interest to the dentist. Dent Digest 63:447-53, Oct 57; 502-5, Nov. 57 12. Pritchard, J.J., Scott, J.H., and Girgis, F.G.: The structure and development of cranial and facial sutures. J Anat 90:73-86, Jan 56 13. Magoun, H.I.: Osteopathy in the cranial field. Ed. 2. Journal Printing Co., Kirksville, Mo., 1966 14. Yavelow, I., and Arnold, G.S.: Temporomandibular joint clicking. Oral Surg 32:708-15, Nov 71 15. Bessette, R., Bishop, B., and Mohl, N.: Duration of masseteric silent period in patients with TMJ syndrome. J Appl Physiol 30:864-9, Jun 71 16. Sutherland, W.G., cited by Magoun" 17. Kudler, G.D., et al.: Oral orthopedics. A concept of occlusion. J Periodontol 26:119-29, Apr 55 18. Salmon, T.N., Tracy, N.H., Jr., and Hiatt, W.R.: Hysterical trismus (conversion reaction). Report of a case. Oral Surg 34:187-91, Aug 72 19. Solberg, W.K., and Rugh, J.D.: The use of bio-feedback devices in the treatment of bruxism. J South Calif Dent Assoc 40:852-3, Sep 72 20. Half-minute test. Headaches traced to temporomandibular joints. JAMA 209:1153, 25 Aug 69 21. Cathie, A.: Fascia of the head and neck as it applies to dental lesions. JAOA 51:260-1, Jan 52 22. Strachan, F., and Robinson, MI.: Short leg linked to malocclusion. Osteopath News, Apr 65 23. Cathie, A.: Some anatomicophysiologic aspects of vascular and visceral disturbances with special reference to cardiac disease. Academy of Applied Osteopathy Year Book, Carmel, CaL, 1959, pp. 43-6 24. Henningsen, M.G.: Personal communication Submitted for publication in July 1974. Updating, as necessary, has been done by the author. Dr. Magoun is in private practice in Belen, New Mexico, and is a trustee of the Sutherland Cranial Teaching Foundation, Inc., Meridian, Idaho. Dr. Magoun, 460 Goddard Court, Rio Grande Estates, Belen, New Mexico 87002.

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