Donald A.

Seligman, DDS
Association of Occlusal Variables Lecturer

Among Refined TM Patient Andrew G. Pullinger, DDS, MSc

Associate Professor

Diagnostic Groups Section of Cnathology and Occlusion

UCLA School of Dentistry
Correspondence lo:
Dr A.C. Pullinger
Section of Cnalhology and Occlusion
One hundred ninety-six TMJ patients differentiated into five UCLA School of Dentistry
diagnostic groups (disk displacemenl with reduction fn = 40], Los Angeles, California 90024
disk displacement without reduction [n = 14], TMJ
osteoarthrosis with a history of past locking [n = 32], TMJ
osteoarthrosis without a history of past locking [n = 30],
myalgia only [n = 80]) were compared with 222 nonpatient
controls for specific occhisal variahles. The patient groups could
not be differentiated according to the absence of RCP-ICP .slide
per se, crossbite, or symmetry of RCP contacts. Among males
with reducing disk displacement, Class I was less common and
Class II division I was more cotnmon than in controls.
Asymmetric RCP-ICP slides and a combination of unilateral RCP
contact and no clinically visible RCP-ICP slide were more
prevalent in women with reducing disk displacement. Large RCP-
ICP slides, asymmetric slides, and anterior open bite were
associated with osteoarthrosis, but this study could not state if
these associations were etiologic or secondary. Totally
asymptomatic controls were characterized by a lack of anterior
open bite, small symmetric RCP-ICP slides (>0<J mm), and
bilateral occlusal contact in RCP. By comparing a control group
to well-defined patient diagnostic groups rather than according to
symptoms, selective occlusal variables appear more closely
associated with some TMJ disorders than indicated in past
studies with less specific populations. (J CRANIOMANDIB DISORD
FACIAL ORAL PAIN 1989;3:227-236.)

o consensus has been found based only on symptoms may

N between the many occlusal have masked associations to spe-
variables and symptoms of TMJ cific diagnoses. For example, the
disorders in prior studies. How- symptom of TMJ clicking may
ever, many of the past studies be tic
attributed to several diagnos-
categories, and the specific
were purely descriptive and did patient diagnosis
not use control populations. Fur- from osteoarthrosis may range
with unsta-
ther, previous approaches clas- ble disks to purely a soft-tissue
sified craniomandibular patient derangement.
groups according to symptoms
rather than diagnoses. Patients
with TMJ disorders need to be Atigle Class
treated as a potentially heterog- Journal of
enous group,'"^ and studies con- The association of broad mea- Craniomandibular Disorders:
sidering and grouping patients sures of occlusal types with Facial & Oral Pain 227
Seligman
craniomandibular disorders has
been equivocal and contradic-
tory. Earlier studies'*^ reported a
predominance of Angle Class II
division 2 subjects among dental
patients with TMJ symptoms.
Williamson' reported a predom-
inance of Class II division 1 pa-
tients, whereas Moiin et aP found
that more Class II men had mus-
cle tenderness and that Class III
men were overrepresented in a
severe dysfunction population.
In contrast, other studies show
no association of symptoms to
Angle class; namely, there was
no difference in class between
myofascial pain/dysfunction pa-
tients compared to controls' and
between patients witb TMJ click-
ing compared to controls.^ Epi-
demiologie surveys of children
and teenagers"" ' similarly stated
a lack of association of temporo-
mandibular disorders to Angle
class. Surveys of nonpatient den-
tal student populations found no
association between Angle class
and masticatory muscle tender-
ness'' or TMJ clicking.'^ Janson'"
studied Class II division 1 cases
and found no relationships be-
tween occlusal patterns and func-
tional disturbances within that
population. Evidently, past re-
search has failed to establish a
consensus on any assocation be-
tween Angle class and temporo-
mandibular disorders.
Functional Occlusal
Relationships
Excursive Interference. Few
occlusal factors have been stud-
ied more than mediotrusive (bal-
ancing) contacts. While this fac-
tor has been associated witb pain
and dysfunction in a few early
studies,'^ '^ a larger body of more
contemporary research seems
to refute this association. Sev-
eral studies of nonpatients'^'^'^
found no association. This neg-
ative finding is supported in
studies of pain/dysfunction pa-
tients.*-^"" No association was
found between the severity of me-
diotrusive facets and TMJ click-
ing, TMJ tenderness, or muscle
228 Volume 3, Number 4, 1989
tenderness in a nonpatient pop-
ulation." Further, one study of 75
postorthodontic patients and a
control group found no indica-
tion that mediotrusive contacts
predispose to temporomandihu-
lar disorders.^'
Lederman and Clayton''' asso-
ciated laterutrusive interferences
with dysfunction, hut in another
study"' the severity of latcrotru-
sive molar facets was not found
to be associated with TMJ click-
ing, TMJ tenderness, or muscle
tenderness.
Occlusal Slides. Possible asso-
ciations to craniomandibular dis-
orders have included occlusal
slides between the retruded con-
tact position (RCP) and the inter-
cuspal position (ICP). Longer
slides (>l mm) have been said to
be overrepresented in patients
with temporomandibular joint
dysfunction,-' and they have been
associated with temporomandib-
ular joint clicking'*"'^' and mus-
cle tenderness.'"'' In contrast, no
association has been shown he-
tween symptoms and tbe length
of slide in many studies of pain
and dysfunction patients,'^'""'*-'
adult nonpatients,'-'^-'*"'"'' and
children and teenagers."-^" A few
studies have speculated a rela-
tionship regarding coincident
RCP and ICP as a risk factor pre-
disposing to derangement."'^^
Functional Occlusal Asymme-
try. Much evidence has impli-
cated the asymmetry of the RCP-
ICP slide. Solberg et al" was the
first to describe this assocation of
TMJ tenderness to lateral slides
^ 1 mm in a large survey of rmi-
versity students, and this was
supported in later Swedish epi-
demiologic surveys involving
men'" and children and teenag-
ers." A recent study involv-
ing dental students''* associated
asymmetric slides with joint
pain, and this was supported as
a trend to TMJ tenderness in an-
other nonpatient group.'' A study
of 21 patients with TMJ clicking"
descrihed an association with
asymmetric slides when larger
than 1 mm.
Another body of research has
however, has found no associa-
tion between the asymmetry of
tbe RCP-ICP slide and signs and
symptoms of disorders. These
studies have involved patients
compared with nonpatients,''"*'*
surveys of dental students," and
children."
Unilateral contact in RCP has
been associated with TMJ click-
ing in an epidemiologic study of
children and teenagers,-'' but con-
versely, in another study of adult
TMJ patients'" unilateral contact
was negatively associated with
symptoms. Solberg et al" found
no association between unilat-
eral contact in RCP and signs of
dysfunction in a young adult
population, and Pullinger et al,"
studying a similarly aged non-
patient group, found a rela-
tionship only when in combina-
tion with other specific occlusal
factors.
Single Morphological
Occlusal Variables
Anterior open bite has been re-
ported to be overrepresented in
dysfunction patients'" and was
absent in an asymptomatic nor-
mal population.''"
The prevalence of crossbite was
reported to he high in dysfunc-
tion patients,-'^ and Dawson"'
claimed crosshite to be a cause of
temporomandibular joint pain.
Unilateral posterior crossbite in
a nonpatient population was as-
sociated with jumping of the con-
dyle over the eminence (luxa-
tion), which was differentiated
from other types of temporoman-
dibular joint clicking." However,
crossbite was not associated with
other types of TMJ clicking and
tenderness or with masticatory
muscle tenderness in this same
group.^° Indeed, TMJ tenderness
was more prevalent in subjects
witbout crossbite in these stud-
ies.'"" Mohlin and Kopp^° found
no relationship between cross-
bite and the severity of pain or
dysfunction in 56 TMJ patients,
and this factor was also not found
to be associated with joint
sounds, joint tenderness, or mas-

ticatory muscle tenderness in
a population of cbildren and
teenagers."
The current refined morpbom-
etric study attempted to correct
for some of tbe shorfalls in
methodology in past studies by
using a documented control pop-
ulation'"""'- and by dividing
the patient experimental popu-
lation into refined diagnostic
groupings.-'
Materials and Methods
A non-TMJ-patient control
group consisting of 222 freshman
dental and dental bygiene stu-
dents (102 females, 120 males)
was previously described in
detail."-'""'- The experimental
group was identified from 230
consecutive TMJ patients exam-
ined by one of the authors (DAS)
between 1981 and 1987 in a pri-
vate practice setting (Table 1). A
total of 196 patients was assigned
to five independent diagnostic
groups, previously defined and
validated"-': (J) disk displace-
ment with reduction (n = 40); (2)
TMJ locking without signs of ar-
throsis but witb a bistory of click-
ing (n = 14); (3) TMj" osteoar-
throsis with a prior history of
TMJ locking (n = 32): (4) TMJ os-
teoarthrosis without a prior bis-
tory of locking (n = 30); and (5)
myalgia only (n = 80). Tbe re-
maining 34 patients were as-
signed to diagnoses not associ-
ated with tbe above groups. Tbe
heterogeneity of tbe TMJ patients
is supported by the independence
between tbese diagnostic groups
according to sex and age distri-
bution,^ as well as in mandibular
range of opening.^
All samples were examined
according to the same strict cri-
teria."'^ The TMJ dysfunction
groups were also examined by
serial tomographic imaging in
tbe sagittal and frontal planes of
both TMJs, and these were inter-
preted by an independent oral
radiologist.
Occlusal factors were deter-
mined from clinical examination
and evaluation of dental casts.
Seligman
Table 1 Patients According to Diagnostic Categories
Major Diagnostic Croups Studied
Disk displacement with reduction (n = 40)
Disk displacement without reduction in = 14)
Osteoarthrosi5 with a history of prior derangement (n = 32)
Osteoarthrosis with no history of prior derangement (n = 30)
Masticatory myalgia only (n = 80)
Miscellaneous Groups Not Included in this Study ¡
Atypical facial pain (n = 1)
Benign hypermobility (n = 2)
Multiple sclerosis (n = 1)
Muscle contracture in = 1)
Odontalgia |n = 1)
Osteoarthrosis, juvenile (n - 10)
Polyarthritic disease (n = 3)
Traumatic arthritis (n = 2)
Trigeminal neuralgia (n = 5)
Trismus (n - 1)
Subluxation only (n - 7)
Unknown (n = 1)
Angle class of occlusion was as- cording to sex. The number of
signed according to molar or ca- males with disk displacement
nine relationship using an inter- without reducLion (n - 0), os-
maxillary discrepancy in molar teoarthrosis witb a bistory of
relationship of greater than one- locking (n - 1), and osteoar-
half of the cusp width as the cri- throsis without a history of lock-
teria to determine Class II and III ing (n = 3) was too limited to al-
relationships. Unilateral Class ÏI low for testing.
and III relationships were clas- All diagnostic groups described
sified as Class II and III. were analyzed for association
Tooth contact in RCP with pas- witb nominal occlusal variables
sive manipulation was judged as by chi-square analysis using a
bilateral or unilateral after the Yates correction when expected
subject was questioned. Tbe mag- cell values were less tban 10. Ex-
nitude of tfie discrepancy be- pected cell values beiow 3 were
tween ICP and RCP was evalu- considered insufficient for anal-
ysis."" Differences were ranked
ated clinically according to a
previously described technique."*- by strength of association (<b =
The direction of the contact + 1.00 to~- 1.00). A significant dif-
movement from RCP to ICP was ference was defined at a level of
noted as symmetric or asymmet-
ric. Crossbites were identified.
Anterior open bite was identified
Results
as a negative incisor overbite
relationship or 0-mm incisor This study was limited to com-
overbite without edge-to-edge parisons between tbe diagnostic
contact. groups and the controls.
Because the prevalence of
symptoms was slightly different Angle Class
between men and women in the
epidemiologic control sample''' Generally, tbe patient diagnos-
and the patient diagnostic tic groups could not be differen-
groups,^ associations to occlusal tiated according to Angle class
parameters were analyzed ac- (Table 2). However, Class I was
journal of Craniomandibular Disorders: Facial & Oral Pain 229
Seligman

Table 2 Angle Class

Total
Population
Patient diagnostic groups

Disk displace Disk displace Osteoarth Osteoarth Myalgia

Controls with reduction no reduction with lock no lock only
Class (n = 222) (n = 40) (n = 14) (n = 32) (n = 30) (n = 80)

1 68% 65% 86% 75% 70% 59%

NS NS NS NS NS

11-1 15% 23% 14% 16% 23% 23%

NS NS NS NS NS

11-2 4% 5% 0% 6% 0% 4%
NS NS NS

III 13% O /fr 0% 3% 7% 14%

NS NS NS

Females
Patient diagnostic groups

Disk displace Disk displace Osteoarth Osteoarth Myalgia

Controls with reduction no reduction with lock no lock only
Class (n = 102) (n = 29) (n = 14) (n = 31) (n = 27) (n = 52)

1 71% 79% 86% 74% 74% 62%

NS NS NS NS NS

11-1 16% 14% 14% 16% 19% 23%

NS NS NS NS NS

11-2 6% 0% 0% 6% 0% 4%
t NS
III 8% 7% 0% 3% 7% 12%
t NS NS

Males
Patient diagnostic groups

Disk displace Myalgia

Controls with reduction only
Class (n = 120) (n - 11) in = 28)

1 67% 27% 54%

P < 0.05 NS
4) = - 0 . 2 0

11-1 14% 45% 21%

P < 0.01 NS
* = +0.23

11-2 3% 18% 4%
t
17% 9% 18%

'Inadequate cell size pr ecluded statist: at anatysis.

i Adequate cell size wbf. ed (see lotnl population).

230 Volume 3, Number 4, 1989


less common in the male patients
with reducing disk displacement
than in controls (P < 0.05; * =
-0.20). Furthermore, Class II di-
vision 1 was more common in
tnale patients with reducing disk
displacements compared lo the
male controls (P < 0.01; 41 =
-1-0.23). However, these findings
were based on only 11 male stib-
jects in this diagnostic group, and
the differences may be random
associations.
RCP-ICP Slides
Large symmetric and asym-
metric RCP-ICP slides (>l mm)
were more common in osteoar-
throsis patients with a prior his-
tory' of derangement (P < O.OOi,
<>t = +0.20), osteoarthrosis pa-
tients without a prior history
of derangement (P < 0.05, 6 =
-I-,14), and patients with myal-
gia only ( P O . 0 2 5 , 4> = -f.13)
compared to controls (Table 3).
Examining the genders separ-
ately, large slides were more
common in the female osteoar-
throsis groups, hoth with (P <
0.001; (jj - -(-0.28) and without
(P<0.005; * = -HO.25) a past
history of derangement, than in
controls (Table 3). As stated,
there were too few men to ana-
lyze osteoarthrosis among males.
Large slides, >1 mm, were more
common in male patients with
only myalgia ( P < 0.025; 4.=
-1-0.21) compared to controls, but
this did not show up in women
with myalgia (Tahle 3).
Asymmetric RCP-ICP slides
were more common in patienls
with reducing disk displace-
ments (P < 0.05; 4i = -1-0.17) and
in osteoarihrosis patients with
(P<0.05, * = +0.15) and with-
out ( P < 0.001, <1> = +0.25) a
prior history of derangement
(Table 3), The strengths of asso-
ciation increased when females
were tested separately. The myal-
gia only group showed little dif-
ference in asymmetric slide from
the controls.
A lack of RCP-ICP slide per se
was not statistically associated
with any diagnostic group, ex-
cept for a negative association
among males with myalgia only
(P<0.05; <1> - -0.17)' (Table 3).
Similarly, unilateral or bilateral
RCP relationships as isolated fac-
tors were not more common in
any of the patient groups when
compared to controls (Table 4).
However, the combined presence
of unilateral RCP contact and a
lack of a clinical RCP-ICP slide
(Table 4) was a feature of female
patients with disk displacement
with reduction (P < 0.025; <i> =
+ 0.20) compared to the controls.
Crassbite
The occurrence of crossbite in
each patient diagnostic group
was similar to the control sample
(Table 4).
Anterior Open Bite
Because anierior open bite was
so rare in the control population
(2%), comparisons for the sepa-
rate genders were not possible.
Consequently, anterior open bite
was tested as a nominal grouping
combining the genders. This oc-
clusal feature was more common
in patients with osteoarthrosis
with a preceding history of de-
rangement (P < 0.001; 4) =
+ 0.41), osteoarthrosis without a
preceding locking history (P <
0.001; * = +0.25), and in pa-
tients with myalgia only (P <
0.025; 4) = +0,15) compared to
controls (Table 4).
Discussion
Because the sample sizes were
restricted, associations could
not be tested in males with disk
displacement without reduction
(n = 0) or osteoarthrosis both
with (n = 1) and without (n =- 3)
a history of derangement.
Angle class was not useful in
differentiating patients from con-
trols, except for men with reduc-
ing disk displacement, who had a
lower prevalence of Class I occlu-
sions and a higher prevalence of
Class II division 1 (Table 2). How-
ever, hecause only 11 men with
Journal oi^ Craniomandibulat Disorders: Facial & Oral Pain
Seligman
this diagnosis were studied, con-
firmation is needed with a larger
male sample before attributing
significance. Furthermore, a ran-
dom occurrence must be ruled
out, because no association was
found in the female diagnostic
groups, or when both genders
wete pooled. The authors rec-
ommend that caution be ex-
pressed over occlusal associa-
tions if a relationship exists only
in one sex in the absence of even
a trend in the opposite sex in a
diagnostic group in which both
sexes are represented.
Contrary to Mohlin et al,' who
studied symptoms rather than di-
agnostic groups, no association
was found in either men or
women between the diagnostic
groupings and Class 111 malocclu-
sions. And contrary to popular
belief, the prevalence of Class II
division 2 occlusions was not sta-
tistically greater in any patient
group compared to the controls.
In fact, there were tio cases with
this class of maiocclusion among
the disk displacement without re-
duction group and the osteoar-
throsis group without a history of
derangement, and the other di-
agnostic groups showed preval-
ances of only 4% to 6%.
Large symmetric and asym-
metric slides from RCP to ICP
(> 1 mm) were associated wilh os-
teoarthrosis. This was statisti-
cally significant in women (Ta-
ble 1), but could not be analyzed
in men because of the stnall num-
bers. Other studies based on the
less specific problems of XMJ
noise^"'^" or general intracapsuiar
dysfunction^' rather than diag-
nosis describe a similar relation-
ship to large sagittal slides. Men
with myalgia only had a higher
prevalence of large slide than
controls, but this finding was not
duplicated in women (Table 3);
therefore, caution is advised in
interpreting this finding. This
skepticism is supported by a
prior study of the control popu-
lation used in this study,'^'"
whereby no relationship could be
found between the length of a
sagittal slide and any sign or
231
Seligman

Table 3 RCP-ICP Slides

Total Population
Patient diagnostic groups

Disk displace Disk displace Osteoarth Osteoarth Myalgia

Controls with reduction no reduction with lock no lock only
(n = 222) (n = 40) (n = 14) (n = 32) (n - 30) (n = 80)

Slide length
RCP = ICP 29% 38% 29% 28% 43% 29%
NS NS NS NS NS

> 0 < 1 mm 60% 40% 50% 41% 30% 50%

P < 0.05 NS P < 4>.O5 P < 0,005 NS
<j) = - 0 - 1 4 * = -0.13 i> = - 0 , 1 B

>1 mm 11% 23% 21% 31% 27% 21%

NS NS P < 0.001 P < 0.05 P < 0.025
4) = 4-0.20 ) = -(-0,14 * = -1-0.13

Asymmetric slide In = 157) (n = 24) (n = 10) (n = 23) (n = 16) ¡n = 53)

36% 63% 60% 61% 81% 45%
P < 0.05 NS P < 0.05 P < 0,001 NS
cji = -1-0.17 * = -1-0.15 Í) = -1-0,25

Females
Patient diagnostic groups

Disk displace Disk displace Osteoartfi Osteoarth Myalgia

Controls with reduction no reduction with lock no lock only
(n = 102) in = 29] (n = 14) (n = 31) In - 27) (n = 52)

Slide length
RCP - ICP 29% 45% 29% 29% 41% 38%
NS NS NS NS
> 0 < 1 mm 63% 38% 50% 39% 30% 46% 1
P < 0.05 NS P < 0.05 P < 0.005 NS I
4> = - n . 2 O 4) = - 0 . 2 0 4) = - 0 . 2 6
2:1 mm 9% 17% 21% 32% 30% 15% 1
NS + P < 0.001 P < 0.005 NS •
* = -F0.28 * = -1-0.25
Asymmetric slide (n = 72) (n - 15) (n = 10) (n - 22) (n = 15) in = 29)
38% 15% 60% 64% 80% 41%
P < 0.01 NS P < 0.05 P < 0.005 NS
* = +0.27 4> = -fO.22 * =- -1-0.32

symptom. Other studies show-
ing no relationship of signs
or symptoms to the length of
the RCP-ICP slide involved non-
patients'^''•'*"'"•'•' or nondiffer-
entiated TMJ patient popula-
tions,""-^^" Our findings involv-
ing specific diagnostic groups
should be validated by studies
using expanded populations.
The absence of a clinically vis-
ible RCP-ICP slide was not as-
sociated with the diagnostic
groups, except that a lack of slide
was less common in men with
masticatory myalgia compared
to controls (P< 0.05; c|) = -0,17)
(Table 3). However, this may be
a random finding, because it was
not duplicated in women or when
both genders were combined.
A combination of unilateral
contact in RCP and the absence
of a clinically visible RCP-ICP
slide was significantly more prev-
alent in women with reducing
disc displacement (31%) com-
pared to controls (13%) (P <
0,025) (Table 4). Unfortunately,
inadequate cell sizes precluded

232 Volume 3, Numter 4, 1989


Table 3 (Continued)
Males
Controls
(n = 120]
Slide length
RCP = ICP 29%
>0 < 1 mm 58%
=:1 mm 13%
Asymmetric slide (n = 85)
34%
tlnsdequate cell size prectuded statistical anitysis, but adequate cell size
Statistical analysis of men with
this diagnosis, Tbis significance
is enhanced by the prior finding
that TMJ clicking was also asso-
ciated with this occlusal variable
in the control group,'' and we
conclude that these comhined
factors may represent a destabil-
izing influence on TMJ function.
Asymmetric slides from RCP to
ICP were significantly more com-
mon in patients with TMJ
changes. This finding is comple-
mentary to other studies exam-
ining symptoms.'^"'"-"-" In tbe
current more refined examina-
tion of diagnostic groups, asym-
metric occlusal slides occurred
significantly more frequently in
female osteoarthrosis patients
(64% to 80%, Table 3) compared
to the controls (38%). Tbe 60%
prevalence of asymmetric slide
among female disk displacement
without reduction patients was
not significant at the sample size
(Table 3).
Because asymmetric slides are
more common in patients with
TMJ changes, it is clinically im-
portant to consider that the pri-
mary responsibility for asym-
Palient diagnostic groups
Disk displace
with reduction
(n = 11]
18%
NS
45%
NS
36%
t P < 0.025
(n = 9]
44%
NS
.f..nsc.escorr,b.nedis.e..,popula.on,.
metric slides may be TMJ
alterations. Tbe position of inter-
cuspation may be correct in
many of these cases and the slide
due instead to an ability to over-
retrude one joint because of in-
tracapsular alterations. How
much an asymmetric slide pre-
disposes to joint alteration or
whether these slides are mostly
the result of TMJ osteoarthrosis,
however, remains unanswered.
Miscellaneous Occlusal Factors
In agreement with several
studies,"'•^-^"•^'' crossbite was not
a distinguishing feature of any ol
the experimental groups (Table
4). While crossbite may be an im-
portant restorative or orthodon-
tic consideration, its contribu-
tion to the development of
craniomandibular pain and dys-
function in adults must be seri-
ously questioned. The lack of
association is possibly due to suc-
cessful skeletal adaptation in
most cases."
Anterior open bite had a strong
association to groups with os-
teoarthrosis (<t) = -i-0.25 to
Journal of Craniomandibular Disorders; Facial & Oral Pain
Seliüman
Myalgia
only
[n = 28]
11%
. P < 0.05
<t> = - 0 . 1 7
57%
NS
32%
* = -I-0.21
(n - 24)
50%
NS
-H0.41) (Table 4), and to a lesser
extent to patients with myalgia
only (6 = -1-0.15). Open bite was
completely absent in tbe asymp-
tomatic group of the control pop-
ulation in this study, in a previ-
ously described asymptomatic
normal sample,'"' and it only oc-
curred in 2% of the entire con-
trol sample. The possibility that
intracapsular changes and even
extracapsular conditions can
induce an open bite should
be investigated in longitudinal
studies.
Occlusal Features of Patient
Diagnostic Groups
Some occlusal features helped
to differentiate the patient
groups. Women with reducing
disk displacements had a greater
prevalence of asymmetric slide
from RCP to ICP than controls
(P < 0.01). A comhination of uni-
lateral RCP contact with no clin-
ically evident RCP-ICP slide was
also more common in women
with tbis condition than controls
{P < 0.025).
A higher prevalence of large
233
Seligman

RCP-ICP slide (>l mm) and to +0.41) opens speculation terior open bite was jnore cotn-
asymmetric slides typified whether open bite predisposes mon in patients with masticatory
women witn
women with osteoarthrosis.
osteoarttirosis. The
me to
to osteoarthrosis
osieoarinrosis or
or is
is aa conse-
conse- myalgia
myaigia only
oniy compared
LUH.K"^^" to
-" con-
-""
strong association of arthrosis to quence of intracapsuîar or cap- trois (P < 0.025). Future studies
anterior open bite (^ = +0.25 sular changes. Additionally, an- sbould examine whether anterior

Table 4 Miscellaneous Occlusal Variables

Total Population
Patient diagnostic groups

Disk displace Disk displace Osteoarth Osteoarth Myalgia

Controls with reduction no reduction witb lock no lock only
(n = 222) (n = 40) (n = 14) (n = 32) In = 30) (n = 80)

Crossbite 32% 18% 36% 27% 20% 23%

NS NS NS NS NS

Unilateral RCP 59% 55% 50% 53% 63% 50%

NS NS NS NS NS

Unilateral RCP 14% 23% 14% 16% 23% 15%

plus RCP = ICP NS NS NS NS NS

Incisor open bite 2% 3% 7% 31% 20% 10%

P < 0.001 P < 0.001 P < 0.025
(b = +0.41 cl> = +0.25 4. = +0.15

Fetnales
Patient diagnostic groups

Disk displace Diïk displace Osteoarih Osteoarth Myalgia

Controls with reduction no reduction with lock no lock only
(n = 102) (n = 29) (n = 14) (n - 31) (n = 27) (n = 52)

Crossbite 25% 14% 36% 15% 22% 21%

NS NS NS NS NS

Unilateral RCP 60% 59% 50% 55% 70% 56%

NS NS NS NS NS

Unilateral RCP 13% 31% 14% 16% 26% 21%

plus RCP = ICP P < 0.025 NS NS NS
4) = +0.20

Males
Patient diagnostic groups

Disk displace Myalgia

Controls with reduction only
(n = 120) (rt = 11) (n = 28) .

Crossbite 37% 27% 25%

NS NS :
Unilateral RCP 58% 45% 39%
NS NS
Unilateral RCP 12% 0% 4%
plus RCP = ICP t
'inadequate cell size preclu ded statistical ana ysis.
Mdecjuate ceil size when sé tes combined Ise e total population)

234 Volume 3, Number 4, 1989


open bite provokes or aggravates
muscle strains, or il' musculopos-
tural imbalances cati produce the
occlusal patterns observed.
Occiusal Features of Healthy
Asymptomatic Controls
Within this sample were 61
asymptomatic subjects who were
without any sign or symptom of
a TM disor'dcr {49 males, 12 fe-
males). The Wellness features ty-
pifying an asymptomatic popu-
lation may be meaningful for
clinical practice guidelines. In
this sample there was an absence
of anterior open bite in the
asymptomatic controls. Further,
bilateral occlnsal stability, as in-
dicated by a small symmetric
slide (>0 <1 mm in length), and
bilateral contact in RCP in those
with minimal slides were com-
mon features of the asymptom-
atic population.
Conclusion
Belief in the contribution of oc-
clusion to the etiology of cran-
iomandibular pain and dysfunc-
tion, together with the dental and
mandibular orthopedic treat-
ments of these disorders, keeps
this field of medicine within den-
tal practice. Notwithstanding,
contemporary research has been
unable to support a strong occlu-
somorpho log ical linkage to cran-
iomandibular disorders. It has
been said that dento-occlusal fac-
tors are not strongly correlated to
treatment outcome,"'^ are not
good predictors of dysfunction,"'
and are not reliable for predicting
symptom severity.'* It may be
that a malocclusion must be pres-
ent for a considerable time period
to induce an effect.'" The multi-
factorial etiology and pathophys-
iology of craniomandibular dis-
orders is well accepted today, and
occlusion may only be one feature
of this mechanism.
Biophysiology would expect
some contribution of morphology
to functional status. The inability
o£ much past research to find a
consensus on morpho-occlusal
associations may be the result of
poorly defined experimental and
control groups. In addition, many
prior studies circularly defined
the study population according
to the symptom being tested. We
believe the importance of study-
ing discrete diagnostic groups
and comparing them to uncom-
promised control populations
cannot be overemphasized.
This study has demonstrated
several significant relationships
that clarify some of the past con-
flicts. By studying well-defined pa-
tient diagnostic groups rather
than symptoms and comparing
the patient groups to a control
group, selective aspects of occlu-
sion have been shown to be more
closely associated with TMJ dis-
orders than indicated in many
past studies with less specified
populations. It is important to
emphasize that epidemiologic
studies, while demonstrating as-
sociations, cannot prove the eti-
ologic contributions of occlusion.
Some occlusal features may be
the consequence of articular dis-
orders, some may encourage dis-
orders and their progression, and
others may be protective. D
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