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Relationship between occlusion and temporomandibular disorders: Implications for the gnathologist
Rudolf Slavicek Vienna, Austria

he succession of hominids about 5 or 6 million years ago led to continuous development that culminated in Homo. The rst Homo, also known by the basic designation of Homo habilis, appeared about 2 million years ago. Some reasons for anthropogenesis include posture, speech, brain development, and social behavior. The decisive step in evolution occurred when the new phase of linguistic communication emergedie, descriptive language. In a discussion between a Nobel prize winner and one of the greatest philosophers of the twentieth century, namely Konrad Lorenz and Karl Raimund Popper, the following statement emerged: Brain is language, and language is brain. Popper took things farther, claiming that brain is speech, and speech is brain, and that man created himself by descriptive speech.1,2 Indeed, the brain developed with drastic speed, and the evolution culminated in Homo sapiens. The masticatory organ and occlusion are at the center of this link to the development of the brain, because linguistic communication occurred through this new function.

CYBERNETICS AND ORGANISMS

In 1948, Wiener3 published a provocative scientic book that rst described the concept of networking in biology. He stated that cybernetic thinking is the link in the no mans land between the recognized sciences. I describe an organism from the cybernetic point of view as a highly complex and self-contained system that is unied by a common (external and internal) ow of information, which compels all internally dependent subsystems to undergo reactive changes, and is therefore in a state of permanent unstable homeostasis. The permanent reactive adaptation of an organism to maintain

Professor emeritus, Danube University, Krems, Austria. Reprint requests to: Rudolf Slavicek, Widerhoferplatz 4/7/51, 1090 Wien, Austria; e-mail, r.slavicek@aers.at. Am J Orthod Dentofacial Orthop 2011;139:10-6 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.11.011

homeostasis can be termed life. The main purpose of an organism is survival.4 Adaptation and habituation were rst elaborated upon by Jean-Baptiste Lamarck in his second thesis, which discussed the genetic outcome if both sexes are habituated. This denition might also be viewed from the perspective of the second main theorem of thermodynamics. Biologic systems are open systems with a time direction. Here, Prigogine5 described the so-called dissipative structures in general for open systems and thus also for biologic systems. Processes in biologic systems are irreversible. A major aspect of open systems is that all interventions (also therapy) are irreversible. From the perspective of evidence-based medicine, when we separate teeth with occlusal aids and then remove the appliance, a condition of restitutio ad integrum can be achieved. From a scientic point of view, this is absolutely incorrect. Uexkll6 initiated a further major modication in u biology when he described his new viewpoint about organisms in their environment. If an organism is confronted with a problem in its environment, the organism recognizes the problem, states its importance, reacts, and arrives at a solution to the problem. This reaction is received by the environment as a new reality. The problem is solved both directly and cognitively! Humans are a suprasystem with a strong relationship between the soma and the psyche. Based upon self-consciousness, the human being creates his or her own individual reality. Because of social structures, education, conventions, inhibited aggression, or the unwillingness to be aggressive, problems are usually not solved directly but, rather, in a delayed manner, or they remain unresolved. We name this psychic behavior suppression. Thus, the psyche becomes a dumping ground for unresolved problems that remain concealed and cognitively inaccessible. In summary, the masticatory organ of Homo sapiens is an entirely new evolutionary concept with newly networked functional spheresie, a new organ.4 In our individual ontogenesis, we must rediscover and relearn the phylogenetic new functions.

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ONTOGENESIS OF THE MASTICATORY ORGAN

Before erupting into the oral cavity, the dental crowns are complete morphologic structures, which I dene in genetic terms as the 1 structure of the human body that can be altered only by destruction. Due to the sequence of ontogenesis, I prefer to speak in terms of functional periods rather than use the usual classication of growth periods: the postnatal period, breathing and communication, ingestion and digestion, preparation of the spine, changing nutrition, and mastication and swallowing.
Uprighting

the molars determine the movement pattern of the mandible.10 Compensation of sagittal and transverse discrepancies occurs during this time. The rst main factor of compensation during ontogenesis is dentoalveolar development. The second main factor to compensate skeletal discrepancies is vertical development. The third main factor, especially in skeletal Class II malrelationships, is articular compensation (temporomandibular joint). Malocclusion in the early mixed dentition must be recognized.
Second functional period of the changing dentition

During the second functional period of the changing Mans ontogenetic uprighting caused a massive dentition, the premolars erupt, there is narrowing of change in the region of the temporal bone. Because of lateral control, retrusive control in the rst premolar octhe position of the organ of balance and the archways, curs, and the psychic stress of the beginning of puberty the pyramid had to rotate in the opposite direction durstarts. The morphology of the premolarsespecially ing uprighting. Counterrotation concerned not only the that of the rst premolar is the most important prepatemporal bone but also all bones of the cranium.7,8 ratory basis for the nal dynamics of lateral, retrusive, During the period of the deciduous dentition, the foland protrusive mandibular movements. From the lowing typically occur: full development of communicaorthodontic point of view, extractions in this region are tive speech, general learning, social adjustment, psychic functionally critical.11 stress management through the masticatory organ, and abrasion of the deciduous dentition. Malfunction and During the maturation of the denti- Functional period of malocclusion form during this maturation period. The phase of the ma- tion, the position of the mandible is During the functional peture deciduous dentition is determined 3-dimensionally by the riod of maturation, canine the longest and most effective occlusion of the teeth. dominance12 is established, learning period in life. Therethe craniomuscular system fore, it is a period of extreme matures into the reference position, second molar psychic narrowing and loading. At this age, bruxing is intercuspation develops, and there is increasing psychic a normal function to unload the psyche.9 The resulting loading with puberty and increased social integration. abrasion favors the required protrusive advancement In conclusion, during the maturation of the dentiof the mandible. tion, the position of the mandible is determined 3-dimensionally by the occlusion of the teeth.13 It is First period of the mixed dentition habituated and controlled proprioceptively, while With the eruption and coupling of the permanent closing the jaw. The joints are secured vertically by rst molars, the anterior permanent teeth are also the teeth.14 exchanged, intercuspal positions are dened, structural limitations are established, functional adaptations FUNCTIONS OF THE JAW (chewing and speech) occur, and the structural adaptaMastication tion of the temporomandibular joint begins. During In the phase of bolus formation, mastication should this period, the temporomandibular joint adapts just be more of a translatory process. There should be as rapidly. The initial adaptation is functional but is minimum rotation. In modern man, optimum dynamic followed by structural adaptation. This means that mastication is achieved when the rows of teeth are as occlusion dictates adaptation. This ability to adapt close to each other as possible without functional interfunctionally as well as structurally persists throughout ferences.15 Hence, occlusion is undoubtedly the major life, but in a less pronounced manner. As early as this and dominant factor of the system. Occlusion and point in time, the morphology of the rst molars strucarticulation determine the functional patterns of turally determines the lateral and retral pattern of the mandibular movement. craniomuscular system. The position and rotation of

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The term disclusion in our modern occlusal concepts is a perversion of the central signicance of the masticatory organ: to cut food efciently. The quality of intercuspation is important for the physiology of chewing. Chewing is concluded by the act of swallowing. Intercuspation should be achieved without interference. The difference between retral contact position and intercuspation in chewing and deglutition is of minor importance. Chewing and swallowing are patterns adapted to the quality of food and controlled proprioceptively during the sequence of mastication. The necessary information is provided by individual tooth contacts during chewing. The front teeth are avoided in mastication. Functional interferences in occlusion can cause avoidance patterns. Avoidance patterns during mastication and swallowing might be a reason for temporomandibular disorders.
Speech

compromises or not at all. Such no solving of problems is deposited in the garbage dump of the psyche and can be realized at the somatic level through nonpurpose-related emotions. If chronic pressers and grinders use their masticatory organ as a psychic stress valve, then grinding and pressing might be assigned to the normal functions of the masticatory organ.18 For these people, decrying parafunction in the treatment of the masticatory organ would signify an additional restriction. What is the role of occlusion in coping with stress? This discussion must be conducted unemotionally on the basis of scientic ndings and conclusions. Grinding and clenching are expressions of psychic stress assimilation and are controlled by the neuromuscular system and occlusion.19-33

Therapy of occlusion: Goals and concepts

Communication is the main function of the masticatory organ, and pronunciation is predominantly related to the anterior teeth. Other teeth and occlusion might create avoidance patterns causing TMD.
Bruxing and clenching (the role of teeth in stress management)

The limbic system is the complex system belonging to the archaeocerebellum, located between the brain stem and the neocortex, which is considered to be responsible for emotion and instinctive behavior. Humanization leads to proportional shifts, which cause aggressive behavior.16 In the evolution of the primate, a strong shift in balance occurs in the region of the amygdaloid nucleus. The centromedial portions (aggression) are markedly reduced compared with the centrobasolateral (pleasure-oriented) portions. Kail17 stated in her dissertation on our bruxing patients in the Department of Prosthetic Dentistry at the Dental University of Vienna, Austria, that any deciency or disability in direct aggressive behavior could be a reason to use the masticatory organ for reducing stress through bruxism. As a result of her research, she found that the total group of 98 bruxers had significantly reduced general well-being. Furthermore, the personality structures in the study were signicantly different from standard random samples of matched groups in regard to general aggressive behavior. In addition, both spontaneous and reactive aggressive behaviors were markedly less than in the control group. In the lives of the subjects, problem solving frequently occurs either in a delayed manner or by way of

Interventions in the structure of occlusion are irreversible. This is based on the widely accepted axioms of the natural sciences. All assertions of reversibility are scientically unfounded. Therapeutic interventions must have a causal reason. The purpose should be dened, and the aim should concur with the purpose. This is applicable to restorative and prosthetic interventions in equal measure as it is to orthodontic and maxillofacial surgical corrections. After completion of the treatment, the result should be biologically stable.34 So-called retentions might be indicated in the phase of stabilization, but a general retention of the occlusal outcome is incorrect. Defensive assertions to the effect that therapeutic interventions can have no negative consequences are absurd. Gnathology is dened as the science that treats the biology of the masticatory mechanism as a whole: morphology, anatomy, histology, physiology, and therapeutics of the jaws or masticatory system and the teeth as they relate to the health of the whole body, including applicable diagnostic, therapeutic, and rehabilitation procedures. The conceptual dogmatism of the term gnathology in earlier days was a problem or cause that split occlusionists from nonocclusionists. But dogmatic wars are counterproductive. Independent from skeletal individuality, human teeth are nearly morphologically the same. Canines and anterior teeth are controlling and/or guiding; posterior teeth support and disclude. The modern gnathologic concept is clearly proven and can be recommended. Any other concept in orthodontics must be dened but must t with the natural morphology of teeth and must be veried by scientic data.35,36

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CONCLUSIONS

The teeth occlude and determine the motion pattern of the mandible. Furthermore, motion patterns occur in the neuromuscular system and are regulated proprioceptively. The signals of proprioception occur in the teeth, the periodontal ligament, the temporomandibular joints, and the muscles themselves. Intact teeth provide the most rapid information to the brain in monosynaptic fashion. The functions of the masticatory organ are entirely different and closely networked with the somatic and psychic functions of the brain. Of course, there are adaptability and a compensatory capacity. However, the masticatory organ and the psyche are strongly linked.
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