SPECIAL ARTICLE

A contemporary and evidence-based view

of canine protected occlusion
Donald J. Rinchuse,a Sanjivan Kandasamy,b and James Sciotec
Pittsburgh, Pa, and St Louis, Mo

entists and orthodontists at one time or another

have been exposed to the gnathological concept of occlusion. Certainly, a well-known and
advocated precept of gnathology is that of canine
(mutually) protected occlusion (CPO). The basic
premise of CPO is that, on laterotrusive movements of
the mandible, only the canines (possibly first premolars) contact and therefore protect the remaining dentition from adverse occlusal torsion forces on contacts to
and from centric occlusion (and/or centric relation).
Furthermore, it is contended that CPO is the optimal
(ideal) type of functional occlusion for the natural
dentition vis--vis dentures and is the functional occlusion type toward which restorative and orthodontic
treatments should be directed.1,2 It is also argued that
orthodontists who do not obtain canine protected functional occlusions are doing a disservice to their patients
and possibly not practicing state-of-the-art orthodontics.3-10 That is, gnathologists maintain that orthodontists who do not establish a gnathologic finish,
including CPO, potentially predispose patients to temporomandibular disorders (TMD) and orthodontic tooth
relapse.3-7,11
However, many past notions in dentistry and orthodontics, particularly related to gnathology, have not
withstood the test of time or the rigors of science.12,13
And, with the recent emphasis for dentists to practice
evidence-based decision making,14-16 it makes sense to
fully investigate and evaluate the concept of CPO. The
purpose of this article is to discuss past and present
knowledge and information on the general topic of
functional occlusion (particularly regarding CPO and
orthodontics) and relate it to logical considerations
a

Clinical professor, Department of Orthodontics and Dentofacial Orthopedics,

School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pa.
Visiting postdoctoral fellow, Center for Advanced Dental Education, Saint
Louis University, St Louis, Mo.
c
Associate professor and chair, Department of Orthodontics and Dentofacial
Orthopedics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, Pa.
Reprint requests to: Dr Donald J. Rinchuse, 510 Pellis Rd, Greensburg, PA
15601; e-mail: [email protected].
Submitted, September 2005; revised and accepted, April 2006.
Am J Orthod Dentofacial Orthop 2007;132:90-102
0889-5406/$32.00
Copyright 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.04.026
b

90

relevant to science and evidence-based decision making. We provide a provocative and insightful perspective on what constitutes the optimal functional occlusion type for orthodontic treatment. Our goal was to
call orthodontists to reconsider their views on functional occlusionparticularly CPOin light of current
knowledge and evidence. Many peripheral topics, issues, and controversies about functional occlusion,
such as centric relation,17 articulators in orthodontics,18
and the general topic of occlusion, TMD, and orthodontics19-23 was addressed in previous studies.
Classic studies by Angle24,25 and a later study by
Andrews26 established criteria for the optimal (ideal)
morphologic relationship of the human dentition (although there is little evidence of a biological relationship associated with these criteria). However, the optimal functional occlusion type has not been so easily
identified and has essentially eluded the dental profession. Ash and Ramjford27 wrote: Orthodontic classifications are related more to anatomic and esthetic
standards than to neuromuscular harmony and functional stability. It has not been possible to develop a
consensus on a numerical index or system of values that
applies both to form and function of the masticatory
system. Based primarily on laterotrusive movements
from centric occlusion, several functional occlusion
types were recognized or advocated: balanced occlusion,28,29 CPO,1,30-36 group function occlusion,37-41
mixed canine-protected and group function,42 flat plane
(attrition) teeth occlusion,43,44 and biologic (multivaried, physiologic) occlusion.45
No single type of functional occlusion has been found
to predominate in nature. For example, DAmico,1 Ismail
and Guevara,46 and Scaife and Holt2 all found that CPO
predominated, whereas Beyron41 and MacMillan37
found predominance of group function occlusion. In
addition, the natural occurrence of balanced occlusion
(ie, with nonworking contacts) was found in populations studied by Weinberg,47 Yuodelis and Mann,48
Ingervall,49 Gazit and Lieberman,50 Sadowsky and
BeGole,51 Sadowsky and Polson,52 Rinchuse and Sassouni,53 Shefter and McFall,54 deLaat and van Steenberghe,55 Ahlgren and Posselt,56 Egermark-Eriksson

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et al,57 and Weinberg and Chastain.58 Although balanced

occlusion for the natural dentition is considered injurious and contravening by gnathologists, it is perhaps the
norm rather than the exception with regard to prevalence. Woda et al29 stated, Pure canine protection or
pure group function rarely exists and balancing contacts
seem to be the general rule in the populations of
contemporary civilization.
LITERATURE REVIEW
Brief history of CPO

Well over a century ago, Bonwill and Gysi recommended balanced occlusion (bilateral balanced and
3-point contact) for denture construction.27 The thinking was that, to prevent dislodgement, the denture must
have at least 3 points of contact during all possible
mandibular movements: Bilateral balanced and threepoint contact has been sponsored chiefly by prosthetists
in order to secure a supposed mechanical advantage in
stabilization of dentures.37 In the 1930s, McLean59
contended that this concept also applied to the natural
dentition. He based his conjecture on his examinations
of animals and humans. He further believed that periodontal bone resorption would result from excessive
occlusal forces if teeth were not bilaterally balanced.
About the same time, MacMillan37 took a different
view and recommended a shift from balanced occlusion
(ie, bilateral balanced) to unilateral balanced occlusion
for both natural and prosthetically restored dentitions.
He believed that bilateral balanced occlusion never
existed in nature, either in animals or man. His evidence was based on the evaluation of various types of
masticatory excursions of lower animals. Arguing in
favor of unilateral balanced occlusion over bilateral
balanced occlusion, MacMillan37 stated: Unilateral
balance in molar mastication is beautifully illustrated in
comparative anatomy. He also contended that the
analysis of the masticatory process in humans via
cinematography demonstrated that the nonworkingside teeth do not come in contact during mastication:
The buccal cusp of the mandibular molar of the idle
side never comes in contact with the lingual cusp of the
maxillary molar.
Once balanced occlusion was considered obsolete,
with general agreement that nonworking-side contacts
(balancing) were to be precluded (this is debated
today), the next issue that needed to be addressed was
what type of working-side lateral functional occlusion
is preferred. Two working-side schemes took precedenceCPO and group function occlusion (unilateral
balanced). The requisites for CPO are that only the
canines contact (an alternate scheme includes the first
premolars) on the working side during eccentric lateral

Rinchuse, Kandasamy, and Sciote 91

mandibular movements, whereas, on the nonworking

side, there are no balancing-side contacts.27 The advocates of CPO argued that humans innately possess the
long and dominant canine that is evident in carnivorous
animals.1,60,61 They further argued that the canine is the
strongest human tooth type and has the most sensitive
proprioceptive fibers. They therefore concluded that the
canines are the best teeth to protect the occlusion from
eccentric forces that occur on movements to and from
centric occlusion (and/or centric occlusion). The CPO
enthusiasts also argued that population studies confirm
the prevalence of CPO over group function occlusion.
They further maintained that the only reason some
modern humans do not have CPO is that they eat coarse
and abrasive diets that adversely wear down their
canines.1,61,62 In a telemetry study (miniaturized radio
transmitters placed in temporary bridges and gold
inlays), Butler and Zander62 found that, when the
functional occlusions of 2 subjects were periodically
changed from CPO to group function occlusion, there
were fewer lateral contacts when each subject worn
canine protected occlusion (perhaps CPO restricts lateral excursive movements). Also, Ash and Ramjford27
believed that a steep canine rise on the so-called
Michigan occlusal splint can reduce the electromyography (EMG) activities of the masseter and anterior
temporalis muscles.
On the other hand, the group function occlusionists37-41 argued that equivalent population studies confirm the prevalence of group function occlusion, not
CPO. They also indicated that Australian aborigines
had group function occlusions.41 Furthermore, they
reasoned that the canine is not necessarily the strongest
human tooth (molars have at least 4 roots and offer
great support for the dentition). Furthermore, the canines are not necessarily the last teeth lost with age and
do not necessarily have more sensitive proprioceptive
systems than any other teeth.39 In addition, Ash and
Ramjford27 argued that prominent canines can adversely restrain normal lateral movements and the
patient may develop chewing motions with a steep path
of closure into centric occlusion. As previously discussed, in addition to CPO and group function occlusion, several other less popular functional occlusion
types have also been advocated.43-45
The issue of balanced occlusion

Nine studies published from 1972 to 1991 that included a total of 959 subjects reported the occurrence of
balancing contacts ranging from 34% to 89%.20,49,51-55,57
Ingervall49 found that approximately 85% of 100 subjects with normal static occlusions had balanced occlusions. Rinchuse and Sassouni53 found that 85% of 27

92 Rinchuse, Kandasamy, and Sciote

normal static occlusion subjects had balanced occlusions. Sadowsky and BeGole51 reported that 89% of 75
subjects with various types of Angle malocclusions had
balancing contacts. Furthermore, de Laat and van
Steenberghe55 found that 61% of 121 Belgian dental
students with various Angle malocclusions had balancing contacts. Shefter and McFall54 reported that 56% of
66 subjects with Angle malocclusions had balancing
contacts. Also, Sadowsky and Polson52 found that 45%
of 111 subjects with Angle malocclusions had balancing contacts. Egermark-Eriksson et al57 reported that
34.5% of 238 subjects with Angle malocclusions had
balancing contacts. In addition, Ahlgren and Posselt56
found that 34% of l20 subjects with Angle malocclusions had balancing contacts. Finally, Tipton and Rinchuse20 found that 75% of 101 subjects (52 of 101, or
51.1%, with normal static occlusions) had balanced
occlusions.
In the 1970s, orthodontic gnathologists argued that
orthodontic patients functional occlusions should be
finished to CPO.3-5 They then alleged that, when
orthodontists ignore patients functional occlusions and
rely on hand-held models rather than articulators, patients would predictably finish with balancing contacts
and eventual TMD. These orthodontic gnathologists
were partially accurate in their assessment of nongnathologically treated postorthodontic patients; they did
have balanced occlusions. However, comparison
groups consisting of subjects with ideal static occlusions and Angle malocclusions also had balanced
occlusions and to an equivalent extent.12,13,18-21,42,51,52
In addition, there was no difference in the TMD signs and
symptoms between orthodontically treated and untreated
subjects.12,13,18-21,51,52,63 Also, TMD increases with age
irrespective of orthodontic treatment.57,64
Several points need to be clarified regarding nonworking-side functional tooth contacts. Two terms are
often used synonymously when describing when and
where teeth touch, ie, tooth contacts vs tooth interferences. Although both terms indicate that the teeth
touch, there is a semantic difference between an occlusal contact and an occlusal interference. Occlusal
contacts are considered benign compared with occlusal
interferences. Ash and Ramjford27 wrote: A balancing
side contact is not a balancing side interference if
it does not interfere with function nor cause
dysfunction . . . or . . . injury to any of the components
of the masticatory system. Furthermore, Ash and
Ramjford27 argued against the claim that all lateral
forces and stresses on the teeth from balancing contacts
are problematic and undesirable: Lateral stress on the
teeth is desirable within physiologic limits; it stimulates
the development of a strong fibrous periodontal attach-

American Journal of Orthodontics and Dentofacial Orthopedics

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ment around the neck of the teeth and lessens the

potential for traumatic periodontal injury from incidental or accidental occlusal forces.27 Thus, the term
occlusal balancing contact refers to a condition when
the teeth come together usually without incident; ie,
without tooth mobility, deflection of the mandible, or
effect on the temporomandibular joints.
On the other hand, an occlusal interference is
generally considered destructive and a harsher condition. Ash and Ramfjord27 stated: the term occlusal
interference refers to an occlusal contact that interferes
in a meaningful way with function or parafunction.
The sixth edition of Glossary of Prosthodontic Terms
defines an occlusal interference as any tooth contact
that inhibits the remaining occluding surfaces from
achieving stable and harmonious contacts.65 That is, an
occlusal interference is a contact that can force the
mandible to deviate from a normal pattern of movement. Based mostly on empirical data, gnathologists
claimed that occlusal interferences can cause tooth
mobility, trauma from occlusion, deflection of the
mandible, bruxism, relapse of tooth position, and
TMD.66-68 The type of balancing side occlusal contacts
typically found in young postorthodontic subjects and
their matched comparison groups are contacts and
generally not interferences.69
The criterion for the acceptance of a functional
occlusion type as the optimal or preferred was based on
2 notions: a single functional occlusion type predominates in nature and provides subjects (or is found
associated) with the fewest TMD signs and symptoms.20 As previously discussed, a single type of
functional occlusion has not been demonstrated to
predominate in nature. Furthermore, electromyographic70 and intraoral telemetry62 studies (miniature
radio implants embedded in dental prostheses and
occlusal contacts monitored outside the mouth similar
to the telemetry used for monitoring space flight) of
functional occlusions that used prosthetically restored
or replaced teeth are equivocal. In addition, the findings
from provocation studies, in which functional occlusal
interferences (high crowns) were produced in subjects, were also inconclusive (ie, symptoms other than
TMD found; samples biased because of dental nurses or
students).71-76
The superiority of 1 type of static or functional
occlusion to ameliorate TMD has not been demonstrated. Data from epidemiologic studies led to the
conclusion that morphological or functional occlusion
variables play a minor role, or no role, in the multifactorial etiology of TMD.20,22,23,42,51-53,57,62,77-87 In this
regard, Dolwich88 stated: Although proposed occlusal
factors appear to be mechanically logical, they are based

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upon empirical, clinical observations and have not been

proven by controlled studies. A cause-and-effect relationship has not been established between occlusion (ie,
morphologic or functional) and TMD.12,13,19,22,58,89-92 At
best, there might be an association between these 2
variables. Also, confusion has sometimes arisen because
correlation or association research was wrongly interpreted as causality. There are several anecdotal and
correlational reports of relationships between TMD signs
or symptoms and Angle malocclusions in general,93,94
overbite,57,82,95-99 overjet,57,82,100,101 Angle Class
II,57,79,89,102-105 Angle Class III,57 crossbite,56,84,106,107
tilted teeth,108 loss of molars,109-112 functional occlusal
interferences,88,113-122 and centric slides greater than 4
mm.63,111 Interestingly, many of these conditions were
speculated to be a result of TMD, rather then the cause of
TMD.63
There is the belief that treating to a functionally
optimal occlusion, including the attainment of CPO,
might be of greater relevance to orthodontic alignment
stability than to TMD.68 In this regard, Roth3-5 and
Cordray6 believed this to be particularly true in regard
to establishing a correct centric relation position. However, Luther123 believed that, even if a particular
functional occlusion is achieved, it will not be stable.
Furthermore, Lopez-Gavito et al124 found no difference
in the long-term stability of mandibular arches between
patients with anterior tooth contacts and those with
anterior open-bite malocclusions with no canine contact
in centric occlusion (and in functional excursions). This
leads to the contention that the final assessment of
functional occlusion contacts for orthodontic patients is
never quite finished because human occlusion is in flux
(unless, of course, there is lifetime retention).125
Although some EMG data suggest that CPO elicits
a better EMG recording than any other type of functional occlusion, other studies contradict or minimize
these findings. Some EMG studies that support the
superiority of CPO follow. For instance, Williamson
and Lundquist126 found that the EMG activity from the
temporalis and masseter muscles was less (better)
during lateral excursions in subjects with CPO vs group
function occlusion. Their findings were supported by
those of McDonald and Hannam127 and Shupe et al.128
Belser and Hannam129 reported that, although CPOs do
not significantly alter muscle activity during mastication, they significantly reduce muscle activity during
parafunctional clenching. Boero130 believed that CPO
(vs group function) produced the least EMG activity
and would therefore have the least occlusal loading.
Interestingly, several authors surmised that the canines
perhaps have some special proprioceptive function that
reduces muscle activity.131,132

Rinchuse, Kandasamy, and Sciote 93

Conversely, the validity of EMG analyses was

recently questioned: quantitative electromyography of
the masticatory muscles seems to have limited value in
diagnostics and in evaluation of individual treatment
results. . . . Despite EMG findings . . . it has yet to be
shown in clinical, prospective trials that canine protected occlusion has a therapeutic effectprevents or
cures TMD.133 A descriptive study of 300 dental
students by Bush134 showed that bilateral canine guidance does not offer protection from facial muscle
tenderness. Furthermore, Clark and Evans125 argued
that EMG functional occlusion studies are seriously
flawed. That is, there is no proper description of what
constitutes normal EMG activity in the masticatory
muscles, and the studies lack appropriate control or
comparison groups.
Relationship of static occlusion to functional
occlusion

Few studies have examined the possible relationship between static occlusion and functional occlusion.
Scaife and Holt2 studied the dentitions of 1200 US
military trainees and found that 940 had Angle Class I
occlusions. CPO was found to be associated with Angle
Class II and then with Angle Class I occlusions and was
the least associated with Angle Class III malocclusions.
That study was limited in that it did not differentiate
between Class I malocclusions and normal (ideal)
occlusions and did not identify or describe other functional occlusion types besides CPO. Sadowsky and
BeGole51 examined 75 subjects with various types of
Angle malocclusions and found that 91% had balanced
occlusions. Tipton and Rinchuse20 found a trend for
101 subjects to have balanced occlusions more often
associated with normal (ideal) static occlusion (or Class
I occlusions). It appears that balanced occlusion exists
to a far greater extent than gnathologists maintain and
that balanced occlusion appears to be more predominant in subjects with normal (ideal) static occlusions (or
Class I occlusions) vs Angle malocclusions.
Clarification of balancing contacts

Some clarification and qualification of the balanced

occlusions in postorthodontic subjects and their comparison groups need to be addressed. The balancing
contacts, for the most part, were contacts and not
interferences. Next, most balancing-side contacts (interferences were not found) were on the distal sides of
the posterior molars.42,53 The exact order of frequency
of teeth found to have balancing contacts were the
distal aspect of the second molars, the distal aspect of
the first molars, and the mesial aspect of the second
molars.42,53 Of note, all teeth (tooth types in addition to

94 Rinchuse, Kandasamy, and Sciote

molars eg, incisors, canines, and premolars) were

prone to have balancing-side contacts, although the
occurrence was very limited. Furthermore, statistical
analysis of the data confirmed that, when there was
canine contact alone on the working side, there was a
greater probably for a lack of balancing-side contacts
on the nonworking side.42,53 This is apparently the
justification of some orthodontists for the extrusion of
canines past their normal contact points or the addition
of resin buildups to the worn incisal edges of these teeth
to attain CPO. However, one must be mindful of the
negative esthetic effect of canine extrusion on the smile
arc. A contemporary esthetic treatment objective involves attaining a consonant smile arc whereby the
incisal edges of the maxillary incisors and canines
should be parallel to the curvature of the lower lip upon
smiling.135 It is argued that the unjustified extrusion of
the maxillary canines to obtain CPO creates a nonconsonant smile arcie, flattening of the maxillary incisal
curvature relative to the curvature of the lower lip.
If one considers the aforementioned and reflects on
the relationship between static and functional occlusion, some provocative thoughts come to mind. Notably, there can be little doubt that the typical and normal
type of functional occlusions in postorthodontic subjects and their nonorthodontically treated ideal static
occlusion counterparts is balanced occlusion and not
CPO (or even group function occlusion).42,51-53,56,57
Importantly, however, not all balanced occlusions are
identical. With this in mind and for any who consider it
heretical to consider any version of balanced occlusion
as normal, it might be just as logical and correct to
consider an alternate term, modified canine protected/
group function occlusion, rather than balanced occlusion. The balancing-side contacts (not interferences) in
these groups were generally minor and for the most part
on the distal aspects of the most posterior teeth, and,
from the perspective of the gnathologist or occlusionist,
easily amendable to occlusal equilibration.42,53 Therefore, when discussing the predominance of balanced
occlusion in orthodontically treated subjects and their
matched counterparts, the nature of balanced occlusion
must be made clear.
Masticatory chewing patterns

When jaw motions are examined from the frontal

plane, 7 patterns have been identified that appear to be
sex-specific and related to craniofacial morphology and
the interdigitation of teeth.136 Subjects with normal
occlusions tend to have more simple, uncrossed, and
elliptical movements than do subjects with malocclusions.137 The characteristics of the shape of the masticatory cycle are finalized in the second year of life

American Journal of Orthodontics and Dentofacial Orthopedics

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when the deciduous dentition reaches full occlusion138

and do not vary much throughout life. When malocclusions are corrected with orthodontic treatment, the
chewing cycles that were characteristic of the malocclusion generally remain, even with a new normalized
occlusion in place.139 Parenthetically, it is possible that
subjects with more vertical chewing patterns (shapes)
would best fit a canine protected functional occlusion
scheme and those with horizontal chewing patterns
would prefer more lateral freedom that would be
consistent with balanced or group function occlusions.
Chewing efficiency is closely related to the amount
of tooth surface used during the maceration of food.140
Subjects with normal occlusions have more efficient
chewing than those with malocclusions,141 but no
specific masticatory pattern has been identified as the
most efficient.142 The relative efficiency of how the
occlusal interdigitations of teeth interact with the different masticatory patterns of jaw movement is still
largely unanswered.
Views and concepts of functional occlusion must
consider and account for the current knowledge of
human mastication and chewing pattern type to establish efficacious guidelines concerning the optimal functional occlusion to achieve for each patient. The potential relationships between chewing pattern type,
craniofacial morphology, static occlusion type, and
functional occlusion type should be studied and evaluated to ascertain appropriate compatibility matches.
Questionable validity of the functional
occlusion data

The validity of the functional data from research

studies, as well as those from traditional gnathological
functional occlusion recordings, is subject to question.
The contrary research findings that show very different
occlusal patterns during lateral excursions might reflect
more a difference in methodology than the actual
results from the studies.143 Although many functional
occlusion recordings can be demonstrated to be
reliable, are they valid? For the most part, the
recordings and measurements are static and not
dynamic. Subjects are not typically asked to chew,
swallow, or exercise any parafunctional movements.
Subjects are usually asked to move or place their
teeth or mandibles in a certain test position, and this
static position is then recorded.20,43,53 For instance, to
record lateral eccentric jaw movements, a subject is
typically asked to slide his or her mandible to a
cusp-to-cusp end position (some 3-5 mm laterally), and
this stationary border position is then recorded.
Whether the subject actually functions in this position
appears to be irrelevant. For instance, 1 person with a

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more vertical chewing pattern might only function

laterally 1 mm or so from centric occlusion, whereas
another with a more horizontal chewing pattern can
actually function in the more extreme lateral cusp-tocusp border position (some 3-5 mm from centric
occlusion). Because the extent of the lateral mandibular
movements can vary from person to person, the question is how does a researcher or practitioner know a
priori the extent of the lateral mandibular movement for
each subject? (The lateral border movement might be 1
mm for 1 subject and 4 mm for another.) The laterotrusive records in research studies assume that all
subjects naturally move and exercise mandibular movements similarly. Is this logical?
Another type of recording scheme used in research
studies is to have each subject slide his or her mandible
so many millimeters (maybe 3-5) to the right or left,
rather than to the cusp-to-cusp border end position.
Parenthetically, the range of lateral tooth contacts can
vary up to 5 mm62,144-150; this represents half of the
lateral width of an average tooth or the width of a cusp.
However, Ingervall et al151 stated that lateral excursive
movements greater than 3 mm are probably rare, and
tooth contacts closer to centric occlusion are more
relevant.
A further variation is to record several different
lateral eccentric movements at several progressive millimeter test positions to the right and then to the left.20
Also, at times, the entire slide from centric to the
laterotrusive cusp-to-cusp position is recorded rather
than any particular millimeter movement to the right or
left. In addition, studies and findings differ on how the
occlusal contacts were recorded based on whether they
were directly viewed or aided by an intermediate
material such as impression compound, wax, articulating paper, or dental floss.152 The location and severity
of the occlusal contacts in any subject vary throughout
the day.153 A further consideration is whether functional recordings (static) are doctor manipulated or
patient governed. In this regard, doctor-manipulated
records are considered more reliable, but less valid and
physiologic, than patient guided and generated records,
and vice versa.154-156
An exception to the above were the recommendations many years ago of Masserman157 and Masserman
et al.158 Masserman157 recommended a technique for
recording functional occlusion that involved the placement of 30-gauge green wax over half of the occlusal
surfaces of the mandibular arch (and repeated for the
other side). Then the subject was asked to eat an
apple, and the cusp contacts were evaluated by
observing the extent of the perforations in the occlusal wax on the nonworking side (opposite the side on

Rinchuse, Kandasamy, and Sciote 95

which the apple was chewed). Masserman157 explained: While in conversation, the patient is asked to
chew a section of an apple on the side opposite the wax
only. This is done very casually and as the patient
chews reflexly, he produces a functional recording of
tooth contact in the wax. He believed that this method
was far superior to using an articulator: In the diagnosis or treatment, an occlusion should be proved on a
functional level. . . . [R]egardless of the instrument
employed or the technique used, every occlusion must
be functionally validated in the mouth. He further
argued that humans can never exactly duplicate on a
conscious level functions that are naturally performed
on a preconscious level. He stated:157
[M]astication is a preconscious act. When patients
are asked to record jaw movements on articulation
paper, typewriter ribbon, wax, etc., the patient becomes confused in conflict between cortex (conscious) and brain stem (preconscious) function. . . .
Stop a man walking, and ask him to show you how he
walks. The resulting demonstration will be an
awkward imitation of his natural gait. Accordingly,
mandibular movements are at best a pantomime or
mimicry of true functional movements. The recording is erroneous and results only in fallacious
treatment.157

In addition, it is claimed that the type of occlusion

(static or functional) is not as important as how the
subject uses (or misuses) his or her occlusion.27,123
Some people have the most perfect occlusions (both
static and functional), and yet they have significant
TMD,159 whereas others have the most horrendous
static and functional occlusions but no TMD. Furthermore, it is well known that the most destructive of all
occlusal forces is that from parafunction (bruxing and
clenching). Interestingly, this type of tooth contact is
not evaluated in any functional occlusion study dealing
with CPO or any gnathologic record used in contemporary clinical practice. Parenthetically, it was estimated that, under normal circumstances (swallowing
and mastication), the teeth come in contact as little as 2
to 7 minutes per day in 1 study160 and 15 to 40 minutes
per day in another (possibly 2-6 hours with added
parafunction).27 Considering this, gnathologists can be
criticized because they presumably do not record any
relevant and meaningful dynamic aspects of mandibular movementmost importantly, patient parafunction.
DISCUSSION
Consideration of other functional occlusion types

If one accepts the rationale and validity of CPO

(and this is highly debatable), there are still many other
arguments against the general recommendation of this

96 Rinchuse, Kandasamy, and Sciote

type of functional occlusion for all orthodontic patients.

First, individual functional occlusion schemes (eg,
CPO) at best describe only partial and incomplete
aspects of the true functional occlusion. That is, no
functional occlusion type singularly describes the full
and complete essence of human mandibular lateral
eccentric movements. Even all the various functional
occlusion schemes considered collectively do not approach the actual dynamic aspects of human mandibular motion. Thus, it does not appear to be too great a
leap of faith that no 1 functional occlusion type is ideal
for every patient. Ascribing to only 1 of the many
functional occlusion types (ie, CPO) as superior and
preferred for all patients might be fallacious.
The argument here is not so much against CPO per
se as it is a call for consideration of other functional
occlusion types that might be just as physiologic and
healthy as CPO depending on each patients unique
stomatognathic characteristics. Therefore, it is possible
that CPO is merely 1 of several optimal laterotrusive
functional occlusion schemes. Isnt the normal in
biology and physiology usually a range and not a single
point or entity? Ash and Ramjford27 stated: Normal
implies a situation commonly found in the absence of
disease, and normal values in a biologic system are
given with an adaptive physiologic range.
The recommendation of Isaacson45 for a biological
concept of occlusion some 3 decades ago seems
prophetic today. His eclectic view was based on the
premise that many functional occlusion types, besides
CPO, could be biologic and physiologic for individual
patients. That is, no single type of functional occlusion
will be physiologic for every patient. For instance, he
argued that, for a patient with periodontal bone loss
involving the anterior teeth and who also bruxes,
perhaps occlusal forces and stresses should be removed
from these teeth and more force placed on the posterior
teeth. The notion of a biologic and physiologic concept of occlusion might best be in keeping with the
recommendation of the 1996 National Institutes of
Health conference on TMD in which only a gross
analysis of the occlusion (vs a detailed, microscopic
analysis) was recommended.161
Also, irrespective of the type of functional occlusion established in a patient, how stable will it be in the
future, especially CPO, when attrition of these teeth is
inevitable with advanced age?68 Will a CPO produced
during orthodontics eventually evolve into a group
function occlusion and then a balanced occlusion with
posttreatment occlusal settling, wear, and continued
facial growth and aging? Storey162 wrote that CPO
will tend to become Group Function in time due to the
wear of the maxillary canines.

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Furthermore, the axiomatic notion that, to achieve a

physiologic occlusion during orthodontics or prosthodontics, a practitioner must merely reestablish a previously healthy occlusal scheme (whether it be CPO,
group function, or even perhaps balanced occlusion) is
not logical and correct. The fallacy related to this type
of dialectics is: when in time can a practitioner really be
certain that the previous (or existing) functional occlusion is physiologic and healthy and worthy of retracing or re-establishing? That is, orthodontic treatment might have begun in the late mixed dentition
when the deciduous canines (often with much incisal
wear and attrition) are still present or during the very
early stages of the development of the permanent
dentition, and a final functional occlusion scheme has
not yet been established or identified. Also, even if the
preorthodontically treated functional occlusion is
healthy and free of diseases or disorders, how can a
clinician predict the future oral health of an occlusal
scheme and determine it is worthy of copy?
Functional occlusion, gnathology, and TMD

It appears that some gnathologists are confident and

dogmatic in their knowledge of the optimal type of
functional occlusion to direct orthodontic patient treatment: the goal of an excellent functional occlusion
would be met by achieving Andrews Six Keys, along
with a seated condyle position and a mutually protected
occlusion.163 However, the evidence for this declaration and myopic view of functional occlusion has yet to
be proven. Furthermore, this type of rhetoric is both
naive and dangerous, particularly the general recommendation of this functional occlusion scheme for all
patients. The self-serving notion that excellence in
orthodontics can be accomplished only by achieving
CPO is condescending to those who have a different
viewpoint. The dogmatic, indiscriminant, and universal
recommendation of CPO, and other gnathologic principles, has made orthodontists prisoners to the whims
of this litigious society.
Perhaps orthodontists who have overly focused on
the minute details of occlusion, including the need to
establish CPO for all patients, should take a few steps
back and thoroughly reflect on what they are doing. Do
some long-held beliefs and techniques involved in
gnathology seem logical today in light of evidencebased knowledge on occlusion and TMD? TMD is now
considered a collection of disorders embracing many
clinical problems that involve the masticatory muscles,
joints, and associated structures.19,63,88,90,92,161,164 The
role of occlusion has been demonstrated to have less
importance than once thought.13,63,88,90,92,161,164 Studies in the 1960s and 1970s that placed inordinate

Rinchuse, Kandasamy, and Sciote 97

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emphases on occlusion as causing TMD were found to

lack control or comparison groups (poor diagnostic
specificity). That is, there is poor diagnostic sensitivity
and specificity of occlusal factors related to
TMD.165,166 In addition, condyle position has not been
causally related to TMD. The centricity of the condyles
in the glenoid fossa involves a range, and eccentricity
does not necessarily indicate TMD.13,63,90,161,164,167-171
The evidence-based view on occlusion and TMD
does not argue or conclude that occlusion (or condyle
position) has no relevance to TMD or that orthodontists
should ignore it.63,90,161,164 What can be gleaned from
the evidence-based paradigm is that occlusion is no
longer considered the primary and only factor in the
multifactorial nature of TMD. The gross evaluation and
analysis of occlusion are still important in the diagnosis
and treatment of TMD: assessment of occlusion is
necessary as part of the initial oral examination to
identify and eliminate gross occlusal discrepancies such
as those that may inadvertently occur as a result of
restorative procedures.161 McNamara et al63 estimated
the percentage contribution of occlusal factors to the
multifactorial characterization of TMD at about 10% to
20% (and this might only be in an associational context,
not cause and effect). They further stated: Although a
stable occlusion is a reasonable orthodontic treatment
goal, not achieving a specific gnathologic ideal does not
result in TMD signs and symptoms.63 The evidencebased view on occlusion and TMD would include the
amelioration of gross occlusal interferences that cause
tooth mobility, fremitus, and deviation or deflection of
mandibular closure and movement.13
A first step for experience-based orthodontists, who
find themselves indoctrinated into many unproven gnathological precepts, would be to take a candid look at the
evidence-based literature and then evaluate what they are
doing that is different from the information in this body of
knowledge. For instance, at present, there are 8 systematic reviews of literature (evidence-based model number 3 highest level, most compelling evidence) on the
subject of TMD.14,172 These reviews deal with TMD
etiology, including the roles of occlusion and orthodontic treatment in relation to TMD, diagnostic imaging,
and TMD treatments. From an evaluation of these 8
reviews, it can be concluded that occlusion and orthodontic treatment do not cause TMD, and occlusal
adjustments are not recommended for the initial treatment of TMD.172 This information certainly concurs
with the views of the 2 national American ental
Association conferences published in 1983190 and
1990,164 and the 1996 National Institutes of Health161
conference on TMD.
Furthermore, the astute recommendation of Ash

and Ramjford27 regarding what constitutes normal occlusion should be considered: Normal occlusion . . . should
imply more than a range of anatomically acceptable
values; it should also indicate physiologic adaptability
and the absence of recognizable pathologic manifestations . . . and the capability of the masticatory system to
adapt to or compensate for some deviations within the
range of tolerance of the system.
CONLUSIONS

As judged by the popularity of CPO, it appears that

it is perceived as proven fact rather than 1 concept of
functional occlusion. Nonetheless, Clark and Evans143
emphatically stated: The criteria that denote an ideal
functional occlusion have not been conclusively established. In addition, the terminology, nomenclature,
and concept of CPO, as well as group function and
balanced occlusions, can be challenged based on its
questionable validity. Not all subjects actually function
in the laterotrusive extreme border positions represented by this functional occlusion paradigm. Those
who make, or accept, the claims of the superiority of
the CPO paradigm over other worthy functional occlusion types have the burden of proof, and not vice versa.
The arbitrary selection of CPO for all patients
ignores the value and importance of each persons
unique stomatognathic and neuromuscular functional
status. Other functional occlusion types and patterns
might be just as acceptable as CPO. The important
point here is that, irrespective of how you define
patients functional occlusion type, there should not be
any occlusal interferences (vs contact). Perhaps patients
with different craniofacial structures or chewing patterns might adapt better to 1 type of functional occlusion vs another. Furthermore, a person with parafunctional bruxing habits that have much side-to-side lateral
excursive movements might welcome the lateral excursive freedom of group function or balanced occlusion.
There is little evidence of benefit for establishing CPO
in all orthodontic patients. The at all cost goal of
attaining CPO and the deliberate elongation of the
canines through orthodontic extrusion or resin buildup
is unwarranted and possibly iatrogenic.
Ackerman15 appropriately stated: The challenge
facing orthodontists in the 21st century is the need to
integrate the accrued scientific evidence into clinical
orthodontic practice. With this in mind, it is time for
dentistry and orthodontics to take a fresh look at what
is being taught and advocated in clinical practice in
regard to functional occlusion. With evidence-based
dentistry at the forefront of clinical practice, some old
experience-based perfunctory approaches to functional

98 Rinchuse, Kandasamy, and Sciote

occlusion must be revisited and perhaps abandoned in

favor of more valid evidence-based information.
A first step in accomplishing this goal would be to
develop more appropriate and valid research in the area
of functional occlusion. In this respect, there is a need
to develop more sophisticated methods for recording
functional occlusion including parafunction that are
dynamic, rather than static. Next, practitioners must
acquire model level 3 evidence-based (systematic review) information about occlusion and TMD and put it
into practice. The periodic dental and orthodontic
journals are the vehicles for the dissemination of these
materials (some new journals focus entirely on this
issue). The old-guard notion and practice of acquiescence to experience-based gurus, who have little or
no understanding of research, experimental design, and
statistics, will be yesteryear. The hope of the new
millennium is that the use of unproven tests, devices,
and techniques in orthodontics will become extinct and
replaced by scientifically verified concepts and procedures.

A single type of functional occlusion has not been

demonstrated to predominate in nature.
CPO, as the optimal type of functional occlusion to
establish in orthodontic patients, is equivocal and
unsupported by the evidence-based literature.
CPO might be merely 1 of several possible optimal
functional occlusion types toward which to direct
orthodontic patients treatments.
Group function occlusion and balanced occlusion
(with no interferences) appear to be acceptable functional occlusion schemes depending on the patients
characteristics.
The stability and longevity of CPO is questionable.
Reestablishing a functional occlusion through orthondontic treatment back to the type of functional
occlusion that existed before treatment is problematic.
Consideration of a patients chewing pattern shape,
craniofacial morphology, static occlusion type, current oral health status, and parafunctional habit might
provide important and relevant information about the
most suitable functional occlusion type for each
patient.

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