Sixty-eight years of experimental occlusal interference studies: What have we

learned?
Glenn T. Clark, DDS, MS,a Yoshihiro Tsukiyama, DDS, PhD,b Kazuyoshi Baba, DDS, PhD,c and
Tatsutomi Watanabe, DDS, PhDd
School of Dentistry, University of California, Los Angeles, Calif.
Statement of problem. Understanding is needed regarding the effect that occlusal interferences have on
the teeth, periodontium, and especially on jaw function.
Purpose. This article summarizes research in which experimental occlusal interferences have been placed
on the teeth of animals and human volunteers.
Material and Methods. Data from 18 human and 10 animals studies were reviewed. Experimental
occlusal interferences were grouped into those that alter intercuspal position and those contacting on lateral
jaw movement only. The outcome of these interferences were analyzed according to their local pulpal-peri-
odontal, jaw function, or bruxism effects.
Results. Experimental occlusal interferences in maximum intercuspation had a deleterious effect on peri-
odontal and pulpal tissues of the affected tooth; sometimes this produces a disruption of smooth jaw func-
tion and occasionally jaw muscle pain and clicking. Experimental occlusal interferences that contact only in a
lateral jaw movement are infrequently harmful to jaw function. Furthermore, no reliable evidence demon-
strates that occlusal interferences can cause nocturnal bruxism, or stop it.
Conclusion. Transient local tooth pain, loosening of the tooth, a slight change in postural muscle tension
levels, chewing stroke patterns, and sometimes a clicking joint can be induced by an experimental occlusal
interference. Because such findings are present in relatively asymptomatic patients, these data do not prove
that occlusal interferences are causally related to a chronic jaw muscle pain or temporomandibular joint dys-
function problems. (J Prosthet Dent 1999;82:704-13.)

CLINICAL IMPLICATIONS
Although occlusal therapy may be justified for reasons of esthetics, gross occlusal insta-
bility, or dental disease, the data do not exist showing that occlusal interferences are
the cause of chronic jaw dysfunction problems. Conversely, this review suggests that
when a patient’s complaint is tooth pain or mobility, occlusal interferences are a poten-
tial and likely contributing factor.

O ver the years, many researchers have claimed that

occlusal interferences cause a variety of deleterious local
The purpose of this literature review is to focus on
experiments where artificial occlusal interferences have
dental and masticatory system effects.1-5 However, been placed on the teeth of animals or human subjects.
proof of a causal relationship must be provided through The review addresses 4 questions regarding: (1) the
rigorous experimentation. The accumulation of data on effect of experimental interferences (all kinds) on the
the broad question, “Are occlusal interferences delete- periodontal and pulp tissues of individual teeth in
rious?” has been gathering for over 68 years. experimental trauma; (2) the effect of high restoration
on jaw function; (3) the effect of excursive occlusal
interferences on jaw function; and (4) the effect of
Presented at the annual meeting of the Academy of Prosthodontics, occlusal interferences (all types) on bruxism.
Colorado Springs, Colo., May 1998.
aProfessor and Chair, Section of Oral Medicine and Orofacial Pain. EXPERIMENTAL OCCLUSAL
bVisiting Scholar, Section of Oral Medicine and Orofacial Pain; and
INTERFERENCES AND INDIVIDUAL
Research Associate, Department of Removable Prosthodontics,
TEETH
Faculty of Dentistry, Kyushu University, Fukuoka, Japan.
cVisiting Scholar, Section of Oral Medicine and Orofacial Pain; and
The quest for a better understanding of the effects
Research Associate, First Department of Prosthodontics, Faculty
of occlusal trauma began with a study by Gottlieb and
of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan.
dVisiting Scholar, Section of Oral Medicine and Orofacial Pain; and Orban6 in 1931. They experimentally placed high
Associate Professor, Second Department of Prosthodontics, crowns on the teeth of young and old dogs (n = 33)
School of Dentistry, Showa, Tokyo, Japan. and then killed the animals at various time points, rang-

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ing from 12 hours to 13 months. Harvested jaws were tium and 4 had experimental periodontitis in the
submitted to qualitative histologic analysis. The mandibular fourth premolar region. Dogs were killed
authors reported that local resorption of the alveolar after 7, 14, 30, and 180 days. They reported that the
bone around the teeth with the high crowns was periodontal ligament in the periodontally healthy
induced within 24 hours. The rapidity of bone resorp- group was wider and the teeth more mobile. These
tion appeared to be dependent on the age of the ani- changes suggested the teeth had more or less become
mal, being more rapid in the young than in the old. adapted to the altered occlusion by the end of the
Unfortunately, no information was provided about any experiment. In the experimental periodontitis group,
pulpal changes and the magnitude of the interference there was increased vascular leakage, leukocyte migra-
was never quantified. In those situations where longer tion, and osteoclastic activity. Despite these changes,
periods (greater than 13 months) elapsed before the they did not report or demonstrate acceleration of
animal was killed, the traumatized teeth of the animals actual periodontal attachment loss with subsequent
presumably moved into new positions to relieve the accelerated pocket deepening as a result of occlusal
trauma because normal supporting bone was evident at trauma. At the same time, Polson et al10,11 were
examination. Overall, these data were a convincing conducting studies on squirrel monkeys using experi-
demonstration of the local but transient, traumatic mental occlusal interferences (EOI) on teeth with and
effects of a high crown on the investing alveolar tissues. without periodontal inflammation. They found that
These data did not assess whether irreversible pulpal plaque-induced tissue inflammation, not occlusal
damage occurred or the issue of whether occlusal trau- trauma, was the major factor in the progression of
ma contributed to periodontal disease progression. periodontal disease. Their data were in complete agree-
The role of occlusal trauma in periodontal disease ment with Svanberg and Lindhe,9 and they concluded
was first evaluated by Box,7 who placed a high crown that plaque-induced tissue inflammation and not
on the lower incisor of a sheep and, after 104 days, occlusal trauma was the major factor in the progression
killed the animal. By using a combination of qualitative of periodontal disease.
clinical and histologic analysis methods, he reported an Few studies have actually been conducted on trau-
increased mobility and deepening of the gingival pock- matic occlusion on pulpal tissues. Animal studies
et on the experimental teeth and suggested that peri- reporting occlusal trauma as a cause of pulpal inflam-
odontal disease progression was enhanced by occlusal mation have not conducted actual pulp testing. How-
trauma. Although this data were extremely limited, ever, a unique study was performed on human subjects
Box’s study precipitated the assumption that “occlusal by Ikeda,12 who placed experimentally high inlays (75-
trauma is an important co-factor of periodontal dis- 280 µm) on teeth and measured pain and sensory
ease.”7 This assumption resulted in dentists frequently thresholds with an electronic pulp tester. Ikeda report-
using occlusal adjustment as a critical part of their peri- ed that 10 of 14 teeth in 6 healthy human subjects with
odontal treatment program. high inlays showed a strong and consistent decrease in
Twenty-three years after Box’s study, Wentz et al8 pulpal pain threshold to electric stimulation immedi-
evaluated the effect of “jiggling” forces on periodontal ately after the inlays were placed (within 2-29 days). He
tissues. They applied “jiggling” forces to the maxillary also demonstrated that the decreased pain threshold
right second premolar in 6 monkeys by using a combi- returned to normal in 6 of these 10 teeth when the
nation of a high crown and lingual arch wires for 2 days high inlay was removed by adjustment. In another 4 of
to 6 months. They described alveolar bone resorption the 10 teeth, the tooth pain threshold was still slightly
and inflammation of the investing periodontal tissues. diminished at the end of the observation (even though
However, they also reported that the inflammatory the tooth was adjusted back into normal contact). He
changes disappeared and functional adaptation, such as concluded that the majority of the teeth demonstrated
widening of the periodontal ligament, was observed in a predictable decrease in pain threshold when a high
the 3- to 6-month specimens. Unfortunately, they did inlay is placed on a tooth. Moreover, this threshold will
not carefully control periodontal inflammation as a return to normal in a majority of teeth, if occlusal
variable and therefore did not definitively answer the adjustment is performed, or if enough time passes so
question about whether occlusal trauma accelerated that the tooth can be physiologically intruded by the
periodontal disease (as determined by attachment loss) occlusal forces.
or simply made the teeth loose and sore for a period.
Summary of local effects
In 1974, Svanberg and Lindhe9 evaluated the effect
of long-term “jiggling” forces on experimentally Iatrogenically placed high crowns or restorations in
induced periodontitis in beagle dogs. They placed a cap maximum intercuspation can have a local deleterious
splint device in the upper jaw and a bar on the lower effects (inflammation and sensory change) on the
jaw that caused “jiggling”-type occlusal trauma. Of the investing alveolar tissues and pulpal tissues of teeth.
13 beagle dogs studied, 9 dogs had healthy periodon- This effect appears to be transient, from several days to

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Table I. Articles in which EOIs were used in human subjects: Description of study
Size Type Duration of No. of
Authors of EOI of EOI study subjects Outcome assessment method

Anderson and Picton16 500 µm ICP N/A 4 Occlusal forces measured

Graf and Zander25 N/A Balancing Same-day 5 Number of tooth contacts and clinical
effect symptoms
Schaerer and Stallard26 N/A Balancing 2 days 4 Occlusal contacts with chewing and clinical
symptoms
Shaerer et al27 500 µm Balancing 2 days 3 Occlusal contact
De Boever28 N/A Balancing 8 days 4 EMG levels
Randow et al17 250 µm ICP contact on 14 days 8 Clinical symptoms and EMG balance
first molar
Funakoshi et al18 300 µm ICP contact on 7 days 6 Resting EMG in various head positions
first molar
Bakke and Møller5 50 to 200 µm ICP contact on Same-day 4 EMG during clenching
first molar effect
Hannam et al30 N/A Working side Same-day 5 EMG during clenching and jaw movement
contact on first effect
premolars
Riise and Sheikholeslam19 ~500 µm ICP contact 7 days 11 Clinical symptoms and resting EMG
Rugh et al38 0.5-1 mm ICP contact 10 to 21 days 10 EMG activity during sleep
(lateral on first molars
and forward)
Magnusson and Enbom32 N/A Balancing contact 2 wk 12 Clinical symptoms
Ikeda12 75 to 280 µm ICP contact on first 29 days 6 Electric pain threshold
and second
premolar
Karlsson et al33 N/A Balancing contact 1 wk 12 Masticatory movement
Rossouli and Christensen22 240 µm ICP contact on Same day 12 Jaw tipping
premolar and
molar
Christensen and Rassouli20 240 µm ICP contact on Same day 12 EMG balance
premolar and
molar
Shiau and Syu39 1500 µm Balancing 1 mo 27 EMG levels and jaw movement
Baba et al24 N/A Working and Same day 12 EMG levels with clenching
balancing
contact on
molars

several weeks, because the traumatized teeth tend to monkeys) had only a flat occlusal plane splint, whereas
move away from the adverse occlusal forces. These local the other group (4 monkeys) had a premature contact
adverse sensory and periodontal-osseous effects of at the first molar area on the splints. The metal splints
occlusal trauma would appear to be well-accepted as were placed for 15 and 55 days before the monkeys
indications for occlusal adjustment therapy. were killed, and the TMJs were submitted to histolog-
ic analysis. Results showed that destructive bony tissue
EFFECT OF A HIGH CROWN ON JAW
changes were evident in the condyles, glenoid fossa,
FUNCTION
and neck of the condyle in both the 15- and 55-day
The putative role of occlusal interferences and the specimens. In 55-day specimens, the condyle was dis-
masticatory motor system and temporomandibular placed mesioinferiorly and there was flattening of the
joint (TMJ) has been addressed in several animal and articular eminence and the condylar head. Both flat and
human studies. Available animal studies in the literature pivoted splints caused traumatic changes in the TMJs.
begin with Ruben and Mafla,13 who placed metal Another animal model–based study of the effect of
splints bilaterally in 6 monkeys, where the vertical occlusal interferences on TMJs was conducted by
dimension of occlusion (VDO) was increased by 4 mm Kvinnsland et al,14 who reported on the effect of exper-
at the first molar area. One experimental group (2 imental traumatic occlusion on blood flow in the TMJ

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Table II. Articles in which EOIs were used in human subjects: Results of study

Anderson and Picton16 The load on the EOI was 2 times greater than on a same tooth without EOI.
Graf and Zander25 Reported increased number of contacts during chewing and no significant effect on jaw pain or function with
balancing EOI.
Schaerer and Stallard26 Immediate adaptation in that the teeth touch more often initially, but no perceptible change in chewing pat-
tern. They reported no clinical symptoms with balancing EOI.
Schaerer et al27 The number of occlusal contacts increased about 2 times above normal.
De Boever28 EMG patterns during mastication did not change within the 8 days after insertion of balancing-EOI.
Randow et al17 Asymmetric resting EMG persisted until EOIs were removed. Six subjects had TMJ and muscle tenderness, 3
had clicking, and in 1 subject, this problem persisted for 9 mo.
Funakoshi et al18 Asymmetrical resting EMG after EOI, but when interference was reduced, EMG levels returned to normal.
Bakke and Møller5 ICP-EOI (unilateral) caused EMG changes during clenching. Specifically, increased EMG on ipsilateral side
and decreased on contralateral side.
Hannam et al30 Some subjects showed small differences, but no consistent effects of working EOI on EMG or jaw movement.
Riise and Sheikholeslam19 2 subjects showed increased EMG in temporalis, but no changes in masseter. 1 mo after the removal of EOI,
the resting EMG had returned to original pattern in all subjects. 7 subjects had transient pain, tenderness, and
fatigue in jaw muscles.
Rugh et al38 No relationship between ICP-EOI and EMG levels. Some subjects had mild jaw muscle and TM joint tender-
ness and mobility on the EOI teeth.
Magnusson and Enbom32 Balancing EOI group had 10/12 subjects report subjective jaw pain symptoms. In controls, 3/12 reported
subjective jaw pain symptoms during 2-wk study.
Ikeda12 10 of the14 teeth had decreased pain threshold after an ICP-EOI. These thresholds return to baseline in only
6/10 teeth after OA.
Karlsson et al33 Opening magnitude and movement velocity were different after OA.
Rassouli and Christensen22 Assumed no bending of mandible and calculated 0.7 degree frontal plane rotation from a 240 µm EOI. The
contralateral condyle to EOI would be elevated 0.5-1.0 mm.
Christensen and Rassouli20 EMG with EOI increased +21% more on same side and decreased –14% on opposite side (P = NS).
Shiau and Syu39 The velocity of jaw closing decreased immediately after the insertion of the overlay, and the closing pathway
near the occlusal phase of chewing cycle was narrower.
Baba et al24 Balancing EOI increased temporal EMG on nonworking side and decreased on working side when compared
with baseline EMG without EOI when clenching in a canine edge-to-edge position.

of the rat. They placed a 1-mm high EOI (using com- These 3 animal studies hint that when substantial
posite material) unilaterally on the first maxillary right disruption in the occlusal scheme might be deleterious
molar in 30 rats. At 1, 5, 10, 15, and 20 days after to the TMJ and alter jaw muscle function. What these
placement of the interference, blood flow in the TMJ studies cannot answer is whether these changes are nor-
was assessed by injecting fluorescent microspheres just mal accommodative responses or the beginning of a
before killing the rats. Results revealed that there was chronic dysfunction. Moreover, it is hard to know
an increase in blood flow at 15 to 20 days on the ipsi- whether the effects described in these animals can be
lateral side, compared with the contralateral side. There generalized to the human because the size of the inter-
was also an increase in blood flow in both ipsilateral ferences are quite large. Last, the fact that human
and contralateral TMJs in the experimental animals orthognathic surgery patients can and do have substan-
compared with 10 control animals. They interpreted tial changes in their occlusion without consistently hav-
these results as demonstration of altered joint loading ing jaw function problems argues that the above animal
as a result of the interference. data reflects accommodative remodeling changes and
In a similar experiment, Richardin et al15 placed an not pathologic jaw dysfunction.
EOI (occlusal splint) of 2 heights (low and high but of As there is always a question about the applicability
unknown height) bilaterally in 12 rats, and measured of animal study data to the human situation, in recent
EMG activity of the anterior temporalis, superficial years, human subjects have been the preferred experi-
masseter, and anterior digastric muscles. Increased mental model for occlusal trauma research (Tables I
activity in the anterior temporalis and superficial mas- and II). Anderson and Picton16 began the process by
seter muscles was reported during the late phase of placing either “normal height” or “500 µm high”
opening that was not observed in the control animals. onlays on the occlusal surface in 4 subjects. They posi-
Unfortunately, these EMG data were subjectively inter- tioned load-sensors in these onlays to record occlusal
preted and the authors did not perform any quantita- forces during bread mastication under the 2 conditions.
tive statistical analysis. They found that the load on the 500-µm high onlay

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was 2 times greater than on the same tooth with the face EMG during clenching, recording bilaterally from
normal height onlay. Randow et al17 experimentally anterior and posterior temporalis and masseter muscles.
placed a “high” gold onlay on the occlusal surface of a They reported asymmetric muscle activity during
mandibular molar in 8 healthy subjects. This interfer- clenching that was increased on the ipsilateral side and
ence was approximately 250 µm above the contacting decreased on the contralateral side; however, they did
plane, thus putting the tooth in supracontact. They not attempt to test the validity of their observations
used bilateral resting surface EMG recordings from the with a statistical analysis.
masseter, temporalis, and suprahyoid muscles. The EOI Riise and Sheikholeslam19 experimentally placed a
was in place for 14 days and the EMG recordings were high amalgam restoration on the occlusal surface of a
performed immediately before and after the placement, right maxillary first molar that was 500 µm above the
and then again 7 days later. They described bilaterally occlusal surface in 11 subjects without symptoms of
increased EMG activity in 3 subjects, bilaterally functional disorders in the stomatognathic system.
decreased activity in 3 subjects, and higher EMG activ- EOI was in place for 7 days and EMG recordings were
ity on the ipsilateral side with a reduced EMG activity recorded before placement, during (at 1 hour, 48
on the contralateral side in the temporalis after the hours, and 1 week) and up to 1 month after the EOI
interference. This study also reported on, but did not was removed. They used surface EMG of masseter and
measure, a disturbed mandibular coordination with anterior temporalis at rest and reported that 1 hour
function in 6 of the 8 subjects. Randow et al17 report- after insertion of the interference 2 subjects showed
ed that these 6 subjects complained of TMJ tenderness increased activity in the resting anterior temporalis
and muscle tenderness as a result of the occlusal inter- muscle of 1 side. At 48 hours and 1 week after inser-
ference. Finally, new spontaneous TMJ clicking was tion of the interference, there was still a significant
reported during mandibular opening bilaterally in 3 increase in the resting EMG activity of the right and
subjects during this experiment (these symptoms left anterior temporalis muscles. Like Funakoshi,18
occurred at 7 to 14 days after insertion of the inlay). In they found that 1 month after the removal of the
1 subject, there was still severe irregularities of the interference, the postural activity had returned almost
movement in both joints near maximal mandibular to its original pattern in all subjects. Regarding mas-
opening 1 week after the removal of the inlay. This seter muscle, there was no significant increase of pos-
symptom persisted for 9 months and abated after treat- tural activities throughout the experimental period.
ment with stabilization splint. They also reported (3 hours after the placement of the
In the same year, Funakoshi et al18 studied the sur- interferences) that 7 subjects complained of pain, ten-
face EMG activity at rest taken from the masseter, derness, and fatigue in the elevator muscles. More-
temporalis, and digastric muscles of 3 subjects where a over, 8 subjects developed dysfunctional symptoms in
300 µm experimental high restoration (metal overlay) the masticatory muscles or TMJ within 12 hours after
was placed on a molar for 7 days in 3 subjects. EMG the insertion of the EOI. Importantly, within a week,
recordings were performed before placement, during these symptoms gradually subsided in 4 subjects,
(at 7 days), and up to 1 month after the interference whereas 4 subjects still reported moderate dysfunction
was removed. Like Randow et al,17 Funakoshi et al18 symptoms until the interference was removed. This
reported that an asymmetric postural muscle activity study used an improved quantitative analysis of the
resulted from the occlusal interferences, which were EMG levels and performed statistical testing. Unfor-
not present before the overlay’s placement. When this tunately, the clinical observations of pain and tender-
interference was removed, the asymmetric activity lev- ness were not quantified in any fashion.
els were reported as diminished to a normal, balanced In a 2-part study, Christensen and Rassouli20,21
level. However, they did not comment on any clinical reported the effects that a unilateral EOI had on both
effect of the EOI on masticatory muscle or TMJ func- the surface EMG activity at rest and on the tipping of
tion, except for a note that one of the subjects com- the mandible. EMG recordings were taken from the
plained of transient periodontal pain at the tooth where masseter muscle of 12 subjects where a minimum
the overlay was placed. Moreover, they categorized height of 0.24 ± 0.21 mm rigid acrylic resin onlay
EMG into balanced or unbalanced types but did not splint was placed unilaterally in the second premolar
perform any statistical analyses on these data. and first molar region. EMG recordings from bilateral
Bakke and Møller5 reported that unilateral prema- masseter muscles were performed with and without an
ture contact caused a significant asymmetry of activity acrylic resin onlay. They reported relative masseteric
in masseter and temporalis muscles during clenching. EMG activity (EMG with the splint/EMG without the
They incorporated the EOI by inserting 1 to 4 celluloid splint) during clenching showed 121% ± 69% in the
strips between the first molars unilaterally in 4 subjects. ipsilateral side to the onlay and 86% ± 19% in the con-
The heights of the interferences were 50, 100, 150, tralateral side, respectively. These changes were not sta-
and 200 µm above the contacting plane. They used sur- tistically significant. Christensen and Rassouli also

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described the tipping effect that the EOI had on the De Boever28 investigated whether an experimental
mandible.22,23 Rotation of the mandible during clench- occlusal balancing interference would cause changes in
ing was measured with the jaw tracking device (elec- the EMG during mastication. He placed an experimen-
trognathograph) whose target (magnet) was attached tal occlusal balancing interference (gold inlay) on the
to the labial surface of the mandibular incisor in the first premolar in 4 dental students with normal occlu-
same 12 subjects of the previously mentioned study. sion for 8 days. Masticatory EMG recorded from ante-
The results revealed an upward rotation of the rior temporalis muscles 1 month and immediately
mandible (0.7 ± 0.3 degrees) contralateral to the inter- before, immediately, 3, and 8 days after the insertion,
ference side in the frontal plane. They also reported a then immediately and 10 days after the removal of the
significant linear association between upward rotation interference. He found that EMG patterns during mas-
of the mandible in the frontal plane and relative masse- tication did not change either immediately or 8 days
teric EMG activity (EMG with or without the splint) after the insertion of the experimental balancing inter-
during clenching on the ipsilateral side to the interfer- ference. In addition, teeth on which the gold inlays
ence. Unfortunately, the system they used had some were placed did not exhibit induced mobility during
limitations. The rotation in the frontal plane could be the experiment.
affected by the rotation in the sagittal and horizontal Kloprogge and Griethuysen29 did not actually place
planes. The calculation of the rotation was made under “high crowns,” but reported that abnormalities in the
the assumption that the mandible is rigid and would pattern of coordination of the masticatory muscles
not deform during clenching. They also speculated that were related to dental restorations. They measured
the condyle contralateral to the interference could ele- EMG from anterior temporalis and masseter muscles in
vate 0.5 to 1.0 mm. Furthermore, it is still unknown if 3 normal subjects without any dental restoration and 8
a 0.7-degree rotation could actually cause structural temporomandibular disorder (TMD) patients with
damage to the TMJs or if this degree of change is well restorations. Presence of a number of wear facets on the
within the capacity of the TMJ to adopt. restoration revealed by detailed occlusal examination
with articulating paper was linked with the abnormali-
EFFECT OF LATERAL INTERFERENCES
ties in the EMG (decreased activity, time difference
ON JAW FUNCTION
between right and left side). They reported removing
In addition to the effect of high restorations on jaw these wear facets caused instantaneous disappearance of
function, it has been claimed that posterior teeth, symptoms of TMD in some patients and partial
which contact in a lateral motion (namely, working and improvement in other patients. However, actual data
balancing interferences), have adverse effects on jaw were not provided. There are a number of flaws in this
function. Graf and Zander25 used a telemetric system study. There was no description regarding the number
to study the number of times an experimentally placed of restorations and how well they occluded with the
balancing interference would touch during function. rest of the teeth. It was not clear what type of occlusal
They reported that a balancing-EOI had an increased adjustment was performed and what type interferences
number of contacts during chewing, but no significant were present (on natural teeth or on restored teeth) in
effect on jaw pain or function was observed. Schaerer these patients. Furthermore, the method by which the
and Stallard26 placed an experimental lateral occlusal patients’ symptoms were assessed was entirely unblind-
interference of unknown height in 4 subjects and noted ed and subjective.
that the only change was that these teeth touched more Hannam et al30 evaluated the effects of working side
often. They reported no change in the number of occlusal interferences on muscle activity and jaw move-
chewing strokes or the overall pattern of the chewing ment. They introduced the EOI by putting a compos-
cycle, nor did they describe any jaw dysfunction. By ite material on the buccal cusp of the working side max-
using the same method, Schaerer et al27 performed an illary right first premolar in 5 normal subjects. They
experiment to examine the effect of balancing interfer- recorded EMG from anterior and posterior temporalis
ence on the EMG activity during mastication. They and masseter muscles and jaw movement during gum-
recorded tooth contact and EMG activities in the ante- chewing, before and immediately after the insertion of
rior and posterior temporalis and masseter muscles dur- the working side interference. The experiment was per-
ing chewing movements before and immediately after formed on the same day (< 2 hours from start to fin-
the insertion of the balancing interference in 3 subjects. ish). No consistent effects were found for the experi-
The result showed that there was an increase in the mental working side interference on EMG or jaw
number of tooth contacts at the balancing interference. movement changes.
Although 40% of these tooth contacts elicited the inhi- One theory of balancing interferences is that canine
bition of EMG activity, they could not demonstrate a guidance is protective of the jaw. In other words, when
deleterious effect of the balancing interference on the subjects contact on a canine only in a lateral jaw posi-
jaw-closing muscles. tion, the subject produces less force than if they were

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contacting on several teeth, including a posterior tooth. placement of the interference. They reported that
Rugh et al31 performed actual testing of this concept EMG activity of the anterior and posterior temporalis
by using splints that had molar guidance versus canine muscles during maximum clenching with nonworking
guidance built into the splint. They found that it did side EOI increased on the working side and decreased
not matter which tooth was the guiding tooth, because on the nonworking (balancing) side in a lateral jaw
the subject was not willing to clench as hard on one position. For masseter muscles, the activity remained
tooth versus multiple teeth, whether canine or molar, unchanged.
in a lateral jaw position. The whole concept of canine
Summary of jaw function effects
guidance and canine-protected occlusion is actually a
concept that is illogical if protection from parafunction The data reviewed suggest the following relationship
is the subject of debate. That canines do not inherent- between iatrogenic occlusal interferences (both in ICP
ly protect the jaw and teeth from bruxism is clear and on a lateral movement) and jaw function. First, it
because in the strong bruxer, the clinical observation of can be concluded that a high crown or restoration will
canine attrition is common. likely induce accommodations in postural and
Magnusson and Enbom32 studied the effects of functional jaw muscle patterns. The magnitude and
experimentally placed balancing interferences in 2 variability of these alterations are less for lateral occlusal
healthy subject groups. In 1 of the groups, bilateral bal- interferences than for ICP interferences. What is not
ancing side interferences were applied, whereas the clear is whether these varied (sometimes present, some-
application was simulated in the control group. In the times not) postural elevations and asymmetries of
experimental group, 10 of 12 subjects reported subjec- muscle function under experimental interference con-
tive symptoms and 7 developed clinical signs of TMD ditions are associated in any way with the initiation of a
during the 2 weeks. In the control group, 3 of 12 sub- chronic muscle pain or TMJ dysfunction problems.
jects reported subjective symptoms and 3 developed While this is possible, data are not strong or consistent
clinical signs of TMD during the 2-week study period. and the degree of accommodation is probably related
It was concluded that there is no simple relationship to the degree to which the interference disrupts the
between interferences and signs and symptoms of occlusion. In other words, the bigger the interference
TMD, but they do induce accommodative behaviors in in ICP, the more it alters jaw function. In addition,
many subjects. many of the interferences used in these experiments
Another theory of how interferences induce TMD were moderately large (>300 µm). Actually, it is a log-
problems is “avoidance of the occlusal interferences.” ical and expected result that the jaw would alter its
At best it can be demonstrated that mandibular move- function in response to a high tooth contact, especially
ment patterns are influenced by occlusal changes but considering that the tooth would be somewhat painful
the significance of these movement pattern changes is to chew upon. The most direct evidence between EOIs
not known. For example, Karlsson et al33 examined (for interferences in ICP but not lateral motion) and
changes in masticatory movement patterns by insertion TMDs is that sometimes they have induced long-
of an experimental balancing side interference and lasting TM joint symptoms (clicking) in some subjects
reported that some of the movement variables (open- and sore jaw muscle in other subjects. These data are
ing magnitude, movement velocity) were significantly limited and largely based on unblinded observations
changed immediate after insertion of balancing side collected without careful calibrated examination.
interferences, but an adaptation of the neuromuscular Although sore jaw muscles and painless clicking are not
system (to the interference) was evident within 1 week desirable results, they alone do not constitute a sub-
after the insertion. stantial or serious TMD. Overall, these data suggest
In a recent study on this topic, Baba et al24 studied that, although occlusal interferences are harmful local-
the effect of the EOI on the masticatory muscle activi- ly, the likelihood of a substantial TMJ or masticatory
ty during clenching in various positions. They placed 3 muscle pain disorder developing is moderately low, but
types of EOI (metal onlay) with unknown height on 12 not absent.
normal subjects. The interference types were (1) canine Moreover, if symptoms develop, they are most like-
raiser on the upper right canine, which discluded all ly to be transient in nature. This conclusion is based on
other teeth during a right eccentric jaw motion; (2) the fact that most studies, which kept the interference
working side (right) interference on the second molar; in place more than a few days, showed some resolution
and (3) nonworking (balancing, left) side interference of the subjective tooth soreness and jaw muscle com-
on the second molar. EMG activity in the anterior and plaints. Unfortunately, no study kept the EOI in place
posterior temporalis and masseter muscles during max- longer than 4 weeks with most being 2 weeks or less.
imum clenching for 2 seconds in intercuspal position Additional work on the effect of long-term EOIs on
(ICP) and in a right canine edge-to-edge position was jaw function is needed. Such studies need at a mini-
recorded bilaterally before and immediately after the mum: (1) controls “normal height” inlays or onlays;

710 VOLUME 82 NUMBER 6

CLARK ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

(2) careful measurement of the size of interference over In human subjects, Bailey and Rugh36 conducted
time (as was performed by Ikeda et al); (3) blinded and unilateral EMG recordings of the masseter muscle of 9
calibrated examiners; (4) a standardized protocol for patients with bruxism. The recordings were taken
the clinical examination of jaw function; and (5) out- before, during, and after occlusal adjustment and
come measures that are clearly understood as jaw dys- revealed no significant increase or reduction in bruxism
function behaviors, such as medication use, pain in 8 of the 9 patients as a result of the treatment. Kar-
diaries, chewing modifications, and loss-of-motion dachi et al37 measured nocturnal masseter EMG levels
measures. on 4 bruxism patients before, during, and 3 months
after an occlusal adjustment. In another 2 subjects with
EFFECT OF OCCLUSAL
bruxism, they performed the same recordings but the
INTERFERENCES ON BRUXISM
treatment was a mock equilibration. No significant dif-
Although it is accepted that heavy bruxism can trau- ferences in the EMG levels between the groups were
matically injure a tooth, a variation on this relationship found. Finally, Rugh et al38 placed deflective molar
is that an occlusal interference can induce bruxism or occlusal interferences (0.5 to 1 mm forward and later-
other forms of involuntary motor responses in the mas- al deflection from centric relation) in 10 normal sub-
ticatory system, often described as “muscle hyperactiv- jects. They monitored the level of nocturnal masseter
ity.” The basis of this latter theory can be described as muscle activity for at least 10 nights before, during, and
the “occlusal contact avoidance theory.” Some propo- after placement of the interference. The study showed
nents of the avoidance theory state that the avoidance no relationship between occlusal interferences and
occurs during the day, and during sleep there is a loss increased levels of bruxism. However, several subjects
of the avoidance response, so the patient subsequently exhibited some mild unilateral muscle tenderness, TMJ
attempts to grind away the offending interference. The tenderness, and mobility on the tooth with the inter-
hypothesis of occlusal interferences are an inducer of ference.
sleep-bruxism or other forms of muscle hyperactivity Shiau and Syu39 studied the effect of working side
during sleep is disputed. interferences on daytime mandibular movement pat-
Budtz-Jorgensen34 cemented occlusal overlays bilat- terns in bruxers. They placed a metal overlay (1.5 mm
erally on the posterior teeth of 8 Macaca irus monkeys in thickness) on the buccal cusps of the adjacent upper
for 4 weeks. These overlays raised the vertical dimen- premolar and molar in 13 bruxers and 14 nonbruxers.
sion by 3 to 4 mm and an additional occlusal interfer- Chewing movements were measured at the mandibular
ence was added unilaterally for 4 weeks. He reported incisor in 2 dimensions. They also recorded EMG of
that the monkeys showed distinct signs of bruxism dur- the anterior temporalis, masseter, and anterior digastric
ing this experimental period, but unfortunately, objec- muscles. These measurements were performed before,
tive evidence of the bruxism events (EMG recordings immediately, 1 day, 1 week, and 1 month after the
during sleep) was not recorded. insertion of the overlay, and 9 bruxers and 13 non-
In 1981, Budtz-Jørgensen35 again cemented bruxers completed the experiment. Results revealed
occlusal overlays on the posterior teeth of 6 Macaca that the velocity of jaw closing decreased immediately
irus monkeys. These splints also raised the vertical after insertion of the overlay, and the closing path near
dimension by 3 to 4 mm and an occlusal interference the occlusal phase was narrower. For clinical symptoms,
was given unilaterally for 3 weeks. Cortisol levels of 1 nonbruxer complained of pain in the masseter mus-
plasma, 24-hour urine samples, body weight, and cles 1 day after the insertion of the overlay. Four of 9
mobility of the teeth were measured. Immediately after bruxers reported less frequent or no bruxism during
the insertion of the splints, approximately 2-fold rise of the experimental period. The flaws of these studies are
the mean 24-hour urinary cortisol excretion rate and a that the 2 experimental groups were not gender
significant decrease of urinary volume and body weight matched, and there was no description of their ages and
occurred. Teeth on the interference side showed the inclusion criteria for the bruxer group was not pro-
increasing mobility, and occlusal wear facets developed vided. No actual measurement of sleep bruxism was
on the splint during the 3-week experimental period. performed and there was no description of which
Urinary cortisol levels reduced to that of baseline 4 statistical test was used to analyze the parameters of
weeks after the splints were removed. He concluded jaw movement.
this result supported the hypothesis that a dysfunction-
Summary of bruxism effects
al occlusal relationship may result in bruxism associated
with emotional stress. It was not clear whether he was The relationship of occlusal interferences and noc-
saying that the experiment itself was a stressor and the turnal bruxism behaviors, no reliable evidence has
monkeys bruxed more or if the occlusal interference demonstrated that occlusal interferences can cause noc-
induced the bruxism. Without a control group, this turnal bruxism, or stop it, if the naturally occurring
question cannot be answered by the study. interferences are removed.

DECEMBER 1999 711

THE JOURNAL OF PROSTHETIC DENTISTRY CLARK ET AL

SUMMARY of a substantial TMJ or masticatory muscle pain disor-

The first item addressed in this review was whether der developing is moderately low but not absent and, if
EOIs have a deleterious effect on the periodontal and symptoms develop, they are most likely to be transient
pulpal tissue of the effected tooth. On the basis of the in nature.
current review, the answer to this question is, emphati- The third question addressed was “are eccentric
cally, YES. Several reports demonstrate alveolar bone contact EOIs (eg, high crowns that interfere with nor-
remodeling and irritation of the local periodontal tis- mal anterior tooth guidance patterns only on a lateral
sues with an EOI. However, these induced traumatic movement) harmful?” This answer is RARELY, IF
and inflammatory changes are transient, and best con- EVER. The research reviewed mostly focused on bal-
sidered as a functional adaptation to the increased load. ancing EOIs and the data suggested a much less sub-
In most situations, the tooth appears to move over time stantial effect on jaw function than ICP-EOIs and no
within the alveolus to a new position such that the evidence of pain and dysfunction was identified for the
increased forces are minimized, or the tooth develops eccentric-only interferences.
an increased mobility. With regard to the specific role Finally, with regard to the last question “do EOIs
occlusal trauma plays in the loss of periodontal attach- of any kind induce nocturnal bruxism behaviors?” The
ment levels when bacterial-induced periodontal disease answer is NO. No reliable evidence has been put forth
is controlled, these data suggest that plaque-induced demonstrating that EOIs can cause nocturnal brux-
tissue inflammation and not occlusal trauma is the ism, or stop it, if the naturally occurring interferences
major causative factor. are removed.
Regarding pulpal tissue damage from EOIs, the
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contact occurrence during mastication. Helv Odontol Acta 1966;10:49- DEPARTMENT OF OROFACIAL PAIN AND ORAL MEDICINE
56. UCLA SCHOOL OF DENTISTRY
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occlusal interferences on muscle activity and associated jaw movements 0022-3913/99/$8.00 + 0. 10/1/102522
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