General Considerations in Occlusal Therapy “If ceclusion ix fone to significantly comibure ro a TMD, dents is the only beat profisom hat can provide lating ec. If eclaon isnot related tothe TMD, i should not be altered other than for retorative or sesthesic reasons.” JPo ‘Occlusal therapy is considered to be any treatment that alters a patient’ occlusal condition. Iz can be used to improve function of the masticatory system through the influence of the occlusal contact patterns and by altering the functional jaw position. There are wo types: reversible and ireversble Reversible occlusal therapy temporaily alters the occlusal con- divion andior joint position but when removed returns the patient to the preexisting condition. An example would be an occlusal appliance (Fig 17.1). When the occlusal appliance is used, it cre ates a favorable alteration in the occlusal contacts and joint posi- tion. When it is removed, the patient's original occlusal condition Inreverible occlusal. therapy permanently alters the occlu sal condition so the original condition cannot be recovered. An example would be selective grinding of the teeth whereby the ‘occlusal surfaces are reshaped with the goal of improving the ‘occlusal condition and orthopedic stability. Since this procedure involves the removal of enamel, it becomes irreversible and there- fore permanent. Other forms of ireversible occlusal therapy are fixed prosthetic procedures and orthodontic therapy (Fig, 17.2. Tn the previous chapters, reversible occlusal therapies (occlusal appliances) were discussed 25 treatment for many TMDs. In the following chapters, the emphasis of occlusal therapy will bon the irreversible types. Since ireversible occlusal eherapy is permanent, it must be provided only when ic is determined to be beneficial to the patient. There are two general indications that suggest the need for ireversible occlusal therapy: (1) treatment of TMD, and (2) treatment in conjunetion with other necessary measures that will significantly alter the existing occlusal condicion. Treatment of Temporomandibular Disorders Irreversible occlusal therapy is indicated when sufficient evi- dence exists thatthe primary etiologic factor creating 2 TMD is the prevalent occlusal condition andor orthopedic instability. In ‘other words, permanent improvement of the oelusal condition is likely to eliminate che functional disturbance of the masticatory system, ‘Ac one time, the dental profession fle thac most TMDs were caused by malocclusion. With that belief, permanent occlusal changes became a routine pat of the management of TMD. Now that we have more evidence-based information, we have gained a better appreciation of the complexity of TMD. We understand thatthe occlusal condition is only one of five major etiologic fac- tors that may lead to TMD (see Chapter 7). Therefore, permanent ‘occlusal cherapy is only indicated when signifcanc evidence exists to support thatthe occlusal condition is an etiologic factor. One should not routinely alter che occlusion withoue such evidence, Also remember that there are wo ways the occlusal condition can bbecome an etiologic factor in TMD: an acute change in the occlu- sal condition (altered sensory input) and by way of orthopedic inseabilty (plus loading) (see Chapser 7). [vis also important for the clinician wo secogoize thatthe occlusal management of these ‘wo considerations is quite different Sufficient evidence to change a patient's occlusion is commonly derived ehrough successful occlusal appliance therapy. However, the mere fact that the occlusal appliance relieves symptoms is not alone sufficient evidence to start izeversble occlusal therapy As discussed in Chapter 15, the occlusal appliance can affect symproms in several diferent manners. Effort must be made to determine which feature of the appliance is responsible for the climination of the symptoms. When che multiple effets of occlu- sal appliance cherapy are overlooked, an imeversible procedure such as selective grinding is likely co fil to eliminate the symp- toms of the disorder. Since ireversble occlusal therapy is perma- ‘ncn, care is always taken to confirm che nced for these procedures before they ae instituted Treatment in Conjunction With Other Dental Therapies Ineversible occlusal therapy is often indicated in the absence of any functional disturbance of the masticatory system. When patients have a dentition that is severly compromised by broken, decayed, or missing cecth, there is a need co restore masticatory function. Restoring the dentition wich operative procedures or with fied and/or removable prostheses isa form of irreversible ‘occlusal therapy. Even in the absence of any obvious TMD, the ccclusal condition needs to be carefully restored co a condition that will promote and maintain health for the patient (Fig. 17-3. ‘There is lice doubt tha providing occlusal sherapy for patients with debiliated dentitions is an important service provided by dents. This type of cherapy, however, can lead to some very 433CESMNOASMN Occlusal Therapy inceresting and importanc questions regarding treatment. Imagine 4 24-year-old woman who comes to the dental office for a routine checkup. She has no signs of functional disturbances of the mas- ticatory system. However, the examination reveals that she has a significant malocclusion. The question now posed is one of preven- tion, Should occlusal eherapy be provided to improve the occlusal condition in an attempe to prevent any faeure TMD? Many prom= nent dentists would suggest just that. Yet, a ths time, there is no scientific evidence that this patient will at any time in the furure have problems if left untreated, She is functioning within her + Fig. 17.2. Exensive restorative procedure isa form of irverstle occ sal eran physiologic adaprabiliy even though the malocclusion appears to bo significant. One might think that at some time in the future perhaps her level of physiologic adaptability may be exceeded by ‘other etiologic facts such as trauma, increased emotional ses, ‘or deep pain input. However, we have no evidence in any given patient thar this will happen, and iit did the management would likely be quite different chan oeclusal therapy. More recenly there hhave been significant studies published shedding light on factors that may influence the onset and progresion of TMD.24° Inthe future, these studies wil certainly help clinicians determine the most appropriate teatment considerations for their patients. Remember also thatthe patients dental malocclusion may noc pose a significant risk factor for TMD. The malocclusion needs to be evaluated for it relationship to the join positions. Ifthe inter- ccuspal position is in harmony with the musculoskeletal stable postion of the condyles (see Chapter 5), it does not pose a sig- nificant rsk factor for TMD (a stable malocclusion). This concept was presented in Chapter 7 and needs to be considered any time the clinician is developing a treatment plan for treating TMD. ‘Av this time, with the daca on hand, itis impossible co predict whether any individual patient will develop TMD. Therefore, usti- fication of prevention therapy is dificult, especialy when the appro- priate weatment is expensive and time consuming. If, howeves, ‘extensive treatments are indicated for other reasons (eg. aesthetics, ‘aries, missing teeth), occlusal cherapy should be provided in con- junction with the treatment so that when i is completed optimal ‘occlusal and orthopedic conditions will have been established. Treatment Goals for Occlusal Therapy ‘The aced to provide permanent occlusal therapy for a TMD should be determined first by a tral wit a stabilization appliance Ifthe occlusal appliance does not significantly alter the symptoms permanent occlusal therapy should not be considered. When ‘celusal appliance therapy reduces or eliminates the TMD symp- toms many clinicians want co proceed directly into permanent ‘occlusal therapy. This can be a big mistake. It should always be remembered that occlusal appliances can alter the patient's TMD sympcom in many dfferenc ways (see Chapter 15). Once the symp- toms are resolved, the clinician must determine why the patient responded favorably. As previously mentioned, there are eight dif ferent factors that could be responsible for the suecess, and many have nothing o do with occlusal fators. The clinician is obligated to demonstrate the reason for symptom reduction before moving fon to permanent occlusal changes (see Chaprer 15). Nothing is permanently ceented inthe patent's mouth. (Courtesy Dr Wes Cotman, Lexington, KY.)more discouraging tothe patient and the clinician chan to com- plese an elaborace and expensive dental srestment plan only to Ihave the symptoms return, To those cases where the occlusal condition has been deter- mined to be a significant factor in the TMD, permanent occlu- sal changes ate indicated. As with the stabilization appliance, the treatment goals for these changes should be establishing orthope- dic sabi in the masticatory stuctures. The ueatment goals are therefore the same for both reversible and ireversible therapies (orthopedic stabil) When aa anterior positioning appliance has eliminated the symptoms, it does not immediarely suggest that permanent occlu- sal therapy should be completed in the forward therapeutic posi tion, As sated in Chapter 13, the main purpose of the anterior positioning appliance isto promote adaptation of the retrodiscal tissues. Once this adaptation has occured, the condyle should be returned to che musculosklealy sable postion. Therefore, fol lowing successful anterior positioning therapy and stabilization appliance therapy, the condyle should be inthe musculoskeletally stable positon. The treatment goals of permanent occlusal therapy at esublish orthopedic stably inthis psiion Treatment Goals for the Musculoskeletally Stable Position Patient suffering from a masticatory muscle disorder ae generally tueated with stabilization appliance that provides the optimum ‘occlusal conditions when the condyles are in their most mus- culoskeletally sable position (See Chapter 5). Patients suffering from an inflammatory disorder, as well as a severely debilitated dentition, ate also best weated using this criterion, In all these conditions, the treatment goals for occlusal therapy ate £0 permit the condyles to assume their musculoskeletally stable positions (centric relation) atthe same time that the teeth are in their maxi- mum intecuspal position (orthopedic stability). More specifically tweatment goals ae as follows: 1. The condyles are resting in their most superoanterior position against the posterior slopes ofthe articular eminences 2. The articular dses are properly interposed becween the con- diyles and the fossae, In those cases when a disc derangement disorder has been treated, the condyle may now be artculat- ing on adaptive fibrotic tissue with the dise sill displaced or even dislocated. Although this condition may not be idea, iis adaptive and should be considered functional inthe absence of 3, When the mandible is brought ito closure in the muscu skeletaly stable position, the posterior teeth contact evenly and simultaneously. Al contacts occur between centric cusp tips and fla surfaces, directing occlusal forces through the long axes of the teeth, 4, When the mandible moves eccencrically, the anterior teeth contact and disocclude the posterior eth. 5. In che upright head position (alert feding postion), the poste- Fior tooth contacts are more prominent chan the anterior tooth Because these teatment goals ate most effective in relieving the symptoms of many TMDs, they become the treatment goals for permanent occlusal therapy. These goals also offer a stable and reproducible mandibular postion, which is absolutely needed to restore the denticion, As suggested in Chapter 5, it appears that ‘when the patient is reared ¢o this jone position and stable occlu- sal condition, che likelihood is great shat health wil prevail CHAPTER 17 General Considerations in Occlusal Therapy Ea Treatment Planning for Occlusal Therapy ‘When it has been determined that occlusal therapy will benefit the patient, the proper method of weatment needs wo be identified. Genet~ ally, the best choice is wo perform the leastamount of dene alterations ‘that wil full he retment goals. Frequent only minor changes are required to alter an existing occlusion to one that is more favorable "When only minor changes are needed, the occlusal surfaces of the teeth can ofien be merely reshaped to achieve a desired occlusal con- tact patter, This ype of treatment is called selective grinding oF occlu sal adjestment (alo oeclusal equilibration) (Vig, 17). Ie involves the removal of tooth structure and is therefor limited wo the thickness of the enamel f enamel is completely removed, denin wll be exposed, posing a problem wich sensitivity and posible denral cari. ‘As the interarch alignment of the teth becomes farther from ideal, more extensive alteration ofthe existing ocelusal conditions is needed co mece the treatment goals. If selective grinding proce- dures cannot be successfully performed within the confines of the cnamel, restoration of the teeth may be indicated. Crowns and fixed prosthetie procedures ate used (o alter an occlusal condition to the desired treatment goals (Fig, 17.5), As the interarch alignment of the teeth becomes even poorer, crowns and fixed prosthetic procedures alone may not be able 1 Fig. 174, Soootie gfnding & a form of reversibe costs therapy by hich the teeth ae cartulyeshaced to mest te occlusal reatment goa. 1 Fig. 175. Fxed prosthodontic procedures are a form of ireversble ‘ects therapy that may be inccated when selectve ginding cannot accoralish the occlusal treatment goals,CEMENT Occlusal Therapy complece che treatment goals. Posterior crowns must be fabri- cated such that occlusal forces are directed through the long axes of the roots. This cannot always be accomplished as the incerarch, :alaligament becomes great. Therefore, otthodontic procedures are sometimes necessary co accomplish the creatment goals. Orthodontic procedures are used co align teeth in the dental arches to a more favorable occlusal relationship (Fig. 17.6). On. + Fig. 17.6. Orthodontic therapy is a form of rovrstle occlusal therapy that may be indicated when maalgnment ofthe dental arches isso great ‘hat fee prostnodonice cannot successtuly acomplah tre occlusal troarron: goal ‘occasion, the poor interarch tooth alignment is created by poor alignment of the dental arches themselves. When this condition is present, a surgical procedure to correct the skeletal malalign- ment (Fig, 17.7) in conjunction with orthodontics, is likely to be the most successful method of achieving the treatment goals (orthognathic surgery). “The appropriate occlusal therapy is therefore olten determined by the severity of the malocclusion, ‘The treatment choices range from selective grinding to crowns, fixed prostheses, removable prostheses, orthodontics, and even surgical correction. Ie is often appropriate to combine teatments to achieve the proper teat mnt goals. For example, after orthodontic therapy is completed, aseletive grinding procedure may be helpfl in refining the exact contact pattern of the teeth. All these treatment options empha- size the need for developing a precise eeatment plan. There are two general considerations: (1) The simples teatment that will accomplish the treatment goals is generally the best, and (2) creat- ment should never begin until che elinician can visualize the end results In most routine cases, the final result can be easily seen and ‘therefore progress can be made roward that goal. However, when ‘more complex treatments are planned, its sometimes diffeult to visualize exactly how each step or phase will ontsibute to the end results. With these complex cass, itis advisable ro seck out the information necessary to predict the final treatment results aceu- ately before che acwual treatment begins. Ibis ie bese accomplished Majer arch with discrepancy. The aor actor creating these protlrsis tho skeet lationship betwoon the ‘asia and marl, Donal harap alone wil a6 be suciet to conect the stato, A surgical procedure in corjurction wih proper cera herapy ag, rthedents, kes prosthodontic} wil have o be consiradby accurately mounting diagnostic cass on an articulator and by performing the suggested eearment on the casts, For example, a selective grinding procedure performed on diagnostic cass can help determine the difficulty chac will be encountered when pet- forming this treatment in the mouth It can also reveal the degree of tooth structure that will need to be removed (Fig. 17.8). This © Fig. 17.8, Bole perorming salctv gncng on the patent t shoul frst be completed on sccually mourted dagnasc cats. Ths intormaton wi heb he clnican detarmine haw excansve the soctve giralng noods to be to accorelsh the task I sgn’canttocth snucture reeds to be removes, he alert shuld be iniormad ofthe nea fractional restorative ooo re, © Fig. 79. A agnostic prowax is used to pradict the form and design CHAPTER 17 General Considerations in Occlusal Therapy will help predict nor only the success of the procedure but also the need for any restorative procedures after selective grinding, The patient can therefore be informed in advance of che number of crowns, ifany, that wll be needed after the selective grinding, ‘When missing teeth ate to be replaced by fxed prostheses or ‘implants, the Future expected occlusal condition ean be visualized by completing a work-up and prewax on the mounted study casts (Fig, 17-9), "The same can be accomplished when aesthetics ate to be changed (Fig. 17-10). This prewax assists in determining prepa- ration design and allows the patient to visualize the expected acs- thetis. Orthodontic procedures can also be accomplished on the cast by sectioning ceeth and moving them to the desied position (Fig. 17.11), When diagnostic casts are used in this manner, the expected final results are easily visualized as well a any problems in achieving these results are identified in advance. Never begit. ‘occlusal creatment for a patient without being able co visualize the final resule as well a each step that will make ie possible Rule of Thirds Selecting appropriate occlusal ereatment is an important and sometimes dificult ask In most instances, the choice must be sade among selective grinding, crown and fixed prosthodontic procedures, and orthodontics. Often the critical factor determin- ing the appropriate treatment isthe buccolingual arch discrepancy of the maxillary and mandibular posterior teth, The extent ofthis discrepancy establishes which treatment will be appropriate, the fed prosthodontic procedures. A. Pretreatment. Noto the missing tooth and the mesial tipping of the mandibuar mola. B. Expected esi! ofa fixed partal denture conunction with moby upigring ang thc mela extraction, + Fig. 1710, AnAesteticPrewax. A. This patina Sqnfcnt cath wear anc ceckson, The eva errensaing be expected aesthetic ard tinct ruts (Courtesy Or Wes Caran, Lexhgton KY}rer TI) Occlusal Therapy This relationship is best examined by first placing the condyles in the musculoskeletally stable position (centric relation) with a bilateral manual manipulation technique. In this postion, che mouth is gently closed in a hinge axis movement until che firs tooth touches lightly. Ar this point, the buccolingul relationships of the maxillary and mandibular tecth are examined. Ifthe cen- tric cusps are located near the opposing central fosse, only slight alterations in the occlusal condition will be needed to achieve the treatment goals, The greater the distance that the centric cusps are positioned from the opposing fossae the more extensive will be the treatment needed to achieve the treatment goals “The rule of thirds"”® has been developed to aid in determin- ing the appropriate treatment. Each inner incline of the posterior centric cusps is divided inco chree equal parts. If when the man- dibular condyles are in their desired position, the centric cusp tip of one arch contacts the opposing centric eusp inner incline in the third closest co the central fossa, selective grinding can usually be performed without damage to the teth (Fig. 17.128), Ifthe opposing centric cusp tip makes contact in the middle third ofthe opposing inner incline (Fig, 17.128), crown and fixed prosthodontic procedures will usually be most appropriate for achieving the treatment goals. In these cases, selective grinding is likely to perforate the enamel, creating the need for a restorative procedure If the cusp tip contacts the opposing inner incline on the third closest to the cusp tip or even on the cusp tip (Fig. 17-120), the spprapriate treatment is orthodontic procedures, Crown and fixed prosthodontics in these instances will often create restorations that ‘cannot adequately direct accusal forces through the long axes of the roots, thus producing a potentially unstable occlusal relationship, “The rule of chitds is applied clinically by drying the ceth,loeat- ing the condyles in the desired posicion, and having the patient close lightly on marking paper in a hinge axis movement, The con- tact area is visualized and its postion on the incline determined. Te is equally important co visualize the buecolingual relationship of ‘the entire arch in determining appropriate treatment (Vig. 17.13). (On occasion, the tooth contact will not be typical of the entire arch and therefore will not be the best determinant of treatment. Tn many cases, the selection of treatment is obvious and can be made with confidence by merely visualizing the teesh clinically, In other instances, however, the judgment ie more difficult, for instance when the mandible isnot easily guided to centric closure ‘or when the teeth are not easily visualized. When itis difficult co decermine the appropriate treatment, diagnostic casts accurately mounted on an articulator are helpful. Inthe absence of soft tis sue, muscles, and silva, a more accurate diagnosis can be made. “The casts ate also helpful (as previously mentioned) for tcheatsing the treatment to determine the degree and difficulty of success Factors That Influence Treatment Planning ‘After careful analysis ofthe occlusal condition, the most appropri- ate treatment is determined. If it has heen decided that selective «grinding can successfully accomplish the teatmene goals wiehout ig, 172. Setup for Predting the Success of Ot the Qoneraized intrdental spacing (A) ar the results of ernest final ertnosonto posi odontic Procedures. A.and B. Proteatmiont. No:e anterior guidance (8). C and D ars the expectes foned from the casts and moved in wax to teir wed anteror guCHAPTER 17 General Considerations in Occlusal Therapy Ea 32% 1 Fig. 1722. Rule of Tits The inner incines of the posterior ceric cusps ae vided int hrs. When the condyles ae in the dested treatment postion (cen relation) and the opposing centric cusp tip ‘contac on the thra closest o the central fossa (A), seictve grinding the ost appropriate occlusal lwoatment. Whon the oppesing contre cusp Up contacts on the mide tha (B), crowns or other fxd prosthetic procedures are genealy inccates, When the oppasing centic cusp tp Cortacts onthe third ‘loses othe eppasing contc cus tp (C), otnedontice is the most appropriate cccusal Vealment * Fig. 17233. Wit the condyes In centric relation postion, the buecoln ‘ual relaonship of both aches canbe vsuaized, Not that fortis patient ‘he mandibular buccal cusps almost contac the maxllary buccal cusps, Using tne re of thes, comacton ofthis condition would best bo accom plisned by orthodontic therapy fnotselecive grin, damaging the teeth, this procedure is completed. If, however, it is decided thar more aggressive procedures are indicated (eg, crowns of orthodontic therapy), other factors may need <0 be considered. Since these proveduites involve & considerable amount of time and expense, the suggested creatment must be weighed agains: the porental benefits. There are five factors that ean influ ence the selection of trestment: (1) symproms, (2) condition of the dentition, (3) systemic health, (4) aesthetics and (5) finances Symptoms “The symptoms associated with TMDs vary greatly from patient to patient, Some patients experience short durations of mild dis- comfort that recurs only occasionally. When extensive restorative or orthodontic therapy is considered, itis often too extreme for the symptoms being experienced, However, when the symptoms are severe and ithas been decermined chat occlusal therapy would be helpful (.c., occhusal appliance cherapy), these more extensive ypes of therapy become indicated, Therefore, the severity of the symptoms can help determine the need for permanent occlusal therapy, Condition of the Dentition “The health of the dentition also influences the selection of teat- ment. When 2 patient has multiple missing and broken-down teeth, restorative, implants and/or fixed prosthetic procedures ‘maybe indicated not only for the TMD but also for the general improvement in health and function of the masticatory system, On the other hand, patients with healthy and vireually unrestored dental arches that are merely poorly aligned are more likely to be best treated orthodontically rather than restoratvely. In this sense, the condition of the dentition influences the most appropriate ccclusal therapy for the patient Systemic Health Although the majority of dental patients are healthy and tolerate dental procedures well, some do not, In developing an occlusal tweatment pla, the systemic health ofthe patent always needs to be considered. The prognosis of some treatments can be greatly inducnced by che general health of the patient. For example resolving « petiodontal condition may be greatly influcneed by & systemic disorder such as diabetes or leukemia. Even along dental ppointmenc can have desrimental effects on some chronically ill patients. These considerations may greatly infuence the selection of appropriate occlusal therapy Aesthetics Almost all of dentistry centers around the establishment and ‘maintenance of funetion and aesthetics in the masticatory system. In eating a TMD, functional considerations are by far the most important. However, aesthetic considerations ar sl likely to be ‘major concern. When an occlusal treatment plan is being devel ‘oped, aesthetic considerations should not be overlooked of under emphasized. The patient should be questioned regarding aestheveTY) Occlusal Therapy ‘concerns, Sometimes treatments are unacceptable hecause ofthese concerns. For example, a patient may not wear an occlusal appli= ance because it is aesthetically unpleasing, In other instances, aesthetics may encourage certain treatments. A patienc with mild for moderace TMD symptoms may be an excellenc candidate for omhodontie procedures when it is learned that this person is unhappy with his or her presene appearance and wishes to have improvements made, Orthodontics can then simultaneously peo: vide improvement in both function and aesthetics, chereby more completely treating the patient's needs, Finances ‘As with any service, the patients ability can significantly influence the tzeatment plan, Even though cost should not influence teatment selection, in faet it aften docs There are patients who would benefit from a complete restoration, of the dentition perhaps including dental implants but cannot alford such treatment. Alternatives must be developed, In some inscances, removable partial dentures, removable overlay paztil 2 complete dentures can provide the desirable ‘occlusal conditions ata fraction of the cost ofa full mouth recon- struction, These financial considerations can only be assessed by the patient in light of che values placed on appearance, health, and ccomfore, which cannot be put into any formula, finance the treatment before an appro- priate occlusal treatment plan ean be developed. Ie is important to realize that the priority of the Factors may be different for the patient and for the therapist. When symptoms ate not severe, finances and aesthetics will often be more important concerns of the patient. Ar the same time, however, the dentist may believe that che condition of the dentition is more important. In any case, the patients concerns must always remain foremost in the deve ‘opment ofa successfl treatment plan, In some instances, the appropriate treatment will be obvi- fous and therapy can begin. In others, however it may be neces saty co labor over which treatment is best for the patient, When this occurs, occlusal appliance maintenance may be ‘Most patients who are considered for irreversible o have already received an occlusal appliance that has proved to be successful in relieving the TMD symproms. In occlusal appliance maintenance, the patient is encouraged so continue using the appliance as needed to relieve of eliminate symptoms, Occlusal appliance maincenance is especially appropriate when the symp: ams are episodic or related co increased levels of emotional stress. Many patients aze able to remain comfortable by using the occli- sal appliance during specific times, sich as sleep, Other patients have learned chat high emotional stress periods promote symptoms and thus the occlusal appliance is worn dur- ing these times. Patients who cannot afford extensive treatment ‘or in whom systemic health considerations prevent treatment are ‘ofien good candidates for occlusal appliance maintenance. When this is suggested, itis important that the patient understand the use, care, and maintenance of the appliance. It is also extremely importane thac the appliance provide occlusal stops for all teeth so that prolonged use will no allow eruption of any teeth References 1. Slade GD, Obrbich R, Greenspan JD, et al Painfl temporoman ddibular disorder: decade of discovery fom OPPERA studies, J Dent ‘Res 95(10)"1084-1092, 2016, Bair E, Gaynor S, de GD, et al: Kdentifiation i vials relevant to temporomanelibular disorders a other chronic pain conditions: che OPPERA study, Pun 157(6):1266-1278, 2016. 43, Smith SB, Mir E, Bai E, et al Genetic variants avvociated with development of TMD and its intermediate phenorypes: the genetic archieecture of TMD in the OPPERA prospective cohort study, J Pain 14(Suppl 12)-T91-101 e123, 2013. 4, Slade GD, Fillngim RB, Sanders AB, ct al: Summary of findings from the OPERA prospective coher stedy of incidence of istonset temporomandibslar disorder implications and future directions, J Pain VSSuppl 12)-T116-T124, 2013, 5. Obsbach R Bair E, Filling RB, et al: Clinical orofacial characteris ties atociated wit risk of fit-onset TMD: che OPPERA prospective cohort study, J Pain 14 Suppl 12}'T33-50, 2013. 6. Bureh JG: The selection of eclusal paterns in periodontal therapy, ens Clin Norh A 24:343-356, 1980. 7. Burch JG: Orchodondic and restorative considerations, In Cla J editor: Clinical dentiery: prevention, orthodontic, and oclton, Neve York, NY, 1976, Harper & Row Publishes (chapter 42), 8, Fox CW, Neff P: The rule of thirds. In Fox CW, Nef P, editor Principles of exluion, Anaheim, CA, 1982, Socery for Occlusal, Seudies, p31