I want to thank Dr Hudson for his very positive comments about my Counterpoint article. He included 4 occlusal and TMJ recommendations by Dr Okeson in the textbook by Graber et al, and he asked for my opinion on those points. We use that same book in our orthodontic program, and I have reviewed that chapter with our residents, along with another article by Okeson, which I cited in my Counterpoint. It is hard to quarrel with any of Okeson’s rules, but they still require some discussion to prevent an overly rigid interpretation.
One good way to add some perspective to Okeson’s rules is to compare them with the anthropologist Henry Beyron’s “essential features of a healthy natural occlusion,” which were promulgated over 50 years ago. Beyron’s 5 points were cited in a review article by myself and 2 European colleagues about occlusal concepts over the past century, and our conclusion was that they do indeed describe the essential elements of a healthy and successful occlusion. The most striking difference between these 2 lists is that Beyron did not specify exactly where the condyle should be when the teeth are in maximum intercuspation. Also, like most anatomists, he stated that the mandible needs to have freedom to move retrusively as well as in all other directions.
Okeson has proposed the term “orthopedically stable” to describe his version of where the condyle should be in relation to the skull, but in the end that position is no different from the most recent definitions of centric relation; therefore, it does not allow for posterior movement as described by Beyron. Having the disks properly interposed is a nice point to include, but what if they are displaced (as is true for many people in the random population)? Having canine rise is nice, but what if group function is the best you can do with orthodontic or prosthodontic treatment? Protrusive guidance does provide posterior disclusion, but what if an orthodontic patient cannot be treated to that “ideal” relationship because of financial or biologic limitations? Should a failure to achieve the exact relationships proposed by Okeson be regarded as biologically unacceptable or potentially bad for the patient? Those who think that is the case need to present their evidence before criticizing other outcomes.
So in the end, I would encourage orthodontists to be somewhat flexible in applying the standards of ideal jaw relationships as well as ideal occlusal functional relationships to their finishing of patients. As I mentioned in my article, this means that we should not have conversations about tenths of millimeters when discussing where the condyle should be. However, I think that most orthodontists appreciate the need to maintain a stable retruded position of the TMJ as they go through their treatment mechanics, and eventually they need to finish every patient in that zone. I don’t recommend any specific techniques for accomplishing this, because none has been proven scientifically to be better than another. As they say with Valentine’s Day cards: it’s the thought that counts.