I want to heartily thank Dr Greene for his response to Dr Slavicek’s article (Greene CS. Relationship between occlusion and temporomandibular disorders: implications for the orthodontist. Am J Orthod Dentofacial Orthop 2011;139:10-6). It was impressive in its restraint of avoiding the irrelevant and refreshing in its addressing of specific and meaningful issues of interest to the daily practice of orthodontics. Dr Greene is to be congratulated for this contribution to this spirited topic. Perhaps he will give some more. I was particularly interested that Dr Greene teaches his orthodontic residents that they are in the “occlusion-disrupting business, so you must have reasonable treatment objectives and procedures to move every patient’s dentition to a new set of occlusal and craniomandibular relationships that will be biologically acceptable.” Okeson has already placed in print his occlusal recommendations for all orthodontic patients regardless of symptoms. They are (briefly) the following.
The condyles should be in their most superior anterior positions, with the discs properly interposed. In this position, all posterior teeth should have even and simultaneous contact, and the anterior teeth more lightly touching.
In excursive positions, adequate tooth-guided contacts should be present to disocclude immediately the mesiotrusive (nonworking) side. Canine guidance is the most desirable.
In protrusive positions, the anterior teeth should immediately disocclude the posterior teeth.
Sitting upright, the posterior teeth contacts should be heavier than the anterior contacts.
I am sure that other readers, beside myself, are wondering what are Dr Greene’s specific occlusal recommendations to his orthodontic residents. This is particularly pertinent in light of his participation in the survey into the curricula of orthodontic programs in the United States and Canada and the comments within.
The only specific recommendation Dr Greene gave us in his response was that “[orthodontists] should try to finish treatment with the TMJ in a reasonable and biologically acceptable retruded position.” I was hoping that Dr Greene would define this “acceptable retruded position” with more detail. In addition, I was wondering how this position deviated from the superior anterior position that Okeson recommends. And to bring this to clinical relevance, how does he recommend that we orthodontists locate his “biologically acceptable retruded” position at the diagnosis, during active treatment, and when deciding when a case is finished? Is it bilateral manipulation as Okeson advocates? 1
Dr Okeson had stepped up to the plate to give orthodontists clear occlusal guidelines and a means to identify them from beginning to end. I hope that Dr Greene will do the same. Possibly, this could be the basis of a truly enlightening Point/Counterpoint.