TMJ Disorders and Orofacial Pain The Role of Dentistry in a Multidisciplinary Diagnostic Approach

Color Atlas of Dental Medicine

Editors: Klaus H. Rateitschak and Herbert F. Wolf

TMJ Disorders and Orofacial Pain

The Role of Dentistry in a

Multidisciplinary Diagnostic Approach

Axel Bumann and Ulrich Lotzmann

In Collaboration with James Mah

Translated by Richard

Jacobi, D.D.S. Belton, TX,

U.S.A.

1304 Illustrations

Thieme

Stuttgart • New York

iv

Authors' Addresses

Dr. Axel Bumann, D.D.S., Ph. D.

Clinical Assistant Professor

Dept. of Craniofacial Sciences and

Therapy

University of Southern California

925 W 34 St, Suite 312

Los Angeles, CA 90089-0641

USA

[email protected]

MEOCLINIC

International Private Clinic

Friedrichstr. 71,10117 Berlin

Germany Prof.Dr.A.Bumann@kfo￾berlin.de

Dr. Ulrich Lotzmann, D.D.S., Ph. D.

Professor and Chair

Dept. of Prosthodontics

Philipps-University

Georg-Voigt-Strasse 3

35039 Marburg/Lahn

Germany

lotzmann®

post.med.uni-marburg.de

James Mah, D.D.S., M.Sc, D.M.S.c.

Assistant Professor

Dept. of Craniofacial Sciences

and Therapy

University of Southern California

925 W 34 St, Suite 312

Los Angeles, CA 90089-0641

USA

[email protected]

Editors' Addresses

Klaus H. Rateitschak, D.D.S., Ph.D.

Dental Institute, Center for Dental

Medicine

University of Basle

Hebelstr. 3,4056 Basle,

Switzerland

Herbert F. Wolf, D.D.S.

Private Practitioner

Specialist of Periodontics SSO/SSP

Lowenstrasse 55, 8001 Zurich,

Switzerland

Library of Congress Cataloging-in￾Publication Data is available from the

publisher.

Illustrations by

Design Studio Cornford, Reinheim

Joachim Hormann, Stuttgart

Cover design by Martina Berge, Erbach

This book, including all parts thereof, is

legally protected by copyright. Any use,

exploitation, or commercialization out￾side the narrow limits set by copyright

legislation, without the publisher's con￾sent, is illegal and liable to prosecution.

This applies in particular to photostat

reproduction, copying, mimeographing

or duplication of any kind, translating,

preparation of microfilms, and electronic

data processing and storage.

This book is an authorized translation

of the German edition published and

copyrighted 2000 by Georg Thieme

Verlag, Stuttgart, Germany.

Title of the German edition:

Funktionsdiagnostik und

Therapieprinzipien

© 2002 Georg Thieme Verlag,

RiidigerstraBe 14,

D-70469 Stuttgart, Germany

http://www.thieme.de

Thieme New York, 333 Seventh Avenue,

New York, N.Y. 10001 USA

http://www.thieme.com

Typesetting by G. Muller, Heilbronn

Printed in Germany by Grammlich,

Pliezhausen

In the Series "Color Atlas of Dental Medicine"

K. H. & E. M. Rateitschak, H. F. Wolf, T. M. Hassell

• Periodontology, 3rd edition

A. H. Geering, M. Kundert, C. Kelsey

• Complete Denture and Overdenture Prosthetics

G.Graber

• Removable Partial Dentures

F.A.Pasler

• Radiology

T. Rakosi, I.Jonas, T. M. Graber

• Orthodontic Diagnosis

H.Spiekermann

• Implantology

H.F. Sailer, G.F. Pajarola

• Oral Surgery for the General Dentist

R. Beer, M. A. Baumann, S. Kim

• Endodontology

P. A. Reichart, H. P. Philipsen

• Oral Pathology

J.Schmidseder

• Aesthetic Dentistry

A. Bumann, U. Lotzmann

• TMJ Disorders and Orofacial Pain

Important Note: Medicine is an ever￾changing science undergoing continual

development. Research and clinical expe￾rience are continually expanding our

knowledge, in particular our knowledge

of proper treatment and drug therapy.

Insofar as this book mentions any dosage

or application, readers may rest assured

that the authors, editors, and publishers

have made every effort to ensure that

such references are in accordance with

the state of knowledge at the time of pro￾duction of the book.

Nevertheless this does not involve,

imply, or express any guarantee or respon￾sibility on the part of the publishers in

respect of any dosage instructions and

forms of application stated in the book.

Every user is requested to examine care￾fully the manufacturers' leaflets accom￾panying each drug and to check, if neces￾sary in consultation with a physician or

specialist, whether the dosage schedules

mentioned therein or the contraindica￾tions stated by the manufacturers differ

from the statements made in the present

book. Such examination is particularly

important with drugs that are either

rarely used or have been newly released

on the market. Every dosage schedule or

every form of application used is entirely

at the user's own risk and responsibility.

The authors and publishers request every

user to report to the publishers any

discrepancies or inaccuracies noticed.

Some of the product names, patents

and registered designs referred to in this

book are in fact registered trademarks or

proprietary names even though specific

reference to this fact is not always made

in the text. Therefore, the appearance of a

name without designation as proprietary

is not to be construed as a representation

by the publisher that it is in the public

domain.

ISBN 3-13-127161-2 (GTV)

ISBN 1-58890-111-4 (TNY) 1 2 3

To my sons Philipp and Sebastian, as

well as to my parents, in gratitude for

their love, patience, support and their

understanding

To my teachers,

Rolf Ewers, Louis C Gerstenfeld,

Asbjorn Hasund, Marcel Korn,

Robert M. Ricketts and Edwin H. K. Yen,

who influenced my development significantly

Axel Bumann

To my parents, my wife Martina,

my son Christian Ulrich, as well as

to my brothers and sisters and my godchildren,

with great love and gratitude

To the crew of Apollo XII:

Charles "Pete" Conrad (1930-1999), in memory;

Richard Gordon and Alan Bean,

in admiration and friendship

Ulrich Lotzmann

vii

Foreword

The title of this opus presents the philosophy of the authors,

namely that dentistry is only one part of a multi-faceted

service for temporomandibular dysfunction. Dentists would

argue that their service is the most important. Indeed, TMJ

problems are largely within the province of dental care;

however, like a horse with blinders, therapy has concen￾trated on the mechanical aspects, largely ignoring the phys￾iological and psychological areas that are so important, if we

are to render optimal service. In other words, dentistry itself

must broaden its diagnostic and therapeutic horizons and

de-emphasize the tooth-oriented vision and mechanical

procedures. The authors clearly state this in their preface -

based on their great clinical experience. If the reader is look￾ing for a fancy articulator that replicates the stomatognathic

system, he is in the wrong place.

Too many dentists have been led down the primrose path,

aided by TOT (tincture of time) as patients improve, regard￾less of the therapy employed. TMJ problems are largely

cyclic, and are often self-correcting via homeostasis, with

time and advancing age.

The pseudo-science of Gnathology has been built around

the mechanical contrivances of articulators and facebows,

but provide only part of the answer, at best. Lysle Johnston,

a highly respected professor of orthodontics at the Univer￾sity of Michigan, has facetiously defined Gnathology as "The

science of how articulators chew!" They are only a tool in

the panoply of diagnostic aids; sometimes more important,

if the teeth are a major factor in the TMJ complaint. Too

often, however, they are only a part, as the authors wisely

say, based on their great clinical experiences. Thus this book

is dedicated to making dentists into applied biologists,

applied physiologists, applied psychologists, as well as good

mechanics who can restore, reshape, reposition and beau￾tify teeth and get that smile winning smile. Mounting of

casts is carefully and completely covered by Drs. Bumann

and Lotzmann, as only one part of the diagnostic mosaic.

The beautifully illustrated section on the anatomy and

physiology of the stomatognathic system provides a com￾prehensive discourse on all essential components of the

stomatognathic system. Skeletal, structural, and neuromus￾cular aspects are well illustrated, providing an excellent

understanding of each part and the interrelationships, with￾out verbosity. We must remember that the teeth are in

contact roughly 60-90 minutes per 24 hours. The dominant

structures are the neuromuscular structures, which suspend

the mandible and provide its vital function in mastication,

deglutition, breathing and speech. Dentistry must get over

its pre-occupation with the idea that it is "the teeth, the

whole teeth, nothing but the teeth!" This book is a breath of

fresh air, as it analyzes the basic structures involved and the

roles that the skeletal osseous parts, the condyle, the

glenoid fossa, the articular disk, the capsule, ligaments,

muscles and that too-often neglected retrodiskal pad

(bilaminar zone) play in the whole picture. Equally impor￾tant, as we assemble the diagnostic mosaic for treatment, is

the psychological role, the stress-strain-tension release

mechanisms that we resort to in our complex society today.

We must make sure, in our diagnostic exercise, that we

know which is cause and which is effect. Wear facets on

teeth may well be the result of nocturnal parafunctional

activity, i.e., bruxism. And even more important, and too

often neglected, is nocturnal clenching, which is also a man￾ifestation of the stress-strain release syndrome, especially

at night. Lars Christensen showed conclusively that as little

as 90 seconds of clenching can cause neuromuscular

response, i.e., pain and muscle splinting. Does the condyle

impinge on the retrodiskal pad, with it's network of nerves

and blood vessels, and the important role it plays in the

physiology of the temporomandibular joint? Here again,

important information is provided by the authors, based on

the landmark work of Rees, Zenker and DuBrul. Recent

research validates the important role that the bilaminar

zone or retrodiskal pad plays in TMJ physiology. Thilander

showed in 1961 that pain response in the temporomandibu-

VIII

lar joint can come from condylar impingement on this

neglected post-articular structure. Isberg showed graphi￾cally the damage possible by forced impingement on the

same tissues. Yet we have to be smart enough to know the

difference between cause and effect.

Functional analysis is a key to most TMD diagnostic exer￾cises. Only then can articulator-oriented rebuilding of teeth

be biologically based and physiologically sound. Drs

Bumann and Lotzmann have stressed this orientation in

their fine book. Their sections on functional analysis is state

of the art. The role of physical therapy is clearly defined.

Orthodontist perhaps have been exposed to this more in

their training and the knowledge should benefit general

dentists. As well.

We realize that we are clearly in the new millennium, when

we read the section on Imaging Procedures. What are the

best diagnostic tools available? For what structures?

Because of the difficulty of getting precise images of the

complex temporomandibular joint, more than one radio￾graphic assessment may be needed. Knowing what each

imaging tool can produce is important. Yet, the material

presented is lucid and understandable and not needlessly

technical. Criteria are tied to the various potential abnor￾malities.

Diagnosis is the name of the game and its imperfect appli￾cation by countless clinicians has made it the Achilles heel

of TMJ therapy. Tying together the anatomic, physiologic,

and psychological elements is essential for optimal patient

service. As in all other sections, a comprehensive bibliogra￾phy permits the reader to explore these tools further.

The multifaceted nature of cause-oriented TMD therapy is

covered well, as the various types of appliances are

described and the indications for their use given. The

aphorism that "a splint is a splint is a splint" is ludicrous, in

light of the biologic background elucidated by the authors.

Depending on the diagnostic assessment and classification

described beforehand, the clinician may use a relaxation

splint, a stabilization splint, a decompression splint, a

repositioning splint, or a verticalization splint. Again,

diagnosis is the name of the game in their choice. Along

with supplemental use of muscle relaxants, heat, infrared

radiation, stress relief and counseling.

Profuse color illustrations make following the text easy and

enhance the understanding of the concepts. A recent scien￾tific study showed conclusively that color pictures are easier

to comprehend by the human brain. This color atlas is a

good example of this fact. Excellent production, for which

Thieme is noted, enhances the value of the book. Read,

enjoy and learn!

T.M. Graber, DMD, MSD, PhD, MD, DSc, ScD, Odont.Dr. FRCS.

Professor

IX

Foreword

The authors of this extraordinary atlas have given the dental

profession an extremely comprehensive and well-organized

treatise on the functional diagnosis and management of the

masticatory system. Historically, dental literature in the field

of occlusion has been primarily based on clinical observa￾tions, case reports and testimonials. This extremely well ref￾erenced atlas is a welcome addition to the momentum

within the dental profession to move the field forward to a

more evidenced-based discipline. The multidisciplinary

diagnostic approach presented in the atlas is well estab￾lished and supported by published data. Chapters include

up-to-date information and exquisite photography on the

anatomy, physiology, pathology and biomechanics of masti￾catory system, as well as detailed diagnostic techniques. The

theme of the atlas is based on the importance of the coordi￾nated functional interaction between the tissue populations

of the various stomatognathic structures. The authors

emphasize the need for thorough functional analyses in

order to accurately determine if the dynamic physiologic

relationship between the various tissue systems is functional

or dysfunctional. As so beautifully illustrated in the text,

when there is a disturbance in this dynamic functional equi￾librium due to injury, disease, adverse functional demands

or a loss in the adaptive capacity of the tissues, tissue failure

and functional disturbances can occur. The authors present

precise and very comprehensive clinical functional analysis

techniques for establishing specific diagnoses, and ulti￾mately, improved treatment planning. Multidisciplinary

treatment planning based on the data derived from diagnos￾tic functional analyses including established orthopedic

techniques, intraoral examinations, imaging and instru￾mented testing systems is expertly explained in easy to fol￾low steps. The emphasis throughout the atlas is that diag￾nostic-driven treatment is based on the specific needs of the

individual patient rather than based on a preconceived belief

system or on a stereotyped concept thought to universally

ideal. Treatment plans are based on cause-oriented func￾tional disturbances that may need to be modified by the

patient's compliance, general health and emotional status in

addition to the clinician's abilities, training and experience. I

congratulate Drs. Alex Bumann and Ulrich Lotzmann for

their outstanding efforts in providing the profession with an

extremely well organized, skillfully written, and beautifully

illustrated atlas. I especially appreciated their attempt to

provide the reader with, wherever possible, current and

complete references and, thus, add important evidenced￾based literature to the field. This treatise on functional dis￾turbances of the stomatognathic system should be required

reading for anyone interested in the diagnostic process and

treatment planning in dentistry in general. Additionally, the

detailed chapters describing the various diagnostic func￾tional techniques with accompanying exquisite illustrations

make this an outstanding comprehensive teaching atlas in

occlusion for students and clinicians.

Charles McNeill, D.D.S.

Professor of Clinical Dentistry & Director,

Center for Orofacial Pain

School of Dentistry, University of California, San Francisco

Foreword

Dr Bumann and Dr Lotzmann are two authors with an out￾standing amount of information and illustrations at their

disposal. Working together with Thieme, a publisher known

for its ability to communicate through the use of illustra￾tions, to produce this book has proven to be a perfect col￾laboration.

Imaging can play an important role in the diagnostic and

treatment processes associated with orthodontic, restora￾tive, and craniomandibular disorder patients, because find￾ing the correct diagnosis is crucial for the development of

the optimum treatment strategy as well as for the applica￾tion of the appropriate treatment. This book illustrates suc￾cessfully a range of complex anatomic conditions involving

the maxillofacial structures through the clever use of high￾quality illustrations and diagnostic images.

Nevertheless, rather than recommending diagnostic imag￾ing as a routine procedure, the authors correctly point out

that diagnostic imaging is best applied when there is a like￾lihood of benefiting the patient. The potential value of the

use of imaging for a patient is most often determined dur￾ing the physical examination and history taking. To achieve

the full value of diagnostic imaging, the clinician is required

to develop specific imaging goals, to select the appropriate

imaging modalities, to develop an imaging protocol, and to

interpret the resultant image(s). The ideal imaging solution

is one which meets the clinically derived imaging goals

while maintaining the lowest achievable patient risk and

patient cost. The authors discuss and illustrate the most

common imaging modalities available today.

Dr Bumann and Dr Lotzmann applied a "systems" approach

to facilitate understanding of the functional or biomechani￾cal relationships between the craniomandibular structures,

including the jaws, teeth, muscles, and temporomandibular

joints. This type of approach would seem to be a must for all

clinicians interested in the restoration of occlusion or in the

diagnosis and management of selected craniomandibular

disorders.

This textbook illustrates a wide range of maxillofacial,

musculoskeletal, and articular conditions that may be asso￾ciated with crandiomandibular disorders. I was intrigued by

the proposed functional analysis which produces selected

diagnostic data about intracapsular conditions of the

temporomandibular joints that until now have been the

exclusive domain of diagnostic imaging.

The authors have created a well-illustrated textbook, detail￾ing many of the biomechanical aspects of craniomandibular

disorders. The imaging portions alone would make this a

valuable reference text for all practitioners trying to under￾stand or diagnose patients with craniomandibular disor￾ders.

David C. Hatcher, DDS, MSc, MRCD (c)

Acting Associate Professor

Department of Oral and Maxillofacial Surgery

University of California San Francisco

San Francisco, CA

XI

Foreword

Craniomandibular disorders are a group of disorders that

have their origin in the musculoskeletal structures of the

masticatory system. They can present as complicated and

challenging problems. Almost all dentists encounter them

in their practices. In the early stages of the development of

this field of study the dental profession felt that these dis￾orders were primarily a dental problem and could most

often be resolved by dental procedures. As the study of

craniomandibular disorders evolved we began to appreciate

the complexity and multifactorial nature that makes these

disorders so difficult to manage. Some researchers even

suggested that these conditions are not a dental problem at

all. Many clinicians, however, recognize that there can be a

dental component with some craniomandibular disorders

and when this exists the dentists can offer a unique form of

management that is not provided by any other health pro￾fessional. Dentists therefore need to understand when den￾tal therapy is useful for a craniomandibular disorder and

when it is not. This understanding is basic to selecting

proper treatment and ultimately achieving clinical success.

This is the greatest challenge faced by all dentists who man￾age patients with craniomandibular disorders.

The purpose of this atlas is to bring together information

that will help the practitioner better understand the pa￾tient's problem thereby allowing the establishment of the

proper diagnosis. A proper diagnosis can only be deter￾mined after the practitioner listens carefully to the patient's

description of the problem and past experiences (the His￾tory) followed by the collection of relative clinical data (the

Examination). The interpretation of the history and exami￾nation findings by the astute practitioner is fundamental in

establishing the proper diagnosis. Determining the proper

diagnosis is the most critical factor in selecting treatment

that will prove to be successful. In the complex field of

craniomandibular disorders misdiagnosis is common and

likely the foremost reason for treatment failure.

Dr. Alex Bumann and Dr. Ulrich Lotzmann have brought

together a wealth of information that will help the practic￾ing dentist interested in craniomandibular disorders. This

atlas provides the reader with techniques that assist in the

collection of data needed to establish the proper diagnosis.

This atlas brings together both new and old concepts that

should be considered when evaluating a patient for cranio￾mandibular disorders. Some of the old techniques are well

established and proven to be successful. Some of the newer

techniques are insightful and intuitive, and will need to be

further validated with scientific data.

In this atlas the authors introduce the term "manual func￾tional analysis" as a useful method of gaining additional

information regarding mandibular function. They have

developed these techniques to more precisely evaluate the

sources of pain and dysfunction in the craniomandibular

structures. Each technique is well illustrated using clinical

photographs, drawings and, in some instances, anatomical

specimens. Elaborate, well thought out, algorithms also help

the reader interpret the results of the mandibular function

analysis techniques. Although these techniques are not fully

documented, they are conservative, logical, and will likely

contribute to establishing the proper diagnosis. The authors

also provide a wide variety of methods, techniques and

instrumentations for the reader to consider.

This atlas provides an excellent overview of the many

aspects that must be considered when evaluating a patient

with a craniomandibular disorder. Appreciating the wealth

of information presented in this atlas will certainly assist

the dentist in gaining a more complete understanding of

craniomandibular disorders. It will also guide the practi￾tioner to the proper diagnosis. I am sure that the efforts of

Dr. Bumann and Dr. Lotzmann will not only improve the

skills of the dentists, but also improve the care of patients

suffering with craniomandibular disorders. My congratula￾tions to these authors for this fine work.

Jeffrey P Okeson, DMD

Professor and Director

Orofacial Pain Center

University of Kentucky College of Dentistry

Lexington, Kentucky, USA 40536-0297

XII

Preface

Medicine and dentistry are continuously evolving, due

largely to the influences and interactions of new methods,

technologies, and materials. Partly because of outdated test￾ing requirements, our students can no longer adequately

meet the increasing demands these changes have placed on

a patient-oriented education. With limited classroom and

clinic time and an unfavorable ratio of teachers to students,

the complex interrelations within the area of dental func￾tional diagnosis and treatment planning are precisely the

type of subject matter that usually receives only perfunc￾tory explanation and demonstration in dental school. Con￾sequently, recent dental school graduates are obliged to

compensate for deficiencies of knowledge in all areas of

dentistry through constant continuing education. And so

the primary purpose of this atlas is to provide the motivated

reader with detailed information in the field of dental func￾tional diagnosis by means of sequences of illustrations

accompanied by related passages of text. The therapeutic

aspects are dealt with here only in general principles. Diag￾nosis-based treatment will be the subject of a future book.

The method of clinical functional analysis described in

detail in this atlas is based largely on the orthopedic exam￾ination techniques described earlier by Cyriax, Maitland,

Mennell, Kalternborn, Wolff, and Frisch. Hansson and

coworkers were the first to promote the application of these

techniques to the temporomandibular joint in the late sev￾enties and early eighties. In cooperation with the physical

therapist G. Groot Landeweer this knowledge was taken up

and developed further into a practical examination concept

during the late eighties. Because the clinical procedures dif￾fer from those of classic functional analysis, the term "man￾ual functional analysis" was introduced.

The objective of manual functional analysis is to test for

adaptation of soft-tissue structures and evidence of any

loading vectors that might be present. This is not possible

through instrumented methods alone. The so-called

"instrumented functional analysis" (such as occlusal analy￾sis on mounted casts or through axiography) is helpful nev￾ertheless for disclosing different etiological factors such as

malocclusion, bruxism, and dysfunction. Thus the clinical

and instrumented subdivisions of functional diagnostics

complement one another to create a meaningful whole.

In recent years the controversy over "occlusion versus psy￾che" as the primary etiological element has become more

heated and has led to polarization of opinions among teach￾ers. But in the view of most practitioners, this seems to be

of little significance. In an actual clinical case one is dealing

with an individualized search for causes, during which both

occlusal and psychological factors are considered.

Within the framework of a cause-oriented treatment of

functional disorders one must consider that while the elim￾ination of occlusal disturbances may represent a reduction

of potential etiological factors, it may not necessarily lead to

the elimination of symptoms. The reason for this is that

there can be other etiological factors that lie outside the

dentist's area of expertise.

Some readers may object to the fact that the chapters

"Mounting of Casts and Occlusal Analysis" and "Instru￾mented Analysis of Jaw Movements" do not reflect the mul￾titude of articulators and registration systems currently

available. We believe that for teaching purposes it makes

sense to present the procedural steps explained in these

chapters by using examples of an articulator and registra￾tion system that have been commercially established for

several years. This should not be interpreted as an endorse￾ment of these instruments over other precision systems for

tracing and simulating mandibular movements.

Fall 2002 Axel Bumann Ulrich Lotzmann

XIII

Acknowledgments

The physical therapist Gert Groot Landeweer deserves our

special thanks for the many years of friendly and fruitful

collaboration. Before his withdrawal from the team of

authors he made a great impact on the contents of this atlas

through numerous instructive professional discussions.

Furthermore we owe a debt of gratitude to the Primer Gang

General Radiology Practice in Kiel, especially to Dr. J. Hezel

and Dr. C. Schroder for 10 years of excellent cooperation and

their friendly support in the preparation of special images

beyond the clinical routine. Almost all the magnetic reso￾nance images shown in this atlas were produced by this

clinic.

We thank Prof. B. Hoffmeister, Berlin, and Dr. B. Fleiner,

Augsburg for the years of close cooperation with all the

surgically treated patients.

The Department of Growth and Development (Chair: Dr. L.

Will) of the Harvard School of Dental Medicine, the Depart￾ment of Orthopedic Surgery (Chair: Dr. T. Einhorn) and the

Laboratory of Musculoskeletal Research (Director: Dr. L.C.

Gerstenfeld) of the Boston University School of Medicine

deserve our gratitude for their understanding support.

Graphic artist Adrian Cornford has demonstrated his great

skill in translating our sometimes vague sketches into

instructive illustrations. For this we are grateful.

Our thanks are due also to Prof. Sandra Winter-Buerke who,

in posing as our patient for the photographs demonstrating

the manual functional analysis procedures, submitted to a

veritable "lightning storm" of strobe flashes. She endured

the tedious photographic sessions with amazing patience.

Our thanks go also to the dentists Katja Kraft, Nicole Schaal,

and Sandra Dersch for their assistance with the photo￾graphic work in the chapters "Instrumented Analysis of Jaw

Movements" and "Mounting of Casts and Occlusal Analysis."

Furthermore, we would like to thank Dr. K. Wiemer and Mr.

A. Rathjen for their support in organizing the illustrations

and the intercontinental transmission of data.

We thank the dental technicians Mrs. N. Kirbudak, Mr. U.

Schmidt, and Mr. G. Bockler for the numerous laboratory

preparations.

We are grateful to the firms Elscint (General Electric), Girr￾bach, KaVo, and SAM for their support in the form of mate￾rials used in the preparation of this book.

We thank our students and seminar participants for their

critical comments and stimulating discussions. These

exchanges were a significant help in the didactic construc￾tion of this work.

We are also very grateful to Dr. Richard Jacobi for his excel￾lent translation.

In closing, we wish in particular to express our heartfelt

thanks to Dr. Christian Urbanowicz, Karl-Heinz Fleisch￾mann, Markus Pohlmann, Clifford Bergman, M. D., and Gert

Kriiger as well as to all the other staff at Georg Thieme

Verlag who worked with us, the Reproduction Department,

the printer's, and book binder's for their engagement and

professionalism in the design and preparation of this

volume.

Table of Contents

vii Forewords

xiii Acknowledgments

XV Table of Contents

1 Introduction 53 Manual Functional Analysis

2 The Masticatory System as a Biological System 54 The Masticatory System as a Biological System

3 Progressive/Regressive Adaptation and Compensation/ 55 Specific and Nonspecific Loading Vectors

Decompensation 56 Examination Form for Manual Functional Analysis

4 Functional Diagnostic Examination Procedures... 58 Patient History

5 ...and their Therapeutic Consequences 60 Positioning the Patient

6 The Role of Dentistry in Craniofacial Pain 61 Manual Fixation of the Head

62 Active Movements and Passive Jaw Opening with

Evaluation of the Endfeel

7 Primary Dental Evaluation 67 Differential Diagnosis of Restricted Movement

8 Findings in the Teeth and Mucous Membrane 68 Examination of the Joint Surfaces

10 Overview of Dental Examination Techniques 70 Manifestations of Joint Surface Changes

72 Conducting the Clinical Joint Surface Tests

74 Examination of the Joint Capsule and Ligaments

11 Anatomy of the Masticatory System 78 Clinical Significance of Compressions in the Superior

12 Embryology of the Temporomandibular Joint and the Direction

Muscles of Mastication 84 Examination of the Muscles of Mastication

14 Development of the Upper and Lower Joint Spaces 89 Palpation of the Muscles of Mastication with Painful

16 Glenoid Fossa and Articular Protuberance Isometric Contractions

18 Mandibular Condyle 94 Areas of Pain Referred from the Muscles of Mastication

20 Positional Relationships of the Bony Structures 96 Length of the Suprahyoid Structures

22 Articular Disk 98 Investigation of Clicking Sounds

23 Anatomical Disk Position 102 Active Movements and Dynamic Compression

24 BilaminarZone 104 Manual Translations

26 Joint Capsule 106 Dynamic Compression during Retrusive Movement

28 Ligaments of the Masticatory System 108 Differentiation among the Groups

31 Arterial Supply and Sensory Innervation of the 110 Differentiation within Group 1

Temporomandibular Joint 112 Differentiation within Group 2

32 Sympathetic Innervation of the Temporomandibular 114 Differentiation among Unstable, Indifferent, and Stable

Joint Repositioning

33 Muscles of Mastication 116 Differentiation within Group 3

34 Temporal Muscle 118 Differentiation within Group 4

35 Masseter Muscle 120 Unified Diagnostic Concept and...

36 Medial Pterygoid Muscle 121 ...Treatment Plan for Anterior Disk Displacement

37 Suprahyoid Musculature 122 Tissue-Specific Diagnosis

38 Lateral Pterygoid Muscle 122 —Principles of Manual Functional Analysis

40 Macroscopical-Anatomical and Histological Studies of the 122 —Protocol for Cases with Pain

Masticatory Muscle Insertions 123 —Protocol for Clicking Sounds

41 Force Vectors of the Muscles of Mastication 123 —Routine Protocol

42 Tongue Musculature 123 —Protocol for Limitations of Movement

43 Muscle of Expression 123 —Primary and Secondary Diagnoses

44 Temporomandibular Joint and the Musculoskeletal System 124 Investigation of the Etiological Factors (Stressors)

45 Peripheral and Central Control of Muscle Tonus 125 Neuromuscular Deprogramming

46 Physiology of the Jaw-Opening Movement 126 Mandibular and Condylar Positions

47 Physiology of the Jaw-Closing Movement 128 Static Occlusion

48 Physiology of Movements in the Horizontal Plane 130 Dynamic Occlusion

49 The Teeth and Periodontal Receptors 132 Bruxism Vector or Parafunction Vector

50 Condylar Positions 134 Dysfunctional Movements

51 Static Occlusion 135 Influence of Orthopedic Disorders on the Masticatory

52 Dynamic Occlusion System

XV

xvi Table of Contents

136 Supplemental Diagnostic Procedures 175 Total Disk Displacement

136 —Mounted Casts, Axiography 176 Types of Disk Repositioning

137 —Panoramic Radiograph 177 Disk Displacement without Repositioning

137 —Lateral Jaw Radiograph 178 Partial Disk Displacement with Total Repositioning

137 —Joint Vibration Analysis (JVA) 179 Partial Disk Displacement with Partial Repositioning

138 Musculoskeletal Impediments in the Direction of 180 Total Disk Displacement with Total Repositioning

Treatment 181 Total Disk Displacement with Partial Repositioning

140 Manual Functional Analysis for Patients with no History of 182 Condylar Hypermobility

Symptoms 183 Posterior Disk Displacement

184 Disk Displacement during Excursive Movements

185 Regressive Adaptation of Bony Joint Structures

141 Imaging Procedures 186 Progressive Adaptation of Bony Joint Structures

142 Panoramic Radiographs 188 Evaluation of Adaptive Changes: MRI Versus CT

144 Portraying the Temporomandibular Joint with Panoramic 189 Avascular Necrosis Versus Osteoarthrosis

Radiograph Machines 190 Metric (Quantitative) MRI Analysis

146 Asymmetry Index 192 Examples of Bumann's MRI Analysis

147 Distortion Phenomena 194 MRI for Orthodontic Questions

148 Eccentric Transcranial Radiograph 195 Three-Dimensional Imaging with MRI Data

(Schuller Projection) 196 Dynamic MRI

149 Axial Cranial Radiograph According to Hirtz and 196 -Cine MRI

Conventional Tomography 197 -Movie MRI

150 Posterior-Anterior Cranial Radiograph according to 198 MR Microscopy and MR Spectroscopy

Clementschitsch 199 Indications for Imaging Procedures as Part of Functional

151 Lateral Transcranial Radiograph Diagnostics

152 Computed Tomography of the Temporomandibular Joint 200 Prospects for the Future of Imaging Procedures

153 Computed Tomography of the Temporomandibular Joint

and its Anatomical Correlation

154 Three Dimensional Images of the Temporomandibular 201 Mounting of Casts and Occlusal Analysis

Joint... 202 Making of Impressions and Stone Casts

155 ...with the Aid of Computed Tomography Data 205 Fabrication of Segmented Casts

156 Three-Dimensional Reconstruction for Hypoplastic 206 Registration of Centric Relation

Syndromes 207 Techniques for Recording the Centric Condylar Position

157 Three-Dimensional Models of Polyurethane Foam and 208 Transcutaneous Nerve Stimulation for Muscle Relaxation￾Synthetic Resin "Myocentric"

158 Magnetic Resonance Imaging 210 Interocclusal Registration Materials

159 T1- and T2-Weighting 211 Centric Registration for Intact Dentitions

160 Selecting the Slice Orientation 212 Occlusal Splints used as Record Bases

161 Practical Application of MRI Sections 214 Centric Registration for Posteriorly Shortened Dental

162 Reproduction of Anatomical Detail in MRI Arches

164 Visual (Qualitative) Evaluation of an MR Image 215 Jaw Relation Determination for Edentulous Patients

165 Classification of the Stages of Bony Changes 216 Mounting the Cast in the Correct Relationship to the

166 Disk Position in the Sagittal Plane Cranium and Temporomandibular Joints

167 Disk Position in the Frontal Plane 217 Attaching the Anatomical Transfer Bow

168 Misinterpretation of the Disk Position in the Sagittal Plane 220 Mounting the Maxillary Cast using the Anatomical

169 Morphology of the Pars Posterior Transfer Bow

170 Progressive Adaptation of the Bilaminar Zone 222 Mounting the Maxillary Cast using a Transfer Stand

171 Progressive Adaptation in T1 - and T2-Weighted MRI 223 Mounting the Maxillary Cast following Axiography

172 Disk Adhesions in MRI 226 Mounting the Mandibular Cast

173 DiskHypermobility 228 Axiosplit System

174 Partial Disk Displacement 230 Split-Cast Control of the Cast Mounting

Table of Contents xvii

231 Check-Bite for Setting the Articulator Joints 301 Principles of Treatment

232 Effect of Hinge Axis Position and Thickness of the Occlusal 302 Specific or Nonspecific Treatment?

Record on the Occlusion 303 Nonspecific Treatment

233 Occlusal Analysis on the Casts 304 Elimination of Musculoskeletal Impediments

236 Occlusal Analysis using Sectioned Casts 306 Occlusal Splints

239 Diagnostic Occlusal Reshaping of the Occlusion on the 308 Splint Adjustment for Vertical Disocclusion and Posterior

Casts Protection

242 Diagnostic Tooth Setup 309 Relationship between Joint Surface Loading and the

243 Diagnostic Waxup Occlusal Scheme

246 Condylar Position Analysis Using Mounted Casts 310 Relaxation Splint

311 Stabilization Splint

312 Decompression Splint

248 Instrumented Analysis of Jaw Movements 313 Repositioning Splint

250 Mechanical Registration of the Hinge Axis Movements 314 Verticalization Splint

(Axiography) 316 Definitive Modification of the Dynamic Occlusion

261 Evaluating the Axiograms and Programming the 318 Definitive Alteration of the Static Occlusion

Articulator 322 Examination Methods and Their Therapeutic Relevance

262 Hinge Axis Tracings (Axiograms) as Projection Phenomena

263 Effect of an Incorrectly Located Hinge Axis on the 323 Illustration Credits

Axiograms

264 Electronic Paraocclusal Axiography 324 References

354 Index

269 Diagnoses and Classifications

270 Classification of Primary Joint Diseases

271 Classification of Secondary Joint Diseases

272 Hyperplasia, Hypoplasia, and Aplasia of the Condylar

Process

273 Hyperplasia of the Coronoid Process

274 Congenital Malformations and Syndromes

275 Acute Arthritis

276 Rheumatoid Arthritis

277 Juvenile Chronic Arthritis

278 Free Bodies within the Joints

279 Styloid or Eagle Syndrome

280 Fractures of the Neck and Head of the Condyle

281 Disk Displacement with Condylar Neck Fractures

282 Fibrosis and Bony Ankylosis

283 Tumors in the Temporomandibular Joint Region

284 Joint Disorders—Articular Surfaces

286 Joint Disorders—Articular Disk

287 Joint Disorders—Bilaminar Zone and Joint Capsule

295 Joint Disorders—Ligaments

297 Muscle Disorders