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 Editors' Addresses Dr. Axel Bumann, D.D.S., Ph. D. Dr. Ulrich Lotzmann, D.D.S., Ph. D. James Mah, D.D.S., M.Sc, D.M.S.c. Klaus H. Rateitschak, D.D.S., Ph.D. Clinical Assistant Professor Professor and Chair Assistant Professor Dental Institute, Center for Dental Dept. of Craniofacial Sciences and Dept. of Prosthodontics Dept. of Craniofacial Sciences Medicine Therapy Philipps-University and Therapy University of Basle University of Southern California Georg-Voigt-Strasse 3 University of Southern California Hebelstr. 3,4056 Basle, 925 W 34 St, Suite 312 35039 Marburg/Lahn 925 W 34 St, Suite 312 Switzerland Los Angeles, CA 90089-0641 Germany Los Angeles, CA 90089-0641 USA lotzmann® USA Herbert F. Wolf, D.D.S. [email protected] post.med.uni-marburg.de [email protected] Private Practitioner Specialist of Periodontics SSO/SSP MEOCLINIC Lowenstrasse 55, 8001 Zurich, International Private Clinic Switzerland Friedrichstr. 71,10117 Berlin Germany Prof.Dr.A.Bumann@kfo- berlin.de Library of Congress Cataloging-in- Important Note: Medicine is an ever- Publication Data is available from the In the Series "Color Atlas of Dental Medicine" changing science undergoing continual publisher. development. Research and clinical expe- K. H. & E. M. Rateitschak, H. F. Wolf, T. M. Hassell rience are continually expanding our knowledge, in particular our knowledge • Periodontology, 3rd edition of proper treatment and drug therapy. Insofar as this book mentions any dosage A. H. Geering, M. Kundert, C. 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Therefore, the appearance of a This book is an authorized translation name without designation as proprietary of the German edition published and A. Bumann, U. Lotzmann is not to be construed as a representation cVoeprlyargig, hStetudt t2g0a0rt0, Gbey rGmeaonryg. Thieme • TMJ Disorders and Orofacial Pain bdoy mthaein .p ublisher that it is in the public 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 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, The beautifully illustrated section on the anatomy and namely that dentistry is only one part of a multi-faceted physiology of the stomatognathic system provides a com- service for temporomandibular dysfunction. Dentists would prehensive discourse on all essential components of the argue that their service is the most important. Indeed, TMJ stomatognathic system. Skeletal, structural, and neuromus- problems are largely within the province of dental care; cular aspects are well illustrated, providing an excellent however, like a horse with blinders, therapy has concen- understanding of each part and the interrelationships, with- trated on the mechanical aspects, largely ignoring the phys- out verbosity. We must remember that the teeth are in iological and psychological areas that are so important, if we contact roughly 60-90 minutes per 24 hours. The dominant are to render optimal service. In other words, dentistry itself structures are the neuromuscular structures, which suspend must broaden its diagnostic and therapeutic horizons and the mandible and provide its vital function in mastication, de-emphasize the tooth-oriented vision and mechanical deglutition, breathing and speech. Dentistry must get over procedures. The authors clearly state this in their preface - its pre-occupation with the idea that it is "the teeth, the based on their great clinical experience. If the reader is look- whole teeth, nothing but the teeth!" This book is a breath of ing for a fancy articulator that replicates the stomatognathic fresh air, as it analyzes the basic structures involved and the system, he is in the wrong place. roles that the skeletal osseous parts, the condyle, the glenoid fossa, the articular disk, the capsule, ligaments, Too many dentists have been led down the primrose path, muscles and that too-often neglected retrodiskal pad aided by TOT (tincture of time) as patients improve, regard- (bilaminar zone) play in the whole picture. Equally impor- less of the therapy employed. TMJ problems are largely tant, as we assemble the diagnostic mosaic for treatment, is cyclic, and are often self-correcting via homeostasis, with the psychological role, the stress-strain-tension release time and advancing age. mechanisms that we resort to in our complex society today. We must make sure, in our diagnostic exercise, that we The pseudo-science of Gnathology has been built around know which is cause and which is effect. Wear facets on the mechanical contrivances of articulators and facebows, teeth may well be the result of nocturnal parafunctional but provide only part of the answer, at best. Lysle Johnston, activity, i.e., bruxism. And even more important, and too a highly respected professor of orthodontics at the Univer- often neglected, is nocturnal clenching, which is also a man- sity of Michigan, has facetiously defined Gnathology as "The ifestation of the stress-strain release syndrome, especially science of how articulators chew!" They are only a tool in at night. Lars Christensen showed conclusively that as little the panoply of diagnostic aids; sometimes more important, as 90 seconds of clenching can cause neuromuscular if the teeth are a major factor in the TMJ complaint. Too response, i.e., pain and muscle splinting. Does the condyle often, however, they are only a part, as the authors wisely impinge on the retrodiskal pad, with it's network of nerves say, based on their great clinical experiences. Thus this book and blood vessels, and the important role it plays in the is dedicated to making dentists into applied biologists, physiology of the temporomandibular joint? Here again, applied physiologists, applied psychologists, as well as good important information is provided by the authors, based on mechanics who can restore, reshape, reposition and beau- the landmark work of Rees, Zenker and DuBrul. Recent tify teeth and get that smile winning smile. Mounting of research validates the important role that the bilaminar casts is carefully and completely covered by Drs. Bumann zone or retrodiskal pad plays in TMJ physiology. Thilander and Lotzmann, as only one part of the diagnostic mosaic. showed in 1961 that pain response in the temporomandibu- VIII lar joint can come from condylar impingement on this Diagnosis is the name of the game and its imperfect appli- neglected post-articular structure. Isberg showed graphi- cation by countless clinicians has made it the Achilles heel cally the damage possible by forced impingement on the of TMJ therapy. Tying together the anatomic, physiologic, same tissues. Yet we have to be smart enough to know the and psychological elements is essential for optimal patient difference between cause and effect. service. As in all other sections, a comprehensive bibliogra- phy permits the reader to explore these tools further. Functional analysis is a key to most TMD diagnostic exer- cises. Only then can articulator-oriented rebuilding of teeth The multifaceted nature of cause-oriented TMD therapy is be biologically based and physiologically sound. Drs covered well, as the various types of appliances are Bumann and Lotzmann have stressed this orientation in described and the indications for their use given. The their fine book. Their sections on functional analysis is state aphorism that "a splint is a splint is a splint" is ludicrous, in of the art. The role of physical therapy is clearly defined. light of the biologic background elucidated by the authors. Orthodontist perhaps have been exposed to this more in Depending on the diagnostic assessment and classification their training and the knowledge should benefit general described beforehand, the clinician may use a relaxation dentists. As well. splint, a stabilization splint, a decompression splint, a repositioning splint, or a verticalization splint. Again, We realize that we are clearly in the new millennium, when diagnosis is the name of the game in their choice. Along we read the section on Imaging Procedures. What are the with supplemental use of muscle relaxants, heat, infrared best diagnostic tools available? For what structures? radiation, stress relief and counseling. Because of the difficulty of getting precise images of the complex temporomandibular joint, more than one radio- Profuse color illustrations make following the text easy and graphic assessment may be needed. Knowing what each enhance the understanding of the concepts. A recent scien- imaging tool can produce is important. Yet, the material tific study showed conclusively that color pictures are easier presented is lucid and understandable and not needlessly to comprehend by the human brain. This color atlas is a technical. Criteria are tied to the various potential abnor- good example of this fact. Excellent production, for which malities. 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 their outstanding efforts in providing the profession with an profession an extremely comprehensive and well-organized extremely well organized, skillfully written, and beautifully treatise on the functional diagnosis and management of the illustrated atlas. I especially appreciated their attempt to masticatory system. Historically, dental literature in the field provide the reader with, wherever possible, current and of occlusion has been primarily based on clinical observa- complete references and, thus, add important evidenced- tions, case reports and testimonials. This extremely well ref- based literature to the field. This treatise on functional dis- erenced atlas is a welcome addition to the momentum turbances of the stomatognathic system should be required within the dental profession to move the field forward to a reading for anyone interested in the diagnostic process and more evidenced-based discipline. The multidisciplinary treatment planning in dentistry in general. Additionally, the diagnostic approach presented in the atlas is well estab- detailed chapters describing the various diagnostic func- lished and supported by published data. Chapters include tional techniques with accompanying exquisite illustrations up-to-date information and exquisite photography on the make this an outstanding comprehensive teaching atlas in anatomy, physiology, pathology and biomechanics of masti- occlusion for students and clinicians. catory system, as well as detailed diagnostic techniques. The theme of the atlas is based on the importance of the coordi- Charles McNeill, D.D.S. nated functional interaction between the tissue populations Professor of Clinical Dentistry & Director, of the various stomatognathic structures. The authors Center for Orofacial Pain emphasize the need for thorough functional analyses in School of Dentistry, University of California, San Francisco 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 Foreword Dr Bumann and Dr Lotzmann are two authors with an out- This textbook illustrates a wide range of maxillofacial, standing amount of information and illustrations at their musculoskeletal, and articular conditions that may be asso- disposal. Working together with Thieme, a publisher known ciated with crandiomandibular disorders. I was intrigued by for its ability to communicate through the use of illustra- the proposed functional analysis which produces selected tions, to produce this book has proven to be a perfect col- diagnostic data about intracapsular conditions of the laboration. temporomandibular joints that until now have been the exclusive domain of diagnostic imaging. Imaging can play an important role in the diagnostic and treatment processes associated with orthodontic, restora- The authors have created a well-illustrated textbook, detail- tive, and craniomandibular disorder patients, because find- ing many of the biomechanical aspects of craniomandibular ing the correct diagnosis is crucial for the development of disorders. The imaging portions alone would make this a the optimum treatment strategy as well as for the applica- valuable reference text for all practitioners trying to under- tion of the appropriate treatment. This book illustrates suc- stand or diagnose patients with craniomandibular disor- cessfully a range of complex anatomic conditions involving ders. the maxillofacial structures through the clever use of high- quality illustrations and diagnostic images. David C. Hatcher, DDS, MSc, MRCD (c) Acting Associate Professor Nevertheless, rather than recommending diagnostic imag- Department of Oral and Maxillofacial Surgery ing as a routine procedure, the authors correctly point out University of California San Francisco that diagnostic imaging is best applied when there is a like- San Francisco, CA 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. XI Foreword Craniomandibular disorders are a group of disorders that atlas provides the reader with techniques that assist in the have their origin in the musculoskeletal structures of the collection of data needed to establish the proper diagnosis. masticatory system. They can present as complicated and This atlas brings together both new and old concepts that challenging problems. Almost all dentists encounter them should be considered when evaluating a patient for cranio- in their practices. In the early stages of the development of mandibular disorders. Some of the old techniques are well this field of study the dental profession felt that these dis- established and proven to be successful. Some of the newer orders were primarily a dental problem and could most techniques are insightful and intuitive, and will need to be often be resolved by dental procedures. As the study of further validated with scientific data. craniomandibular disorders evolved we began to appreciate the complexity and multifactorial nature that makes these In this atlas the authors introduce the term "manual func- disorders so difficult to manage. Some researchers even tional analysis" as a useful method of gaining additional suggested that these conditions are not a dental problem at information regarding mandibular function. They have all. Many clinicians, however, recognize that there can be a developed these techniques to more precisely evaluate the dental component with some craniomandibular disorders sources of pain and dysfunction in the craniomandibular and when this exists the dentists can offer a unique form of structures. Each technique is well illustrated using clinical management that is not provided by any other health pro- photographs, drawings and, in some instances, anatomical fessional. Dentists therefore need to understand when den- specimens. Elaborate, well thought out, algorithms also help tal therapy is useful for a craniomandibular disorder and the reader interpret the results of the mandibular function when it is not. This understanding is basic to selecting analysis techniques. Although these techniques are not fully proper treatment and ultimately achieving clinical success. documented, they are conservative, logical, and will likely This is the greatest challenge faced by all dentists who man- contribute to establishing the proper diagnosis. The authors age patients with craniomandibular disorders. also provide a wide variety of methods, techniques and instrumentations for the reader to consider. The purpose of this atlas is to bring together information that will help the practitioner better understand the pa- This atlas provides an excellent overview of the many tient's problem thereby allowing the establishment of the aspects that must be considered when evaluating a patient proper diagnosis. A proper diagnosis can only be deter- with a craniomandibular disorder. Appreciating the wealth mined after the practitioner listens carefully to the patient's of information presented in this atlas will certainly assist description of the problem and past experiences (the His- the dentist in gaining a more complete understanding of tory) followed by the collection of relative clinical data (the craniomandibular disorders. It will also guide the practi- Examination). The interpretation of the history and exami- tioner to the proper diagnosis. I am sure that the efforts of nation findings by the astute practitioner is fundamental in Dr. Bumann and Dr. Lotzmann will not only improve the establishing the proper diagnosis. Determining the proper skills of the dentists, but also improve the care of patients diagnosis is the most critical factor in selecting treatment suffering with craniomandibular disorders. My congratula- that will prove to be successful. In the complex field of tions to these authors for this fine work. craniomandibular disorders misdiagnosis is common and likely the foremost reason for treatment failure. Jeffrey P Okeson, DMD Professor and Director Dr. Alex Bumann and Dr. Ulrich Lotzmann have brought Orofacial Pain Center together a wealth of information that will help the practic- University of Kentucky College of Dentistry ing dentist interested in craniomandibular disorders. This Lexington, Kentucky, USA 40536-0297 XII Preface Medicine and dentistry are continuously evolving, due ertheless for disclosing different etiological factors such as largely to the influences and interactions of new methods, malocclusion, bruxism, and dysfunction. Thus the clinical technologies, and materials. Partly because of outdated test- and instrumented subdivisions of functional diagnostics ing requirements, our students can no longer adequately complement one another to create a meaningful whole. meet the increasing demands these changes have placed on a patient-oriented education. With limited classroom and In recent years the controversy over "occlusion versus psy- clinic time and an unfavorable ratio of teachers to students, che" as the primary etiological element has become more the complex interrelations within the area of dental func- heated and has led to polarization of opinions among teach- tional diagnosis and treatment planning are precisely the ers. But in the view of most practitioners, this seems to be type of subject matter that usually receives only perfunc- of little significance. In an actual clinical case one is dealing tory explanation and demonstration in dental school. Con- with an individualized search for causes, during which both sequently, recent dental school graduates are obliged to occlusal and psychological factors are considered. compensate for deficiencies of knowledge in all areas of dentistry through constant continuing education. And so Within the framework of a cause-oriented treatment of the primary purpose of this atlas is to provide the motivated functional disorders one must consider that while the elim- reader with detailed information in the field of dental func- ination of occlusal disturbances may represent a reduction tional diagnosis by means of sequences of illustrations of potential etiological factors, it may not necessarily lead to accompanied by related passages of text. The therapeutic the elimination of symptoms. The reason for this is that aspects are dealt with here only in general principles. Diag- there can be other etiological factors that lie outside the nosis-based treatment will be the subject of a future book. dentist's area of expertise. The method of clinical functional analysis described in Some readers may object to the fact that the chapters detail in this atlas is based largely on the orthopedic exam- "Mounting of Casts and Occlusal Analysis" and "Instru- ination techniques described earlier by Cyriax, Maitland, mented Analysis of Jaw Movements" do not reflect the mul- Mennell, Kalternborn, Wolff, and Frisch. Hansson and titude of articulators and registration systems currently coworkers were the first to promote the application of these available. We believe that for teaching purposes it makes techniques to the temporomandibular joint in the late sev- sense to present the procedural steps explained in these enties and early eighties. In cooperation with the physical chapters by using examples of an articulator and registra- therapist G. Groot Landeweer this knowledge was taken up tion system that have been commercially established for and developed further into a practical examination concept several years. This should not be interpreted as an endorse- during the late eighties. Because the clinical procedures dif- ment of these instruments over other precision systems for fer from those of classic functional analysis, the term "man- tracing and simulating mandibular movements. ual functional analysis" was introduced. Fall 2002 Axel Bumann Ulrich Lotzmann 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-