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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 concentrated on the mechanical aspects, largely ignoring the physiological 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 looking 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, regardless 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 University 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 beautify 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 comprehensive discourse on all essential components of the stomatognathic system. Skeletal, structural, and neuromuscular aspects are well illustrated, providing an excellent understanding of each part and the interrelationships, without 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 important, 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 1 and which is 1 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 manifestation 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 temporomandibular joint can come from condylar impingement on this neglected post-articular structure. Isberg showed graphically 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 exercises. 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 radiographic 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 abnormalities.

Diagnosis is the name of the game and its imperfect application 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 bibliography 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 scientific 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