52

"The Internotionol Journal of Periodontics and Restorotive Dentistry" 6/1985


The Optimum Temporo-
mandioular Joint Condyle
Position in Clinical Practice*
Chorles McNeill. D.D.S."
Six questions concerning the op-
timum posifion of fhe femporoman-
dibular joint condyle will be explored
from a clinical standpoint. They are:
Where Is the optimum TMJ condyle
position? How is it determined? How
is it achieved? Whaf constitutes TMJ
dysfunction relative to candyie posi-
tion? How is it freated (Fig. 1)?
The temporomandibular joint con-
sists of concave and convex surfaces
as do all diarthrodial joints in the
body. The opposing convex osseous
surfaces ore separated by a bicon-
cave articular disk. The disk acts in
reality as a third bone in this joint, al-
lowing for an upper articulation and
a lower articulation' (Fig. 2). This al-
* Presenfed fo ffie Nevi^porf Harbor
Academy of Dentisfr/, April 1984.
*• Associafe Ciinicai Professor, Depart-
ment of Restorative Dentisfry, Director of
Posf-Groduate Confinuing Education
Articulation and Occlusion Study
Groups, and Director of ffie Craniofacial
Poin-TMJ Clinic, University of California,
Scfiool of Dentisfr/, Son Francisco,
Colifornia 94143
Reprint requests to 1802 San Miguel
Drive, Wolnut Creek, CA. 94596 (Dr.
McNeilll.
"The Internotional Journol of Periodontics ond Restorotive Dentistry" 6/1985
53
lows the craniomandibular articula-
tion fo be a bilaterally gliding hinge
joint sysfem supported by ligaments
and manipulated by the muscula-
ture. The functioning part of the fossa
is the posterior slope of fhe emi-
nence, nof in fhe depth of fhe fossa
(Fig. 3). The anterior superior aspect
of fhe condyle wifh ifs disk fifs againsf
fhe posferior slope of fhe eminence.^
The roof of the fossa is thin and nof
architecturally designed fa withstand
loading, whereas the buttress of
bone af fhe eminence is suited fo
loading (Fig. 4). Histologically the
bone frabeculation patterns in fhe
condyle and eminence support fhe
concept of an anferior superior po-
sifion of fhe condyle.
The femporomandibular ligament is
a restraining or limiting structure to
the joint, allowing for a posterior bor-
der pasifion. It becomes a useful
anatomical structure when perform-
ing certain clinical procedures fhat
are replicable (Figs. 5 and 6). In the
healfhy joint fhis sfrucfure can be
utilized to record a border position.
In fact it can be a functional end
paint of closure for patients that have
healthy functioning temporoman-
dibular joints.''"^ Many articulations
function in a border position momen-
tarily, far example, the elbow when
throwing a baseball or carrying a
heavy suitcase.
The articular surfaces are not lined
with synovial fissue. They are avas-
cular and non-Innervated. They also
have a thick layer of connecfive tis-
sue, as shown in Fig. 7. Histologie
specimens show that on the anterior
superior aspecf of the condyle and
on fhe posferior slope of the emi-
nence there is a thicker layer of fi-
brous connective (arficulafing) tissue
(Fig. 8). Conversely, the nonar-
54
Questions
1. Where is It?
2. How is This Determined?
3. How is This Achieved?
4. What Constitutes Dysfunction?
5. How is Dysfunction Diagnosed?
6. How is Dysfunction Treated?
ticulating areas within the joint are in-
nervated, are vascularized and have
a synovial lining.'^ These areas in-
clude the periphery of the disk as
well as anteriorly or posteriorly to the
articular portion of the disk. The col-
lateral ligaments, usually attached
above the attachment of the capsule,
are highly innervated, vascularized,
and covered with synovial lining.
The stability of the disk is provided by
the lateral pterygoid muscle, the
upper belly attaching into the cap-
"The Internationol Journol af Periodontics and Restorotive Dentistry" 6/1985
sule as well as into the neck of the
condyie, and the attachment of the
right and left collateral ligaments
(Figs. 7 and 8). The relationship of
the disk to the condyie is controlled
by these structures. It must be re-
membered that disks come in vary-
ing sizes and shapes (Figs. 9 and 10|.
Disks can undergo remodeling,
hyperplastic, and/or metoplostic
changes throughout life. When the
condyie is seated by muscle action
across the joint, it cannot be seated
Fig. 1 Questions regording fhe optimum position
of fhe temporomondibutor joinf condyte.
any further superiorly than the thick-
ness of the disk in a healthy joint. The
articular disk serves as a shock ab-
sorber, it helps to reduce wear, and
it fills the incongruous spaces be-
tween the condyie and the posterior
slope of the eminence^ (Fig. 11). The
osseous irregularities of these struc-
tures are compensated for by the
disk and thus help to stabilize the
joint.
 55

Fig. 2 The convex condyle and convex articular eminence articulat-

ing with the biconcave disk.

Fig. 3 The functioning areo of the fossa is the heavy buttress of

bone of the eminence represented in blue in this illustration.

Fig. 4 in fhe dried skull, the roof of the fossa is shown to be very
thin.

"The internotionol Journal of Periodontics and Restorotive Dentistr/" 6/1985

56

. 5 and 6 The heavy, dense temporomondibulor ligament

ch restrains or limits posterior movement of the condyle.

Temporomandibular Ligament figure 6

figs. 7 and 8 The connective tissue is shown to be thicker on the

articular areas of the candyle and eminence both in the drawing and
in the autoposy specimen. Note that the upper belly ot lateral
pterygoid attaches into the neck al the condyle os well as the disk.
These figures also show the relationship afthe superior belly of the
lateral pterygoid and the posterior attochment or bilaminar zone of
the disk.

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 57

Figure 8

Figs. 9 and 10 Particular disks can vary in size and shape, as

shown in these two examples. The variation in thicknesses of the disk
- all of which con be normal - will oppear as varying degrees of
superior jaint space radiographicolly.

Figure 10

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58
The Optimum Position of fhe Condyle
The optimum condylar posifion is the
structural or anatomical position (in a
healthy joint) of the condyle with ifs
biconcave disk braced against the
eminence in on anferior superior di-
rection (Fig. 12). Ideally, an optimum
condylar disk position occurs wifh
optimum integrated muscle activity
as well as with maximum occlusal
stability (Fig. 13).
Clinicians do nof determine the op-
timum posifion of fhe condyle in the
healthy joint. Certainly x-rays do nof.
The physiology of fhe stomatog-
nathic sysfem determines if.® The
muscle action wifh ligamentous sup-
port or resfriction determines the op-
timum posifion of fhe condyle, and
the dentist has liftle, if any, confrol
over It in mosf patients. Neurologi-
cally, fhe input from fhe feefh, fhe
muscles, the capsule, and also from
fhe CNS determine the optimum
posifion of the condyle. Sicher's Law
states that, in all movements of an
"The Internotional Journal af Periadontics and Restorotive Dentiistry" 6/1985
Fig. J1 The orticulor disk as seen from a frontal vievi
articulation, fhe articulating bones
are kept in sharp contact by the mus-
cles thaf move fhe articulation (Fig.
14). As fhe condyle-disk assembly
moves, fhe muscles that act across
fhe joint confrol how the condyle is
going fo be related with its disk
against the posferior slope of fhe
eminence. DeBrul has also stated
fhat a well integrated neuromuscular
sysfem attempts fo maintain confacf
across fhis joinf as if does in oil
joints.'
On opening the arficular disk rotates
posteriorly as the condyle comes for-
ward. As fhe condyle goes back-
ward on closing, fhe disk rotates an-
teriorly (Fig. 15). There is a changing
relationship of the surface of the con-
dyle to the inferior biconcave surface
ot the disk and the superior bicon-
cave aspect of this disk to the convex
surfoce of the articular eminence.
The relationship of the disk fo the
condyle changes as muscle activity
moinfalns sharp contacf of fhe bones
of fhe articulation. At rest if is main-
fained fhrough muscle spindle reflex
activity, and during function it is
maintained by fhe muscles that pro-
vide the movement. During swallow-
ing, chewing, speaking, and all other
movemenfs the muscle activity main-
tains contact of the condyle wifh ifs
disk against fhe articular eminence.
Most pafients have the ability to
adapt fo structural irregularities or
imperfections. Neuromuscular adap-
fafions usually come first and fhen
osseous changes can occur, particu-
larly if fhere is o prolonged, chronic
neuromuscular adaptation. This, of
course, is modified by the patient's
ability fo cape wifh stress. A number
of patients can adapt fo occlusions
that are ofher fhan ideal and wifh
condylar positions that are other
than optimum. The histologisfs tell us
that fhe fibrous connective fissue disk
has the propensity to undergo
change and adapt to some new
equilibrium.'° Fig. 16 shows a dis-
placed disk thot appears fo be un-
dergoing o change in the attachment
 59

Optimum Condyiar Position

The Physiologic Position of the Condyie With
Its Biconcave Disk Braced Against the
Eminence in an Anterior, Superior Direction.

Fig. 12 The Optimum condylor position is determined sfrucfurolly.

Structurol Position

• Optimum Condyle/Disk Position

• Optimum Integrated Muscle Activity
• Maximal Ocdusal Stability

Möller

Fig. 13 Criteria tor on ideol occlusion.

Sicher's Law:
In All Movements of an Articulation, the
Articulating Bones Are Kept in Sharp Contact
by the Muscles That Move The Articulation.

Fig. 14 Sicher's Law.

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60

Rotation Closed Rest

Fig. 15 The candyte and disk rotóte in different
directions during translotion.

Fig. 16 Specimen depicting on onteriorly displaced disk that oppears to hove un-
dergone metaplostic chonge af the junction of the thick posterior band or rim and
the posterior attachment or bilominor zone (from Solberg and Hannson).

"The International Journal of Periodontics and Restorative Dentistry" 6/1985


oreo of the thick posterior band and
the bilaminar zone or posterior liga-
ment (Fig. 16). The previously vascu-
lar, innervated portion now has be-
come avascular and noninnervoted.
It can become articulating tissue, not
as an optimum joint with optimum
function, but pain free and with rela-
tively normal function. This concept is
important relative to definitive treat-
ment planning. Understanding that
as clinicians we do not necessarily
have to recapture even/ disk either
surgically or otherwise is important.
There are a large number of patients
that can be successfully managed off
the disk.
Determining the Optimum Condylar
Position
The optimum condylar position is de-
termined physiologically. It is the
physiologic position of the condyle
with its attached biconcave disk
against the eminence in the direction
of the muscle action across that joint
(Fig. 17). The patient's own function,
the physiology of the stomotognathic
system, will determine the position in
a healthy, normal functioning joint
hence the term "physiologic condy-
lar position."
Achieving the Optimum Condylar
Position
In healthy functioning joints the pa-
tients themselves achieve optimum
condylar position for us unless we as
clinicians confuse them. If there is
dysfunction or pathology, however, it
can become difficult. The condyle
disk position is determined by muscle
action until movement into maximum
intercuspation (Fig. 18). The teeth
then influence condylar position.
Centric relationship has traditionally
been defined as the relationship of
the mandible to the maxilla when the
condyles are in the most posterior
superior unstrained positions in the
glenoid fossae from which lateral
movements can be made at any de-
gree of jaw separation." Stated
more simply, the centric relation jaw
position is the relationship when the
mandible is in the most posterior
hinge axis border position to the
cranium.^^ Thus it is on the rotational
arch of closure. As has been pointed
out rather clearly, this is an abnormal
movement and occurs only when the
mandible is being manipulated by
the dentist; in fact, patients can actu-
ally be trained to open on the hinge
axis. It is not normal movement. Any
normal functional movement has a
certoin amount of translation when
the patient opens. It is a border po-
sition that is used to relate casts.'''"'^
The craniomandibular articulation is
the only joint system with a rigid end
point of dosure.^'^ As a patient is
functioning in an intraborder posi-
tion, the teeth come together at a
rigid end point or border position.
The dentist can retrude the mandible
into the hinge rotation and seat the
condyles at the same time. The state
of the art clinically is to aid the action
of the elevator muscles, bracing the
condyles against the posterior slope
of the eminentia. Thus there is a rota-
tion of the mandible which seats the
condyles in an anterior superior po-
sition as the mandible is simultane-
ously retruded (Fig. 19). Dowson's
technique of achieving this clinically
is certainly one of the most repeat-
able types of manipulations.'^
Joint stability is maximal as occlusion
occurs. Joint stability is provided by
a bilaterally symmetrical occlusion.
The occlusion of the teeth absorbs
"The international Journal of Periodantics ond Restorative Dentistry" 6/1985
61
most of the force, in part relieving the
joints and muscles of maintaining
stobility. The dentist should provide
the patient with structural and func-
tional stability between the occlusion
and joints as well as with neuromus-
cular harmony. Centric jaw relation is
reproducible. Reproducibility does
not necessarily make it valid phys-
iologically, even though it may be
convenient. It is acceptable phys-
iologically, however, as the end point
of closure as measured in milli-
seconds. It is stable orthopedically.
The mandibular muscles tend to seat
the condyles back and up in the
fossa on swallowing and at the end
of the chewing stroke on the working
side'^ (Fig. 20). Patients function in
centric relation if it is available, that
is, if there are no interferences pre-
venting the closure. After involved re-
storative, prosthodontic, orthodontic
and/or orthognathic treatment pa-
tients unknowingly utilize the posi-
tion.
The stomatognathic system is in a
constant state of flux and the fact that
the patient develops a new man-
dibular position of a few tenths of a
millimeter as measured in the con-
dyle with time does not invalidate the
concept of centric relation. It simply
helps to prove that the stomatog-
nathic system is a dynamic system.
Dentists are not treating articulators;
they ore treating human beings. De-
pending upon the complexity of the
treatment involved, they must use
some sort of anatomical aid, that is a
semiadjustable or a fully adjustable
articulator. They would the like to
relate an upper cast to the articulator
as the teeth are related to the pa-
tient's skull and, utilizing some sort of
recording media, try to relate the
lower cast in the same spacial
62

Optimum Condylar Position

The Physiologic Positian af the Candyle
With Its Attached Biconcave Disk Against
the Eminence in the Directian af
Muscle Actian Acrass the Jaint.

Fig. 17 The optin condylar position is determined physiologi-

colly.

Optimum Condylar Position

The Mast Anteriar Superiar Physialagic
Articulatian af the Candyle Disk Camplex
With the Eminence in Maximum
Intercuspatian.

Fig. 18 The condylor position is determined by muscle action until

maximum intercuspotion accurs.

Fig. 19 As the mandible is retruded by the clinicion, rotation of the

mandible should allaw the condyles to seat in an anterior superior
position against the posterior slope of the eminentio.

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 63

Condyiar Seating
Muscle Action During Closing Pulls Condyle
Disk Complex Upward and Backward
I Along Slippery Incline

Fig. 20 The mandibulor muscles tend ta seat the candyles pos-

teriorly up the slippery incline of the eminence during swallowing.

maxillo-mandibular relafionship as is An artificially stimulated neuromus-

found clinically. cular response will not necessarily
Many patients have constantly give a functionally correct position.
changing muscle acitivify as a resulf, Some questions and problems may
in parf, of fatigue, improper posfure, be answered by more sophisticated
or parafuncfional habit patterns. In electronic equipment, which will be
these situations, or where fhere Is avoilable within fhe next ten years. In
iaxify or looseness in the joint, den- summary, I believe fhat the optimum
tists have difficulty stabilizing oc- condylar posifion is achieved during
clusal relationship and achieving the function. It is a funcfional position.
optimum condylar position. Some of It is the most anterior superior
fhese situations may require an area physiologic position of fhe condyle
of "freedom" in the occlusion. If is disk complex wifh fhe eminence in
a more difficult occlusion to maximum intercuspation.
deal wifh clinically because as the
patient goes info and leaves numer-
ous occlusal positions, lateral inter-
ferences in fheir posferior teeth, par-
ticularly contralateral interferences,
are more difficult to prevenf.
Myocentric, another way to relafe
the jaws, seems fo be one of the least
reproducible ways to relote the lower
jaw to the cranium. A number of
studies have reported thaf its loca-
tion is anterior to the acquired centric
or fhe intercuspal position.'^^' It is
certainly anterior to centric relation.

"The International Jaurnal of Periodontics and Restorolive Dentistry" 6/1985

64

TMJ (Craniomandibular) Disorders

Organic Origin
Articular
Nonarticular
Nonorganic Origin
Nonorganic With Secondary
Organic Changes

Fig. 21 Ctassiticafion of craniomoridibulor disorders.

Fig. 22 Illustration of on anteriorly displaced disk.

TMS Dysfunctions
As reported by the American
Academy of Craniomandibular Dis-
orders in the Journol of Prosthetic
Dentistry, temporomandibuiar or
craniomandibular disorders are clas-
sified into categories of organic (true
physical problems) and nonorganic
(psychological) problems. Further,
unfortunately, when a psychological,
or nonorganic, problem continues
for a long enough period of time, it
can cause secondary organic
changes (Fig. 21 ). Organic problems
can be articular problems such as in-
ternal derangements or pathological
processes (for example osteoar-
thritis) or they can be non- or periar-
ticular conditions seen as muscle
and/or occlusal problems.
There can be many changes in the
optimum condylar position as o re-
sult of articular problems that relate
to internal derangements. Displaced
disks with their articulating portion
anterior and medial to the condyie
cause the condyie to articulate on
the nonorticulating portion (pos-
terior attachment) of the disk (Fig.
22). During surgery the disk does not
always appear normal; rather, it can
be folded, wrinkled, or macerated. A
closed lock condition occurs when it
is impossible to reduce the articulat-
ing portion of the disk (Figs. 23 and
24). This anterior mass of soft tissue
prevents the normal range of transla-
tion of the condyie. Many times there

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 65

Fig. 23 Illustration of o closed lock (nonreducing disploced disk).

Fig. 24 Specimen showing a large mass of soft tissue preventing

normal tronslation of the condyle.

Fig. 25 The perforated articular disk is compromised to fhe point

that "recapture" is most likely impossible.

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66

Fig. 26 Lo s af vertical dimension from a lack of posterior support

ond bruxisi

fig. 27 A loss of vertical dimension can couse a superior campres-

sion in the joint and create o tendency for an anteriorly displaced
disk.

already have been fears, perfora-
tions, and other types of structural
changes within the disk. With o se-
verely stretched or torn posterior at-
tachment, it will most likely be impos-
sible to "recapture" the disk (Fig.
25). If able to perform o repair, the
surgeon will never recreate o normal
joint, just as the orthopedic surgeon
cannot recreate a normal knee. Only
if nonsurgical approaches are un-
successful in controlling poin or if se-
vere limitation in movement remains
should surgical management be
considered.
Nonarticular conditions include
these occlusal conditions: loss of
posterior support, a "distal thrust" of
fhe mandible causing a compression
posteriorly in the joint, ond posterior
supra-contacts or fulcrums causing a
distraction in the joint. A loss of verti-
cal support in the occlusion can
cause a compression in the joints.
When this occurs, with an increased
hyperactivity of the elevator muscles.
even more loading occurs, and this
tends to push the disk anteriorly in
some patients (Figs. 26 and 27). Thus
the beginning of a displaced disk
may result from this occlusal (struc-
tural) problem. Also, with increased
parafunctional activity the elevator
muscles can force the condyles
superiorly, and the lateral pterygoids
can chonge the relationship of the
disk, resulting in a tendency to de-
velop an anterior displaced disk.
The clinical support for the belief that

"The Internationoi Journal af Penodontics and Restorotive Dentistn/" 6/1985


there is a muscular component to
displaced disks is that, with the use of
gnathological appliances or other
types of routine splint therapy, inter-
nal derangement symptoms are re-
lieved. Along with a reduction in the
hyperactivity of muscles, clicking
many times decreases and even
sometimes is eliminated. Further-
more, some patients that clinically
have clicking can be treated simply
with biofeedback relaxation tech-
niques and the clicking will diminish.
The reduction of hyperactivity of the
muscles allows for a better relation-
ship of the disk and the condyle. Not
all internal derangements by any
means are muscle mediated. Many
are a combination of problems and
need articular treatment as well as
muscular treatment.^"
Unfortunately, too often in dentistry
we iatrogenically create overloading
or compression in the TMJ.^'^ Over
carving or over polishing restorations
causes a loss of centric contacts and
thus creates interferences in lateral,
contralateral, and protrusive man-
dibular movements. This can also
occur through the over equilibration
of teeth, especially since equilibra-
tion has come into prominence in the
last 10 to 20 years. Removable pros-
thodontic appliances, poorly fabri-
cated or poorly maintained, can
cause loss of vertical dimension, put-
ting more demands on the joint.
Some patients can adapt to the
above conditions; those who cannot
develop dysfunction or true disease.
Another acclusal condition is referred
to as "distal thrust" of the mandi-
ble^^ (Figs. 28 and 29). A Class II di-
vision 2 skeletal and dental discre-
pancy can cause a "distal thrust." In
these cases the condyles are raflexly
guided posteriorly in the fossae. This
67
creates a potential pathologic pos-
terior compression in the joint. A dis-
placed disk or other internal de-
rangement problems can develop.
The other common occlusal condi-
tion effecting the joint is the posterior
fulcrum related distraction of fhe
condyle^^ (Figs. 30 and 31 ). Mounted
casts from a centric relation in-
terocclusal record on an Arcon ar-
ticulator allow the condylar ball to
seat in the articular housing in centric
relation. When the lower member of
the articulator is remaved into the
maximum intercuspated position of
the casts, the condylar balls are
forced down and back (Fig. 32). A
Hanau or other fixed condylar path
articulator will not demonstrate this
distraction. A comparison of this clin-
ical test to a radiographie image of
the same patient verifies that the
candyle is distracted away from the
posterior slope of the eminence (Fig.
33). This does not happen clinically
to the same magnitude as is de-
picted mechanically on the ar-
ticulator. Rather, what happens clini-
cally is an effort biomechanically to
maintain the contact of the condyle-
disk assembly against the articulat-
ing surface of the eminence. Muscle
activity increases, preventing a dis-
traction caused by the occlusal ful-
crum (posterior interference) (Fig.
34). Condylar distraction can occur
with a bolus of food on the working
side or with on interference or supra-
contact in the molar ^^
"The Internotional Journal of Periodontics ond Restorotive Dentistry" 6/1985
68

Fig. 28 Class II division 2 molocclusion creoting o "distal thrust " of

the mandible.

Fig. 29 Illustration of a posterior compression in the ¡oint fram a

"distol thrust" of the mandible.

Fig. 30 Illustration of the optimum seoted position of the condyle.

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 69

Fig. 31 itlustration of a condylar distraction due to a motar supra-

cantact of fulcrum.

Fig. 32 Condytor botl ot ariicutator distracted by posterior occlusol

fulcrums on the mounted costs as the lower member of fhe or-
ficutator is moved info maximum intercuspofion.

Fig. 33 Radiogroph of o condyte being distrocfed by posferior

supracontocts in second molor region.

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70
Distraction
(power stroke
ogainst
resistance
Fig. 34 During distraction the lateral pterygoid muscle reflexly changes fhe disk-condyle relationship attempting to mointain contact af the articulation structures.
Diagnosis
Dysfunction is diagnosed by means
of diagnostic tests, good base line
records, and a good data base,^'"-^^
The following base line records
should normally be mode for pa-
tients suspected of having TMJ dys-
function; medical and dental his-
tories, clinical examination, radio-
graphic examination of the teeth and
TMJ, and diagnostic casts. In addi-
tion, newer techniques of soft tissue
imaging, arthrography, ond man-
dibular motion data can prove to be
of important diagnostic value,
A thorough history may be the most
important means of diagnosing TMJ
"The international Journal of Periodontics and Restorative Dentistry" 6/1985
Disk Rotation
(I muscle activity)
disorders, and the dentist must be
willing to spend the necessary time to
make a comprehensive history. This
may require an hour or more of in-
depth questioning and probing,
A thorough ciinicai examination
should include the TMJ region and
mandibular function, the muscles of
the head and neck, and the orol cav-
ity as well as an analysis of the occlu-
sion. This analysis should be per-
formed intraorally ond, when possi-
ble, with properly mounted cosfs,
Aiso, fhe newer electronic mandibu-
lor movement recording techniques
may well prove to be of invaluable
diagnostic importance,
Radiographic examination can in-
clude transcranial radiographs, to-
mograms, corrected cephalometric
tomography, nuclear scanning, CAT
scanning, and magnetic resonance
imoging. The most typical film series
is the transcranial TMJ survey, which
can be performed using x-ray equip-
ment presently found in dental of-
fices,•'^^^ Transcranial films, how-
ever, have some limitations; the dis-
advantages include distortion and
lack of reproducibility.
There are presently more occurate
techniques than transcranioi x-rays
of fhe temporomondibular ¡oint.
There are tomographic units on the
market which take a corrected
cepholmetric tomogram, correcting

for the angulation of the long axis
of the condyle.•'^"^^ In corrected
cephalometric tomography the
radiographie source moves in one
direction and the film in the opposite
direction. The technician can pre-
determine the depth of cut. By taking
the x-ray along the long axis of the
condyle a more accurate relation-
ship of the condyle to eminence is
achieved. And because of the
cephalometric headholder, and the
ability to reposition the patient to the
same measurements, tomograms
are reproducible.
There are other diagnostic imoging
tests that can be used today.
Dynamic soft tissue information re-
garding the condition of the disk is
availoble utilizing arthrographic
techniques and floroscopy and more
recently utilizing C. T. Cine-scan-
ning.'^'"^^ Magnetic resonance imag-
ing can image the soft tissues without
any radiation. Computerized en-
hancement of radiographs is a new
way to look at two-dimensional x-
rays in o three-dimensional profile.
Besides the sophisticated tests from
outside sources, in-office the dentist
con use EMG muscle testing,
psychological testing, and new
sophisticated electronic jaw move-
ment recording equipment. There are
a number of diagnostic tests includ-
ing diagnostic injections, measure-
ment of masseteric silent periods with
EMG equipment, and the use of
diagnostic oppliances. This data
base is established in an attempt to
make o specific working diagnosis.
No longer can the dentist have a
single treatment concept and fit all
patients into the concept.
71
Treatment
Treatment really means manage-
ment (Fig. 35). Treatment of TMJ dys-
function is difficult at best. There are
not necessarily cures. The dentist
must try to maintain or to improve
signs, but he may never regain a nor-
mal, healthy joint for the patient. It is
the dentist's responsibility to educate
and assure the patient. The dentist
attempts to reduce the hyperactivity
in the muscles and stabilize the po-
sition of the condyles with treatment.
To achieve this, many times the pa-
tient must learn to control parafunction-
al activity. Finally, in some patients,
the dentist has to provide long-term
occlusal stability (Fig. 36). The treat-
ment usually is multi-disciplinary.
Modalities are used that aid the re-
pair and regeneration of the tissues
as well as modify the behavior af the
individual. If needed, the dentist may
have to provide orthopedic stobilizo-
tion with definitive occlusal therapy
(Fig. 37).
The results of treating 553 private
practice patients treated with non-
surgical modalities over a 2V2 year
period between 1980 and 1983 were
published in 1984.'"' The patients,
primarily referred from other prac-
ticing dentists and physicians, had a
wide variation in signs and
symptoms. However, they all exhi-
bited at least one or more of the car-
dinal signs or symptams of pain on
palpation lateral to the tem-
poromandibular ¡oint and/or mus-"
des of mastication, limited range of
mandibular movement and/or joint
sounds. The patients were treoted
with a combination of modalities in-
duding orthopedic appliance (splint)
therapy, EMG biofeedbock, physical
therapy, medications and/or
"The internotional Journal af Periodantics and Restorative Dentistry" 6/1985
 72

Treatment = Management
• Alleviate, Not Cure Symptoms
• Maintain Or Improve Signs

Fig. 35 Treatn

Treatment Goals
Educate And Assure Patient
i Hyperactivity Of Muscles
Stabilize Pasitian Of Candyles
i Parafunctianal Activity
Stabilize Occlusian, p.r.n.

Fig. 36 Treotment goals for the craniomandibular patient.

Treatment Regimen

Behaviar Repair &

Madificatians Regeneratian

Fig. 37 Following the establishment of a data base, treatment con-

sists of modalities that aid the recuperative powers of the patient
and/or that modify behavior. Stabilization of the occlusion may be
necessory for long-term treotment results.

"The International Journal of Periodontics end Restorotive Dentistry" 6/1985

fig. 38 The combination of treatment modalities 73
utilized in the clinicol study.

Treatment Modality
553 TMJ Patients, 1980-3

463 (84%)
500 456 (82%)

400

300
181

Ii
(33%)
200
56
(10%) 15

m
100

Splint Med. Inject.

BFB
P.T.

therapeutic muscle injections (Fig. fhis sfudy, there was an overall 94% tions of fheir symptoms after chewing
38). They were all placed on a 3, 6, improvement in sympfoms and a 6% hard foods or after an increase in
and 12 month recall program for as- lack of improvement. Only 12 of fhe tension due fo some stressful
patients who did not improve were episode. They had been trained dur-
sessment of fhe clinical results. Pa-
freafed surgically. To date, 11 of ing treatmenf fo understand the signs
fients without at least one recall ap-
fhose 12 pafienfs hove progressed and symptoms and could usually re-
pointment assessment were nof In-
satisfactorily. verse fheir renewed complaints
cluded in the tabulation of the resulfs.
Even though in fhe clinical studies themselves. The patients who had no
All patients were diagnosed, treated,
there was a significant group of pa- improvement or who were worse
and assessed by fhe same dentist
fients with partial improvement were referred for surgical carrection
(Figs. 39 and 40).
(51%), the overall symptom im- or for further medical consultation.
The patient progress was as follows:
provement was encouraging (94%). These results would compare favor-
43%, or 237 patients, reported total
The group that reported partial im- ably wifh fhe management of other
remission of their symptoms; 51 %, ar
provement should nof be considered orthopedic management problems
284 patients, reported partial remis-
as a failure. This group demon- in medicine.
sion; 5%, or 27 patients, were the
strated slight and even insignificant
same; and 1 %, or 5 patients, re-
signs of minor episodic exacerba-
ported they were worse (Fig. 40). In

"The Internotiono l Journol of Periodontics and Restoralive Dentistry" 6/1985

 Length of Treatment
553 TMJ Patients, 1980-3

500 —

400 —

300 205

123 107 ^^^^_/ 118

200 - (23%)
(19%) ^ ^ ^ ^ (21%)

100

^P^ 3 Mos.
6 Mos. 1 Yr. 2Yrs.

Fig. 39 iengfh of treotmenf ot the patients in fhe ctinicot sfudy.

"The Internotional Journal of Periodontics and Restorative Dentistry" 6/1985

 75

Patient Progress
553 TMJ Patients, 1980-3

•1
500

400
284
237 (51%)
300 (43%)

200 —

27
100 (5%) 5
(1%)

/ /

Total Same Worse

Remission
ParTial
Remission
Fig. 40 Tabulation of the results of patient progrt

"The International Journal of Periodontics and Restorative Dentislry" 6/1985

i
76
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