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 bumann@usc.edu 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 Jamesmah@usc.edu 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. Axel Bumann Ulrich Lotzmann Fall 2002 [...]... Neuritic pain Traumatic neuralgia Atypical tooth pain Postherapeutic neuralgia Herpes zoster Peripheral neuritis Neurovascular pain Vascular pain Episodic pain Paroxysmal neuralgia Glandular, ocular, and auricular pain Pulpaf pain Viscera! pain Visceral mucosal pain Physical pain Periodontal pain Connectivetissue pain Mucogingival pain Ostealgia m6 periosteal pain Cutaneous pain jyjpaln Deep pain — Migraine... with aura Migraine without aura Cluster headache Paroxysmal unilateral headache Neurovascular variants Arteritis pain Carotidynia joint surface pain Retrodiscal palm Capsule pain Ligament pain Arthritic pmn Myofascial pain Myositis Muscle spasm Muscle shortening Primary Dental Evaluation The dental examination is the conditio sine qua non for arriving at a correct diagnosis and effective dental treatment... middle and central third of the disk and the cesses have united at the midline to complete the separa- lower belly inserts at the condyle (Merida-Velasco et al tion of the oral and nasal cavities At the same time, bony 1993) At a CRL of 95 mm all structures of the temporoanlagen of the maxilla form in the region of the future mandibular joint can be clearly identified and thereafter infraorbital foramina... have made the role of the dentist in diagnosing and treating pain in the head and neck region increasingly obscure rather than more clear In the academic debate concerning the etiology—predominantly psychological factors versus predominantly occlusal factors -the practitioner facing the problem of treating a patient has been largely ignored The argument of multicausal genesis was previously taken as an... Temporomandibular Joints 217 Attaching the Anatomical Transfer Bow 220 Mounting the Maxillary Cast using the Anatomical Transfer Bow 222 Mounting the Maxillary Cast using a Transfer Stand 223 Mounting the Maxillary Cast following Axiography 226 Mounting the Mandibular Cast 228 Axiosplit System 230 Split-Cast Control of the Cast Mounting Table of Contents 231 Check-Bite for Setting the Articulator Joints... usually result in an increase of the load and restriction of movement Adaptations of surrounding structures are always oriented in the direction of the loading vector and therefore impede treatment Within the framework of an interdisciplinary treatment, it is the duty of the physical therapist to eliminate any adaptive conditions in the surrounding structures through manual therapy and measures to increase... The Role of Dentistry in Craniofacial Pain 54 55 56 58 60 61 62 7 Primary Dental Evaluation 8 Findings in the Teeth and Mucous Membrane 10 Overview of Dental Examination Techniques 11 Anatomy of the Masticatory System 12 Embryology of the Temporomandibular Joint and the Muscles of Mastication 14 Development of the Upper and Lower Joint Spaces 16 Glenoid Fossa and Articular Protuberance 18 Mandibular... Functional Analysis Patient History Positioning the Patient Manual Fixation of the Head Active Movements and Passive Jaw Opening with Evaluation of the Endfeel Differential Diagnosis of Restricted Movement Examination of the Joint Surfaces Manifestations of Joint Surface Changes Conducting the Clinical Joint Surface Tests Examination of the Joint Capsule and Ligaments Clinical Significance of Compressions in. .. At this time there is no practical alternative available to test for loading vectors and evidence of adaptations in the masticatory system Because of their multiplicity and variety of origins, the influences can be only partially clarified within a dental practice For this the dentist has at his/her disposal the techniques of clinical occlusal analysis and instrumented functional analysis (in the articulator)... loading vector)? • Is the loading vector related to the occlusion? • Can the occlusion-related portion of the total loading vec tor be reduced with reasonable effort and expense? • Would symptomatic treatment in the dental office be rea sonable? Superficial pain Sympathetic pain * Continuous pain Neuropathic pain Deafferentation pain Manual functional analysis Dental primary diagnosis Other disciplines . 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. Evaluating the Axiograms and Programming the 318 Definitive Alteration of the Static Occlusion Articulator 322 Examination Methods and Their Therapeutic