Temporomandibular joint dysfunction: A practi-tioner’s guide

Annika IsbergIsis Medical Media Ltd., 59 St Aldate, Oxford, UK,

0X1 1ST; $200 (US); available July 2000; Webaddress, www.isismedical.com.

The dawn of the new millennium heralds great promise inthe arts and sciences. Observers are highly optimistic aboutcontinuing progress in our battle with disease. We are on thethreshold of conquering cancer, and even inherited abnormal-ities with genetic engineering. In dentistry, however, one ofthe gnawing problems that has engendered much controversyand multiple diagnostic errors and misapplied therapy in thepast is temporomandibular joint (TMJ) dysfunction. The lit-erature is replete with articles that purport to be authoritative,but are, in truth, anecdotal experiences, so often based onpoor diagnostic assessment and mechanical thinking.Gnathology, which analyzes condylar position, is based on anarbitrary articular emulation of a biologic phenomenon. LysleJohnston facetiously comments that “Gnathology is the sci-ence of how articulators chew.” There is much truth to thisobservation, as the dental profession is mesmerized by thelectures and writings of mechanically oriented gurus, whosemechanical reconstructions of the TMJ fail to take into con-sideration the multiple anatomic and physiologic variationsof the human TMJ. Controversy rules the roost.

What a breath of fresh air to read the manuscript of thislandmark volume by Annika Isberg! The timing is perfect! Ihave known the author for almost 20 years and have avidlyread every article she has written, after seeing her doctoraldissertation on cinefluorography of the TMJ at the Karolin-ska Institute. As one of the world’s authorities on radiologyof the TMJ, Professor Isberg has significantly broadened thediagnostic horizons, substituting reason for rote, and exhaus-tive studies for selected case reports. This monumental workis the culmination of all those years of research in this con-tentious field and is a “must” for all dentists and a ready ref-erence for medical confreres, physical therapists, and psy-chologists who deal with craniofacial pain. This is not an

esoteric discourse on the problems, but rather a practitioner’sguide—a patient-oriented work that is dominantly clinicaland immediately applicable to daily practice.

The volume is divided into 2 parts. Part I deals with theDiagnostic Scheme. Tragically, this has been the quicksand ofthe past, the “Achilles heel” (or joint!) of dental manipulationsand ill-considered therapies. Inadequate diagnostic studyleads to jumping to improper therapeutic conclusions. Thewoefully inadequate, 2-dimensional transcranial radiographsthat have been used as a diagnostic source by thousands ofdentists are totally inadequate and misleading in manypatients. Having been in the TMJ field since 1946 when Ijoined Jack Thompson, one of the pioneers in TMJ at North-western University, I have seen the passing parade of occlusalreconstructionists, as well as the leaders in the field, like HarrySicher, the great anatomist, with whom I worked on my PhDin 1950. I dissected 198 cadaver condyles and learned muchunder his tutelage. I learned methodology from Arne Björk,when he visited us for 3 months in 1953. Nevertheless, I mademy share of mistakes and diagnostic errors. It became clear tome that not only is a thorough knowledge of the anatomy andphysiology essential, but also an appreciation of the broadrange of normal structure and function and a comprehensivebackground of the potential departures from normal, ie, thepathologic manifestations. Clearly, the overly simplistic andmechanistic conclusions that dental occlusion was the basisfor most TMJ abnormalities was and is patently wrong.

Part I of the present volume is the answer to the practi-tioner’s prayer. It deals with sections on the normal TMJfunction, with pain from the TMJ region, TMJ sounds, andTMJ dysfunction. Based on seminal research and extensiveclinical experience, the evidence-based 4 chapters could be astand-alone volume. Surely, it is essential reading for all den-tists, whether they treat TMJ disorders or not. The multipleillustrations are a great help for the average reader. The textis documented with numerous studies by world-class author-ities. Dental students around the world would greatly benefitfrom this text, as well as dental practitioners.

Part II deals specifically with TMJ disorders. The 12chapters provide an exhaustive analysis and illustrations ofmultiple departures from the normal, based on the

American Journal of Orthodontics and Dentofacial Orthopedics/July 2000 122

DEPARTMENT OF REVIEWS AND ABSTRACTSEdited byAlex Jacobson, DMD, MS, PhDBirmingham, AlaAll inquiries regarding information on reviews and abstracts should be directedto the respective authors. For ordering books, contact your local bookstore or write directly to the publishers. Articles or books for review in this department should beaddressed to Dr Alex Jacobson, University of Alabama School of Dentistry,University Station/Birmingham, AL 35295

American Journal of Orthodontics and Dentofacial Orthopedics Department of Reviews and Abstracts 123Volume 118, Number 1

anatomic and physiologic sections in Part I. Unlike somany texts by multiple authors, where correlation is diffi-cult and repetition is common, this essentially single authorvolume is built block on block, with constant referral andinterrelationship of the various sections. It is magnificentlyorganized and presented, with straightforward text andunequalled illustrative material!

Chapter 5 deals with TMJ anatomy as related to TMJ dis-orders. Chapter 6 covers trauma. Chapter 7 is a magnificentdiscussion and illustration of internal derangement and diskdisplacement. So much has been written by so many authorson this subject, but none equal the authoritative well-illus-trated chapter here. It is another stand-alone section for stu-dents and practitioners alike.

Subsequent chapters on osteoarthrosis and osteoarthritis,hypermobility, infectious arthritis, inflammatory diseases, mis-cellaneous conditions, nerve entrapment, growth changes, andtumors cover the broad panoply of potential abnormalities.Chapter 16 is a dual author chapter on radiographic imaging byJan Ahlqvist and Annika Isberg. Again, this is a fantastic, pro-fusely illustrated section that is a “must read” for students andpractitioners alike. It discusses the various radiographicapproaches, showing advantages of each technique, ie, theinformation best displayed by each radiographic approach.

I congratulate all who had a part in this new millenniummasterpiece on the temporomandibular joint. The chal-lenges of reproducing histologic and radiologic images arevery real, but the production details rise to the level of theactual text. The book sets a standard that others will finddifficult to emulate. The book shows that even after 55 yearsin the field, TMG can be truly excited by a new “bible” inthe field of TMJ/TMD.

T. M. Graber, Editor-Emeritus

Premolar autotransplantation in orthodontic treat-ment: A clinical and radiographic long-term study

Hans Ulrik PaulsenKongl Carolinska Medico Chirurgiska Institutet,

Stockholm, 1999

Everything you have ever wanted to know about auto-transplantation is included in this easy-to-read publicationauthored by Hans Ulrik Paulsen. This joint effort of the ortho-dontic departments located at the Karolinska Institute (Stock-holm), the Copenhagen Municipal Dental Health Service,and the Institute of Odontology (Aarhus) provides a compre-hensive look at a clinical procedure long overlooked by cli-nicians throughout the dental profession.

The introduction includes a review of significant studiesinvolving the autotransplantation of premolars, beginningwith John Hunter (1728–1793) and including the most recent

of articles published in the European Journal of Orthodonticsand the American Journal of Orthodontics and DentofacialOrthopedics. The 96 papers referenced are convenientlygrouped together in a review of the materials and methodsused to achieve the desired treatment results. This review ofthe literature is divided into studies in animals, studies inhuman beings, and studies of eruption.

The general aim of this long-term research by Paulsenwas to assess the outcome of autotransplantation of premo-lars with respect to pulp and periodontal healing, root resorp-tion, and root development subsequent to orthodontic rota-tion. In the period from 1973 to 1985, a total of 440premolars were autotransplanted in 289 patients. J. O.Andreasen performed all transplantations at the Departmentof Oral Surgery and Oral Medicine, University Hospital inCopenhagen, Denmark. The surgical procedures used arecarefully described, as are the postoperative follow-up find-ings, including pulpal sensitivity, periodontal ligament heal-ing, tooth length, and statistical methods.

The results of this comprehensive study were publishedin a series of 7 articles beginning in 1990. Perhaps the mostinteresting portion of this book is the 6-page discussion ofthe clinical implications of this technique where the authornotes that “Autotransplantation opens up new avenues oftreatment as it enables problems in the dental arches to bemoved to regions where they may be managed more easilywith subsequent orthodontic treatment.” He continues withthe advice that “it has been shown that the stage of rootdevelopment at the time of grafting and the periodontal lig-ament condition are the most essential factors determiningsuccessful healing.” Paulsen concludes the discussion witha description of a new technique developed to visualizechanges that take place after premolar transplantation byradiographic color-coding.

Not to be neglected in the practical presentation ofresearch findings is a discussion of alternative treatmentmodalities. “In the choice between implants and autotrans-planted teeth, the skeletal age of the individual and thepresence of teeth with incomplete root formation for trans-plantation are therefore decisive.” Clearly, autotransplanta-tion of immature premolars is a viable method for restoringedentulous areas in patients in whom alveolar growth is notyet complete. The method provides the potential to replacea missing tooth with a natural tooth rather than a prosthe-sis or osseointegrated implant. “Autotransplantation,”notes Paulsen, “if applied with knowledge of the predictiveoutcomes, is a method that supplements and enhancesorthodontic treatment.”

I heartily recommend the reading of this book as a meansof broadening your perspectives of orthodontic treatment. Itwill add another dimension to your treatment planning process.

David L. Turpin, Editor