Prosthetic

disorders
Jens

C. Tiirp,

rehabilitation
Dr

Med

Dent,

and

in patients
JSrg

R.

Strub,

Prof

with temporomandibular
Dr.

Med

Dentb

School of Dentistry, University of Michigan, Ann Arbor, Mich., and School of Dentistry,
Albert Ludwigs University, Freiburg, Germany
Decision-making
in prosthetic
dentistry
and in the management
of patients
suffering
from
temporomandibular
disorders
is strongly
influenced
by the
clinical
and educational
background
of the dentist.
The prosthetic
rehabilitation of patients
affected
by one of the various
subsets
of temporomandibular
disorders
is a particularly
challenging
task,
and the literature
about
this topic
is limited.
This
article
reviews
the current
situation
and gives
suggestions
on
how
the dentist
should
proceed
in the prosthetic
treatment
of these
patients.
(J Prosthet
Dent
1996;76:418-23.)

dentistry
forms one of the main pilrosthetic
lars of the dental profession.
The major aims associated
with prosthetic
rehabilitation
are improvement
of an impaired masticatory
function,
enhancement
of a compromised esthetic situation,
improvement
of the patients
phonetics,
and prevention
of further
direct or indirect
destruction
in the masticatory
system. In this regard,
prosthetic
dentistry
may be seen as the epitome of clinical dentistry.
In the course of the past few decades, additional
topics have gained increasing
attention
among
dentists-one
of them is the subject of temporomandibular disorders (TMDs). A continuously
increasing
body of
literature
about TMD and related
issues reflects the
importance
that has been attached to this area of interest. Antczak-Bouckom2
reported that between the years
1980 and 1992, more than 4000 references
related to
TMD were published.
The management
of TMD patients is a particular
challenge for the dentist. Surprisingly,
yet only a handful of
articles has focused on the topic of prosthetic
rehabilitation in patients with TMD. Therefore, the purpose of this
study is to evaluate this topic on the basis of the information available
in the literature
and to suggest guidelines on how to proceed in these cases.

TEM.POROMANDIBUIAR

DISORDERS

TMD conditions
are among the most puzzling and intractable problems in clinical dentistry. Undoubtedly,
the
most salient and annoying
TMD symptom is pain, often
Presented at the Annual Meeting of the American Equilibration Society, Chicago, Ill., February 1996.
Visiting Assistant Professor, Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan.
bProfessor and Chairman, Department
of Fixed and Removable Prosthodontics,
School of Dentistry, Albert Ludwigs
University.
418

THE

JOURNAL

OF PROSTHETIC

DENTISTRY

accompanied
by a restricted range of mandibular
motion.
TMD is probably best described as a self-limiting
chronic
pain condition.3 Therefore, pain control is considered the
primary
goal of TMD managementP
Once pain control
has been achieved, improvement
of function is likely.
In spite of multitudinous
research activities,
the etiology of TMD is still enigmatic.
According
to Lund,5 no
definite scientific support for any of the prevailing
etiologic hypotheses
exists. If the etiology of a disease is
unknown,
however, treatment
cannot be specific. Thus,
it is not surprising
that the management
of TMD is characterized
by considerable
heterogeneity.6
The current
lack of a solid understanding
of TMD is also reflected in
the literature.
Antczak-Bouckoms7
reported that the vast
majority
of TMD-related
publications
were review articles,
descriptions
of techniques,
uncontrolled
or
nonrandomized
studies, and case reports or series. From
the almost 1300 articles related to TMD therapy
that
appeared between 1980 and 1992, only 55 articles (4%)
were randomized
controlled
trials. However, even these
studies are not without
weaknesses;
there was little or
no consensus regarding
description
of subjects and diagnoses and a wide variation
in the outcome measures that
were used to evaluate efficacy. These publications
were
culled from more than a dozen different journals.
Some
articles are not listed in MEDLINE,
thus have to be found
by hand searching?
Antczak-Bouckoms2
therefore
concludes that it is likely that clinicians are influenced
more
by the predominant
uncontrolled,
potentially
biased reports they encounter.

DECISION-MAKING
DENTISTRY

IN PROSTHETIC

The choice of prosthetic

treatment
relies heavily, but
not exclusively,
on a thorough
analysis and interpretation of the findings that the dentist has acquired during
the medical and dental history and the clinical examiVOLUME

76

NUMBER

TfJRP

AND

STRUB

THE JOURNAL

nation. Radiographs
and mounted
diagnostic
casts are
sources of information
that complete the process of data
gathering
and decision making.8 Furthermore,
intraoral
and extraoral
photographs
are often useful, especially
when esthetic issues are involved. In addition to the pure
dental situation,
a number of other important
points influence the kind of treatment
that can be delivered (Table
I). Among them, an often underestimated
or neglected
factor is the treatment
bias caused by the dentists professional background.
In an attempt to increase the quality of clinical decision making, approaches
derived from
clinical epidemiology,
biostatistics,
and medicine
have
been introduced
into dentistry.gJO These techniques
aim
to enhance
the clinical
predictability
of the different
treatment
options by applying
more scientifically
oriented methods, such as probability
factors that are based
on the result of randomized
controlled
clinical trials.ll
This endeavor should be seen as part of a more general
concept that is known as evidence-based
medicine.
The
common denominator
of this new approach is to provide
patient care that is based on evidence derived from the
best available
. . . studies,12 as opposed to unsystematic observations
from clinical
experience13
and intuition. Considering
the favorable
response the concept of
evidence-based
medicine
has received in most medical
fields including
dentistry, I4 it is a promising
start for an
approach that is likely to enhance considerably
the quality of patient care.

CONTROVERSIES
BILITATION

IN PROSTHETIC

REHA-

The history of prosthetic

dentistry
has seen endless
and often fruitless debates about two topics deemed pivotal for prosthetic
rehabilitation,
namely condylar position and occlusal concepts. Despite the interest given to
these issues, the scientific
basis behind them does not
always seem to be conclusive.
The following
is a summary of the authors view concerning
this matter.

Condylar

position

For decades the position

of the mandibular
condyles
relative
to the glenoid fossae has been one of the most
disputed subjects in dentistry.
The gradual shifts in perception that have occurred over the years may be best
epitomized
by the changes in the meaning
of the term
centric relation
(CR). In the sixth edition of the Glossary
of Prosthodontic Terms, centric relation is defined as the
maxillomandibular
relationship
in which the condyles
articulate
with the thinnest
avascular
portion of their
respective
disks with the complex in the anterior-superior position against the shapes [sic-Authors
note: presumably, slopes is meant] of the articular
eminences.15
The current description
makes a remarkable
difference
as compared with the most posterior
or most retruded
position of the mandible
as defined in previous editions
of the Glossary. I6 That CR in the past has been used to
OCTOBER

1996

Table I. Factors

that

influence

OF PROSTHETIC

prosthetic

DENTISTRY

treatment

Urgency of the situation

Patients medical condition
l
Patients psychological condition
l
Patients general attitudes towards oral health and dental
treatment
l
Patients wishes and the preferences regarding the kind of
dental rehabilitation
l
Patients expectations of the proposed prosthetic
rehabilitation
. Patients anticipated compliance
l
Patients financial resources
l
Patients age and mlobility
l
Prosthodontists
trarining, experience, knowledge, attitudes,
skills, and treatment preferences
l
l

specify a variety ofjaw relation may be a potential

source
of confusion
among dentists. Therefore,
the usefulness
of this term has been questioned.17
Definitions
such as the current one for CR may lead
to the conclusion
that this condylar
position
is more
physiologic
than others. Radiographic
investigations
that use corrected sagittal tomograms
have shown, however, that positions of the mandibular
condyles vary considerably
among healthy
subjects. For example, Ren et
all6 reported in 1995 that in a sample of 34 asymptomatic
subjects, only 41% of the condyles were centrically
positioned in the glenoid fossae. By concluding
that the
condyles could be either in a significant
anterior
position or in an extreme posterior position,18 these investigators corroborated
the findings
obtained by other authors in earlier studies.1g,20
Consequently,
there is disagreement
over whether
centric relation
is rleally the most physiologic
condylar
position.17J1 Likewise,
scientific evidence is missing that
the concurrence
of CR and centric occlusion-here
defined as the occlusion of opposing teeth when the mandible is in centric relation15-represents
the most physiologic form of occlusion.zz
Despite these remarks, we agree that CR is usually a
convenient
mandibular
reference
position when extensive prosthetic treatment
is indicated
and posterior tooth
support is lacking because it is relatively
well-reproducible. It should be kept in mind, however, that condylar
reference positions may change in the course of time and
should therefore
not be considered
as absolutely
fixed
and stable as is the case in articulators.23-27

Occlusal

concepts

It is agreed on in dentistry
that any suitable occlusal
design should allow for a high degree of chewing effciency without
causing harm to the masticatory
system
and, in the case of removable
dentures,
for stability
of
the dental prosthesis.
Dependent
on the occlusal contact relationships
during tooth-guided
mandibular
movements, namely articulation,
three main occlusal schemes
419

THE JOURNAL

OF PROSTHETIC

DENTISTRY

TtJRP

are usually distinguished?

(1) anterior or canine guided
(mutually
protected)
occlusion, (2) group function ocelusion, and (3) (bilaterally)
balanced
occlusion. Anterior
or canine protected
occlusion is characterized
by guidance of the anterior
teeth or the canines alone during
excursive mandibular
movements,
thus allowing
a disengagement
of posterior teeth. This occlusion scheme has
been preferred
for restorative
dental work by authors
such as Hobo et a1.,2g Parker,2s and Okeson21 because of
convenience.
Variations
of this concept include, among
others, the extension of the guidance to the premolars
or
to all posterior
teeth of the working
side (group function).30 The decision
as to which scheme to apply in
occlusal rehabilitation
is not only dictated by the clinical situation,
but is also subject to the opinion and preference of the clinician.30
A balanced
occlusion is the most favored concept in
rehabilitation
with complete dentures.
It is supposed to
allow greater denture stability
than any other occlusal
scheme. However, alternative
occlusal designs have been
proposed. For example, at the University
of Innsbruck,
Austria,
complete dentures
with anterior-canine
guidance have been used for years with success.31,32
The application
of a particular
occlusal concept and
the issue of the condylar
position still rely much on the
personal preference
of the dentist. So it is not surprising
that these topics remain
an area of continued
controversy. 30 Consequently,
Mohl and Davidsons30 advice to
be hesitant in treating
any occlusion that deviates from
the dentists own conception
of an ideal occlusal organization
seems more than justified.
Hence, whenever
possible, the authors try to adapt the occlusal design of
a new prosthetic
restoration
to the occlusal scheme that
already exists in the dentition
of the patient.

TMD PATIENTS
WHO ARE IN NEED
PROSTHETIC
REHAHILITATION

OF A

Patients
who are in need of a prosthetic
rehabilitation, but who are also afflicted
by one or more of the
various
subsets of TMD, need special attention.
The
prosthodontist
cannot and should not treat these patients without the advice and collaboration
of colleagues
who are specially trained
in dealing with TMD and facial pain.33 Because of the coexisting
musculoskeletal
disorder,
prosthetic
rehabilitation
has to become part
of a structured
plan whose emphasis
lies on management of the overall problem,
as opposed to a simple
treatment
of the
dental
situation.
Because
prosthodontic
interventions
should not be the primary
approach
in solving
such combined
cases, treatment
should be prudent, although from a purely prosthodontic
standpoint
extensive
and permanent
restorations
may
be advisable.34m36 Hence, as pointed out by Litvak
and
Malament,
the prosthodontists
role within
the team
of specialists
involved
in management
of the patient is
confined to delivery
of the necessary prosthetic
reha420

AND

STRUB

bilitation
after control of pain and dysfunction
has been
achieved.
A patient
afflicted by a persistent
and painful
TMD
usually experiences
a great amount of physical discomfort and often endures a substantial
degree of pain-related disability.
Besides the suffering of the patient, there
are other reasons that point to a more reluctant
attitude
toward prosthetic
rehabilitation
during a painful
TMD
condition.
Pain is known to have a direct influence
on
function; it limits the range of motion of the affected body
parts. Thus, pain located in the masticatory
muscles
leads to a decrease in mandibular
mobility,
for example
limited mouth opening and restricted
movements
in the
horizontal
plane. There is scientific evidence that in the
presence
of pain the mandible
is likely
to assume a
slightly more protruded
position. As a result, the patients
complain
that the bite no longer feels right.37 These
observations
have direct implications
for prosthetic
rehabilitation,
because the determination
of the vertical
and horizontal
maxillomandibular
relationships
is most
likely to be hampered
in the presence of pain and will
result in a mandibular
position
that is different
from
one in a pain-free
state.
Once an improvement
in the TMD symptomatology
has occurred and proved to be stable over a certain period of time, considerations
regarding
necessary prosthetic procedures
can be made. How such a desired improvement
should be defined, however, is subject more
to the clinicians
personal judgment
than to scientifically
derived results. Neither the clinician nor the patient can
be certain whether
resolution
of pain and rehabilitation
of mandibular
function will last; there is always the possibility
of relapse. It must be realized
that there is a
significant
number
of TMD patients
for whom a longlasting resolution
of symptoms cannot be achieved. Instead, these individuals
are likely to experience
phases
of aggravation,
followed again by periods of relief. Therefore, patients should be specifically
reminded
that there
is a chance of symptoms
exacerbating
during or after
the prosthetic
rehabilitation.
Such relapses can happen
independently
from the intervention,
just by chance
alone. They can also occur as a consequence
of the treatment procedures.
Two examples are trauma caused by a
prolonged
mouth opening or a new maxillomandibular
relation
that exceeds the functional
adaptability
of the
masticatory
system.
The possibility
of aggravating
an existing TMD condition during or after a prosthetic
rehabilitation
makes
the long-term outcome and the prognosis of the prosthetic
treatment
much more unpredictable
than in pure
prosthodontic
cases.
The prosthodontist
should also be alert when he or
she treats a patient who is symptom-free
at the time but
has a history of TMD. Such a patient may experience
more difficulties
in incorporating
new restorations
and
may be more easily prone to litigation
if the TMD condiVOLUME

76

NUMBER

TthP

AND

STRUB

tion recurs after restorative

care.38 With this in mind, it
is obvious that the necessity of informed
consent before
starting
any prosthetic
rehabilitation
cannot be emphasized enough. An informed consent, such as the Informed
Consent Treatment
Report,3g serves as an important
safety belt, for the dentist in the case of dental malpractice suits by patients
who are dissatisfied
with the delivered treatment.
In 1995, the Committee
on Temporomandibular
Disorders
of the American
College
of
Prosthodontists
provided a useful example of an informed
consent form for patients with TMD who are in need of
prosthetic
treatmenL40
If we accept the assumption
that the adaptive capacity of the masticatory
system is reduced in TMD patients,
then we must admit that any major alteration
to the
existing
maxillomandibular
relations
in which the patient feels comfortable
has the potential
of being an additional
risk factor in the reoccurrence
or deterioration
of symptoms. Accordingly,
at the University
of Freiburg
the following
principles
have been adopted:
Whenever
possible, the existing
maxillomandibular
relations
as defined by the current intercuspal
relationships
(maximum
intercuspation)
are maintained.
Three to five occlusal units are necessary to allow a
stable jaw relationship
at maximum
intercuspation.41
(A pair of occluding premolars
is counted as one unit;
a pair of occluding molars as two occlusal units.)
If sufficient
posterior
support is missing, the restoration is made in centric relation;
however, a more anterior position may be acceptable
if CR is an uncomfortable position for the patient.
In the instance
of temporomandibular
joint (TMJ)
arthropathies,
it is often necessary
to restore in a
mandibular
position that is ahead of CR. It is recommended to test the favored condylar position with the
help of an oral splint before prosthetic
rehabilitation
is begun.36
Once the time seems propitious
to begin the necessary
prosthetic
treatment,
the prosthodontist
has to decide
which of the possible options has the potential
to yield
the best results. Unfortunately,
there is a dearth of scientifically
supported
information
about this question. Uncertainty
about clinical decision-making
is not limited to
prosthodontic
situations. Many issues in dentistry have a
similar problem, and this quandary
seems more prevalent in dentistry
than in medicine.l
The prosthodontist
who is looking for hard data about treatment
planning
for TMD patients who are in need of prosthetic
rehabilitation will discover that overview articles, opinion articles,
suggestions
by individual
authors, and case reports are
more or less the only sources available.
Such articles
should be generally
judged with caution, because they
often reflect the personal viewpoint
of the author or authors and are therefore filled with subjectivity.
Thus, information
gained from overview and opinion articles and
case reports should be interpreted
with a critical mind.
A way out of this predicament
is consultation
for recOCTOBER

1996

THE JOURNAL

OF PROSTHETIC

DENTISTRY

ommendations
given by respected
authorities
and/or
expert committees.
Such advice represents
a significant
source of information
for the dental practitioner.
Yet it
should be realized that expert reports, if based on clinical experience
and descriptive
studies, constitute
the
lowest form of scientifically
acceptable
information
designed to address a specific clinical problem. On the other
end of the scale are properly
designed randomized
controlled trials, which are regarded
as the most scientifically
rigorous
method
of hypothesis
testing
in
epidemiologic
and chnical studies.12 In the field of dentistry, not many useful studies of this kind exist, as exemplified
before about the assessment of treatment
efficacy in TMD management.
In this situation,
guidelines,
such as the recent report of the Committee
on Temporomandibular
Disorders,36 provide helpful information
for
the process of decision-making
in patients with a known
history of or a present TMD condition.
In their report,
the American
College of Prosthodontists
gives advice on
issues that should be considered
in treating
a TMD patient who needs a prosthetic
rehabilitation.
The following points are given special attention3?
1. Ongoing
TMD therapy,
such as physical
therapy,
pharmacotherapy,
or behavioral
therapy,
should be
continued
during the prosthodontic
treatment.
2. Before prosthetic rehabilitation
is started, radiographs
that portray the current condition of the temporomandibular
joints should be available.
Although
radiographs may reveal advanced bone disease, they are
not able to reveal small structural
defects.42
3. Fixed restorations
should be temporarily
cemented
and the patient
should be rescheduled
on a regular
basis. When final cementation
is considered,
a segmental approach
may be advantageous.
In addition,
Wise43 gives some useful suggestions
for
trying to alleviate
some distress for the patient during
treatment:
1. Follow-up
appointments
should not be too frequent.
2. The dentist shou.ld allow for adequate breaks within
single treatment
sessions.
3. Overstretching
of the TMJs and the facial muscles
should be avoided.
4. The use of a mouth prop may be beneficial,
because
the patient is not required
to keep her or his mouth
actively open.
Despite the lack of randomized
controlled
clinical trials, there is evidence that functional
stability
is advantageous
in patients
with
TMJ osteoarthrosis
or
osteoarthritis.
Consequently,
occlusal splints and prosthetic rehabilitation.
with fixed or removable
partial dentures have been advocated for patients who have missing molar support or multiple
tooth loss, to improve function and possibly to reduce and redistribute
the loading
of the compromised
TMJs. 35*44The probable benefit from
a restoration
of molar support with the help of an oral
splint or prosthetic
means has also been mentioned
for
other forms of arthritic
TMJ involvement,
such as
421

THE JOURNAL

OF PROSTHETIC

DENTISTRY

TijRP

ankylosing
spondylitis.
45 However,
at least as far as
healthy subjects are concerned, molars are not seen as a
prerequisite
for adequate
oral function
and sufficient
occlusal stability.41,46-4g Moreover,
free-end
removable
partial
dentures
(RPDs) do not seem to contribute
to
occlusal
stability
in patients
with shortened
dental
arches41 nor do they improve oral function
in terms of
oral comfort.4g From the results of a 6-year longitudinal
study, Witter
et a1.4g came to the conclusion
that the
absence of molar support is not a risk factor for the development
of TMD and that, on the other hand, free-end
RPDs that compensate
for the loss of molars in the mandible did not prevent TMD. However, as mentioned,
enlarging the posterior
support
in patients
with painful
arthropathies
may be beneficial
to improve occlusal stability and masticatory
function and potentially
to reduce
the amount of articular
loading.
In certain situations,
the need for prosthetic
rehabilitation emerges as a direct consequence of an existing systemic disease, for example rheumatoid
arthritis. However,
the prosthodontist
should avoid performing
irreversible
treatment
in an active phase of the disease at all costs.
Therefore, collaboration
with a rheumatologist
is obligatory. When the acute condition has subsided, the fabrication of a stabilization
splint may be a safer approach to
compensate for the unstable occlusal condition than the
immediate
preparation
of a removable
or fixed partial
denture. The advantage
of an oral splint is that it can
easily be adjusted when further changes in the occlusion
take place as a result of flare-ups. It is also useful to test
the maxillomandibular
relationship
before performing
a
prosthetic treatment
that may be indicated when the disease activity in the TMJs has proved to be 10w.~O.
As far as other cases are concerned,
we do not see a
difference between the indication
for prosthetic
rehabilitation in prosthodontic
patients and in combined TMD/
prosthodontic
cases. The goals are the same, namely improvements
of function, esthetics, and phonetics, regardless of whether the patients suffer from TMD or not. Unlike other authors,51,52 we are not convinced that altered
horizontal
maxillomandibular
relationships,
permanently fixed by prosthodontic
means, are the key factors
in the management
of TMD patients. In that regard we
fully concur with Greene and La&S3
who concluded in
1983 that major alterations
of mandibular
position or
dento-alveolar
relationships
do not appear to be necessary for obtaining
either short-term
or long-term
success, and therefore
they can be generally
regarded
as
inappropriate
treatment
for this disorder.

CLINICAL
SIGNIFICANCE
CONCLUSION

AND

Many important
questions regarding
the management
of TMD patients are still unanswered.
At the same time,
decision-making
in prosthodontics
often is not based on
the results of randomized
controlled
scientific
studies
422

AND

STRUB

but, like most medical disciplines,

driven by clinical experience and intuition.
Although
to a different
extent,
both TMD management
and prosthodontics
are characterized by limitations
in providing
reliable
and valid
information
about the rationale
for specific treatment
options in a specific case. Because of these shortcomings,
it is impossible
to give more than general recommendations for an area that combines both TMD and prosthetic
dentistry.
In this situation,
the prosthodontist
should
be judicious
and should not take unnecessary
risks.
It is our hope that with the introduction
of evidencebased medicine in dentistry
and possible improvements
in decision-making
processes, this unsatisfying
condition will improve.
Evidence-based
medicine,
however,
relies on valid and clinically
useful studies. More research is needed to create a better understanding
of the
etiology of TMD. More randomized,
controlled,
clinical
trials are required
to get a better understanding
of the
treatment
approaches
that yield more successful results
than those gained by the regression
to the mean phenomenon and the placebo effect.
Without
doubt, the current situation
is daunting
and
frustrating.
However, ignoring the lack of knowledge
and
giving detailed recipes for treating
patients without
a
sound scientific background
would not only be dishonest
but also dangerous.
The medieval
philosopher
and logician William of Occam (c.1285-1349)
once postulated
that
assumptions
to explain
a phenomenon
must not be
multiplied
beyond necessity.iz
This famous statement
is also known as the principle
of scientific parsimony.
After a slight adaptation
to the topic of prosthetic
rehabilitation
in the context of coexisting
TMD, Occams remark should stand as a reminder
for prosthetic
parsimony: Endeavors
to provide prosthetic treatment
in the
presence of TMD should not be made beyond necessity.
REFERENCES
1. Wild W. Functional
prosthodontics.
[In German]
Bawl: Schwabe;
1950.
2. Antczak-Bouckoms
AA. Epidemiology
of research
for temporomandibular disorders.
J Orofac Pain 1995;9:226-34.
3. Dworkin
SF. Perspectives
on the interaction
of biological, psychological and social factors in TMD. J Am Dent Assoc 1994;125:856-63.
4. Zarb GA, Carlsson
GE, Rugh JD. Clinical
management.
In: Zarb
GA, Carlsson
GE, Sessle BE, Mohl ND, editors. Temporomandibular joint and masticatory
muscle disorders.
St Louis: Mosby-Year
Book; 1994529-48.
5. Lund JP. Review and commentary:
basic sciences.
J Craniomand
Disord Facial Oral Pain 1992;6:346-50.
6. Arbree NS, Campbell
SD, Renner RP, Goldstein
GR. A survey
of
temporomandibular
disorder
conducted
by the Greater
New York
Academy of Prosthodontics.
J Prosthet
Dent 1995;74:512-6.
7. Antczak-Bouckoms
A. Reaction paper to chapters 12 and 13. In: Sessle
BJ, Bryant
PS, Dianne RA, editors. Temporomandibular
disorders
and related pain conditions.
Seattle: IASP Press; 1995:237-45.
8. Bowley JF, Stockstill
JW, Attanasio
R. A preliminary
diagnostic
and treatment
protocol. Dent Clin North Am 1992;36:551-68.
9. McCreery
AM, Truelove E. Decision making in dentistry.
Part I: a historical and methodological
overview. J Prosthet Dent 1991;65:447-51.
10. McCreery
AM, Truelove
E. Decision making
in dentistry.
Part II:
clinical
applications
of decision
methods.
J Prosthet
Dent
1991;65:575-85.

VOLUME

76

NUMBER

rijRp

AND

STRUB

11. Stockstill
JW, Bowley JF, Attanasio
R. Clinical decision analysis in
fixed prosthodontics.
Dent Clin North Am 1992;36:569-80.
12. Last JM. A dictionary
of epidemiology.
New York
Oxford University Press, 1995:58,17.
13. Evidence-based
medicine working
group. Evidence-based
medicine.
A new approach
to teaching
the practice
of medicine.
JAMA
1992;268:2420-5.
14. Evidence-based
medicine
working
group. Evidence-based
health
care: a new approach to teaching the practice of health care. J Dent
Educ 1994;58:648-53.
15. The Academy
of Prosthodontics.
Glossary
of prosthodontic
terms.
6th ed. St Louis: Mosby-Year
Book 199459.
16. The Academy
of Denture
Prosthetics.
Glossary
of prosthodontic
terms. 3rd ed. St Louis: Mosby 1968:16.
17. Gilboe DB. Centric relation
as the treatment
position.
J Prosthet
Dent 1983;50:685-9.
18. Ren YF, Isberg A, Westesson
PL. Condyle position in the temporomandibular
joint. Comparison
between
asymptomatic
volunteers
with normal disk position and patients with disk displacement.
Oral
Surg Oral Med Oral Path01 Oral Radio1 Endod 1995;80:101-7.
19. Blaschke
DD, Blaschke
TJ. Normal TMJ bony relationships
in centric occlusion.
J Dent Res 1981;60:98-104.
20. Pullinger AG, Hollender
L, Solberg WK, Petersson
A. A tomographic
study of mandibular
condyle position in an asymptomatic
population. J Prosthet
Dent 1985;53:706-13.
21. Okeson JP. Management
of temporomandibular
disorders
and occlusion. St. Louis: Mosby 1993;111,125,569.
22. Wilkinson
TM. Equilibration
and restorative
dentistry.
In: McNeil1
C, editor. Current
controversies
in temporomandibular
disorders.
Chicago: Quintessence
1992:162-5.
23. Shafagh I, Yoder JL, Thayer
KE. Diurnal
variance
of centric relation position. J Prosthet
Dent 1975;34:574-82.
24. Mongini F. Anatomic
and clinical evaluation
of the relationship
between the temporomandibular
joint and occlusion.
J Prosthet
Dent
1977;38:539-51.
25. Schubert R. Reproducibility
of the terminal
hinge axis position-a
1
year study. [In German]
Dtsch Zahnarztl
Z 1985;40:96-9.
26. Piehslinger
E, Celar A, Celar R, Jager W, Slavicek R. Reproducibility
of the condylar
reference position. J Orofacial
Pain 1993;7:68-75.
27. Korber E, Landt H. The reproducibility
of bite registrations.
[In German] Dtsch Zahnarztl
Z 1979;34:202-5.
28. Parker
MW. The significance
of occlusion
in restorative
dentistry.
Dent Clin North Am 1993;37:341-51.
29. Hobo S, Ichida E, Garcia LT. Osseointegration
and occlusal rehabilitation.
Tokyo: Quintessence,
1989:318,325-6.
30. Mohl ND, Davidson
RM. Concepts
of occlusion.
In: Mohl N, Zarb
GA, Carlsson
GE, Rugh JD, editors. A textbook
of occlusion,
Chicago: Quintessence,
1988:161-75.
31. Gausch K. Experiences
with anterior/cuspid-controlled
complete dentures. [In German]
Dtsch Zahnarztl
Z 1986;41:1146-9.
32. Grunert
I, Kofler
M, Gausch
K, Kronenberg
M. Masseter
and
temporalis
surface electromyography
in patients
wearing complete
dentures
comparing
anterior
and posterior
occlusal concepts-a
pilot study. J Oral Rehabil 1994;21:337-47.
33. Litvak H, Malament
KA. Prosthodontic
management
of temporomandibular disorders
and orofacial pain. J Prosthet Dent 1993;69:77-84.
34. McNeil1 C. Temporomandibular
disorders.
Guidelines
for classification, assessment,
and management.
2nd ed. Chicago:
Quintessence, 1993:93,120.
35. Plesh 0, Stohler CS. Prosthetic
rehabilitation
in temporomandibular disorder
and orofacial
pain patients.
Clinical
problem solving.
Dent Cllin North Am 1992;36:581-9.
36. Hilsen KL. Temporomandibular
disorder
prosthodontics:
treatment
and management
goals. J Prosthodont
1995;4:58-64.

OCTOBER

1996

TRE JOURNAL

OF PROSTHETIC

DENTISTRY

37. Obrez A, Stohler CS. Jaw muscle pain and its effect on gothic arch
tracings.
J Prosthet
Dent 1996;75:393-8.
38. Wise MD. Restorative
implications
ofinternal
derangement.
In: Wise
MD, editor. Failure in the restored dentition:
management
and treatment. London: Quintessence,
1995:413-21.
39. Murrell
GA, Sheppard GA. The informed consent treatment
report.
J Prosthet
Dent 1992;68:970-3.
40. Kinderknecht
KE, Hilsen KL. Informed consent for the prosthodontic
patient with temporomandibular
disorders. J Prosthodont
1995;4:2059.
41. Witter
DJ, de Haan AF, Kayser Al?, van Rossum GM. A g-year follow-up study of oral function
in shortened
dental arches. Part I:
occlusal stability.
J Oral Rehabil 1994;21:11325.
42. Dixon DC. Indications
and techniques
for imaging the temporomandibular joint. In: Zarb GA, Carlsson
GE, Sessle BE, Mohl ND, editors. Temporomandilbular
joint and masticatory
muscle disorders.
St Louis: Mosby-Year
Book 1994:435-61.
43. Wise MD. Restorative
management
of the patient with a history
of
facial arthromyalgia,
or internal
derangement
of the TMJ. In: Wise
MD, editor. Failure in the restored dentition: management
and treatment. London: Quintessence,
1995381-95.
44. Zarb GA, Carlsson
GE. Osteoarthrosis/osteoarthritis.
In: Zarb GA,
Carlsson GE, Sessle BE, Mohl ND, editors. Temporomandibular
joint
and masticatory
muscle
disorders.
St Louis: Mosby-Year
Book
1994:298-314.
45. Wenneberg
B. Other disorders.
In: Zarb GA, Carlsson
GE, Sessle
BE, Mohl ND, editors. Temporomandibular
joint and masticatory
muscle disorders.
St Louis: Mosby-Year
Book 1994367-88.
46. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil
1981;8:457-62.
47. Witter DJ, van Elteren P, Kayser AF. Signs and symptoms
of mandibular
dysfunction
in shortened
dental arches. J Oral Rehabil
1988;15:413-20.
48. Witter DJ, Van Elteren P, Kayser AF, Van Rossum GM. Oral comfort in shortened
dental arches. J Oral Rehabil 1990;17:137-43.
49. Witter
DJ, De Haan AF, Kayser
AF, Van Rossum
GM. A B-year
follow-up
study of or,al function
in shortened
dental arches. Part II:
craniomandibular
dysfunction
and oral comfort.
J Oral Rehabil
1994;21:353-66.
50. Kopp S. Rheumatoid
arthritis.
In: Zarb GA, Carlsson
GE, Sessle
BE, Mohl ND, editors. Temporomandibular
joint and masticatory
muscle disorders.
St Louis: Mosby-Year
Book 1994:346-66.
51. Weinberg
LA. Definitive
prosthodontic
therapy
for TMJ patients.
Part I: anterior and posterior
condylar displacement.
J Prosthet Dent
1983;50:544-57.
52. Weinberg
LA. Definitive
prosthodontic
therapy
for TMJ patients.
Part II: posterior
and superior condylar
displacement.
J Prosth Dent
1983;50:690-9.
53. Greene CS, Laskin
DM. Long-term
evaluation
of treatment
for
myofascial
pain-dysfunction
syndrome:
a comparative
analysis.
J
Am Dent Assoc 1983;107:235-8.
Reprint
requests to:
DR. JENS C. TURP
DEPARTMENT OF BIOLOGIC mm M~ERIALS
SCHOOL OF DENTISTRY
UNIVERSITY OF MICHIGAN
hN ARBOR, MI 48109-1078

Copyright
0 1996 by The
Prosthetic
Dentistry.

0022-3913/96/$5.00

Editorial

SCIENCES

Council

of The

Journal

of

+ 0. 10/l/75428

423