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Management of
TEMPOROMANDIBULAR
DISORDERS
AND OCCLUSION
7
JEFFREY P. OKESON, DMD
Professor and Chair, Department of Oral Health Science
Provost’s Distinguished Service Professor
Director of the Orofacial Pain Center
College of Dentistry
University of Kentucky
Lexington, Kentucky
i
3251 Riverport Lane
St. Louis, Missouri 63043
MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS AND OCCLUSION 7 ED ISBN: 978-0-323-08220-4
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such informa-
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edge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
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tained in the material herein.
Library of Congress Cataloging-in-Publication Data
Okeson, Jeffrey P.
Management of temporomandibular disorders and occlusion / Jeffrey P. Okeson. -- 7th ed.
p. ; cm.
ISBN 978-0-323-08220-4 (hardcover : alk. paper)
I. Title.
[DNLM: 1. Temporomandibular Joint Disorders. 2. Dental Occlusion. 3. Malocclusion. WU 140.5]
617.6’43--dc23 2011053490
Vice President and Content Strategy Director: Linda Duncan
Executive Content Strategist: John Dolan
Senior Content Development Specialist: Brian Loehr
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Design Direction: Teresa McBryan
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2
This text is personally dedicated to my wife, Barbara, for her continued
unconditional love, support, and understanding throughout my entire professional life.
This text is professionally dedicated to all of our patients.
It is my hope that this text may in some way help reduce their suffering.
ABOUT THE AUTHOR
JEFFREY P. OKESON, DMD DR. OKESON IS A 1972 GRADUATE of Dr. Okeson is also the author of Bell’s Orofacial Pains. This text is
the University of Kentucky also widely used in orofacial pain programs throughout the world.
College of Dentistry. After Dr. Okeson is an active member of many TMD and orofacial
graduation he completed two pain organizations. He holds many offices and serves on numer-
years with the Public Health ous committees and boards. He is a past president and found-
Service in a rotating dental ing fellow of the American Academy of Orofacial Pain (AAOP).
internship and directorship of He is a founding diplomate and past president of the Ameri-
an outpatient clinic. He joined can Board of Orofacial Pain. He has been active in the AAOP,
the faculty at the University developing treatment and curriculum guidelines for TMDs and
of Kentucky in 1974. At pres- orofacial pain. He edited the third edition of the AAOP guide-
ent he is Professor, Chairman lines, titled Orofacial Pain: Guidelines for Classification, Assessment,
of the Department of Oral and Management, which has been used as treatment standards
Health Science, and Director throughout the world. Dr. Okeson has presented more than
of the College’s Orofacial Pain 1000 invited lectures on the subject of TMDs and orofacial pain
Center, which he established in all 50 United States and 51 foreign countries. At national
in 1977. The Orofacial Pain Center represents a multidisciplinary and international meetings he is frequently referred to as “the
effort in the management of chronic orofacial pain problems. world ambassador for orofacial pain.” Dr. Okeson has received
Dr. Okeson has developed several postgraduate training pro- several teaching awards from his dental students, as well as the
grams in the Center, including a Master of Science Degree in campus wide University of Kentucky Great Teacher Award. He
Orofacial Pain. He led the program in becoming one of the first has received the Provost’s Distinguished Service Professorship,
fully accredited orofacial pain graduate training programs by the American Academy of Orofacial Pain’s Service Award and
the Commission on Dental Accreditation in the United States. the first ever “Distinguished Alumni Award” from the College
Dr. Okeson has more than 220 professional publications in the of Dentistry. Dr. Okeson has also received “The International
areas of occlusion, temporomandibular disorders (TMDs), and Dentist of the Year Award” from the Academy of Dentistry Inter-
orofacial pain in various national and international journals. Dr. national. This is the highest award recognized by this Academy
Okeson’s textbook, Management of Temporomandibular Disorders and was given to him in recognition of his worldwide efforts in
and Occlusion, is used in the majority of U.S. dental schools and providing education in the area of temporomandibular disorders
has been translated into eleven languages. In addition to this text, and orofacial pain.
iv
PREFACE
THE STUDY OF OCCLUSION AND ITS RELATIONSHIP TO FUNCTION of the masti- The purpose of this text is to present a logical and practical
catory system has been a topic of interest in dentistry for many approach to the study of occlusion and masticatory function.
years. This relationship has proved to be quite complex. Tre- The text is divided into four main sections: The first part con-
mendous interest in this area accompanied by lack of complete sists of six chapters that present the normal anatomic and physi-
knowledge has stimulated numerous concepts, theories, and ologic features of the masticatory system. Understanding normal
treatment methods. This, of course, has led to much confusion occlusal relationships and masticatory function is essential to
in an already complicated field of study. Although the level of understanding dysfunction. The second part consists of four
knowledge today is greater than ever before, there is still much chapters that present the etiology and identification of common
to learn. Some of today’s techniques will prove to be our most functional disturbances of the masticatory system. Significant
effective treatments in the future. Other methods will be demon- supportive documentation has been included in this edition.
strated as ineffective and will have to be discarded. Competent The third part consists of six chapters that present rational treat-
and caring practitioners must establish their treatment methods ments for these disorders according to the significant etiologic
based on both their present knowledge and their constant evalu- factors. Recent studies have been added to support existing treat-
ation of information received from the massive amount of ongo- ments, as well as for new considerations. The last part consists of
ing research. This is an enormous task. It is my hope that this text four chapters that present specific considerations for permanent
will assist students, teachers, and practitioners in making these occlusal therapy.
important treatment decisions for their patients. The intent of this text is to develop an understanding of, and
I began my teaching career at the University of Kentucky in rational approach to the study of masticatory function and occlu-
1974 in the area of occlusion. At that time I believed there was a sion. To assist the reader, certain techniques have been presented.
need for a teaching manual that presented the topics of occlusion It should be recognized that the purpose of a technique is to
and temporomandibular disorders (TMDs) in an organized, logi- achieve certain treatment goals. Accomplishing these goals is the
cal, and scientific manner. In 1975, I developed such a manual significant factor, not the technique itself. Any technique that
to assist in teaching my dental students. Soon, several other den- achieves the treatment goals is acceptable as long as it does so in
tal schools requested use of this manual for their teaching pro- a reasonably conservative, cost-effective manner, with the best
grams. In 1983 the CV Mosby Publishing Company approached interests of the patient kept in mind.
me with the concept of developing this manual into a complete
textbook. After two years of writing and editing, the first edition Acknowledgments
was published in 1985. I am very pleased and humbled to learn
that this text is currently being used in most of the dental schools A text such as this is never accomplished by the work of one per-
in the United States and has been translated into eleven foreign son, but rather represents the accumulation of many who have
languages for use abroad. This is professionally very satisfying, gone before. The efforts of these individuals have led to the pres-
and it is my hope that the true benefit of this text is found in the ent state of knowledge in the field. To acknowledge each of these
improved quality of care we offer our patients. would be an impossible task. The multiple listing of references at
It is a privilege to have the opportunity to update this text the end of each chapter begins to recognize the true work behind
for the seventh time. I have tried to include the most significant this text. There are, however, a few individuals whom I feel both
scientific findings that have been revealed in the past 4 years. I obligated and pleased to acknowledge. First and foremost is Dr.
believe the strength of a textbook lies not in the author’s words, Weldon E. Bell. Although we lost this giant in 1990, he remains
but in the scientific references that are offered to support the my mentor to this day. He was the epitome of an outstanding
ideas presented. Unreferenced ideas should be considered only thinker, information simulator, and teacher. Within the seven
as opinions that require further scientific investigation to either texts he wrote on TMD and orofacial pain is found enough infor-
verify or negate them. It is extremely difficult to keep a textbook mation to keep a normal man thinking forever. He was a very
updated, especially in a field in which so much is happening special man, and I sorely miss him still.
so quickly. Twenty-seven years ago, in the first edition of this I would like to thank Dr. Terry Tanaka of San Diego, Califor-
text, I referenced approximately 450 articles to support the state- nia, for generously sharing his knowledge with me. Over the years
ments and ideas. The concepts in this edition are supported by I have come to value Terry’s professional and personal friend-
nearly 2300 scientific references. This reflects the significant sci- ship more and more. His anatomic dissections have contributed
entific growth of this field. It should be acknowledged that as greatly to the profession’s understanding of the functional anat-
future truths are uncovered, the professional has the obligation omy of our complex masticatory system.
to appropriately respond with changes that best reflect the new I would like to thank my colleague, Charles Carlson, PhD,
information. These changes are sometimes difficult for the clini- for all that he has taught me regarding the psychology of pain.
cian because they may reflect the need to change clinical pro- Charley and I have worked together for more than 20 years in
tocol. However, the best care for our patients rests in the most our Orofacial Pain Center, and I have seen him develop and
scientifically supported information. successfully document his concepts of physical self-regulation.
v
vi Preface
These techniques have helped many of our chronic pain patients. drawings and many new photos. Jodie was an extremely valuable
He has generously shared his ideas and concepts in Chapter 11. contributor in this process. Of course this project could not have
I would also like to thank the following individuals for allow- been completed with out the support and assistance of Executive
ing me to use some of their professional materials and insights Content Strategist John Dolan, Senior Content Development
in this text: Dr. Per-Lennart Westesson, University of Roches- Specialist, Brian Loehr, and the entire staff at Elsevier Publishers.
ter, Rochester, NY, Dr. Jay Mackman, Milwaukee, Wisconsin; I also wish to acknowledge and thank my more than fifty full-
Dr. Joseph Van Sickels, University of Kentucky, Lexington; Dr. time residents over the years at the University of Kentucky for
Larry Cunningham, University of Kentucky, Lexington; Dr. Ger- keeping me alert, focused, and searching for the truth.
hard Undt, Vienna, Austria; Dr. Steve Burke, Centerville, Ohio; Last, but by no means least, I wish to express my gratitude to
Dr. Carol Bibb, UCLA, Los Angles, CA; Dr. William Solberg, my family for their constant love, support, encouragement, and
UCLA, Los Angeles, CA; Dr. Douglas Damm, University of Ken- sacrifice during my writings. My mother and father inspired and
tucky, Lexington, KY. I also wish to thank Dr. David Hoffman for encouraged me from the very beginning. My sons have under-
helping me acquiring some the patient images used in the text. stood the time commitment, and my wife has given up many
I would also like to acknowledge and thank Ms. Jodie Bernard evenings to my computer. I have been blessed with a wonder-
at Lightbox Visual Communications and her team of wonder- ful, loving wife for 41 years, and her sacrifice has resulted in this
ful artists for making this edition possible. Converting the past textbook.
edition from black and white format to color required all new JEFFREY P. OKESON, DMD
TABLE OF CONTENTS
PART I FUNCTIONAL ANATOMY, 1
1 Functional Anatomy and Biomechanics of the Masticatory System, 2
2 Functional Neuroanatomy and Physiology of the Masticatory System, 21
3 Alignment and Occlusion of the Dentition, 46
4 Mechanics of Mandibular Movement, 62
5 Criteria for Optimum Functional Occlusion, 73
6 Determinants of Occlusal Morphology, 86
PART II ETIOLOGY AND IDENTIFICATION OF FUNCTIONAL
DISTURBANCES IN THE MASTICATORY SYSTEM, 101
7 Etiology of Functional Disturbances in the Masticatory System, 102
8 Signs and Symptoms of Temporomandibular Disorders, 129
9 History of and Examination for Temporomandibular Disorders, 170
10 Diagnosis of Temporomandibular Disorders, 222
PART III TREATMENT OF FUNCTIONAL DISTURBANCES OF
THE MASTICATORY SYSTEM, 257
11 General Considerations in the Treatment of Temporomandibular Disorders, 258
12 Treatment of Masticatory Muscle Disorders, 291
13 Treatment of Temporomandibular Joint Disorders, 317
14 Treatment of Chronic Mandibular Hypomobility and Growth Disorders, 362
15 Occlusal Appliance Therapy, 375
16 Treatment Sequencing, 399
PART IV OCCLUSAL THERAPY, 421
17 General Considerations in Occlusal Therapy, 422
18 Use of Articulators in Occlusal Therapy, 430
19 Selective Grinding, 443
20 Restorative Considerations in Occlusal Therapy, 457
vii
NEW TO THIS EDITION
viii
