Temporomandibular disorders (TMD) Occlusion and Orthodontic treatment

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• Temporomandibular disorders (TMD) Occlusion and
  Orthodontic treatment

Thor Henrikson
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TMD views and opinions.

• Patients
• Colleagues
• Non systematic reviews. Viewpoints
• Commercial interests

Not everybody with TMJ clicking needs TMJ
surgery
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TMD in relation to Orthodontic treatment

• Causing TMD?
• Curing TMD?
• Neutral?

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Knowledge about TMD
Explain the problem
How common ?
Treatment ?
Prognoses?
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TMD, Occlusion and Orthodontic treatmentPresentat
ion outline

• Introduction to Temporomandibular disorders (TMD)
• How do we measure and register TMD?
• How do we diagnose TMD?

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TMD, Occlusion and Orthodontic treatment

• Aetiology?
• Scientific evidence regarding the influence of
  occlusal factors?

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TMD, Occlusion and Orthodontic treatment

• Orthodontic treatment and TMD?
• TMD in treated and untreated cases.
• Short and long term

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TMD

• Collective term
• clinical problems
• Masticatory muscles
• TMJ and associated structures

10

Anamnestic data Symptoms of TMD

• TMJ sounds
• Pain from the masticatory muscles
• Pain from the TMJs
• Feelings of fatigue in the the jaws
• Tension headache

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Clinical data Signs of TMD

• TMJ sounds
• Tenderness to palpation masticatory muscles
  and/or the TMJs
• Pain on movement of the mandible
• Reduction in mandibular mobility

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Symptoms and signs of TMD

• are mostly mild in childhood.
• increase with age, both in prevalence and
  severity during adolescence. Cross sectional,
  adult, childrenadolescents

• Magnusson et al. Community Dent Oral Epid 1985
• De Bouver et al. Community Dent Oral Epidemiology
  1987
• Wänman and Agerberg. Acta Odontol Scand 1986

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Magnusson et al. Four year study of mandibular
dysfunction in children. Community Dent Oral
Epidemiol 1985
Four year interval. Two cohorts 7-11 years,
11-15 Signs and symptoms of TMD increased in
frequency and severity Only a few cases with
severe TMD.
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• Higher prevalence of headaches, TMJ clicking and
  muscular signs of TMD in
• girls compared with boys...

• Nilner 1986
• Wännman and Agerberg 1986
• Pilley et al 1992
• Kremenak et al 1992
• Nebbe et al 2000.

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• Men and woman have different courses of symptoms
  of TMD
• Men seem to recover to a greater extent than
  woman
• Wänman A. Longitudinal course of symptoms of
  craniomandibular disorders in men and woman.
  Acta Odontol Scand
  1996.

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Symptoms and signs of TMD

• often fluctuates over the course of time
• With both improvement and impairment in the
  individual

• Longitudinal studies of TMD
• Könönen and Nyström J Orofacial Pain 1993
• Heikinheimo et al. Eur J Orthod 1990
• Dibbets and van der Weele Am J Orthod 1987
• Magnusson et al. J Craniomandib Pract 1986

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In view of the normal fluctuation over time.

• Symptoms and signs of TMD does not mean that TMD
  treatment is necessary

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• In most cases the natural course and prognosis is
  good
• Conservative treatment approach when considering
  TMD treatment in children and adolescents

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5 TMD treatment demand in children and
adolescents

• Wänman and Agerberg 1986. 5 demand
• Sonnesen et al. 1998. 7 were referred for TMD
  treatment
• List et al. 1999. 4 treatment demand.
• Henrikson et al. 2000. 3 treatment demand.

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Reliable and valid TMD registrations

• RDC TMD
• Dworkin and LeResche. Research diagnostic
  criteria for TMD J of Craniomandibular
  DisordersFacial Oral Pain. 19926.

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RDC/TMD Dworkin and LeResche (1992)

• Provides a standardized clinical registration
• TMD diagnoses and diagnostic criteria
• Diagnoses are nonhierarchical and allows for of
  multiple diagnoses for a given subject

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Muscle disorders

• myofascial pain,
• myofascial pain with limited opening (lt 40 mm).

Dworkin and LeResche. Research diagnostic
criteria for TMD J of Craniomandibular
DisordersFacial Oral Pain. 19926
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Disk displacements

• disk displacement with reduction
• disk displacement without reduction, with limited
  opening
• disk displacement without reduction, without
  limited opening.

Dworkin and LeResche. Research diagnostic
criteria for TMD J of Craniomandibular
DisordersFacial Oral Pain. 19926
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Arthralgia, arthritis, arthrosis

1. Arthralgia
2. osteoarthritis of the TMJ
3. osteoarthrosis of the TMJ

Dworkin and LeResche. Research diagnostic
criteria for TMD J of Craniomandibular
DisordersFacial Oral Pain. 19926
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J Orofac Pain. 200620(2)138-44.The reliability
and validity of self-reported temporomandibular
disorder pain in adolescents.Nilsson, List and
Drangsholt

• CONCLUSION Very good reliability and high
  validity were found for the self-reported pain
  questions.
• In adolescent populations, the questions in this
  study can be used to screen for TMD pain

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TMD, Occlusion and Orthodontic treatment

• What is Temporomandibular disorders (TMD)?
• How do we measure and register and diagnose TMD?
• Aetiology?
• Scientific evidence regarding the influence of
  occlusal factors?

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• Multifactorial aetiology

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• Anatomical factors, including the occlusion and
  the TMJ
• Neuromuscular factors
• Psychogenic factors
• DeBoever and Carlsson Copenhagen, Munksgaard,
  1994

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• Occlusal interferences
• Angle Class II, severe retrognathia
• Large overjet
• Anterior open bite
• Posterior cross bite
• Controversy
• Kirveskari et al. 1986, 1989, 1992
• Miller et al 2004, 2005. Gidarako et al 2004
• Riolo et al. 1987
• Egermark-Eriksson et al. 1990
• Pullinger et al.1993
• Tanne et al.1995
• Sonnesen et al. 1998

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Association between occlusal factors and signs
and symptoms of TMDbut no causal relationship
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• Since.
• An association is necessary but not a sufficient
  criterion for a causal relationship

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Nebbe et al. Eur J Orthod 1998

• Adolescent female craniofacial morphology
  associated with bilateral TMJ disk displacement.
• Bilateral DD subjects (diagnosed with MRI) Hyper
  divergent and Class II characteristics

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AssociationTMD and cephalometric
variables-Retrognatic -Hyper divergent

• Hwang et al. Lateral cephalometric
  characteristics of malocclusion patients with TMJ
  symptoms. AJO 2006
• Miller et al. Severe retroganthia as a risk
  factor for recent onset painful TMJ disorders
  among...J. Orthod..2005 32 249-256
• Gidarako et al. Comparison of skeletal and dental
  morphology in asymptomatic volonteers and
  symptomatic patients with unilateral
  diskdisplacements without reduction. Angle Orthod
  2003

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John MT et al.Overbite and Overjet are not
Related to Self-report of Temporomandibular
Disorder Symptoms J Dent Res 81(3) 164-169, 2002

• No associations were found between overjet,
  overbite and reported TMD (TMJ pain, joint noises
  and limited mouth opening)
• This study provides the strongest evidence to
  date that there is no association between
  overbite or overjet and self-reported TMD

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Pullinger Seligman J Prosthet Dent. 2000
84(1)114-5 Quantification and validation of
predictive values of occlusal variables in TMD
using a multifactorial analysis.

• Occlusal factors explained no more than 5 to 27
  of the log likelihood.
• CONCLUSION Occlusal factors may be cofactors in
  the identification of patients with TMD, but
  their role should not be overstated

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Consensus that the cause of TMD is
multifactorialbut

• Centrally acting factors like depression and
  somatization have more evidence to support them
  as risk factors than local factors
• Nevertheless because local factors occur with
  notable prevalence and may be accessible for
  prevention they could still have major public
  health impact
• Drangsholt and LeResche 1999

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Conclusion TMD-Occlusion

• Aetiology?!
• Occlusal factors are not strong causal factors
• Occlusal factors may be contributing factors
• The importance of occlusal factors for the
  development of TMD should not be neglected and
  not be overstated

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Conclusion

• Well designed studies will continue to improve
  understanding
• Overall prognoses for TMD is good
• Do not over-treat
• Except in rare occasions simple and reversible
  TMD treatment

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Orthodontic treatment is a risk factor for the
development of TMD ?

• Solberg and Seligman. Philadelphia, Lea Febiger
  1985
• Thompson JR. Angle Orthod 1986
• Wyatt WE. Am J Orthod Dentofac Orthop 1987
• Nielsen et al. Eur J Orthod 1990

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Background

• These claims have been questioned and discussed
  in recent literature reviews.
• McNamara et al. 1995 J Orofacial Pain
• Luther. 1998a Angle Orthod

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Few prospective and controlled studies
!Orthodontics and TMD A meta analysis Am J
Orthod Dentofac Orthop 2002121438-46

• Controlled, prospective and longitudinal
• OReilly et al. 1993
• Keeling et al.1995
• Egermark-Eriksson et al. 1995
• Henrikson et al. 1999, 2000a, 2000b

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Few prospective and controlled studies
!Orthodontics and TMD A meta analysis Am J
Orthod Dentofac Orthop 2002121438-46

• Controlled, prospective and longitudinal
• OReilly et al. 1993
• Keeling et al.1995
• Egermark-Eriksson et al. 1995
• Henrikson et al. 1999, 2000a, 2000b

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Subjects
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• Results
• Differences between and within the groups
• Individual changes over the 2 year period

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Results Clinical findings
Orthodontic
Class II
Normal
Clinical signs
group
group
group
of TMD



start end
start end
start end
15 20
12 18
3 10
TMJ clicking
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Orthodontic group
Examination 1
Examination 2
5
13
TMJ clicking 10
8
5
46
No clicking 55
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Class II group

TMJ clicking 7
10
6
4
1
46
No clicking 51
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Normal group

1
6
TMJ clicking 2
5
1
53
No clicking 58
54
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Results
Orthodontic
Class II
Normal
Clinical signs
group
group
group
of TMD



start end
start end
start end
Pain on maximal
mandibular movement
31 16
26 23
3 8
Muscle tender to
palpation gr 2 and 3
45 20
38 44
15 18
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Results
Orthodontic
Class II
Normal
Clinical signs
group
group
group
of TMD



start end
start end
start end
Pain on maximal
mandibular movement
31 16
26 23
3 8
Muscle tender to
palpation gr 2 and 3
45 20
38 44
15 18
50
Extraction / non extraction orhtodontic
treatment. ?
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Anamnestic findings. Extraction vs
non-extraction treatment
Before Before 1 year 1 year 2 years 2 years 3 years 3 years
Non ex Ex Non ex Ex Non ex Ex Non ex Ex
Weekly headaches 20 31 14 29 14 29 14 35
Weekly headaches
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Anamnestic findings. Extraction vs
non-extraction treatment
Weekly pain TMJs and/or mastic. muscles
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Clinical findings. Extraction vs non-extraction
treatment
3 years
2 years
1 year
Before

Ex
Ex
Ex
Non ex
Non ex
Non ex
Ex
Non ex
29
29
31
57
7
10
14
30
Muscles tender to palpation
P0.03
P0.03
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Clinical findings. Extraction vs non-extraction
treatment
3 years
2 years
1 year
Before

Ex
Ex
Ex
Non ex
Non ex
Non ex
Ex
Non ex
18
20
11
43
4
10
10
17
Pain on maximal mandibular movement
P0.02
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Clinical findings. Extraction vs non-extraction
treatment
Before Before 1 year 1 year 2 years 2 years 3 years 3 years
Nonex Ex Non ex Ex Non ex Ex Non ex Ex
TMJ clicking 20 11 17 20 20 21 22 24
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What happened to the functional occlusion during
orthodontic treatment?
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Functional occlusal interferences

• The clinical relevance of occlusal and functional
  interferences and the relationship between
  interferences and TMD is debated
• Carlsson and Droukas 1984
• Pullinger et al 1993

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Functional occlusal interferences ()
Occlusal Interferences () Orthodontic group Start End Class II group Start End Normal group Start End
Non-working side interferences 31 13 9 9 8 10
Lateral sliding CR-CO ? 0.5 mm (functional shift) 26 14 17 14 7 5
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Functional occlusal interferences in per
cent Orthodontic group
Functional occlusal interferences Before During After 1 year after
Working side inteferences
Non working side
Protrusion
Sagittal distance CR - CO ? 1.5 mm
Lateral sliding CR-CO ? 0.5 mm
14
8
9
8
31
16
13
13
11
17
6
7
6
3
3
5
26
22
14
10
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Functional occlusion orthodontic
treatmentDecreased prevalenceEgermark-Eriksso
n Rönnerman 1995.Henrikson et al. 1999,
2000.
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Milosivec Samuels Functional occlusion after
fixed appliance treatment. Eur J Orthod 1988

• Retrospective UK three centre study
• More interferences than Henrikson et al.
• Post graduate studentsgtOrthodontic specialist

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No occlusal adjustment by grinding
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Number of occlusal contacts
Occlusal contacts Orthodontic group Start End Class II group Start End Normal group Start End
Maximal biting force 15 19 16 20 19 25
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Number of occlusal contacts Orthodontic group
Before 15
During 14
After 19
1 year after 22
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Discussion

• Low prevalence of TMD in the normal group
• Mohlin 1991,Pilley 1992, Sonnesen 1998

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Discussion

• Extraction vs non extraction treatment
• Janson and Hasund 1981, Kremenak 1992,
  OReilly 1993, Beattie 1994

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Discussion

• TMD during orthodontic treatment must be seen in
  the light of normal longitudinal changes in
  untreated populations of the same age

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Discussion

• The decreased prevalence of TMD of a muscular
  origin
• Reason?
• Occlusion/psychological aspects??

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Discussion

• Important with a prospective study design

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Registrations
Start
2 years
10 years
Orthodontic group
Class II group
Normal group
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Methods

• Registrations of symptoms of TMD were made by
  questionnaire.
• Same questionnaire as in previous registrations

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Subjects Aged 21-24 years (2003) 152/183
83 Orthodontic group 54/65 83 Class II
group 45/58 78 (10 subjects treated since 2
year reg.) Normal group 53/60 88
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Self estimated level of anxiousness on a VAS
Very anxious/nervous
Very calm/relaxed
Group N Mean VAS Mann Whitney U
Orthodontic group 54 33 (25) N.S
Class II group Normal group 45 53 34 (32) 37 (25) N.S
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Pain from the TMJs and/or masticatory muscles
Symptoms in Weekly Orthodontic group Start 2yr 10 yr Class II Group Start 2yr 10 yr Normal Group Start 2yr 10 yr
Pain from TMJs jaw muscles 14 6 9 7 16 11 7 5 10
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Reported weekly TMJ clicking Orthodontic group
Before After
active 10 years from
treatment treatment
from start

7
9
13 52
6
9
Yes No
6
2
3
5
55
49
45
40
Total 65
64 54
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Self-rated overall symptoms of TMD Verbal scale
Orthodontic group Start 2yr 10 yr Class II Group Start 2yr 10 yr Normal Group Start 2yr 10 yr

Severe 3 0 0 2 11 2 0 2 0
Very severe 2 0 0 2 2 0 0 2 0
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Discussion

• Orthodontic group Unchanged
• Class II group Somewhat decreased prevalence of
  symptoms. (10 subjects received
  Orthodontic treatment)
• Normal group Increased prevalence.

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Conclusions

• In the individuals, symptoms of TMD fluctuated
  substantially over time with no predictable
  pattern

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Conclusions

• Orthodontics did not increase the risk for TMD on
  a short or long term basis.

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• TMD during orthodontic treatment must be seen in
  the light of normal longitudinal changes in
  untreated populations of the same age

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Results

• Henrikson T, Ekberg EC, Nilner M. Symptoms and
  signs of TMD in girls with normal occlusion and
  Class II malocclusion. Acta Odontol Scand 1997
• Henrikson T, Kurol J, Nilner M. TMD before,
  during and after orthodontic treatment. Swe Dent
  J 1999
• Henrikson T, Nilner M, Kurol J. Signs of
  temporomandibular disorders in girls receiving
  orthodontic treatment. A prospective and
  longitudinal comparison with untreated Class II
  malocclusions and normal occlusion subjects. Eur
  J Orthod, June, 2000.
• Henrikson T, Nilner M. Temporomandibular
  disorders and need of stomatognathic treatment in
  orthodontically treated and untreated girls.
  Eur J Orthod, June 2000
• Henrikson and Nilner. Temporomandibular
  disorders, occlusion and orthodontic
  treatment.Journal of Orthodontics 2003
  Jun30(2)129-37