Temporomandibular disorders (TMD) Occlusion and

Orthodontic treatment

Thor Henrikson

PatientsColleagues Non systematic reviews. “Viewpoints”Commercial interests

TMD views and opinions….

“Not everybody with TMJ clicking needs TMJ surgery”

TMD in relation to Orthodontic treatment

• Causing TMD?

• Curing TMD?

• Neutral?

TMD, Occlusion and Orthodontic treatmentPresentation outline

• Introduction to Temporomandibular disorders (TMD)

• How do we measure and register TMD?

• How do we diagnose TMD?

TMD, Occlusion and Orthodontic

treatment

• Aetiology?

• Scientific evidence regarding the influence of occlusal factors?

TMD, Occlusion and Orthodontic treatment

• Orthodontic treatment and TMD?

• TMD in treated and untreated cases.

• Short and long term

TMD

• Collective term

• # clinical problems

• Masticatory muscles

• TMJ and associated structures

• TMJ sounds

• Pain from the masticatory muscles

• Pain from the TMJs

• Feelings of fatigue in the the jaws

• Tension headache

Anamnestic data: Symptoms of TMD

• TMJ sounds

• Tenderness to palpation masticatory muscles and/or the TMJs

• Pain on movement of the mandible

• Reduction in mandibular mobility

Clinical data: Signs of TMD

Symptoms and signs of TMD

• are mostly mild in childhood.• increase with age, both in

prevalence and severity during adolescence. Cross sectional, adult, children&adolescents

•Magnusson et al. Community Dent Oral Epid 1985

•De Bouver et al. Community Dent Oral Epidemiology 1987

•Wänman and Agerberg. Acta Odontol Scand 1986

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.

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.

• 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.

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

In view of the normal fluctuation over time….

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

• 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.

5% TMD treatment demandin children and adolescents

Reliable and valid TMD registrations

• RDC TMD

• Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6.

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

Muscle disorders

a) myofascial pain, b) myofascial pain with limited

opening (< 40 mm).

Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6

Disk displacements

a) disk displacement with reductionb) disk displacement without reduction,

with limited openingc) disk displacement without reduction,

without limited opening.

Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6

Arthralgia, arthritis, arthrosis

a) Arthralgiab) osteoarthritis of the TMJc) osteoarthrosis of the TMJ

Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6

J Orofac Pain. 2006;20(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

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?

Multifactorial aetiology

• Anatomical factors, including the occlusion and the TMJ

• Neuromuscular factors

• Psychogenic factors

DeBoever and Carlsson Copenhagen, Munksgaard, 1994

• Occlusal interferences• Angle Class II, severe retrognathia• Large overjet• Anterior open bite• Posterior cross biteControversy

• 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

Association between occlusal factors and signs

and symptoms of TMDbut

no causal relationship

• Since….

• An association is necessary but not a sufficient criterion for a causal relationship

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

Association:TMD 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

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”

Pullinger & SeligmanPullinger & SeligmanJ Prosthet Dent. 2000; 84(1):114-5J 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

Consensus that the cause of TMD is multifactorial

but

• 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

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

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

•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

Orthodontic treatment is a risk factor for the development of TMD

?

Background

These claims have been questioned and discussed in “recent” literature reviews….

•McNamara et al. 1995 J Orofacial Pain•Luther. 1998a Angle Orthod

Few prospective and controlled studies !

Orthodontics and TMD: “A meta analysis” Am J Orthod Dentofac Orthop 2002;121:438-46

• Controlled, prospective and longitudinal

• O´Reilly et al. 1993

• Keeling et al.1995

• Egermark-Eriksson et al. 1995

• Henrikson et al. 1999, 2000a, 2000b

Few prospective and controlled studies !

Orthodontics and TMD: “A meta analysis” Am J Orthod Dentofac Orthop 2002;121:438-46

• Controlled, prospective and longitudinal

• O´Reilly et al. 1993

• Keeling et al.1995

• Egermark-Eriksson et al. 1995

• Henrikson et al. 1999, 2000a, 2000b

Subjects

N orm al occlusion60 subjects

65 subjectsO rthodontic treatm ent

58 subjectsN o orthodontic treatm ent

C lass II m alocclusion123 subjects

183 adolescent fem ales

Results

• Differences between and within the groups

• Individual changes over the 2 year period

Results: Clinical findings

Clinical signs of TMD

Orthodonticgroup

% start end

Class II group

%start end

Normal group

% start end

TMJ clicking 15 20 12 18 3 10

5 TMJ clicking 10

Examination 1 Examination 2

46

85

No clicking 55

13

51

Orthodontic group

6 TMJ clicking 7

46

41

No clicking 51

10

47

Class II group

1 TMJ clicking 2

53

5 1

No clicking 58

6

54

Normal group

Results

Clinical signs of TMD

Orthodonticgroup

%start end

Class IIgroup

%start end

Normalgroup

%start end

Pain on maximalmandibular movement 31 16 26 23 3 8

Muscle tender topalpation gr 2 and 3 45 20 38 44 15 18

Results

Clinical signs of TMD

Orthodonticgroup

%start end

Class IIgroup

%start end

Normalgroup

%start end

Pain on maximalmandibular movement 31 16 26 23 3 8

Muscle tender topalpation gr 2 and 3 45 20 38 44 15 18

Extraction / non extraction

orhtodontic treatment.

?

%Before 1 year 2 years 3 years

Non ex Ex

Nonex Ex

Non ex Ex

Nonex Ex

Weeklyheadaches 20 31 14 29 14 29 14 35

Anamnestic findings. Extraction vs non-extraction treatment

15

Ex

9

Ex

6

ExNonex

Non ex

NonexEx

Non ex

17 43711

3 years2 years 1 yearBefore

%

Anamnestic findings. Extraction vs non-extraction treatment

Weekly painTMJs and/or mastic. muscles

P=0.03P=0.03

29

Ex

29

Ex

31

ExNonex

Non ex

NonexEx

Non ex

57 7101430Muscles tender to palpation

3 years2 years 1 yearBefore

%

Clinical findings. Extraction vs non-extraction treatment

P=0.02

18

Ex

20

Ex

11

ExNonex

Non ex

NonexEx

Non ex

43 4101017Pain on maximal mandibular movement

3 years2 years 1 yearBefore

%

Clinical findings. Extraction vs non-extraction treatment

%Before 1 year 2 years 3 years

Nonex Ex

Nonex Ex

Non ex Ex

Nonex Ex

TMJ clicking 20 11 17 20 20 21 22 24

Clinical findings. Extraction vs non-extraction treatment

What happened to the functional

occlusion during orthodontic treatment

?

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

Functional occlusal interferences (%)

Occlusal Interferences

(%)

Orthodonticgroup

Start End

Class IIgroup

Start End

Normal group

Start End

Non-working side interferences

31 13 9 9 8 10

Lateral slidingCR-CO 0.5 mm (functional shift)

26 14 17 14 7 5

Functional occlusal interferences %

Before During After 1 year

after

Working side inteferences

Non working side

Protrusion

Sagittal distanceCR - CO 1.5 mm

Lateral slidingCR-CO 0.5 mm

14 8 9 8

31 16 13 13

11 17 6 7

6 3 3 5

26 22 14 10

Functional occlusal interferences in per cent

Orthodontic group

Functional occlusion & orthodontic treatment

Decreased prevalence:

Egermark-Eriksson & Rönnerman 1995.

Henrikson et al. 1999, 2000.

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 students>Orthodontic specialist

No occlusal adjustment by

grinding

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

Number of occlusal contacts Orthodontic group

Before

15

During

14

After

19

1 year after

22

Discussion

• Low prevalence of TMD in the normal group

Mohlin 1991,Pilley 1992, Sonnesen 1998

Discussion

• Extraction vs non extraction treatment

Janson and Hasund 1981, Kremenak 1992, O´Reilly 1993, Beattie 1994

Discussion

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

Discussion

• The decreased prevalence of TMD of a muscular origin

Reason?

Occlusion/psychological aspects??

Discussion

• Important with a prospective study design

Registrations

Start 2 years

Orthodontic group

Class II group

Normal group

10 years

Methods

• Registrations of symptoms of TMD were made by questionnaire.

• Same questionnaire as in previous registrations

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%

Self estimated level of anxiousness on a VAS

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)

Very anxious/nervousVery calm/relaxed

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

Pain from the TMJs and/or masticatory muscles

Before After active 10 years from

treatment treatment from start

Reported weekly TMJ clicking

Orthodontic group

7

913

52

6

55

2

49

6 9

5

3

45 40

Total 65 64 54

Yes

No

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

Self-rated overall symptoms of TMD: Verbal scale

Discussion

• Orthodontic group; Unchanged

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

• Normal group; Increased prevalence.

Conclusions

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

Conclusions

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

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

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 Jun;30(2):129-37