temporomandibular disorders (tmd) occlusion and orthodontic treatment thor henrikson
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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