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Temporomandibular disorders (TMD) Occlusion and Orthodontic treatment

Temporomandibular disorders (TMD) Occlusion and Orthodontic treatment. Thor Henrikson. TMD views and opinions…. Patients Colleagues Non systematic reviews. “Viewpoints” Commercial interests. “Not everybody with TMJ clicking needs TMJ surgery”. TMD in relation to Orthodontic treatment.

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Temporomandibular disorders (TMD) Occlusion and Orthodontic treatment

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  1. Temporomandibular disorders (TMD) Occlusion and Orthodontic treatment Thor Henrikson

  2. TMD views and opinions…. • Patients • Colleagues • Non systematic reviews. “Viewpoints” • Commercial interests “Not everybody with TMJ clicking needs TMJ surgery”

  3. TMD in relation to Orthodontic treatment • Causing TMD? • Curing TMD? • Neutral?

  4. TMD, Occlusion and Orthodontic treatmentPresentation outline • Introduction to Temporomandibular disorders (TMD) • How do we measure and register TMD? • How do we diagnose TMD?

  5. TMD, Occlusion and Orthodontic treatment • Aetiology? • Scientific evidence regarding the influence of occlusal factors?

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

  7. TMD • Collective term • # clinical problems • Masticatory muscles • TMJ and associated structures

  8. 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

  9. 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

  10. Symptoms and signs of TMD • are mostly mild in childhood. • increase with age, both in prevalence and severity duringadolescence.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

  11. 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.

  12. 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.

  13. 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.

  14. 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

  15. In view of the normal fluctuation over time…. • Symptoms and signs of TMD does not mean that TMD treatment is necessary

  16. 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.

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

  18. RDC/TMD Dworkin and LeResche (1992) • Provides astandardized clinical registration • TMD diagnosesand diagnostic criteria • Diagnoses arenonhierarchicaland allows for ofmultiple diagnosesfor a given subject

  19. Muscle disorders • myofascial pain, • myofascial pain with limited opening (< 40 mm). Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6

  20. 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 Disorders:Facial & Oral Pain. 1992;6

  21. Arthralgia, arthritis, arthrosis • Arthralgia • osteoarthritis of the TMJ • osteoarthrosis of the TMJ Dworkin and LeResche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders:Facial & Oral Pain. 1992;6

  22. 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

  23. 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?

  24. Multifactorialaetiology

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

  26. 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

  27. Association between occlusal factors and signs and symptoms of TMDbut no causal relationship

  28. Since…. • An association is necessary but not a sufficient criterion for a causal relationship

  29. 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

  30. 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

  31. 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”

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

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

  38. 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

  39. 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

  40. Subjects

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

  42. Results: Clinical findings Orthodontic Normal Class II Clinical signs group group group of TMD % % % start end start end start end 15 20 12 18 3 10 TMJ clicking

  43. Orthodontic group Examination 1 Examination 2 5 13 TMJ clicking 10 8 5 No clicking 55 46 51 Class II group TMJ clicking 7 10 6 4 1 No clicking 51 46 47 Normal group 1 6 TMJ clicking 2 5 1 No clicking 58 53 54

  44. Results Normal Orthodontic Class II 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

  45. Results Normal Orthodontic Class II 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

  46. Extraction / non extraction orhtodontic treatment. ?

  47. Anamnestic findings. Extraction vs non-extraction treatment

  48. % Before 1 year 2 years 3 years Non ex Ex Non ex Ex Non ex Ex Non ex Ex 11 17 7 6 3 9 4 15 Anamnestic findings. Extraction vs non-extraction treatment Weekly pain TMJs and/or mastic. muscles

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