Temporomandibular disorders TMD Occlusion and Orthodontic treatment Thor

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 • Causing TMD? • Curing TMD? • Neutral?

TMD, Occlusion and Orthodontic treatment Presentation 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

Anamnestic data: Symptoms of TMD • • • TMJ sounds Pain from the masticatory muscles Pain from the TMJs Feelings of fatigue in the jaws Tension headache

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

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

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.

Reliable and valid TMD registrations • RDC TMD • Dworkin and Le. Resche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders: Facial & Oral Pain. 1992; 6.

RDC/TMD Dworkin and Le. Resche (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 Le. Resche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders: Facial & Oral Pain. 1992; 6

Disk displacements a) disk displacement with reduction b) disk displacement without reduction, with limited opening c) disk displacement without reduction, without limited opening. Dworkin and Le. Resche. Research diagnostic criteria for TMD: J of Craniomandibular Disorders: Facial & Oral Pain. 1992; 6

Arthralgia, arthritis, arthrosis a) Arthralgia b) osteoarthritis of the TMJ c) osteoarthrosis of the TMJ Dworkin and Le. Resche. 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 De. Boever and Carlsson Copenhagen, Munksgaard, 1994

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

Association between occlusal factors and signs and symptoms of TMD but 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 & 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

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 Le. Resche 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

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

Background These claims have been questioned and discussed in “recent” literature reviews…. • Mc. Namara et al. 1995 J Orofacial Pain • Luther. 1998 a 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, 2000 a, 2000 b

Subjects

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

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

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

Results Clinical signs of TMD Orthodontic group % start end Class II group % start end Normal group % 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

Extraction / non extraction orhtodontic treatment. ?

Anamnestic findings. Extraction vs non-extraction treatment % Weekly headaches Before Non ex 20 1 year Ex Non ex 31 14 2 years Ex Non ex 29 14 3 years Ex Non ex Ex 29 14 35

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

Clinical findings. Extraction vs non-extraction treatment % Muscles tender to palpation Before Non ex 30 1 year Ex Non ex 57 14 P=0. 03 2 years Ex Non ex 31 10 3 years Ex Non ex Ex 29 7 29 P=0. 03

Clinical findings. Extraction vs non-extraction treatment % Pain on maximal mandibular movement Before Non ex 17 1 year Ex Non ex 43 10 P=0. 02 2 years Ex Non ex 11 10 3 years Ex Non ex Ex 20 4 18

Clinical findings. Extraction vs non-extraction treatment Before % TMJ clicking 1 year 2 years 3 years Non Non ex Ex 20 11 17 20 20 21 22 24

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 (%) Non-working side interferences Lateral sliding CR-CO 0. 5 mm (functional shift) Orthodontic group Start End 31 26 13 14 Class II group Start End 9 9 17 14 Normal group Start End 8 7 10 5

Functional occlusal interferences in per cent Orthodontic group Functional occlusal interferences % Before During After 1 year after Working side inteferences Non working side 14 8 9 8 31 16 13 13 Protrusion 11 17 6 3 3 5 26 22 14 10 Sagittal distance CR - CO 1. 5 mm Lateral sliding CR-CO 0. 5 mm

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 Maximal biting force Orthodontic group Start End 15 19 Class II group Start End 16 20 Normal group Start 19 End 25

Number of occlusal contacts Orthodontic group Before During 15 14 After 1 year after 19 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 Orthodontic group Class II group Normal group 2 years 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 Very calm/relaxed Very anxious/nervous Group N Orthodontic group 54 Mean VAS Mann Whitney U 33 (25) N. S Class II group 45 34 (32) Normal group 53 37 (25)

Pain from the TMJs and/or masticatory muscles Symptoms in % Orthodontic group Start 2 yr 10 yr Class II Group Start 2 yr 10 yr 14 7 Normal Group Start 2 yr 10 yr Weekly Pain from TMJs & jaw muscles 6 9 16 11 7 5 10

Reported weekly TMJ clicking Orthodontic group Before treatment Yes 13 After active treatment 7 9 10 years from start 6 2 3 6 No Total 52 65 49 9 5 55 64 40 45 54

Self-rated overall symptoms of TMD: Verbal scale Orthodontic group Start 2 yr 10 yr Class II Group Start 2 yr 10 yr Normal Group Start 2 yr 10 yr Severe 3 0 0 2 11 2 0 Very severe 2 0 0 2 0

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