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?

Knowledge about TMD Treatment ? Explain the problem Prognoses? How common ? Will it need any further treatment and in that case what kind of treatment. Prognoses? Treatment ?

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 the jaws Tension headache So we go further on to some background factors. Symptoms of TMD is used for anamnestic data which we get from a questionnaire or when interviewing the patient Examples of symptoms of TMD can be Reported TMJ sounds Pain from the masticatory muscles Pain from the TMJs Feelings of fatigue in the 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 Signs of TMD is data obtained from a clinical investigation. Examples of signs of TMD can be TMJ sounds obtained by a clinical examination Tenderness to palpation of the masticatory muscles and 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

Four year interval. Two cohorts 7-11 years, 11-15 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. From longitudinal studies we have learned that TMD in the individual, often fluctuates over the course of time, with both improvement and impairment in the individual.

girls compared with boys... 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. We have also learnt that there are some gender differences and that TMJ clicking, TMD of a muscular origin and Tension headache are more common in the female population

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. Men and woman seems to have different courses of symptoms of TMD Men seem to recover to a greater extent than woman This could be one explanation that more woman than men are seeking TMD treatment.

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 People in general seems to have relatively strong opinions about TMD. Wei our self in this group has as you already have noticed different opinions about TMD. Patients have their views and our dental colleagues have their different views. Sometimes we are exposed to non systematic reviews that are written just to prove a point or an opinion so called viewpoint articles. Further on we are exposed to economical interests from manufactures who want to sell appliances and also dentist who wants to make a good living from treating TMD.

In most cases the natural course and prognosis is good Conservative treatment approach when considering TMD treatment in children and adolescents The mere occurence of symptoms and signs of TMD does not indicate a need of stomatognathic treatment. Instead, the fluctuation over the course of time suggests expectancy or a concervative treatment approach when considering stomatognathic treatment in children and adolescents. In those patient who have symptoms and pain for a long period of time some type of stomatognathic treatment could be considered. .

in children and adolescents 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 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 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

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

Arthralgia, arthritis, arthrosis 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

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 Many theories have been presented in the past regarding the etiology of TMD. Specific etiological factors for TMD have not been found, and today the etiology is believed to be multifactorial.

Anatomical factors, including the occlusion and the TMJ Neuromuscular factors Psychogenic factors DeBoever and Carlsson Copenhagen, Munksgaard, 1994 During the eighties it became generally accepted that three main groups of etiological factors are involved: anatomical factors, including the occlusion and the TMJ itself, neuromuscular factors and psychogenic factors. If two or all three of these groups of factors were present, the risk of developing pain and dysfunction increased

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 Different types of occlusal interferences, the overall need for orthodontic treatment, Angle Class II and III malocclusion, large overjet, anterior open-bite and posterior cross-bite have been associated with signs and symptoms of TMD. However, there is still controversy about the relative importance of occlusion in relation to other contributing factors

Association between occlusal factors and signs and symptoms of TMD but no causal relationship The role of morphological occlusion and functional occlusion as contributing factors in the development of TMD has been discussed during the last three decades.

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 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

Orthodontic treatment is a risk factor for the development of TMD ? Solberg and Seligman 1985 claimed that orthodontic could be a risk by inducing occlusal interferences. While Thompson and Wyatt calimed that premolar extractions in combination with orthodontic treatment causes TMD. They claimed that patients with overretracted incisors, as a result of orthodontic treatment with premolar extractions, had a high incidence of TMD. Further on Nielsen in 1990 found in a retrospective study that tenderness to palpation of the musculature and the TMJ area was more prevalent among orthodontically treated subjects than in untreated controls 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…. McNamara et al. 1995 J Orofacial Pain Luther. 1998a Angle Orthod These claims have been questioned and discussed in recent literature reviews….

Few prospective and controlled studies 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 Only a few studies have so far been controlled prospective studies as we could read in a recent published meta analysis in Amercican journal of orthodontics

Few prospective and controlled studies 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 Only a few studies have so far been controlled prospective studies as we could read in a recent published meta analysis in Amercican journal of orthodontics

Subjects To investigate the relation between occlusion and orthodontic treatment on the one hand and TMD on the other hand we choose a research model consisting of 183 girls. But before going in to the results of our research I just want to go trough some background factors for TMD

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

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

Orthodontic group Class II group 4 Normal group Examination 1 Examination 2 TMJ clicking 10 5 13 8 5 No clicking 55 46 51 Class II group TMJ clicking 7 6 10 4 1 No clicking 51 46 47 Sedan går vi vidare med individuella förändringar vad det gäller käkledsknäppningar. Normal group TMJ clicking 2 1 6 5 1 No clicking 58 53 54

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

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

Extraction / non extraction orhtodontic treatment. ?

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

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

Extraction vs non-extraction treatment Clinical findings. Extraction vs non-extraction treatment % Before 1 year 2 years 3 years Non ex Ex Non ex Ex Non ex Ex Non ex Ex 30 57 14 31 10 29 7 29 Muscles tender to palpation P=0.03 P=0.03

% Clinical findings. Extraction vs non-extraction treatment Before 1 year 2 years 3 years Non ex Ex Non ex Ex Non ex Ex Non ex Ex 17 43 10 11 10 20 4 18 Pain on maximal mandibular movement P=0.02

Extraction vs non-extraction treatment Clinical findings. Extraction vs non-extraction treatment % Before 1 year 2 years 3 years Nonex Ex Non ex Non ex TMJ clicking 20 11 17 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 (%) Orthodontic group Start End Class II Normal group 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

Functional occlusal interferences in per cent Orthodontic group 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

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 Orthodontic group Start End Class II Normal group 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

Low prevalence of TMD in the normal group Discussion Low prevalence of TMD in the normal group Mohlin 1991,Pilley 1992, Sonnesen 1998 One of the most interesting findings was the relatively low prevalence pf TMD in the Normal group both in comparison with the orthodontic group and the untreated Class II group and also in comparison with girls in the same age goups selected on the presens of malocclusion as presented by Mohlin 1991, Pilley 1992 and Soneson 1998. The reason for the low prevalnce of TMD in the nirmal group could be that the Normal group was homogeneous and consisted of subjects with close to an ideal occlusion while previous studies often compared malocclusion groups with groups with an Angle Class I relationship which only implies that the sagittal relations are normal but contains some other type of malocclusion

Extraction vs non extraction treatment Discussion Extraction vs non extraction treatment Janson and Hasund 1981, Kremenak 1992, O´Reilly 1993, Beattie 1994 The differences between the extraction and non extraction group concerning muscular signs of TMD was in accordance with the findings of Janson and Hasund 1981 but were unexpected since several Kremenak 1992, Oreilly 1993 and Beattie 1994 did not indicated differences between extraction and non extraction groups.

Discussion TMD during orthodontic treatment must be seen in the light of normal longitudinal changes in untreated populations of the same age There is therefore a need for knowledge about the occurrence of symptoms and signs of TMD during orthodontic treatment in the light of normal longitudinal changes in subjects of the same age with similar but untreated populations.

Occlusion/psychological aspects?? Discussion The decreased prevalence of TMD of a muscular origin Reason? Occlusion/psychological aspects?? One other major finding was the decreased prevalence of TMD of a muscular origin within the orthodontic group. The reason for this improvement is not well understood but might be due to a a better occlusal stabiltity with less functional interferences and more occlusal contacts. While another explanation might be psychological aspects of an improved dental appearance in some individuals

Important with a prospective study design Discussion Important with a prospective study design In our study since the increased prevalence of TMD in the extraction group were found before the orthodontic treatment started it appears to be the selection criteria for extractions rather than extraction treatment itself that explains the higher prevalence of TMD. This finding underline the importance with a prospective and longitudinal study design.

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

Methods Registrations of symptoms of TMD were made by questionnaire. Same questionnaire as in previous registrations Anamnestic data and symptoms of TMD a questionnaire.

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 Mean VAS Mann Whitney U Orthodontic group 54 33 (25) N.S Class II group Normal group 45 53 34 (32) 37 (25)

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 Pain from TMJs & jaw muscles 14 6 9 7 16 11 7 5 10

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

Self-rated overall symptoms of TMD: Verbal scale Orthodontic group Start 2yr 10 yr Class II Group Start 2yr 10 yr Normal Severe 3 0 0 2 11 2 0 2 0 Very severe 2 0 0 2 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 In the individuals, symptoms and signs 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. Orthodontics either with or without tooth extractions did not increase the risk for symptoms and signs or worsen pre-treatment TMD.

TMD during orthodontic treatment must be seen in the light of normal longitudinal changes in untreated populations of the same age There is therefore a need for knowledge about the occurrence of symptoms and signs of TMD during orthodontic treatment in the light of normal longitudinal changes in subjects of the same age with similar but untreated populations.

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 Results. The results I am going to present first are parts of these four papers which were published between 1997 and 2000 in the European Journal Of Orthodontics. Since we have registered a substantial number of variables I have choose to present a part of the overall results in this presentation