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?

5. 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 ?

6. TMD, Occlusion and Orthodontic treatment Presentation outline
Introduction to Temporomandibular disorders (TMD)
How do we measure and register TMD?
How do we diagnose TMD?

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

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

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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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.

16. 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

17. 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.

18. 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. .

19. in children and adolescents
5% TMD treatment demand
in children and adolescents
Wänman and Agerberg % demand
Sonnesen et al % were referred for TMD treatment
List et al % treatment demand.
Henrikson et al % treatment demand.

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

21. 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

22. 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

23. 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

24. 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

25. J Orofac Pain. 2006;20(2): 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

26. 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?

27. 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.

28. 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

29. 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, 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

30. 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.

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

32. 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

33. 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:
Gidarako et al. Comparison of skeletal and dental morphology in asymptomatic volonteers and symptomatic patients with unilateral diskdisplacements without reduction. Angle Orthod 2003

34. John MT et al. Overbite and Overjet are not Related to Self-report of Temporomandibular Disorder Symptoms J Dent Res 81(3): , 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”

35. 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

36. 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

37. 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

38. 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

39. 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

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

42. 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

43. 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

44. 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

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

46. Results: Clinical findings
Orthodontic
Class II
Normal
Clinical signs
group
group
group
of TMD % % %
start end
start end
start end
TMJ clicking

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

48. Results Orthodontic Class II Normal Clinical signs group group group
of TMD % % %
start end
start end
start end
Pain on maximal
mandibular movement
Muscle tender to
palpation gr 2 and 3

49. Results Orthodontic Class II Normal Clinical signs group group group
of TMD % % %
start end
start end
start end
Pain on maximal
mandibular movement
Muscle tender to
palpation gr 2 and 3

50. Extraction / non extraction
orhtodontic treatment. ?

51. 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

52. 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

53. 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

54. % 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

55. 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

56. What happened to the functional occlusion during orthodontic treatment ?

57. 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

58. Functional occlusal interferences (%)
Orthodontic
group
Start End
Class II
Normal group
Non-working side interferences
Lateral sliding
CR-CO  0.5 mm (functional shift)

59. 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

60. Functional occlusion & orthodontic treatment Decreased prevalence: Egermark-Eriksson & Rönnerman Henrikson et al. 1999, 2000.

61. 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

62. No occlusal adjustment by grinding

63. Number of occlusal contacts
Orthodontic
group
Start End
Class II
Normal group
Maximal biting force

64. Number of occlusal contacts Orthodontic group
Before 15
During 14
After 19
1 year after 22

65. 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

66. 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.

67. 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.

68. 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

69. 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.

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

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

72. 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%

73. 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)

74. 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

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

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

77. Discussion
Orthodontic group; Unchanged
Class II group: Somewhat decreased prevalence of symptoms (10 subjects received Orthodontic treatment)
Normal group; Increased prevalence.

78. 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 .

79. 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.

80. 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.

81. 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