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Temporomandibular Disorders and Orthodontic Treatment � A Review with a Reported Clinical Case

Temporomandibular Disorders
and Orthodontic Treatment –
A Review with a Reported Clinical Case
Tomislav Badel1, Miljenko Marotti2 and Ivana Savić Pavičin3
1Department of Prosthodontics,
School of Dental Medicine, University of Zagreb
2Department of Diagnostic and Interventional Radiology,
“Sestre Milosrdnice” University Hospital Center, University of Zagreb
3Department of Dental Anthropology, School of
Dental Medicine, University of Zagreb
1. Introduction
Temporomandibular disorders (TMDs) are musculoskeletal disorders affecting the
temporomandibular joint (TMJ), the masticatory muscles (myogenic subgroup), or both, and
they are the most common cause of orofacial somatic nonodontogenic pain. Osteoarthritis
(OA) and disc displacement (DD) of TMJ belong to the arthrogenic subgroup of TMDs
(Okeson & de Leeuw, 2011).
The aim of the paper is to evaluate the relationship between malocclusion, orthodontic
treatment and development of TMD. The article includes a 5-year follow-up of a female
patient who underwent orthodontic treatment instead of TMD treatment.
2. Diagnostics of painful TMDs
The multifactorial etiopathogenic models of TMDs have no practical use at patient level
because certain occlusal conditions, exposure to psychological macrotrauma, bruxist
behaviour, etc., cannot be associated with TMD symptoms which are exhibited by the
patient. Idiopathic (nonspecific) etiology imposes a personalised approach to every single
patient during diagnostics, planning and the use of treatment modalities as well as during
recall. TMD symptomatology includes the main symptoms such as pain of masticatory
muscles and/or TMJ, limited and painful mouth opening as well as pathologic noise in the
joints. Pain is the most important symptom in TMDs pathogenesis due to which patients
seek treatment and therefore, the main aim of the treatment is pain removal (Jürgens, 2009).
The biopsychosocial component is strongly based on chronification of musculoskeletal pain.
The biopsychosocial concept includes a combination of biological and psychological
considerations on the etiology of TMDs, particularly those accompanied by chronic pain.
Chronic pain has its etiologic basis in somatosensory and psychosocial factors. Patients with
Orthodontics – Basic Aspects and Clinical Considerations
chronic pain live with their biological problem (pain activation with or without obvious
pathology), which can have a psychological foundation as well as effects on their behaviour.
Specific social (interpersonal) relations often have negative effects for patients (Türp, 2000;
Giannakopoulos et al., 2010).
The most widespread system of standardised examination of patients and asymptomatic
individuals is the use of RDC (Research diagnostic criteria)/TMD, which includes a clinical
examination in Axis I, and a psychiatric testing in Axis II (Dworkin & Le Resche, 1992).
RDC/TMD system classifies TMDs into three subclasses: muscle disorders, DD, and
arthralgia/arthritis/arthropathy. The importance of such a system is that it shows a
possibility of defining certain diagnoses of TMDs wherein the diagnosis of one subgroup
does not exclude the diagnosis from the other subgroup in the same patient. Nevertheless,
there are certain limitations because RDC/TMD does not include a supplementary magnetic
resonance imaging (MRI) diagnostics.
2.1 Manual functional analysis
Bumann in collaboration with Groot Landeweer provided an overall system to diagnose
TMDs, and, together with Lotzmann, confirmed it by thorough MRI diagnostics of TMJ
(Bumann & Lotzmann, 2002). The use of manual functional analysis (MFA) is particularly
stressed in the evaluation of the condition of the stomatognathic system prior to major
irreversible procedures in order to avoid delayed detection of more or less pronounced
clinical signs and symptoms of TMDs which would not be recognized and treated on time in
such a case (Figure 1). MFA is a result of collaboration between the orthodontist and
physiotherapist and its first purpose was to perform screenings prior to orthodontic
treatment (Bumann & Lotzmann, 2002). By including MRI along with prior use of MFA, the
less known diagnoses can be established such as partial DD and DD upon excursive
movement of TMJ (Badel et al., 2009a).
Fig. 1. Dynamic compression starts with the therapist cranially pressuring the distal edge of
the mandibular corpus (left), and dorsal passive compression (right).
The main purpose of clinical diagnostics is to determine the pathological condition of
masticatory muscles and/or the TMJs. A standard dental examination focusing on dental
status and occlusion is insufficient for diagnostics as well as just measuring the mouth
opening (Kropmans et al., 2000). Manual diagnostic methods of the stomatognathic system
are necessary for (von Piekartz, 2005):
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
differential diagnostics of muscular, arthrogenic disorder or both;
determining the status of the articular disc and the articular surfaces;
measuring the passive capacity of mouth opening, and
making specific diagnoses.
2.2 Clinical importance of imaging modalities
A limiting factor in the study of TMDs is radiologic diagnostics, which is often used in
dental treatment of teeth and jaw bones. Traditional x-ray images as well as conventional
and computed tomography (CT) cannot show all the functional elements of TMJ. The key
component in articular biomechanics is the relationship between the articular plate or disc
as a cartilaginous structure and the condylar head as an osseous structure. Another factor is
the disc-condyle complex relationship with the posterior plane of the articular eminence,
across which the articular complex moves simultaneously on mouth opening.
Ahmad et al. (2009) believe that panoramic x-ray and TMJ radiography should not be
included into diagnostic procedure at the specialist level. CT is indicated in individuals who
have clinical signs of OA and who cannot be exposed to strong magnetic field due to
claustrophobia, metal implants or pacemakers. In individuals with such limitations, CT
would not be an adequate diagnostic means if they only have DD without any changes in
hard osseous tissues. When the MRI finding of OA needs to be confirmed by CT, which is
still the gold standard in diagnostics of osseous tissues of joints (Figure 2), one should bear
in mind the exposure to x-ray radiation. MRI is a radiologic technique of layered imaging in
the desired plane without moving the body and without exposing the patient to ionised
radiation. As in the other fields of diagnostics in medicine, MRI is qualitatively better
because it enables imaging of soft tissues without invasive effects on the recorded object as
opposed to arthrography. Therefore, MRI has become the gold standard of diagnostics and
the dominant radiologic technique in diagnostics of TMDs enabling the imaging of
cartilaginous articular surfaces and it can successfully show the position of the articular disc
(Badel et al., 2009a; Badel et al., 2010a).
Fig. 2. Computed tomography (left) of temporomandibular joint with degenerative bone
changes (1 condyle, 2 articular eminence, 3 external acoustical meatus, 4 osteophyte) and
magnetic resonance imaging (right) with anterior displaced disc (arrow).
In orthopedics, the possibilities of manual tests and limitations of traditional radiologic
examinations as well as advantages of MRI have already been evaluated. The relationship
Orthodontics – Basic Aspects and Clinical Considerations
between pain and diagnostic findings has also been researched, particularly the relationship
between the knee and the lumbar region of the spine. Regarding clinical diagnostics, Palla
(1998) concluded that certain forms of TMDs do not have specific signs, that is, certain
diagnostic tests have low validity and reliability.
3. Epidemiology of TMD and the use of MRI
A high prevalence of symptoms, 25-75%, out of which the major part of the symptoms were
pathological noise in the TMJ, was determined in general population by various methods of
data gathering (questionnaires, clinical examination, use of radiologic modalities). Although
there are some methodological discrepancies which can be hinder the direct comparison of
epidemiologic results of TMD, it is certain that temporomandibular pain has a low
prevalence, mostly less than 10% of general population, and most often only 5% (Durham,
2008). In an epidemiologic study, Gesch et al. (2004a) determined by a clinical examination
of 49.9% of the population that there is at least one clinical sign of TMD, whereas only 2.7%
had painful TMJ.
Another issue in the TMD epidemiology is dependence on the age and gender of the patient.
Manfredini et al. (2010) differentiated two age peaks (two peaks of greatest incidence) in
TMD patients (30-35 and 50-55 years) with female: male ration 5:1, which partly coincides
with previous knowledge that the greatest prevalence is in women of reproductive age (that
is between 18-45) (Palla, 1998; Badel, 2007a; Durham, 2008). Although osteoarthritis has only
partly greater prevalence in elderly people, it is obvious that TMDs do not progress with
patients’ age. Using MRI, Schmitter et al. (2010) proved that in elderly population, each
gender equally, there is a discrepancy of high incidence (70%) of OA signs accompanied by
low incidence of clinical signs of TMD (out of 30 subjects only one had painful TMJ).
Predominance of females in TMD patients is explained by the effects of female hormones or
attribute this to the gender distinction, biological and physiological differences, behavioural
characteristics, and genetic factors (Wang et al., 2008).
In order to plan and perform orthodontic treatment, it is important to have all the data
regarding TMD symptoms as well as the need to treat them in the population of children
and adolescents during the period of growth and the development of jaws and teeth. The
issue of orthodontics is related to data gathered within epidemiologic studies of young
people. In this way, in a group of adolescents and young adults, Casanova-Rosado et al.
(2006) found that 16.55% of them had orthodontic treatment. Some grade of TMD was found
by clinical examination in 46.1% of subjects, predominantly females with bruxist behaviour
and psychosocial variables (stress and anxiety). However, it is not evident to what extent
were the subjects treated orthodontically. Le Resche et al. (2005) pointed to the higher
prevalence of pain, including TMD pain (in terms of multiple pain problems) during
pubescent development of girls. Pereira et al. (2009) found at least one sign or symptom of
TMD in 12.26% of children aged between 4-12 (in 5 boys and 8 girls). Bonjardim et al. (2003)
determined a low prevalence of TMD signs and symptoms in children aged between 3 and 5
(primary dentition): 3.03% had TMJ sounds and 4.04% had jaw pain without any gender
differences. Köhler et al. (2009) followed the occurrence of signs and symptoms of TMD
during 20 years, with the first examination at the age of three. It was determined that TMD
symptoms had higher incidence in later examinations (incidence 5-9%) while at the
youngest age, there was almost none. However, the need for treatment is particularly low
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
(1-2%). Huddleston Slater et al. (2007) did a targeted research into prevalence of anterior DD
with reduction (accompanied by reciprocal clicking in the TMJ) in children and adolescents
which increases with their age, yet there is no statistical difference in prevalence between a
subgroup of 18-year-old adolescents and two age groups of adults aged on average 21.9 and
43.5. Prevalence of DD with reduction je rose to 26.6% in adulthood.
MRI diagnostics of a 12-year-old female patient with clinical signs and symptoms of clicking
in both jaws was performed as a part of pre-orthodontic treatment. The MRI finding
confirmed DD with reduction in the left and without reduction in the right TMJ. The MRI
follow-up finding remained unchanged after the treatment of unilateral cross bite. Painless
clicking as a compensated condition of TMJ was not sufficient as a symptom which would
indicate TMD treatment (Badel et al., 2008a).
In a sample of 40 patients with DD confirmed by MRI, Badel (2007a, 2008b) showed that
25% of them underwent orthodontic treatment (mainly by removable appliances), while
in 5 asymptomatic subjects (20%) DD was also determined. Nevertheless, since the
asymptomatic group was a population of students of similar age, the share of those with
previously performed orthodontic treatments was 40%. Treatment by a fixed appliance
was previously performed in an asymptomatic female subject with physiological disc
position. Similarly, Katzberg et al. (1996) did not find any correspondence between
orthodontic treatment and DD prevalence in patients (77%) and also in asymptomatic
subjects (33%).
MRI provides better imaging of soft and hard TMJ structures and since it is not an invasive
procedure, it is also used in children of the youngest age. Research has shown that DD is
not a congenital disorder and according to Paesani et al. (1999), which has also been
confirmed by clinical epidemiologic studies, develops only in older children and adults with
the prevalence of as much as 45% (Haiter-Neto et al., 2002). However, studies do not show
to what extent is asymptomatic DD related to a possible previous orthodontic treatment
(Haiter-Neto et al., 2002).
Numerous studies of TMD patients confirmed the efficiency of MRI use with respect to
clinical signs of the disorder (Moen et al., 2010). MRI was very useful in finding or
controlling a therapeutic condylar position and its effects on the intraarticular function of
TMJ, especially disc position. It has been used in long-term follow-ups of patients without
evidence of serious progression of pathological changes in intraarticular structures (de Bont
et. al., 1997). Even the subsequent occurrence of osteoarthritic changes in joints of DD
patients during the follow-up period did not have clinical manifestations (Kurita et al.,
2006). On the other hand, Tominaga et al. (2007) pointed to the changes in disc position with
partial displacement occurring in the period of children’s growth and development. This
stresses the need for thorough analysis of TMJ on three representative layers in an oblique
sagittal line in order to avoid doubts about the usefulness of MRI findings (Bumann &
Lotzmann, 2002), which still poses a problem of how to interpret the disc image with respect
to its physiological position or anterior displacement (Petersson, 2010).
Jensen & Ruf (2007) followed subclinical and clinical symptoms of TMD which were
detected and managed by MFA in a group of students. In a period of 2.4 years on average,
an increase of those with clinical signs of TMD occurred. Subclinical signs fluctuated a great
deal yet one out of three students in the subgroup developed clinically manifested TMD.
Orthodontics – Basic Aspects and Clinical Considerations
4. Occlusion and TMD
Occlusion was considered a possible etiopathogenic factor of TMD but their relationship is
complex and still remains partially unexplained. Occlusal treatment is important not only to
patients but also to dentists – nearly half of the interviewed Swedish dentists consider that
the replacement of molars is necessary due to development of TMD and compromising of
masticatory function (Lyka et al., 2001). The importance of occlusion in etiopathogenesis has
been redefined by refuting the mechanistic conception which has been present from the
beginning of scientific research of TMD. Loss of teeth and/or disorders of occlusion are
certainly illnesses by nature but any type of irreversible occlusal treatment cannot be
associated with causal treatment of TMD (Slavicek, 2009; Carlsson, 2010).
In an epidemiologic study, Gesch et al. (2004b) found a low incidence of certain variables of
malocclusion (unilateral open bite, negative overjet and unilateral cross-bite in men, and
edge-to-edge bite in women) with signs or symptoms of TMD. In both genders,
anatomically correct occlusion was not significantly associated with TMD compared with
malocclusions. By including static and dynamic factors of occlusion, a significant correlation
with TMD incidence has been statistically determined but with a low correlation coefficient.
Anterior open bite, deep overjet 6 mm or more, unilateral cross-bite and difference between
centric relation and maximal intercuspidation amounting to more than 2 mm with more
than six posterior teeth to be replaced can be considered increased risk factors for TMD
(Pullinger et al., 1993). Conversely, Rammelsberg (1998) offered a review of etiopathogenic
model of DD development wherein high abrasion and insufficient restorative procedure on
posterior teeth are risk factors causing occlusal instability. In their research, 34% of patients
with DD with reduction previously underwent orthodontic treatment. As opposed to that,
only 16% of asymptomatic individuals and 14% of patients with DD without reduction were
previously orthodontically treated. In order to further confirm the relationship between
orthodontic treatment and development of TMD, a follow-up targeted study should be
carried out prior to and after orthodontic treatment.
In a population of children, Pereira et al. (2009) did not find any correlation between
malocclusion and TMD but they identified bruxism and posterior cross bite as risk factors
for TMD. Tecco et al. (2010a) and Tecco & Festa (2011) found a correlation between TMD
with painful symptoms in children (5-15 years of age) and unilateral cross bite, but not with
TMJ sounds. Myofascial pain was more prevalent in females. Huddleston Slater et al. (2007)
found that age, history of orthodontic treatment, overbite and protrusion were significantly
associated with DD with reduction. In their study, Badel et al. (2008b) found a significantly
higher prevalence of hyperbalance and interference contacts in asymptomatic patients
compared to TMD patients. No difference was found between Angle’s classes in patients
with DD and asymptomatic individuals. There was a statistically significant difference in
teeth contact between the maximal intercuspidation and centric positions patients and
asymptomatic subjects. Augthun et al. (1998) did not find any correlations between occlusal
variables and forms of DD. However, it has been established that the rate of class II
increases consecutively depending on the following subjects: asymptomatic subjects,
patients with DD with reduction and patients with DD without reduction (14%/33%/52%),
while the share of subjects with class I decreases simultaneously (43%/30%/18%).
Taking into account the great number of static and dynamic occlusal variables, it is difficult to
comprehend the overall correlation with the development of TMDs due to the often non-
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
standardised studies based on occlusal analysis (John, 1996). According to John et al. (1998),
‘complex interaction’ is the only but scientifically non-defined link between occlusion and
TMDs. Occlusion ensures orthopedic stability of TMJ whereas the occlusal stability is ensured
by mutually antagonistic contacts in a position of maximal intercuspidation. When the
relationship between the two factors is compromised, it could lead to an overload of articular
structures and consequently pose a risk of TMD development. The changes in occlusal
relations are pronounced in etiopathogenesis, causing co-contraction of antagonist muscles the
purpose of which is to protect the agonists and remove pain. The influence of possible adverse
chronic effects can be avoided by the adaptation of muscular activity (Okeson, 2003).
The importance of occlusal interferences was perceived differently regarding the
etiopathogenesis of TMDs. Le Bell et al. (2002) found that artificial interferences do not
stimulate the development of dysfunctional symptoms in healthy subjects, instead they
adapt successfully to them. In patients whose medical histories show TMD interferences
stimulate the recurrence of stronger symptoms.
There is a dichotomy between scientific and clinical concepts of occlusion, which can be
explained by the concept of integrated neurobiological system (Türp & Schindler, 2003).
Occlusion is a basic component of dental restorative procedures, which changes or
supplements the compromised or lost occlusal relations in each segment of planning the
procedure. Pathogenetic and therapeutic effects of myofascial pain can be explained only as
a mutual relationship between occlusion and neuromusculature. The results of La Bella et al.
(2002) are explained by the neurobiological hypothesis based on the differentiated activity of
the part of the muscle in which increased tension and pain can occur. The changes in
occlusal relations cause a mild unloading in painful muscles or within the structures of TMJ
which means that different condyle positions during treatment can have the same effect.
However, the mutual relationship between occlusal interferences and microtrauma has not
been completely explained (Türp & Schindler, 2003).
4.1 Hypervigilance
Reflex response to peripheral stimulus, that is, occlusal interference via periodontal
receptors, can be modulated in the central nervous system in such a way that the stimulus
causing normal opening in that case causes mouth closing. The hypothalamus and the
limbic system mediate in tonus increase in affective conditions and under stress, whereas
the reflex response to occlusal stimulus depends on the current state of agitation of those
centres. In patients, even the slightest interference can produce the state of high stimulation
and muscle hyperactivity, which can cause TMD at a lower level of adaptation. In other
individuals with low level of activity of those centres an increase of muscle tonus due to
occlusal interference does not occur. Parafunction is initiated only when the occlusal
changes turn into a disturbance which leads to an awareness of pathological occlusal
relations. A patient does not react to a harmful periodontal stimulus due to disturbed
efficiency of behavioural mechanisms by diminishing the parafunction, instead it gains
strength. Only in cases of hypervigilance, the occlusal changes will lead to TMD, due to
increased awareness of one’s own body and intensified activity of emotional motor
system such as stress, pain or psychosocially caused parafunction. Hypervigilance is a
changed form of observation wherein the harmful nociceptive stimuli are intensified
(Hollins et al, 2009; Palla, 1998).
Orthodontics – Basic Aspects and Clinical Considerations
5. Concepts of TMDs treatment
The concept of TMDs treatment procedures is indirectly connected with the already
established symptoms and signs from the medical history and clinical examination. Since the
exact pathophysiological mechanism of TMDs development has not been fully explained, the
main goal of the treatment is the management, reduction and removal of temporomandibular
pain. Treatment procedures are divided into reversible and irreversible procedures. Since the
treatment is mostly empirical, that is, performed by evaluating the clinical significance if the
established symptoms, the reversible procedures are mostly used. Treatment indications, type
of treatment procedures and their practical application are based on the existence of a specific
form of myogenic and/or arthrogenic disorder in the stomatognathic system accompanied by
certain intensity of temporomandibular pain (Gremillion, 2002; Palla, 1998).
The course of development of neuroplastic processes in the central nervous system is
prevented by the treatment of acute temporomandibular pain, and those processes result in
development of chronic pain (pain present longer than 6 months). The treatment of
temporomandibular pain is based on the following (Green, 2006; Palla, 1998, Palla, 2003):
symptoms and clinical signs have complex features of musculoskeletal disorder;
the morphofunctional features do not make the TMJ absolutely unique in the human
occlusion is not a crucial etiopathogenic factor;
patients are successfully treated by simple and non-invasive treatment procedures;
the patient’s psychological reaction should not be in proportion with the somatic
the treatment approaches to non-chronic and chronic temporomandibular pain differ;
the evaluation of the purposefulness and the optimal efficiency of the initial treatment
is necessary.
5.1 Aims and forms of the initial treatment
The initial treatment comprises different and to a certain extent, specific procedures and
means the main feature of which is to be as non-invasive as possible. The diagnosis should
be discussed with the patient as well as its possible etiology and pathophysiology and the
prognosis and its possible course of treatment. The patient should understand the diagnosis,
especially if it is accompanied by chronic pain. Successfully informing the patient creates a
placebo effect thus reducing the secondary induced psychological disorder which can
compromise the success of the treatment. The patient is additionally motivated by the good
prognosis of treatment. Diet consisting of soft food is recommended as well as instructions
on how to change oral activity in the sense of self-observation and self-correction of oral
habits and parafunctions (Green, 2006).
Physical and manual therapy plays an important role in treatment of all rheumatic disorders
and at the same time it actively involves the patient in the course of the treatment. The aim
is to remove musculoskeletal restrictions such as pain removal, detoning and stretching of
hypertonic muscles. Therapy is conducted by ultrasound, TENS, laser, kinesiotherapy by
Schulte, localised massage, etc. (Badel et al., 2010b). Nonsteroidal anti-rheumatics are
indicated in acute pain of different etiologies. Due to systemic side-effects in the gastro-
intestinal tract and due to blood circulation disorders in kidneys, it s recommended to
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
prescribe selective inhibitors of the prostaglandin synthesis which should be taken during a
longer period of time (Badel et al., 2007b).
The irreversible treatment mostly implies surgical procedures. Arthrocentesis (removal of
inflammatory exudate), surgical reposition of articular disc (arthrotomy), discectomy,
placement of articular disc implants and condylectomy can be performed on the TMJ.
Arthroscopy is a diagnostic-treatment method used for imaging of intraarticular pathologic
changes with the possibility of their simultaneous removal (Machon et al., 2010; Palla, 1998).
5.2 Occlusal splints
The occlusal splint is the most common and efficient treatment procedure of arthrogenic
and/or myogenic forms of TMDs and bruxism. The occlusal stability is established by
specific morphology of the splint which is placed on the teeth alignment of one jaw thus
serving as an orthopedic means of TMJ stabilisation (de Leeuw, 2008; Okeson, 2003). The
occlusal splint is used as a temporary means of obtaining therapeutic occlusion and as a
preparatory stage for definite prosthetic treatment (Badel, 2003).
Depending on the indications of use and treatment effects of the occlusal splint,
hyperactivity is reduced, that is, the masticatory muscles are relaxed, the condyle is
therapeutically positioned, that is, placed into the centric relation position and the
behavioural effects increase awareness about the position, function and parafunction of the
mandible thus achieving placebo effect (Dylina, 2001).
5.2.1 Classification of occlusal splints
In occlusal splint treatment the following changes occurred in: biomechanic concepts of their
effects, features of their placement and retention on the teeth, morphology of the occlusal
plane of the splint and their effect on the position and movements of the mandible.
Relaxation splints are used in the treatment of bruxism as well as in management of
arthrogenic and myogenic temporomandibular pain. The Michigan splint (occlusal bite
plane stabilisation splint with cuspid rise and freedom in centric) by Ramfjord and Ash is a
splint covering all the teeth in the jaw, enabling antagonistic contacts on the flat planes
according to occlusal concepts of freedom in centric position. Guiding by canines along the
modelled planes of the splint is achieved in each extracentric movement (Ash &
Schmieseder, 1999).
Distraction splint (pivot splint) vertically unloads intraarticular structures by condyle
distraction and is indicated in arthroses, perforation of articular disc and anterior DD
without reductiong. The splint acts as a hypomochlion in individual bilateral contacts in the
molar region, by which distraction (decompression) of TMJs is obtained (Okeson, 2003).
Repositioning (protrusion/distraction) splint causes the excentric (anterior) positioning of
the mandible and is used for treatment of anterior displacement of the articular disc with
repositioning. The aim of the splint treatment is repositioning of the articular disc into the
physiological position with respect to the condyle, which is achieved by its occlusal plane.
The splint achieves a protrusive (anterior) position of the condyle with a slight distraction
effect on the TMJs (Okeson, 2003).
Orthodontics – Basic Aspects and Clinical Considerations
With respect to the variety of design characteristics and the biomechanical effect of occlusal
splints, previous concepts of initial treatments have been revised. The effect of anterior
displacement/position of the articular disc and subsequent irreversible changes in
physiological occlusal relations is questionable. Stabilisation of the mandible in anterior
position leads to intraarticular partitioning which can lead to permanent anterior habitual
occlusion resulting in malocclusion (back open bite due to extrusion of posterior teeth and
orthodontic displacement of anterior teeth) (Brenkert, 2010). In order to avoid irreversible,
unwanted changes in the structures of the masticatory system, the Michigan splint is the
device of choice due to the proved beneficial effect in alleviation and removal of symptoms
TMDs (Badel, 2009b). The occlusal splint, according to the individual case, is combined to a
certain extent with other forms of initial treatment of TMDs. In treatment of DD, it is
important to consider that repositioning of the articular disc is not satisfactory in as much as
50% of cases and recurrences are possible in 1/3 of the cases (Le Bell & Kirveskari, 1990).
5.3 Implications of orthodontic treatment on TMD
Orthodontic treatment can be viewed from two different points of view: whether orthodontic
treatment has a negative impact on development of signs and symptoms of TMDs and what
the role of orthodontic treatment is regarding the modality of TMDs treatment. MRI helped
with detection, that is, follow-up of the influence of orthodontic treatment on the intraarticular
structures of TMJ. In a group of 15 orthodontic patients (aged between 12 and 17) Pancherz et
al. (1999) found clinical signs of TMD in two patients (partial DD in one patient and
osteoarthritic changes in the other). All orthodontic patients wore a Herbst appliance during 7
months due to Class II malocclusion. In the follow-up period, DD improved (metric
evaluation) and in the other patient, the loss of osteoarthritic changes was considered the
result of compensatory joint remodelling. Aidar et al. (2006) performed a metric evaluation of
the effects of Herbst treatment in adolescents with Class II Division 1 malocclusion. There was
no significant influence of orthodontic treatment on DD development.
Tullberg et al. (2001) conducted a research with a follow-up on the correlation between early
(children with primary dentition) and late (children with mixed or permanent dentition
treatment of unilateral posterior cross-bite. There was no evidence that early treatment, even
the later treatment repeated in 11 out of 44 subjects, was related to significant development
of signs and symptoms of TMD. Therefore, even in a case of malocclusion as a risk factor,
orthodontic treatment could not be related to the development of TMD. Even the first (early)
orthodontic treatment could be repeated in older age (as a late treatment) and the subjects
aged 19 would not have more significantly manifested TMD. During a 4-month follow-up,
Bourzgui et al. (2010) did not find any correlation between development of TMD symptoms
and Angle classes. Although the unilateral posterior cross bite is mentioned as a significant
variable in DD of TMJ, in a group of children (average age of 9.3 years) their correlation
could not be established by MRI analysis (Pellizoni, 2006).
During a long follow-up, Egermark et al. (2003) investigated the relationship between
occlusal variables and development of clinical signs and symptoms of TMDs. From a long-
term perspective, subjects were very pleased with the orthodontic treatment, and the
treatment received in childhood did not increase the risk for TMDs later in life. In some
subjects, lateral forced bite between retruded contact position and intercuspal position, as
well as unilateral cross bite might be of importance in this respect. Henrikson & Nilner
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
(2003) followed the clinical signs and symptoms of TMDs during the fixed orthodontic
treatment, especially in girls with Class II malocclusion. They were compared with girls
who did not receive treatment and controls with normal occlusion. It was observed that
signs and symptoms of TMDs equally develop in all three groups and, over time, they
fluctuate considerably and unpredictably. A part of patients with Class II and the myogenic
form of TMDs even experienced improvement of their condition due to orthodontic
treatment. In any case, fixed orthodontic treatment did not particularly aggravate TMDs
compared to the pre-treatment period.
Tecco et al. (2010a) compared the efficiency of TMDs treatment by a fixed orthodontic
appliance and the anterior repositioning splint. DD was diagnosed by MRI and the effect of
both treatments was beneficial to treatment of myogenic and arthrogenic pain, whereas the
repositioning splint proved to be more efficient for removal of pathological noise in the
joint. Siegmund & Harzer (2002) showed a detailed orthodontic treatment of a patient with
DD. Clinical diagnostics was based on MFA and it was supplemented by axiography. The
need for pre-treatment diagnostics and treatment planning was stressed which leads to a
successful outcome of fixed orthodontic treatment as well as to the avoidance of
complications related to possible exacerbation of TMD symptoms.
Jensen & Ruf (2007) showed that during a long-term orthodontic treatment, significant
development of TMD is not to be expected. Likewise, the transformation of subclinical signs
into clinical signs of TMD can be expected, which should not be associated with the course
of possible orthodontic treatment. Although the results of the above mentioned studies
reveal that orthodontic treatment does not have a special effect on the condition of TMDs, it
should be taken into account that the studies described the treatment which was indicated
for entirely orthodontic reasons. However, each treatment, particularly irreversible ones,
runs the risk of adverse effects. Condylar resorption is one of the iatrogenic examples of
TMDs development possibly related to orthodontic treatment. Orthodontic forces can often
cause undesired reactions of partitioning within the alveolar bone. As in the described case,
TMD symptoms were not observed on time thus causing the lack of consistent radiological
follow-up (Shen et al., 2005).
Idiopathic condyle resorption is the term for the progressive form of OA of TMJ, which is
associated with trauma and orthopedic procedure. Although it is an unwanted complication
or an independent pathologic process manifested during orthodontic treatment, it certainly
gives an impression of failure and of an even worse condition of the stomatognathic system.
In the above mentioned study of patients with DD (Badel, 2007a), in the course of the
follow-up of intraarticular condition during the treatment by Michigan splint, a rapid
osteoarthritic process in a female bruxist patient with unilateral anterior DD without
reduction and also malocclusion of Class II division 1 was found by MRI. Condyle
resorption resulting in drastically pronounced open bite was not accompanied by
exacerbation of TMD symptoms.
6. Clinical case
A 26-year-old female patient, previously under orthodontic treatment, was referred to a
prosthodontic specialist, complaining of pain in her right TMJ and clicking in the left one
with limited mouth opening. The pain was intensified upon chewing.
Orthodontics – Basic Aspects and Clinical Considerations
Patient's history. Without any particular reason, the patient experienced clicking in her left
TMJ and she contacted her dentist, which happened 7 months prior to her visiting the
prosthodontist. Her dentist referred her to an orthodontist. She was treated by a bimaxillary
removable appliance (bionator) in order to correct a large horizontal overjet (Angle class
In the course of the orthodontic treatment, the patient still complained about the clicking
and after 4 months pain in the right TMJ appeared. She had difficulties opening her mouth,
pain appeared upon each movement of the mandible; she had difficulties adjusting to the
new occlusal relations established by the orthodontic appliance and had a swelling in the
region of the right TMJ. With respect to the above mentioned symptoms, she felt more
comfortable in habitual occlusion than in the anterior therapeutic position achieved by the
bionator. However, the patient did not realise at first that the pain in the TMJ was not being
treated. The orthodontist did not realise that her intention was not to treat the orthodontic
anomaly. Since the treatment by bionator obviously did not affect the TMJ symptomatology
in that period, and her condition even worsened, the patient realised that her problems were
not resolved by the treatment – instead of the TMJ symptoms she was treated for the
orthodontic anomaly. According to the patient, the orthodontist realised this and attempted
to stop the treatment by bionator without any particular explanation or further counselling
with colleagues.
Occlusal analysis. At the first intraoral examination of the patient, two habitual intercuspal
positions were detected. Until the lips were spread apart for a detailed dental examination,
there was an impression of a physiological relationship between the anterior teeth.
However, it was an acquired and forced anterior bite caused by regular wear of the
bionator. In this position, the posterior teeth were in non-occlusion (Figure 3).
Fig. 3. Occlusion in anterior forced bite without (left) and with inserted bionator (right) in
the mouth.
The real anterior-posterior relations between the dental arches were shown in the habitual
intercuspal position: Angle Class II/1, an 11 mm horizontal overjet and a 4 mm overbite of
upper teeth over the lower ones. In the transversal plane there was a 1 mm displacement of
the medial line between lower central incisors to the right compared with the upper central
incisors due to the loss of previously extracted first molars, especially of the extracted tooth
46 (Figure 4). In both teeth alignments, there was a crowding of posterior regions. The upper
anterior teeth were provided with ceramic crowns. In both lateral movements there was a
canine guidance, without balanced contacts or interferences. The teeth did not show any
clinical signs of dental abrasion.
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
Fig. 4. Habitual occlusion in maximum intercuspidation (left), and lateral view of the model
transferred to the articulator. Note: a pronounced horizontal overjet (right).
Clinical diagnostics. Painful right TMJ with limited mouth opening was diagnosed by
clinical examination and MFA according to Bumann and Groot Landeweer (Bumann and
Lotzmann, 2002). Active mouth opening amounted to 36 mm, whereas passive mouth
opening, that is mouth opening by exerting a mild downward passive force on the lower
incisors amounted to 41 mm. Protrusive movement amounted to 6 mm, laterotrusion to the
right amounted to 8 mm and laterotrusion to the left amounted to 4 mm. The pain intensity
on the visual-analogue scale (VAS) (VAS=0-10; 0-10; 0, no pain; 10, the worst pain) was rated
7.4. On mouth opening there was a deviation to the right. On the right and also left
laterotrusal movement, the pain appeared only in the right TMJ. Based on clinical findings
and according to MFA (painful right TMJ under active and passive compressions) an
anterior DD without reduction in the right TMJ was confirmed. Since the clinical signs of the
disorder of the left TMJ were not present (the patient stated that she previously experienced
reciprocal clicking), a clinical diagnosis of the left TMJ could not be made.
Radiological diagnostics. Panoramic x-ray shows a non-symmetrical relationship between
the left and the right condyle: the right condylar head is pointed with a deplaned anterior
surface. The bilateral anterior DD was confirmed by MRI. Imaging of both TMJs was
performed on a 1T magnetic field device in three different positions: closed mouth position
(habitual maximal intercuspidation, anterior position of the mandible caused by orthodontic
treatment and open mouth position). The imaging sequences (matrix 256 x 192; 160 x 160
field of view) included the T1 weighted image (TR 450/TE 12), and gradient echo T2
weighted image (TR 760/TE 32), and T2 weighted image (TR 3000/TE 72).
Anterior DD without reduction was confirmed, with collections of inflammatory exudates
which are most visible on T2 weighted images (Figure 5). In closed mouth position, the
condylar head is anteriorly dislocated (Figure 5a), which is more visible in a forced anterior
position (Figure 5b). Further dislocation is minimal (open mouth position) while the disc is
constantly anteriorly dislocated and is deformed (Figure 5c). The condyle reaches the peak
(zenith) of the articular eminence. Mild osteoarthritic changes in cortical bone of the
condylar head in slightly pointed forms without subchondral changes are visible.
The anterior DD with reduction was determined in the left TMJ (Figure 6), which explains
the previous symptom of clicking, which vanished in the course of orthodontic treatment. In
closed mouth position, the condylar head was centrically placed within the glenoid fossa
Orthodontics – Basic Aspects and Clinical Considerations
but in a slightly distraction position resulting in an enlarged intra articular fissure (Figure
6a). The disc was placed anteriorly and remained in this position even when the patient’s
mandible was in a forced anterior position (Figure 6b). In open mouth position, the disc
achieved physiological position with respect to the condyle but it did not reach the peak of
the articular eminence (Figure 6c). However, the mobility of the left condyle is more
pronounced than in the right joint. The condylar head was slightly pointed with a hint of
osteoarthritic changes appearing as a thickened tip of the cortical bone. Subchondral
structures had an adequate signal and there was no articular effusion.
Fig. 5. Magnetic resonance images of the right temporomandibular joint in the position of
maximum habitual intercuspidation (a), forced anterior position (b) and open mouth
position (c). Note: non-reduced anterior displaced disc (short arrow), joint effusion (marked
with *), and degenerative changes of cortical condylar head (long arrow).
Fig. 6. Magnetic resonance images of the left temporomandibular joint in the position of
maximum intercuspidation (a), forced anterior position (b) and open mouth position (c).
Note: anterior displaced disc with reduction (short arrows) and degenerative changes of
anterior part of cortical condylar head (long arrow).
Treatment. The stabilization splint (according to some authors the Michigan splint) (Badel,
2007a) is indicated for the initial treatment of pain caused by anterior DD (Figure 7). It
temporarily provides stable joint position, and in addition, reduces abnormal muscle
activity. Both jaw alginate impressions were taken and the splint was fabricated in a new
therapeutic position, that is, in a position of centric relation. This was also the best position
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
for stabilization splint fabrication since it ensures a stable position of condyle in the articular
fossa. It also enables the removal of the retrodiscal tissue load exerted by the condyle since
the articular disc is permanently protruded, that is displaced anteriorly (Badel et al., 2003).
The patient was instructed to wear the appliance while sleeping and was asked to come for
a check-up in a week.
Fig. 7. Michigan splint on a model (left) and the inserted splint in the patient’s mouth (right).
In collaboration with a rheumatologist-physiatrist, the patient was referred to physical
therapy, which consisted of a routine protocol: TENS (transcutaneous electroneural
stimulation), topical non-steroidal analgesic ketoprofen (Fastum gel) three times a day and a
kinesiotherapy programme by Schulte (Badel et al., 2010b). She continued performing the
exercises by Schulte three times a day at home.
Besides stopping the orthodontic treatment, the patient initially wore the Michigan splint for
about 5 months. After 6 months, a more significant ability of mouth opening (45 mm) was
measured but pain in both joints was still present, particularly upon yawning (VAS=8).
While the left joint was painful on wider mouth opening, pain in the right joint was more
expressed and accompanied by slight crepitations. The patient was aware of the chronic
nature of her pain because, as she stated, she ‘got used to’ the pain. She stressed the
efficiency of oral exercises and topical application of the ketoprofen gel (Fastum gel).
Long year follow-up. At a recall 5 years later, the patient did not have pain in the TMJs and
only felt discomfort in the right TMJ during wide mouth opening with clinically evidenced
minor crepitations. However, she felt discomfort in the right joint on yawning ad sleeping
on the right side of her face. When eating an apple and yawning, she sometimes felt pain in
the right joint (VAS=4). Also, she mentioned rare occurrences of clicking in the right joint
which was also painful. Maximum mouth opening still amounted to 45 mm, which is
significant regarding the pre-treatment measurements and equal to the measurements after
the initial treatment. Now, she does not have any esthetic or functional needs for
orthodontic treatment.
A control MRI taken on the same device showed visible degenerative changes in both
TMJs. Significant changes in the sense of OA development occurred in the right joint: the
condyle was deplaned and an osteophytic formation on the anterior edge contributed to
the unshapely appearance. The disc was deformed with anterior displacement (Figure 8a).
Even in the anterior position, the disc still remained in front of the condyle (Figure 8b). In
open mouth position, the condyle reached the eminence while the disc remained non-
reduced (Figure 8c).
Orthodontics – Basic Aspects and Clinical Considerations
Fig. 8. Follow-up examination of the right temporomandibular joint by magnetic resonance
imaging in the position of habitual maximum intercuspidation (a), forced anterior position
(b) and open mouth position (c). Note: non-reduced and deformed anterior displaced disc
(short arrow) and the osteophyte formation on the anterior edge of the condyle (long arrow).
In closed mouth position (habitual occlusion), a compensatory fibrosation of retrodisc tissue
along with the deplaned condylar head of an appropriate size was visible in the left joint
(Figure 9a). In the forced anterior position, the greatest part of the disc was placed anteriorly
from the condyle (Figure 9b), whereas there was an almost complete reduction of
displacement in open mouth position, that is, the disc was almost symmetrically
repositioned on the condyle (Figure 9c). The condyle-disc complex almost reached the peak
of the eminence when the patient wore the bionator, and also in the position of maximum
mouth opening.
Fig. 9. Follow-up examination of the left temporomandibular joint by magnetic resonance
imaging in the position of habitual maximum intercuspidation (a), forced anterior position
(b) and open mouth position (c). Note: disc displacement with reduction (arrows), and
fibrosation of the retrodisc tissue (marked with *).
7. Discussion and general remarks
Orthodontic treatment should be planned carefully if there are underlying symptoms of
TMDs. Clinical importance of certain dysfunctional symptoms has altered the concept of
normal functioning of the stomatognathic system. A perfected interpretation of certain
diagnostic symptoms enables the correct establishing of clinical diagnostic parameters and
other diagnostic modalities of TMDs. The approach to patient in the sense of personalised
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
dental medicine gains importance when dealing with patients suffering from certain
diagnoses of TMDs. Furthermore, the issue of occlusion in dental medicine has reached a
dogmatic level, which in case of TMD patients should not apply, particularly the use of
irreversible treatment methods as well as planning of possible preventive procedures
(Carlsson, 2010).
As with many other musculoskeletal disorders in the human body, according to modern
biomedical beliefs, they are of non-specific etiopathology, that is, they are idiopathic on the
level of the individual patient (Green, 2006). Correlating TMDs with numerous
etiopathogenic factors does not result in efficient determination of their cause-effect relation.
Therefore, current opinion is that TMDs are idiopathic in origin and the correlation with
certain etiologic factors cannot be entirely confirmed; on the other hand, the question of
chronic musculoskeletal (or non-malignant) pain becomes dominant within the field of pain
medicine. Consequently, pain and TMDs cannot be observed only on the level of occlusion,
individual patients’ wishes regarding esthetic dentistry and relying on scientifically
unverified but traditional treatment indications.
Clinical examination, particularly manual examination techniques of patients with TMDs
are an indispensable part of diagnostics by which the indication for imaging techniques is
determined. MRI has become the gold standard in diagnostics and differential diagnostics of
TMDs because it enables imaging of hard and soft tissues of TMJ (primarily the disc) and
joint effusion. Although MRI is the gold standard in TMJ diagnostics, there is still no gold
standard in diagnostics of temporomandibular pain. Indeed, MRI is not an appropriate
screening method but a strictly applied diagnostic and differential-diagnostic method
(Ahmad et al., 2009).
TMDs treatment planning can be carried out as the initial treatment and upon reaching a
satisfactory degree of recovery, the definitive treatment can be planned as well. This may be
applied to all TMDs patients, regardless of their having intact teeth with respect to
physiological occlusal relations as well as to patients in need of orthodontic or prosthodontic
treatment or even an oral surgical procedure. One should bear in mind the fact that definite
treatment should have its indications and should be in accordance with the patient’s wishes
as well as with the actual state of occlusion and the level of TMDs treatment. In managing of
TMDs patients there are always doubts about the indications for definite treatment, if there
was a possibility of treating the painful TMD only by reversible treatment modalities, that is,
by initial treatment. By recognizing the signs and symptoms of TMDs and by choosing
initial methods of treatment as the methods of choice, the excessive use of diagnostics (for
example, MRI) as well partial or complete overtreatment modalities are avoided (De Boever,
et al., 2008; Türp, 2002).
The possibility of incorrect treatment in cases of TMDs patients can happen as it was shown
in the clinical case of the female patient described in this paper, which was contrary to her
wishes and individual needs of malocclusion treatment. Excessive, unnecessary and
incorrect treatment methods of TMDs patients can have legal repercussions (Manfredini et
al., 2011).
The patient has a input in the planning of own treatment and the dentist should consider the
patient’s wishes, and the current trend is to collaborate with other dental and medical
specialists which is a multidisciplinary approach (De Boever et al., 2008).
Orthodontics – Basic Aspects and Clinical Considerations
Since clinical TMDs symptoms range from painless clicking up to severe pain causing
problems in basic functioning upon eating and speech, the question arises when TMDs
symptoms should be treated. In cases of adolescent patients with an occlusal anomaly there
are considerations of whether orthodontic treatment can prevent their exacerbation,
particularly pain. Since prevention implies the possibility of affecting causal factors of the
disease, there is a lack of scientific facts to support that (Luther, 1998).
The absence of temporomandibular pain and mild functional difficulties caused by
remaining TMD symptoms represent the group of passive need for TMD treatment. The
idiopathic concept of development of TMDs cannot accept the concept by Kutilla et al.
(1996) of active and passive TMD prevention. Preventive measures cannot be planned in
patients with unknown etiology. Since the topic of this paper is the relationship between
orthodontics and TMDs (although numerous studies are not methodologically coordinated
and neither is the sample of patients who are primarily orthodontic or primarily with
TMDs), the review papers on this subject constantly reach the conclusion that orthodontics
neither treats TMDs nor causes them in particular (Macfarlane et al., 2009). As it happens in
every definitive treatment in the stomatognathic system, painful forms of TMDs aggravate
orthodontic treatment which was previously planned due to malocclusion rather than
TMDs. In the course of orthodontic treatment previously latent symptoms of TMDs may
appear (that is why MFA is significant as a clinical screening test) or manifested TMDs
symptoms may develop although the patient did not experience such symptoms at any level
prior to this. Such a condition particularly aggravates further orthodontic treatment so that
it is recommended to temporarily discontinue the orthodontic treatment according to the
need and the level of the presence of symptoms (Michelotti & Iodice, 2010). The part of the
functional treatment termed initial symptomatic treatment, which should provide a
satisfactory degree of painful function of stomatognathic system, should be carried out in
order to continue the orthodontic treatment (Badel, 2007a).
In a review of methods of clinical TMD evaluation in population of children and
adolescents, Toscano & Defabianis (2009) pointed to a great variability of results which
causes problems in their direct possibility of comparison. However, it can be concluded that
joint sounds and TMJ symptoms are the most common in that subgroup of population.
Bionators initially look like a sort of combined upper and lower Hawley retainer, but do not
fasten to the teeth and are not used for post-brace removal treatment. Bionators are held in
the mouth within the space that the teeth surround when biting. In the described clinical
case, a distinction should be made between short-term wear of bionator and the
exacerbation of painful clinical signs and symptoms of TMD as well as manifestation of
osteoarthritis with prior DD within a 5-year-follow-up, which was confirmed by MRI. Such
long-term effects of MRI imaging of TMJs cannot be ascribed to orthodontic treatment
because degenerative changes accompanied by various conditions of DD, according to
Kurita et al. (2006) develop even without any clinical symptoms. After all, DD of TMJ can be
expected even in asymptomatic subjects (Badel et al., 2008c).
According to the American Academy of Pediatric Dentistry (2010) there are reversible and
irreversible methods of TMD treatment. Irreversible methods of treatment include occlusal
adjustment, mandibular repositioning (by a repositioning appliance) and also orthodontic
treatment, without specific instructions on which group of treatment modalities is
recommendable. Regarding the use of reversible treatment methods, there are some positive
Temporomandibular Disorders and
Orthodontic Treatment – A Review with a Reported Clinical Case
results obtained by, for example, Tecco et al. (2010) who found a positive effect of a fixed
orthodontic appliance and the anterior repositioning splint on TMDs. Arthrocentesis proved
to be efficient in combination with the occlusal splint (Machon et al., 2011). The use of the
repositioning splint should be controlled and short-term because it can result in
development of posterior open bite as a result of partitioning of intraarticular structures of
TMJ on forced anterior bite (Türp, 2002; Brenkert, 2010). In such a case the initial treatment
can be a failure because repositioning of this kind does not imply moving the anteriorly
displaced disc (displacement reduction) but moving the condyle into a position which
reduces the displacement thus causing clicking. Asymptomatic causes in non-patients show
that DD does not necessarily mean the appearance of symptoms suggesting that such
causative treatment is not in accordance with the principle of symptomatic treatment of
TMDs (Badel et al, 2008c; Türp, 2002). When choosing the right initial occlusal treatment,
permissive and non-invasive occlusal splints, such as the Michigan splint, are given the
advantage (Dylina, 2001).
Optimal cost-effectiveness and health care efficiency are achieved by using palliative
treatment procedures which cannot result in potentially incorrect, excessive, insufficient or
untimely treatment of TMDs (Figure 10).
Fig. 10. The relationship between diagnostic and treatment procedures in patients with
temporomandibular disorders.
Orthodontics – Basic Aspects and Clinical Considerations
8. Acknowledgment
This paper is a part of the scientific project No. 065-0650445-0441 supported by the Ministry
of Science, Education and Sports, Republic of Croatia.
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The temporomandibular joint receives its name from the two bones that enter into its formation, namely the temporal bone and the mandible. This complex synovial system is composed of two temporomandibular joints together with their articulating ligaments and masticatory muscles. The causes of temporomandibular disorders are complex and multifactorial. There are numerous factors that can contribute to temporomandibular disorders. The successful management of temporomandibular disorders is dependent on identifying and controlling the contributing factors. There is a long time debate whether orthodontic treatment is the cause of Temporomandibular joint disorders (TMD) or it is used to alleviate the symptoms associated with these disorders such as clicking joints, Muscular pains etc..
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Purpose: To identify and document the literature regarding treatment objectives for anterior disc displacement with reduction / reciprocal TMJ clicking and to formulate treatment recommendations. Materials and methods: the following areas of the available literature were scrutinized: diagnostics, etiology and treatment objectives of anterior disk displacement with reduction, therapeutic interventions, occlusal splint therapy, orthodontics and TMD. Results: Painless reciprocal clicking of the temporomandibular joint without dysfunction represents an anatomical condition not an disorder and must not be treated. In most cases simple therapeutic interventions will be adequate to resolve the condition of the clicking when associated with pain or joint dysfunction. These include patient education, self-care, physio-therapy, an occlusal appliance and eventually pharmaco-therapy. Discussion: This review has demonstrated that the treatment objectives and outcomes for anterior disc displacement with reduction are well documented in the literature. Although published high quality reviews report that there is weak evidence to suggest the use of Stabilization Splints for the treatment of painfull TMJ dysfunction, it can be concluded because of the quality of the systematic reviews and/or evidence available at the time of publication, the systematic reviews did not provide the best available evidence for clinical decision making. When all available literature is critically appraised in making clinical decisions the use of stabilization splints for the treatment of TMD pain can be highly recommended in cases of anterior disc displacement with reduction due to orthopedic instability in the masticatory system.
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Literature review: Anterior disc displacement with reduction. Diagnostics, Etiology and treatment objectives. What the orthodontist should know.
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These were to 1) estimate the prevalence of subjective symptoms and clinical signs of temporomandibular disorders (TMD) in children and adolescents in the city of Jönköping, Sweden, 2) follow possible variations in TMD signs and symptoms over a 20-year period, and 3) study possible associations between TMD symptoms and signs and factors of interest. About 100 individuals in the age groups of 3, 5, 10 and 15 years participated in cross-sectional stratified epidemiological investigations in 1983, 1993 and 2003. All participants were asked to fill in a questionnaire including questions on general and oral health, dental care habits and some socio-demographic issues. More specific questions recorded the presence or absence of subjective symptoms: tiredness in the jaws on awakening or during chewing; clicking sounds or crepitations from the temporomandibular joints (TMJs); locking/ catching of the mandible; luxation of the mandible; reduced jaw movement capacity; pain during jaw movements; other pain conditions in the jaws or in the TMJ regions. Subjects were examined clinically at each time period for; jaw mobility (maximum jaw opening including vertical overbite, maximum laterotrusion to the right and to the left, maximum protrusion); TMJ function (normal function, deflection on jaw opening of >2 mm, TMJ clicking or crepitations, TMJ locking, TMJ luxation); pain on jaw movement (no pain on movements, pain on one movement, pain on more than one movement); muscle pain (no muscle pain, pain on palpation in 1-3 sites, pain on palpation in >3 sites); TMJ pain (no joint pain, pain on lateral palpation of one or both joints, pain on posterior palpation of one or both joints). No functional examination of the masticatory system was performed in children aged 3 and 5 years. TMD-related symptoms were very rare in 3- and 5-year-olds. In the age groups of 10- and 15-year olds, 5-9% of the participants reported more severe symptoms, up to 50% showed one or more TMD signs, while it was estimated that 1-2% were in need of TMD treatment. Several symptoms and signs increased with age. No gender differences, with the exception of recurrent headache, were noted. Oral parafunctions were reported by 11-47%. Apart from a few variables, no statistically significant changes in the prevalence of TMD symptoms and signs were observed over the 20-year period. Clenching/grinding of teeth and general health factors were found to be associated with TMD symptoms and signs. The prevalence of more severe TMD symptoms and signs in children and adolescents was generally low in all three examinations and did not change significantly during the 20-year period. Increasing age, general health factors and oral parafunctions were associated with TMD symptoms and signs in 10- and 15-year-olds.
The objective of this prospective study was to verify changes in the position of the temporomandibular joint (TMJ) disc by means of magnetic resonance images (MRIs) in adolescent patients treated with the Herbst appliance. Methods: Twenty consecutive Class 11 Division 1 patients treated with Herbst appliances were selected for the study. MRIs were analyzed at 3 stages: immediately before Herbst treatment (T1), 8 to 10 weeks after appliance placement (T2), and at the end of the 12-month Herbst treatment, immediately after appliance removal (T3). Results: Class I or overcorrected Class I dental-arch relationships were observed after Herbst therapy. The qualitative evaluation showed that each patient had the disc within normal limits at T1. At T2, a slight tendency toward disc retrusion because of mandibular advancement was observed, but, at T3, the disc returned to normal, similar to T1 values. By using a quantitative evaluation, parasagittal MRIs (central, medial, and lateral slices) of the TMJs showed that there was no change of disc position from T1 to T3, except in the central slice, which had a retrusive position of the articular disc at T3. Conclusions: During the 12-month period of Herbst appliance treatment, mild changes in the position of the disc occurred in patients whose articular discs were within normal limits at T1. These changes were within normal physiological limits when evaluated in the short term.
This article discusses the aetiology, signs and symptoms, diagnosis, psychological factors and management of temporomandibular disorders (TMD). It highlights the difficulty of evidence-based practice with respect to TMD.
Evidence based Medicine (EbM) is used to support decision making in medicine and dentistry. Scientific evidence is available in different hierarchic levels. But the fundament of EbM is not only scientific evidence, but also carried by the clinical expertise of the attending physician and the preference of the informed patient. Contemporary scientific literature concludes quite often, that specific diagnostic procedures or therapies are not supported by EbM. This article puts this point up for discussion. Clinical decisions are feasible and permitted also in situations with low external evidence. The clinical expertise of the attending dentist and the informed patient should be able to draw a conclusive decision, which is adjusted to the level of EbM. It has to be avoided to hold back a promising therapy for the disadvantage of the patient.
In order to examine the diagnostic significance of typical clinical symptoms in temporomandibular joint (TMJ) disorders for diagnosis of anterior disk displacement, clinical findings were compared with the degree of disk displacement in 84 TMJs of 59 patients with TMJ disorders, who were examined clinically and by means of magnetic resonance imaging (MRI). The control group consisted of 31 subjects with no TMJ symptoms. No significant correlation between the degree of anterior disk displacement and palpation pain of the masticatory muscles or clicking/crepitus of the TMJ could be found. Joint clicking was observed in 65% of patients with TMJ symptoms in normal disk position (NDP). The percentage of joint clicking was almost the same in patients with anterior disk displacement with reposition (ADWR) (68%). There were significant correlations between active mouth opening and disk position as well as between a history of pain and disk position. Patients with NDP and ADWR had almost identical mouth opening values: 48 (+/- 5) mm and 46 (+/- 5) mm respectively. In contrast to these groups the mean values decreased significantly to 42 (+/- 6) mm in patients with anterior disk displacement without reposition (ADWOR). There were no significant correlations between occlusal findings (centric relation and habitual relation, early occlusal contacts, abrasion facets) and disk position when viewed either collectively or individually.
This study investigated the prevalence of the signs and symptoms of temporomandibular disorders (TMD) in a population of children and adolescents. TMD signs and symptoms were recorded in 1134 subjects (593 males and 541 females; age range 5-15 years), divided into various groups according to the: (i) Angle dental class; (ii) presence and type of crossbite; (iii) gender; and (iv) age (ages 5-11 and 12-15 years). The percentages of signs and symptoms were compared using the chi2-test to determine the differences among the groups for the rates of TMD symptoms, bruxism, joint sounds, deviation during opening, reduced opening/lateral/protrusive movements, and myofascial pain. Subjects who were 12-15 years old showed a significantly higher prevalence of myofascial pain than those who were 5-11 years old (chi2 = 4.263; p < 0.05). Females showed a significantly higher prevalence of myofascial pain than males (chi2 = 3.882; p < 0.05). Subjects with posterior, unilateral crossbite showed a significantly higher prevalence of TMD symptoms (chi2 = 33.877; p < 0.001) and reduction of functional movements (chi2 = 10.800; p < 0.05) than those with no crossbite, or with anterior or posterior bilateral crossbite. TMD's signs and symptoms seem to be associated to some definite characteristics of the patient, such as female gender, young age, and presence of posterior unilateral crossbite.
There are many types of pain conditions that are felt in the orofacial structures. Most of the conditions treated by the dentist are associated with the teeth, periodontal structures, and associated mucosal tissues. This article focuses on the differential diagnosis of other common pain conditions the dentist will likely face, such as temporomandibular disorders, neuropathic pain disorders, and common headaches; and the clinical presentation of each. Controlling or reducing pain can be accomplished by controlling perpetuating factors such as parafunctional habits and by some simple behavioral modifications. Finally, this article offers some simple treatment considerations.
Unlabelled: The aim of our study was to investigate the prevalence of temporomandibular dysfunction (TMD) during orthodontic treatment. Material and method: the study investigated all the patients receiving orthodontic treatment in the dentofacial orthopedic department in Casablanca in the course of the different stages of treatment over a 4-month period. We looked for a possible association between the presence of at least one sign of TMD, the Helkimo anamnesis index, the clinical Helkimo index and the following factors: age, gender, extractions, or not, of premolars, duration, type and stage of orthodontic treatment, molar and canine class, crowding, overjet, overbite and unilateral crossbite. Data were analysed using Epi-info software. The analysis of the results was done using the Chi(2) test (P<0.05). Results and conclusion: no statistically significant association could be established between TMD and the various factors under investigation with the exception of the association between gender and the Helkimo anamnesis index, stage of treatment and the Helkimo anamnesis index and the Angle molar class and the Helkimo clinical index.