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104
J Pediatr Res 2019;6(2):104-9
DO I: 10.4274/jpr.galenos.2018.14890
Can Temporomandibular Joint Disorders Be
Diagnosed Beforehand by Assessment of Postural
Irregularities?
Ad dress for Cor res pon den ce
Akif Demirel MD, Ankara University Faculty of Medicine, Department of Pediatric Dentistry, Ankara, Turkey
Phone: +90 506 287 33 80 E-mail: akifdemirel@ankara.edu.tr ORCID ID: orcid.org/0000-0002-1433-0452
Re cei ved: 31.07.2018 Ac cep ted: 26.09.2018
1Ankara University Faculty of Dentistry, Department of Private Pediatric Dentistry, Ankara, Turkey
2Ankara University Faculty of Medicine, Department of Pediatric Dentistry, Ankara, Turkey
Canan Dağ1, Akif Demirel2, Nurhan Özalp2
Introduction
The temporomandibular joint (TMJ) is an ellipsoid variety
of the synovial joints forming a bicondylar articulation. TMJ
includes a disk, fibrous capsule, synovial membrane and
ligaments (1). TM disorders (D) are defined as neuromuscular
and musculoskeletal problems characterized by TMJ,
masticatory muscles and clinical findings associated with
the related structures (2). TMD are known as functional
irregularities of the general masticatory system, TMD
associated disk displacements and degenerative and
inflammatory diseases of these structures (3,4).
TMD occurs with multiple aetiological factors (5)
and common causes are parafunctional habits such
as macrotrauma, bruxism and clenching, skeletal and
occlusal disorders, psychosocial factors and systemic
factors (6). The prevalence of TMD is highly variable due
to differences in populations studied in children and
adolescents (6). In general, clinical symptoms associated
©Copyright 2019 by Ege University Faculty of Medicine, Department of Pediatrics and Ege Children’s Foundation
The Journal of Pediatric Research, published by Galenos Publishing House.
ABS TRACT
Aim: In many studies, the relationship between postural status and temporomandibular disorders (TMD) have been investigated, however
there is no consensus on this regard. The aim of this study was to investigate the relationship between postural irregularities forward head
posture (FHP) and different shoulder levels (DSL) and TMD prevalence in different dentition stages.
Materials and Methods: This study, which included children between 4 and 14 years of age attending public schools in Ankara, was planned
as a cross-sectional study. Temporomandibular joint (TMJ) was examined intra- and extra-orally. After the examination, the relationship
between TMD and body posture (FHP and DSL) was investigated. For statistical analysis, chi-square test and Fisher’s exact test were used
with significance level of p<0.05.
Results: FHP and DSL were statistically related to TMD (p<0.05). In primary dentition, there was no significant relation between FHP and
TMD, however, DSL were found to be significantly related to TMD (p<0.05). In mixed dentition, both of these parameters were statistically
related to TMD (p<0.05). However, in the permanent dentition, there was no relationship between body posture and TMD.
Conclusion: Since there is a strong correlation between postural irregularities and TMD especially in the mixed dentition stage, TMJ and
postural status of pediatric patients should be examined as early as possible in the stages of the life. In this regard, the awareness of
pediatricians and pediatric dentists to this matter needs to be improved.
Keywords: TMJ, TMD, head posture, body posture
105
with TMD are less common in the primary dentition
period than in the mixed and permanent dentition periods
(7).
It is known that TMD is positively related to head
and body posture (8-13). The body posture is a position
associated with muscle activation regulated by the central
nervous system (14). The biomechanical organization of the
body posture is regulated by the functional integration of the
various body structures, and the changes in any biological
subunit result in the differentiation and reorganization of
the postural control systems (11,13).
The stomatognathic system includes structures
which have an important role in postural control such
as the lower and upper jaw, dental arches, neurovascular
soft tissues and muscle groups related to TMJ (14). The
muscular groups of the stomatognathic system belong
to the muscle groups of the neck and all units of the
muscular chain are related to each other. As a matter of
fact, TMJ is a structure which is connected to the neck
region via the muscular and ligamental structures and
this functional unit is called “cranio-cervico-mandibular”
system (14,15). In light of these points, any disorder of the
muscular component leads to a reorganization of other
subunits (11). Therefore, the relationship between body
posture and the incidence of TMD needs to be clearly
defined (11,16) in order to provide the optimal treatment
for TMD patients.
The aim of this study is to investigate the relation
between postural irregularities and TMD prevalence in
different dentition stages. The secondary goal of this
research is to improve the awareness of pediatric dentists
and pediatricians in order to facilitate the early diagnosis
of TMD by additional examinations which include postural
status.
Materials and Methods
Sample Selection and Ethical Approval
This study, which included children between 4-14 years
of age attending public schools in Ankara, was planned as
a cross-sectional study including intra-oral and extra-oral
examinations. The study protocol was approved by the
Ethics Committee of Ankara University (approval number:
150/2). The participants of the study were selected based
on a voluntary basis and the parents of the children who
participated in the study gave informed written and verbal
consent. After detailed information was provided, informed
consent forms were signed by the parents. A power analysis
was performed to determine the sample size by using the
number of children at different dentition groups included in
the study (Table I).
Evaluation of the Postural Status
A total of 6 photographs (3 profile, 3 facade) were
taken for the postural evaluation of the children. After the
participants were positioned on a flat surface, photographs
were taken from a distance of 2 meters. Right and left
shoulder location levels were evaluated in the facade
photographs and the average value of the photographs
were recorded as a result. Similarly, in the photographs
taken in profile, the location of the shoulder and the
ear was evaluated and averages of photographs were
Dağ et al.
Relation Between Posture and Temporomandibular Disorders
Figure 1. Photos taken for posture evaluation and guide lines
Table I. Sample sizes of different dentition groups
Ages n
4-6 (Primary dentition) 298
7-11 (Mixed dentition) 669
12-14 (Permanent dentition) 408
Total 1375
106
recorded. Digital guide lines were used in the evaluation of
photographs (Figure 1). The shoulder levels were examined
based on a horizontal line and in case of inequality in
shoulder location, it was recorded as different shoulder
level (DSL). In the photographs taken from the profile,
the guide line passing over the shoulders was taken as the
criterion and the anterior head position were recorded as
forward head posture (FHP).
Examination of Temporomandibular Joint and
Diagnose of Temporomandibular Disorders
The examination of TMJ and diagnosis of TMD were
performed by observing the bilateral palpation of the skin,
muscles and joints and all movements of the mandible.
Palpation of the joint was carried out intra-orally and
extra-orally. Thus, the presence of tenderness on palpation
and irregularities of lower jaw movements were recorded
as “tenderness of masticatory muscles and TMJ”. The
presence of any findings such as deflection, deviation,
disk displacement and joint sounds (clicking, popping, and
crepitation) in TMJ examination were recorded as TMD.
After this detailed examination, mouth opening capacity,
maximum mouth opening, laterotrusion, retrusion,
protrusion and presence of pain findings were recorded.
Statistical Analysis
The relationship between postural status and TMD in
different dentition stages were analyzed using chi-square
test and Fisher’s exact test with a significance level of
p<0.05.
Results
The percentage distribution of the postural irregularities
based on FHP and DSL in different dentition stages is shown
in Table II.
The relationship between postural status and TMD
presence in primary, mixed and permanent dentition is given
Dağ et al.
Relation Between Posture and Temporomandibular Disorders
Table II. Presence of postural irregularities in different dentition
stages
FHP (%) DSL (%)
Primary dentition 5.4 5.4
Mixed dentition 5.8 5.5
Permanent dentition 6.4 6.9
FHP: Forward head posture, DSL: Different shoulder levels
Table III. Relationship between postural irregularities and presence of TMD in different dentition periods
TMD
Chi-square test p valueAbsence Presence Tot al
n % n % n %
Primary dentition
FHP
Absence 267 94.68 15 5.32 282 100
Fisher’s exact test 0.063Presence 13 81.25 3 18.75 16 100
Total 280 93.96 18 6.04 298 100
DSL
Absence 268 95.04 14 4.96 282 100
Fisher’s exact test 0.011*Presence 12 75.00 4 25.00 16 100
Total 280 93.96 18 6.04 298 100
Mixed dentition
FHP
Absence 553 87.78 77 12.22 630 100
27.381 0.000*Presence 22 56.41 17 43.59 39 100
Total 575 85.95 94 14.05 669 100
DSL
Absence 552 87.34 80 12.66 632 100
16.325 0.000*Presence 23 62.16 14 37.84 37 100
Total 575 85.95 94 14.05 669 100
Permanent dentition
FHP
Absence 317 82.98 65 17.02 382 100
Fisher’s exact test 0.107Presence 18 69.23 8 30.77 26 100
Total 335 82.11 73 17.89 408 100
DSL
Absence 316 83.16 64 16.84 380 100
3.180 0.075Presence 19 67.86 9 32.14 28 100
Total 335 82.11 73 17.89 408 100
TMD: Temporomandibular disorders, FHP: Forward head posture, DSL: Different shoulder levels, *Statistically significant difference
107
in Table III. According to the results, there was no relation
between TMD and the FHP in primary dentition, while the
presence of TMD was found to be statistically significant in
DSL (p<0.05). Additionally, the presence of TMD was found
to be statistically significant (p<0.05) in both postural
irregularities in mixed dentition. In permanent dentition,
both postural irregularities were not statistically related to
TMD. Nevertheless, it has been determined that the rate
of TMD was higher in the individuals in whom the postural
irregularities were observed.
The rate of presence of TMD was 34.6% in the
presence of FHP, whereas the rate of TMD in normal head
position was 12.1%. The presence of TMD was statistically
significantly higher in the presence of FHP (p<0.05) (Table
IV). Additionally, the incidence of TMD was 33.3% and 12.2%
in patients with and without DSL, respectively. The presence
of TMD was statistically significantly higher in the presence
of DSL (p<0.05) (Table IV).
Discussion
TMD are common diseases in children and adolescents
being at least as prevalent as for adults (17-20). TMD
develop with multiple etiological factors and occur with
signs and symptoms affecting the joint related muscular
and neuromuscular components (21-23). In the treatment
of TMD, in order to provide preventive procedures, it is
necessary to investigate factors that may lead to this
disease especially during different dentition periods.
Regulation of the postural structure of the body is
possible if the changes in the biological subunit reorganize
the postural control systems (11,13). The neck muscles
that are adjacent to the TMJ region play an important role
in providing the balance of the head and stomatognathic
muscles. It means that any level of differences in these
structures can cause changes throughout the whole
complex. The masticatory muscles can be affected by
alterations in head posture and vice versa. Thus, any
manipulation of the mandibular muscles can lead to
changes in head posture (13,24) and changes in the
cervical spine structure can also play a role in developing
TMD (13).
As the TMJ region is directly adjacent to the cervical
and scapular regions, postural changes in the upper neck
and head region correlate with TMD (13). Gonzalez and
Manns (25) stated that FHP was caused by an extension of
the upper cervical spine (C1-C3) and a flexion of the lower
cervical spine (C4-C7) called hyperlordosis. The authors
also emphasized that hyperextension was observed in the
head and upper cervical spinal region in TMD patients.
Alarcón et al. (26) suggested that the position of the
jaw can affect the muscles in the peripheral region and
cause postural adaptations at the spine level. Asymmetric
malocclusions such as unilateral cross bite have been
reported to be a risk factor for unbalanced muscle activity
and postural dysfunction. Similarly, Solow and Sonnesen
(27) stated that there is a strong relationship between the
cervical lordosis grade and vertical craniofacial morphology,
overjet, class 2 and class 3 anomalies. It is thought that
TMD and postural irregularities are related and risk factors
for each other. In this way, it can be stated that there is a
positive relationship between head/body posture and TMD
(8,9,11). In the present study, the aim was to investigate
the relationship between TMD and head/body posture
and this relationship was examined in different dentition
periods. The presence of disk displacement, joint sounds,
muscular irregularities, movement limitations and pain
were accepted as TMD. In postural status evaluation, FHP
and DSL were examined.
In order to determine the postural status, several
techniques (e.g. surface electromyography, kinesiography,
different clinical and instrumental posturographic
approaches) have been used over the years (28). Despite
some studies on the stomatognathic system and its
relationship with posture (29-33), they have restrictive
factors to their clinical application because of the absence
of normative values for age, sex, weight, height and facial
Dağ et al.
Relation Between Posture and Temporomandibular Disorders
Table IV. The relationship between postural irregularities and TMD
TMD Statistical analysis
Absence Presence Tot al
n % n % n % Chi-square p value
FHP
Absence 1137 87.9 157 12.1 1294 100
31.051 0.000*Presence 53 65.4 28 34.6 81 100
Total 1190 86.5 185 13.5 1375 100
DSL
Absence 1136 87.8 158 12.2 1294 100
27.423 0.000*Presence 54 66.7 27 33.3 81 100
Total 1190 86.5 185 13.5 1375 100
TMD: Temporomandibular disorders, FHP: Forward head posture, DSL: Different shoulder levels, *Statistically significant difference
108
morphology. For these reasons, this study was carried
out in an out-of-clinical setting and simple photographic
techniques were used as an evaluation criterion.
In the present study, the presence of TMD was found to
be statistically significant (p<0.05) in those individuals with
FHP and DSL in mixed dentition. In permanent dentition,
an association with both postural parameters and TMD
was not observed as statistically significant. Similar to the
findings of this study, it has been reported that TMD is not
frequently observed during primary dentition, while it is
increasingly observed during mixed dentition (7). Chaves et
al. (34) reported that the alterations in head position were
observed in 56% of cases of moderate to severe TMD in
individuals in the 10-18 years age group. Cortese et al. (35)
stated that FHP was one of the most common postural
anomalies at 10-15 years of age, and this was a risk factor
for TMD. It seems that there is a need for more standardized
studies concerning the relationship between postural
irregularities and TMD in different dentition periods in
children.
Patients in the mixed dentition period should be
carefully assessed for the presence of TMD and postural
irregularities, since TMJ related diseases are expected to
increase especially after the primary dentition period.
It has been reported that TMD stimulate the effects of
masticatory muscles on the compensator mechanism
and this biomechanical adaptation pulls the shoulders
upwards (34). The occurrence of postural disorders is
believed to be due to excessive stresses on the cervical
muscles depending on the increased activity of the
masticatory muscles to compensate for joint disease
in TMD individuals (34). Nicolakis et al. (9) reported
that training for postural correction in those patients
with TMJ disk displacement have had promising results.
Consequently, it is not certain that TMD is caused by
postural changes or postural disorders are caused by TMD
(36). In this respect, both situations should be considered
as a potential risk factor for each other. These patients
should be diagnosed and treated as early as possible by
medical doctors, pediatricians and pediatric dentists using
multidisciplinary approaches.
Conclusion
TMD is not only a problem affecting adults but can also
be seen in pediatric patients. However, when considering
the relationship between postural status and changes and
presence of TMD, it is unclear which one is the etiological
factor for the other. The disorders mentioned should be
diagnosed at the youngest possible age. This approach
will be beneficial in terms of the elimination of both TMD
and postural irregularities. Therefore, it is recommended
that pediatric dentists and pediatricians should evaluate
the findings that may raise suspicions about the diagnosis
of TMD and postural irregularities in a multidisciplinary
manner.
Ethics
Ethics Committee Approval: The study protocol was
approved by the Ethics Committee of Ankara University
(approval number: 150/2).
Informed Consent: Informed consent was obtained by
the parents.
Peer-review: External and internal peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: C.D., N.Ö., Concept:
C.D., A.D., N.Ö., Design: C.D., A.D., N.Ö., Data Collecting or
Processing: C.D., N.Ö., Analysis or Interpretation: C.D., A.D.,
N.Ö., Literature Search: C.D., A.D., N.Ö., Writing: A.D., N.Ö.
Conflict of Interest: No conflict of interest was declared
by the authors.
Financial Disclosure: The authors declared that this
study received no financial support.
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