Association Between and Temporomandibular Disorders in Orthodontic Patients Before Treatment

Kazuo Tanne, DDS, DDSc The association between malocclusion and the prevalence of tem- Assistant Professor and Lecturer pormandibular disorders (TMD) was studied in an orthodontic Eiji Tanaka, DDS patient population before orthodontic treatment was started. A Graduate Student total of 305 patients, 232 with general malocclusion and 73 who also had cleft lip or palate, were given a questionnaire about the Mamoru Sakuda, DDS, DDSc subjective symptoms of TMD. Clinical examinations for type of Professor and Chaimisn malocclusion and TMD signs were also conducted. No significant Department of differences in the prevalence of TMD were observed between the Osaka University Facuity of sexes or between the two patient groups. Temporomandibular joint Osaka. Japan sounds and difficulty of movement were the most common of Correspondence to: tbe TMD signs and symptoms. Open bite, posterior , and Dr Kazuo Tanne deep bite were tbe most prevalent types of malocclusion in both Department of Orthodontics groups. Thus, some specific types of malocclusion were significant- Osaka University ly associated with the occurrence of TMD. Faculty of Dentistry J OROFACIAL PAIN 19y3;7:156-162. 1-8 Yamadaoka, Suita Osaka 565. Japan

emporomandibular disorders (TMD) have become a great topic in orthodontics, and in dentistry in general. As a conse- T quence, various studies have been conducted to elucidate the nature of TMD and its causes.'"'These studies have described the causes of TMD, such as masticatory muscle problems, chronic trau- matic change in the TMJ, internal derangement of the TMJ, and degenerative change of the TMJ components, although TMD are considered multifactorial in natute. These studies have also indicated that malocclusion may be relevant to inducing functional imbalance of the musculature and malposition of the condyie in the TMJ,'"" which are further related to the occurrence of TMD'. From these considerations it may be speculated that malocclusion is one of the causes of 'I'MD, although previous articles'-'^ have suggested it plays only a limited tole. Thus, it is still unclear whether malocclusion is a cause of ot only a ptedisposing factor in TMD. To answer this question, epidemiologic studies""""'" have been designed extensively. In these studies, the prevalence of TMD was examined in general subjects or patient populations with various types of malocclusion. Varying values were reported, ranging from 35% by Williamson" to 71.6% by Nilner and Lassing.'" It was also indicated that TMD signs are found in all age groups from adoles- cence to adultbood, altbough children exhibit lower prevalences than adults.'""""'" Further, another aspect of TMD as it relates to occlusion has been studied in association with orthodontic treat- ment.""-^ There are opposing views on this subject: that orthodon- tic treatment has no association with TMD"-''"-' and that ortho- dontic treatment is responsible for curing or inducing

156 Volume 7. Number 2, 1993 Tanne

Table 1 Summary of Subjects with vertical skeletal discrepancies. Crowding is a

Patients Men •>Women Total result of dentoalveolar discrepancies. If several types of malocdusion were detected Ordinary orthodontic 86 146 232 for a subject, all the were included Cleft Up/palate 33 40 73 during data sampling. Total 119 186 305

Subjective Symptoms and Clinical Signs of TMD However, it has not been confirmed whether Temporomandibular disorders herein include specific types of tnalocclusion are more highly subjective symptoms and clinical signs for TMJ associated with TMD occurrence than others, and sounds, TMJ pain, muscle tenderness, and difficul- such information would be very useful in identify- ty of jaw movement. The subjective symptoms ing at-risk patients. were first recorded on a questionnaire, ie, which The present study was conducted ro investigate symptoms are recognized by the subjects and how the association between malocclusion and the troublesome are they? Further, TMD signs were TMD prevalences in orthodontic patients before examined during mitial orthodontic diagnosis fol- treatment and further to determine the specific lowing the methods proposed by Helkimo'" and type or types of malocclusion that predispose Krogh-Poulsen-': toward TMD occurrence. 1. Temporomandibular joint sounds, including clicking and crepitation, were determined on palpation of both TMJs laterally and posteri- Materials and Methods orly during opening and closing of the . A total of 305 subjects, examined but untreat- 2. Temporomandibular pain was examined on ed, were selected from patients at the orthodontic palpation of both TMJs from the lateral and clinic of Osaka University Dental Hospital. These posterior sides. included 232 ordinary orthodontic patients and 3. Muscle tenderness was determined on palpa- 73 cleft lip and palate (CLP) patients. Male and tion of the temporalis, masseter, and medial and lateral pterygoid muscles. female distributions in each group are shown in Table 1. 4. Maximum pain-free mouth openmg was mea- For each subject, types of malocclusion and sub- sured by use of calipers. Difficulty of jaw movement was defined as mandibular opening jective symptoms and clinical signs of TMD were of 35 mm or less.' evaluated by trained orthodontists according to the following items by means of interview and These data were summarized as two-way fre- clinical exammation. quency tables and subjected to statistical treat- ments. Chi-square test was used to evaluate the Malocdusion differences in the TMD frequency between the sexes and between the two patient groups. Further, Type of malocdusion was determined using the association between TMD and malocclusions patient dental casts and classified as follows: was investigated by use of independence test for 1. Mandibular prognathism—malocdusion with two attributes. anterior crossbite 2. Maxillary protrusion^malocdusion with overjet greater than 5 mm Results 3. Posterior crossbite—malocdusion with poste- rior unilateral or bilateral crossbites The prevalence of TMD was 18.5% in men and 4. Open bite—malocdusion with negative 19.4% in women (Table 2). No significant differ- 5. Deep bite—malocdusion with overbite greater ences were observed between hoth values. The than 5 mm prevalences of TMD in the orthodontic patients 6. Crowding—malocdusion with malposition of and CLP groups were 21.1% [men, 21.9%; women, 21.2%) and 12.3% (men, 12.1%; women, teeth 12.5%), respectively. The values exhibited no sig- The first three malocclusions are associated with nificant differences (Table 2). Thus, no significant horizontal skeletal discrepancies, the second two

Journal of Orofaeiai Pain 157 Tanne

Table 2 Prevalence of TMD

Men Women Total

Patients n No.(%) n No. (%) n No. (%)

Ordinary ortiiodontic 86 18(20.9) 146 31 (21.2) 232 49(21,1) Cleft lip and/or palate 33 4(12.1) 40 5(12 5) 73 9(12 3) Total 119 22(18.5) 186 36(19 4) 305 58(19.0)

No significant differenc and between the groups.

Non-CLP patients CLP patients

Qlju^ D •i-i^rn^ 4 5 6 7 S 9 in 11 i: i.í 14 15 16 17 IS 15 20 21 22 23 24 25 26 27 28 29 5 6 7 N y 10 11 12 13 14 1Î 22 26 Age Age

Fig 1 Frequency of TMD by age (years) in patients with and without cleft lip or palate. Unshaded areas represent patients without TMD, shaded areas respresent patients with TMD.

differences were observed between the sexes and level of confidence, indicating an existence of spe- the groups in tbis particular patient population. cific malocclusion significantly associated witb the Figure 1 shows tbe TMD prevalences for each occurrence of TMD (Table 3). age in both groups. From 6 to 8 years of age, tbe Figure 2 shows the TMD signs and symptoms of prevalence in tbe CLP group was higher than in open bite, deep bite, maxillary protrusion, tbe non-CLP group, although tbe value was mandibular prognathism, and posterior crossbite, approximately 30% at the maximum. For tbe sub- whicb exhibited relatively bigb prevalences of sequent ages, the prevalence increased substantial- TMD (Table 3). Temporomandibular joint sounds ly in tbe non-CLP group; however, because of a were observed frequently in cases of open bite, lack of CLP subjects at these ages, the prevalences whereas difficulty of jaw movement was promi- in both groups were not compared. nent in cases of deep bite. Distribution of TMD Table 3 sbows the prevalence of TMD for vari- signs and symptoms for maxillary protrusion was ous types of malocclusion. For two subject groups similar to that for mandibular prognatbism. Tbe tbe prevalence of TMD was greater in cases of prevalences of TMJ pain and difficulty of jaw open bite, posterior crossbite, mandibular prog- movement were substantially higher in cases of nathism, and deep bite. An interesting finding was posterior crossbite than in mandibular prog- that open bite presented tbe highest values in botb nathism, while TMJ sounds were slightly more groups, reaching almost 50%. The association prevalent in mandibular prognatbism cases tban in between TMD and malocclusion type was posterior crossbite cases. observed in the whole subject group at tbe 5% Distribution of TMD signs and symptoms in

158 Volume 7. Number 2, 1993 Tanne

Table 3 Prevalence of TMD in Each Malocclusion

Orditiary Cleft lip/ orthodontic patients palate patients Total*

Malocclusion n No. {%) n No. 1%) n No. ¡%)

Maxillary protrusion 73 14(19.2) 2 0 75 14(18.7) Mandibular prognathism 65 16124,6) 60 7(11 7) 125 23(18.4) Posterior erossbite 64 23 Í35.9) 53 8(15.1) 117 31 (26.5) Open bite 21 9 (42.9) 6 3 (50.0) 27 12(44.4) Deep bite 50 11 (22 0) 8 1 (12.5) 58 12(20.7) Crowding 91 18(198) 6 0 97 18(18.6)

•Significant association between TMD .and nah al 5% lEvel

1 TMJ sounds TMJ sounds Zl TMJ pain TMJ pain

Muscle tenderness Muscle tenderness Diillcull}' of jaw niovenifnl Difticult}' of jaw moveraenl

0 5 0 5 10

Open bite (12 subjects) Deep bite (12 subjeetsi

TMJ sounds

TMJ pain TMJ pain

Muscle leiiderness Muscle ienderness

Difficuitv of jaw movement Diflicuitj of jaw niovemerl

Maxiliar]' protrusion (14 subjeclsl • Mandibular prognathism |23 subjects)

TMJ sounds TMJ puin

Muscle tenderness Difficuity of jaw movement

0 10 20

Posterior crossbiteOJ subjects)

Fig 2 Distribution of TMD signs and symptoms in cases of open bice, deep bite, maxillary protrusion, mandibular prognathism, and posterior erossbite. Numbers on tlie horizontal axis mdicate the number of patients who exhibited TMD signs and symptoms.

Journal of Orofacial Pain 159 Tanne

Table 4 Prevalence of TMD Symptoms that skeletal discrepancies in adolescent CLl patients have not fully developed and thai m^'it of No. of patients {%) with sytiiptoms CLP patients undergo an initial examination before tbe age of 9, Hence, the number i'¡ CLl No. Difficulty subjects in this study is small at the subsequent Patients of with TMJ Muscle TMJ jaw ages. These clinical factors may explain wby the Patients TMD sounds tenderness pain movement frequency of TMD in tbe CLP group was lower than that expected. Ordinary Ir is well known that women are more percep- orthodontic tive of pbysicai cbanges than men; therefore, the (n = 232) 49 30 (12.9) 8 (3.4) 18 (7 6) 23 (9 6) prevalence of TMD in women is greater in general Ciefi iip/ palate than in men." However, in this study tbe preva- (n = 73) 9 6(8.2) 1 (1.4) 1 (t.4) 6(8 2) lences of TMD did not differ significantly between Total(n = 305) 58 36(11.8) 9(3 0) 19(6.2) 29(9 5) the sexes- This finding may be explained by the fact that the present subjects were younger tban those in previous studies''" and tbat perceptual differences are not well developed in adolescent patients with TMD is shown in Table 4. In both patients compared with adults- groups, TMJ sounds exhibited the highest preva- In previous studies'"'"*-'"' TMJ sounds were the lence, followed by difficulty of jaw movement, most commonly occurring signs of TMD. Tbis was TMJ pain, and muscle tenderness. It was also also found in the present study. From tbese consid- found that TMJ sounds were frequently associated erations, it may be implied tbat tbe majority of witb TMJ pain and difficulty of jaw movement. adolescent ortbodontic patients who also manifest However, no statistically significant association TMJ sounds first experience malposition of tbe was found between two of the TMD signs in eitbet condyle in the TMJ space, whicb furtber induces group. displacement of the articular disc or internal derangement of the TMJ without producing severe pathologic conditions in tbe TMJ. Tbus, TMJ Discussion sounds and reduced maximum opening, resulting in general from inrernal derangement in tbe TMJ, As the number of TMD diagnoses has were observed more frequently tban muscle ten- increased, approaches have been used to elucidate derness and TMJ pain in this patient population. tbe nature of TMD and tbeir etiologic factors.'"" With respect to tbe association between TMD These studies indicated tbat TMD are multifactori- and malocclusions,'""'''"-- controversy exists as to al in nature, but tbey also suggested a possibility wbether or not TMD are produced in association tbat malocclusion may affect tbe occurrence of with malocclusions. In a recent study by Egermark TMD. and Thilander," it was shown that persons with a The overall prevalence of TMD in tbis study history of ortbodontic treatment have a lower was approximately 20%. This value is very close prevalence of subjective TMD symptoms, includ- to tbe result by Brandt,'' whereas higher frequen- ing TMJ sounds, tban those who have not received cies were also reported elsewhere.'"" In our study, orthodontic treatment. Sadowsky et al™ found the from 6 to 8 years of age, prevalence in tbe CLP same tendency in terms of less frequency of TMJ group was higher than in the non-CLP group, sounds in tbe group given orthodontic treatment. although tbe value was approximately 30% at tbe Further, it has been demonstrated that some TMD maximum. For the subsequent ages, tbe prevalence patients can be cured by splint tberapy''and increased in the non-CLP subjects, as was oeclusal adjustment,*-" wbicb are rbougbt to play described in previous studies,'""'"''" However, tbe a role in eliminating occlusal interferences in sucb overall prevalence in tbe CLP group was not sig- patients. These findings empbasize an association nificantly different from tbat of the non-CLP of TMD occurrence witb tbe occlusion. group. Because CLP patients in general have more In the present study, open bite, deep bite, and severe skeletal discrepancies in tbe anteroposterior posterior crossbite appeared to induce TMD more and mediolateral directions, tbc prevalence of frequently tban other malocclusions. Tbus, it is TMD in the CLP subjects would be expected to be suggested tbat certain types of malocclusion may mucb bigber than in ordinary orthodontic patients. induce TMD more frequently,'""" and bence not One explanation for this finding may be the fact all types of malocclusion always pertain to the

160 Volume 7, Number 2, 1993 Tanre occurrence of TMD. In open bite and deep bite, 15. Egermark-Eriksson I, Carlsson GE, Magnusson T. A long- the amount of anterior guidance is not absolute in term epidemiologic sttidy of tbe relationship between occlusal factors and mandibular dysfunction in children protrusive movements of the mandible. Fot poste- and adolesL-ents. J Dem Res I987;66:67-71. rior ctossbite, occlusal interferences are occasion- 16. Egermark-Eriksson I, Catlsson GE, lngervall B. Prevalence ally induced during latetal movements of the of mandibular dysfunction and oriifacial parafunction in 7-, mandible. These occlusal factors may lead to an I I-, and 15-year-old Swedisb children. Eur ] Orthod imbalance of biomechanical stresses in the TMJ.''' 1981;3:163-I72. Further, malposition of the condyle and/or articu- 17. Brandt D, Temporomandibular disorders and their associa- tion with morphologic malocclusion in children. In: lar disc may be produced by mesiodistal and medi- Carlson DS, McNamara JA Jt, Ribhens KA (eds). olateral shifts of the mandible.-"'"' These maloc- Developmental Aspect of Temporomandibular Juint elusions, which are tnore likely to induce malposi- Disorders. Ann Arbor, MI: Univ of Michigan Center uf tion of the condyle in the TMJ space, may be more Human Growth and Development, 1989:279-298. relevant to the occurrence of TMD than otbers. 18. Riolo ML, Brandt D, Ten Have TF. Association between occlusal characteristics and signs and symptoms of TMJ Furtber investigation with cephalometric dysfunction in children and young adults. Am j Otthod appraisal for craniofacial morphology in patients Dentofac Orthop Í 987;92:467--i77. with TMD would mtegtate the morphology with 19. Egermark I, Thilander B. Craniomandibular disorders with condylar position in the TMJ space. special reference to orthodontic treatment: An evaluation from childhood ro adulthood. Am J Orthod Denrofac Orthop 1992^101:28-34. 20. Larsson £, Ronnerman A. Mandibular dysfunction symp- References toms in orth odóntica I ly treated patients ten years after the completion of treatment. EurJ Orthod 1981;3:89-94. 1. Reynders RM. Orthodontics and temporomandibular dis- 21. Dibbets JMH. van der Weele LT. Orthodontic treatment in orders: A review of the literature (1966-1988). Am J relation to symptoms attributed to dysfunction of rhe tem- Orrhod Dentofac Otthop 1990^97:463-471. poromandibular joint: A 10-year report of the University 2. Weinberg LA. Posterior bilateral condylar displacement: 1rs of Groningen study. Am J Orthod Dentofac Orthop diagnosis and treatment. J Prosthet Dent 1976; 1987;91:193-205. 36:426-^40. 22. Sadowsky C, BeGole EA. Long-term status of temporo- 3. Solberg WK. Tempnromandi bular disorders: Function and mandibular joint function and functional occlusion after radiological considerations. Br Dent J 1986;22:195-200. orthodontic treatment. Am J Orthod 1980;78:201-212. 4. Laskin DM. Etiology of the pain-dysfunction syndrome. J 23. Rinchuse DJ. Counrerpoint: Preventing adverse effects Am Dent Assoc 1973;79d47-153. on the remporomandibukr joint through orthodontic 5. Ramfjord SP. Dysfunctional temporomandibular joint and treatment. Am J Orthod Deniofac Orrhop 1987;91: muscle pain. J Prosthet Dent l961;ll:353-373. 500-506. 6. Perry HT. Temporomandibular joint and occlusion. Angle 24. Wyatt WE. Preventing adverse effects on the temporo- Orthod 1976;46:284-293. mandibular joint through orthodontic treatment. Am J 7. Agerberg G, Carlsson GE. Funcrional disorders of the mas- Orthod Dentofac Orrhop 1987;91:493-t99, ticatory system. I. Distribution of symptoms according to 25. Roth RH. Temporomandibular pain-dysfuncrion and age and sex as judged from investigation by questionnaire. occlusal relationships. Angle Orthod 1973i43:136-152. Acta Odontol Scand 1972;30:597-613. 26. Helkimo M. Epi dem i o log i cal surveys of dysfunctions of 8. Moblin B. Prevalence of mandibular dysfunction and tela- the masticatory system. Oral Sei Rev 1976;l:54-69. tion between malocclusiun and mandibular dysfunction in 27. Krogh-Poulsen WG. Management of the occlusion of the a group of women in Sweden. Eur J Orthud 1983; teeth. In: Schwanz L, Chayes CM (eds). Eacial Pain and 5:601-602. Mandibular Dysfunction. Philadelphia: Saunders, 1968: 9. Williamson EH. Tempo rom a ndi bular dysfunction in pre- 236-279. treatment adolescent patients. Am J Orthod 1977; 28. Hansson T, Nilner M. A study of the occurrence of symp- 72:429-^33. toms of diseases of the temporomandibular joint, mastica- 10. Nilner .M, Lassing SA. Prevalence of functional distur- tory musculature and related structures. J Oral Rehabil bances and diseases of the stomatognathic system in 7-14 1975;2:313-324. years old. Swed Dent J 1981;5;I73-187. 29. Shiffman EL, Fricton JR, Haley DP, Shapiro BL. The 11. Grosfeld O, Czarnecka B. Musculo-articular disorders of the prevalence and treatment needs of subjects with TM disor- stomatognathic systtm in school children examined accord- ders. J Am Dent Assoc 1990;120i295-303. ing to clinical criteria. J Oral Rehabil 1977;4t 193-200. 30. Sadowsky C, Theison TA, , Sakols EL Orthodontic treat- 12. Seligman DA, Pullinger AG. The role of intercuspal tnent and temporomandibular joint sound — A longitudi- occlusal relationships in temporomandibular disorders: A nal study. Am J Orthod Dentofac Orthop 1991;99: review. J Craniomandib Disord pacial Oral Pain 441^47. 1991;5:96-I06. 31. Sakuda M, Tanne K, Tanaka E, Takasugi H. An analytic 13. Talknts RH, Catania J, Sommers E. Temporomandibular method fur evaluating condylar position in the TMJ and its joint findings in pédiatrie populations and young adults: A application to orthodonic patients with painful clicking. Am J Orthod Dentofac Orthop 1992;101:88-96. critical review. Angle Orthod 199I;61:7-16, 14. 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Joumal of Orofacial Pain 161 Tanne

33. Wenneberg N, Nystrom T, Carlsson GE. ücdusal equili- bration and other stomatognachic treatment in patients wich mandibular dysfunction and headache. J Prosthet Resumen Dent]9g8;59:478-4g4. 34. Tanaka E, Tanne K, Sakuda M. Stress analysis in the TMJ Asoeiación enlre la maloclusión y los desórdenes tem- by means of finiré element merhod: Construction of a 3-D poromardibulares en pacientes que van a someterse a model and its analytical results |absttact|. The 50th tratamiento de ortodoncia. Annual Meeting and the 1st Asian Pacific Orthodontic Conference of Japan Orthodontic Society. Osaka, Se esludió la asociación entre la maloclusión y \a prevalencia de 1991:103. los desórdenes temporomandibLilares tDTM), en una población de pacientes que iba a someterse a tratamiento de ortodoncia. De un total de 305 pacientes. 232 sufrían de maloclusión gener- al y 73 también tenían sus íabios fisurados o sus paladares hen- didos Los pacientes tomaron un cuestionario acerca de los sin- tomas subjetivos de los DTM. y fueron examinados clinica- mente para determinar el tipo de malociusión y los signos rela- cionados a iost DTívi No se observaron diferencias significati- vas en cuanto a ia prevalenoia de los DTÍui, entre los sexos o enlre los dos grupos de pacientes. Los signos y síntomas mas comunes relacionados a los DTM fueron ios sonidos de la artic- ulación temporomandibuiar y la dificultad para mover la mandibula. Los tipos mas prevalentes de maloculsión en ambos grupos fueron la mordida abierta, ia mordida cruzada posterior, y la sobremordida. Por lo tanto, algunos tipos específicos de maloclusión fueron asociados significativamente a la occurencia de los DTM,

Zusammenfassung

Assoziation zwischen Malokklusion und Myoarthropathren des Kau system s bei Orthodontie-Patienten

Die Assoziation zwischen Malokklusion und Pravalenz von Myoarthropathien des Kausystems (MAP) wurde an 305 Ort hod on tie-Patienten vor Behandlungsbeginn studiert. 233 hat- ten eine Malokklusion und 73 auch Lippen- oder Gaumenspalten, Die Patienten mussten einen Fragebogen über subjektive MAP- Symptome ausfüllen und wurden klinisch bezüglich Malok- klusionsform und MAP-Symptomen untersuch!. Es konnten weder zwischen den beiden Patientengruppen noch zwischen den Geschlechtern signifikante Unterschiede in der Pravaienz von Myoarthropathien festgestellt werden Kiefergelenks- gerausche und eine erschwerte Unterkieferbeweglichkeit waren die häufigsten MAP-Symptome Als Malokklusionsformen kamen der offene Biss, der seitliche Kreuzbiss und der Tiefbiss am häufigsten vor. Dementsprechend waren einige spezifische Malokklusionsformen mit denn Vorliegen von MAP-Symptomen signifikant assoziiert

162 Volume 7. Number 2, 1993