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Orthodontic Treatment and Its Relation to Temporomandibular Joint Pathologies 1NN Shabeer, 2Fawas Shaj, 3KM Shukoor, 4B Satheesh Kumar, 5Jayanth Jayaranjan

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Orthodontic Treatment and Its Relation to Temporomandibular Joint Pathologies 1NN Shabeer, 2Fawas Shaj, 3KM Shukoor, 4B Satheesh Kumar, 5Jayanth Jayaranjan IJPCDR Orthodontic Treatment and Its Relation to 10.5005/jp-journals-10052-0030Temporomandibular Joint Pathologies REVIEW ARTICLE Orthodontic Treatment and Its Relation to Temporomandibular Joint Pathologies 1NN Shabeer, 2Fawas Shaj, 3KM Shukoor, 4B Satheesh Kumar, 5Jayanth Jayaranjan ABSTRACT problems that involve the masticatory musculature, the There are many temporomandibular joint (TMJ) conditions that temporomandibular joint (TMJ) and associated structures, can cause orthodontic treatment instability and relapse. These or both, being identified as the leading cause of nondental conditions are often associated with dentofacial deformities, pain in the orofacial region and is considered as a subclass malocclusion, TMJ pain, headaches, myofascial pain, TMJ of musculoskeletal disorders.5 There are many TMJ condi- and jaw functional impairment, ear symptoms, etc. Many of tions that can cause orthodontic treatment instability and these TMJ conditions can cause progressive and continuous relapse. The most common of these conditions include: changes in the occlusion and jaw relationships. Patients with these conditions may benefit from corrective orthodontic and (1) Articular disk dislocation, (2) reactive arthritis, (3) surgical intervention. The difficulty for many clinicians may lie adolescent internal condylar resorption (AICR), (4) con- in identifying the presence of a TMJ condition, diagnosing the dylar hyperplasia (CH), and (5) end-stage TMJ pathology specific TMJ pathology, and selecting the proper treatment for (i.e., connective tissue/autoimmune diseases, advanced that condition. This paper will discuss the most common TMJ reactive arthritis and osteoarthritis, traumatic injuries, pathologies that can adversely affect orthodontic stability and ankylosis, etc.). These conditions are often associated outcomes as well as present the treatment considerations to correct the specific TMJ conditions and associated jaw deformi- with dentofacial deformities, malocclusion, TMJ pain, ties to provide stable and predictable treatment results. headaches, myofascial pain, TMJ and jaw functional impairment, ear symptoms, etc. Many of these TMJ con- Keywords: Orthodontic treatment, Orthognathic surgery, Relapse, Temporomandibular joint. ditions can cause progressive and continuous changes in the occlusion and jaw relationships. Patients with these How to cite this article: Shabeer NN, Shaj F, Shukoor KM, conditions may benefit from corrective orthodontic and Kumar BS, Jayaranjan J. Orthodontic Treatment and Its Relation surgical intervention. The difficulty for many clinicians to Temporomandibular Joint Pathologies. Int J Prev Clin Dent Res 2016;3(2):139-142. may lie in identifying the presence of a TMJ condition, diagnosing the specific TMJ pathology, and selecting Source of support: Nil the proper treatment for that condition. This paper will Conflict of interest: None discuss the most common TMJ pathologies that can adversely affect orthodontic stability and outcomes as INTRODUCTION well as present treatment considerations to correct the specific TMJ conditions and associated jaw deformities The problems associated with the diagnosis and man- to provide stable and predictable treatment results.6 agement of temporomandibular disorders (TMD) have aroused interest to the orthodontists. Their attention to RELATION BETWEEN TEMPOROMANDIBULAR signs and symptoms associated with TMD has modified JOINTS AND RELAPSE the clinical management before and during orthodontic The TMJs are the foundation and support for jaw posi- treatment.1-4 According to the American Academy of tion, function, occlusion, and facial balance necessary for Orofacial Pain, the term TMD refers to a set of clinical quality treatment outcomes in orthodontics and orthog- nathic surgery. If the TMJs are not stable and healthy 1Senior Lecturer, 2,3,5Reader, 4Professor (nonpathological), treatment outcomes may be unsatis- factory relative to function, esthetics, stability, and pain. 1Department of Orthodontics and Dentofacial Orthopedics, Sree Anjaneya Institute of Dental Science, Calicut, Kerala, India Contrary to popular belief, orthognathic surgery to correct a malocclusion and jaw deformity will not “fix” or elimi- 2-5Department of Orthodontics and Dentofacial Orthopedics Azeezia College of Dental Sciences and Research, Kollam nate coexisting TMJ pathology and symptoms. Studies Kerala, India demonstrate that performing orthognathic surgery only Corresponding Author: NN Shabeer, Senior Lecturer on patients with coexisting TMJ pathology can result Department of Orthodontics and Dentofacial Orthopedics, Sree in unsatisfactory treatment outcomes, such as relapse, Anjaneya Institute of Dental Science, Calicut, Kerala, India malocclusion, TMJ pain, headaches, myofascial pain, and Phone: +919846645959, e-mail: [email protected] masticatory dysfunction. Clinical, radiographic imaging, International Journal of Preventive and Clinical Dental Research, April-June 2016;3(2):139-142 139 NN Shabeer et al dental model, magnetic resonance imaging (MRI), and/ and stabilize it using the Mitek anchor (Mitek Surgical or computed tomography scan evaluations, as well as Products Inc., Westwood, MA) technique,12 and then patient history are very important for accurate diagno- perform the indicated orthognathic surgery. The Mitek sis of the TMJ pathology and treatment planning. With anchor technique uses a bone anchor, i.e., placed into the appropriate selection and execution of the orthodontics lateral aspect of the posterior head of the condyle with and surgical procedures, as well as proper postsurgical subsequent osseointegration of the anchor. management, good outcomes can usually be achieved.7,8 Temporomandibular joint surgery (i.e., disk repositioning, REACTIVE ARTHRITIS arthroplasties, high condylectomies, etc.) can significantly Reactive arthritis (also called seronegative spondyloar- alter the position of the mandible and the occlusion. thropathy) is an inflammatory process in joints commonly Therefore, the surgical sequencing for performing TMJ related to bacterial and/or viral factors, usually occur- and orthognathic surgery at one operation or divided into ring in the 3rd to 4th decade, but can develop at any age. two operations (the TMJ and orthognathic procedures are These bacteria are known to stimulate the production of done separately) is important to achieve good outcomes substance P, cytokines, and tissue necrosis factor, which and includes TMJ surgery first, followed by mandibular are all pain modulating factors. We have also identified ramus sagittal split osteotomies with rigid fixation, and specific genetic factors, human leukocyte antigen markers then if indicated, maxillary osteotomies with rigid fixa- that occur at a significant greater incidence in TMJ patients tion. With the mandibular osteotomies being performed than the normal population indicating a genetic predis- after the TMJ surgery, the mandible will be positioned into position to TMJ pathology.13 Patients with localized TMJ its predetermined position regardless of the amount of reactive arthritis will usually have displaced disks, pain, mandibular displacement resulting from the TMJ surgery. TMJ and jaw dysfunction, ear symptoms, headaches, etc. The jaws are not wired together postsurgery since rigid As the disease progresses, condylar resorption and/or fixation (bone plates and screws) is used to stabilize bony deposition can occur, causing changes in the jaw and the osteotomy sites. Light vertical elastics (3/16 inch, occlusal relationships, as well as function. Patients with 3½ ounce) with a slight class III vector are usually used moderate to severe reactive arthritis may have other body postsurgery to control the occlusion and minimize inter- systems involvement, such as other joints, genitourinary, capsular edema. Close monitoring and managing of the gastrointestinal, reproductive, respiratory, cardiopulmo- occlusion in the postsurgery period as well as control- nary, ocular, neurological, vascular, hemopoietic, immune, ling the para-functional habits (i.e., clenching, bruxism) etc.14 Most patients with mild to moderate reactive are very important to provide quality outcomes. Open arthritis, without significant involvement of other body TMJ surgery provides direct access to the TMJ allowing systems, may respond well to articular disk repositioning manipulation, repair, removal, and/or reconstruction of and the appropriate orthognathic surgery procedures. the anatomical structures that cannot be accomplished by other means, such as arthroscopy, arthrocentesis, splint ADOLESCENT INTERNAL CONDYLAR therapy, orthodontics, or other nonsurgical treatment RESORPTION modalities. Although, arthroscopy and arthrocentesis Adolescent internal condylar resorption is a pathological, may have a role in some TMJ conditions, these proce- hormonally mediated condition primarily affecting dures are contraindicated when jaw deformities coexist teenage females (ratio 9:1, females to males), which and orthognathic surgery is required. Arthroscopy and get initiated as they enter their pubertal growth phase. arthrocentesis do not reposition the articular disk into a Patients with AICR have a classic facial morphology: proper anatomical position with adequate stabilization to (1) Retruded mandible, (2) high occlusal plane angle, and withstand the increased TMJ loading that is unavoidable (3) tendency for a class II open bite that worsens with in orthognathic surgery, particularly with mandibular time. In AICR, it
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