Int. J. Oral Maxillofac. Surg. 2000; 29: 183–187 Copyright C Munksgaard 2000 Printed in Denmark . All rights reserved
ISSN 0901-5027
Kari Panula1, Matti Somppi2, Kaj Finne1,Kyo¨ sti Oikarinen3 Effects of orthognathic surgery 1 Department of Oral and Maxillofacial Surgery, Vaasa Central Hospital; 2Department of Oral and Maxillofacial Surgery, Seina¨joki on temporomandibular joint Central Hospital; 3Department of Oral and Maxillofacial Surgery, University of Oulu, dysfunction Finland A controlled prospective 4-year follow-up study
K. Panula, M. Somppi, K. Finne, K. Oikarinen: Effects of orthognathic surgery on temporomandibular joint dysfunction. A controlled prospective 4-year follow-up study. Int. J. Oral Maxillofac. Surg. 2000; 29: 183–187. C Munksgaard, 2000
Abstract. A prospective follow-up study was performed to examine the influence of contemporary orthognathic treatment on signs and symptoms of TMJ dysfunction. Sixty consecutive patients were examined once preoperatively and twice postoperatively, and Helkimo’s Anamnestic and Dysfunction Indices (Ai and Di) were determined. The prevalence of headache was also assessed. The average follow-up was 4 years from the initial examination. A group of 20 patients with a similar type and grade of dentofacial deformity, who did not wish to have surgery or other occlusal therapy, served as a control group. The majority (73.3%) of the patients had signs and symptoms of TMJ dysfunction (TMD) in the initial phase. At final examination the prevalence of TMD had been reduced to 60% (PΩ0.013). There was a dramatic improvement in headache: initially 38 (63%) patients reported that they suffered from headache, but at the final visit only 15 (25%) did so. It is concluded that functional status can be significantly improved and pain levels reduced with orthognathic treatment. The Key words: orthognathic treatment; TMJ dysfunction; dentofacial deformity; headache. risk for new TMD is extremely low. No association, however, could be shown between TMD and the specific type or magnitude of dentofacial deformity. Accepted for publication 16 November 1999
Apart from improvement in appear- On the other hand, some authors have tients with similar malocclusions who ance, an important goal of orthogna- not found any significant improvement had refused surgery, was used as a con- thic treatment is to improve masticatory in TMD or any particular relation be- trol group. function. It is, however, somewhat con- tween TMD and the specific type of troversial as to whether this goal is al- dentofacial deformity2,13,21,22,27. The ways achieved1,13,19–21,28. Even though growing demand to cut costs of health Material and methods many studies report reduction in TMJ care forces clinicians to provide evi- The study group consisted of 60 consecutive dysfunction (TMD) symptoms after dence-based and cost-effective treat- patients (49 women, 11 men) with a mean age orthognathic surgery3,4,10–12,14,16,18,29, ment. of 33.2 years (median 32.7 years, range 16– most studies have some serious flaws in It has been mentioned that retrospec- 56 years) referred for consultation and treat- that small patient samples are used14,18, tive studies tend to overestimate treat- ment to the Departments of Oral and Max- whereas others are retrospective in na- ment benefits25. The aim of this study illofacial Surgery of the Central Hospitals of Vaasa or Seina¨joki. All of the patients had ture3,4,14,29. In some studies periods of was to analyse prospectively the effects preoperative orthodontics and they were op- intermaxillary fixation (IMF) have been of orthognathic surgery with contem- erated on in Vaasa between 1993 and 1995, 11,12,14,18 used , while in others the fol- porary rigid fixation methods on TMD. using rigid internal fixation without IMF. low-up seemed rather short3,4,11,18 or In order to facilitate a comparison with Fixation was performed with AO-position the studies have been case reports10,16. a non-treatment group, a group of pa- screws in the mandible and miniplates in the 184 Panula et al. maxilla. There were initially 65 patients, but examined on panoramic tomographies at the Data analysis was not performed until the 5 were deleted from the study; two patients first and latest examination in the study last patient had been examined for the last were treated with orthodontics only, one group. In order to assess any possible associ- time to prevent bias from the examiner’s could not be reached for final examination, ation of mandibular plane angle to the sever- awareness of any trends in the basic data. one was found to suffer from a neuromuscu- ity of TMD, the SN-MeGo angle was meas- lar disorder and one had a severe psycho- ured on the lateral cephalograms preopera- logical disorder. tively as described by DC et al.3, K- Results A group of 20 patients (16 women, 4 men) et al.12 and S et al. 23, who There were no significant differences be- seeking treatment for similar deformities but compared the measurements to a value of who did not wish to have treatment after the 32æ. tween the study and control groups in information was given at the first visit, The frequency of headache was assessed age, gender distribution and type or served as a control group. The mean age in using the following categories: (1) one or two magnitude of the dentofacial deformity. this group was 31.5 years (median 33.0 years, times a month, (2) one or two times a week, Signs and symptoms of TMD were range 15–44 years). (3) more than one or two times a week, (4) frequently seen throughout the follow- The patients in the study group were as- ‘‘migraine type’’ (symptoms like in migraine up, as shown in Table 3. Forty-four pa- sessed for signs and symptoms of temporo- but no diagnosis made by neurologist). Some tients (73.3%) had at least one sign or mandibular dysfunction three times: (1) be- patients did not have headache at all or less symptom of TMD preoperatively and fore orthodontic treatment (approximately than once a month. 36 after 4-year follow-up (60%), which 19 months preoperatively, range 7–32 The distributions of diagnosis and oper- months), (2) approximately 12 months post- ations performed are shown in Tables 1 and represented a significant reduction (PΩ operatively (range 9–16 months), when active 2. The majority of patients in both study and 0.013). Muscle palpation tenderness orthodontic treatment was finished, (3) ap- control groups had mandibular hypoplasia, and headache were also reduced sig- proximately 29 months postoperatively 32 had class II division 1 and 16 class II divi- nificantly (Table 3). The control group (range 20–44 months). The mean total fol- sion 2 malocclusion in the study group, while was initially almost identical: 75% (15) low-up time was thus four years on average. 15 had class II division 1 and 4 division 2 had some sign or symptom, but in con- Eight of the patients had previously had oc- malocclusion in the control group. Twelve trast to the study group, this score in- clusal splint therapy and four had had oc- study patients and four control patients had creased during the follow-up to 85% clusal grinding. an anterior open bite. (17). Four (6.7%) patients who had no The control group was examined twice: (1) Statistical analysis was performed using at the first visit, and (2) approximately 52 the Wilcoxon matched pairs signed-ranks TMD preoperatively, developed signs months later (range 33–70 months). test to test the difference between measure- and symptoms of TMD postopera- Each examination included a written an- ments (two-tailed P-values in results) and by tively. One patient in the study group amnestic questionnaire and both a clinical Spearman rank correlation (rs). and one in the control group underwent and a radiological examination, but because some subjects in the control group refused radiography at the final visit, no radiological Table 1. Distribution of preoperative diagnosis among 60 patients in study group and 20 comparison could be made in the control control patients group. In the questionnaire the patient answered Study group Control group yes or no to questions concerning joint Diagnosis (nΩ60) (nΩ20) noises, locking, joint pain, pain in the facial Mandibular hypoplasia 40 16 musculature, stiffness/difficulties in mouth Mandibular hypoplasia, anterior open bite 5 3 opening, clenching of the teeth and ear pain, Mandibular hyperplasia 5 and reported the frequency of headache. Mandibular hyperplasia, anterior open bite 4 1 The clinical examination was performed Maxillary hypoplasia 1 by one of the two researchers (KP, MS) and Maxillary hypoplasia, anterior open bite 1 consisted of occlusal classification according Maxillary hyperplasia (VME), anterior open bite 2 to Angle and assessment of overjet, overbite, Maxillary and mandibular hypoplasia 2 maximal mouth opening, deviation at mouth opening, lateral and protrusive movements, VMEΩvertical maxillary excess. horizontal and lateral glide between retruded contact position (RCP) and intercuspal posi- tion (ICP), mediotrusive and laterotrusive in- Table 2. Number of operations performed for 60 patients terferences, number of occluding pairs of BSSO/advancement 35 teeth, pain when moving the jaw, palpation BSSO/set-back 2 and auscultation of the joints and palpation BSSO/advancement Genioplasty 5 of the masticatory muscles. The underlying π LF I 3 skeletal deformity was assessed on lateral ce- Bimaxillary 15 phalograms. -LF I adv. with BSSO/adv. 1 The basic data from the questionnaire and -LF I adv. with BSSO/set-back 3 clinical examination were calculated and -LF I adv. with mandibular anterior segment 1 classified according to H’s 8 Anamnes- -LF I intrusion with BSSO/adv. (one with GP) 5 tic Index (Ai) (graded on a scale of Ai0Ωno -LF I intrusion with BSSO/set-back 1 subjective symptoms, AiIΩmild subjective -LF I with segmentalization with BSSO/adv. 1 symptoms, and AiIIΩsevere subjective symp- -LF I inferior repositioning with BSSO/adv. 1 toms) and clinical Dysfunction Index (Di) -LF I inferior repositioning with BSSO/set-back 1 (Di0Ωno symptoms, DiIΩslight symptoms, -Posterior maxillary segmentalization with BSSO/adv. 1 DiIIΩmoderate symptoms, DiIIIΩsevere symptoms). BSSOΩbilateral sagittal split osteotomy of the ramus, LF IΩLeFort I osteotomy, GPΩgenio- The morphology of the condyles was plasty, adv.Ωadvancement. Orthognathic surgery and TMJ dysfunction 185
Table 3. Numbers of patients with signs and symptoms of TMJ disorders in various examinations (nΩ60) (in parentheses: control group, nΩ20) Muscle Joint Joint Joint pain palpation Max. opening clicking crepitation on palpation tenderness* Headache ∞40 mm Before treatment 25 (8) 13 (4) 27 (6) 30 (7) 37 (10) 0 (0) One year after treatment 25 (–) 12 (–) 7 (–) 12 (–) 11 (–) 8 (–) The latest examination 29 (8) 6 (4) 11 (11) 11 (5) 12 (10) 6 (0) PΩ0.09** PΩ0.0003** PΩ0.0005** PΩ0.0000** PΩ0.313** * ±6 muscles of 12 tender to palpation ** Wilcoxon ranked signed test, study group (between first and latest examination). No statistically significant changes seen in control group.
arthroscopy before final examination. parison to 7.0 muscles in the headache and the specific type or magnitude of Resorption or condylar remodelling group at initial examination. No associ- skeletal deformity, either in sagittal or was found in six cases on the preopera- ation with diagnosis, Ai, Di, overlap or vertical assessment. tive panoramic tomographies, but no overjet was, however, found. All the parameters of occlusion (ov- progressive changes were noticed during A weak positive correlation (rsΩ0.27, erjet, overbite, number of occluding follow-up. Two of these patients had PΩ0.04) was found between age and Ai pairs of teeth, RCP-ICP glide, retrusive mandibular plane angles of more than before treatment. Significant improve- and mediotrusive interferences, later- 32æ, but none had anterior open bite. ment in Ai in the whole study group otrusion, protrusion) showed significant There was no reduction in joint click- was found (PϽ0.0005) between the first improvement in the study group and ing, instead the incidence of this slightly and the final examination (Fig. 2). The seemed to remain stable during the ob- increased during follow-up. A minor older group of patients (Ͼ30 years) servation period. A slight tendency to but not statistically significant reduc- benefited most from the treatment. impaired maximal mouth opening was tion was found in joint crepitation (PΩ Di showed significant improvement found, but this was not significant. The 0.09), the change being greatest in skel- (PΩ0.0009) between the preoperative mean maximal mouth opening was 52 etal class I and III groups. Significant and final examination (Fig. 3); this mm both at initial and latest examina- improvement in joint pain on palpation change being already significant at the tion, but in six cases the opening re- was observed (PΩ0.0003), as well as first postoperative examination and duced to below 40 mm. In the control in muscle palpation tenderness (PΩ more marked among women. In the group in some individuals minor oc- 0.0005). control group, no changes in Ai, Di or clusal changes were found. No occlusal At initial examination, 38 (63%) pa- signs or symptoms of TMD were no- grinding had been performed in these tients reported suffering from recurrent ticed between the first and the second control patients. headache, whereas this score had examination (Figs. 2 and 3), except for The occlusal parameters were tested dropped to only 15 patients (25%) at a slight increase in joint pain on pal- for a relationship to Ai, Di and specific final examination (PϽ0.001) (Table 3, pation. On the other hand, maximal type of malocclusion, but no significant Fig. 1). The frequency of the remaining mouth opening did not become im- correlations were found. headache had also reduced (Fig. 1). Im- paired at all during follow-up, as it did provement was not found in the control to a small degree in the study group group (Table 3, Fig. 1). Patients without (Table 3). headache had on average 5.4 muscles No association could be found be- Discussion (out of 12) tender to palpation, in com- tween Ai, Di or the age of the patient The most marked improvement in this study was found in the frequency of headache (PϽ0.0005). This was already noticed at the first follow-up examina- tion. A significant reduction was also observed in signs and symptoms of TMD, as shown in Table 3. This was mainly due to reduced joint pain on palpation and less crepitation in the joints, while joint clicking increased slightly. The reduced symptoms from the joints and the reduced muscle pal- pation tenderness (Table 3) contributed significantly to an improvement in Ai and Di, when compared to the initial phase and to the control group. In a long-term follow-up study by F- Fig. 1. Distribution of frequency of headache at different follow-up examinations in study & P5, crepitation was found group (three highest columns) and in control group (two lowest columns). to increase and clicking to decrease, in 186 Panula et al.
Fig. 2. Distribution of Helkimo’s Anamnestic Index (Ai) at various Fig. 3. Distribution of Helkimo’s Dysfunction Index (Di) at various follow-up examinations in study group (three highest columns) and follow-up examinations in study group (three highest columns) and in control group (two lowest columns). in control group (two lowest columns).
contrast to our findings, but they also from 7.9% to 11.9%. Since in our study were no significant changes in Ai or Di found improvement in masticatory three patients in the control group also for the controls. The improvement in Di muscle pain postoperatively in the rigid developed new symptoms, this can be as- was mainly due to reduced muscle ten- fixation group. sumed to be within the limits of spon- derness and joint pain. No association The reduced muscle tenderness taneous variation. L & N15 between Ai, Di or TMJ disorders and (which initially was slightly higher in concluded in their study that if internal the specific diagnosis or magnitude the headache group) and the altered derangements were discovered after of the skeletal deformity or occlusal functional pattern of the muscles as orthognathic surgery, they probably pre- interferences could be shown, despite well as stable occlusion, may have con- existed and were not caused by the the fact that the occlusion had been tributed to the considerable improve- surgery. Progressive condylar resorption improved and stabilised. Similar find- ment in headache. Similar beneficial ef- was not noticed in the present study, in ings have also been published by fects on headache after orthognathic contrast to the findings of S others2,13,21,22. The majority of patients treatment have also been reported by et al.23. All six patients who had condy- had mandibular hypoplasia, most of the others14,17,18. lar resorption or remodelling already be- malocclusions were Angle class II and The prevalence of signs and symp- fore treatment were women, but no one the prevalence of other discrepancies toms of TMJ dysfunction (73.3%) was had open bite deformity and only two was too low to allow reliable compari- high in the present study as compared to had high mandibular plane angle. These son. Our findings are very similar to the many others: L et al. (14%)13, features seem to be risk factors for results of a study by R-G- K et al. (16.2%)12, DC et condylar resorption, in addition to some et al.22, who examined only class II al. (26.5%)3, K & M morphological characteristics of the patients in their multicenter study. (40.8%)11, S et al.23 (45.6%), condyle9. Some studies have found that there are W & D (49.3%)29. Studies Only a temporary reduction in more symptoms in patients with man- performed by L & N15 and mouth opening was noticed when rigid dibular hypoplasia14,15,29, and especially S & W24 reported figures of internal fixation was used. This un- those with low mandibular angle the same magnitude as ours: 97% and doubtedly is one of the main advan- (Æ32æ)4,15. These symptoms are sup- 80%, although the patient sample was se- tages of this method since it allows for posed to be caused by the high condylar lected in the former. The explanation for rapid function of the TMJs. compressive loadings during function. this difference in comparison to most When measured with Ai and Di, sig- The results of the present study did not other studies may either lie in the criteria nificant improvement in symptoms was reveal any association between the man- for the recorded symptoms or in the pa- achieved. The degree of improvement dibular plane angle and TMD, similar tient sample itself: the patterns of refer- was greater on Ai, especially in the to the findings of S et al.23. rals may vary in different countries and older group of patients (Ͼ30 years), It is concluded that the functional cultures, e.g. L et al.13 mention whereas Di showed no correlation with status and headache of a patient with that: ‘‘... majority of programs found age. This may demonstrate that these major skeletal and occlusal deformity most of their potential orthognathic patients may experience certain TMJ can be significantly improved with surgery patients to be normal in terms of dysfunctions as being more annoying orthognathic surgery and orthodontics. TM function‘‘. This may suggest that than do younger patients. The study by The risk of causing new TMJ dysfunc- cosmetic motives are more pronounced S et al.26 showed that with in- tion or condylar resorption is extremely when seeking treatment6,7. In our study creasing age there may be more mor- low. The present study does not, how- group, only 6.7% (4) patients developed phologic changes in the TMJ associated ever, support the theory that there is a new TMJ dysfunction symptoms, which with malocclusion; such morphologic direct relationship between TMJ dys- is similar to others3,12,29, who report changes may effect functioning. There function and dentofacial deformities. Orthognathic surgery and TMJ dysfunction 187
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